| 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: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 0570 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Assure the security of all personal funds of residents deposited with the facility. Based on interview and record review, the facility failed to maintain a surety bond, to | |
| F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and record review, the facility failed to provide a Skilled Nursing |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) -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 #192’s Skilled Nursing Facility Beneficiary Protection Notification Review, completed by facility staff on 1/17/19, showed the following: -Medicare Part A skilled services start date 9/17/18; -Last covered day of Medicare Part A service as 10/2/18; -Facility staff could not provide any documentation they issued the resident or his/her legal representative the SNFABN form CMS- , alternative denial letter, or a NOMNC form CMS- . 2. Record review of Resident #61’s Skilled Nursing Facility Beneficiary Protection Notification Review, completed by facility staff on 1/17/19, showed the following: -Medicare Part A skilled services start date 9/19/18; -Last covered day of Medicare Part A service as 12/7/18; -Facility staff could not provide any documentation they issued the resident or his/her legal representative the SNFABN form CMS- , alternative denial letter, or a NOMNC form CMS- . 3. Record review of Resident #127’s Skilled Nursing Facility Beneficiary Protection Notification Review, completed by facility staff on 1/17/19, showed the following: -Medicare Part A skilled services start date 10/22/18; -Last covered day of Medicare Part A service as 12/11/18; -Facility staff could not provide any documentation they issued the resident or his/her legal representative the SNFABN form CMS- , alternative denial letter, or a NOMNC form CMS- . 4. During an interview on 1/17/19 at 9:00 A.M., the administrator said the facility sent the beneficiary notification letters to the resident’s responsible party, but did not keep a copy of the letters and did not document they had sent the letters. The responsible parties did not return the forms. The administrator could not provide any documentation the letters were issued. | |
| 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 safe, clean, |
| 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: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) where the plaster was cracked, peeling, hung down and an approximate 6 inch by 6 inch area with the plaster missing; -The window blinds had approximately 21 slats bent or broken; -The base of the toilet had 2 bolts exposed and sticking upward approximately 3 inches. 2. Observation of Resident #123’s room on 1/17/19 at 11:39 A.M., 1/18/19 at 9:40 A.M., and 1/22/19 at 9:26 A.M., showed the heater/air conditioner with a hole in the protective boarder around the wall unit. The hole was approximately 2 inches by 2 inches in size. The cold air from the outside could be felt blowing into the resident’s room and the outside could be seen from the hole. The resident’s heater was set to 80 degrees Fahrenheit (F). During an interview on 1/18/19 at 9:40 A.M., the resident said he/she could feel the cold air blowing into the room from the hole in the protective boarder around the wall unit. 3. During an observation on 1/16/19 at 11:56 A.M., 1/17/19 at 12:17 P.M., and 1/18/19 at 10:00 A.M., showed Resident #2’s heater/air conditioner wall unit without a protective boarder on the left side with an opening of approximately 12 inches by 1 inch. The cold air from the outside could be felt blowing into the resident’s room. During an interview on 1/18/19 at 10:00 A.M., the resident said he/she could feel the cold air on the left side of the wall unit. His/her side of the room was closest to the wall unit, so his/her side of the room was cooler. During an interview on 1/22/19 at 9:26 A.M., the maintenance director said during the weekend, there was a problem with the resident’s wall unit. He noticed the wall unit needed a protective boarder. It was fixed and cold air was no longer blowing into the resident’s room. 4. During an observation on 1/16/19 at 9:52 A.M., 1/17/19 at 11:45 A.M., 1/18/19 at 2:06 P.M., and 1/22/19 at 9:35 A.M., showed several brown stains on Resident #27’s ceiling that covered part of his/her side of the room. During an interview on 1/16/19 at 9:52 A.M., the resident said he/she did not know what the brown stains on the ceiling were, but they had been there since he/she moved in. He/she did not feel like his/her room was a homelike environment. 5. During an interview on 1/18/19 at 12:34 P.M., Nurse J showed forms in a box by the door leading from the hallways to the lobby and said whenever staff identify anything that needs to be repaired, they fill out the form and then maintenance picks up the completed form from the box. 6. During an interview on 1/22/19 at 9:26 A.M., the maintenance supervisor said the head of each department complete rounds and turn in the sheets to maintenance every day. If there are repairs that needed to be completed then a work order is filled out. He would expect staff to check the wall units in the resident’s room to ensure the protective boarder is intact. He was not aware of the damaged protective boarder. He would expect staff report any damage or stains to the walls and ceilings in the resident’s room. 7. During an interview on 1/22/19 at 10:39 A.M., the administrator said rounds are completed seven days a week, and the head of the department complete the rounds Monday through Friday. If there are any repairs that are needed, they are expected to fill out a work order. She would expect staff to ensure there is a protective boarder around the resident’s wall unit to ensure cold air is not blowing into the room. | |
| F 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement policies and procedures to prevent abuse, neglect, and theft. |
| 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: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) Based on interview and record review, the facility failed to complete the required criminal background checks (CBC), employee disqualification list (EDL, a listing maintained by the Department of Health and Senior Services, of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident) checks and nurse aide (NA) registry check for federal indicators (FI, an indicator applied to the certification for any certified nursing assistant (CNA) found guilty of Abuse, Neglect, or Misappropriation of property). Of 10 employee files reviewed, issues were identified with six. The census was 138. Review of the facility’s Abuse, Neglect and Grievance procedures, revised (MONTH) 28, (YEAR), showed: -Potential employees are screened for a history of abuse, neglect, mistreating of residents. For details on the employee screening. See the Screening- Applicant, Employee, Volunteer and Vendor Policy and Procedure. Review of the facility’s Screening- Applicant, Employee, Volunteer and Vendor Policy and Procedure, dated 3/1/14, showed: -Purpose: To establish a written procedure for applicant, employee, volunteer and vendor background checks and screening. -Pre-Employment Screening: -Company Human Resources (HR) will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any federal or state healthcare programs, is eligible to work in the United States and, if applicable, is duly licensed or certified to perform the duties of the position for which they applied; -Procedure: HR staff will conduct the following screens on potential employees prior to hire: -A. Criminal history. No applicant may be hired if they have been convicted of, pled guilty or nolo contendere to a crime which under Missouri law would be a class A or B felony in violation of Missouri codes; -B. Federal Exclusion List. If the results indicates that the applicant is excluded, they cannot be hired; -C. Licensure. If an applicant has any restrictions on their license, that restriction must be shared with the RCMC Executive Director, Human Resources and the RCMC Chief Compliance Officer for review before the applicant can be hired; -D. Family Care Safety Registry (FCSR). This screening will check the sex offender, employee disqualification list and other Missouri databases automatically. Registration and background check must be completed before the applicant can begin work; -E. CNA Registry. The CNA Registry must be checked for all applicants regardless of the position for which they are applying. Any applicants listed with background problems or with an inactive or suspended CNA license will not be hired; -AUDIT: RCMC HR staff will periodically, but not less than annually, review a sample of employee background check files to ensure the Company HR staff has conducted the background checks listed in this policy. 1. Review Laundry Aide B’s employee file, showed: -Date of hire, 11/15/18; -CBC requested 1/17/19, no documentation the results received; -EDL check completed 1/17/19; -NA registry check completed 1/17/19. 2. Review of CNA C’s employee file, showed: -Date of hire, 4/5/18; |
| 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: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) -Date of separation, 4/11/18; -CBC requested 7/15/18, and the results received 7/17/18; -No documentation the EDL check completed; -NA registry check completed 7/15/18. 3. Review of CNA D’s employee file, showed: -Date of hire, 6/7/18; -EDL check completed 6/5/18; -No documentation the CBC requested or received; -No documentation the NA registry check completed. 4. Review of Licensed Practical Nurse (LPN) E’s employee file, showed: -Date of hire, 7/30/18; -CBC requested 8/31/18, and the results received 8/31/18; -EDL check completed 8/31/18; -NA registry check completed 8/31/18. 5. Review of LPN F’s employee file, showed: -Date of hire, 11/27/18; -CBC requested 1/17/19, and the results received 1/17/19; -EDL check completed 1/17/19; -NA registry check completed 1/17/19. 6. Review of the Assistant Director of Nursing (ADON’s) employee file, showed: -Date of hire, 10/11/18; -CBC requested 1/17/19, and the results received 1/17/19; -EDL check completed 1/17/19; -NA registry check completed 1/17/19. 7. During an interview on 1/17/19 at 11:45 A.M., the Human Resource (HR) Director she knew there were some employees that had their background, EDL and FI checks completed, but she was unable to locate them, so she ran them again. She would expect background, EDL and FI checks to be completed per facility policy. | |
| F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) -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 or the resident’s representative received written notice upon the emergency transfers. 3. Review of Resident #144’s medical record, showed: -Transferred to the hospital on [DATE]; -Returned to the facility on [DATE]; -No documentation the resident and/or the representative was provided a notice upon the emergency transfer. 4. Review of Resident #14’s medical record, showed: -Transferred to the hospital on [DATE]; -Returned to facility from the hospital on [DATE]; -No documentation the resident and/or the representative was provided a notice upon the emergency transfer. 5. Review of Resident #111’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 or the resident’s representative received written notice upon the emergency transfers. 6. Review of Resident #128’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]; -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. 7. Review of Resident #61’s medical record, showed: -Transferred to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative received a written transfer notice upon the emergency transfer. 8. 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]; -No documentation the resident and/or the representative received a written transfer notice upon the emergency transfers. 9. Review of Resident #106’s medical record, showed: -Transferred to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident or the resident’s representative received written notice upon the emergency transfers. 10. Review of Resident #127’s medical record, showed: |
| 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: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) -Transferred to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative received a written transfer notice upon the emergency transfer. 11. During an interview on 1/18/19 at 10:35 A.M., Nurse I said when a resident is sent to the hospital, a copy of their face sheet, current physician order [REDACTED]. Nursing does not issue any transfer notice to the resident and/or their representative when the resident is transferred to the hospital with a return anticipated. 12. During an interview on 1/22/19 at 7:48 A.M., the Director of Nurses (DON) said the nurses are responsible for issuing the discharge letter to the resident upon an emergency transfer to the hospital with a return anticipated. This should be documented in the nurses’ notes. They had not been issuing the transfer notices as required. 13. During an interview on 1/22/19 at 8:03 A.M., the administrator said she was unaware of the regulation to issue a written transfer notices to the resident upon an emergency transfer to the hospital and they had not been issued as required. | |
| F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) -Returned to the facility from the hospital on [DATE]; -No documentation the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfers. 5. Review of Resident #128’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]; -No documentation the resident and/or the representative received information in writing of the facility’s bed hold policy at the time of transfers. 6. Review of Resident #61’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 information in writing of the facility’s bed hold policy at the time of transfer. 7. Review of Resident #106’s medical record, showed: -Discharge to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfers. 8. Review of Resident #127’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 information in writing of the facility’s bed hold policy at the time of transfer. 9. During an interview on 1/22/19 at 7:48 A.M., the Director of Nurses (DON) said the nurses are responsible for issuing the bed hold policy to the resident upon an emergency discharge to the hospital with a return anticipated. This should be documented in the nurses notes. They had not been documenting the bed hold policy had been issued and they should document in the nurses notes. 10. During an interview on 1/22/19 at 8:03 A.M., the Administrator said they have been giving the bed hold policy to the residents upon emergency discharge to the hospital with a return anticipated, but could not provide any documentation. | |
| 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 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 8) 1. Review of Resident #14’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/28/18, showed: -[DIAGNOSES REDACTED]. -Cognitively impaired with short and long term memory problems; -Incontinent of bowel and bladder; -Required total assistance from the staff for transfers, dressing, eating, hygiene and bathing. Observation on 1/17/19 at 7:20 A.M., showed the resident lay in bed. Certified Nurse Assistant (CNA) K brought equipment into the resident’s room, told the resident what he/she was going to do, washed his/her hands, put on gloves, filled a wash basin with water and changed his/her gloves. CNA K placed a clean washcloth in the wash basin, squeezed shampoo and body wash into the wash basin and washed the resident’s perineal area and genitals. Soap was visible on the resident’s skin. Without rinsing the soap off of the skin, he/she dried the resident’s perineal area and turned the resident onto his/her right side. CNA K changed the soapy water in the wash basin and changed his/her gloves. CNA K placed a clean wash cloth in the clean water, squeezed shampoo and body wash into the wash basin, washed the resident’s left hip, buttock, back of thigh and rectal area, dried the areas, turned the resident onto his/her left side, washed and dried the resident’s right hip, buttocks and back of thigh. Soap was visible on the resident’s skin. CNA K placed a clean brief on the resident and dressed the resident. At 7:56 A.M., CNA L came into the room and assisted CNA K to transfer the resident into his/her wheelchair. At 7:58 A.M., CNA L took the resident to the main dining room. CNA K did not rinse the soap off of the resident’s skin prior to dressing or transferring him/her into his/her wheelchair. Observation of the shampoo and body wash bottle, showed directions to rinse the soap off the skin. During an interview on 1/18/19 at 2:30 P.M., the Director of Nurses (DON) said she would expect staff to rinse the soap off the resident’s skin to prevent skin breakdown and infections. | |
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/12/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) -A Physician order [REDACTED]. -A Nurse’s note, dated 11/28/18, showed restorative nursing orders received; -A POS for (MONTH) 2019, showed an undated order for restorative as follows: -RNP three times a week for bilateral (both sides) upper extremity exercises; -RNP three times a week bilateral therapeutic exercise with three pound (lb.) weights for 15 repetitions standing or bilateral leg bike for 15 minutes; -Skilled PT four times a week for four weeks; -Skilled occupational therapy four times a week for four weeks; -A care plan, updated on 1/17/19, as follows: -Resident discharged from skilled therapy services and referred to RNP; -Passive range of motion/stretching to bilateral knees/hamstrings for 10 repetitions and sit to stand with bilateral upper extremity support as tolerated, three times a week to maintain bilateral lower extremity range of motion and sit to stand as tolerated; -Bilateral upper extremity exercise for 20 repetitions. Two lb. dumbbells and hand gripper for 50 repetitions twice a week to maintain bilateral upper extremity range of motion and muscle strength for activities of daily living. During an interview on 1/16/19 at 11:37 A.M., the resident said he/she should have been receiving restorative therapy, but the restorative aides were too busy to get to him/her. During an interview on 1/22/19 at 8:23 A.M., Restorative Aide (RA) G said restorative is provided to residents in the program twice a week. The resident was on his/her caseload in the past, but could not recall the last time he/she had seen the resident for therapy. At 8:40 A.M., RA G pulled his/her notes regarding the resident and said he/she had begun restorative with the resident once since the resident had been referred to the program in (MONTH) (YEAR). Restorative services were not provided in (MONTH) (YEAR) or (MONTH) 2019 by either of the RAs. During an interview on 1/22/19 at 10:57 A.M., the Director of Nursing (DON) said it is expected for restorative orders to be followed. Nursing is ultimately responsible for ensuring restorative services are provided as ordered. It is important to ensure restorative is provided as ordered in order to maintain a resident’s mobility and range of motion. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, |
| 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: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 10) -Test the water temperature level, must be at 120 degrees Fahrenheit (F); -Test the chlorine and chemical test strip, must be at 50 parts per million (ppm); -At the end of the service the machine must be cleaned and delimed for the next day service; -If the temperature and the chlorine level are not at the correct setting please inform the manager so that the repair person can be called out; -This must happen before and after every meal service; -At no time will the dishes be washed if these steps have not been followed. During an observation and interview on 1/16/19 at 9:20 A.M., Dietary Aide H used the dish machine to sanitize the dishes that were used during meal service. Dietary Aide H said the dish machine used chemical and hot water temperature to sanitize the dishes. The machine was tested daily with the use of a strip. He/she ran the dish machine and placed a test strip inside the water that flowed out of the dish machine during the test cycle. The test strip immediately turned light purple. He/she matched the test strip with the color tube. He/she confirmed that the light purple test strip indicated it was 10 ppm. He/she ran a second cycle and used a new test strip. The test strip turned light purple. He/she confirmed that the second strip was 10 ppm. He/she said he/she did not know what range the sanitizer should be or where to find the information on the dish machine. Dietary Aide H said he/she could check the temperature by looking at the temperature gauge on the machine. The temperature on the gauge showed 120 degrees F. He/she said staff only used the gauge to check the temperature. There were no test strips or a thermometer. He/she confirmed that if the sanitizer was low, he/she would get the dish machine serviced. Further observation, showed a label on the front of the dish machine that showed the sanitizer should be at least 50 ppm. During an interview on 1/16/19 at 9:30 A.M., the dietary manager said they have had the dish machine serviced three times because it was not properly sanitizing the dishes. 2. During an observation of the ice machine in the kitchen, showed: -On 1/16/19 at 9:10 A.M., a collection of water inside the drain. The ice machine drain pipe inside the drain and touched the water; -On 1/17/19 at 10:50 A.M., 1/18/19 at 2:11 P.M., and 1/22/19 at 9:51 A.M., there was no longer water build up inside the drain; however, water could be seen running out of the pipe into the drain. The pipe lay directly inside the drain. 3. Observation of the inside of the walk-in cooler, showed: -On 1/17/19 at 10:50 A.M., water dripped from four different areas of the ceiling on the left side of the walk-in cooler. Water dripped onto the covered food. There was frost build up along the bottom part of the door to the entrance of the walk-in freezer; -On 1/18/19 at 2:11 P.M., there was frost build up along the bottom part of the door to the entrance of the walk-in freezer; -On 1/2/19 at 9:51 A.M., icicles approximately 2 inches formed on the ceiling on the left side of the walk-in cooler. There was frost build up along the bottom part of the door to the entrance of the walk-in freezer. 4. During an interview on 1/22/19 at 10:12 A.M., the dietary manager said she was not aware of the need of an air gap from the ice machine pipe to drain; however, it was problematic if the water traveled up the pipe. It would contaminate the ice. She would expect staff to test the sanitizer of the dish machine before and after meal service. The test strip should read 50 ppm. She would expect staff to know that the strip should read 50 ppm and to not use the dish machine if the sanitizer was less than 50 ppm. The dish machine sanitize chemically, not with a hot water temperature. She would expect staff to know that information. She was aware of the frost build up on the bottom of the door as |
| 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: 265823 |
| (X3) DATE SURVEY COMPLETED 01/22/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER CRESTWOOD HEALTH CARE CENTER, LLC | STREET ADDRESS, CITY, STATE, ZIP 11400 MEHL AVENUE | |||||||||
| 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 11) well as the water leaking from the ceiling. Water should not leak inside the walk-in cooler because it could cause cross contamination to the food. | |
| F 0914 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide bedrooms that don’t allow residents to see each other when privacy is needed. Based on observation and interview, the facility failed to ensure curtains were placed in | |
