| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) He/She would rather not wear the aprons, but that is the way it is. 5. Review of Resident #29’s quarterly MDS, dated [DATE], showed the following: -admission date of [DATE]; -Understood, understands; -BIMS of 14 out of 15, cognitively intact; -No behaviors; -Independent in all ADLs; -No impairments in ROM in upper or lower extremities; -Does not use mobility devices; -[DIAGNOSES REDACTED]. -Current tobacco use not marked yes or no. Review of the resident’s Smoking Assessment, dated 7/19/18, showed he/she is a safe smoker. During an interview on 7/20/18 at 5:15 P.M., the resident said he/she does not like to wear the smoking apron, and he/she does not think he/she should have to wear it. 6. During an interview on 7/20/18 at 1:45 P.M. Laundry Aide C said all residents who smoke must wear an apron and it is not based on any evaluation. He/She said everyone wears one so no one feels pointed out. The aide said the apron protects the residents in case they fall asleep or accidentally drop the cigarette. He/She said Residents #26 and #29 are independent and able to do everything for themselves so it is not really necessary for them to wear one, but they do. 7. During an interview on 7/20/18, at 7:00 P.M., the administrator said all residents are required to wear a smoking apron. | |
| 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, facility staff failed to provide the resident |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0565 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) administrator gave her and residents’ concerns are written on the second page under the section titled New Business. The staffs’ responses to the residents’ concerns for the previous month are recorded on the front page of the form under Old Business. He/She talks to different departments about the residents’ concerns, but what he/she writes on the form does not address each of the concerns. He/She said the notes simply restate the residents’ concerns from the previous month. He/she said he/she did not know he/she needed to address each concern in writing for the residents. The AD said facility staff have not responded to any of the residents’ concerns in writing, to include actions taken or rationale. 4. During an interview on 7/20/18, at 5:26 P.M., the administrator said resident council members should receive follow up information from their concerns. He/She said the facility staff need to make sure they communicate more clearly to the resident council. | |
| 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Review of Resident #18’s quarterly Minimum Data Set (MDS), a federally mandated 2. Review of Resident #39’s quarterly MDS, dated [DATE], showed the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0567 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) said she does not keep petty cash at the facility, because she does not have a safe. She has a locked closet and does not feel that is secure to hold the resident’s money. When a resident requests petty cash, she goes to the bank and withdraws it and tries to withdraw money on the same day the resident requests it. She said she is not able to give residents their money right on the spot, if a resident needs money immediately, then she cannot do that. She said she typically goes to the bank around noon and residents who request money after noon, have to wait until the next day to get their money, even if it is less than $50. She is the only facility staff person that can withdraw resident money and if she is not at the facility, the residents do not get money until she returns. The residents cannot get money while she is on vacation. 6. During an interview on 7/20/18 at 2:30 P.M., the bookkeeper said the corporate office staff put together the current admission packet. She said she reviews the section labeled Financial Section with new residents and/or their responsible party. She explains the form as authorizing deposits into the resident’s account, not as having money on hand at the facility. The Authorization for Resident Fund Petty Cash on Hand form is part of the current admission packet, but the form does not apply to everyone. If someone insisted that they have petty cash, then she would do it, she would just have to go out and get a lock box. She said it is her personal preference not to have petty cash at the facility. | |
| 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) 3. Observation on 7/17/18, at 11:12 A.M., showed the wall behind both resident’s beds in room [ROOM NUMBER] with missing paint and the outlet by the beds with the dry wall cut, and the sheet rock exposed. Additional observation showed the paint around the soap dispenser. 4. Observation on 7/17/18, at 11:14 A.M., showed an unpainted and unfinished piece of ply wood attached to the wall by the resident’s bed in room [ROOM NUMBER] B. 5. Observation on 7/17/18 at 11:15 A.M., showed gouges and scratches in the bathroom door of resident room [ROOM NUMBER] and 402, and in the room door of 400, 401, and 402. 6. Observation on 7/17/18, at 11:18 A.M., showed in room [ROOM NUMBER]/310, the bathroom with chips in the paint on the door frame, exposed brown tape around the soap dispenser, and the wall across from toilet with long discolored rub marks in the wall with breaks in the paint. 7. Observation on 7/17/18, at 11:26 A.M., showed in room [ROOM NUMBER]/311, the bathroom contained deep gouges in the wall next to the sink. 8. Observation on 07/17/18 at 3:48 PM, showed the room door and bathroom door of resident room [ROOM NUMBER] contained multiple gouges and scratches in the paint and wood, and the vanity contained a large section of missing trim from the front area near the sink. 9. Observation on 7/19/18, at 11:45 A.M., showed in room [ROOM NUMBER] A, the nightstand/dresser with chips in the wood exposing the raw ply wood on the top corner and the front. 10. During an interview on 7/19/18, at 11:45 A.M., certified nurse assistant (CNA) B said there is a maintenance log where they document the repairs needed like light bulbs, or something that is broken. He/She said the staff do not usually put painting needs or furniture damage in the log unless it needs to be fixed right away. During an interview on 7/27/18, at 2:52 P.M., the maintenance director said staff are expected to put repairs needed on the maintenance log and let him/her know what repairs need to be done. He/She said he/she put up the ply wood in 307 a couple of months ago, until he/she could get a hole in the wall patched and has not gotten back to it. He/She said he/she does an environmental walk through to look for areas that need to be painted or repaired every two weeks or so, but he/she does not get to address all the needs right away because he/she has to prioritize. During an interview on 7/20/18, at 5:26 P.M., the administrator said that there is a maintenance repair log at the nurses station for staff to communicate with the maintenance director what is needed. He/She said the maintenance director is expected to do environmental rounds to look for painting and minor repairs. | |
| F 0620 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0620 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 5) – admission date of [DATE]; – Sometimes understood, usually understands; – Moderately impaired cognition, decisions are poor, supervision required; – [DIAGNOSES REDACTED]. Review of the resident’s Consents and Authorizations form, showed the following: -The resident agreed for the facility to maintain his/her personal laundry, understood commercial grade equipment is used for laundering, and released the facility from any responsibility for damage to personal clothing; -The resident agreed for the facility to provide basic cable television service, but released the facility from any responsibility for damage to the personal television set as a result of the television cable installation and connection; -Signed by the responsible party; -Dated 4/3/15. 2. Review of Resident # 15’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Understood, understands; – BIMS score of 12 out of 15, moderate cognitive impairment; – [DIAGNOSES REDACTED]. Review of the resident’s Non-Liability Statement for Personal Property showed the following: – The resident waived the facility’s responsibility for personal items brought into the facility which were lost or damaged while residing at the facility; – Signed by the responsible party; – Dated 5/18/15. 3. Review of Resident #17’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Usually understood, sometimes understands; – Severe cognitive impairment; – [DIAGNOSES REDACTED]. Review of the resident’s Personal Laundry Agreement form, showed the following: – The resident agreed for the facility to maintain his/her personal laundry, understood commercial grade equipment is used for laundering, and released the facility from any responsibility for damage to personal clothing; – Signed by the Power of Attorney; – Dated 8/4/17. Review of the resident’s Cable/Satellite Services form, showed the following: – The resident authorized payment for the facility to provide basic cable television service, but released the facility from any responsibility for damage to the personal television set as a result of the television cable installation and connection; – Signed by the Power of Attorney; – Dated 8/4/17. 4. Review of Resident #34’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Usually understood, usually understands; – BIMS score of 7 out of 15, severe cognitive impairment; – [DIAGNOSES REDACTED]. Review of the resident’s Consents and Authorizations form, showed the following: -The resident agreed for the facility to maintain his/her personal laundry, understood commercial grade equipment is used for laundering, and released the facility from any |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0620 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 6) responsibility for damage to personal clothing; -The resident agreed for the facility to provide basic cable television service, but released the facility from any responsibility for damage to the personal television set as a result of the television cable installation and connection; -Signed by the responsible party; -Dated 12/6/17. Review of the resident’s Personal Laundry Agreement form, showed the following: – The resident agreed for the facility to maintain his/her personal laundry, understood commercial grade equipment is used for laundering, and released the facility from any responsibility for damage to personal clothing; – Signed by the responsible party; – Dated 12/7/17. Review of the resident’s Cable/Satellite Services form, showed the following: – The resident authorized payment for the facility to provide basic cable television service, but released the facility from any responsibility for damage to the personal television set as a result of the television cable installation and connection; – Signed by the responsible party; – Dated 12/7/17. 5. Review of Resident #39’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Understood, understands; – BIMS score of 15 out of 15, cognitively intact; – [DIAGNOSES REDACTED]. Review of the resident’s Personal Laundry Agreement form, showed the following: – The resident agreed for the facility to maintain his/her personal laundry, understood commercial grade equipment is used for laundering, and released the facility from any responsibility for damage to personal clothing; – Signed by the resident; – Dated 3/16/18. Review of the resident’s Cable/Satellite Services form, showed the following: – The resident authorized payment for the facility to provide basic cable television service, but released the facility from any responsibility for damage to the personal television set as a result of the television cable installation and connection; – Signed by the resident; – Dated 3/16/18. 6. Review of Resident #51’s annual MDS, dated [DATE], showed the following: – admission date of [DATE]; – Understood, understands; – BIMS score of 14 out of 15, cognitively intact; – [DIAGNOSES REDACTED]. Review of the resident’s Cable/Satellite Services form, showed the following: – The resident authorized payment for the facility to provide basic cable television service, but released the facility from any responsibility for damage to the personal television set as a result of the television cable installation and connection; – Signed by the resident – Not dated. The resident agreed for the facility to maintain his/her personal laundry, understood commercial grade equipment is used for laundering, and released the facility from any responsibility for damage to personal clothing; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0620 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 7) -The resident agreed for the facility to provide basic cable television service, but released the facility from any responsibility for damage to the personal television set as a result of the television cable installation and connection. 7. Review of the facility’s Personal Laundry Agreement form, showed the resident could agree for the facility to maintain his/her personal laundry, understood commercial grade equipment is used for laundering, and released the facility from any responsibility for damage to personal clothing. 8. Review of the facility’s Cable/Satellite Services form, showed the resident authorizes payment for the facility to provide basic cable television service, but releases the facility from any responsibility for damage to the personal television set as a result of the television cable installation and connection. 9. Review of the facility’s Non-Liability Statement for Personal Property showed the resident waived the facility’s responsibility for personal items brought into the facility which were lost or damaged while residing at the facility. 10. During an interview on 7/20/18 at 2:15 P.M., the Social Worker said he has worked as the social worker at the facility for [AGE] years. He is responsible for reviewing the admission packet with the new residents and/or the responsible party. The current admission packet was put together by the corporate office staff. He reviews the section labeled Social Services Section. The Consents and Authorization page is part of the current admission packet. It is a corporate policy. The third paragraph discusses the facility doing the resident’s laundry. This paragraph asks the resident to release the facility from any responsibility for damage to personal clothing. He does not know why it asks the residents to waive responsibility. He would expect the staff to provide reasonable care for the resident’s laundry. He is not sure if the items would be replaced if lost or damaged as this is handled by the business office. The fourth paragraph discusses the facility providing basic cable television service. This paragraph asks the resident to release the facility from any responsibility for damage to the personal television set as a result of the television cable installation and connection. That section is not relevant to their residents, because the facility provides basic cable to the resident. The form does ask the resident to waive the facility’s responsibility if anything would happen to the television due to the basic cable service. He was not aware the resident’s could not be asked to waive the facility’s responsibility for their personal belongings. He does not know why this was put into the admission packet. During an interview on 7/20/18 at 2:30 P.M. the Business Office Manager said the current admission packet was put together by corporate office staff. She reviews the section labeled Financial Section with the new residents and/or responsible party. The Consents and Authorization page is part of the current admission packet, but it is part of the Social Services section. She does not review it with the residents. Her section does have some forms which basically say the same thing as the Consents and Authorization form. The Cable/Satellite Services form asks the resident to waive the facility’s responsibility for damage to their television as a result of the cable or satellite installation or connection. The facility will not be responsible for the resident’s television due to wiring, lightning strikes, or anything of that nature. She was told by management that the facility does not cover those losses. The Personal Laundry Agreement asks the resident to waive the facility’s responsibility for loss or damage of the resident’s personal belongings during the laundering process. She is not sure why the form asks the resident to waive the responsibility, because the facility usually does replace clothing that is lost or damaged. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0620 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | ||
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) bathing; -Functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot). The MDS did not contain Restorative Nursing minutes or oxygen use. Review of the Nurse’s notes, dated 5/21/2018, showed staff documented the resident’s portable oxygen was empty. The resident’s oxygen level is 70% on room air. Administered a [MEDICATION NAME] (medicated aerosol treatment) breathing treatment as per physician’s orders [REDACTED]. A concentrator for the resident has been ordered, waiting for delivery. Review of the resident’s Nurse’s notes, dated 5/31/2018, showed staff documented the resident’s oxygen saturation was 80% on room air. This nurse administered a scheduled breathing treatment and resident’s oxygen saturation stabilized at 95% on 2 L/NC. Review of the resident’s Nurse’s notes, dated 6/07/2018, showed staff documented the resident had shortness of breath and decreasing oxygen saturation when not on oxygen. Review of the resident’s Nurse’s notes, dated 6/11/2018, showed staff documented the resident had oxygen at 2 L, and oxygen saturation at 95%. Review of the resident’s physician’s orders [REDACTED]. Review of the resident’s Care Plan, last updated 6/26/18, did not contain directions to staff related to the resident’s limited range of motion or oxygen use. Staff did not develop a comprehensive person centered care plan, including measurable objectives and timeframes to address the resident’s limited range of motion or oxygen use. 2. Review of Resident #34’s admission Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 12/19/17, showed staff assessed the resident as follows: -Indwelling catheter (tube inserted into the bladder to drain urine); -Urinary incontinence not rated, resident had a catheter in place during the entire lookback period; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, last updated 1/25/18, showed staff are directed: -[DIAGNOSES REDACTED]. -Resident experiences bladder incontinence at times; -Ask the resident if he/she needs to use the bathroom on a routine basis. Additional review showed staff did not document any interventions, goals, or objectives related to the resident’s urinary catheter. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Indwelling catheter; -Urinary incontinence not rated, resident had a catheter in place during the entire lookback period; -[DIAGNOSES REDACTED]. Review of the resident’s physician’s orders [REDACTED]. Review of the resident’s nurse’s notes dated 7/8/18, showed staff documented the resident’s foley catheter was leaking urine. Staff documented they removed the catheter and replaced it. Observation on 7/19/18 at 10:09 A.M. showed the resident in his/her room in a wheelchair with a cather in place. Observation on 7/19/18 at 11:47 A.M. showed the resident in his/her room with a catheter in place. Staff did not develop a comprehensive person centered care plan, including measurable objectives and timeframes to address the resident’s urinary catheter. 3. 10. Review of Resident #206’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) -Did not display behaviors or reject care; -Dependent on two or more staff for transfers and bathing; -Required extensive assistance of two or more staff for bed mobility, dressing, toilet use, and personal hygiene; -Required extensive assistance of one staff for eating. Review of the facility’s restorative nursing documentation for (MONTH) and (MONTH) (YEAR), showed staff did not provide restorative nursing services to the resident. Review of the resident’s care plan, last updated 7/19/18, showed staff are directed: -The resident requires assistance with all activities of daily living (ADLs); -Requires hoyer lift (mechanical lift) for transfers. Additional review showed the care plan did not provide any direction to staff related to the resident’s mobility, contractures, or need for restorative nursing services. Observation on 7/18/18 at 4:22 P.M., showed the resident with contracted hands. Observation and interview on 7/19/18 at 9:35 A.M., showed CNA F and CNA B transferred the resident into bed from his/her wheelchair with the hoyer lift. Observation showed the resident with contracted knees. CNA F said he/she does not think staff provide any restorative services to the resident. Staff did not develop a comprehensive person centered care plan, including measurable objectives and timeframes to address the resident’s contractures. 4. During an interview on 7/20/18 at 7:36 P.M., the MDS Coordinator said staff update the care plans on Tuesdays with preferences, weight loss, medication changes, behaviors, and falls. He/She also said if resident information related to care is not in the care plan he/she must have missed it. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to revise or |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) implement necessary assessment, care planning, and clinical interventions, even though an MDS assessment is not required. -Residents’ preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. 2. The facility did not have a policy to direct staff on revisions and updates of resident care plans. 3. Review of Resident # 15’s care plan, last reviewed on 9/18/17, showed the following: – Problem start date: 7/23/17; – Problem: The resident has a history of falls; – Goal: The resident will remain free from injury through the next review; – Approach: Staff to give resident verbal reminders not to ambulate or transfer without assistance; – No updates for falls on 3/25/18, 5/25/18, 5/30/18, and 7/2/18. Review of the resident’s progress notes, dated 3/25/18, showed staff documented at 1:33 A.M., the resident observed on the floor in front of his/her bed. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 5/14/18, showed the following: – admission date of [DATE]; – BIMS score of 12 out of 15, moderate cognitive impairment; – Required limited assistance with bed mobility, locomotion on and off unit; – Required extensive assistance with transfers, dressing, toilet use, and personal hygiene; – [DIAGNOSES REDACTED]. – No falls since admission. Review of the resident’s progress notes, dated 5/25/18, showed staff documented at 8:15 A.M., the nurse was alerted to resident’s room due to the fact that he/she was on the floor. The nurse approached the resident, and he/she was sitting on the floor next to his/her bathroom. The resident stated that he was attempting to transfer himself/herself from the toilet to the wheelchair. The resident missed the wheelchair and landed on the floor. Review of the resident’s progress notes, dated 5/30/18, showed staff documented at 9:33 A.M., the resident in his/her wheelchair in the dining room and slid out of his/her wheelchair. Unwitnessed fall. Review of the resident’s progress notes, dated 7//2/18, showed staff documented at 11:59 A.M., the resident had no signs of injury from fall earlier today. Staff did not update the resident’s care plan with revisions related to the resident’s repeated falls, or document review of the current interventions. 4. Review of Resident #19’s quarterly MDS, dated ,[DATE] /18, showed the staff assessed the resident as: -Severe cognitive impairment; -Limited physical assistance of one staff member for eating, toilet use, hygiene; -Dependent with one staff for bathing; -No falls since last assessment. Review of the resident’s Care Plan, last updated 2/28/18, directed staff to: -Resident at risk for falling; -Staff to Provide toileting assistance; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 12) -Staff to keep room free of clutter; -Staff to keep floors dry; -Staff to keep frequently used items within reach; -Staff to monitor resident for fatigue; -Staff to notify physician and guardian of any falls/injuries. The care plan did not contain updates or reevaluation of interventions after the resident fell on [DATE], 4/30/18, and 7/8/18. Review of the resident’s Nurses Notes, dated 3/29/2018, showed staff documented staff found the resident on the floor in front of his/her bed. Review of the resident’s Nurses Notes, dated 4/30/2018, showed staff documented the resident slid out of his/her shoes falling backward and hit the back of his/her head on the floor. Resident complained of pain in the back right side of his/her head and right hip pain. The resident is increasingly lethargic and struggling to keep his eyes open. The physician sending the resident to the emergency room . Review of the resident’s quarterly MDS, dated ,[DATE] /18, showed the staff assessed the resident as: -Severe cognitive impairment; -Limited physical assistance of one staff member for eating, toilet use, hygiene; -Dependent with one staff for bathing; -No falls since last assessment. The assessment did not contain the resident’s falls from 3/29/18 and 4/30/18. Review of the resident’s Nurses Notes, dated 7/9/18, showed the staff documented the resident fell on [DATE]. Observation on 7/18/18, at 3:44 PM, showed the resident ambulating without devices. Observation showed the resident’s gait unsteady and the resident stumbled. The resident’s care plan did not contain documentation to show the interventions were reviewed or updated after the resident’s falls. 5. Review of Resident #42’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Always incontinent of urine; -Did not have a urinary tract infection in the last 30 days before the assessment; -Required extensive assistance of two or more staff for toileting and personal hygiene. Review of the resident’s nurses’ notes, dated 4/2/18, showed staff documented new orders for [MEDICATION NAME] (antibiotic) 875 mg by mouth twice daily along with acidophilus ([MEDICATION NAME]) tablets daily for UTI, will end 4/12/18. Review of the resident’s nurses’ notes, dated 6/16/18, showed staff documented resident currently on Bactrim (antibiotic) for UTI. Review of the resident’s nurses’ notes, dated 6/24/18, showed staff documented resident currently on Bactrim for UTI. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Always incontinent of urine; -Did not have a urinary tract infection in the last 30 days before the assessment; -Required extensive assistance of two or more staff for toilet use, and personal hygiene. Review of the resident’s physician’s orders [REDACTED]. Review of the resident’s nurses’ notes, dated 7/8/18, showed staff documented this nurse contacted the physician’s office and reported the resident’s labwork, including urinalysis. New orders to start AZO (supplement to treat urinary tract infection symptoms) |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 13) three times daily for five days if resident is symptomatic. Review of the resident’s care plan, last updated on 7/16/18, showed staff did not provide any direction or interventions related to the resident’s frequent urinary tract infections. Staff did not revise the resident’s care plan to include any goals, interventions, or direction to staff for monitoring of the resident’s frequent urinary tract infections. 6. Review of Resident #51’s care plan, last reviewed on 1/28/18, showed the following: – Problem start date: 1/28/18; – Problem: Resident is at risk for falling; – Goal: Resident will remain free from injury; – Approach: Staff to give resident verbal reminders not to ambulate or transfer without assistance; – No update for fall on 3/8/18. Review of the resident’s progress notes showed staff documented on 3/8/18 at 7:45 P.M., the nurse heard a loud noise and found resident lying on the floor of his/her room, near air conditioning unit, on his/her back with head up, knees toward chest. Wheel chair near bed and nightstand. Resident said he/she was trying to get into his/her bed when he/she fell . Review of the resident’s annual MDS, dated [DATE], showed the following: -admission date of [DATE]; – BIMS score of 14 out of 15, cognitively intact; – Required limited assistance with transfers, dressing, toilet use, and personal hygiene; – [DIAGNOSES REDACTED]. – No falls since admission. Staff did not update the resident’s care plan to include the resident’s fall on 3/8/18, any new interventions for falls, or review of current interventions. 7. During an interview on 7/20/18, at 5:26 P.M., the director of nursing (DON) said staff are expected to update the care plan with any changes to conditions, falls, new wounds, or any other changes to reflect the resident’s current care needs. During an interview on 7/20/18, at 7:36 P.M., the MDS coordinator (MDSC) said care plans are updated on Tuesdays with resident preferences, weight loss, medication changes, behaviors. He/She said the staff discuss falls in the quality assurance meeting but do not reevaluate the care plan to see if new interventions need to be added. He/She said he/she follows the Resident Assessment Instrument (RAI) manual on how to code the MDS and complete or revise the care plans. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 14) – Sometimes understood, usually understands; – Moderately impaired cognition, decisions are poor, supervision required; – Required limited assistance with bed mobility, locomotion on unit, dressing, and eating; – Required extensive assistance with transfers, walk in room, toileting, and personal hygiene; – Required total assistance for bathing; – [DIAGNOSES REDACTED]. Review of the resident’s shower sheets, for the month of June, showed staff documented they provided showers on 6/1/18, 6/12/18, 6/15/18, and 6/19/18. Staff did not provide four of eight scheduled showers for the resident. Review of the resident’s shower sheets, for the month of July, showed staff documented they provided a shower on 7/17/18. Staff did not provide five of six scheduled showers for the resident. 2. Review of Resident #5’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 10 out of 15, moderate cognitive impairment; – Required limited assistance for transfers, dressing, toilet use, eating, bathing, and personal hygiene; – [DIAGNOSES REDACTED]. Review of the resident’s shower sheets, for the month of June, showed staff documented the resident refused a shower on 6/1/18, and they provided a shower on 6/12/18, and 6/26/18. Staff did not provide five of eight scheduled showers for the resident. 3. Review of Resident #10’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Extensive assistance of one staff member for locomotion, and hygiene; -Extensive assistance of two or more staff members with bed mobility; -Dependent with two or more staff members with transfers, dressing, toilet use, and bathing. Review of the resident’s Care Plan, last updated 5/28/18, directed staff to provide a shower twice a week and prn. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 6/4/18, 6/11/18, 6/14/18, and 6/21/18. Staff did not provide four of eight scheduled showers for the resident. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 7/9/18, and 7/12/18. Staff did not provide four of six scheduled showers for the resident. Observation showed on 7/17/18, at 2:00 P.M., the resident in his/her bed. Observation showed the resident’s hair greasy and uncombed. The resident has a body odor and long facial hair. During an interview on 7/17/18, at 2:00 P.M., the resident said the staff do not have time to do his/her showers twice a week. He/She said it would be nice to feel cleaner. 4. Review of Resident # 15’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Understood, understands; – BIMS score of 12 out of 15, moderate cognitive impairment; – [DIAGNOSES REDACTED]. Review of the resident’s shower sheets, for the month of June, showed staff documented |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 15) they provided showers on 6/4/18, 6/11/18, 6/14/18, 6/18/18, and 6/21/18. Staff did not provide three of eight scheduled showers for the resident. Review of the resident’s shower sheets, for the month of July, showed staff documented they provided showers on 7/2/18, 7/5/18, and 7/12/18. Staff did not provide three of six scheduled showers for the resident. 5. Review of Resident #17’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Usually understood, sometimes understands; – Severe cognitive impairment; – Required limited assistance with bed mobility and eating; – Required extensive assistance with dressing, toileting, and personal hygiene; – Required total assistance for transfers and bathing; – [DIAGNOSES REDACTED]. Review of the resident’s shower sheets for the month of June, showed staff documented they provided showers on 6/1/18, 6/15/18, 6/19/18, and 6/26/18. Staff did not provide four of eight scheduled showers for the resident. Review of the resident’s shower sheets for the month of July, showed staff documented they provided showers on 7/10/18, 7/13/18, 7/17/18, and 7/20/18. Staff did not provide two of six scheduled showers for the resident. 6. Review of Resident #18’s Care Plan, dated 2/18/18, directed staff to provide a shower twice a week and prn. Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -[MEDICAL CONDITION] or [MEDICAL CONDITION] (paralysis on one side); -Limited physical assistance of one staff member for bed mobility, transfers, locomotion, dressing, and hygiene; -Extensive assistance of one staff member for toilet use, and bathing. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 6/4/18, 6/11/18, 6/14/18, 6/19/18, and 6/21/18. Staff did not provide three of eight scheduled showers for the resident. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 7/9/18, 7/12/18, and 7/16/18. Staff did not provide three of six scheduled showers for the resident. Observation on 7/17/18, at 2:44 P.M.,, showed the resident’s hair greasy, and a brown substance under his/her fingernails. During an interview on 7/17/18, 2:44 P.M., the resident said the residents are supposed to get showers twice a week but the facility will take the bath aide off of his/her assignment to work on the floor, so we only get a shower one time a week a lot. He/She said they are always short staffed. He/She said a bath once a week is not enough, it makes him/her feel itchy because of the dry skin. 7. Review of Resident #19’s quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Severe cognitive impairment; -Limited physical assistance with toilet use and hygiene; -Dependent on one staff member for bathing. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 6/4/18, 6/11/18, 6/14/18, 6/18/18, 6/21/18, and 6/26/18. Staff did not provide two of eight scheduled showers for the resident. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 16) Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 7/9/18, 7/12/18, and 7/16/18. Staff did not provide three of six scheduled showers for the resident. Review of the resident’s Care Plan, last updated 7/18/18, directed staff to provide a shower twice a week and as needed. Observation on 7/18/18, at 11:00 A.M., showed the resident at the nurses station. The resident’s hair was unkempt, he/she had a dried brown substance from his/her lips to his/her chin, he/she had long facial hair, and his/her fingernails showed a brown substance under them. He/She had discolored, crusty spots on the front of his/her shirt and on the top thigh area of his/her pants. 8. Review of Resident #42’s care plan, dated 1/1/18, showed staff are directed: -Provide a shower twice a week and as needed; -Assist the resident with activities of daily living (ADLs) as needed. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented the resident refused a shower on 6/13/18, and they provided showers on 6/14/18 and 6/27/18. Staff did not provide five of eight scheduled showers for the resident. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not display behaviors and did not reject care during the look back period; -Required assistance of one staff for bed mobility; -Required extensive assistance of two or more staff for transfers, dressing, toilet use, and personal hygiene; -Dependent on one staff for bathing. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided a shower for the resident on 7/17/18 and 7/18/18. Staff did not provide four of six scheduled showers for the resident. 9. Review of Resident #206’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Did not display behaviors or reject care; -Dependent on two or more staff for transfers and bathing; -Required extensive assistance of two or more staff for bed mobility, dressing, toilet use, and personal hygiene; -Required extensive assistance of one staff for eating. Review of the resident’s shower sheets for (MONTH) (YEAR) showed staff documented they provided a shower on 6/4/18, 6/11/18, 6/18/18, 6/21/18, and 6/26/18. Staff did not provide three of eight scheduled showers to the resident. Review of the resident’s shower sheets for (MONTH) (YEAR) showed staff documented they provided a shower on 7/16/18. Staff did not provide five of six scheduled showers for the resident. Review of the resident’s care plan, last updated 7/19/18, showed staff are directed: -The resident requires assistance with all activities of daily living (ADLs); -Provide a shower twice a week and as needed. Observation on 7/18/18 at 4:22 P.M., showed the resident with dark brown debris under his/her fingernails. Observation on 7/19/18 at 9:20 A.M., showed the resident with dark brown debris under his/her fingernails. Observation on 7/19/18 3:42 P.M., showed the dark brown debris remained under his/her fingernails. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 17) 10. During an interview on 7/20/18, at 10:47 A.M., certified nurse assistant (CNA) H said they have had holes in the schedule for call ins or people that have quit. He/She said the shower aide will have to work the floor with a full assignment if the facility does not have enough staff, and then the showers do not get completed. During an interview on 7/20/18, at 2:00 P.M., licensed practical nurse (LPN) A said staff should offer residents a shower at least twice a week and as needed or requested. He/She said staffing is tight sometimes and showers do not get completed as scheduled. During an interview on 7/20/18, 5:26 P.M., the director of nursing (DON) said staff are expected to offer showers at least twice a week and as needed. | |
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide activities to meet all resident’s needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, facility staff failed to provide an |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) – No other activity was scheduled for Sundays. 4. Review of the (MONTH) calendar showed the following: – Two activities occurred after dinner time. The activities occurred at 7:00 P.M. on 6/19/18 and 6/21/18, and both were music related activities; – There were no other activities were scheduled for weekdays after 3:30 P.M.; – Resident’s individual activity of choice was scheduled for all Saturdays during the month and on Sunday, 6/24/18. No time was listed on the activity calendar; – A church activity was scheduled for 2:00 P.M. for Sundays on 6/3/18, 6/10/18, and 6/17/18; – No other activities were scheduled for Saturdays or Sundays. 5. Review of the (MONTH) activity calendar showed the following: – Two activities occurred after dinner time. The activities occurred at 7:00 P.M. on 7/17/18 and 7/19/18, and both were music related activities; – There were no other activities scheduled for weekdays after 3:30 P.M.; – Resident’s individual activity of choice was scheduled for Saturdays on 7/14/18, 7/21/18, and 7/28/18 and for Sundays on 7/1/18 and 7/22/18. No time was listed on the activity calendar; – A church activity was scheduled for 2:00 P.M. for Sundays on 7/8/18, 7/15/18, and 7/29/18; – No other activities were scheduled for Saturdays or Sundays. 6. Review of Resident #9’s annual MDS, dated [DATE], showed the staff documented the resident as: -Moderate cognitive impairment; -Mild depression; -Limited physical assistance with bed mobility, ambulation, dressing, and toilet use; -Extensive physical assistance with transfers, and hygiene; -Dependent assistance with bathing; -Somewhat important to have things to read and listen to music. Review of the resident’s Care Plan, dated 4/28/18, showed it directed staff: -Resident prefers activities that identify with prior lifestyle; -Resident will not exhibit boredom/isolation through next review; -Staff to provide a monthly activities calendar; -Staff to remind resident of the daily activity; -Staff to talk with resident about her likes and hobbies; -Staff to Encourage resident to become involved with others and come out of her room; -Staff to provide 1:1 sessions when able; -Staff to encourage residents family/friends to visit often. Review of the resident’s Activity Record, dated (MONTH) (YEAR), showed the resident attended exercise on 6/1/18, and bingo on 6/1/18. The documentation did not contain attendance at any other activities for June. Review of the resident’s Activity Record, dated (MONTH) (YEAR), showed the resident attended fourth of (MONTH) celebration on 7/4/18, root bear floats on 7/5/18, and pretty nails on 7/6/18. The documentation did not contain attendance at any other activities for July. Observations on 7/17/18-7/20/18, showed the resident in bed in his/her room. Observation showed the resident was not engaged in any activities in his/her room, and staff did not engage the resident in an activity. During an interview on 7/17/18, at 11:23 A.M., the resident said that he/she gets bored. He/She said that there is one staff member that will paint his/her nails. He/She said no |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) one ever comes just to visit with him/her, just to do what they have to do. 7. Review of Resident #13’s, admission MDS, dated [DATE], showed the staff documented the resident as: -Severe cognitive impairment; -Severe depression; -Extensive assistance of one staff member for dressing, toilet use, bathing, and hygiene -Dependent on one staff member for bed mobility, and transfers; -Somewhat important to listen to music, be around animals, keep up with the news, go outside when the weather is good, and attend religious services. Review of the resident’s Care Plan, dated 1/24/18, showed it directed staff: -Resident prefers activities that identify with prior lifestyle; -Resident will report participation in a satisfying activity program through next review; -Staff to provide a monthly activities calendar; -Staff to remind resident of the daily activity; -Staff to come take resident to the activities gofer choice; -Staff to talk with res/family about her likes and hobbies; -Staff to provide adequate rest periods; -Staff to encourage family and friends to come in and visit often. Review of the resident’s Activity Record, dated (MONTH) (YEAR), showed the resident attended exercise on 6/1/18, and bingo on 6/1/18. The documentation did not contain attendance at any other activities for June. Observations on 7/17/18-7/20/18, showed the resident in bed in his/her room. Observations did not show the resident engaged in any activities in his/her room, and staff did not engage the resident in an activity. 8. Review of Resident #39’s admission MDS, dated [DATE], showed staff assessed the resident as follows: -Intact cognition; -Moderate depression; -Resident prefers activities that identify with prior lifestyle; -Music and outdoors activities are somewhat important; -Dependent on two staff for transfers; -Required assistance of one staff for locomotion on and off the unit; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 3/28/18, showed staff are directed: -Remind the resident of the daily activity; -Talk with the resident about his/her likes and hobbies; -Likes to stay in his/her room a lot. Review of the resident’s (MONTH) activity calendar showed staff documented the resident did not attend any activities on 22 of the 30 days. Staff did not document any one on one activities with the resident. Observation and interview on 7/17/18 at 3:48 P.M., showed Resident #39 in his/her bed with the privacy curtain drawn completely around his/her bed. The resident said staff never get him/her out of bed, there is nothing to do and he/she gets bored and frustrated. Observation on 7/18/18 at 10:06 A.M., showed the resident in his/her bed with the privacy curtain drawn completely around his/her bed. Staff did not engage the resident in an activity. 9. During an interview on 7/20/18 at 12:00 P.M., the Activity Director (AD) said he/she has worked as the Activity Director for three months. He/She is the only staff in the activity department. His/Her hours are from 8/8:30 A.M. to 4:30/5:00 P.M., Monday through |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) Friday. Activities are recorded in a binder. In the binder, each resident has their own activity calendar. When the resident attends the activity, he/she highlights it on the calendar. At the end of the month, the calendar is uploaded into the computer record. (MONTH) and prior months are located in the resident’s hard chart. He/She does not have a list of one-to-one residents, and said he/she does not know what one-to-one activities are. He/She did not know he/she had to do one-to-one activities with some of the residents. Occasionally, he/she will spend time painting a resident’s nails or talking to a resident, but he/she does not record it anywhere. He/She does not have a list of residents, but he/she knows which residents would enjoy one-to-one activities. He/She goes to care plan meetings but was not aware that one-to-one activities are listed in resident care plans. Activity calendars are posted in each resident’s room. He/She goes to each resident’s room to invite them to the daily activities. He/She does not keep record of resident refusals or responses to the activity. The last activity of the day is at 2:30 P.M. so residents can be finished in time for dinner. Residents begin going to dinner at 3:30 – 4:00 P.M. He/she leaves work at 5:00 P.M. so there are no activities after dinner. One exception is on the third Tuesday of the month when a music group comes to the facility at 7:00 P.M. There are no other evening activities. Saturday activities are resident individual activity of choice. The residents can play games, do puzzles, or color. He/she will set up bingo on Saturdays too. Bingo is on the calendar one time between the months of (MONTH) through June. Sometimes the housekeepers or the nurse’s aides will set up a movie on Saturdays. On Sunday, a church group will come to the facility at 2:00 P.M. There are no other activities besides church. Residents can visit with friends or do an individual activity of choice. If a resident does not attend church then there are no organized activities for them to do on Sundays. During an interview on 7/20/18, at 5:26 P.M., the administrator (ADM) said the AD has been doing activities since April. He/She said the AD is not enrolled in a class to be certified. The ADM said the company that owns the facility does the class and he/she does not know when the next class will be. He/She said the AD should do 1 on 1’s with the resident’s and document them. The ADM said church is the only scheduled activity on the weekend, and music groups are the only scheduled activity in the evening. | |
| F 0680 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure the activities program is directed by a qualified professional. Based on interviews, the facility failed to ensure the activities program was directed by |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0680 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0686 Level of harm – 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: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 22) mattress; – Replace top linen; – Position resident comfortably with call light within reach. 3. Review of the facility’s Care and Prevention of Pressure Ulcer policy, dated (MONTH) (YEAR), showed the following: – Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk area for a pressure ulcer to begin; – Use pressure-reducing devices to relieve pressure; – Turn the resident every two hours and position with pads or pillows to protect bony prominences; – Use elbow and heel protectors if needed. 4. Review of the facility’s General Wound and Skin Care Guidelines, dated 2009, showed the following: – Evaluate the need for a pressure reduction surface for bed and/or chair, as well as the need for heel/elbow protectors or specialized protection; – Select a dressing that keeps the wound bed moist and the periwound skin dry, it should be at least two inches larger than the affected area; – Reevaluate dressing and skin integrity every shift. Reevaluate the wounds response to the prescribed treatment on a regular basis, and when needed make the recommendations for treatment changes and inform the physician of changes in wound status; – Date and initial all dressings at the time of application; – Thoroughly document all wound information such as type, location, stage (if applicable), length, width, depth, drainage, notation of tunneling or undermining, description of tissue, state of periwound area, treatment of [REDACTED]. – Educate residents, families, friends, and staff on interventions to prevent skin breakdown. 5. Review of Resident #5’s Monthly Nurse’s Observation form, dated 5/9/18, showed nursing staff documented the following: – Usually understands and is understood; – Does not express pain; – Pain management is not necessary; – Independent for bed mobility, transfers, locomotion, and toilet use; – Skin appears good; – No reference to specific skin/wound documentation; – No comments/narrative note related to skin appearance; – No other comments or other information. Review of the resident’s Braden Scale (determines risk for pressure ulcer development) assessment, dated 5/16/18, showed a score of 22, Not at Risk. Review of the resident’s medical record showed on 6/6/18 staff documented a weekly skin observation report, skin intact with no skin issues. Review of the resident’s shower sheets/skin monitoring forms showed on 6/12/18, staff documented bruising and swelling present on left wrist area; form signed by Certified Nursing Aide (CNA) only. Staff did not document any information related to the resident’s heels. Review of nurses’ notes, dated 6/13/18, at 1:58 A.M., showed staff documented the resident returned to the facility from hospital emergency room , with a [DIAGNOSES REDACTED]. Order for bed rest. Follow up in 1-2 weeks. Review of the resident’s weekly skin reports showed staff did not document any skin assessment for the week of 6/13/18. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 23) Review of skin assessment/shower sheets showed staff documented on 6/19/18, the resident went to a doctor appointment and staff did not complete any bath or skin monitoring, form signed by CNA only. Review of the resident’s follow-up appointment documentation, dated 6/19/18, showed the resident’s physician documented the following: – [DIAGNOSES REDACTED]. – Note that left iliac has fracture that is old; – Physical and therapy and occupational therapy ordered three times a week for six weeks; – Comments/Precautions are weight bearing as tolerated (WBAT), no restrictions, activity as tolerated. Review of the resident’s weekly skin reports showed: -Staff did not document any skin assessment for the week of 6/20/18; – On 6/25/18, staff first documented, open area on right calf. No other wounds noted. Review of the resident’s skin assessment/shower sheets showed on 6/26/18, staff documented open blisters present on right shin area, form signed by Certified Medication Technician (CMT) only. Review of the skin assessment/shower sheets showed on 7/2/18, staff did not document any comments regarding skin, form signed and dated by CNA and charge nurse. Review of the resident’s weekly skin report showed on 7/2/18, staff first documented the resident with an area on the right heel which measured 1 cm x 1 cm. Wound bed has thick red adherent slough. Wound edges are rolled and white. Surrounding skin is boggy, pale pink, and non-blanchable. Review of the resident’s wound report showed on 7/2/18, staff documented the resident with a Stage 2 pressure ulcer on his/her right heel which measured 1.0 x 1.0, depth is NA. The pressure ulcer was acquired in house. Exudate present. Tunneling is not present. Status is new. Clean wound with normal saline, pat dry, apply xeroform petroleum dressing (medicating, deodorizing, occlusive and non-adhering wound dressing) to wound bed, cover with [MEDICATION NAME] (nonadherent dressing), secure with [MEDICATION NAME] daily and as needed until healed. The wound bed has thick red adherent slough, wound edges are rolled and white. Surrounding skin is boggy and pale pink, non-blanching. Resident takes vitamins and supplements. The doctor was notified. Review of the resident’s physician’s orders [REDACTED]. – admission date of [DATE]; – [DIAGNOSES REDACTED]. – An order dated 7/2/18 through open ended, for right heel: cleanse with wound cleanser, apply xeroform [MEDICATION NAME] to wound bed, cover with gauze, secure with [MEDICATION NAME] every three days and as needed until healed, [DIAGNOSES REDACTED]. Review of the resident’s Care Plan, last reviewed on 7/2/18, showed the following: – Problem start date of 1/23/18; – Problem: Resident is at risk for pressure ulcers; – Goal: Resident’s skin will remain intact through next review; – Approach: Do weekly skin assessments, provide shower twice a week and as needed, staff to inspect skin on shower days and report any issues to the charge nurse; – Note on 7/2/18: Area noted to right heel. treatment of [REDACTED]. Float heels. Review of the resident’s nurses’ notes, dated 7/5/18 at 11:28 A.M., showed staff documented the resident has a Stage 3 pressure wound to right heel and vascular wound to right medial ankle receiving treatment. On antibiotic treatment for [REDACTED]. Review of nurse’s notes showed staff did not document further information after 7/5/18 regarding the Stage 3 pressure wound to the right heel to show ongoing monitoring for |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 24) improvement or decline. Review of the resident’s skin assessment/shower sheet showed on 7/6/18, staff did not document any comments regarding skin, form signed and dated by CNA and charge nurse. Review of the resident’s Monthly Nurse’s Observation form, dated 7/8/18, showed the following: – Usually understands and is understood; – Expresses pain; – Pain management is effective; – Requires assistance for bed mobility, transfers, locomotion, and toilet use; – Skin appears fair, warm, and pale; – Did not document specific skin/wound documentation; – No comments/narrative note related to skin appearance; – No other comments or other information. Review of weekly skin reports showed on 7/9/18, staff documented the resident had an area on his/her right heel which measured 1.7 cm x 3.8 cm. Wound bed has thick red adherent slough, wound edges are rolled and white. Skin appears to be sloughing off around the wound edge. Surrounding skin is boggy, pale pink, and non-blanchable. Review of the resident’s wound report showed on 7/9/18, staff documented the resident with a Stage 2 pressure ulcer on his/her right heel which measured 1.7 x 3.8, depth is NA. The pressure ulcer was acquired in house. Exudate present. Tunneling is not present. Status is deteriorating. Clean wound with normal saline, pat dry, apply xeroform petroleum dressing to wound bed, cover with [MEDICATION NAME], secure with [MEDICATION NAME] daily and as needed until healed. The wound bed has thick red adherent slough, wound edges are rolled and white. Surrounding skin is boggy and pale pink, non-blanching. Resident takes vitamins and supplements. Staff documented the doctor was notified; – No other wound reports present. Review of the resident’s skin assessment/shower sheets, showed on 7/10/18, staff did not document any comments regarding skin, form signed and dated by CNA and charge nurse. Review of the resident’s skin assessment/shower sheets showed: – On 7/13/18 staff did not document any comments regarding skin, form signed and dated by CNA and charge nurse; – On 7/16/18, the resident refused and no bath or skin monitoring was completed, form signed and dated by CNA and charge nurse. Review of the resident’s Braden Scale assessment, dated 7/16/18, showed a score of 16, At Risk. Observation on 7/17/18 at 2:13 P.M. showed the resident in his/her room, in his/her wheelchair. The resident wore a bandage on his/her right foot and ankle. The resident wore two shoes, with the right shoe folded down under his/her heel. The resident did not wear heel floats. The foot rests for the wheel chair were present, but the resident propelled himself/herself in the wheelchair with his/her hands and feet. Observation 7/18/18 at 12:00 P.M. showed the resident propelled himself/herself down the hallway toward his/her room in his/her wheelchair with his/her hands and feet. The resident wore socks, with no shoes or heel floats. Observation also showed a bandage on his/her right heel. Observation on 7/19/18 at 9:45 A.M. showed Nurse Assistant (NA) D assisted the resident from his/her wheelchair into his/her bed. NA D covered the resident with a blanket. NA D did not place heel floats on the resident. The heel floats were not observed in the resident’s room. NA D did not float the resident’s feet with a pillow. The resident’s heels rested directly on the mattress. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 25) During an interview on 7/19/18 at 10:00 A.M., NA D said he/she has worked at the facility for three weeks. He/she usually worked the day shift. He/she has worked with the resident on previous occasions and was familiar with the resident. When he/she laid the resident down in bed, he/she just did what he/she usually did when he/she gets the resident out of bed. He/she did not know how to find information on the resident’s orders or care plans. The NA said he/she would have to ask the head nurse to get more information. Observation on 7/19/18 at 11:19 A.M. showed the resident present for lunch in the dining room. The resident had no heel floats and no foot rests on his/her wheelchair. Observation on 7/19/18, at 2:48 P.M., showed the resident in bed. Observation showed the resident’s right heel with a large wound. The resident’s wound had three areas within the wound. The upper area of the wound showed white, macerated tissue (softening and breaking down of skin due to prolonged exposure to moisture) in a quarter sized area that had depth. The lower part of the wound had pink shiny tissue that raised to an area with bright red tissue that had dead translucent skin covering the area. The wound edges were thick, hard, dead skin that had loosened on the edges separating from the wound, with eschar on the right outer edge of the wound. Observation showed the resident did not have a specialty mattress. During an interview on 7/19/18, at 2:48 P.M., licensed practical nurse (LPN) A said the wound has slough and eschar and you cannot see the base of the wound. He/She said the upper deep part of the wound measured 1.3 cm in length, 2.2 cm in width, and at least 0.4 cm in depth. He/She said the whole wound measured 4.6 in length, and 8.5 cm in depth. He/She said the CNAs are expected to float the resident’s heels when he/she is in bed, and the resident is not supposed to wear tennis shoes, he/she should only have slippers and the slipper should have the back under the heel. The LPN said the resident did not have new interventions started with hip pain and immobility, but staff started the new interventions when they identified the wound. During an interview on 7/19/18, at 3:07 P.M., the nurse practitioner said at this point the wound is at least a Stage 3 pressure ulcer because of the depth and slough in the upper part of the wound, but it is unstageable at this time because you cannot see the wound bed, so the wound could be a Stage 4. Review of skin assessment/shower sheets showed on 7/20/18, staff documented the resident had a red area under his/her stomach and a sore on the right heel, form signed and dated by CNA and charge nurse; – No other shower sheets present. During an interview on 7/20/18, at 5:36 P.M., the director of nursing (DON) said staff are expected to reevaluate residents with a decline in functioning. He/She said with any physical decline a resident’s pressure ulcer risk could increase, the reevaluation helps staff to assess the resident so that interventions could be put in place to prevent pressure ulcers from developing. He/She said that interventions for residents at risk for pressure ulcers would include to float the resident’s heels to keep the pressure off the heels while in bed, or pressure reducing devices to the resident’s feet/chair. He/She said staff are expected to follow the pressure reduction intervention in the care plan to prevent pressure ulcer development or worsening of unhealed pressure ulcers. | |
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 26) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide restorative nursing services to maintain or improve the resident’s ability to function for three residents (Resident #10, #18, and #206) of 15 sampled residents. The facility census was 53. 1. Review of the facility’s policies showed they did not have a policy for the Restorative Nursing Program. 2. Review of Resident #10’s, quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 4/28/19, showed the staff assessed the resident as: -Cognitively intact; -Extensive assistance of one staff member for locomotion, and hygiene; -Extensive assistance of two or more staff members with bed mobility; -Dependent on two or more staff members for transfers, dressing, toilet use, and bathing; -Functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot); -Staff did not document Restorative Nursing minutes on the MDS. Review of the resident’s Care Plan, last updated 6/26/18, showed it did not contain directions to staff related to the resident’s limited range of motion. Review of the resident’s medical record showed it did not contain a Restorative nursing plan or restorative nursing documentation. Observation on 7/18/18, at 4:07 P.M., showed the resident needed physical assistance to move his/her right leg. 3. Review of Resident #18’s Care Plan, last updated 9/11/17, directed staff: -Resident has left sided [MEDICAL CONDITION] due to stroke; -Resident will compensate using her other side through next review; -Staff to apply arm rest to residents wheelchair; -Staff to apply Velcro strap to lower extremity to keep on his/her petal; -Staff to set up his/her meal tray as needed; -Staff to assist resident with all his/her activities of daily living as needed. Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -[MEDICAL CONDITION] or [MEDICAL CONDITION] (paralysis on one side); -Limited physical assistance of one staff member for bed mobility, transfers, locomotion, dressing, and hygiene; -Extensive assistance of one staff member for toilet use, and bathing; -Functional limitation in range of motion (ROM) in one lower extremity (hip, knee, ankle, foot), and one upper extremity (shoulder, elbow, wrist, hand). -Staff did not document Restorative Nursing minutes on the MDS. Review of the resident’s Restorative Nursing Treatment Plan, dated 5/24/18, showed it directed staff: -[DIAGNOSES REDACTED]. -Goal: pain management and improve/maintain alignment; -Two times weekly; -Progressive left upper extremity shoulder and hand ROM for contractor management; -Neck stretches and ROM, neck rotation, and reminders of proper neck positioning; -Left ankle brace |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 27) Review of the resident’s Restorative Nursing Treatment Plan, dated 7/11/18, showed it directed staff: -Function maintenance of transfers, sit to stand with limited assistance of one staff member; -Maintenance of gait with right hand on wheelchair with limited assistance Review of the resident’s Restorative Daily Documentation and Program Note, dated 7/1/18-7/19/18, showed staff documented: -Passive ROM left upper extremity and left lower extremity, staff documented completed on 7/2/18, 7/6/18, 7/10/18, 7/12/18, and 7/13/18 (did not contain documentation for 7/14/18 through 7/20/18); -Ankle Foot Orthosis (AFO) (a support intended to control the position and motion of the ankle, compensate for weakness, or correct deformities), did not contain documentation that staff placed the AFO/splint; -Neck stretches/rotation, staff documented completed on 7/10/18, 7/12/18, and 7/13/18 (did not contain documentation for 7/14/18 through 7/20/18); -Ambulation, did not contain documentation that staff ambulated the resident. Observation on 7/17/18, at 11:01 A.M., showed the resident propelled himself/herself down the 300 hall. Observation showed the resident with hand contractures of the left hand, the resident did not have a hand splint or roll in his/her hand. Further observation showed the resident could not move his/her left leg, and it rested in a twisted position on his/her foot rest. During an interview on 7/17/18, on 3:12 P.M., the resident said he/she does not know what restorative nursing is. He/She said that no one helps him/her stretch his/her left arm and leg, or do any exercises. He/She said he/she did not know that he/she should stretch her left arm/leg to prevent further contractures. He/She said that he/she had a splint for his/her hand and a splint for his/her ankle but no one puts them on him/her. During an interview on 7/20/18 at 3:00 P.M., Certified Nursing Aide (CNA) G said he/she does not document the restorative services provided by CNAs who work on the floor, and if there are items not marked as provided, those are therapies the CNAs provide. He/She said the CNAs are expected to document any restorative therapy they provide. 4. Review of Resident #206’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Did not display behaviors or reject care; -Dependent on two or more staff for transfers and bathing; -Required extensive assistance of two or more staff for bed mobility, dressing, toilet use, and personal hygiene; -Required extensive assistance of one staff for eating; -Did not receive any restorative nursing services during the lookback period; -Did not have any impairment in upper or lower extremity range of motion. Review of the facility’s restorative nursing documentation for (MONTH) and (MONTH) (YEAR), showed staff did not provide restorative nursing services to the resident. Review of the resident’s care plan, last updated 7/19/18, showed staff are directed: -The resident requires assistance with all activities of daily living (ADLs); -Requires hoyer lift (mechanical lift) for transfers. The care plan did not provide any direction to staff related to the resident’s mobility, contractures, or need for restorative nursing services. Observation on 7/18/18 at 4:22 P.M., showed the resident with contracted hands. Observation and interview on 7/19/18 at 9:35 A.M., showed CNA F and CNA B transferred the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 28) resident into bed from his/her wheelchair with the hoyer lift. Observation showed the resident with contracted knees. CNA F said he/she does not think staff provide any restorative services to the resident. During an interview on 7/20/18 at 3:00 P.M., CNA G said the resident does have contractures and staff had provided restorative therapy in the past. The CNA said staff stopped providing services for a time due to issues with the resident’s hips. CNA G said he/she did not know why staff did not start the resident on restorative services after the issue resolved, and said he/she did not receive any orders to restart the resident on restorative services. The CNA said I guess we dropped the ball on this resident. He/She said if staff identify a resident with contractures or a decline, they typically recommend the resident receive restorative therapy. CNA G also said he/she does not document the restorative services provided by CNAs who work on the floor, and if there are items not marked as provided, those are therapies the CNAs provide. He/She said the CNAs are expected to document any restorative therapy they provide. During an interview on 7/20/18, at 10:23 A.M., the MDS coordinator (MDSC) said Resident #206 had a decline in 12/17 so the staff focused on his/[MEDICAL CONDITION] and did not do a restorative program. He/She said when the resident'[MEDICAL CONDITION] resolved the facility did not start him/her on any therapy or restorative nursing program because of his/her confusion. He/She said staff did not try passive ROM. He/She said restorative nursing staff are expected to complete the programs set up for residents and document what they have done. He/She did not know why restorative nursing programs did not contain documentation for Resident #18 or why Resident #10 did not have a restorative plan. During an interview on 7/20/18, at 5:26 P.M., the director of nursing (DON) said that residents with contractures or who need assistance ambulating should be on a restorative plan. He/She said the restorative aides are trained by physical therapy staff and CNA class. He/She is not sure why some residents do not have a plan or why there is not documentation on residents with a current plan. | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 29) did report the coffee was really hot and he/she told the coffee vendor representative. He/she said the coffee vendor representative said that’s the temperature, and there isn’t a way to turn it down. He/She said the coffee is 170 degrees. The DM said he/she does not know what the hot liquid protocol assessment refers to. The DM said he/she did not report the coffee temperatures to the administrator. 2. Review of Resident #2’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/16/18, showed the following: – admission date of [DATE]; – Sometimes understood, usually understands; – Moderately impaired cognition, decisions are poor, supervision required; – Required limited assistance with eating; – [DIAGNOSES REDACTED]. Review of the resident’s medical record showed the following: – admission date of [DATE]; – [DIAGNOSES REDACTED]. – An order dated 2/27/17, regular diet with food cut up for independent feeding; – Nurse’s note, dated 5/16/18 at 7:59 A.M., staff documented the nurse gave the resident a cup of coffee, per resident’s request. The resident spilled the entire cup on his/her right leg. The resident’s right thigh is really red and warm to the touch. Family and Director of Nursing notified. Review of the resident’s hot liquid assessment, dated 2/27/17 showed staff assessed the resident as not at risk when drinking hot liquids. The resident’s record did not contain an updated form. Review of the resident’s care plan, last reviewed on 7/18/18, showed the following: – Problem start date: 7/18/18 – Problem: Resident has a regular diet with food cut up for independent feeding; – Goal: Resident will eat more independently; – Approach: Staff to sit resident at the cuing table for assistance as needed; – Did not address or mention hot liquid spills or precautions. Observation of the resident on 7/19/18 at 11:20 A.M., showed the resident ate a lunch of soup, cornbread, okra, water, and red liquid. The resident eats with his/her hands. Staff encourages the resident to use utensils, but the resident continues to eat with hands. The staff assist the resident with eating and drinking. The resident did not have coffee. 3. Review of Resident # 15’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Understood, understands; – Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 12 out of 15, moderate cognitive impairment; – Required limited assistance with eating; – [DIAGNOSES REDACTED]. Review of the resident’s medical record showed the following: – admission date of [DATE]; – [DIAGNOSES REDACTED]. – An order dated, 9/15/17, regular diet with food cut up for independent eating, nectar thick liquids. Review of the resident’s hot liquid assessment, dated 12/26/17, showed the resident was at risk while drinking hot liquids and the Protocol for Hot Liquid Safety should be initiated. Review of the resident’s care plan, last reviewed on 9/18/17, showed the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 30) – Problem start date: 7/23/17; – Problem: Resident has a regular diet with nectar thick liquids; – Goal: Resident will not have any adverse effects from his diet; – Approach: Staff to monitor for signs and symptoms of aspiration; – Did not address or mention hot liquid spills or precautions. Observation of the resident at meal times on 7/20/18 at 11:45 A.M. showed the resident drank coffee from a coffee cup unassisted, and without facility staff present at the resident’s table during meal time. During an interview on 7/20/18 at 5:26 P.M., the administrator said the facility does not have a hot liquid protocol. 4. Review of Resident #5’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Usually understood, usually understands; – BIMS of 10 out of 15, moderate cognitive impairment; – Requires limited assistance for bed mobility, transfers, toilet use, eating, bathing, and personal hygiene; – [DIAGNOSES REDACTED]. Review of the resident’s medical record showed the following: – [DIAGNOSES REDACTED]. – hosptalized on [DATE] for pain in right due to fall. X-rays showed suspected right inferior pubic ramus (pelvis) fracture; – Recommendation from doctor during hospital discharge, dated 6/12/18, included wear shoes that fit well and have soles that grip; – Follow-up appointment for fall dated 6/19/18 noted [DIAGNOSES REDACTED]. Review of the resident’s Care Plan, last reviewed on 7/2/18, showed the resident was a fall risk and needed assistance with activities of daily living (ADL). The care plan did not provide direction to staff related to the resident’s transfer status. Review of the resident’s Lift Assessment, dated 1/24/18, showed a score of 3 points, requires a minimum of two staff to lift/transfer. Observation and interview on 7/19/18 at 9:45 A.M. showed the resident sat in his/her wheelchair with slippers on his/her feet, and waited to be transferred into his/her bed. Nurse’s assistant (NA) D used a gaitbelt to transfer the resident from the wheelchair to the bed. NA D wrapped the gait belt around the resident and locked the wheelchair. The resident’s wheelchair faced the bed. NA D stood on the left side of the resident. NA D put his/her right arm under the resident’s right arm and grabbed the gaitbelt on the resident’s back with his/her left hand. NA D lifted the resident using the resident’s right arm and gaitbelt. The resident attempted to stand, but said his/her feet and slippers were slipping on the floor. NA D sat the resident back into the wheelchair and left the slippers on the resident. NA D assisted the resident to stand again with his/her hands in the same position, using the resident’s right arm and gaitbelt. NA D lifted the resident with the gaitbelt and the resident’s right arm and turned to his/her right with the resident. The resident shuffled his/her feet in an unsteady gait, turned his/her body leading with the left side, and put his/her hand on the bed. NA D reached over the wheelchair to turn the resident 180 degrees from the wheelchair to the bed. The resident sat on the bed, and NA D stepped in front of the resident. NA D removed the gaitbelt and said he/she should have made the gaitbelt a little tighter around the resident. The resident attempted to scoot backward on the bed but said his/her feet were slipping in the slippers again. NA D put his/her feet in front of the resident and told the resident to push his/her feet up against his/her feet. The resident rested his/her feet up against NA |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 31) D’s feet and scooted back on the bed. NA D removed the resident’s slippers. The NA did not transfer the resident in a manner to prevent accidents. During an interview on 7/19/18 at 10:00 A.M., NA D said he/she has worked at the facility for three weeks. He/she usually worked the dayshift. He/she has worked with the resident on previous occasions and was familiar with the resident. He/she was aware of the resident’s transfer status because he/she asked another certified nurse’s assistant (CNA). He/she did not know how to find a resident’s transfer status without asking another staff. He/she would have to ask the head nurse. When he/she laid the resident down in bed, he/she just did what he/she usually did when he/she gets the resident up out of bed. He/she did not know how to find information on the resident’s orders or care plans. The NA said he/she would have to ask the head nurse to get more information. Review of the facility’s Positioning the Resident policy, dated (MONTH) (YEAR), showed the following steps to move a resident up in bed when a resident can sit up: – Assist resident to sitting position; – Place resident’s hand flat on bed above buttocks; – Place on arm across lower back and other arm under knee close to thighs; – Instruct resident to push with feet and, on signal, guide hips toward head of bed. 5. Review of Resident #18’s quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -[MEDICAL CONDITION] or [MEDICAL CONDITION] (paralysis on one side); -Limited physical assistance of one staff member for bed mobility, transfers, locomotion, dressing, and hygiene; -Extensive assistance of one staff member for toilet use, and bathing; -Functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot), and one upper extremity (shoulder, elbow, wrist, hand). During an interview on 7/17/18, at 2:50 P.M., the resident said his/her transfer aide bed rail completely turns and is loose. He/She said that he/she depends on it to get out of bed and he/she is, scared it is going to turn and I am going to fall. He/She said he/she reported it over a month ago but the maintenance man said it could not be fixed. Observation on 7/17/18, at 2:50 P.M., showed the resident’s transfer aide bed rail turns all the way around and moves back and forth when the resident placed his/her hand on the transfer aide. During an interview on 7/20/18, at 5:26 P.M., the administrator said he/she did not know about the transfer rail being loose, and it should be fixed immediately. During an interview on 7/27/18, at 2:52 P.M., the maintenance director said he/she did not recall the transfer aide bed rail needing repair. He/She said resident equipment should be fixed right away. 6. Review of Resident #23’s annual MDS, dated [DATE], showed the following: – admission date of [DATE]; -Understood, understands; – BIMS of 15 out of 15, cognitively intact; – No behaviors; – [DIAGNOSES REDACTED].>- Currently uses tobacco. Observation on 7/18/18 at 10:45 A.M., the resident propelled himself/herself outside to the smoking area outside the facility’s front entrance door. The resident did not remove his/her oxygen tank before going outside to smoke. The resident propelled out the door and past the residents who were smoking while his/her oxygen tank and nasal cannula were on. Observation showed on 7/19/18, at 10:58 A.M., showed the resident outside smoking. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 32) Observation showed the resident extinguished his/her cigarette and Laundry Aide C pulled the resident’s oxygen tubing from the back of his/her chair and placed his/her nasal cannula on. Additional observation showed the resident with a portable oxygen tank attached to the back of his/her chair while he/she was smoking. During an interview on 7/19/18, at 11:05 A.M., the administrator (ADM) said staff are expected to take off the resident’s oxygen prior to him/her going outside and put the tank in a safe cart inside the door of the facility. He/She said an oxygen tank should not be in the smoking area. During an interview on 7/20/18 at 5:00 P.M., the resident said he/she usually does not smoke while his/her oxygen tank is on his wheelchair. Sometimes he/she gets in a hurry to get outside on time and forgets to leave it inside. The staff in the smoking area will remove it and set it away from the group. Yesterday, he/she was in a hurry, because he/she was running late. He/she only took off his/her nasal cannula and hung it on the back of his/her wheelchair. He/she left the oxygen tank on his/her wheelchair while he/she was outside smoking. No one removed the oxygen tank from his/her wheelchair while he/she was smoking. He/She does not know if the oxygen was turned on or off at the time. During an interview on 7/20/18 at 1:45 P.M., Laundry Aide C said he/she was outside with the smokers yesterday. He/she was present when the resident came outside with his/her oxygen tank on the back of his/her wheelchair. The resident wanted to come outside for a real quick cigarette. The rest of the residents were already outside when Resident #5 came outside. The resident’s oxygen tank should have stayed inside by the door. He/she did not take the oxygen tank off the resident’s wheelchair. He/she did not take the oxygen tank inside or away from the group. He/she let the resident stay outside with the tank on the back of his/her wheelchair. All the residents outside were smoking, including Resident #5, near the oxygen tank. He/she does not remember if the tank was turned on or off. He/she remembers the nasal cannula was off, because he/she helped the resident put it back on. | |
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide enough food/fluids to maintain a resident’s health. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 33) -Bacterial pneumonia; -Acute upper respiratory infection; -Urinary tract infection; -Diarrhea; -Severe protein-calorie malnutrition; -Vitamin deficiency. Review of the resident’s Physician’s Orders Sheets (POS), dated 1/1/18-7/18/18, showed the physician directed staff to serve: -Regular diet, no meat per resident’s request may supplement protein with other foods; -Provide snack for the resident at bedtime with small frequent snacks throughout the day; -6/27/18 to discontinue Protein pudding twice a day. -6/27/18 start house supplement drink 4 ounces (oz) with meals. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 1/28/18, showed the staff documented the resident as: -Moderate cognitive impairment; -Mild depression; -No behaviors; -Set up assistance with eating; -Limited physical assistance with bed mobility, ambulation, dressing, and toilet use; -Extensive physical assistance with transfers, and hygiene; -Dependent assistance with bathing; -101 pounds (lbs); -No oral problems (edentulous not checked). Review of the resident’s Progress Notes, dated 3/9/18, showed the dietitian documented: -Resident’s weight is down 3 lbs. 3.9% over the last 30 days now 94 lbs, body max index (BMI) is 19.64 underweight; -Receives Regular diet and is supplemented with Boost Pudding; -Meal intake varies, usually 25-75%; -Prefers to eat in his/her room; -Has previously been on VHC (high calorie nutritional drink), but was discontinued after some weight gain; -Recommend: Clarify Boost pudding order to include two times daily with meals, add super cereal at breakfast, and restart Boost VHC 120 cubic centimeters (cc) three times daily with medication pass. Review of the resident’s comprehensive Nutrition Assessment, dated 4/6/18, showed the dietitian documented: -[DIAGNOSES REDACTED]. -Regular diet, no meat per resident’s request, likes peanut butter and jelly sandwiches in place of meat, and boost pudding; -Likes peanut butter and jelly sandwiches, and cottage cheese; -Current weight 92.8 lbs, -No oral problems (edentulous not checked); -Body Mass Index 92.8 underweight; -More than 5% weight change in 30 days; -Recommend Clarify boost pudding orders to twice a day with meals, add cottage cheese to lunch and dinner meals for additional protein, add super cereal at breakfast, and boost VHC (a high protein supplement) three times a day with med pass. Review of the resident’s annual MDS, dated [DATE], showed the staff documented the resident as: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 34) -Moderate cognitive impairment; -Mild depression; -No behaviors; -Set up assistance with eating; -Limited physical assistance with bed mobility, ambulation, dressing, and toilet use; -Extensive physical assistance with transfers, and hygiene; -Dependent assistance with bathing; -93 pounds (lbs) (7.9% weight loss since 1/28/18); -No oral problems (edentulous not checked). Review of the resident’s Care Plan, dated 4/28/18, directed staff: -At risk for weight loss; -Provide resident with ordered diet; -Offer double portions of things the resident likes; -Offer alternative if the resident does not like the main meal; -Resident does not want meat; -Resident prefers peanut butter and jelly sandwiches often; -Provide ordered boost pudding; -Notify the physician and durable power of attorney with significant weight loss; -Monitor for need to change diet consistency. Review of the resident’s weight record showed staff documented: -1/1/18: 101 pounds (lbs); -1/19/18: 100.6 lbs; -2/1/18: 97.8 lbs; -2/19/18: 94.2 lbs; -3/1/18: 94.4 lbs; -3/20/18: 93.8 lbs; -4/1/18: 92.8 lbs; -4/11/18: 93.6 lbs; -4/27/18: 91.4 lbs; -5/1/18: 92.8 lbs; -5/19/18: 91.8 lbs; -6/1/18: 90 lbs, (10.89% wt loss since 1/1/18); -6/14/18: 92 lbs; -7/1/18: 91 lbs; -7/12/18: 90 lbs, (10.89% wt loss since 1/1/18). Observation on 7/17/18 at 11:23 A.M., showed CNA B offered the resident dressing and gravy, onion rings and a banana for his/her meal order. The resident asked if there is any other option, and the CNA repeated dressing and gravy, onion rings and a banana. The resident said I cannot eat meat, and the staff member repeated dressing and gravy, onion rings and a banana. Further observation showed the staff did not serve the resident a 4 oz supplement drink, or boost pudding. The staff did not offer the resident a protein or an alternate entree that did not contain meat, or a protein supplement. During an interview on 7/17/18 at 11:25 A.M., the resident said he/she cannot eat meat and a lot of the food here, because he/she does not have teeth, mainly he/she cannot chew it, and some of it bothers his/her stomach. He/She said sometimes he/she gets a peanut butter and jelly sandwich. He/She said they finally had cottage cheese that he/she could eat. The resident said it would be nice to have a cheese sandwich or something like that, but it is not an option. The resident said her family used to bring him/her snacks but they do not anymore, and the facility will bring him/her snacks sometimes but not every day. He/She |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 35) said he/she is hungry all the time. He/She said, I don’t get enough protein and I only weigh 91 pounds. Observation on 7/17/18 at 12:20 P.M., showed staff served the resident in his/her room, dressing with gravy, onion rings, a banana, and lemonade. Further observation showed the staff did not serve the resident a 4 oz supplement drink, or boost pudding. Observation on 7/18/18 at 12:12 P.M., showed staff served the resident in his/her room, Mexican casserole with meat, onion rings, boost pudding and a banana. Observation showed the resident’s meal ticket on his/her tray said cottage cheese. During an interview on 7/18/18 at 12:14 P.M., the resident said he/she requested cottage cheese and did not receive it. The resident said he/she did not like the casserole, it was too spicy and had meat in it. He/She said staff did not offer him/her an alternate. Observation on 7/19/18 at 12:41 P.M., showed the activity director served the resident chicken and dumplings, two pieces of corn bread, strawberries and lemonade. The resident said to the staff member, I don’t like cornbread, and the staff member replied you do not have to eat the cornbread. The staff member did not offer the resident an alternative to the meat in the chicken and dumplings, or an alternative for the cornbread. Further observation showed staff did not serve the resident a 4 oz supplement drink, or boost pudding. During an interview on 7/19/18 at 12:45 P.M., the resident said he/she would try to eat the noodles in the chicken and dumplings. He/She said the staff did not offer him/her an alternate. Observation on 7/20/18, at 12:21 P.M., showed the resident in his/her bed with his/her tray. The tray contained french fries, onion rings, boost pudding, and cobbler. During an interview on 7/20/18 at 12:21 P.M., the resident said staff told him/her the kitchen did not have cottage cheese. He/She said the staff did not offer him/her an alternate. He/She said, the staff talk so fast and I don’t have time to think of what I want to eat, or even ask for anything else before they are gone. 3. Review of the resident’s current Face Sheet, undated, showed the resident has the following Diagnosis: [REDACTED]. -Adult failure to thrive; -Unspecified open wound, right lower leg; -Dry eye syndrome of bilateral lacrimal glands; -Major [MEDICAL CONDITION], single episode; -Deficiency of other vitamins; -Hypertension; -Constipation; -Injury of unspecified body region; -Paresthesia of skin; -History of falling; -Abrasion, right lower leg; -Cachexia; -Multiple fractures of ribs, right side; -Cardiomegaly. Review of Resident #13’s POS, dated 1/19/18-7/19/18, showed staff are directed to -1/21/18 start house shakes/supplements three times a day with medication pass; -1/24/18 oxygen at three liters per nasal cannula continuous; -2/2/18 start Mechanical soft diet; -5/2/18 discontinue mechanical soft diet; -5/2/18 start regular diet. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 36) Review of the resident’s significant change status assessment (SCSA) MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Severe depression; -Limited physical assistance of one staff member for eating; -Extensive assistance of one staff member for dressing, toilet use, bathing, and hygiene -Dependent on one staff member for bed mobility, and transfers; -81 lbs.; -Oxygen use. Review of the resident’s Care Plan, dated 1/24/18, shows staff are directed to: -Provide ordered diet; -Monitor intake; -Provide double portions of the things that he/she likes; -Offer alternate if the resident does not like the main dish; -Encourage family to bring in favorite foods/snacks; -Notify physician and durable power of attorney of any significant weight loss. Review of the Physician’s Certification for Medicare Hospice Benefit, dated 2/5/18, showed the resident has a terminal [DIAGNOSES REDACTED]. Review of the resident’s weight record showed staff documented: -1/19/18 81.6 lbs; -2/1/18 80.6 lbs; -2/7/18 77 lbs; -3/1/18 71.6 lbs; -4/1/18 68.8 lbs (15.68 % weight loss); -5/1/18 67.2 lbs (17.64 % weight loss); -6/1/18 70.4 lbs; -7/1/18 72.4 lbs. Review of the resident’s Progress Notes, dated 3/09/2018, showed the dietitian documented: -Resident has lost 10 lbs, 12.9% over the last 30 days, now 70.2 lbs, BMI 13.71 very underweight; -Unsure of diet, no order in chart; -Gets house supplement three times a day for snacks; -Nursing and dietary report resident has been refusing to come to the dining room or eat at all; -Usually likes milk; -Family here often and sometimes brings in food; -Takes [MEDICATION NAME] 15 milligrams (antidepressant) which should improve appetite; -Is on Hospice care; -Continue encouraging food and fluids; -Recommend: Add diet orders to chart. Review of the resident’s Progress Notes, dated 4/06/2018, showed the dietitian documented: -Resident continues to lose weight, down 12 lbs,15.7% in 90 days, down 2 lbs, 3.9% in 30 days now 68.8#; -BMI 13.44 underweight; -Has been evaluated by Speech Therapy- they have recommended Mechanical soft diet; -Intake poor 1-25% usually; -Receives house supplement three times a day; -The resident has been requesting regular consistency meat- especially bacon; -Family wound like him/her to have bacon, and other regular consistency foods; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 37) -Family has been educated on choking hazards, but feel Regular consistency better; -Takes [MEDICATION NAME] 7.5 mg which can improve appetite; -Liberalize diet to regular per family and resident preference; -Recommend: Add house supplement three times a day with meals for additional calories. Review of the physician’s orders and care plan showed staff did not document or obtain directions for the staff to serve bacon, or other regular foods. Review of the Nutrition quarterly review, dated 5/1/18, showed staff documented: -Mechanical soft diet; -Current weight 69 lbs; -House shakes/supplements three times a day; -Resident refuses all shakes sent from dietary department. Review of the resident’s Progress Notes, dated 5/2/18, showed the dietitian documented: -Resident has lost 14 lbs, 17.8% over the last 90 days, down 1 lbs in 30 days. Now 67.2# BMI 13.12; -Receives mechanical soft diet and house supplement three times a day; -Has poor appetite (0-25%) and often refuses house supplement – shakes & ice cream attempted with poor intake; -Continues requesting bacon, but not allowed on mechanical soft diet; -Evaluated by speech therapy today; -Will be trying regular diet over the next several days and bacon will be allowed; -Takes [MEDICATION NAME] 15 mg which can improve appetite; -Continues on Hospice care; -Recommend: Boost Breeze or VHC (depending on resident preference) 90 cc three times a day with med pass, discontinue house supplement- refuses to drink. Review of the physician’s orders and care plan showed staff did not obtain or document direction to the staff to administer Boost Breeze or VHC. Review of the resident’s quarterly MDS, dated [DATE], showed the staff documented the resident as: -Severe cognitive impairment; -Severe depression; -Limited physical assistance of one staff member for eating; -Extensive assistance of one staff member for dressing, toilet use, bathing, and hygiene -Dependent on one staff member for bed mobility, and transfers; -67 lbs.; -Oxygen use. Review of the assessment showed the staff did not code the resident as a weight loss. Review of the resident’s Progress Notes, dated 6/7/2018, showed the dietitian documented: -Resident’s weight is down 11 lbs, 14% over the last 6 months, but has been steady over the last 90 days; -Diet has been liberalized to Regular, -BMI 13.71 underweight -Intake generally poor 1-25%; -House supplement three times a day; -Takes [MEDICATION NAME] 15 mg which can improve appetite; -No new recommendations. Review of the resident’s Progress Notes, dated 7/5/2018, showed the dietitian documented: -Wt down 9 lbs, 11.3% over the last 6 months, but has been trending up over the last 90 days. -Now 72.4 lbs BMI 14.14 underweight; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 38) -Is on Hospice care; -Receives Regular diet, fluids are encouraged 120 ml water four times a day with med pass; -Intake fair 25-75% usually; -Spoke with dietary, he/she does not like supplement drink/ice milk, prefers milk; -Takes [MEDICATION NAME] 15 mg which can improve appetite; -Recommend: Whole milk three times a day with meals. Observation on 7/17/18 at 12:21 P.M., showed the resident in bed in a fetal position with his/her eyes closed. Further observation showed his/her lunch tray with his/her plate covered, his/her dessert covered with a transparent film, his/her silverware still wrapped in a napkin as it came from dietary, and a glass of koolaide. The resident’s tray did not contain milk. Observation on 7/17/18 at 12:52 P.M., showed the resident in bed in a fetal position with his/her eyes closed. Further observation showed his/her lunch tray with his/her plate covered, his/her dessert covered with a transparent film, his/her silverware still wrapped in a napkin as it came from dietary, and a glass of koolaide. Observation on 7/17/18 at 3:01 P.M., showed staff collected the resident’s lunch tray from his/her room. Observation showed his/her lunch tray remained with his/her plate covered, his/her dessert covered with a transparent film, his/her silverware still wrapped in a napkin as it came from dietary, and a glass of koolaide. Observation on 7/18/18 at 12:15 P.M., showed the resident in bed in a fetal position with his/her eyes closed. Observation showed the resident’s lunch on the bedside table and the resident’s food untouched. Observation on 7/19/18 at 12:27 P.M., showed the resident sat on the side of his/her bed with his/her oxygen on. Observation showed CNA B served the resident chicken and dumplings, cornbread, fried okra, peaches, a banana, and a glass of milk. Observation on 7/19/18 at 12:44 P.M., showed the resident consumed 25% of his/her chicken, a few pieces of okra, and drank his/her milk. During an interview on 7/17/18 at 3:02 P.M., the resident’s family member said the food choices are terrible, they have one alternate for a week and there is nothing else. If he/she doesn’t like a riblet, he/she is stuck for the whole week. He/She said, having the same alternate twice a day for a week is crazy to me, or they have chicken as the alternate and a different version of chicken as the meal so if you don’t like chicken what are you supposed to eat?. The family member also said staff took the resident’s tray at 3:00 and the tray looked like they didn’t even set it up for him/her, the silverware was still wrapped up and his/her lunch remained untouched. He/She said he/she thinks the staff try not to wake him/her up because the resident is grumpy. The family member said they have asked the staff to give the resident bacon at least every breakfast, but they don’t always do that, and sometimes that is all he/she eats. He/She said, I don’t know why they can’t give him/her bacon every meal, can’t they make extra at breakfast and reheat it? He/She said they have problems getting him/her to eat anything else. He/She said the family buys the resident bran flakes because he/she will eat that, but the facility does not have them, and he/she will drink milk. The family member said the resident receives hospice services because of his/her weight loss. During an interview on 7/20/18 at 11:13 A.M., the MDS coordinator (MDSC) said the resident is on hospice for abnormal weight loss. During an interview on 7/20/18 at 12:26 P.M., the resident said he/she ate some of his/her riblet sandwich, and his/her milk. During an interview on 7/20/18, at 1:44 P.M., the dietary manager (DM) said the dietician instructed him/her to supplement the protein for Resident #9 with boost pudding. He/She |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 39) said if he/she has cottage cheese he/she will give it to him/her. He/She said he/she has to be careful with food substitutions, because he/she can’t do for one what he/she cannot do for all. He/She said if the resident wants cottage cheese every meal then other residents will want it and then it gets out of control. The DM said he/she expects staff to offer the resident items he/she can eat, and said there is not a list of appropriate protein foods the resident prefers. The DM said the resident consumes the Boost pudding sometimes. He/She said he/she is not aware the resident requested cottage cheese yesterday. He/She said he/she is not aware the resident was served casserole with meat in it or chicken and dumplings. He/She said the kitchen does not have a menu for residents who do not eat meat. He/She said the resident continues to lose weight, and they have not tried anything new. He/She said Resident #13 prefers bacon, bran flakes, and coffee every morning and he/she usually eats breakfast. He/She said that staff have not tried bacon at other meal times, because they would have to cook it. He/She said staff are expected to send whole milk with every meal. During an interview on 7/20/18 at 3:09 P.M., the DM said he/she interviews residents about their likes and dislikes on admission and it is put into the electronic record. He/She said the information about likes and dislikes is not available to the kitchen staff or the CNA’s. He/She said the alternate is the same for a week for lunch and supper, so it may be pork fritter one week and riblet sandwiches the next. He/She said the staff are not expected to cook any other foods for residents by request. During an interview on 7/20/18 at 5:26 P.M., the administrator (ADM) said dietary staff are expected to interview the residents about their likes/dislikes and document on their dietary card. He/She said if a resident does not like something, a substitution of equal nutritional value should be offered. He/She said if Resident #9 does not like meat an alternate of equal nutritional value should be offered. He/She said Resident #13 likes bran flakes, and bacon. The administrator said he/she never thought about serving bacon at meals other than breakfast. During an interview on 8/1/18 at 8:00 P.M., the registered dietitian (RD) said he/she expects the staff to interview each resident for his/her likes and dislikes, and honor those requests. He/She said staff are expected to offer the resident an alternate of equal nutritional value. He/She said Resident #9 does not like meat, and the staff should offer the resident the alternate food he/she likes, such as a peanut butter and jelly sandwich, grilled cheese, or cottage cheese as often as he/she will eat it. The RD said if Resident #13 only eats bacon, bran flakes, and milk it is reasonable to send him/her those items every meal to encourage him/her to eat something. He/She said both residents are malnourished and need whatever calories and protein they can get. The RD also said if he/she recommends new interventions or supplements, the staff are expected to try those interventions, and if the resident does not like them, staff are expected to document the results. The RD said that then he/she can recommend something else for staff to try. | |
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide safe and appropriate respiratory care for a resident when needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 40) bacterial contaminates that spread infection for three resident’s (Resident #9, #10, and #13). The facility census was 53. 1. Review of the facility’s policy Oxygen Administration, dated (MONTH) (YEAR), showed staff are directed: -To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; -Check the physician’s orders [REDACTED]. -Set the flow meter to the rate the ordered by the physician; -Place mask or cannula on resident as indicated above; -Label humidifier and/or tubing with date and time opened. The policy did not contain directions to staff on when to change the oxygen and medication nebulizer tubing. 2. Review of Resident #9’s annual Minimum Data Set (MDS), a federally mandated resident assessment, dated 4/28/18, showed the staff documented the resident as: -Moderate cognitive impairment; -Mild depression; -No behaviors; -Set up assistance with eating; -Limited physical assistance with bed mobility, ambulation, dressing, and toilet use; -Extensive physical assistance with transfers, and hygiene; -Dependent assistance with bathing; -93 pounds (lbs); -Oxygen therapy. Review of the resident’s Care Plan, last updated on 5/4/18, showed staff are directed: -Oxygen use; -Provide oxygen as ordered; -Staff to ensure that tubing is clean and change per protocol; -Staff to monitor oxygen saturation levels; -Staff to monitor lung sounds/coughing; -Staff to notify physician and durable power of attorney of any respiratory distress. Review of the resident’s physician’s orders [REDACTED]. Observation on 7/17/18, at 11:23 A.M., showed the resident’s nebulizer pump on the floor and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her bed. Observation showed the concentrator tubing dated 7/7/18, and the oxygen concentrator set at 1.5 liters (L). Observation on 7/18/18, at 10:18 A.M., showed the resident’s nebulizer pump on the floor and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her bed. Observation showed the concentrator tubing dated 7/7/18, and the oxygen concentrator set at 2.5 L. Observation on 7/19/18, at 11:32 A.M., showed the resident’s nebulizer pump on the floor and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her bed. Observation showed the concentrator tubing dated 7/7/18, and the oxygen concentrator set at 2.5 L. The resident told Certified Nurse’s Aide (CNA) B, I cannot breathe. Observation on 7/20/18, at 12:21 A.M., showed the resident’s nebulizer pump on the floor and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her bed. Observation showed the concentrator tubing dated 7/7/18, and the oxygen concentrator set at 3 L. 3. Review of Resident #10’s quarterly MDS, dated [DATE], showed the staff assessed the resident as: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 41) -Cognitively intact; -Extensive assistance of one staff member for locomotion, and hygiene; -Extensive assistance of two or more staff members with bed mobility; -Dependent with two or more staff members with transfers, dressing, toilet use, and bathing; -Functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot). The MDS did not contain documentation of oxygen use. Review of the Nurse’s notes, dated 5/21/2018, showed staff documented the resident’s portable oxygen was empty. The resident’s oxygen level is 70% on room air. Administered a [MEDICATION NAME] (medicated aerosol treatment) breathing treatment as per physician’s orders [REDACTED]. A concentrator for the resident has been ordered, waiting for delivery. Review of the resident’s Nurse’s notes, dated 5/31/2018, showed staff documented the resident’s oxygen saturation was 80% on room air. This nurse administered a scheduled breathing treatment and resident’s oxygen saturation stabilized at 95% on 2 L/NC. Review of the resident’s Nurse’s notes, dated 6/07/2018, showed staff documented the resident had shortness of breath and decreasing oxygen saturation when not on oxygen. Review of the resident’s Nurse’s notes, dated 6/11/2018, showed staff documented the resident had oxygen at 2 L, and oxygen saturation at 95%. Review of the resident’s physician’s orders [REDACTED]. Review of the resident’s Care plan, last updated 6/26/18, showed it did not contain direction to staff about oxygen use. Observation on 7/17/18, at 11:09 A.M., showed the resident with oxygen on via nasal cannula with the tubing dated 7/7/18. Observation showed the oxygen concentrator set at 2.5 L. Observation on 7/18/18, at 10:30 A.M., showed the resident with oxygen on via nasal cannula dated 7/7/18. Observation showed the oxygen concentrator set at 2.5 L. 4. Review of Resident #13’s Care Plan, dated 1/24/18, showed it directed staff: -Resident has Oxygen; -Staff to administer oxygen as ordered; -Staff to monitor oxygen saturation; -Staff to monitor for respiratory distress; -Staff to monitor lung sounds; -Staff to change oxygen tubing per facility protocol; -Staff to notify physician and responsible party of any respiratory distress. Review of the resident’s significant change (SCSA) MDS, dated [DATE], showed the staff documented the resident as: -Severe cognitive impairment; -Severe depression; -Limited physical assistance of one staff member for eating; -Extensive assistance of one staff member for dressing, toilet use, bathing, and hygiene -Dependent on one staff member for bed mobility, and transfers; -81 lbs.; -Oxygen therapy. Review of the resident’s physician’s orders [REDACTED]. -Oxygen 3 Liters per minute per nasal cannula continuous for shortness of breath; -Change oxygen tubing weekly; -Change nebulizer tubing weekly. Observation on 7/17/18, at 11:19 A.M., showed the resident on his/her right side curled into a ball on his/her bed with his/her eyes closed. Observation showed the resident’s |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 42) nasal cannula tubing connected to his/her concentrator on the floor under the end of his/her bed. Further observation showed the resident’s concentrator set on 1 L the nasal cannula dated 7/7/18, and the resident’s portable oxygen tank on his/her wheelchair dated 7/7/18. Observation on 7/18/18, at 12:09 P.M., showed the resident in bed. Observation showed the resident’s oxygen concentrator off and the nasal cannula tubing in a bag dated 7/7/18. Observation on 7/19/18, at 11:29 A.M., showed the resident in his/her bed in a fetal position. Observation showed the resident’s oxygen nasal cannula tubing dated 7/17/18 in a bag on the floor, and the concentrator turned off. During an interview on 7/19/18, at 12:53 P.M., the certified nurse assistant (CNA) B said the resident’s concentrator is set at 1 L/minute. The CNA said the resident only uses it when he/she is anxious to make him/her feel better. Observation on 7/20/18, at 12:26 P.M., showed the resident in bed with his/her nasal cannula on the bed next to him/her. Observation showed his/her oxygen set at 1 L/min per nasal cannula, with the oxygen tubing undated. 5. During an interview on 7/19/18, licensed practical nurse (LPN)A said staff are expected to follow physician’s orders [REDACTED]. He/She said if the tubing is on the floor the staff should replace it for infection control reasons. During an interview on 7/20/18, at 5:26 P.M., the director of nursing (DON) said oxygen should be administered according to a physician’s orders [REDACTED]. | |
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 43) of eight scheduled showers for the resident. Review of the resident’s shower sheets, for the month of July, showed staff documented they provided a shower on 7/17/18. Staff did not provide five of six scheduled showers for the resident. 3. Review of Resident #5’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 10 out of 15, moderate cognitive impairment; – Required limited assistance for transfers, dressing, toilet use, eating, bathing, and personal hygiene; – [DIAGNOSES REDACTED]. Review of the resident’s shower sheets, for the month of June, showed staff documented the resident refused a shower on 6/1/18, and they provided a shower on 6/12/18, and 6/26/18. Staff did not provide five of eight scheduled showers for the resident. 4. Review of Resident #10’s, quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -Extensive assistance of one staff member for locomotion, and hygiene; -Extensive assistance of two or more staff members with bed mobility; -Dependent with two or more staff members with transfers, dressing, toilet use, and bathing. Review of the resident’s Care Plan, last updated 5/28/18, directed staff to provide a shower twice a week and prn. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 6/4/18, 6/11/18, 6/14/18, and 6/21/18. Staff did not provide four of eight scheduled showers for the resident. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 7/9/18, and 7/12/18. Staff did not provide four of six scheduled showers for the resident. Observation showed on 7/17/18, at 2:00 P.M., the resident in his/her bed. Observation showed the resident’s hair is greasy, and uncombed. The resident has a body odor and long facial hair. During an interview on 7/17/18, at 2:00 P.M., the resident said that the staff do not have time to do his/her showers twice a week. He/She said it would be nice to feel cleaner. 4. Review of Resident # 15’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Understood, understands; – BIMS score of 12 out of 15, moderate cognitive impairment; – [DIAGNOSES REDACTED]. Review of the resident’s shower sheets, for the month of June, showed staff documented they provided showers on 6/4/18, 6/11/18, 6/14/18, 6/18/18, and 6/21/18. Staff did not provide three of eight scheduled showers for the resident. Review of the resident’s shower sheets, for the month of July, showed staff documented they provided showers on 7/2/18, 7/5/18, and 7/12/18. Staff did not provide three of six scheduled showers for the resident. 5. Review of Resident #17’s quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Usually understood, sometimes understands; – Severe cognitive impairment; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 44) – Required limited assistance with bed mobility and eating; – Required extensive assistance with dressing, toileting, and personal hygiene; – Required total assistance for transfers and bathing; – [DIAGNOSES REDACTED]. Review of the resident’s shower sheets for the month of June, showed staff documented they provided showers on 6/1/18, 6/15/18, 6/19/18, and 6/26/18. Staff did not provide four of eight scheduled showers for the resident. Review of the resident’s shower sheets for the month of July, showed staff documented they provided showers on 7/10/18, 7/13/18, 7/17/18, and 7/20/18. Staff did not provide two of six scheduled showers for the resident. 6. Review of Resident #18’s quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -[MEDICAL CONDITION] or [MEDICAL CONDITION] (paralysis on one side); -Limited physical assistance of one staff member for bed mobility, transfers, locomotion, dressing, and hygiene; -Extensive assistance of one staff member for toilet use, and bathing. Review of the resident’s Care Plan, dated 2/18/18, directed staff to provide a shower twice a week and prn. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 6/4/18, 6/11/18, 6/14/18, 6/19/18, and 6/21/18. Staff did not provide three of eight scheduled showers for the resident. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 7/9/18, 7/12/18, and 7/16/18. Staff did not provide three of six scheduled showers for the resident. Observation on 7/17/18, at 2:44 P.M.,, showed the resident’s hair greasy, and brown substance under his/her fingernails. During an interview on 7/17/18, 2:44 P.M., the resident said the residents are supposed to get showers twice a week but the facility will take the bath aide off his/her assignment to work on the floor, so we only get a shower one time a week a lot. He/She said they are always short staffed. He/She said a bath once a week is not enough, it makes him/her feel itchy because of the dry skin. He/She said call lights are a problem too. He/She said when staff is short I have to wait sometimes over 20 minutes and I have to go in (urinate) in my pants. 7. Review of Resident #19’s quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Severe cognitive impairment; -Limited physical assistance with toilet use and hygiene; -Dependent on one staff member for bathing. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 6/4/18, 6/11/18, 6/14/18, 6/18/18, 6/21/18, and 6/26/18. Staff did not provide two of eight scheduled showers for the resident. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided showers on 7/9/18, 7/12/18, and 7/16/18. Staff did not provide three of six scheduled showers for the resident. Review of the resident’s Care Plan, last updated 7/18/18, directed staff to provide a shower twice a week and as needed. Observation on 7/18/18, at 11:00 A.M., showed the resident sitting at the nurses station. The resident’s hair was unkempt, he/she had a dried brown substance from his/her lips to |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 45) his/her chin, he/she had long facial hair, and his/her fingernails showed a brown substance under them. He/She had discolored, crusty spots on the front of his/her shirt and on the top thigh area of his/her pants. 8. Review of Resident #42’s care plan, dated 1/1/18, showed staff are directed: -Provide a shower twice a week and as needed; -Assist the resident with activities of daily living (ADLs) as needed. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented the resident refused a shower on 6/13/18, and they provided showers on 6/14/18 and 6/27/18. Staff did not provide five of eight scheduled showers for the resident. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not display behaviors and did not reject care during the look back period; -Required assistance of one staff for bed mobility; -Required extensive assistance of two or more staff for transfers, dressing, toilet use, and personal hygiene; -Dependent on one staff for bathing. Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they provided a shower for the resident on 7/17/18 and 7/18/18. Staff did not provide four of six scheduled showers for the resident. 9. Review of Resident #43 quarterly MDS, dated [DATE], showed the following: – admission date of [DATE]; – Understands, understood; – BIMS of 15 out of 15, cognitively intact; – Required limited assistance with transfers, dressing, toileting, personal hygiene, and bathing; – [DIAGNOSES REDACTED]. During an interview, Resident #43 said his/her only concern is that there is no one at the nurse’s station during meals. He/she has pushed his/her call light, and no facility staff answered until meal time was over. He/She is concerned if someone fell that they would have to wait a long time for an answer help. 10. Review of Resident #206’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Did not display behaviors or reject care; -Dependent on two or more staff for transfers and bathing; -Required extensive assistance of two or more staff for bed mobility, dressing, toilet use, and personal hygiene; -Required extensive assistance of one staff for eating. Review of the resident’s shower sheets for (MONTH) (YEAR) showed staff documented they provided a shower on 6/4/18, 6/11/18, 6/18/18, 6/21/18, and 6/26/18. Staff did not provide three of eight scheduled showers to the resident. Review of the resident’s shower sheets for (MONTH) (YEAR) showed staff documented they provided a shower on 7/16/18. Staff did not provide five of six scheduled showers for the resident. Review of the resident’s care plan, last updated 7/19/18, showed staff are directed: -The resident requires assistance with all activities of daily living (ADLs); -Provide a shower twice a week and as needed. Observation on 7/18/18 at 4:22 P.M., showed the resident with dark brown debris under his/her fingernails. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 46) Observation on 7/19/18 at 9:20 A.M., showed the resident with dark brown debris under his/her fingernails. Observation on 7/19/18 3:42 P.M., showed the dark brown debris remained under his/her fingernails. 11. During an interview on 7/17/18, at 3:02 P.M., a family member said sometimes there are only two aides for 50 plus people here on days and evenings but especially after 6 p.m. and there is not enough to put them to bed. Our family stays until 9:00 and puts our family members to bed. He/She said his/her family member wants one shower a week but he/she has gone two -three weeks without a shower at all. He/She said there was one night there were only two aides and another family member and myself felt bad for the staff and the residents so we were helping pass trays and they called the director of nursing (DON). He/she said the DON didn’t come help or send anyone, staff just said that we could not help the staff with resident meals. During an interview on 7/19/18, at 9:19 A.M., the administrator (ADM) said the facility staffs with minimum CNA staffing of three aides on days, three aides on evenings, and two on night shift. He/She said that staffing has been a huge issue for the facility. During an interview on 7/20/18, at 10:47 A.M., certified nurse assistant (CNA) H said they have had holes in the schedule for call ins or people that have quit. He/She said the shower aide will have to work the floor with a full assignment if the facility does not have enough staff and then the showers do not get completed. He/She said there have been evenings after 6 p.m. that there are only 2 aides and we do what we can, there are supposed to be at least three aides. He/She said Resident #9 had to wait on me a really long time to be changed one time and I felt so bad, I just couldn’t get to him/her. He/She said the call lights are all going off and stay on longer than they should when we are short staffed. During an interview on 7/20/18, at 2:00 P.M., license practical nurse (LPN) A said staff should offer residents a shower at least twice a week and as needed or requested. He/She said staffing is tight sometimes and showers do not get completed as scheduled. During an interview on 7/20/18, 5:26 P.M., the director of nursing (DON) said staff are expected to offer showers at least twice a week and as needed. The DON said staffing is a challenge. | |
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 47) -[DATE] Dinner: tomato soup, crackers, grilled cheese sandwich, cucumber onion salad, mandarin oranges, coffee, milk or tea; [DATE] Lunch: peppered pork loin, au gratin potatoes, zucchini and tomatoes, dinner roll, margarine, strawberry ring cake, coffee or tea; [DATE] Dinner: sloppy joe on bun, chips, baked pork and beans, chilled peaches, coffee or tea and milk; [DATE] Lunch: BBQ chicken, red bliss potatoes, cream style corn, bread of choice, margarine, fresh banana, coffee or tea; [DATE] Dinner: Salisbury steak, gravy, mashed potatoes, broccoli, bread of choice, margarine, fruit cup, coffee, tea or milk; [DATE] Lunch: stuffed pepper casserole, capri blend vegetables, bread, margarine, apricot halves, coffee or tea; [DATE] Dinner: egg salad platter crackers, danish or muffin, margarine, baked apples, coffee or tea, milk. 2. Review of the facility’s documentation from the Registered Dietitian (RD), dated [DATE], directed staff about changing the lunch menu for [DATE]. The RD recommended to substitute the turkey, dressing, green beans, gravy, and strawberry ring cake. The RD said to check the spreadsheet from other meals for portion sizes. 3. Review of Resident #9’s physician’s orders [REDACTED]. -Regular diet, no meat per resident’s request, may supplement protein with other foods; -Provide snack for the resident at bedtime with small frequent snacks throughout the day; -[DATE]: discontinue Protein pudding twice a day. -[DATE]: start house supplement drink 4 ounces (oz) with meals. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment, dated [DATE], showed the staff documented the resident as: -Moderate cognitive impairment; -Set up assistance with eating; -101 pounds (lbs); -No oral problems (edentulous/did not have teeth not checked). Review of the resident’s Comprehensive Nutrition Assessment, dated [DATE], showed the dietitian documented: -[DIAGNOSES REDACTED]. -Regular diet, no meat per resident’s request, likes peanut butter and jelly sandwiches in place of meat, and boost pudding; -Likes peanut butter and jelly sandwiches, and cottage cheese; -Current weight 92.8 lbs, -No oral problems (edentulous not checked); -Body Mass Index 92.8 underweight; -More that 5% weight change in 30 days; -Recommend clarify boost pudding orders to twice a day with meals, add cottage cheese to lunch and dinner meals for additional protein, add super cereal at breakfast, and boost VHC (a high calorie/protein supplement) three times a day with med pass. Review of Resident #9’s annual MDS, dated [DATE], showed staff documented the resident as: -Moderate cognitive impairment; -Set up assistance with eating; -93 pounds (lbs) (7.9% weight loss since [DATE]); -No oral problems (edentulous not checked). Review of the resident’s Care Plan, dated [DATE], showed it directed staff: -At risk for weight loss; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 48) -Provide resident with ordered diet; -Offer double portions of things that the resident likes; -Offer alternative if the resident does not like the main meal; -Resident does not want meat; -Resident prefers peanut butter and jelly sandwiches often; -Provide ordered boost pudding; -Notify the physician and durable power of attorney with significant weight loss; -Monitor for need to change diet consistency. Review of the resident’s weight record showed staff documented: -[DATE] 101 pounds (lbs); -[DATE] 100.6 lbs; -[DATE] 97.8 lbs; -[DATE] 94.2 lbs; -[DATE] 94.4 lbs; -[DATE] 93.8 lbs; -[DATE] 92.8 lbs; -[DATE] 93.6 lbs; -[DATE] 91.4 lbs; -[DATE] 92.8 lbs; -[DATE] 91.8 lbs; -[DATE] 90 lbs, (10.89% wt loss since [DATE]); -[DATE] 92 lbs; -[DATE] 91 lbs; -[DATE] 90 lbs, (10.89% wt loss since [DATE]). Observation on [DATE], at 11:23 A.M., showed CNA B offered the resident dressing and gravy, onion rings and a banana for his/her meal order. The resident asked if there is any other option, and the CNA repeated dressing and gravy, onion rings and a banana. The resident said I cannot eat meat, and the staff member repeated dressing and gravy, onion rings and a banana. Further observation showed the staff did not serve the resident a 4 oz supplement drink, or boost pudding. The staff did not offer the resident a protein or an alternate entree that did not contain meat, or a protein supplement. During an interview on [DATE], at 11:25 A.M., the resident said he/she cannot eat meat and a lot of the food provided here, because he/she does not have teeth mainly, so he/she cannot chew it, and some of it bothers his/her stomach. He/She said sometimes he/she can get a peanut butter and jelly sandwich. He/She said they finally had cottage cheese that he/she could eat. The resident said it would be nice to have a cheese sandwich or something like that but it is not an option. The resident said his/her family used to bring him/her snacks but they do not anymore, and staff bring him/her snacks sometimes but not every day. He/She said that he/she is hungry all the time. He/She said, I don’t get enough protein and I only weigh 91 pounds. Observation on [DATE], at 12:20 P.M., showed staff served the resident in his/her room, dressing with gravy, onion rings, a banana, and lemonade. Further observation showed the staff did not serve the resident a 4 oz supplement drink, or boost pudding. Observation on [DATE], at 12:12 P.M., showed staff served the resident in his/her room, Mexican casserole with meat, onion rings, boost pudding and a banana. Observation showed the resident’s meal ticket on his/her tray said cottage cheese, and the resident did not receive cottage cheese. During an interview on [DATE], at 12:12 P.M., the resident said he/she requested cottage cheese and did not receive it. The resident said he/she did not like the casserole, it was |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 49) too spicy and had meat in it. He/She said the staff did not offer him/her an alternate. Observation on [DATE], at 12:41 P.M., showed the Activity director served the resident chicken and dumplings, two pieces of corn bread, strawberries and lemonade. The resident said to the staff member, I don’t like cornbread, and the staff member replied you do not have to eat the cornbread. The staff member did not offer the resident an alternative to the meat in the chicken and dumplings, or an alternative for the cornbread. Further observation showed the staff did not serve the resident a 4 oz supplement drink, or boost pudding. During an interview on [DATE], at 12:45 P.M., the resident said he/she would try to eat the noodles in the chicken and dumplings. He/She said the staff did not offer him/her an alternate. Observation on [DATE], at 12:21 P.M., showed the resident in his/her bed with his/her tray. The tray contained french fries, onion rings, boost pudding, and cobbler. During an interview on [DATE], at 12:21 P.M., the resident said that staff told him/her the kitchen did not have cottage cheese. He/She said the staff did not offer him/her an alternate. He/She said, the staff talk so fast and I don’t have time to think of what I want to eat, or even ask for anything else before they are gone. 4. Review of Resident #13’s significant change (SCSA) MDS, dated [DATE], showed the staff documented the resident as: -Severe cognitive impairment; -Limited physical assistance of one staff member for eating; -81 lbs. Review of the resident’s quarterly MDS, dated [DATE], showed the staff documented the resident as: -Severe cognitive impairment; -Limited physical assistance of one staff member for eating; -67 lbs. Review of the assessment showed staff did not code the resident as a weight loss. Review of the resident’s POS, dated [DATE]-[DATE], directed staff to: -[DATE] start house shakes/supplements three times a day with medication pass; -[DATE] oxygen at three liters per nasal cannula continuous; -[DATE] start Mechanical soft diet; -[DATE] discontinue mechanical soft diet; -[DATE] start regular diet; -[DATE] Discontinue House shakes/supplements. Review of the resident’s Care Plan, dated [DATE], directed staff to: -Provide ordered diet; -Monitor intake; -Provide double portions of the things that he/she likes; -Offer alternate if the resident does not like the main dish; -Encourage family to bring in favorite foods/snacks; -Notify physician and durable power of attorney of any significant weight loss. Review of the resident’s weight record showed staff documented: -[DATE] 81.6 lbs; -[DATE] 80.6 lbs; -[DATE] 77 lbs; -[DATE] 71.6 lbs; -[DATE] 68.8 lbs (15.68 % weight loss); -[DATE] 67.2 lbs (17.64 % weight loss); |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 50) -[DATE] 70.4 lbs; -[DATE] 72.4 lbs. Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented: -Resident has lost 10 lbs, 12.9% over the last 30 days, now 70.2 lbs,BMI 13.71 very underweight; -Unsure of diet, no order in chart; -Gets house supplement three times a day for snacks; -Nursing and dietary report resident has been refusing to come to the dining room or eat at all; -Usually likes milk; -Family here often and sometimes brings in food; -Takes [MEDICATION NAME] 15 milligrams (antidepressant) which should improve appetite; -Is on Hospice care; -Continue encouraging food and fluids; -Recommend: Add diet orders to chart. Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented: -Resident continues to lose weight, down 12 lbs,15.7% in 90 days, down 2 lbs, 3.9% in 30 days now 68.8#; -BMI 13.44 underweight; -Has been evaluated by Speech Therapy- they have recommended Mechanical soft diet; -Intake poor ,[DATE]% usually; -Receives house supplement three times a day; -The resident has been requesting regular consistency meat- especially bacon; -Family wound like her to have bacon, and other regular consistency foods; -Family has been educated on choking hazards, but feel Regular consistency better; -Takes [MEDICATION NAME] 7.5 mg which can improve appetite; -Liberalize diet to regular per family and resident preference; -Recommend: Add house supplement three times a day with meals for additional calories. Review of the physician’s orders [REDACTED]. Review of the Nutrition quarterly review, dated [DATE], the staff documented: -Mechanical soft diet; -Current weight 69 lbs; -House shakes/supplements three times a day; -Resident refuses all shakes sent from dietary department. Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented: -Resident has lost 14 lbs, 17.8% over the last 90 days, down 1 lbs in 30 days. Now 67.2# BMI 13.12; -Receives mechanical soft diet and house supplement three times a day; -Has poor appetite (,[DATE]%) and often refuses house supplement – shakes & ice cream attempted with poor intake; -Continues requesting bacon, but not allowed on mechanical soft diet; -Evaluated by speech therapy today; -Will be trialing regular diet over the next several days and bacon will be allowed; -Takes [MEDICATION NAME] 15 mg which can improve appetite; -Continues on Hospice care; -Recommend: Boost Breeze or VHC (depending on resident preference) 90 cc three times a day with med pass, discontinue house supplement- refuses to drink. Review of the physician’s orders [REDACTED]. Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 51) -Resident’s wt is down 11 lbs, 14% over the last 6 months, but has been steady over the last 90 days; -Diet has been liberalized to Regular, -BMI 13.71 underweight -Intake generally poor ,[DATE]%; -House supplement three times a day; -Takes [MEDICATION NAME] 15 mg which can improve appetite; -No new recommendations. Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented: -Wt down 9 lbs, 11.3% over the last 6 months, but has been trending up over the last 90 days. -Now 72.4 lbs BMI 14.14 underweight; -Is on Hospice care; -Receives Regular diet, fluids are encouraged 120 ml water four times a day with med pass; -Intake fair ,[DATE]% usually; -Spoke with dietary, he/she does not like supplement drink/ice milk, prefers milk; -Takes [MEDICATION NAME] 15 mg which can improve appetite; -Recommend: Whole milk three times a day with meals. Observation on [DATE], at 12:21 P.M., showed the resident in bed in a fetal position with his/her eyes closed. Observation showed his/her lunch tray with his/her plate covered, his/her dessert covered with a transparent film, his/her silverware still wrapped in a napkin like it came from dietary, and a glass of koolaide. Further observation showed the resident’s tray did not contain milk, bacon, bran flakes, or a nutritional supplement. During an interview on [DATE], at 3:02 P.M., the resident’s family member said the food choice is terrible, they have one alternate for a week and there is nothing else. If he/she doesn’t like riblet, he/she is stuck for the whole week. He/She said, having the same alternate twice a day for a week is crazy to me, or they have chicken as the alternate and a different version of chicken as the meal so if you don’t like chicken what are you supposed to eat. He/She said we asked the staff to give him/her bacon at least every breakfast but they don’t always do that, and sometimes that is all he/she eats. He/She said I don’t know why they can’t give her bacon every meal, can’t they make extra at breakfast and reheat it. He/She said we have problems getting him/her to eat anything. He/She said the family buys him/her bran flakes because he/she will eat that, and drink milk. He/She said the resident is on hospice because of his/her weight loss. Observation on [DATE], at 12:15 P.M., showed the resident in bed in a fetal position with his/her eyes closed. Observation showed the staff served the resident Mexican casserole, au gratin potatoes, zucchini and tomatoes, a dinner roll, margarine, and strawberry ring cake. Observation showed the resident’s food is untouched. Further observation showed the resident’s tray did not contain milk, bacon, bran flakes, or a nutritional supplement. Observation on [DATE], at 12:27 P.M., showed the resident sitting on the side of his/her bed. Observation showed CNA B served the resident chicken and dumplings, cornbread, fried okra, peaches, a banana, and a glass of milk. Further observation showed the resident’s tray did not contain bacon, bran flakes, or a nutritional supplement. Observation on [DATE], at 12:44 P.M., showed the resident consumed 25% of his/her chicken and dumplings, a few pieces of okra, and drank his/her milk. During an interview on [DATE], at 11:13 A.M., the MDS coordinator (MDSC) said the resident is on hospice for abnormal weight loss on the hospice admission form. During an interview on [DATE], at 12:26 P.M., the resident said he/she ate some of his/her riblet sandwich, and his/her milk. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 52) 5. Review of Resident #19’s quarterly MDS, dated 5/ /18, showed the staff assessed the resident as: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Insulin injections seven days a week; -Limited physical assistance of one staff member for eating. Review of the resident’s physician’s orders [REDACTED]. -[MEDICATION NAME] (a fast acting insulin) on a sliding scale: If blood sugar is 200 to 249- give 6 units, 250 to 299- give 8 units, 300 to 349- give 12 units, 350 to 399- give 15 units, greater than 400- call the physician. Check blood sugar and administer insulin at 8:00 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M.; -Levimer (a long acting insulin) administer 14 units at 7:00 A.M., and 8:00 P.M. Review of the resident’s Care Plan, last updated [DATE], directed staff to: -Resident is an Insulin dependent Diabetic; -Goal: Resident will be absence of signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION]; -Staff to provide diet as ordered; -Staff to take all accu checks (check blood sugar) as ordered; -Staff to provide all ordered medications; -Staff to administer all insulins as ordered; -Staff to rotate insulin sites; -Staff to monitor for signs and symptoms of hypo/hyper glycemia (low or high blood sugar, symptoms include: fatigue, shakiness, change in mental status, sweating, change in mood or behavior); -Staff to provide a bedtime snack; -Staff to notify physician of any significant changes. Observation on [DATE], at 12:,[DATE]:55 P.M., showed the staff did not serve the resident a tray. Observation showed a staff member entered the resident’s room at 12:30 P.M. and reminded him/her it is time for lunch. During an interview on [DATE], at 12:55 P.M., certified nurse assistant (CNA) B said the staff were done serving lunch trays. He/She said he/she did not know that the resident did not get a tray. During an interview on [DATE], at 1:05 P.M., licensed practical nurse (LPN) A said that if the resident does not eat the staff are expected to let the nurse know. He/She said staff are expected to bring every resident a tray even if they say they do not want one to see if they change their mind. The LPN said that the resident’s blood sugar was over 200 so he/she received six units of insulin so it is important that he/she eat. He/She said the staff did not make him/her aware the resident did not get a tray. During an interview on [DATE], at 10:23 A.M., the MDS coordinator (MDSC) said that the resident has hypoglycemic episodes. He/She said if the resident refused the meal staff should immediately notify the nurse. He/She said the staff are expected to bring a tray to every resident no matter what. He/She also said if you bring the tray to the resident he/she usually will go ahead and eat it. 6. During an interview on [DATE], at 12:00 P.M., Resident #10 said the facility only serves one alternate for the week, or we can have peanut butter and jelly. He/She said if you like the alternate for the week it is ok, you may get a little tired of it. He/She said if you don’t like it, it’s the pits. 7. During an interview on [DATE], at 2:58 P.M., Resident #18 said he/she does not always like the food items the facility serves and the alternate isn’t much better. He/She said |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 53) the alternate is the same food for lunch and dinner for a week, so if you don’t like it, tough luck. 8. During an interview on [DATE], at 1:44 P.M., the dietary manager (DM) said he/she was instructed by the dietitian to supplement the protein for Resident #9 with boost pudding. He/She said if he/she has cottage cheese he/she will give it to him/her. He/She said he/she has to be careful with food substitutions because he/she can’t do for one what he/she cannot do for all. He/She said if the resident wants cottage cheese every meal then the next resident wants it and then it gets out of control. The DM said that he/she expects staff to offer the resident items he/she can eat, and said there is not a list of appropriate protein foods that the resident prefers. The DM said the resident only consumes the Boost pudding sometimes. He/She said he/she is not aware the resident requested cottage cheese yesterday. He/She said he/she is not aware the resident was served casserole with meat in it or chicken and dumplings. He/She said the kitchen does not have a menu for residents who do not eat meat. He/She said the resident continues to lose weight, and they have not tried anything new. He/She said Resident #13 prefers bacon, bran flakes, and coffee every morning and he/she usually eats breakfast. He/She said that staff have not tried bacon at other meal times, because they would have to cook it. He/She said staff are expected to send whole milk with every meal. He/She said staff are expected to bring every resident a tray at meals, and Resident #19 got missed because his meal card got turned the wrong way. During an interview on [DATE], at 3:09 P.M., the DM said he/she interviews residents about their likes and dislikes on admission and enters the information into the electronic record. He/She said the information about likes and dislikes is not available to the kitchen staff or the CNA’s. He/She said that the alternate is the same for a week for lunch and supper, so it may be pork fritter one week and riblet sandwiches the next. He/She said the staff are not expected to cook any other foods for residents by request. During an interview on [DATE], at 5:26 P.M., the director of nursing (DON) said that staff are expected to follow the physician’s orders [REDACTED]. During an interview on [DATE], at 5:26 P.M., the administrator (ADM) said dietary staff are expected to interview the resident’s about their likes/dislikes and place on their dietary card. He/She said if a resident does not like something then a substitution of equal nutritional value should be offered. He/She said if Resident #9 does not like meat an alternate of equal nutritional value should be offered. He/She said that Resident #13 likes bran flakes, and bacon. He/She never thought about serving bacon more than breakfast. He/She said the alternate is the same for lunch and dinner for a week, and then it is changed to another alternate. During an interview on [DATE], at 8:00 P.M., the registered dietitian (RD) said he/she expects the staff to interview each resident for his/her likes and dislikes, and honor those request. He/She said staff are expected to offer the resident an alternate of equal nutritional value. He/She said Resident #9 does not like meat, and the staff should offer the resident the alternate food he/she likes like peanut butter and jelly sandwich, grilled cheese, or cottage cheese as often as he/she will eat it. He/She said if Resident #13 only eats bacon, bran flakes, and milk it is reasonable to send him/her those items every meal to encourage him/her to eat something. The RD said both residents are malnourished and need whatever calories and protein they can get. He/She said that if he/she recommends new interventions or supplements, the staff are expected to try those interventions, and if the resident does not like them to document the results. He/She said that then he/she can recommend something else for staff to try. The RD also said all residents should receive a tray for each meal. He/She said with Resident #19, he/she may |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 54) have consumed some of the tray if it were there for him/her to see, and with diabetic residents it is important to report to the charge nurse if they do not eat a meal. The RD said the alternate always available menu is new to the facility. He/She said facility staff were supposed to start with a few options like corn dogs, hamburgers, chicken strips, french fries, and onion rings and then expand the menu to include more foods each week until they had a large always available menu. He/She said the facility did not consult with him/her about offering one alternate for every lunch and dinner for a week. He/She said having one alternate for lunch and dinner for a week is not an adequate method to ensure that residents have a variety of food options. | |
| F 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 55) -[DATE] Dinner: tomato soup, crackers, grilled cheese sandwich, cucumber onion salad, mandarin oranges, coffee, milk or tea; [DATE] Lunch: peppered pork loin, au gratin potatoes, zucchini and tomatoes, dinner roll, margarine, strawberry ring cake, coffee or tea; [DATE] Dinner: sloppy joe on bun, chips, baked pork and beans, chilled peaches, coffee or tea and milk; [DATE] Lunch: BBQ chicken, red bliss potatoes, cream style corn, bread of choice, margarine, fresh banana, coffee or tea; [DATE] Dinner: Salisbury steak, gravy, mashed potatoes, broccoli, bread of choice, margarine, fruit cup, coffee, tea or milk; [DATE] Lunch: stuffed pepper casserole, capri blend vegetables, bread, margarine, apricot halves, coffee or tea; [DATE] Dinner: egg salad platter, crackers, danish or muffin, margarine, baked apples, coffee or tea, milk. Staff did not provide a gluten free diet menu. Additional review showed staff listed the meal alternate for lunch and supper for [DATE] through [DATE] as BBQ rib on bun, onion rings, and apricots. Observation on [DATE] at 12:08 P.M., showed staff served the resident turkey, and gravy with dressing. Staff did not provide the resident a gluten free meal, and did not offer the resident a gluten free alternative. Observation on [DATE] at 12:00 P.M., showed staff served the resident chicken and dumplings, peaches and tea. Staff did not provide the resident a gluten free meal, and did not offer the resident a gluten free alternative. 2. During an interview on [DATE] at 12:15, the Dietary Manager (DM) said staff served the resident hot tea, broth, and two packages of crackers for lunch. The DM said the crackers are not gluten free, and the facility does not have gluten free crackers available at this time. During an interview on [DATE] at 1:45 P.M., the DM said the only gluten free alternative currently available to the resident is gluten free cereal. The DM said staff have offered the resident gluten free bread but the resident didn’t like it. He/She did not know if staff tried more than one brand of gluten free bread. The DM said staff have never provided a completely gluten free menu to the resident, because he/she doesn’t stick to the diet. He/She said staff tell the resident what is on the menu, and if he/she selects an item with gluten, they tell the resident it contains gluten and ask if he/she still wants it, but do not offer a gluten free substitute of the same food item such as a hamburger bun or pasta. The DM said staff offer the gluten free cereal or other things we have on hand that do not contain gluten as an alternative to the food items with gluten. Staff do not prepare gluten free menu items for the resident and do not offer to prepare gluten free versions of the items on the menu. The DM said he/she did not know if staff have attempted to prepare gluten free versions of the resident’s preferred foods, like biscuits and gravy. During an interview on [DATE] at 5:26 P.M., the DON and administrator said staff have not provided gluten free items to Resident #1, and the facility does not have a menu with gluten free substitutes of equal nutritional value. During an interview on [DATE] at 5:30 P.M., Certified Nurse’s Aide (CNA) B said staff do not offer the resident gluten free alternatives when they ask him/her what he/she wants to eat at meals. The CNA said if the resident selects an item that is not gluten free staff will remind him/her it contains gluten, but the resident usually chooses to eat it. The CNA said staff do not offer a gluten free option, just remind the resident what he/she |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 56) chose contains gluten. During an interview on [DATE] at 5:38 P.M., Licensed Practical Nurse (LPN) A said the resident often chooses the main entree offered, even if it contains gluten. He/She said staff do not offer the resident gluten free options, they just remind the resident that the items he/she selected contain gluten. The LPN said staff have not contacted the resident’s physician and asked about changing or modifying the ordered diet. LPN A also said he/she does not know if staff have tried to prepare various gluten free foods for the resident to determine if there are gluten free foods he/she would enjoy in place of the items on the menu with gluten. The LPN said staff can tell when the resident eats gluten, because he/she will have loose stools, especially after foods like biscuits and gravy. LPN A said the resident continues to eat the biscuits and gravy because he/she really likes them. The LPN said he/she thought staff had tried to offer the resident gluten free biscuits and gravy for breakfast some time ago, but did not remember if staff had attempted to prepare the resident gluten free biscuits and gravy recently. During an interview on [DATE], at 8:00 P.M., the registered dietitian (RD) said staff are expected to offer the resident the gluten free diet. He/She said the staff have a spreadsheet column with a gluten free diet for every meal. He/She said the staff should not offer the regular meal but honor requests, if a resident wants something not on his/her menu. He/She said the resident has very bad side effects from eating gluten, and it is important to try to offer him/her a variety of gluten free options to choose from because of the effects it has on him/her. He/She said that there is gluten free bread that can be stored in the freezer that would make it affordable for one resident. He/She said some of the menus are a slight variation to the regular menu and some are a whole different meal. The RD said he/she did not know the staff were not offering the gluten free menu available to them, and that gluten free cereal did not have enough nutrition to be an equal substitute for meals. | |
| 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: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 57) infection. Observation on 7/19/18 at 9:23 A.M., showed CNA F and CNA B transferred Resident #206 into bed from his/her wheelchair with the hoyer lift. CNA F provided incontinence care to the resident. He/She used the same area of the wipe for multiple wipes of the resident’s perineal area. The CNA did not provide perineal care in a manner to prevent the spread of infection. Observation on 7/19/18 at 2:30 P.M., showed CNA B and CNA F transferred Resident #7 into bed from his/her gerichair and provided incontinence care. CNA B cleansed the resident’s bottom, and changed his/her gloves but did not wash his/her hands. The CNA touched the resident’s clean brief, clean bed linens, and the hoyer lift pad with his/her contaminated gloves. The CNA did not provide care in a manner to prevent the spread of infection. Observation on 7/19/18, at 3:24 P.M., showed nurse assistant (NA) H, and NA D assisted Resident #23 to the bathroom. NA D cleansed the resident’s back folds, soiled with feces. Observation showed NA D removed his/her gloves, did not cleanse or wash his/her hands, and touched the residents skin, the mechanical lift, propelled his/her chair out of the bathroom, and applied his/her nasal cannula oxygen tubing with his/her contaminated hands. The NA left the room and did not cleanse his/her hands. The CNA did not provide care in a manner to prevent the spread of infection. 3. During an interview on 7/19/18, at 3:30 P.M., NA H said staff are expected to cleanse or wash their hands before they provide care to a resident and after care of a resident. Staff are expected to change their gloves and cleanse their hands between dirty and clean areas, and when they change their gloves. During an interview on 7/20/18, at 10:47 A.M., NA D said staff are expected to wash their hands when they go in a room and when they go out, and between dirty and clean task. He/She said, I totally forgot to wash my hands. During an interview on 7/20/18, at 5:23 P.M., certified nurse assistant (CNA) B said staff are expected to change their gloves and wash their hands before and after care, between dirty and clean areas, and when they change gloves. He/She said he/she forgot to wash his/her hands when providing care. 4. Review of the facility’s policy on blood glucose monitoring, dated (MONTH) (YEAR), showed staff are directed: -Place equipment on a clean surface; -Disinfect glucose monitor after use and return to cart. Review of the facility’s policy on blood glucometer disinfecting, dated (MONTH) (YEAR), showed staff are directed to clean the blood glucose meter prior to use with approved with 10% bleach or comparable product, place on clean field and let air dry according to manufacturer’s directions. Do not touch the clean field with gloves including the test port. Glucometer may be wrapped in another wipe and stored. 5. Review of the manufacturer’s recommendations for the facility’s multiple resident use glucometer showed staff are directed: -Use a manufacturer approved product to clean and disinfect the glucometer; -Allow the surface of the glucometer to remain wet at room temperature for the contact time listed on the wipe’s directions for use; -Wipe all external areas of the meter, including both front and back surfaces until visibly wet; -Wipe the meter dry, or allow to air dry. 6. Observation on 7/19/18 at 11:15 A.M., showed CMT E at the medication cart. The CMT placed the multiple resident use glucometer on top of the medication cart and gathered supplies to check Resident # 10’s blood sugar. CMT E entered the resident’s room, placed |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 58) the glucometer on the resident’s bed, prepared the resident, and checked the resident’s blood sugar. The CMT returned to the medication cart and placed the glucometer on top of the cart. He/She did not sanitize the glucometer before or after he/she checked the resident’s blood sugar. Observation on 7/19/18 at 11:20 A.M., showed CMT E removed the glucometer from the top of the medication cart, gathered supplies, and entered Resident #19’s room. The CMT placed the glucometer on top of the resident’s refrigerator, prepared the resident, and checked his/her blood sugar. The CMT returned to the medication cart and placed the glucometer on top of the cart. He/She did not sanitize the glucometer before or after he/she checked the resident’s blood sugar. Observation on 7/19/18 at 11:27 A.M., showed CMT E removed the glucometer from the top of the medication cart, gathered supplies, and entered Resident #16’s room. The CMT placed the glucometer on the resident’s bed, prepared the resident, and checked the resident’s blood sugar. The CMT returned to the medication cart and placed the glucometer on top of the cart. He/She did not sanitize the glucometer before or after he/she checked the resident’s blood sugar. During an interview on 7/19/18 at 11:42 A.M., CMT E said he/she did not know staff are expected to sanitize multiple use resident glucometers between each resident. The CMT said he/she did not receive instruction to sanitize the glucometer between residents, but it makes sense. 7. Review of the facility’s policy Oxygen Administration, dated (MONTH) (YEAR), showed staff are directed: -To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; -Check the physician’s orders [REDACTED]. -Set the flow meter to the rate the ordered by the physician; -Place mask or cannula on resident as indicated above; -Label humidifier and/or tubing with date and time opened. The policy did not contain directions to staff on when to change the oxygen and medication nebulizer tubing, or how to store the tubing and equipment when not in use. 8. Observation on 7/17/18, at 11:23 A.M., showed Resident #9’s nebulizer pump on the floor and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her bed. Observation showed the concentrator tubing dated 7/7/18. The staff did not store or change the resident’s respiratory equipment in a manner to prevent the spread of infection. Observation on 7/18/18, at 10:18 A.M., showed the resident’s nebulizer pump on the floor and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her bed. Observation showed the concentrator tubing dated 7/7/18. The staff did not store or change the resident’s respiratory equipment in a manner to prevent the spread of infection. Observation on 7/19/18, at 11:32 A.M., showed the resident’s nebulizer pump on the floor and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her bed. Observation showed the concentrator tubing dated 7/7/18. The staff did not store or change the resident’s respiratory equipment in a manner to prevent the spread of infection. Observation on 7/20/18, at 12:21 A.M., showed the resident’s nebulizer pump on the floor and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her bed. Observation showed the concentrator tubing dated 7/7/18. The staff did not store or change the resident’s respiratory equipment in a manner to prevent the spread of |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265418 |
| (X3) DATE SURVEY COMPLETED 07/20/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER DIXON NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 403 EAST 10TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 59) infection. 9. Observation on 7/17/18, at 11:09 A.M., showed Resident #10’s oxygen on via nasal cannula with the tubing dated 7/7/18. The staff did not change the resident’s respiratory equipment in a manner to prevent the spread of infection. Observation on 7/18/18, at 10:30 A.M., showed the resident with oxygen on via nasal cannula dated 7-7-18. The staff did not change the resident’s respiratory equipment in a manner to prevent the spread of infection. 10. Observation on 7/17/18, at 11:19 A.M., showed Resident #13 on his/her right side curled into a ball on his/her bed with his/her eyes closed. Observation showed the resident’s nasal cannula tubing connected to his/her concentrator on the floor under the end of his/her bed. Further observation showed the nasal cannula dated 7/7/18, and the resident’s portable oxygen tank on his/her wheelchair dated 7/7/18. The staff did not store or change the resident’s respiratory equipment in a manner to prevent the spread of infection. Observation on 7/18/18, at 12:09 P.M., showed the resident in bed. Observation showed the nasal cannula tubing in a bag dated 7/7/18. The staff did not change the resident’s respiratory equipment in a manner to prevent the spread of infection. Observation on 7/19/18, at 11:29 A.M., showed the resident in his/her bed in a fetal position. Observation showed the resident’s oxygen nasal cannula tubing dated 7/17/18 in a bag on the floor. The staff did not store or change the resident’s respiratory equipment in a manner to prevent the spread of infection. Observation on 7/20/18, at 12:26 P.M., showed the resident in bed with his/her nasal cannula on the bed next to him/her. Observation showed the oxygen tubing undated. The staff did not change the resident’s respiratory equipment in a manner to prevent the spread of infection. 11. During an interview on 7/19/18, licensed practical nurse (LPN)A said staff are expected to change oxygen tubing and nebulizer tubing once a week. He/She said if the tubing is on the floor the staff should replace it for infection control reasons. He/She said staff are expected to wash their hands before and after care of a resident, between dirty and clean task while providing care, and with glove changes. He/She said the glucometer should be cleansed between residents according to manufacturer’s instructions. During an interview on 7/20/18, at 5:26 P.M., the director of nursing (DON) said staff should change oxygen tubing and medication nebulizer tubing weekly. He/She said when the tubing is not in use it should be coiled and in a bag. He/She said staff are expected to wash their hands before and after care of a resident, between dirty and clean task while providing care, and with glove changes. He/She said the glucometer should be cleansed between residents according to manufacturer’s instructions. | |
