DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
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(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0565
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Honor the resident’s right to organize and participate in resident/family groups in the facility. Based on interviews and record reviews, the facility failed to follow their policy to |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0565
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 1) of six residents agreed they have been told they are not allowed to hold resident council meetings unless the administrator, Director of Nursing (DON) or SSD are in the building. The explanation they have been given for this is because. 4. Review of the resident council meeting minutes for July, (MONTH) and (MONTH) (YEAR), did not show staff discussed old business and feedback from previous meetings with the residents in attendance. 5. During an interview on 10/15/18 at 11:02 A.M., the AD said she takes notes at each resident council meeting. She did not know how concerns were followed up with residents. She said she informed each department of the any concerns or suggestions brought up at the meeting and they took it from there. She covers old business at the beginning of each meeting, but does not give minutes to the residents. When she started as the AD, she was told resident council could only be held if the administrator, DON or SSD were in the building. Normally resident council is the last Monday of the month. If a holiday falls on the last Monday of the month and the department heads are off, they will reschedule the meeting to the next day. This has happened a couple of times since she has been in this position. 6. During an interview on 10/16/18 at 11:00 A.M. the SSD verified she is the grievance officer. Sometimes she gets a complaint from residents or family members and can look into it immediately. Otherwise, she will have to do an investigation if the issue will take longer than a day to resolve. The investigation can take up to 10 days. She goes directly to the person who made the grievance to discuss the conclusions. She documents her conclusions on a grievance log, but does not provide written documentation to the family or resident. Resident council concerns are addressed by the department head the issue pertains to. She will get a copy of minutes if there’s a problem with her department. She will address each resident individually with their concerns. She also has two residents who always provide her with the concerns brought up at the meeting. During the meetings they are supposed to cover old business and concern resolutions for the previous meeting. They can also invite the department head to the meeting to further discuss concerns. She is not aware of any rule stating resident council cannot be held if she or the administrator or the DON is not in the building. During an interview on 10/16/18 at 2:22 P.M., the AD said there is a resident bulletin board on each floor. The boards will have things like resident art work or writings by residents on them. She did not know the grievance policy should be posted on the boards and confirmed it was not. During an interview on 10/17/18 at 7:20 A.M. the administrator said she was not aware her policy said to post the grievance/complaint procedure on the resident bulletin boards. She follows up with concerns from resident council personally and residents are given resolutions in writing. If residents want a copy of the resident council minutes and feedback they can ask for it. The SSD may not provide something in writing, but it is discussed in person. During an interview on 10/17/18 at 8:30 A.M., the administrator, DON and SSD denied there was a rule that resident council could only be held if they were in the building. They did not know why residents would say that. The only times the meetings have been rescheduled have been at the groups’ request. |
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F 0567
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Honor the resident’s right to manage his or her financial affairs. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
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(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0567
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Based on interview and record review, the facility failed to provide and make available personal funds on an ongoing basis for all residents for which the facility held funds. The facility census was 82. 1. During the resident council meeting on 10/12/18 at 2:00 P.M., six of six residents agreed the facility only held banking hours Monday through Friday from 1:00 P.M. to 2:00 P.M. The resident bank was never open on weekends or federal holidays. 2. During an interview on 10/15/18 at 8:40 A.M. the business office manager said petty cash is available Monday through Friday from 1:00 P.M. to 2:00 P.M. She will rearrange her schedule on Fridays to accommodate a resident if they have to leave early or have an appointment. Petty cash is not available on the weekends. She encourages residents to get their money before the weekend. 3. During an interview on 10/15/18 1:11 P.M., the administrator said she thought funds only needed to be made available during banking hours Monday through Friday. She did not know it had be available for longer hours or on weekends. |
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F 0576
Level of harm – Potential for minimal harm Residents Affected – Many |
Ensure residents have reasonable access to and privacy in their use of communication methods. Based on interview and record review, facility staff failed to deliver resident mail on |
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F 0582
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on record review and interview, the facility failed to provide a Skilled Nursing |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0582
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 3) (Residents, #44, #37 and #79). The facility census was 82. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -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 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 his/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. Record review of Resident #44’s Skilled Nursing Facility Beneficiary Protection Notification Review, completed by facility staff on 10/11/18, showed the following: -Medicare Part A skilled services start date 4/6/18; -Last covered day of Medicare Part A service as 5/18/18; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -Facility staff did not provide the resident or his/her legal representative the SNFABN form CMS- or alternative denial letter. 2. Record review of Resident #37’s Skilled Nursing Facility Beneficiary Protection Notification Review, completed by facility staff on 10/11/18, showed the following: -Medicare Part A skilled services start date 5/23/18; -Last covered day of Medicare Part A service as 8/14/18; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -Facility staff did not provide the resident or his/her legal representative the SNFABN form CMS- or alternative denial letter. 3. Record review of Resident #79’s Skilled Nursing Facility Beneficiary Protection Notification Review, completed by facility staff on 10/11/18, showed the following: -Medicare Part A skilled services start date 4/4/18; -Last covered day of Medicare Part A service as 6/8/18; -The facility initiated the discharges from Medicare Part A services when benefit days were not exhausted; -Facility staff did not provide the resident or his/her legal representative the SNFABN form CMS- or alternative denial letter. 4. During an interview on 10/16/18 at 8:00 A.M., the administrator said she was unaware of the required SNFABN for CMS- and had never given the form to a resident discharged from Medicare Part A when benefit days were not exhausted. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
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(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0582
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
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F 0584
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to provide a dignified and |
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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** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0657
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 5) -The care plan failed to identify the resident’s choice to stay in bed nor how staff should approach the resident when he/she refused to get out of bed. During an interview on 10/12/18 at approximately 11:00 A.M., the resident said sometimes he/she doesn’t want to stay in bed all day and sometimes maybe he/she does. During an interview on 10/17/18 at approximately 8:31 A.M., the Director of Nursing (DON) said, this is a new behavior resulting from a change in condition after a recent hospital stay and should be documented on the resident’s care plan. 2. Review of Resident #2’s quarterly MDS, dated [DATE], showed the following -Short and long term memory problems; -Moderately impaired cognitive skills for daily decision making; -Total dependence on staff for dressing, eating, toilet use, personal hygiene and bathing; -Incontinent of bowel and bladder; -Gastrostomy ([DEVICE], a tube surgically inserted into the stomach to provide hydration, nutrition and medications) tube; -Upper extremity impairment on one side; -Not at risk for pressure ulcers; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, in use during the survey, showed the following: -Problem, potential for impaired skin integrity related to decrease in mobility, bowel and bladder incontinence and debility, skin currently intact; -Goal, will maintain good skin integrity/skin integrity will be preserved through next review; -Interventions, provide treatment to affected areas as directed, monitor hand skin integrity, provide treatment to left hand as directed; -Handwritten update, 7/16/18, no skin concerns reported. Continue with weekly skin assessments and provide incontinence care as needed, report change in skin integrity to physician; -Handwritten update, 10/8/18, provide skin care as directed. Continue weekly skin assessments, report skin concerns to the physician; -Nothing in the careplan regarding a contracture, previous wound to the hand or the use of gauze to the resident’s hand. Review of the resident’s physician order [REDACTED]. -An order, dated 6/6/18, to cleanse wound to left hand with wound cleanser, apply triple antibiotic ointment and dry dressing daily until healed. Review of the resident’s treatment administration record (TAR), dated 10/11/18 to 11/10/18, showed, staff to cleanse wound to left hand with wound cleanser, apply triple antibiotic ointment and dry dressing daily until healed. Staff initialed as done 10/11/18 through 10/16/18. Review of the facility’s wound report, showed no mention of a wound on the resident’s left hand. Observation of the resident, showed the following: -On 10/11/18 at 1:33 P.M., the resident sat in a wheelchair in the televison area with a white dressing inside his/her contracted left hand; -On 10/12/18 at 12:48 A.M., the resident lay in bed with a white dressing inside his/her contracted left hand; -On 10/15/18 at 8:25 A.M., the resident sat in a wheelchair in the television area with a white dressing inside his/her contracted left hand; -On 10/15/18 at 1:52 P.M., the resident lay in bed with a white dressing inside his/her contracted left hand; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0657
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 6) -On 10/16/18 at 7:00 A.M. and 12:33 P.M., the resident sat in a wheelchair in the television area with a white dressing inside his/her contracted left hand; -On 10/17/18 at 7:32 A. M., the resident lay in bed with a roll of gauze inside his/her contracted left hand. During an interview on 10/16/18 at 12:15 P.M., the Assistant Director of Nursing (ADON) said the resident did not have an open area on his/her left hand. A dry dressing is placed there because of moisture to keep it from breaking down. A while back the fingernail on his/her left pinky finger caused a sore on on his/her palm but that cleared up. If there was a wound on his/her hand, it would be on the weekly wound report. During an interview on 10/17/18 at 8:30 A.M., the Administrator said the use of the dressing inside the resident’s contracted hand was because of moisture. The order should be reworded. 3. Review of Resident #74’s quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Limited assistance required with personal hygiene, dressing and walking in the halls; -[DIAGNOSES REDACTED]. Review of a list of resident’s receiving restorative therapy (RT-aides in maintaining the full movement potential of a joint), provided by the facility on 10/12/18, showed the resident received RT. Review of the RT binder, showed the resident received RT for the following: -Goal: Maintain strength and range of motion (ROM) for functional mobility and orthotic management; -Approach: General sitting exercises and ROM program, gait as tolerated and check orthotic devices to left leg and hand splint as tolerated. Review of the physician’s orders [REDACTED]. Review of the RT log, showed the resident received RT three times a week since 11/1/17 for general sitting exercises, range of motion (ROM) and for use of a hand splint. Review of the care plan, dated 7/5/18, showed the following: -Problem: Potential for self-care deficit related to stoke with paralysis; -Goals:Resident will maintain current level of function and be clean and well groomed; -Interventions: Assist as needed with transfers and personal care, monitor for changes, resident has a hand splint due to a stroke with right sided paralysis and ambulate with resident to and from the dining room; -The care plan did not show the resident receivd RT. 4. Review of Resident #67’s quarterly MDS, dated [DATE], showed the following: -Cognition not assessed; -[DIAGNOSES REDACTED]. -Number of pressure ulcers (Has Injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction): two, Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling) pressure ulcers; -Special services: Hospice. Review of the facility wound report, showed on 9/25/18, the resident had two Stage III pressure ulcers on the proximal (inner) and distal (outer) area of his/her left gluteal area. Review of the resident’s care plan, last updated on 10/4/18, and in use during the survey, showed the following: -Problem: Potential risk for impaired skin integrity related to Stage II (Partial |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
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(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0657
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 7) thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister) pressure area on left gluteal area; -Goal: Resident will receive optimal care and management to preserve skin integrity and for steady improvement of pressure area through next review; -Interventions included provide treatment to area as ordered, monitor and document wound progress on a weekly basis and provide pressure relieving devices to bed/wheelchair as needed; -Problem: Palliative care (care associated with relieving symptoms associated with a condition while receiving active treatment); -Goal included: Symptoms will be managed and resident will remain comfortable; -Staff did not update the care plan to show the resident’s current pressure ulcer staging or the change with the pressure sores. 5. Review of Resident #44’s quarterly MDS, dated [DATE], showed the following: -Cognition not assessed; -Has unclear speech, makes self understood and understands others; -Required extensive assistance with toileting, dressing, transfer and bed mobility; -[DIAGNOSES REDACTED]. -Impairment on one side for upper and lower extremities;e -No restorative nursing program services offered in last 7 days. Review of the resident’s care plan, last updated on 8/30/18, showed the following: -Resident has right sided hemiperisis and uses lap tray for right side upper extremity (UE) positioning. -Staff did not include the resident’s participation in RT. Review of a list of resident’s receiving RT, provided by the facility on 10/12/18, showed the resident received RT. Review of the RT binder, showed the resident received RT for the following: -Goal: maintain current range of motion and strength, maintain current transfer ability as tolerated; -Approach: Right UE and lower (LE), general sitting exercises left UE & LE, general sit to stand pivot transfers; -The binder included documentation for August, (MONTH) and (MONTH) (YEAR); -Staff did not include how often RT should be provided. During an interview on 10/17/18 at 8:30 A.M., the administrator said the resident was discharged from therapy in May. The therapy department made the recommendation the resident continue with RT. This information should be included on the care plan as well as how often the resident receives RT. 6. During an interview on 10/17/18 at 8:30 A.M., the administrator said the MDS coordinator updates the care plan quarterly and as needed. A daily clinical meeting is held and the MDS coordinator is alerted at that time to any changes in resident’s conditions or care needs. Any nurse can also update a care plan. The care plan should reflect the resident’s current needs and condition |
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F 0658
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Ensure services provided by the nursing facility meet professional standards of quality. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
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(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0658
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(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 ensure that care |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0658
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 9) -Supervision required for all care; -Mobility provided with the use of a wheelchair or walker; -[DIAGNOSES REDACTED]. Review of the POS [REDACTED]. No indication for use provided with the order. Review of the POS [REDACTED]. Review of the medical record, showed no documentation of fluid intake. During an interview on 10/17/18 at 9:30 A.M., the DON said all antibiotics should have a [DIAGNOSES REDACTED]. She said the fluid restrictions are recorded on the treatment administration record (TAR). Review of a TAR that was not labeled with what month or year staff were documenting for and provided by the DON on 10/17/18 at 11:00 A.M., showed the following: -240 cc’s for breakfast and initialed every day from the 24th through the 10th; -240 cc’s for lunch and initialed every day from the 24th though the 10th; -240cc’s for dinner and initialed every day from the 24th through the 10th; -340 cc’s free fluid and initialed every day from the 24th through the 10th; -No documentation recorded for the amount of fluid intake. During a second interview on 10/17/18 at 11:00 A.M., the DON said she believed the documentation to be sufficient even though it did not show the amount of fluid consumed. After further review of the TAR she said she realized that the recording is insufficient and the amounts listed total 1060 cc’s instead of the allotted 1500 cc’s. 4. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Extensive assistance required for all personal care; -Frequently incontinent of urine; -[DIAGNOSES REDACTED]. Review of the POS [REDACTED]. Further review of the medical record, showed no results of a UA C&S. During an interview on 10/17/18 at 8:30 A.M., the DON said the results of all lab work would be found in the chart. 5. Review of Resident #74’s quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. Review of the POS [REDACTED]. No indication for use provided with the medication. During an interview on 10/17/18 at 9:30 A.M., the Director of Nursing (DON) said all antibiotics should have a [DIAGNOSES REDACTED]. 6. During an interview on 10/17/18 at 8:30 A.M., the Director of Nursing (DON), said she expected staff to follow physician orders. |
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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: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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 10) Review of the facility’s Perineal Care policy, dated (MONTH) (YEAR), showed: -Purpose: To provide cleanliness and comfort to the resident, prevent infections and skin irritation, and to observe the resident’s skin condition; -Equipment and supplies necessary when performing procedure included wash basin, towels, washcloth, soap (or other authorized cleansing agent), and personal protective equipment (e.g., gowns, gloves, mask, etc., as needed.); -For a male resident; wet washcloth and apply soap or skin cleansing agent, wash perineal area, using fresh water and a clean washcloth, gently dry perineum following the same sequence; -Ask the resident to turn on his side with his upper leg slightly bent, if able; -Rinse wash cloth and apply soap or skin cleansing agent, wash and rinse the rectal area thoroughly, dry area thoroughly; -For a female resident; wash perineal area, wiping from front to back; -Continue to wash the perineum moving from inside outward to the thighs, rinse perineum thoroughly in the same direction, and gently dry perineum; -Wash rectal area thoroughly. 1. Review of Resident #44’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 8/30/18, showed the following: -Moderately impaired cognition; -Resident is rarely/never understood; -Extensive assistance required for bed mobility and toilet use; -Total dependence for personal hygiene; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Observation on 10/12/18 at 6:44 A.M., showed Certified Nursing Assistant (CNA) A provided perineal care to the resident. The resident lay in bed and was incontinent of urine; -CNA A removed the resident’s gown and urine-soaked brief; -CNA A washed the resident’s perineal area with a back and forth, up and down, and circular motion using the wet, soapy towel; -Using the same area of the towel, CNA A washed the resident’s genitals in a back and forth motion many times; -CNA A used the dry portion of the same towel to dry the resident’s peri area and genitals in a back and forth, circular manner; -CNA A used the soiled wet and soapy towel and wiped the resident’s rectal area in a back to front, back and forth, and circular manner; -CNA A then used the dry portion of the soiled towel to dry the resident’s rectal area wiping in a back to front and circular manner many times; -CNA A placed a clean brief under the resident and applied barrier cream (helps to protect the skin from moisture) onto his/her rectal area and buttocks in a back and forth, and circular motion. During an interview on 10/12/18 at approximately 7:00 A.M., CNA A said when cleansing the perineal area the direction of the wiping motion does not matter as long as it was wiped clean. 2. Review of Resident #67’s quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent on staff for mobility and personal hygiene; -Incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Observation on 10/15/18 at 1:10 P.M., showed CNA’s F and G transferred the resident to bed |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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 11) and removed his/her wet with urine slacks and brief. With three wadded pre-moistened wipes, CNA F cleansed the left side of the genitalia three times in a back and forth motion without changing areas of the cloths, with three clean cloths he/she repeated the process on the right side of the genitalia and with three clean cloths he/she repeated the process in the center of the genitalia. He/she then turned the resident to his/her right side and cleansed the left buttock in a circular motion then turned the resident to his/her left side and cleansed the right buttock in a circular motion. During an interview on 10/15/18 at 1:20 P.M., CNA F said when providing perineal care always cleanse from the front to the back and never in a back and forth motion. During an interview on 10/16/18 at 10:10 A.M., the Drector of Nursing said when providing perineal care staff should always cleanse from the front to the back and change the area of the cloth or use a new cloth with each pass. Always cleanse from clean to dirty. |
|
F 0684
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
|||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
|||||||
NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
|||||||||
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 0684
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 12) -No documentation of chest x-ray obtained. During an interview on 10/15/18 at approximately 12:11 P.M., the assistant director of nursing (ADON) said, the resident’s nurse notes should reflect the resident’s condition, when the x-ray and urine specimen was obtained, any communication with the doctor and what the test results are. She was unable to locate this information in the chart and placed a call to the radiology company for results. She knew that the resident’s urine was collected on 10/13/18 by reviewing the nurse’s 24 hour report. The 24 hour report sheet that is not part of the resident’s medical record. During an interview on 10/16/18 at approximately 10:12 A.M., the resident said he/she felt horrible and cannot sleep at night, he/she still did not know his/her test results but did know that she gave them a urine specimen and had a chest x-ray done. Further review of the resident nurse’s notes reviewed on 10/16/18 at approximately 8:00 A.M. showed: -10/15/18 at 12:45 P.M., the laboratory company in to pick up urine specimen; -10/15/18 at 1:00 P.M., new order start Z-pack (an antibiotic used to treat various types of infections) use as directed. Further review of the resident’s medical records, showed a chest x-ray report dated 10/11/2018, electronically signed by a radiologist on 10/11/18 at 3:15 P.M., with an impression of mild [MEDICATION NAME] thickening (is a radiologic sign which occurs when excess fluid or mucus buildup in the small airway passages of the lung causes localized patches of atelectasis (closure of lung)) that could indicate [MEDICAL CONDITION], with hand written note dated 10/15/18 at 12:30 P.M. Z-pack use as ordered. During an interview on 10/17/18 at approximately 8:31 A.M., the DON said she expects staff to follow the physician’s orders [REDACTED]. The resident’s urine lab results were not available at this time. During an interview on 10/19/18 at approximately 3:00 P.M., the resident’s primary care nurse practitioner said he/she expects staff to follow orders given. A delay in prescribed medications can worsen the resident’s symptoms. 2. Review of Resident #58’s quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Required supervision with all personal care; -[DIAGNOSES REDACTED]. -Frequent severe pain; -Received an opioid seven of seven days. Review of the POS, dated 7/11 through 8/10/18, showed the following: -An order, dated 6/13/17, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME]) 10/325 mg’s four times a day; -An order, dated 4/11/18, to administer [MEDICATION NAME] (muscle relaxer) 10 mg twice a day. Review of the POS, dated 8/29/18, showed an order to change the administration of [MEDICATION NAME] from four times a day to three times a day. Review of the annual MDS, dated [DATE], showed frequent severe pain and received an opioid seven of seven days. Review of the nurse’s notes, showed a note written on 9/19/18 at 10:45 A.M., that read the resident complained of knee and back pain and rated the pain as a 10 on a scale of 0-10. He/she said at times his/her knees gave out because of the pain and he/she chose to spend the majority of time in his/her room due to the pain and the fear of falling. Further review of the nurse’s notes, showed no follow up notes. Observation on 10/11/18 at 10:57 A.M., showed the resident sat at the side of his/her bed, |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
|||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
|||||||
NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
|||||||||
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 0684
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 13) panting and frowning and said he/she had just received pain medication after being in severe pain for three hours. Observation on 10/15/18 at 10:27 A.M., showed the resident sat at the side of his/her bed and complained of pain between his/her shoulders. He/she rated the pain as a seven. He/she said the pain on occasion goes as low as a three but is typically stays around a seven. He/she added that the pain medication went from four to three times a day and that leaves too much time between doses because once the pain is severe it takes much longer for the medication to be effective. Further review of the POS, dated 10/11 through 11/10, showed no orders for as needed (PRN) [MEDICATION NAME]. Observation on 10/16/18 at 7:10 A.M., showed the resident sat at the side of the bed, panting and frowning. He/she rated the pain at an eight to nine. Observation on 10/17/18 at 7:45 A.M., showed the resident sat at the side of the bed with a strained face and shallow breathing. He/she rated the pain as a level of eight and again said the time between pain medication needed to be decreased to provide him/her with more relief. During an interview on 10/17/18 at 7:57 A.M., Certified Medication Technician (CMT), said he/she never asks the resident if he/she has any pain. During an interview on 11/17/18 at 8:30 A.M., the Director of Nursing and the Administrator said the physician lowered the dose of [MEDICATION NAME] to see if the resident could tolerate a lower dose in hopes of discontinuing the medication entirely. The DON added that if a resident complains of a pain level of 10 it is the nurse’s responsibility to assess the resident, notify the physician, administer an [MEDICATION NAME] and reassess the effectiveness of the medication. It is not appropriate for a resident to be in pain, especially at a level of 10 and not have any follow-up. She said the pain scale should be documented on the medication administration record (MAR) but not necessarily every day or every shift. She said an order had been obtained for a pain management consult. Further review of the POS, dated 10/11 through 11/10/18, showed no order for a pain management consult. Further review of the MAR, showed no documentation of pain level. 3. Review of Resident #70’s quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Extensive assistance of staff required for personal hygiene; -Occasionally incontinent; -Received an anticoagulant (blood thinner) medication seven of seven days; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, updated 9/24/18, showed the following: -Problem, anticoagulation therapy/aspirin therapy, due to [MEDICAL CONDITION] (A-fib, irregular heartbeat) and [MEDICAL CONDITION]; -Goals, will receive optimal care and management of anticoagulant therapy and be free of adverse side effects through the next review; -Interventions, monitor for bleeding of nose or gums, bruising, petechiae (small red or purple spots on the skin caused by minor bleeding), pain or hematuria (blood in the urine), educate resident/staff to recognize and report signs and symptoms of bleed to nurse and to avoid trauma; -Handwritten update, dated 9/24/18, Eliquis added on 9/11/18, [DIAGNOSES REDACTED]. Review of the resident’s POS, dated 10/11/18 through 11/10/18, showed the following: -An order, dated 9/11/18 for Eliquis (blood thinner) 5 mg twice daily, for A-fib. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
|||||||
NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
|||||||||
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) |
|
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F 0684
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 14) Observation of the resident’s bed on 10/11/18 at 11;00 A.M., showed a fresh blood stain, approximately 5 inches in diameter, on the resident’s pillow covering. During an interview on 10/11/18 at 3:15 P.M., CNA F said the night shift CNA told him/her the resident’s nose bled because he/she had picked at it. This surveyor and CNA F went into the resident’s room, asked him/her where the blood came from and he/she said from his/her nose. During an interview on 10/12/18 at 11:48 A.M., the resident sat in the fourth floor dining room and said he/she had not had bleeding from his/her nose before. It had not bled any more since yesterday. During an interview on 10/11/18 at 3:45 P.M., LPN E said he/she saw the resident that morning and he/she had some cuts on his lip from using the electric razor. Review of the resident’s nurse’s notes, showed the last documentation, dated 10/1/18. During an interview on 10/17/18 at 8:30 A.M., the DON said she expected CNA’s to notify the nurse on duty if a resident had an incident such as bleeding. She expected the nurse on duty to inform her of the incident. The physician should be informed and the incident should be recorded on the care plan, and should be documented in the nurses notes. No one told her about the resident’s bleeding incident on 10/11/18. During an interview on 10/19/18 at 3:16 P.M., the resident’s primary care nurse practitioner said he is part of a group of five doctors and nurse practitioners, and they share calls. He did not recall being told about the resident’s bleeding incident. |
|
F 0686
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
|||||||
NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
|||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
|
---|---|---|
F 0686
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 15) ulcers; -Treatment/Management: -The physician will order pertinent wound treatments, including pressure reduction surface, wound cleansing and debridement approaches, dressings and application of topical agents; -The physician will help identify medical interventions related to wound management; -The physician will help staff characterize the likelihood of wound healing, based on review of pertinent factors; -As needed, the physician will help identify medical and ethical issues influencing wound healing; -Monitoring: -During resident visits, the physician will evaluate and document the progress of wound healing–especially for those with complicated, extensive or poorly-healing wounds; -The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Review of the Census and Conditions form, completed by the facility on 10/15/18, showed the facility identified three residents having pressure ulcers. Of those three, none were admitted with pressure ulcers. Review of Resident #67’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/28/18, showed the following: -Cognition not assessed; -Resident rarely/never understood; -Required extensive assistance from staff for toileting, personal hygiene, dressing and transfers. Independent with bed mobility; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Resident is at risk for pressure ulcers. No pressure ulcers present on prior assessment. Review of the resident’s significant change MDS, dated [DATE], showed the following: -Required extensive assistance with bed mobility and total care for toilet use and personal hygiene; -One or more unhealed pressure ulcers; -One Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister) pressure ulcers; -Were pressure ulcers present at previous assessment? No; -Skin and ulcer treatments included: pressure relieving device for chair/bed, turning/repositioning, nutrition/hydration to manage skin problems, pressure ulcer care; -Special treatments: Hospice. Review of the residents quarterly MDS, dated [DATE], showed the following: -One or more unhealed pressure ulcers: Yes; -Two, Stage III’s (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling) pressure ulcers; -Skin and ulcer treatments included: pressure relieving device for chair/bed, turning/repositioning, nutrition/hydration to manage skin problems, pressure ulcer care; -Special treatments: Hospice. Review of the resident’s care plan, last updated on 10/4/18, and in use during the survey, showed the following: -Problem: Potential risk for impaired skin integrity related to Stage II (Partial |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
|||||||
NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
|||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
|
---|---|---|
F 0686
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 16) thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister) pressure area on left gluteal area; -Goal: Resident will receive optimal care and management to preserve skin integrity and for steady improvement of pressure area through next review; -Interventions included provide treatment to area as ordered, monitor and document wound progress on a weekly basis and provide pressure relieving devices to bed/wheelchair as needed. Review of the facility’s wound report, from 8/2/18 through 10/4/18, showed the following: -On 9/11/18, staff noted the resident had a Stage II pressure ulcer on his/her left buttock, which measured 5.5 centimeter (cm) by 3 cm by 0.1 cm. Resident’s physician made aware. Small to moderate serosanguineous (composed of serum and blood) drainage. Treatment: bordered gauze (multipurpose dressing that is gentle to skin, is non adherent and has tape edges to hold the dressing in place), change every three days and as needed (PRN); -On 9/19/18, staff noted the resident had a Stage II pressure ulcer to his/her left buttock, which measured 4.5 cm by 2 cm by 0.1 cm. Resident’s physician made aware. Small to moderate serosanguineous drainage. Treatment: bordered gauze, change every three days and PRN; -On 9/25/18, staff noted the resident has a Stage III pressure ulcer to his/her left proximal gluteal (interior) area, which measured 1.2 cm by 0.8 cm by 0.1 cm. Resident also had a Stage III pressure ulcer to his/her distal gluteal (exterior), which measured 0.8 cm by 0.8 cm by 0.1 cm. Resident’s physician made aware. Small to moderate serosanguineous drainage. treatment for [REDACTED]. -No information for the resident on the (MONTH) (YEAR) wound report information provided. Review of the resident’s medical record, showed the following: -A nurse’s note on 9/13/18 at 10:00 A.M., resident has an open area on his/her left buttocks measuring 5 cm by 3.5 cy by 0.2 cm, moderate serosanguineous drainage noted to the pink wound bed. Resident’s doctor informed and the wound treatment doctor informed to see resident again. New order received: Cleanse left buttocks, apply border gauze every three days and PRN; -Review of the physician order [REDACTED]. -Review of the treatment administration record (TAR), dated 9/11/18 through 10/10/18, showed staff documented administering this treatment as ordered; -A wound care note, dated 9/25/18 at 8:31 A.M., by the wound treatment doctor. Measurement for left gluteal proximal: 1.2 cm by 0.8 cm by 0.1 cm. Measurement for left gluteal distal: 0.8 cm by 0.8 cm by 0.1 cm. Assessment: coccyx Stage III, recurrent. Plan: Debridement (the removal of damaged tissue from a wound) with a curette (a surgical instrument used to remove material by a scraping action). Treatment ordered: Apply Santyl with silicone boarder gauze. Change dressing every three days and PRN. Offload pressure areas and turn schedule per facility. Roho cushion (specialized pressure relief cushion for wheelchairs) in wheelchair; -On 9/25/18 at 9:10 A.M., Wound treatment doctor here to see resident. Open areas on his/her left gluteal proximal area measuring 1.2 cm by 0.8 cm by 0.1 cm and left gluteal distal measuring 0.8 cm by 0.8 cm by 0.1 cm. New order received for Santyl moistened onto silicone coccyx dressing. Change every three days and PRN; -Review of the POS [REDACTED] -Staff did not include the order for the Roho cushion to the wheelchair; -Review of the TAR dated 9/11/18 through 10/10/18, showed staff documented administering |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
|||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
|||||||
NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
|||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
|
---|---|---|
F 0686
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 17) the treatment as ordered. The TAR did not include an order for [REDACTED].>-Review of the POS [REDACTED]. Apply to coccyx and gluteal proximal and distal. Staff drew a line under the order and wrote no new orders 10/11/18; -On 10/11/18 , no time given, a nurse’s note showed: Resident seen by wound treatment doctor. Discontinue previous treatment. New orders: Start [MEDICATION NAME] moistened into silicone border gauze, change every three days and PRN. Apply to coccyx and gluteal proximal and distal; -Review of the POS [REDACTED] -Review of the TAR, dated 10/11/8 through 11/10/18, showed staff added the new order. The Roho cushion could not be found on the TAR. -Staff did not document providing the new treatment until 10/12/18 and did not document an explanation; -Staff did document the treatment every day from 10/12/18 thorough 10/16/18. Staff did not document an explanation as to why the treatment was given every day; -No further information was found in the nurse’s notes. Observations of the resident, showed the following: -On 10/11/18 at 3:22 P.M., the resident lay in his/her bed on a low air lost mattress (pressure relieving mattress) on his/her left side. A Broda chair (specialized reclining chair propelled by staff) was observed in the resident’s room without a Roho cushion; -On 10/12/18 at 10:47 A.M. and 11:46 A.M., the resident sat up in his/her Broda chair in the common area. A Roho cushion was not under the resident; -Further observation of the resident on 10/12/18 at 12:53 P.M., showed he/she sat in a Broda chair. The chair did not have a cushion. Certified Nurse Aide’s (CNA)’s F and G transferred the resident to bed, and provided incontinence care. With Licensed Practical Nurse (LPN) H present, CNA F removed the dressing from the coccyx and cleansed the pressure ulcers with pre-moistened wipes wearing the same gloves he/she wore to provide incontinence care; -At 1:00 P.M., showed LPN H cleansed the pressure ulcers with wound cleanser and measured the coccyx wound as 3.5 cm wide by 3.1 cm long. He/she staged the wound as a Stage III. A second pressure ulcer located at the lower left buttock measured at approximately 0.25 cm by 2.5 cm. He/she staged the wound as a stage II. LPN H applied a dry bordered gauze dressing. During an interview on 12/12/18 at 1:00 P.M., LPN H said nothing but the bordered gauze dressing is used on the wound. The dressing is changed every three days and PRN. Further observation of the resident, showed the following: -On 10/15/18 at 9:00 A.M. and 11:27 A.M., the resident sat up in the common room in his/her Broda chair without a cushion underneath. The resident sat in the same position; -On 10/16/18 at 7:03 A.M. and 12:45 A.M., the resident sat up in the common room in his/her Broda chair without a cushion underneath. The resident sat in the same position. During an interview on 10/16/18 at 10:46 A.M., LPN E said the resident’s coccyx dressing is changed every three days and PRN. He/she said the treatment to the wound consists only of a bordered gauze dressing. During an interview on 10/16/18 at 10:10 A.M, the Director of Nursing (DON) said it is never permissible to cleanse a wound with a pre moistened cloth and especially with gloves that have cleansed urine. Further observation of the resident on 10/17/18 at 7:35 A.M., showed he/she sat up in the common room in his/her Broda chair without a cushion underneath. During an interview on 10/17/18 at 7:35 A.M., CNA J said the resident does not use a cushion when up in his/her wheelchair. There is only the pad of the seat. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
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(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0686
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 18) During an interview on 10/17/18 at 8:30 A.M., the DON said she is responsible for maintaining the weekly wound report. Wounds should be measured and documented every week. She became aware of the resident’s coccyx wound on 10/10/18 when the wound treatment doctor examined the resident. The new treatment should have started on 10/11/18. Staff should provide treatments as ordered. If a treatment is given PRN, staff should document why the treatment was given. A Roho cushion is a reasonable intervention to prevent further worsening of a pressure ulcer. She did not know where the resident’s cushion was, but said they could get one. The care plan should reflect the resident’s current care needs and condition. During an interview on 10/18/18 at 2:50 P.M., the wound treatment doctor’s nurse said she is familiar with the resident and is present when the wound treatment doctor [MEDICATION NAME] the resident. A Roho cushion was ordered on [DATE] and is a standard order they give for residents with pressure ulcers like Resident #67’s. It is up to the facility to implement the order. Without this cushion in place, the wound areas can become worse if the resident is up in his/her chair and pressure is not being offloaded. |
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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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0690
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 19) Review of the resident’s care plan, updated 8/10/18, showed the following: -Problem, alteration in urinary function related to supra pubic catheter in use, [DIAGNOSES REDACTED].}; -Goal, adequate urinary output and receive optimal care and management of catheter through next review; -Interventions, provide catheter care every shift, irrigate/change catheter per physician’s orders [REDACTED]. -8/10/18 supra pubic catheter, continue to provide catheter care as directed, monitor for signs and symptoms of infection and inform physician. Review of the resident’s POS, dated 10/11/18 to 11/10/18, showed the following: -An order, dated 9/30/18, to send the resident to the emergency room for evaluation; -An order, dated 10/9/18, for [MEDICATION NAME]-clavulanate (antibiotic) 875-125 milligrams (mg), take one tablet twice daily with morning and evening medications for five days; -No order for supra pubic catheter, size, care or when to change the catheter. Review of the resident’s nurse’s notes, showed the following: -10/1/18, staff from the hospital called the facility to review the resident’s current medications and reported the resident was admitted with possible urosepsis (Infection in the bloodstream caused from urinary tract infection); -10/9/18, resident returned to the facility via emergency medical technicians on a stretcher, was admitted to hospital for urosepsis. Observation of the resident showed the following: -On 10/11/18 at 11:00 A.M. and 1:32 P.M., the resident lay in bed on his/her right side with catheter tubing stretched taut from under the blanket, to underneath a wheelchair, into a catheter privacy bag, with urine collected in the tubing unable to drain; -On 10/11/18 at 3:45 P.M., the resident sat in a wheelchair in his/her room with catheter tubing extended from the left pant leg to underneath the wheelchair, up and around, into the catheter drainage bag. The tubing contained urine unable to drain in to the bag; -On 10/12/18 at 12:16 P.M., the resident sat in a wheelchair at the dining room table and fed him/herself lunch and no catheter tubing or drainage bag hung on the wheelchair; -On 10/15/18 at 7:11 A.M., the resident lay in bed with the catheter drainage bag on the floor, not in a privacy bag. At 8:28 A.M., a certified nurse aide (CNA) said the resident wore a leg bag during the day; -On 10/16/18 at 6:58 A.M., the resident lay in bed with the catheter draining bag not contained in a privacy bag and the tubing extended from the resident, looped up and around, and into the drainage bag, with urine in the bottom of the loop, unable to drain into the bag; -On 10/16 at 12:41 P.M., the resident sat in the television area in a wheelchair with the catheter drainage bag contained in a privacy bag, and tubing came out of the pant leg, looped up into the bag, with urine in the tubing unable to drain; -On 10/17/18 at 7:33 a.M., the resident lay in bed with the catheter drainage bag on the floor, not in a privacy bag and tubing looped up and into the catheter drainage bag with urine in the tubing unable to drain. The drainage bag contained approximately 1200 cc’s of yellow urine. During an interview on 10/17/18, the Director of Nursing (DON) said there should be orders on the POS for the resident’s catheter, including size, and instructions for care and changing. The catheter drainage bag should be contained in a privacy bag and should never touch the floor, for infection control purposes. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
|||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
|||||||
NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0690
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
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F 0880
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
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: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
|||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
|||||||
NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
|||||||||
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) |
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F 0880
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 21) During an interview on 10/12/18 at 6:55 A.M., CNA A said it is important to wash your hands when completely finished with care and not necessary any other time. He/she added that if cleaning stool then gloves needed to be changed but not necessary to wash hands and added it is only necessary to wash hands when completed with care. 3. Review of Resident #63’s quarterly MDS dated [DATE], showed total dependence for toileting, personal hygiene, and total dependence for transfer from bed with [DIAGNOSES REDACTED]. Observation on 10/15/18 at approximately 7:10 A.M., showed CNA B providing peri care to the resident as he/she laid in bed. CNA B entered the resident’s room, washed his/her hands with soap and water in the resident’s sink, filled the basin with water, placed the basin on the bed side table and put on gloves. CNA A removed the resident’s urine soaked brief and placed it in the trash bag. With the same gloved hands, he/she placed one clean washcloth into the water basin, added soap onto the washcloth and began to cleanse the resident’s peri area. CNA B then rinsed the soiled wash cloth with gloved hands in the basin of water, used the same washcloth to cleanse the resident’s genitals. CNA B placed the same soiled washcloth in the basin of water and with same gloved hands, grabbed a dry towel and dried the resident’s peri area and genitals. With same gloved hands, CNA B turned the resident to his/her side and used the same soiled washcloth from the water filled basin and cleaned the resident’s backside. CNA B did not change his/her gloves nor wash his/her hands. CNA B then used the same dry towel to dry off the resident’s backside. CNA A then removed his/her gloves and washed his/her hands. He/she put on gloves and applied barrier cream to the resident’s peri area and applied a clean brief. With same gloved hands, CNA B placed a sheet on resident, gathered dirty linen in one hand, opened the resident’s privacy curtain, opened door and exited resident’s room. CNA A returned to the room with no gloves on and washed his/her hands. He/she took the basin of soiled water, to the resident’s sink and dumped it down the sink drain. During an interview on 10/15/18 at approximately 12:00 P.M., CNA B said he/she washed his/her hands with soap and water before and after peri care is provided. During an interview on 10/16/18 at 10:10 A.M., the Director of Nursing (DON) said when providing personal care to a resident it is important to wash their hands as often as possible and added, before providing care, after cleansing urine, after cleansing stool, before dressing a resident and before touching anything in the room. She said it is never permissible to cleanse a wound with a pre-moistened cloth especially with the same gloves that cleaned urine. 4. Observation on 10/12/18 at approximately 11:27 A.M., of the north fifth floor shower room, showed the following: -A large bathtub with a sign that read out of order: -Three trash bags of soiled linen in the bathtub; -A pair of soiled sweat pants and a soiled towel in the bathtub; -Three bags of trash on the ground. Observation on 10/15/18 at approximately 12:05 P.M., showed a bag of soiled linen in the bathtub of the north fifth floor shower room. During an interview on 10/15/17 at 11:27 A.M., CNA C said the north fifth floor shower room is not in use but staff does store dirty linen there. He/she added that linen should be in the dirty clothes hamper and trash belongs in a trash can not on the ground. 5. Observation on 10/11/18 at 3:17 P.M., of the laundry room, showed the following: -Four to five bags of clean bedding, in clear bags, on the ground under the laundry sorting table; -A large pile of soiled linen and clothes lay on the ground near the washing machines; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
|||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
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NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
|
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F 0880
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 22) -Laundry aide D sorted the dirty clothes on the ground. During an interview on 10/11/18 at 3:17 P.M., laundry aide D said, clothes and linen should not be on the ground. During an interview on 10/17/18 at 8:31 A.M., the DON and the administrator said, no laundry should be on the ground nor in the bathtub. Soiled laundry should be kept in a linen hamper and trash belongs in trash cans not on the ground. |
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F 0921
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 |
|||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265668 |
|
(X3) DATE SURVEY COMPLETED
10/17/2018 |
|||||||
NAME OF PROVIDER OF SUPPLIER
CARRIE ELLIGSON GIETNER HOME |
STREET ADDRESS, CITY, STATE, ZIP
5000 SOUTH BROADWAY |
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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) |
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F 0921
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
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F 0924
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Put firmly secured handrails on each side of hallways.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 10/17/18 at 8:30 A.M., the administrator said the hand rails are |
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