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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility staff failed to ensure they provided a | |
F 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement policies and procedures to prevent abuse, neglect, and theft. **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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) -Problem: The resident alleged he/she was hit with a comb on his/her leg by a staff member; -Approach: Assure resident that he/she is safe. Encourage resident to verbalize thoughts. Social Service Director will visit resident one on one as needed. The patient care team will observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and make him/her feel safe. Review of the facility’s Statement of Investigation, written by the Activity Director, dated 6/18/18, showed the following: -The resident’s family member reported to the Activity Director while he/she sat with the resident in the dining room two staff members entered; -The resident began yelling and told the two staff members, a Certified Nurse Aid (CNA) and a Certified Medication Technician (CMT) to leave the dining room because they hit him/her; -The Activity Director notified the administrator and Director of Nurses; -He/she instructed the CNA to leave the unit; -No documentation whether he/she instructed the CMT to leave the unit; -No documentation whether either staff were instructed to leave the facility. During an interview on 6/26/18 at 10:15 A.M., the Director of Nurses said the staff the resident identified as hitting him/her weren’t sent home. She believed the resident had the staff members confused, but staff should have followed the facility’s policy and sent those two staff members home. Review of the facility’s policy on Abuse, Neglect and Exploitation, updated 11/1/16, showed the following: -VI: Resident protection after alleged Abuse, Neglect and Exploitation: Reassignment of nursing and or other staff duties. Time off for nursing and or other staff; -VII: Response and Reporting of Abuse, Neglect and Exploitation: When abuse, neglect or exploitation is suspected, the licensed nurse should: Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately. MO 869 | |
F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) 3. Review of Resident #192’s MDS submission schedule, showed the following: -admission date of [DATE]; -No admission MDS submitted. 4. Review of Resident #193’s MDS submission schedule, showed the following: -admitted d of 4/13/18; -No admission MDS submitted. 5. During an interview on 6/20/18 at 11:50 A.M., the MDS/Care Plan Coordinator said she is the only MDS/Care Plan Coordinator for the facility. She looked through her submission lists and said she could not find evidence where the comprehensive MDSs for Residents #5, #8, #192 and #193 had been submitted timely. She got behind on the MDS process in (MONTH) (YEAR) and (MONTH) (YEAR). There are too many MDSs that come do at the same time, and it is difficult to finish them timely. She does have several MDSs ready to be submitted, but the Director of Nurses (DON) had not added her electronic signature and she can’t submit those MDSs without that signature. When she finishes an MDS she lets the DON know so she is not sure why they have not been signed yet. 6. During an interview on 6/26/18 at 10:20 A.M., the DON said she asks the MDS/Care Plan Coordinator if there is anything to sign on a weekly basis. She signs them as they are given to her. She was not aware there are completed MDSs needing her signature. 7. During an interview on 6/26/18 at 6:26 A.M., the Director of Clinical Operations said she did not know the MDSs were behind. | |
F 0638 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Assure that each resident’s assessment is updated at least once every 3 months. **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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0638 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) -A quarterly MDS dated and submitted on 3/16/18; -No quarterly MDS completed and/or submitted as of 6/26/18. 6. Review of Resident #192’s MDS submission schedule, showed the following: -admission date of [DATE]; -No quarterly MDS completed and/or submitted. 7. During an interview on 6/20/18 at 11:50 A.M., the MDS/Care Plan Coordinator said she is the only MDS/Care Plan Coordinator for the facility. She got behind on the MDS process in (MONTH) (YEAR) and (MONTH) (YEAR). There are too many MDSs that come do at the same time, and it is difficult to finish them timely. She does have several MDSs ready to be submitted, but the Director of Nurses (DON) had not added her electronic signature and she can’t submit those MDSs without that signature. When she finishes an MDS she lets the DON know so she is not sure why they have not been signed yet. 8. During an interview on 6/26/18 at 10:20 A.M., the DON said she asks the MDS/Care Plan Coordinator if there is anything to sign on a weekly basis. She signs them as they are given to her. She was not aware there are completed MDSs needing her signature. 9. During an interview on 6/26/18 at 6:26 A.M., the Director of Clinical Operations said she did not know the MDSs were behind. | |
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** 2. Review of Resident #57’s care plan, located in the facility computer system, and last |
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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) ordered. Observation on 6/22/18 at 4:35 A.M., prior to the MDS/Care Plan Coordinator arriving, showed no care plan in the care plan book located at the nurse’s station for the resident. 3. Review of Resident #79’s care plan, located in the facility computer system, and last 4. Review of Resident #193’s care plan, located in the facility computer system, and last 5. During an interview on 6/26/18 10:20 A.M., the Director of Nurses said care plans are | |
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. Based on observation and interview, the facility staff failed to ensure they kept |
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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) – The Director of Nurse’s office unlocked; – No staff in the DON’s office; – Under the DON’s desk were 13 partial cards of medications and 10 partial bottles of stock medications. During an interview on 6/25/18, at 6:19 P.M., the DON said medications in her office were the expired medications that needed to be destroyed. All medications in the facility needed to be locked at all times, even if they were expired. | |
F 0661 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0661 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) Review of the resident’s physician’s orders [REDACTED]. Observation on 6/25/18, showed staff obtained a weight of 136.7 lbs for the resident. 2. Review of Resident #57’s annual MDS, dated [DATE], showed the following: -Adequate hearing and vision; -Understood/understands; -Clear speech – distinct intelligible words; -Understood and understands; -Supervision and oversight required for eating; -[DIAGNOSES REDACTED]. -Weight of 175 lbs. Review of the resident’s RD progress notes, dated 4/25/18 and again on 5/16/18, showed recommendations each time to discontinue the health shakes and start Med Pass 120 cc three times a day. Review of the resident’s MAR from 5/1/18 through 5/31/18, showed staff documented administering the health shakes until 5/29/18, and then documented administering Med Pass 120 cc three times a day. Review of the resident’s RD progress note, dated 6/20/18, showed the RD recommended to decrease the Med Pass 120 cc from three times a day to two times a day due to weight gain. 3. During an interview on 6/25/18 at 2:13 P.M., the Director of Nurses said the RD sends her a report containing recommendations within a week after she leaves the facility. She gives the recommendations to Nurse H to contact the physicians. She does not know Nurse H’s system for following up to determine if the physician has responded to the recommendation. After receiving the RD’s recommendations, it should not take longer than a week to get a response from the physician. 4. Review of Resident #195’s face sheet, showed an admission date of [DATE] and multiple [DIAGNOSES REDACTED]. Review of the resident’s care plan, last reviewed on 4/12/18, showed the following: -Required tube feeding, related to past stroke and dysphagia (swallowing problems) and also on a pureed diet with thin liquids; -Difficulty communicating, but can write if given a pen and paper; -Total dependence on others for all activities of daily living. Review of the residents POS, dated (MONTH) (YEAR), showed the following: -An order dated 5/7/18, for [MEDICATION NAME] 1.5 (a nutritional supplement containing 1/5 calories per milliliter (ml)) bolus (a single dose administered all at once) 120 ml via [DEVICE] (gastrostomy tube, a tube surgically inserted into the stomach through the abdomen for fluids, nutrition and medication, four times daily; -An order dated 6/4/18, to change tube feeding bolus to three times a day due to weight gain. Observation on 6/22/18 at 5:53 A.M., showed Nurse G took a carton of [MEDICATION NAME] 1.5 from the medication cart, looked at the carton and poured the contents into two plastic cups. He/she picked up the carton, looked at it again and then put it in the trash. The carton showed it contained 8 ounces (237 ml). The nurse entered the room and delivered the contents of the two cups into the resident’s [DEVICE]). Review of the resident’s MAR, dated (MONTH) (YEAR), showed an order for [REDACTED]. During an interview on 6/22/18 at 6:41 A.M., while looking at the MAR and the carton of [MEDICATION NAME] 1.5, Nurse G said he/she thought something wasn’t right but he/she didn’t check. |
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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
F 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Past noncompliance – remedy proposed **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) -Resident is currently on [MEDICATION NAME] (anti-depressant/hypnotic (sleeping aide)) 150 mg at hour of sleep and may be indicated for a dose reduction. Please consider reducing the dose to 125 mg at hour of sleep and document behaviors; -No physician response. Review of the resident’s medical record, showed no changes to reflect the recommendations and no information the physician addressed the pharmacist’s recommendations. 3. Review of Resident #57’s consultant pharmacist’s medication regimen review, dated 3/24/18, showed following: -Recently initiated [MEDICATION NAME] (medication used to treat major [MEDICAL CONDITION] and/or anxiety) 60 mg three times a day. Please consider monitoring the resident’s blood pressure regularly to assess changes from baseline and monitor for adverse reactions. If not clinically appropriate, please provide rationale below. Review of the resident’s POS, undated, showed a handwritten order, dated 5/18/18 (55 days after the recommendation), to monitor the resident’s blood pressure every day per pharmacy recommendation. 4. During an interview on 6/26/18, the Director of Nurses said they receive copies of the pharmacist’s recommendations not long after the pharmacist leaves. The pharmacist is in monthly. They place the pharmacist’s recommendations in the physician’s box to be addressed by the physicians when they are in the building. Most of the physicians are in the building weekly or monthly. It should not take longer than a month to have the physician address the pharmacist’s recommendations. Sometimes they fax the recommendations. Currently there is no system in place to ensure the recommendations are being addressed. | |
F 0790 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide routine and 24-hour emergency dental care for each resident. **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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0790 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) has been done. During an interview on 6/26/18 at 11:48 A.M., the Social Service Designee (SSD) said she did not know the resident was having problems with his/her dentures. The SSD said she had not been at the facility very long and was still learning about the residents. During an interview on 6/26/18 at 1:04 P.M. Certified Nurse Aide (CNA) A said the resident will assist with his/her care. The resident has loose dentures. Last year the resident had an issue with the dentures. The resident has mentioned to him/her about the dentures being loose and he/she would tell the charge nurse. During an interview on 6/26/18 at 1:10 P.M. Nurse B said the resident’s dentures did not fit. The resident has a gum issues that would need to be addressed but the resident’s family did not want to put him/her through it. This happened last year. Nurse B said no one has told him/her about the loose dentures. The previous Social Service team was working on the issue but he/she did not know what happened. During a follow up interview on 6/26/18 at 2:30 P.M., Nurse B said the resident went for a fitting for his/her new dentures on 10/6/17 and the resident was able to come and pick up the dentures. This has been scheduled 7/3/18. He/she did not know the resident had gone out for an appointment regarding his/her dentures. Review of the resident’s medical record, showed no documentation regarding the resident’s dentures. During an interview on 6/26/18 2:37 P.M., the Director Of Operation said the Director of Nursing should be looking into why the resident’s dentures were loose. She did not know why there was no follow up after the resident’s appointment, so his/her dentures could be picked up timely. | |
F 0825 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide or get specialized rehabilitative services as required for a resident. **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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0825 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) any type of support in his/her contracted right hand. He/she would not mine some type of support for his/her hand. During an interview on 6/25/18 at 2:00 P.M., Restorative Aide (RA) C said the resident was not on the restorative program. Therapy evaluates residents for restorative therapy. He/she did not paid attention to the resident’s right hand. Observation with the Director of Nurses (DON) and RA C on 6/25/18 at 2:07 P.M., showed the resident had a contracted closed right hand. The DON said the resident had been at the facility for a while and was not sure if he/she was previously on a restorative program. The resident could benefit from a cushion in the right hand. During an interview on 6/25/18 2:23 P.M., the Director of Physical Therapy (DOPT) said the resident has right sided weakness. No one told about the resident’s contracted right hand, but she should hear about it from the charge nurses. The DOPT looked at the resident’s contracted closed right hand and said he/she could benefit from a type of cushion for the hand. During an interview on 6/26/18 10:39 A.M., the DON said they did get orders put into place regarding splints for the resident. The DON said they should have stayed on top of the resident’s splint. The purpose of the splint would be to prevent further contraction and encourage range of motion. Review of the facility’s Restorative Nursing Program, review date 12/1/17, showed the following: -Policy: It is the policy of the facility that a resident with a length of stay greater than 90 days is given the appropriate treatment and services to maintain or improve his or her abilities and to achieve or maintain the highest practicable outcome; -Procedure: Within 14 days of admission/readmission with significant change or quarterly thereafter, nursing will complete the Activities of Daily Living Functional Assessment; -When the resident is discharge from direct therapy services and would benefit from a restorative nursing program, therapy may make further recommendations for restorative needs; -A resident who has been identified as requiring restorative nursing will receive a care plan outlining their problem, goal and intervention. | |
F 0837 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0837 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 12) During an interview on [DATE] at 12:06 P.M., the Regional Consultant said she was currently the acting administrator at a sister facility. She had been consulting with administrator E on and off since he/she had been the administrator. She is not now and had not been the administrator at this facility since administrator E started at the facility. She did not know, until a few minutes ago, that administrator E’s emergency temporary license had expired. Administrator E had been performing the duties of administrator up until today as far as she was aware. Apparently since [DATE], the facility had not had an legitimate administrator. She had heard administrator E refer to the title of Facility Manager before, but she just thought he/she was using that title as an interchangeable title for administrator. During an interview on [DATE] at 12:27 P.M., administrator E said he/she was not aware his/her emergency temporary license had expired on [DATE]. The Missouri Board of Nursing Home Administrators was meeting on [DATE] to determine his/her license status. He/she assumed the emergency temporary license would not expire until that date. His/her emergency temporary license has been hanging on the office wall, but he/she had not noticed the expiration date. It was his/her responsibility to have known the expiration date of the license and to inform the facility management. He/she had not had any conversations with any representative from the Missouri Board of Nursing Home Administrators regarding his emergency temporary license until about 10 minutes ago. That representative told him/her that an extension for his/her emergency temporary license could not be granted pending the board’s meeting scheduled on [DATE]. He/she acknowledged he/she had been working at the facility as the administrator from [DATE] until today, but is resigning effective immediately and the facility was in search of a new administrator. He/she would be staying at the facility as Executive Director until he/she received his/her permanent administrators license. As Executive Director he/she will be responsible for physical plant operations and will have no duties assumed by the administrator. Review of administrator E’s temporary emergency license showed the facility name and an effective date of [DATE] and an expiration date of [DATE]. Underneath the effective and expiration dates, the following was printed: This Temporary License is only valid between the dates listed above at the facility listed above. MO 711 | |
F 0868 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly **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: 265776 |
| (X3) DATE SURVEY COMPLETED 06/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER ESTATES OF SPANISH LAKE, THE | STREET ADDRESS, CITY, STATE, ZIP 610 PRIGGE ROAD | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0868 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 13) keeping the attendance records. The facility administrator at the time of those two meetings was no longer at the facility. He/she can not find that administrator’s attendance records. During an interview on [DATE] at 6:21 A.M., the Director of Clinical Operations said she and Administrator F were unable to locate the attendance records of the two QAPI meetings held prior to [DATE]. | |