| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 | 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 1) During an interview on 1/30/19, at 8:18 A.M., Maintenance Staff A said they were in the process of stripping floors and replacing bathroom floor tiles. They have 4 more rooms to do on the unit then they will do the front area. A contractor came in and stripped the hallways and failed to seal the doorways and leaked dirty water and wax into the resident rooms which is why the tiles in the doorways look so dirty. During an interview on 1/30/19, at 2:36 P.M., the Maintenance Supervisor said he was just sick about the quality of work the contractor did when they stripped the hallways. The contractor made a big mess, leaving the doorways full of waxed-in dirt and debris. He and his staff started replacing bathroom flooring, and as time allows, plan to continue fixing, replacing and cleaning the facility’s floors. The kitchen floor contains broken and worn tiles that are hard to clean. He hoped they would be able to replace the kitchen floor in the future. | |
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Assess the resident when there is a significant change in condition **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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) The physician diagnosed the resident with lower bilateral extremity [MEDICAL CONDITION] (swelling of both legs) and placed the resident on [MEDICATION NAME] (a diuretic). Review of the resident’s dietary notes, dated 1/7/19, showed significant weight gain; weight gain from 203 pounds on 12/12/18, to 223 pounds on 1/7/19. (Weight gain of 20 pounds or 9.1% in less than a month). During an interview on 1/29/19, at 5:07 P.M., Licensed Practical Nurse (LPN) B said the resident has had significant weight gain. The resident saw the physician in (MONTH) for the weight gain and the Nurse Practitioner (NP) this month. They added [MEDICATION NAME] (40 milligram) twice a day for 10 days for the [MEDICAL CONDITION] in his/her legs and placed the resident on weekly weights. Observation and interview on 1/27/19, at 9:54 A.M., showed the resident sat in recliner with a blanket over his/her legs. The resident looked as if he/she had been crying. The resident said he/she missed his/her daddy and continued to cry. Homemaker A went into the resident’s room and he/she told the homemaker why he/she was so tearful. Observation and interview on 1/27/19, at 2:52 P.M., showed the resident in his/her recliner with his/her feet up and a blanket up to his/her neck. The resident said he/she stayed in his/her room most of the time. He/she did not like all of the yelling and fighting that went on in the facility. There are residents who are mean to staff, yelling and hitting, residents who yell at each other and the code green’s are all very upsetting to him/her. He/she said he/she was unable to stop crying when he/she thinks of his/her daddy. The resident said he/she had a lot of pain but the pain in his/her legs were some better. The resident showed the surveyor his/her legs and they looked puffy and swollen. Observation and interview on 1/28/19, at 3:10 P.M., the resident said he/she felt better today since he/she talked with the tele-psy (Seeing and speaking with the mental health physician located at a remote location over a computer screen) physician. The physician ordered mental health therapy sessions so he/she can get some help about missing his/her daddy so much. The resident’s legs looked swollen and puffy. Review of the medical record on 1/28/19, at 9:00 A.M., showed the facility addressed the resident’s increased depression. The resident spoke with Tele-Psy yesterday, 1/27/19. The physician increased the resident’s [MEDICATION NAME] (used for depression) on 1/28/19 and gave an order for [REDACTED]. Record review and interview on 1/29/19, at 5:07 P.M., LPN B said the resident has increased depression in the last month or two over the loss of his/her father. The resident saw the tele-psy physician this week and counseling was ordered. They also increased his/her antidepressant medication on 12/18/18 and again on 1/28/19. The information in the computer and in the resident’s chart confirmed the information. During an interview on 1/28/19, at 3:55 P.M., the MDS Coordinator said he/she only thought of health issues when addressing the need for a MDS significant change. Significant weight gain and increased depression was not something that triggered in her mind for the need to do an MDS significant change. The resident’s increased weight and increased depression should have been addressed with a significant change MDS. During an interview with the Director of Nursing (DON) on 1/31/19, at 2:50 P.M., the DON said significant weight gain and increased depression should have triggered the need for a MDS significant change. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. |
| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 – Few | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff developed and updated a care plan consistent with residents’ specific conditions and needs which affected three of 18 sampled residents (Resident #13, #44 and #61). The facility census was 82. 1. Review of the facility’s Comprehensive Care Plans policy, dated (MONTH) 6, 2007, showed: – Purpose: To ensure the facility develops a comprehensive care plan for each resident that includes measurable objectives and time tables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. – A registered nurse (RN) has been designated to work with an Inter-Disciplinary Team (IDT) for the purpose of the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, and care planning process. – The Resident Assessment Instrument (RAI) User Manual will be used to look at residents holistically. – Daily nursing meetings will occur Monday through Friday with a review of the resident’s medical, functional, and psychosocial problems and this information will be individualized to the resident’s plan of care. – The care plan will be oriented toward preventing avoidable declines in functioning or functional levels; managing risk factors; addressing residents’ strengths; using current standards of practice in the care planning process; evaluating treatment objectives and outcomes of care; respecting the resident’s right to refuse treatment; using an IDT approach to care plan development to improve the resident’s functional status; involving resident/family/responsible party; assessing and planning for care sufficient to meet the care needs of new admissions; involving the direct care staff with the care planning process relating to the resident’s expected outcomes; addressing additional care planning areas that could be considered in the facility setting; utilizing the Care Area Assessment sheets (CAAS, identifies areas of care needed for caring for a resident) process to identify why areas of concern may have been triggered. – The care plan will be updated toward preventing declines in functioning, will reflect on managing risk factors and building on resident’s strengths. – All treatment objectives will be measureable and corroborate with the resident’s own goals and wishes when appropriate. – Care plans will be initiated and revised timely, accurately, and will be individualized. 2. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/7/18, showed: – A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made his/her own decisions; – No behaviors; – Independent in all care areas; – Received antipsychotic medications, antidepressant medications, antianxiety medications and opioids (narcotic pain medications) seven out of last seven days; – [DIAGNOSES REDACTED]. Review of the January, 2019 physician’s orders [REDACTED]. – Check mouth after giving each medication to prevent cheeking (holding, not swallowing) of medications; – [MEDICATION NAME] 10 milligrams (mg) one tablet daily for [MEDICAL CONDITION]; – [MEDICATION NAME] 1 mg, one tablet BID (twice daily) for [MEDICAL CONDITION] disorder; – [MEDICATION NAME] 5 mg, one tablet at bedtime (HS) for [MEDICAL CONDITION]; |
| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 – Few | (continued… from page 4) – [MEDICATION NAME] 15 mg, two tablets at HS for [MEDICAL CONDITION]; – Trazadone 150 mg, one tablet at HS for [MEDICAL CONDITION]; – Bisopromol [MEDICATION NAME] 5 mg, one tablet daily for hypertension; hold for a systolic (measures the pressure in your blood vessels when your heart beats) B/P less than 100 or a heart rate less than 60; – [MEDICATION NAME] 20 mg, one tablet daily for hypertension; hold for a systolic B/P of less than 100 or a heart rate less than 60; – [MEDICATION NAME] sodium 100 mg, one capsule BID for bowel regulation; – [MEDICATION NAME]-S, two tablets at HS for bowel regulation; – [MEDICATION NAME] 10 mg/15 milliliters (ml), 15 ml daily PRN (as needed) for constipation; – Magnesium [MEDICATION NAME], drink on bottle every three days PRN for constipation; – Milk of Magnesia, 30 ml every other day PRN for constipation; – Polyethylene [MEDICATION NAME] powder, dissolve one scoopful, 17 grams, in 8 ounces of liquid and drink BID PRN for constipation; – Ranitadine 300 mg one tablet BID for reflux disease; – [MEDICATION NAME] liquid, 30 ml every six hours PRN for reflux or indigestion; – [MEDICATION NAME] sulfate 2.5 mg/3 ml, inhale one vial per nebulizer (a machine that changes medication from a liquid to a mist so that it can be more easily inhaled into the lungs) every six hours PRN for [MEDICAL CONDITION]; – [MEDICATION NAME] APAP (narcotic pain medication) 10/325 mg, one tablet every six hours for pain. Review of the care plan last updated on 1/1/19, showed: – Staff did not develop a plan of care for [MEDICAL CONDITION]. – Staff did not develop a plan of care for [MEDICAL CONDITION] disorder (known as manic-depressive illness, a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks). – Staff did not develop a plan of care for the use of antipsychotic, antidepressant, antianxiety, and opioid medications. – Staff did not develop a plan of care for constipation, hypertension (elevated blood pressure, B/P), reflux disease (backing up of stomach contents into the throat), [MEDICAL CONDITION], or [MEDICAL CONDITION] ([MEDICAL CONDITIONS]). 3. Review of Resident #61’s significant change in status MDS, dated [DATE], showed: – Moderately cognitive impaired; – Extensive assist of one staff for activities of daily living (ADLs); – No behaviors; – Received antipsychotic medications, anxiety medications, antidepressant medications, and hypnotic medications seven out of the last seven days; – [DIAGNOSES REDACTED]. Review of the POS [REDACTED] – Duloxetine 20 mg daily for major [MEDICAL CONDITION]; – [MEDICATION NAME] 50 mg daily for depression; – [MEDICATION NAME] 1 mg BID for depression; – [MEDICATION NAME] 0.5 mg three times a day (TID) for anxiety disorder; – [MEDICATION NAME] 100 mg BID for [MEDICAL CONDITION]; – [MEDICATION NAME] 32.4 mg BID for [MEDICAL CONDITION]. Review of the care plan, revised 1/22/19, showed the facility staff did not develop plans of care to address the following: – Major [MEDICAL CONDITION]; |
| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 – Few | (continued… from page 5) – Anxiety disorder; – [MEDICAL CONDITION]; – The use of antipsychotic, antidepressant, antianxiety, [MEDICAL CONDITION], and hypnotic medications. 4. Review of the Resident #44’s Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/18 showed the following: – Independent in decision making; – Independent with care; – No depression of feeling of dread or hopeless; – No significant weight loss or gain; – Weight 210, height 65 inches; – [DIAGNOSES REDACTED]. Review of the resident’s monthly summaries, dated 10/29/18, 11/718, 12/12/18 and 1/7/9, all showed the resident had been feeling or appeared down, depressed or hopeless. Review of the resident’s History and Physical, showed Medical Group A saw the resident on 12/19/18. Physician A saw the resident on 1/8/19, for his/her 19 pound weight gain. The physician diagnosed the resident with lower bilateral extremity [MEDICAL CONDITION] and placed the resident on [MEDICATION NAME] (diuretic). Review of the resident’s dietary notes, dated 1/7/19, showed significant weight gain; weight gain from 203 pounds on 12/12/18, to 223 pounds on 1/7/19. (Weight gain of 20 pounds or 9.1% in less than a month). Review of the current physician order [REDACTED].>Review of the resident’s care plan for nutrition under Problems/needs, dated 1/17/19, showed: – Problems: Resident will stop eating when reaches 200 pounds; Resident will overeat then vomit; Resident ask for seconds for most meals; Resident does not comed down for breakfast; – Goals – I will maintain my weight within 5% of my current weight of 222. Approaches: – Resident on house supplement TID; Montor weight monthly; Record dietary intake; – The care plan did not address the resident’s significant weight gain. – The care plan did not address the resident’s [MEDICAL CONDITION]. – The care plan addressed house supplement but the resident was not on house supplement. During an interview on 1/29/19, at 5:07 P.M., Licensed Practical Nurse (LPN) B said the resident has had a significant weight gain. The resident saw the physician in (MONTH) for the weight gain and the Nurse Practitioner this month. They added [MEDICATION NAME] (40 milligram) twice a day for 10 days for the [MEDICAL CONDITION] in his/her legs and placed the resident on weekly weights. Review of the resident’s care plan for [MEDICAL CONDITION] disorder, dated 1/09/19, showed: – Problem: Resident currently taking antipsychotic medications, antidepressant medications and antianxiety medications to manage mental illness. – Goal: Resident will have minimal to no adverse effects from medications within the next three months; – Resident will have no significant increase in depression or behaviors for the next three months; – Approaches: administer medications as ordered; monitor for any possible adverse effects such as drowsiness, dizziness, tremors, dry mouth etc.; – The care plan did not address the resident’s increased depression and crying related to the loss of his/her father before Christmas. |
| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 – Few | (continued… from page 6) Observation and interview on 1/27/19 at 9:54 A.M., showed the resident sat in a recliner with a blanket over his/her legs. The resident looked as if he/she had been crying. The resident said he/she missed his/her daddy and continued to cry. Homemaker A went into the resident’s room and he/she told the homemaker why he/she was so tearful Observation and interview on 1/27/19, at 2:52 P.M., showed the resident in his/her recliner with his/her feet up and a blanket up to his/her neck. The resident said he/she stayed in his/her room most of the time. He/she did not like all of the yelling and fighting that went on in the facility. There are residents who are mean to staff, yelling and hitting, residents who yell at each other and the code green’s (A call out for staff to come help calm a situtation when a resident might be harmful to self or others – verbal or physicial) are all very upsetting to him/her. He/she said he/she was unable to stop crying when he/she thinks of his/her daddy. The resident said he/she had a lot of pain but the pain in his/her legs were some better. The resident showed the surveyor his/her legs and they looked puffy and swollen. During an interview on 1/28/19, at 3:10 P.M., the resident said he/she felt better today since he/she talked with the tele-psy (a visual conference call between the resident and the mental health pysician who is located at a remote location) physician. The physician ordered mental health therapy sessions so he/she can get some help about missing his/her daddy so much. The resident’s legs looked swollen and puffy. Review of resident’s progress notes writen by the nurses on 1/28/19, at 9:00 A.M., showed the facility addressed the resident’s increased depression. The resident spoke with Tele-Psy yesterday. The physician increased [MEDICATION NAME] (used for depression) and gave order for counseling and for the resident to be reevaluated in 30 days, Record review and interview on 1/29/19, at 5:07 P.M., LPN B said the resident has had increased depression in the last month or two over the loss of his/her father. The resident saw the tele-psy physician this week and counseling was ordered. They also increased his/her antidepressant medication on 12/18/18, and again on 1/28/19. The information in the computer and in the resident’s chart confirmed the information. 5. During an interview on 1/28/19, at 3:55 P.M., and on 1/31/19, at 11:00 A.M., the MDS/Care Plan said – She thought the care plans were up to date, but when she was the acting Director of Nursing (DON) for five months, someone else did the care plans. – She is finding a lot of errors in the care plans and is working to correct them. – Resident #44 had not been on a supplement for about 4 months so that should not have been on the care plan. The resident’s increased weight and increased depression should have been updated on the care plan. – She had not thought to care plan antipsychotic, antidepressant, or antianxiety medications. – All care plans needed to be comprehensive and individualized to each resident’s needs and issues. During an interview on 1/31/19, at 2:50 P.M., and at 4:55 P.M., the Director of Nursing (DON) said: – Care plans should be comprehensive and all areas should be included in the care plan for residents. – Any issues or incidents that happen such as falls, should be care planned immediately. – Significant weight gain and increased depression should have been addressed on the resident’s care plan. – The care plan should not say Resident #44 was on a supplement three times a day. – She expected the care plan to be current with what is happening to the resident today. |
| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 – Few | (continued… from page 7) – They have daily meetings and changes discussed should trigger changes in the resident’s care plan. | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure services provided by the nursing facility meet professional standards of quality. **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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) federally mandated assessment instrument completed by facility staff, dated 11/17/18, showed: – A Brief Interview for Mental Status (BIMS) score of 8 which indicated supervision needed in decision making; – Mechanically altered diet; – [DIAGNOSES REDACTED]. Review of the January, 2019, POS showed: – NAME] DR (used to treat GERD) 40 milligrams (mg), one twice daily (BID) before meals, give on an empty stomach. Review of the January, 2019, MAR showed: – Staff hand recorded NAME] DR, 40 mg, 1 tablet by mouth BID and did not record before meals, on an empty stomach. – Administration times were 8:00 A.M. and 4:00 P.M. Observation and interview on 1/29/19, at 8:56 A.M., CMT A did and said: – Administered NAME] DR, 40 mg to the resident; – Said he/she administered the medication after the resident ate his/her breakfast meal; – Said the MAR did not show to administer before meals, on an empty stomach; – He/she did not know who recorded the medication on the MAR. During an interview on 1/30/19 at 2:49 P.M., RCC A said: – NAME] DR should be given before meals. – Breakfast was scheduled to be served at 8:00 A.M. and the NAME] DR should be given at 7:00 A.M.; – If staff administered the medication at 8:56 A.M., it was not given before breakfast or on an empty stomach; – The POS showed to give the NAME] DR before meals and on an empty stomach. – The pharmacy should have printed the medication and instructions on the January, 2019 MAR and he/she did not know why times were not printed. – The times printed on the January, 2019 were 7:00 A.M. and 4:00 P.M., not 8:00 A.M. as hand written by staff. – CMTs and nurses could record orders on the MAR. 3. Review of Resident #73’s December, (YEAR), POS showed: – Licensed Practical Nurse (LPN) A hand recorded Humalog insulin sliding scale (an amount of insulin given related to the blood sugar level assessed) as verbally ordered by Family Nurse Practitioner (FNP) on 12/16/18; – Blood Sugar (BS) 151 milligrams (mg)/deciliter (dl) to 200 mg/dl give 2 units of Humalog insulin. Review of the resident’s quarterly MDS, dated [DATE], showed: – A BIMS score of 15, which indicated he/she made his/her own decisions; – [DIAGNOSES REDACTED]. – Therapeutic diet; – Received insulin injection seven out of last seven days. Review of the January, 2019, POS showed: – Humalog insulin sliding scale: BS 151 mg/dl to 200 mg/dl, administer 1 unit of Humalog insulin with a physician order date of 9/9/18; – The most recent verbal and handwritten order, dated 12/16/18, for Humalog sliding scale insulin was not printed on the January, 2019, POS. Review of the January, 2019, Weekly Diabetic Report/Flow Sheet showed: – Humalog insulin per sliding scale before meals and at bedtime: BS 151 mg/dl to 200 mg/dl administer 2 units of Humalog insulin; |
| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) – BS 182 mg/dl, Humalog 2 units administered. Observation on 1/30/19, at 11:59 A.M., showed: – LPN A administered Humalog 2 units to the resident for a BS of 182 mg/dl. Review of the January, 2019, MAR showed: – The sliding scale listed as Humalog insulin 1 unit for a BS of 151 mg/dl to 200 mg/dl; – Staff handwrote See DM (diabetes mellitus) Flow Sheet; – No insulin administration charted on the MAR, only on the Weekly Diabetic Report/Flow Sheet. During an interview on 1/30/19, at 2:30 P.M., LPN A said: – The order changed from 1 unit to 2 units for a BS of 151 mg/dl to 200 mg/dl on 12/16/18, and showed the surveyor the written order for the change of dose; – The Weekly Diabetic Report/Flow Sheet, dated January, 2019, showed the change of dose to Humalog 2 units for a BS of 151 mg/dl to 200 mg/dl; – He/she administered the latest, correct dose of insulin to the resident; – He/she did not know why the printed POS did not show the changed sliding scale dose. During an interview on 1/30/19, at 2:33 P.M., RCC A said: – The sliding scale order was changed in December, (YEAR), but did not get carried over to the January, 2019 POS; – He/she reconciled the POS and MAR at the end of each month, but missed the changed order and did not get it corrected. 4. During an interview on 1/31/19, at 4:55 P.M., the Director of Nursing (DON) said: – She expected physicians’ orders to be followed. – RCC A always reconciles POS, MAR, and Weekly Diabetic Record/Flow Sheets monthly. – The pharmacy did not print the correct times on the January, 2019, and she did not know why. – She expected RCC A to reconcile all medications and orders correctly. | |
| F 0865 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Have a plan that describes the process for conducting QAPI and QAA activities. Based on observation, interview and record review, the facility failed to provide |
| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 0865 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) QAPI leadership by being on the QAA committee. – The administrator will facilitate discussion on QAPI activities at the quarterly QAA meetings. – The organization will conduct performance improvement projects (PIP) that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention. During an interview on 1/31/19, at 3:50 P.M., the DON and administrator said: – They have been in their positions for the last three months and have not fully developed and implemented the QAA/QAPI. – The corporation is scheduled to do training on the QAA/QAPI soon in the facility. – QAA should meet monthly and quarterly with the interdisciplinary team (IDT), medical director, and pharmacist. – They met with the medical director this fall to go over some of the QAPI but have no documentation. – There is no documentation from the meeting or signature sheet of who attended. – The DON stated labs have been an issue they are addressing through the QAA. – The DON stated the committee should be identifying, developing, implementing, monitoring, evaluating, and documenting issues and care areas to provide quality of care. | |
| F 0908 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Keep all essential equipment working safely. Based on observation, interview and record review, the facility failed to maintain |
| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 0908 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) door. – He was not aware of any wheelchairs that needed to be repaired. During an interview on 1/30/19, at 10:33 A.M., and on 1/31/19, at 4:55 P.M., the Director of Nursing (DON) said: – Staff should fill out maintenance work slips when they see issues that need to be addressed. – She did not know about the poor condition of the wheelchair arms on any wheelchairs. – Maintenance could repair or replace the wheelchair arms. | |
| F 0921 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 0921 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 12) and said: – Pulled back the linens on the resident’s mattress and the surveyor smelled the mattress cover and mattress; – Both the mattress and cover smelled of strong urine; – CNA A said that housekeeping cleaned the mattresses of residents daily after CNAs stripped the beds, then the CNAs would remake the beds for the residents; – Said the mattress covers should be able to be removed because there were buckles to hold the covers in place; he/she did not know if housekeeping removed and washed the mattress covers or not; – Removed an incontinent pad from a seat cushion in a recliner and the chair and cushion did not smell of urine; – CNA A said the facility got rid of a recliner that Resident #7 used to have because it smelled of urine and the new recliner was gifted to Resident #7 by his/her roommate’s family; – CNA A said they now use the incontinent pad in the chair at all times. During an interview on 1/31/19, at 2:33 P.M., the Housekeeping/Laundry Manager (HLM) said: – Staff check Hot Spots at least three times a day or more if a resident is a heavy |
| 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: 265730 |
| (X3) DATE SURVEY COMPLETED 01/31/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER EASTVIEW MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1622 EAST 28TH 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 0921 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 13) material on center hall near rooms [ROOM NUMBERS]. Observation on 1/29/18, at 2:30 P.M., showed the odors on center hall remain strong and unpleasant. Observation on 1/30/19, at 7:55 A.M., showed strong urine and fecal material odors of urine and fecal material down center hall. During an interview on 1/30/19, at 8:01 A.M., Licensed Practical Nurse (LPN) B said he/she could smell the urine odor today and a hot odor from the copy machine on center hall. The odor on center hall is not consistent. Observation on 1/30/19, between 5:30 A.M. and 6:00 P.M., showed off and on odors in resident rooms when residents or staff placed soiled briefs or pull-up in uncovered trash cans in the bathrooms. Observation on 1/30/19 at 10:55 a.m., showed an odor in the hallways; upon inspection soiled briefs were found in resident rooms; such as in resident room [ROOM NUMBER] and resident room [ROOM NUMBER]. During an interview on 1/30/19, at 2:55 P.M., the Director of Nursing said they really thought they were managing odors. Bathroom trash cans are residents who provide their own incontinence needs. She had staff check the rooms and pull the trash which reduced the odors greatly. During an interview on 1/30/19, at 3:10 P.M., the Administrator said the resident who resides in room [ROOM NUMBER] has a medical condition that caused the strong odor of fecal material and odor. The room is cleaned and deodorized often but she cannot prevent the odor. | |
