| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0568 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Properly hold, secure, and manage each resident’s personal money which is deposited with the nursing home. Based on interview and record review, the facility failed to provide quarterly resident | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 1) social worker spoke to the resident, he/she smacked the social worker in the mouth and bloodied her lip. Nursing staff contacted the primary physician and asked if the resident could be sent to the hospital. The physician said the hospital would not keep the resident and would send him/her right back. A nurse contacted the family member and advised the resident needed a locked unit. Staff called an ambulance to transport the resident to the hospital for psychiatric evaluation; -On [DATE], a late entry note at 11:45 P.M., the resident found on floor in the middle of hallway yelling I’m on the floor, I’m on the floor. Nurse observed resident bleeding from an area on his/her head. Resident assisted back into wheelchair and staff observed a laceration to the right eyebrow, which measured 2.5 centimeter in length. Staff noted the resident currently dozing off, unable to really stay awake, not really responding to verbal stimuli, mumbling at times but unable to communicate to the nurse. Resident will be sent to emergency room for evaluation. Review of the resident’s care plan, last updated on [DATE], and in use during the survey, showed staff did not update the care plan to reflect new issues or interventions related to the resident’s behaviors requiring hospitalization on [DATE] and his/her fall on [DATE]. During an interview on [DATE] at 9:30 A.M., the administrator said the resident’s behaviors and falls and specific interventions to address those issues should be included on the care plan. 2. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following: -Cognition not assessed; -Required two or more staff for transfers and total dependence on staff for toileting; -Impairment to bilateral lower extremities; -[DIAGNOSES REDACTED]. Review of the resident’s progress notes, showed on [DATE], the resident fell to the floor during a Sit to Stand (mechanical lift used to transfer a person from a sitting to a standing position) transfer. On [DATE], the nurse obtained a physician order [REDACTED]. Review of the resident’s care plan, updated [DATE], showed no documentation regarding the resident’s fall on [DATE] or any new interventions. The care plan also failed to address the change in the resident’s transfer status. During an interview on [DATE] at 9:30 A.M., the administrator said the resident’s fall and interventions should be added to the resident’s care plan. 3. Review of Resident #2’s quarterly MDS, dated [DATE], showed the following: -An admission date of [DATE]; -Cognitively intact; -[DIAGNOSES REDACTED].; -Frequent pain; -On [MEDICAL TREATMENT]; -Staff did not include use of oxygen therapy. Review of the resident’s May, (YEAR) physician order [REDACTED]. Review of the resident’s care plan, last revised on [DATE], and in use during the survey, showed no documentation regarding the resident’s use of oxygen. Observations of the resident on [DATE] at 3:30 P.M., [DATE] at 9:48 A.M., [DATE] at 6:39 A.M. and [DATE] at 6:58 A.M., showed the resident wearing a nasal cannula (device used to deliver oxygen with small tubes, which fit into the nostrils), attached to an oxygen concentrator (machine which filters in air, compresses it, and delivers air continuously) set at two liters (flow rate). During an interview on [DATE] at 3:30 P.M., the resident said he/she wears oxygen all the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 2) time. During an interview on [DATE] at 9:30 A.M., the administrator said the resident’s use of oxygen should be included on the care plan. 4. Review of Resident #27’s admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Severe cognitive impairment; -Ambulated independently; -Limited assistance with dressing; -Prognosis of six months or less; -Enrolled in hospice program; -[DIAGNOSES REDACTED]. Review of the resident’s May, (YEAR) POS, showed no order for hospice services. Review of the resident’s care plan, dated [DATE], showed no documentation regarding hospice services. During an interview on [DATE] at 9:30 A.M., the administrator said hospice staff document their visits on the computer, in the progress notes and are supposed to collaborate with the facility on the 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: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 3) Review of the May, (YEAR) POS, showed an order, dated 11/26/12, to administer [MEDICATION NAME] (antibiotic) ointment to the lower right eye lid twice a day for [MEDICAL CONDITION]. During an interview on 6/1/18 at 9:30 A.M., the Director of Nursing and the administrator said when an antibiotic is ordered the nurse should confirm a [DIAGNOSES REDACTED]. They said the physician has been approached about a stop date and they had yet to receive a response. They said they did not know the reason the [MEDICATION NAME] was given and [MEDICAL CONDITION] was not an appropriate diagnosis. | |
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate pressure ulcer care and prevent new ulcers from developing. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) -Goal: To be free from pressure ulcers and moisture associated skin damage; -Approach: Reposition every two hours, place a pressure reducing cushion in his/her wheelchair and a weekly skin assessment by a nurse; -Problem: Urinary incontinence; he/she needs reminders to use the bathroom and to thoroughly cleanse self; -Goal: He/she will participate in the bowel and bladder program; -Approach: Use pull ups for dignity, will participate in the bowel and bladder program every two hours, staff will provide the resident with hygiene products and supervise during hygiene after each incontinent episode. Review of the resident’s skin assessment notes, showed the following: -On 4/21/18, he/she had a red left buttock. Barrier cream applied; -On 4/28/18, a pressure ulcer to the right buttock found. The area measured 1 centimeter (cm) x 0.5 cm. Signs of inflammation and redness to wound area. Continue to apply barrier cream. Review of the resident’s electronic physician order [REDACTED]. Review of the resident’s progress notes, showed the following: -On 5/08/2018 at 9:34 A.M., the treatment to the resident’s pressure ulcer on his/her right buttocks looked healthy. New skin growth over the wound bed with no redness to the surrounding tissue; -On 5/12/2018 at 1:18 A.M., staff provided peri-care (cleaning from the front of the hips, between the legs and buttocks and the back of the hips) during nightly rounds. An area located to the groin and buttocks had redness. An open area to left buttock measured 0.6 cm x 0.5 cm and appeared to be smaller in size. Barrier cream applied to both areas. Will continue to monitor; -On 5/23/2018 at 1:07 A.M., Staff assessed the open area to the resident’s left buttock. The area measured 0.4 cm x 0.3 cm. Minimal redness observed and no slough (yellow stringy tissue adhered to wound bed) or drainage observed. Barrier ointment applied. Informed staff to apply barrier cream to the resident’s buttocks at each nightly round. Will continue to monitor. Review of the resident’s skin assessment on 5/26/18, showed an open area to the buttock. The area measured 0.5 cm x 0.2 cm and minimal redness to the area. Staff continued to apply barrier cream to the area. Further review of the resident’s progress notes, showed the following: -On 5/29/2018 at 10:55 P.M., staff found an open area to the resident’s right buttock. The area measured 0.5 cm x 0.4 cm with minimal redness and no drainage. Barrier cream applied to the area. Night shift staff informed to provide good peri-care and apply barrier cream during each nightly round. Will monitor; -On 5/31/2018 at 12:40 A.M., the nurse assessed the open area to resident’s right buttock. The area measured 0.5 cm x 0.4 cm. Both of the resident’s buttocks had redness. Barrier cream applied. During an observation and interview on 5/31/18 at 9:50 A.M., Certified Nurse Aide (CNA) B assisted the resident to stand in the restroom. He/she pulled down the resident’s pants and exposed the resident’s buttocks. The resident’s buttocks were red and a flaky white substance presented on both of the resident’s buttocks. An open area to the right lower buttock measured approximately 1 cm x 0.5 cm. The area had no treatment in place. CNA B said the open area on the right buttock had been there for several weeks and the charge nurses told the aides to apply barrier cream as treatment. He/she had not seen nurses apply a treatment to the area. The aides should tell the charge nurses if the resident had any changes in the condition of the skin. He/she would tell the charge nurse the area |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) looked bigger than yesterday. During an interview on 5/31/18 at 12:29 P.M., Licensed Practical Nurse (LPN) A said he/she thought the resident had an open area on his/her left buttock. The area to the left buttock had been opened before. A treatment had been applied and the area had healed. He/she thought the area to the left buttock had been reopened. The nurse aides should apply barrier ointment to the resident’s buttocks for treatment. He/she did not know if the physician had been told of any new skin issues. He/she did not know how the facility tracked open areas or skin issues besides report or orders on the treatment administration record (TAR). If he/she discovered an open area, he/she would document the area in the resident’s record, notify the physician to obtain orders and pass on the findings in report. Skin assessments are preformed on the night shift. During an observation and interview on 5/31/18 at 1:18 P.M., LPN A provided a skin assessment to the resident. An open area to the resident’s right lower buttocks appeared red and measured approximately 1 cm x 0.5 cm. LPN A said the night shift nurses perform the skin assessments and document in the computer on those areas. He/she did not know about the open area to the right lower buttock. The area was caused from pressure and appeared to be a stage II pressure ulcer (partial thickness wounds and may involve tissue loss at the epidermis and dermis levels). The area should be cleaned, and a treatment applied. The physician should be notified and orders obtained. Staff do not complete Braden assessment scales (assessment tool used to score risk of pressure ulcer development) on the residents. Further review of the resident’s progress notes on 6/1/18 at 9:00 A.M., showed no documentation that staff notified the resident’s physician, no wound measurements and no treatment orders to the buttock wound. Further review of the resident’s care plan on 6/1/18, showed no updates regarding wounds or pressure ulcers. 2. Review of Resident #22’s quarterly MDS, dated [DATE], showed the following: -BIMS score of five out of 15, which showed severe cognitive impairment; -Limited staff assistance needed with toileting; -Total staff assistance needed with hygiene; -At risk to develop pressure ulcers, no pressure ulcer present at time of assessment; -Frequently incontinent of bowel and bladder; -Diagnoses: [REDACTED]. Review of the resident’s care plan updated 3/4/18, showed the following: -Problem: Urinary Incontinence related to dementia and medication, he/she requires toileting reminders; -Goal: He/she will be clean, dry and odor free; -Approach: He/she prefers to wear pull ups and staff will provide incontinence care after each episode. Staff provide toileting every two hours; -Problem: Risk to develop pressure ulcers related to swelling, incontinence and obesity (over weight); -Goal: Free from infection; -Approach: Reposition every two hours, elevate feet at night and weekly skin assessment. Review of the resident’s POS, showed an order dated 5/18/18 for [MEDICATION NAME] ointment and apply to buttocks every shift after incontinence care. Review of the resident’s hospital wound nurse notes, showed the following: -On 5/17/18 a stage II pressure ulcer to the right buttock measured 1 cm x 1 cm x 0.1 cm deep. Recommendations to reposition every two hours and consider use of a foam dressing to the wound for protection. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) Review of the resident’s progress notes, showed on 5/18/2018 at 4:33 P.M., the resident returned to the facility per ambulance. The hospital nurse reported the resident had a stage II pressure are to his/her buttocks. The pressure ulcer had no treatment and will be left uncovered. Barrier cream applied. Review of the resident’s skin assessments, showed the following: -On 5/24/18 an open area to the left buttock. Staff to provide incontinence care and apply barrier cream. Continue with current treatment; -On 5/29/18 at 4:02 P.M., readmitted from hospital with stage II pressure ulcer to buttock. [MEDICATION NAME] ointment applied; -On 5/31/18 an open area to the left buttock, redness to both buttocks. Staff provide incontinence care and apply barrier cream. Continue with current treatment; -On 5/31/2018 at 12:45 A.M., The area to the left buttock assessed. The area remains open and reddened at this time. The open area measured 0.5 cm x 0.5 cm, no drainage observed. Buttocks are red as well with minimal excoriation. Barrier cream applied. Will monitor. During an observation and interview on 5/31/18 at 8:50 A.M., showed CNA B provided peri-care to the resident. The buttocks appeared red and inflamed. An open area to the right lower buttock measured approximately 0.5 cm x 1 cm and red. The resident moaned out when CNA B cleaned the area. CNA B said the resident had the open area for several weeks, and the charge nurses told him/her to apply [MEDICATION NAME] ointment to the wound when he/she provided care. He/she would inform the nurse the area seemed more red and painful. Further review of the resident’s progress notes on 6/1/18, showed no new treatment orders for the ongoing open area to the resident’s buttocks. Further review of the resident’s care plan on 6/1/18, showed no updated documentation regarding the open area to the resident’s buttocks or treatment. During an interview on 5/31/18 at 10:14 A.M., the Director of Nursing said the facility does not complete the Braden scale assessments on the residents. The charge nurses should perform the weekly skin assessments on the residents. If a wound or pressure ulcer had not improved over a two week period, the nurse should call the physician to get orders to treat the area. When the wound or pressure ulcer is discovered, the nurse is responsible to open an event under the resident’s medical record. Opening an event is used to track the wounds. Nurses are expected to take measurements weekly and communicate wound findings to nursing administration. The care plan should be immediately updated when a wound or pressure ulcer is found and include treatments and measurements. Documentation should be accurate and timely. | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 – Few | (continued… from page 7) -Purpose–intended to protect all residents from injury; -Standard Fall Precautions: -Orient to environment/safety teaching; -Treaded slipper socks or shoes when up moving; -Assistive devices in easy reach after ensuring the resident knows how to use the device; -Hand rails and grab bars in easy reach; -Bed in low position; -Bed wheels and wheelchair brakes locked; -Well lit, clutter free, spill free environment; -Definition–a sudden uncontrolled, unintentional, downward displacement of the body to the ground or other object. Object coming to rest on the floor unintentionally, inadvertently coming to rest on the ground or another lower level; -Policy–all residents are to be evaluated upon admission for fall risk by using the Fall Observation form. All residents are again evaluated every quarter using same form. Any resident found to be a high fall risk will have one or more interventions: -Bed/chair alarms; -Raised edge mattress (bumpers); -Physical or Occupational therapy; -A resident is considered to be a known fall risk as follows: -Any resident ambulating without assistance; -Any resident that has a bed or chair alarm; -Any resident that requires a restraint. 2. Review of Resident #27’s admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/29/18, showed the following: -admitted to the facility on [DATE]; -Severe cognitive impairment; -Ambulates independently; -Limited assistance with dressing; -No falls prior to admission; -Two or more falls since admission; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 3/24/18 and reviewed/revised on 4/16/18, showed the following: -Problem: Has fallen and is at risk of falling related to poor balance and weakness; -Goal: Will be free from injuries from falls; -Approaches: Keep bed in lowest position and locked at all times. Pressure sensitive alarm to be under resident at all times. Assess function of alarm at beginning of the shift. Review of the nursing progress notes, showed the following: -On 3/24/18 at 3:15 A.M., staff found him/her kneeling on the floor beside the bed. Staff returned him/her to bed and found him/her on the floor again at 4:00 A.M. Assessment showed left knee redness; -On 3/27/18 at 3:01 P.M., staff found him/her on the bathroom floor. Therapy placed bed and chair alarms and a mat on the floor next to the bed; -On 4/4/18 at 4:20 A.M., staff found him/her on the bedroom floor with his/her legs straight out in front of him/her. Staff returned the resident to bed; -On 4/12/18 at 7:00 A.M., staff found him/her on the floor in the common bathroom and at 1:37 P.M. staff again found him/her on the floor; -On 5/20/18 at 1:30 P.M., staff found him/her face down on the floor in a hallway utilized only by staff. Upon rolling the resident to his/her back staff members noted a laceration |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 – Few | (continued… from page 8) (deep cut or tear) and blood above his/her right eyebrow and a hematoma (a collection of blood outside of a blood vessel) above the laceration. Observations on 5/29/18 at 12:21 P.M., 5/30/18 at 6:29 A.M., 5/31/18 at 10:56 A.M. and 6/1/18 at 6:36 A.M., showed a large bruise to the resident’s right cheek approximately 2 inches by 3 inches that extended from under the right eye across the bridge of his/her nose. During an interview on 6/1/18 at 9:30 A.M., the administrator said when a resident falls an assessment is completed by the nurse and new interventions are implemented. The new interventions should be noted on the care plan so a staff members are aware. 3. Review of the facility’s undated mechanical lift policy, showed the following: -Residents who are non-weight bearing need to be reported to the charge nurse to be evaluated by therapy for appropriateness of which lift machine needs to be used; -The policy covered the technique used to transfer a resident; -The policy did not include the number of staff needed to provide safe transfers for residents. 4. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following: -Cognition not assessed; -Required two or more staff for transfers and total dependence on staff for toileting; -Impairment to bilateral lower extremities; -[DIAGNOSES REDACTED]. Review of the resident’s progress notes, showed the following: -On 2/28/18 at 1:56 P.M., the resident was being toileted after the lunch meal via the Sit to Stand lift. While being lifted two certified nurse aides (CNA’s) noticed the resident’s clothes were saturated. CNA I left for the resident’s room just a few feet from the shower room to obtain dry clothes. CNA H lowered the resident back down to his/her wheelchair until CNA I returned. However, the resident slipped out to the right side from the Sit to Stand and on to the floor. CNA H called for assistance and this nurse and the treatment nurse went into the bathroom. CNA I arrived at the same time. The resident was assisted and found no obvious injuries. Range of motion within normal limits for the resident. The resident stated he/she hit his/her head on the small front wheel of the wheelchair. No hematoma found during assessment. Will monitor for any bruising or complaint of pain or discomfort for the next 3 days; -On 3/5/2018 at 1:14 P.M., nurse obtained a physician order [REDACTED]. Review of the resident’s (MONTH) (YEAR) physician order [REDACTED]. Review of the resident’s care plan, updated 4/9/18, showed no documentation regarding the resident’s fall on 2/28/18 or any new interventions. The care plan also failed to address the change in the resident’s transfer status. During an interview on 5/30/18 at 8:29 A.M., CNA B said it is the facility’s policy to perform Sit to Stand lift transfers with two aides and that is how staff are trained. During an interview on 6/1/18 at 7:27 A.M., CNA G and licensed practical nurse (LPN) A said the resident always transfers using a Sit to Stand lift. During an interview on 6/1/18 at 9:30 A.M., the administrator said she was aware of the resident’s fall on 2/28/18 and it was due to staff not snapping the safety belt on the Sit to Stand lift. The two aides who were involved in the bad transfer have been educated on the facility’s policy to have two staff members for all mechanical lift transfers. The administrator was not aware the facility’s policy did not specify how many staff were needed for safe mechanical lift transfers. The administrator was unaware of the order to transfer the resident using a Hoyer lift, but said staff should follow physician orders. The resident’s fall and interventions should be added to the resident’s care plan. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 – 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** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) the area as well. Right breast appears grossly enlarged and hard and tender to the touch. Resident had [MEDICAL TREATMENT] yesterday and was sent to the hospital for similar complaint of right shoulder/arm pain, however swelling was not present at that time. A chest and shoulder x-ray were completed at the hospital with negative results. Resident reported changes occurred while out with family today. Nurse recommended for resident to go to the hospital; -On 3/31/18 at 10:00 P.M., ambulance arrived to transport resident to the hospital; -On 4/1/18 at 3:45 A.M., resident returned from hospital. Areas of concern remain unchanged, still appear swollen, hard and tender to touch, and bruising still visible. Resident continues to complain of severe pain to these areas; -On 4/1/18 at 6:23 A.M., resident complains of pain in right arm and breast when getting up this morning. Unable to give as needed pain medication due to not time, Tylenol given; -On 4/1/18 at 4:46 P.M., resident complained of pain. Cannot lift his/her right arm. Right hand is swollen, right abdomen and side swollen and hard to touch and runs all the way up into clavicle area. Resident very uncomfortable. Spoke with family member who expressed unhappiness with the treatment the resident received at the hospital last night. Agreed to send resident to a different hospital for evaluation. Resident’s port (device implanted under the skin to deliver medication and treatments) is in right arm; -On 4/1/18 at 6:00 P.M., ambulance arrived to transport resident to hospital; -On 4/2/18 at 12:54 A.M., spoke with emergency room nurse, who informed this nurse the resident would be kept overnight for observation. As of right now, they believe [MEDICAL CONDITION] (an excess of watery fluid collecting in the cavities or tissues of the body), pain, and bruising is from a [MEDICAL TREATMENT] bleed; -On 4/3/18 at 5:39 P.M., resident’s primary physician made aware of discharge Diagnosis: [REDACTED]. -Staff did not document the resident’s return from the hospital and interventions put in place to monitor and assess the site of the fistula to prevent future complications. Further review of the resident’s progress notes, showed the following: -On 4/5/18 at 4:57 P.M., resident continued to have swelling in right arm and breast. Elevated arm and placed ice on arm. Resident went to [MEDICAL TREATMENT] yesterday and was sent back due to arm pain. He/She went back to [MEDICAL TREATMENT] today. Resident given a pain pill; -On 4/8/18 at 6:44 A.M., resident feeling nauseated and complained of pain all over but mostly in the area of right shoulder and breast area. [MEDICATION NAME] (medication used to alleviate nausea and vomiting) given for nausea and will wait 30 minutes and give [MEDICATION NAME] for pain as requested; -On 4/8/18 at 3:26 P.M., resident continued to feel worse as the day went by today. Vital signs taken. Swelling to right shoulder, breast, arm and hand has worsened during the day. Resident complained of right arm and shoulder pain. Resident stated desire to go to the hospital but is afraid they won’t do anything for him/her; -On 4/8/18 at 10:00 P.M., received report from emergency room nurse. The resident is returning with no new orders, and per report, resident had CT (Computed Tomography scan allows doctors to see inside the body) of chest with angiogram (an X-ray photograph of blood or lymph vessels) and no leakage noted and no change since last hospital visit. It will just take time for [MEDICAL CONDITION] and bruising to heal; -On 4/9/18 at 6:40 P.M., resident returned from [MEDICAL TREATMENT], is in dining room eating dinner at this time; -On 4/11/18 at 6:37 P.M., resident returned from [MEDICAL TREATMENT] and eating and visiting with family; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) -On 4/12/18 at 1:51 P.M., resident’s physician notified resident requested something to decrease swelling to right breast. Ice pack for 20 minutes maximum three times a day. Review of the resident’s care plan, last reviewed on 5/3/18 and in use during the survey, showed staff failed to address the resident’s dependence on [MEDICAL TREATMENT] as well as staff’s role in monitoring and caring for the access site. Review of the resident’s (MONTH) (YEAR) POS, showed no orders for [MEDICAL TREATMENT] treatment or monitoring and assessment of the site. During an interview on 5/30/18 at 9:47 A.M., the resident said he/she goes to [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays in the afternoons. Staff do not check his/her fistula site when he/she returns from [MEDICAL TREATMENT]. The staff at the [MEDICAL TREATMENT] center check it before he/she leaves. The site often hurts after [MEDICAL TREATMENT]. During an interview on 5/30/18 at 10:52 A.M., the Director of Nursing (DON) said all communication with the resident’s [MEDICAL TREATMENT] provider is documented in the resident’s progress notes. During an interview on 5/30/18 at 11:33 A.M., the administrator said they do not have a [MEDICAL TREATMENT] contract with the resident’s [MEDICAL TREATMENT] provider. This is new territory for them and they have had only one other resident on [MEDICAL TREATMENT]. The administrator asked if she needed a contract. During an interview on 5/31/18 at 6:52 A.M., licensed practical nurse (LPN) A said he/she received training on [MEDICAL TREATMENT] patients, but not at the facility. The resident goes out in the afternoons and returns in evening, so he/she is not here when the resident returns, but he/she believes the evening nurse checks the resident’s dressing when he/she returns. During an interview on 6/1/18 at 9:30 A.M., the administrator said physician orders [REDACTED]. There should also be an order for [REDACTED]. Regarding the resident’s hemorrhage of the AV fistula on 4/1/18, the administrator would expect the hospital to give instructions on how to care for the site to keep the nurse from thinking for themselves. During an interview on 5/31/18 at 9:40 A.M., the administrator said she would expect the charge nurse to assess the site when the resident returns, but they only document the resident returned. They do not have a policy for assessment. She does not believe nursing staff received any [MEDICAL TREATMENT] education because she would expect nurses to know what to do. 2. Review of Resident #38’s quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Cognitively intact; -Received [MEDICAL TREATMENT] while a resident; -Diagnoses: [REDACTED]. Review of the resident’s undated care plan, showed no [MEDICAL TREATMENT] care needs, no [MEDICAL TREATMENT] provider, no dates or times for [MEDICAL TREATMENT]. Review of the resident’s POS and Treatment Administration Record (TAR), dated 2/1/18 through 3/1/18, showed no orders for [MEDICAL TREATMENT], [MEDICAL TREATMENT] after care or [MEDICAL TREATMENT] treatment orders. Review of the resident’s progress notes, showed: -On 2/10/18 at 4:20 P.M., the resident refused to go to [MEDICAL TREATMENT] today, staff provided education on the importance of [MEDICAL TREATMENT]; -On 2/17/18 at 5:32 A.M., the resident picked up by transportation for [MEDICAL TREATMENT]; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) -On 2/20/18 at 10:07 A.M., [MEDICAL TREATMENT] nurse called and said the [MEDICAL TREATMENT] physician was going to treat the resident for [MEDICAL CONDITION] (bacterial infection of the skin and tissues beneath the skin) in both of his/her legs; -Staff did not document post [MEDICAL TREATMENT] assessments or care provided. Review of the resident’s POS and TAR, dated 3/1/18 through 3/31/18, showed no orders for [MEDICAL TREATMENT], [MEDICAL TREATMENT] after care or [MEDICAL TREATMENT] treatment orders. Further review of the resident’s progress notes, showed: -On 3/1/18 at 6:31 A.M., the resident returned from [MEDICAL TREATMENT] with an antibiotic for the [MEDICAL CONDITION]; -On 3/29/18 at 5:39 A.M., the resident left for [MEDICAL TREATMENT]; -On 3/29/18 at 12:37 P.M., the resident returned from [MEDICAL TREATMENT] with chest pain and he/she said the [MEDICAL TREATMENT] staff provided medications to him/her. The resident requested a pain pill and facility nurse provided ordered pain medications. The resident went to his/her room; -On 3/29/18 at 11:55 P.M., the resident was brought back to the nurses station by facility staff and complained of chest pain. Ordered medication given with no relief. Vital signs taken. 911 called due to no relief from chest pain; -On 3/29/18 at 12:47 P.M., the [MEDICAL TREATMENT] nurse called the facility and informed the facility charge nurse that the resident had experienced chest pain while at [MEDICAL TREATMENT] earlier in the day. [MEDICAL TREATMENT] staff provided medication and encouraged the resident to go to the emergency room and the resident had refused; -On 3/29/18 at 4:37 P.M., call placed to the hospital. The hospital charge nurse said the resident had been admitted for evaluation and treatment. During an interview on 6/1/18 at 9:30 A.M., the Director of Nursing (DON) said she expected staff to assess and monitor the resident after returning from [MEDICAL TREATMENT] treatments. The facility does not often have residents that require [MEDICAL TREATMENT] and caring for [MEDICAL TREATMENT] resident is new to the facility. No inservices had been given to facility nurses regarding care for [MEDICAL TREATMENT] residents. The [MEDICAL TREATMENT] center should provide report after the resident receives the treatment. She did not know if the facility staff had regular communication with the [MEDICAL TREATMENT] center regarding post [MEDICAL TREATMENT] care. | |
| F 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident’s drug regimen must be free from unnecessary drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) -If a resident becomes verbally aggressive, realize these are signs they are losing impulse control. Anything that causes stress can bring on this behavior; -If you notice a violent episode coming, try to distract with an activity, music, etc.; -If a resident starts a fight, recognize fighting happens most often when a resident feels his or her personal space or possessions are threatened; -An outburst of crying, anger or fighting is a sudden response to feeling overwhelmed. It occurs most often in the morning, when daily care activity is at its peak; -Combative episodes are made worse when you try to restrain the resident in order to finish any type of care. Give the resident time to calm down and then come back. Review of the facility’s undated [MEDICAL CONDITION] Medication Policy (any drug capable of affecting the mind, emotions, and behavior), showed the following: -Physicians and mid-level providers will use [MEDICAL CONDITION] medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring; -Standards: -The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits; -The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED]. -Psychopharmacological medications will never be used for the purpose of discipline or convenience; -[MEDICAL CONDITION] medications include anti-anxiety, antipsychotic (a class of medication primarily used to manage [MEDICAL CONDITION], principally in [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) and antidepressant classes of drugs 2. Review of Resident #15’s annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted on [DATE]; -Severe cognitive impairment with disorganized thinking; -No behaviors noted during seven day assessment period; -No alarms used; -Required extensive assistance from staff for transfers, limited assistance for eating, hygiene and dressing and independent for propelling wheelchair throughout facility; -[DIAGNOSES REDACTED]. -No falls since last review; -Received antipsychotic medications for four of seven days assessed; -Received antidepressant medications (used to treat [MEDICAL CONDITION], mood disorders) for one of seven days assessed; -Received hospice care; -Did not receive psychological services. Review of the resident’s care plan, last revised [DATE] and in use during the survey, showed the following: -Problem: Psychosocial well-being. Resident has little interest in group activities or socializing with other residents; -Goal: Resident will have preferences honored; -Approach: Staff will socialize with resident daily to ensure she is happy and treated with respect; -Problem: Behavioral symptoms. Resident has been verbally aggressive and playing tricks on |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) his/her roommate; -Goal: Resident will treat others with respect; -Approaches: Staff should explain all procedures before attempting to aid resident and obtain his/her preference. Inform resident when it is his/her shower day to determine if he/she is willing to shower that day; -The facility failed to individualized interventions to implement when resident displays behaviors; -The facility failed to include the use of a anti-anxiety for behavior modification; -Problem: [MEDICAL CONDITION] drug use (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness, cognition, or behavior). Resident requires antipsychotic and antidepressant to stabilize mood; -Goal: Resident will be free of adverse effects (falls, poor appetite, decreased cognition); -Approaches: Resident will have behaviors documented every shift, will be followed by a psychiatrist monthly, encourage resident to lay down at 10:00 P.M., request topical medications to be rubbed into skin as needed related to non-compliance with oral medications; -The care plan contained nine staff signatures, but did not contain the resident’s or resident representative’s signature. Review of the resident’s psychiatric note, dated [DATE], showed the following: -Resident has dementia and anxiety and seen for routine care; -No agitation or evidence of [MEDICAL CONDITION]; -Oral medications were discharged due to non-compliance; -Resident has become increasingly more agitated; -Now has as needed (PRN) medications of [MEDICATION NAME] (anti-anxiety) and [MEDICATION NAME] (anti-psychotic), but once his/her behavior escalates it is difficult to help keep him/her calm even with PRN’s; -Plan: Start [MEDICATION NAME] rub routinely, 25 mg at night and titrate as needed. Review of the resident’s (MONTH) (YEAR) physician order [REDACTED]. -An order, dated [DATE], for [MEDICATION NAME] solution, two milligram per milliliter (mg/ml), give 0.5 mg injection every six hours as needed for anxiety; -An order, dated [DATE], to admit the resident to hospice due to [MEDICAL CONDITION]; -An order, dated [DATE] through [DATE], for [MEDICATION NAME] rub 100%, give 0.5 mg topical, every 12 hours as needed for unspecified dementia with behavioral disturbance; -An order, dated [DATE] through [DATE], for [MEDICATION NAME] cream, 25 mg per syringe. Apply [MEDICATION NAME] rub to back of knees or back of shoulders at bedtime for impulsiveness; -An order, dated [DATE]/18, for [MEDICATION NAME] (antipsychotic), give 0.5 mg tablet one time for unspecified dementia with behavioral disturbance. -An order, dated [DATE], for [MEDICATION NAME] cream, 25 mg per syringe. Apply rub to back of knees or back of shoulders twice a day for impulsiveness; Review of the resident’s medical record for (MONTH) (YEAR), showed the following: -On [DATE]: -At 9:12 P.M., the Medication Administration Record [REDACTED] – A nurse’s note at 9:30 P.M., showed [MEDICATION NAME] rub given for excessive wandering and attempts to push fire door open; -On [DATE]: -At 3:15 P.M., a MAR indicated [REDACTED] -No nurse’s note regarding incident; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) -On [DATE]: -At 1:10 A.M., a MAR indicated [REDACTED] -A nurse’s note at 2:03 P.M., showed resident toileted and had been fine with no signs of behavior when he/she bit one certified nurse aide (CNA) on the arm and breast and scratched the left arm, bringing blood, and punched the other CNA in the face. The nurse documented that no PRN medications help the resident’s behaviors. He/she documented that PRN [MEDICATION NAME] had been discontinued, PRN [MEDICATION NAME] rub was changed to every 12 hours and does not phase the resident when behaviors are present and the [MEDICATION NAME] injection is too much and invasive. Will pass on to hospice so they might make some medication changes; -On [DATE]: -At 10:51 A.M., a MAR indicated [REDACTED] -No nurse’s note regarding incident; -On [DATE]: -A nurse’s note at 12:30 P.M., showed resident cleared the dining room table by throwing iced tea and coffee on nursing staff breaking the coffee cup. Resident brought down to the nurse’s station and as the social worker spoke to the resident, he/she smacked the social worker in the mouth and bloodied her lip. Nursing staff contacted the primary physician and asked if the resident could be sent to the hospital. The physician said the hospital would not keep the resident and would send him/her right back. A nurse contacted the family member and advised the resident needs a lock down facility. The ambulance was contacted to transport the resident to the hospital for psychiatric evaluation; -At 2:23 P.M., a MAR indicated [REDACTED] On [DATE]: -At 6:34 A.M., a MAR indicated [REDACTED] -Staff did not document any non-pharmacological interventions attempted prior to administering the PRN or what issue necessitated the use of the PRN; -An administrator’s note at 9:10 A.M., showed she spoke to resident’s family member concerning the resident staying at the facility. The family member was happy because a different facility did not have an opening. The administrator explained taking away [MEDICAL CONDITION] medications which the residents needs is the biggest problem and the resident’s physician would be notified and the issue would be rectified; -An administrator’s note at 10:23 A.M., showed she spoke to the primary physician about the resident and his/her behaviors as a result of not being medicated routinely. The administrator requested [MEDICATION NAME] rub to be done twice daily. The physician asked why not use the oral form. The administrator explained the resident refused the oral medications secondary to delusions. The physician agreed to order the [MEDICATION NAME] cream with applicator; 25 mg; amount: 1 syringe. Apply [MEDICATION NAME] rub to back of knees or back of shoulders twice a day; -At 10:26 A.M., a MAR indicated [REDACTED] -Staff did not document any non-pharmacological interventions attempted prior to administering the PRN or what issue necessitated the use of the PRN; On [DATE]: -At 4:55 A.M., a MAR indicated [REDACTED] -A nurse’s note at 4:56 A.M., showed resident’s bed alarm sounded this morning three times. Resident attempted to get out of bed. While transferring the resident to his/her wheelchair, the resident bit a CNA on the arm leaving a red, swollen area. Resident then began hitting the nurse. Behaviors continued to escalate. [MEDICATION NAME] injection administered as resident is unsafe to self and staff. Will continue to monitor behaviors; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) -Review of the MAR indicated [REDACTED] -Staff did not document any non-pharmacological interventions attempted prior to administering the PRN; -A nurse’s note at 5:06 A.M., showed resident obtained a skin tear to his/her left hand as a result of combative/aggressive behaviors during a transfer; -A nurse’s note at 5:09 A.M., showed resident roaming around hallways in his/her wheelchair going into other resident’s rooms. Redirection attempted several times, but unsuccessful; -At 8:30 A.M., a MAR indicated [REDACTED] -Staff did not document reason PRN [MEDICATION NAME] given, results or specific interventions attempted; -A nurse’s note at 8:56 A.M., showed resident roaming hallways. While in the dining room the resident threw a cup of coffee across the room. PRN [MEDICATION NAME] rub given by this nurse. Resident given another cup of coffee and threw that as well. Resident roamed through the dining room and shoved into other residents. Administrator and physician notified. New order for one time dose of [MEDICATION NAME] 0.5 mg. Nurse with two other staff had to assist to keep resident from biting and hitting while giving medication. Will monitor behaviors; -Staff did not document the administration of the PRN [MEDICATION NAME] rub on the MAR; -On [DATE]: -A nurse’s note at 7:15 P.M., showed resident threw a cup of fluid at a visitor in the dining room. Resident removed from the dining room and given PRN [MEDICATION NAME] injection due to escalating behaviors. While administering the injection the resident attempted to hit and bite staff. Resident began wandering the hallways, going in to other resident’s rooms. A hall tray was offered and the resident threw it across the room. The resident was removed from the lounge area and taken to his/her room due to continued aggressive and combative behaviors. PRN [MEDICATION NAME] rub was applied; -Staff did not document the administration of the PRN [MEDICATION NAME] injection or rub on the MAR; -Staff did not document any non-pharmacological interventions attempted prior to administering the PRN’s. Review of the resident’s (MONTH) (YEAR) POS, showed the following: -An order, dated [DATE] through [DATE], for [MEDICATION NAME] solution; 2 mg/ml, give 0.5 mg injection for anxiety every six hours PRN; -An order, dated [DATE] thorough [DATE], for [MEDICATION NAME] solution; 2 mg/ml, give 0.5 mg injection for anxiety every six hours PRN; -An order, dated [DATE] through [DATE], for [MEDICATION NAME] rub 100%, give 0.5 mg syringe for unspecified dementia with behavioral disturbance every four hours PRN; -An order, dated [DATE] for [MEDICATION NAME] cream with applicator; 25 mg, give one syringe to back of knees or back of shoulders for impulsiveness twice a day; -An order, dated [DATE] through [DATE], for [MEDICATION NAME] tablet, 0.5 mg, crush one tablet with water and give with syringe for anxiety twice a day; -An order, dated [DATE], for [MEDICATION NAME] m-tab, (disintegrating tablet) 0.5 mg, give one tablet for major [MEDICAL CONDITION] two times a day. Further review of the resident’s medical record, showed the following: -On [DATE] at 10:48 A.M., a MAR indicated [REDACTED] -Staff failed to document any attempted non-pharmacological interventions attempted prior or reason for administration; -On [DATE]: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) -At 2:37 P.M., a MAR indicated [REDACTED] -A nurse’s note, at 2:38 P.M., showed resident started to show anxiety and aggressiveness. PRN [MEDICATION NAME] rub given. Resident became very agitated with another resident by grabbing the other resident’s walker hitting him/her with it. The nurse tried to pull the resident back and the resident slid off his/her wheelchair cushion because he/she was still holding onto the walker. Resident sat on floor with no injuries. Three nursing staff assisted resident off the floor. The resident became combative and hit one staff member in the face and tried to bite another staff member. Resident given [MEDICATION NAME] injection. Will continue to monitor behaviors; -Review of the MAR, showed no order for PRN [MEDICATION NAME] injection; -Staff did not document administration of the [MEDICATION NAME] injection or any non-pharmacological interventions attempted prior to administering the PRN medication; -A late entry nurse’s note at 10:00 P.M., showed resident beginning to show combative/aggressive behaviors. Attempted to bite and hit staff members. [MEDICATION NAME] rub administered earlier this evening but has not seemed effective. Resident’s behaviors tend to escalate quickly, where the resident is a danger to both himself/herself and others. PRN [MEDICATION NAME] injection administered at 10:30 P.M. and resident assisted to bed; -Staff did not document administration of the [MEDICATION NAME] injection or any non-pharmacological interventions attempted prior to administering the PRN medication; -A late entry nurse’s note at 11:00 P.M., showed resident attempted to get out of bed. Staff assisted resident to wheelchair. Resident roaming hallways; -A late entry nurse’s note at 11:45 P.M., showed resident found on floor in middle of hallway yelling I’m on the floor, I’m on the floor. Nurse observed resident bleeding from an area on his/her head. Resident assisted back into wheelchair and staff observed a laceration to the right eyebrow which measured 2.5 centimeter in length. Resident currently dozing off, unable to really stay awake, not really responding to verbal stimuli, mumbling at times, but unable to communicate to nurse. Resident will be sent to emergency room for evaluation; -On [DATE] at 1:46 A.M., a nurse’s note, showed resident broke his/her glasses at the time of the fall; -On [DATE]: -At 12:45 P.M., a MAR indicated [REDACTED] -Staff did not document the reason for the administration of the [MEDICATION NAME] injection or any non-pharmacological interventions attempted prior to administering the PRN medication; -On [DATE] at 7:51 A.M., a nurse’s note showed a nurse mixed resident’s [MEDICATION NAME] with apple sauce and gave between bites at breakfast. Resident took the medication with no complications. Resident has bruising surrounding his/her right eyebrow with laceration; -On [DATE] at 11:30 A.M., an administrator’s note showed the resident was seen by nurse practitioner. Staff discussed trouble getting medications in resident’s mouth. Changed [MEDICATION NAME] tablet to the m-tab to ensure it dissolves; -On [DATE] at 10:11 P.M., a nurse’s note showed the resident was combative and aggressive when staff attempted to change clothes and assist to bed. Staff explained they wanted to get resident into clean, dry clothes. Resident appeared tired and did not look like he/she needed a PRN at this time; -On [DATE]: -At 7:14 P.M., a nurse’s note showed the resident very aggressive this evening. Attempting to elope, wandering into other resident’s rooms, name calling and physically |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 18) aggressive with other residents. PRN [MEDICATION NAME] rub given with only mild effectiveness; -Review of the MAR, showed staff did not document administration of the [MEDICATION NAME] injection or any non-pharmacological interventions attempted prior to administering the PRN medication. Review of the resident’s psychiatric note, dated [DATE], showed the following: -Resident has dementia, agitation and anxiety and seen for routine care; -Since resident was last seen, [MEDICATION NAME] m-tab has been started; -According to staff, resident is mostly compliant with medications and his/her behaviors are generally improved; -Plan: Generally stable, remains on hospice, no changes to medications. Further review of the resident’s medical record, showed the following: -On [DATE]: -At 9:52 P.M., a certified medication technician (CMT) note. Gave [MEDICATION NAME] at 11:00 P.M. after charting not given due to condition. Resident awoke presenting behaviors -A late entry nurse’s note at 11:00 P.M. Resident has been extremely agitated this shift. Attempted to bite staff and did hit staff several times while providing care. Snack was given, which resident threw across the room along with anything else in arm’s reach. PRN [MEDICATION NAME] injection administered to left deltoid for continued escalating behaviors; -Staff failed document administration of the [MEDICATION NAME] injection or any non-pharmacological interventions attempted prior to administering the PRN medication. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Physical behaviors one to three days of seven day assessment; -Verbal behaviors one to three days of seven day assessment; -Bed alarm and chair alarm used seven of seven days assessed; -Received antipsychotic medications for seven of seven days assessed; -Received antianxiety medication for two of seven days assessed; -Received psychosocial therapy zero of seven days assessed. Further review of the resident’s medical record, showed the following: -On [DATE] at 9:30 P.M., a nurse’s note, showed resident observed to be tearful; -On [DATE]: -At 1:05 A.M., a MAR indicated [REDACTED] -Staff failed to document administration of the [MEDICATION NAME] rub or any non-pharmacological interventions attempted prior to administering the PRN medication; -At 3:19 A.M., a nurse’s note. Resident tearful at times; -On [DATE]: -At 2:21 A.M., a nurse’s note. Resident combative and aggressive during care. PRN [MEDICATION NAME] injection administered to right deltoid. Prior to behavior, resident was offered to be toileted and refused. Resident requested a snack and then threw it on the floor; -Staff failed to document administration of the [MEDICATION NAME] injection or any non-pharmacological interventions attempted prior to administering the PRN medication. During an interview on [DATE] at 6:58 A.M., CNA F said he/she is newer and has not had dementia training here. Usually two to three aides work with the resident because he/she can hit and bite and it’s better to have more eyes. CNA F has not really dealt with the resident when he/she gets really combative. The resident has been calm over the last few days except for when he/she spilled his/her shake on himself/herself and then fought with |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) staff when they tried to clean him/her up. CNA F is unsure of what interventions are in place when the resident’s behaviors escalate. Staff just do what they can and then tell the nurse and let them handle it. During an interview on [DATE] at 9:30 A.M., LPN A said to his/her knowledge, no one has tried to determine behavioral triggers for resident. The resident, at times, can be up for two days and then sleep for a day. You can tell when the resident is starting to escalate. LPN A will try to redirect with snacks, coffee and talking about family members. Nurses document behaviors on a flow sheet in the resident’s medical record. He/she has done better recently. He/she doesn’t like to take oral medications, so staff will try to give [MEDICATION NAME] behind his/her knee as quickly as possible if redirection doesn’t work. During an interview on [DATE] at 6:59 A.M., CNA G said he/she has not received any dementia or behavioral training since he/she started working at the facility. When the resident is escalating, CNA G tries to talk to the resident about whatever the resident is talking about. He/she will then leave the room and come back later. They always have two to three aides working with the resident because he/she can be so combative. During an interview on [DATE] at 9:30 A.M., the administrator said according to the state, a resident has the right to refuse medications. The resident is on antipsychotic medications because he/she will beat you up if he/she isn’t. The resident is a danger to self and others. The resident’s behaviors increased when he/she stopped taking his/her heart medications and went on hospice. Often what triggers the resident’s behaviors is staff trying to do something the resident does not want to do and he/she will just have an outburst. It usually starts verbally. Staff should update the care plan to show interventions known to work. Staff should attempt interventions prior to administering a PRN and document effectiveness. It is up to the physician to determine the appropriate [DIAGNOSES REDACTED]. | |
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure medication error rates are not 5 percent or greater. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 20) instrument completed by facility staff, dated 4/9/18, showed a [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED]. -An order, dated 1/30/17, to administer [MEDICATION NAME] (used to treat eye pressure caused by [MEDICAL CONDITION]) eye drops, one drop to each eye once a day; -An order, dated 10/21/17, to administer [MEDICATION NAME] (a medication used to open the lung airways) nebulizer (breathed in through the lungs) four times a day and RINSE MOUTH AFTER EACH USE. Observation on 5/30/18 at 11:40 A.M., showed Certified Medication Technician (CMT) C administered one drop of [MEDICATION NAME] to each eye. He/she held the inner canthus of each eye for 10 seconds. He/she then started the [MEDICATION NAME] nebulizer and left the room. Approximately 10-15 minutes later he/she returned to the room to remove the nebulizer, and but the resident had been taken to lunch. CMT C did not take the resident back to the room to rinse his/her mouth. During an interview on 5/31/18 at 10:20 A.M., CMT C said it is important to hold the inner canthus of the eye for about 10 seconds after administering an eye drop and the resident should always rinse his/her mouth after a nebulizer treatment to prevent mouth irritation. During an interview on 5/31/18 at 1:00 P.M., the DON said it is important to hold the inner canthus for one minute after an eye drop and to have the resident rinse his/her mouth after a nebulizer treatment. If the resident left the room, it is the med passers responsibility to return the resident to his/her room to rinse his/her mouth to prevent any oral irritation. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, facility dietary staff failed to use |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 21) -At 12:18 P.M., with gloved hands, the dietary manager (DM) removed a bowl from the reach in freezer, unwrapped it and placed the bowl on a plate. The DM removed her gloves and pulled a new pair of gloves from a pocket in her apron and donned them. She then used her gloved hands to place slices of bread on plates that were served to residents; -At 12:24 P.M., with gloved hands, the DM opened the reach in cooler door and removed two small bowls of salad and two bottles of salad dressing. She then removed her gloves and put on new gloves, which she obtained from the pocket in her apron. She then used her gloved hands to place slices of bread on plates over 10 times. During an interview on 5/31/18 at approximately 11:00 A.M., the DM said at a minimum, staff should use sanitizer to sanitize hands between glove changes. Food should not be touched with bare hands. 3. Observation of the kitchen on 5/29/18 at 4:30 P.M., 5/30/18 at 11:54 A.M., and 5/31/18 at 11:15 A.M., showed a half gallon plastic container labeled butter and dated 5/27/18 sitting on a counter ledge and at room temperature. Further observation on 5/30/18, showed the following: -At 12:00 P.M., Housekeeper L used a butter knife and removed butter from the plastic container on the ledge and placed in a pan with two grilled cheese sandwiches; -At 12:02 P.M., Housekeeper L added more butter to the pan from the plastic container. Review of the packaged blocks of butter in the walk in cooler on 5/30/18 at 12:12 P.M., showed the following, Perishable keep refrigerated. During an interview on 5/31/18 at approximately 11:00 A.M., the DM verified the container on the ledge was butter. Upon reviewing the instructions on the butter package, she agreed if it says to keep refrigerated, then it should be. 4. Observation and interview on 5/29/18, showed: -At 11:34 A.M., dietary aide (DA) J pushed a cart from the kitchen that contained multiple water glasses. He/she used his/her ungloved hands and grabbed the water glasses by the rim and placed the water glasses on the tables in front of the residents. The residents drank from the glasses. -At 11:45 A.M., DA J pushed various residents into the dining room and did not wash or sanitize his/her hands. He/she passed 22 water glasses out by grabbing the water glass rims. He/she said he/she should have worn gloves to pass out food or drink to the residents. He/she did not wash his/her hands before leaving the kitchen with the water glasses. He/she filled the water glasses in the kitchen and then patted his/her hands dry with a towel. If staff assist residents to move, staff should wash their hands between tasks. During an interview on 6/1/18 at 9:30 A.M., the administrator said staff should never touch rims or edges of glasses with ungloved hands. Staff should serve food and drinks with gloves hands. Touching surfaces with ungloved hands could spread infections to residents. | |
| F 0838 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 0838 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 22) residents competently during both day-to-day operations and emergencies as required. The facility census was 36. 1. Review of the facility’s Resident Census and Condition of Residents form, dated 5/29/18, showed a census of 36 and the following resident characteristics: -Alzheimer’s/Dementia: 15; -Documented signs and symptoms of depression: 13; -Documented psychiatric diagnosis (exclude dementia and depression): 16; -Behavioral healthcare needs: 9; -On psychoactive medication: 27; -On a pain management program: 20; -[MEDICAL TREATMENT] treatment: 1. During an interview on 5/30/18 at 8:45 A.M., the administrator said the facility assessment is a maintenance issue. She did not need to complete one because the facility is so small. The administrator knows what type of care they can and cannot provide. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | 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: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 – Many | (continued… from page 23) pad to the sling and placed the resident into the wheelchair. During an interview on 5/29/18 at 12:00 P.M., CNA E said staff hands should be cleaned and gloves changed anytime they touch anything contaminated. Hands should be cleaned during personal care and always before and after removing gloves. During an interview on 6/1/18 at 9:30 A.M., the Director of Nursing (DON) said hands should be washed before and after providing resident care and after touching body fluids or anything contaminated. 2. Review of Resident #31 quarterly MDS, dated [DATE], showed a [DIAGNOSES REDACTED]. Review of the facility’s undated Medications, Administering and Storage Policy, showed the following: -For Administering Eye Drops; -Wash hands and apply latex gloves; Review of the physician’s orders [REDACTED]. Observation on 5/30/18 at 11:40 A.M., showed Certified Medication Technician (CMT) C administered one drop of [MEDICATION NAME] to each eye. CMT C did not wash his/her hands prior to the administration of the eye drops and did not wear gloves. During an interview on 6/1/18 at 9:30 A.M., the DON said the employee’s hands should always be cleansed before administering eye drops and he/she could not remember if staff should wear gloves or not, but expected the staff to follow the facility’s policy. 3. Review of the facility’s undated PPD Policy for New Admissions, showed the following: -All new admissions to facility must have a 2 step PPD unless they have a history of exposure or allergy to the test. If allergy of test or history of exposure a chest x-ray should be obtained to ensure no active disease; -First step should be completed within 48 hours of admission, followed by step 2, 1-3 weeks later; -Yearly assessment for PPD should be signs and symptoms observation. Review of Resident #138’s admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident’s immunization record, showed the first step purified protein derivative (PPD, determines if positive for [MEDICAL CONDITION]) administered on 4/30/18 and the second step administered on 5/3/18. Further review of the resident’s medical record, showed the first and second step PPD’s recorded as negative. Neither PPD testing showed a read date. 4. Review of Resident #188’s medical record, showed: -admitted on [DATE]; -No admission two step PPD test administered. 5. During an interview on 6/1/18 at 9:30 A.M., the administrator said all new admission residents should be administered the two step PPD. She could not locate the resident’s admission two step PPD documentation. The first step admission PPD should be given the day the resident enters the facility and then read three days later. A second administration is given three weeks later for the second step and then read three days later. The resident did not receive any of the PPD testing. During an interview on 6/1/18 at 9:30 A.M., the administrator and DON said they were unaware that their policy did not specify to record the date the PPD was read and said it is best practice to note the date. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A490 |
| (X3) DATE SURVEY COMPLETED 06/01/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FIESER NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 404 MAIN 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 – Many | ||
