| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) -In unoccupied room [ROOM NUMBER], the floor around the toilet was soiled and discolored. The wall to the right of the toilet, was heavily damaged and peeling. The floor under this area of the wall contained a large area of a black mold-like substance. The floor tiles under the sink plumbing were discolored. An approximately 4 inch by 12 inch area of these tiles was covered in a black mold-like substance. The cove base also contained a large area of black mold-like substance. The wall to the left of the sink was missing the wall covering, was brown and had peeling drywall/drywall compound; -In unoccupied room [ROOM NUMBER], the toilet had been removed from the room. The wall behind and to the left of the toilet plumbing was damaged and peeling. The floor around the base of the wall were discolored and contained a black mold-like substance; -In unoccupied room [ROOM NUMBER], a large portion of the wall under the window was not fully intact. The foam board insulation and drywall were broken and pulled away from the wall. The cement block wall underneath was exposed. The exposed surfaces of the foam insulation were covered with a black mold-like substance. The air conditioning unit did not have a cover. The floor around the base of the wall had a heavy buildup of dirt and debris; -In unoccupied room [ROOM NUMBER], the wall, cove base, and flooring to the right of the toilet had a large area of a black mold-like substance. The cove base was missing from the corner of the wall and exposed heavily damaged drywall; -In unoccupied room [ROOM NUMBER], an area of the wall under the sink had a black mold-like substance; -In unoccupied room [ROOM NUMBER], the wall within a 3 feet by 3 feet alcove was damaged. The cove base had been removed exposing the wall behind it. There were holes in the drywall and areas containing a black mold-like substance; -The maintenance supervisor said the 200 hallway had been shut down for years, so repairs have not been made in this area. Observation of the nurse’s station area from 9/18/18 to 9/21/18 showed the outer wall that surrounded the nurse’s station was marred and scuffed. The outer nurse’s station area was scuffed and marred. Observation of the 100 hall from 9/18/18 to 9/21/18 showed the following: -The cove base along the wall was scuffed, loose and gaping away from the wall in various areas; -The vinyl wall covering on the lower portion of the wall was faded and stained; -The hand rail between rooms [ROOM NUMBERS] had dried food splattered on it with tissue wadded and shoved between the rail and the wall; -Each door and door frame on the hall was scuffed and scratched with areas of missing paint. Observation of the 100 hall on 9/21/18 showed the hand rail outside room [ROOM NUMBER] was missing the end cap leaving sharp edges exposed. Observation of the 100 hall shower room on 9/18/18 to 9/21/18 showed the following: -The caulk at the base of the toilet was missing in places and discolored; -On 9/20/18 at 5:16 A.M., a soiled brief and towel lay on the floor, the room was unoccupied; -On 9/20/18 at 7:50 A.M., there was fecal matter in the toilet and on the floor. During interview on 9/20/18 at 2:00 P.M., the members of the resident council said the following: -The shower room stinks; -The shower room in not clean, and there are dirty linens on the floor. Observation on 9/19/18 at 9:29 A.M., showed the following: |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) -The hand rails on both sides of the 300 hall had multiple marred areas and missing paint; -The door to room [ROOM NUMBER] had multiple areas of chipped paint; -The door jams to resident rooms 301, 302, 303, 307, 308, 309 and 314 had multiple areas of chipped paint; -The doors to rooms 303, 304, 309 and 311 had multiple areas of chipped paint; -The cross corridor doors on 300 hall had multiple areas of chipped paint at the bottom of the doors and the door jams; -The doors to rooms [ROOM NUMBERS] were marred. Observation of the 400/500 hall rooms from 9/18/18 to 9/21/18 showed the following: -In occupied room [ROOM NUMBER], the walls along the bathroom door, around the sink and on a part of the trim along the wall were painted in a variety of mismatched colors including a pale, beige color, cream color, and a pale mauve. The wall behind the bed closest to the window was marred; -In occupied room [ROOM NUMBER], the window blinds were bent and broken. The bedside table closest to the door was marred and scratched along the top, the base of the chest against the wall closest to the door was crumbling and deteriorating; -In occupied room [ROOM NUMBER], the wall closest to the door was marred and the vent cover along the wall had brown rust spots. The light cover over the second bed was partially detached from the wall. Observation on 9/20/18 at 7:37 A.M., showed fuzzy debris and dirt behind the cross corridor doors at the beginning of C-hall. 3. Observations in the basement and interviews on 9/19/18 and 9/20/18, during the Life Safety Code tour, showed the following: -In the basement storage area to the east of the elevator, there was a large storage area divided by walls that did not go to the ceiling. In the main storage area, there were large shelves made of particle-type board which contained cardboard boxes of residents’ belongings. The shelves were damp and had expanded from moisture. The surfaces of the shelves had a black mold-like substance throughout. The walls throughout the room also contained a black, mold-like substance. The maintenance supervisor said the water and mold in the basement had been a problem for a long time, but they did not know how bad it was until they started cleaning items out of the storage rooms; -In the smaller storage room adjacent to the large storage area, the walls in each outside corner contained a black, mold-like substance. Storage shelving in this room contained holiday decorations, not contained within boxes. The shelving had expanded from moisture and the surfaces of the shelves had a black, mold-like substance throughout; -In the medical records storage room, an area of the corrugated metal ceiling was covered in a layer of rust around PVC plumbing pipes. The maintenance supervisor said the water damage was caused from a leak in the shower room above. Observation showed there were stacks of cardboard boxes containing paper records below this area where the leak had occurred. Multiple cardboard boxes were heavily damaged from the moisture, and one box had turned black in color. Areas of the walls and the drywall ceiling in this room had a black, mold-like substance; -In the storage room (identified as the new resident storage room), showed the wall above the PTAC unit contained large areas of a black, mold-like substance. The wall below the double windows leading to an adjacent room also had areas of a black, mold-like substance; -In the therapy hallway, the walls were dirty and marred. The wall near the copy machine contained an area of a black, mold-like substance; -In the large storage room at the end of the therapy hallway, there were stacks of metal bed frames with wooden headboards and footboards, mattresses, and spare wheelchairs and |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) equipment. The maintenance supervisor said staff utilize this storage if they need extra beds, mattresses or equipment. Observation showed multiple ceiling tiles over the bed/mattress storage area were damp, had fresh water rings, and also contained areas of a black, mold-like substance. The maintenance supervisor said the storage area is located under the special care unit. At times, residents’ toilets overflow (due to flushing things down them) and cause the water to flow into the storage area below. Observation showed the headboards on some of the beds were covered in a white, mold-like substance. The surface of the mattresses stored in this area were covered in a white, mold-like substance. The window ledge and the wall under the window in this area contained a black, mold-like substance. The arm rests, push handles, and wheels on multiple wheelchairs were covered in a powdery white substance, similar to that on the beds and mattresses. A portion of the wall in the equipment/wheelchair storage area was discolored and contained a black, mold-like substance. The wall board near the exit in this room had been removed exposing the wooden studs. The wood studs/framing and the exposed wall had an accumulation of a black, mold-like substance. In the medical storage room within this room, there were multiple ceiling tiles that were damp and were water damaged; -In the storage room, located near the large storage room on the therapy hallway, there was an area of the wall at least 4 feet by 4 feet that was completely covered in a heavy accumulation of a black, mold-like substance. The wall adjacent to this also had a black, mold-like substance along the base of the wall. A ceiling tile in this area near a sprinkler head was water damaged, had fresh water rings, and contained an area of black, mold-like substance. In the bathroom area, the plumbing pipe leaked water into a 5-gallon bucket. The bucket was full of water, and water was overflowing and pooling on the floor. The wall by the plumbing pipe was heavily water damaged. The wall around the plumbing fixtures and an area approximately 3 feet wide by 1.5 feet tall contained an accumulation of a black, mold-like substance. The adjacent wall was also water damaged and had a black, mold-like substance near the floor. The walls throughout the room were discolored and had areas of a black, mold-like substance. A ceiling tile in the room was heavily water damaged, was bowed and broken. The ceiling tile had a black, mold-like substance throughout. -In the medical records storage room on the therapy hallway, there were stacks of cardboard boxes containing medical records throughout the room. Two ceiling tiles over the window were water damaged. The wall below the ceiling tiles had an accumulation of a black, mold-like substance; -In a bathroom in the basement, the toilet bowl was heavily soiled. The floor around the toilet was littered with debris; -Throughout the storage rooms in the basements, there was a strong musty odor; -The therapy room, utilized by residents for skilled therapy, was located in the therapy hallway in the basement. Dehumidifiers were running in the therapy room. Therapy staff said they run the dehumidifiers and keep the door to the therapy room closed in order to keep the mold out. He/she said some residents have complained about the air in the basement so staff have to take them back upstairs. During interview on 9/20/18 at 9:00 A.M., the administrator said she was unaware of the extent of the issue in the basement. She thought there was only an issue with moisture in the basement, not mold. 4. Observations from 9/18/18 to 9/21/18 showed the residents sat in chairs in the main dining room during each meal and throughout the day. Eight of the dining room chair seat covers were torn and the exposed foam underneath was in contact with the residents’ bodies. The arms of the dining room chairs were marred with a white substance spattered |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) along the arms of the chairs. The arms of the chairs appeared dirty with brown debris. Observation of the 500 hall locked special care unit showed the seats on a couple of the dining room chairs were torn with large pieces of torn vinyl. The handrails had long marred, scarred marks. Observation on 9/20/18 at 5:50 A.M. showed the armrests on Resident #2’s wheelchair were covered with vinyl which was cracked and peeling. Observation from 9/18/18 to 9/21/18 showed the arm rests on Resident #96’s geri-chair were covered with vinyl which was cracked and peeling exposing the yellow foam underneath. Observations from 9/18/18 to 9/21/18 showed Resident #51 sat in a ger-chair throughout the day. The arms of the geri-chair were cracked and exposed the foam underneath. The resident’s arms were in contact with the arm rests. 5. Observation throughout the survey on 9/18/18 through 9/21/18 showed the 500 hall shower room permeated with an odor. The floor was wet with water standing around the toilet and on the surrounding floor. During interview on 9/21/18, Certified Nurse Assistant (CNA) U said the 500 hall shower room always had a bad odor. Observation from 9/18/18 through 9/20/18, there was a strong odor of feces throughout the 100 hall. During interview on 9/20/ 18 at 9:15 A.M., Resident #50 (who resided on the 100 hallway) said the following: -He/she has to try to stand the odor; -The odor on his/her hall bothers him/her; -The resident would like the room to be sprayed more often to control the odor. 6. During interview on 9/21/18 at 2:06 P.M., the director of nursing said all staff are responsible for reporting any areas of concerns that may need the attention of maintenance. Staff should write the problem down in the maintenance book and write out a slip if something needs fixed. During interview on 9/21/18 at 2:45 P.M., the administrator said whoever sees an issue should follow their chain of command and ultimately maintenance is responsible for repairs. | |
| F 0585 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to develop a grievance policy |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0585 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) -After receiving a grievance/complaint, they will seek a problem resolution and will keep the resident informed of the progress toward resolution; -Procedures: Administrator, department manager, supervisor, and unit manager accept grievances/complaints; -The social worker/designee ensures all sections of the complaint/grievance report are completed appropriately and signed by the staff completing the investigation and developing the resolution. Ensure any supportive documentation related to the grievance are attached such as copies of inservices, statements from residents or staff; -Upon completion of the resolution, the administrator reviews and signs the report or the monthly log indicating she has reviewed the complaints; -The completed report is filed in the social service’s grievance binder; -The complaint/grievance is recorded on the Grievance Log form and there will be one log for each month. It will contain all grievances received that month and will be kept in the grievance binder; -At the end of each month, the administrator prints the reports from the grievance log and utilizes it as a look back and summary to complete a tracking and trending of complaints and grievances reviewing the grievance binder; -To discuss all issues whether resolved or unresolved at the next QAPI (quality assurance) meeting; The policy did not address a summary statement of the resident grievance, the steps taken to investigate, a summary of pertinent findings or conclusions regarding resident’s concerns, a statement to whether grievance confirmed or not confirmed, corrective action taken or to be taken by facility, date, and the written decision issued and copy given to the resident or residents. This did not address maintaining evidence demonstrating the result of all grievances for a period of no less than three years from issuance of grievance decision. 2. Review of the facility Resident Council Minutes, dated 6/27/18, showed the following: -Thirteen residents attended; -Staff documented the residents said call lights were not being answered, and one resident gave a list of missing clothing and hadn’t had a response from the housekeeping manager; -Activity staff filed a grievance regarding call lights and would report residents’ complaints to the director of nursing (DON), who was the person responsible for this grievance; -Staff would report residents’ grievance/complaint for their missing clothing to the housekeeping manager, who was the person responsible for finding the clothing; -There was no documentation staff followed up with the residents’ concerns from the meeting. 3. Review of the facility Resident Council Minutes, dated 7/25/18, showed the following: -Eleven residents attended; -Residents said call lights were not being answered; -One resident said he/she had to call the front desk to get his/her call light answered; -Staff was to report residents’ complaints to the DON, who is the person responsible; -Residents want activities to assist in looking for their missing clothing by going through clothing with no names or any lost clothing; -Staff would report residents’ complaints of missing clothing to the housekeeping manager, who is the person responsible for this. -There was no documentation to show staff followed up on the residents’ concerns from the meeting. 4. Review of the facility grievance log, dated 7/31/18, provided by the administrator, |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0585 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) showed the following: -On 7/8/18, Resident #9 complained staff did not answer all lights timely. He/she waited for two hours for the call light to be answered; -The DON closed the grievance on 7/10/18; -Grievance resolved satisfactorily marked in the box; -There was no written documentation to show the summary of the investigation and any corrective action taken by the facility. During interview on 10/1/18 at 2:45 P.M., the DON said the following: -She followed up on the complaint, talked with a particular staff member regarding the issue, inserviced this person and would be inservicing all staff about answering call lights within 15 minutes and not turning off the call light without meeting the resident’s need; -She signed the grievance with Resident #9, but did not give the resident a yellow carbon copy of the grievance; -She began as DON the last of (MONTH) (YEAR) and was not aware he/she was to give a copy of the grievance to the residents. 5. Review of the facility Resident Council Minutes, dated 8/29/18, showed the following: -Eleven residents attended; -Residents said staff was not answering residents’ call lights; -The DON informed the resident council members that she would inservice the nursing staff on customer service and answering the residents’ call lights in a timely manner; -Residents said grievances were not being answered in a timely manner; -Staff filed a grievance against unanswered grievances and gave it to the social worker, who was the person responsible for grievances; -There was no documentation to show staff followed up on the residents’ grievance regarding untimely response to grievances. 6. Review of the facility grievance log, dated 8/31/18, showed the following: -On 8/29/18, the resident council filed a grievance about grievances not being addressed in a timely manner and it was taking too long; -Grievance closed: space left blank; -Grievance resolved satisfactorily: left blank. 7. During the group interview on 9/19/18 at 2:00 P.M., residents in attendance said the following: -Staff answering their call lights on Saturday and Sunday was bad. The residents might have to wait 45 minutes to two hours for staff to answer their call light; -Lost clothing was a problem. The staff had found residents’ clothing in the trash; -The facility staff did not get back with them when they filed a grievance as a resident group at the last resident council meeting held in (MONTH) (YEAR); -Resident #9 said the DON and/or other department heads had not gotten back to him/her about his/her grievances; -Social services handled grievances. There was poor communication regarding how grievances were resolved. 8. During interview on 10/1/18 at 2:42 P.M., the Activity Director said the following: -A resident can write a grievance on their own; -During the resident council meeting, the Activity Director can write a grievance for the group, then turn this in to the social worker to resolve, who will get back to the resident council president about the results; -If the resident council president wants to call a special meeting with the group, he/she can to discuss the results of the grievance with the group. |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0585 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) During interview on 9/20/18 at 10:00 A.M. and 10/1/18 at 2:21 P.M., the Social Services Director (SSD) said the following: -The grievance process usually began with the activity director giving the grievance to the SSD who gave this to the DON, Assistant Director of Nurses (ADON), or administrator and they talked about these grievances in the morning department head meeting; -When a resident fills out a grievance form, social services takes the form to the morning department head meeting; -A copy of the grievance is given to the appropriate department head to follow up; -When the department head resolves the grievance, they bring the form back to social services; -The information regarding the grievance is documented on the grievance log; -The grievance log shows what issues have been resolved; -Social Services or the department head lets the resident know how the grievance was resolved; -The grievance log shows who notified the resident of the resolution; -She was aware Resident #9 filed grievances in (MONTH) (YEAR) and staff followed up, but did not give the resident a copy of the signed grievance with the resolution. 9. During interviews on 09/21/18 at 2:07 PM and 10/1/18 at 2:45 P.M., the DON said the following: -Grievances were given to the social service director (SSD) and to the particular department to review; -She provides education, corrective counseling, and inservicing to staff as needed to resolve the grievances; -If the facility receives grievances regarding nursing, she will report and follow up with the resident when resolved. -Staff document they followed up with the resident on the grievance form. The staff member and the resident (if able) will sign the form. -She had gotten back to particular residents about grievances but did not give a yellow carbon copy of the results signed by her and the resident; 10. During interview on 9/21/18 at 1:00 P.M. and 9/27/18 at 11:50 A.M., the administrator said she keeps a grievance log. The department heads were to address the grievances per department. All department heads were to respond within 72 hours to the grievance and get back with the residents who had the complaint. They discussed grievances and made attempts to resolve them in their daily meetings. They had not provided a copy of the written grievance, signed by staff and the resident and the facility response to their grievances. | |
| F 0623 Level of harm – Potential for minimal harm Residents Affected – Some | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0623 Level of harm – Potential for minimal harm Residents Affected – Some | (continued… from page 8) 1. Review of the facility’s policy, Discharge Planning and Notification, dated 5/1/15, showed the following: -In compliance with federal and state regulations, all transfers and discharges require proper notification to the patient/resident and, if known, a family member or legal representative; -The social services staff /or designee is charged with ensuring systems are in place to provide written notification to the resident and, if known, a family member or legal representative prior to the resident’s transfer. The transfer/discharge notice must comply with federal and state regulations and must contain the following information: the reason for transfer or discharge; the effective date to which the resident is transferred or discharged ; the location to which the resident is transferred or discharged ; a statement that the resident has the right to appeal the action to the State; When appropriate, the name address and telephone number of the state long term care ombudsman; -The facility’s policy did not direct staff to provide a notice of transfer/discharge to the Ombudsman when the facility initiated the resident’s transfer or discharge from the facility. 2. Review of Resident #55’s Physician order [REDACTED]. -The resident was sent from the facility to the emergency room and admitted to the hospital on [DATE]; -The resident was readmitted to the facility on [DATE]; -The resident was sent from the facility to the emergency room and admitted to the hospital on [DATE]; -The resident was readmitted to the facility on [DATE]. Review of the resident’s medical record showed no documentation the facility notified the resident/representative or the Ombudsman of the resident’s transfers to the hospital on [DATE] or 6/28/18. 3. Review of Resident #71’s POS showed the following: -The resident was sent from the facility to the emergency room and admitted to the hospital on [DATE]; -The resident was readmitted to the facility on [DATE]; -The resident was sent from the facility to the emergency room and admitted to the hospital on [DATE]; -The resident was readmitted to the facility on [DATE]. Review of the resident’s medical record showed no documentation the facility notified the resident/representative or the Ombudsman of the resident’s transfer to the hospital on [DATE] and 8/28/18. 4. Review of Resident #87’s nurse note, dated 9/10/18, showed the following: -The resident was sent from the facility to the emergency room and admitted to the hospital on [DATE]; -The resident was readmitted to the facility on [DATE]. Review of the resident’s medical record showed no documentation the facility notified the resident/representative or the Ombudsman of the resident’s transfer to the hospital on [DATE]. 5. Review of Resident #80’s physician orders, dated (MONTH) (YEAR), showed the following: -The resident was sent from the facility to the emergency room and admitted to the hospital on [DATE]; -The resident was readmitted to the facility on [DATE]. Review of the resident’s medical record showed no documentation the facility notified the resident/representative or the Ombudsman of the resident’s transfer to the hospital 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0623 Level of harm – Potential for minimal harm Residents Affected – Some | (continued… from page 9) [DATE]. 6. During interview on 9/21/18 at 9:04 A.M., the Social Services Designee said the following: -She was aware of the requirement to notify the resident and responsible party of a transfer to the hospital; -The facility had planned on the nursing staff to be responsible for this, but had not started it yet; -She did not notify the Ombudsman of residents’ transfers or discharges from the facility. | |
| F 0625 Level of harm – Potential for minimal harm Residents Affected – Some | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0625 Level of harm – Potential for minimal harm Residents Affected – Some | (continued… from page 10) does not notify the resident/representative of the bed hold policy upon transfer to the hospital. | |
| F 0655 Level of harm – Potential for minimal harm Residents Affected – Some | Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0655 Level of harm – Potential for minimal harm Residents Affected – Some | (continued… from page 11) -admitted [DATE]; -The resident/representative signature of receipt section was left blank. Review of the resident’s medical record showed no documentation a summary of the baseline care plan was provided to the resident and his/her representative. 7. Review of the Resident #27’s medical record showed the admitted was 6/22/18. Review of the resident’s undated baseline care plan showed the following: -admitted [DATE]; -The resident/representative signature receipt section was left blank. Review of the resident’s medical record showed no documentation a summary of the baseline care plan was provided to the resident and his/her representative. 8. Review of Resident #87’s medical record showed the resident’s date of readmission to the facility was 9/14/18. Review of the resident’s baseline care plan showed the following: -The baseline care plan was completed on 9/14/18. -The resident/representative signature of receipt section was left blank. Review of the resident’s medical record showed no documentation a summary of the baseline care plan was provided to the resident and his/her representative. 9. Review of Resident #99’s medical record showed the resident’s date of admission to the facility was 9/17/18. Review of the resident’s baseline care plan showed the following: -The baseline care plan was completed on 9/17/18; -The resident/representative signature of receipt section was left blank. Review of the resident’s medical record showed no documentation a summary of the baseline care plan was provided to the resident and his/her representative. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) -Brushing cleans the teeth of food particles, plaque, and bacteria. It enhances well-being and comfort and stimulates the appetite; -Brushing the teeth at least twice a day was effective oral hygiene. 3. Review of the Nurse Assistant in a Long-Term Care Facility, 2001 edition, showed the following: -Wash hands before meals and as needed; -Providing hair care helps the resident maintain self-esteem and helps stimulate the resident’s scalp; -Oral care should be given before breakfast, after meals and at bedtime. 4. Review of Resident #57’s admission Minimum data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/18, showed the following: -Severely impaired cognition; -Limited assistance of one staff for personal hygiene. Review of the resident’s care plan, dated 8/2/18, showed the resident required limited assistance of one staff for personal hygiene and oral care. Observation on 9/20/18 at 6:00 A.M. showed the following: -Certified Nurse Aide (CNA) L and CNA K provided perineal care for the resident, assisted the resident to dress, and transferred him/her to the wheelchair; -CNA K combed the resident’s hair and then took the resident to the dining room; -CNA K did not wash the resident’s hands, and did not offer to provide oral care. The resident’s mouth was dry and crusty. During interview on 09/20/18 at 6:55 A.M., CNA L said he/she was not sure if the resident had a toothbrush or toothpaste since the resident was new to the facility. 5. Review of Resident #80’s admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required limited staff assistance from one staff for personal hygiene. Review of the resident’s care plan, dated 8/12/18, showed the resident required limited assistance of one to two staff for personal hygiene and oral care. Staff was to allow the resident to do as much for himself/herself as tolerated with set up assistance from staff. Observation on 09/20/18 at 6:14 A.M., showed the following: |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) out for him/her. The resident had either upper or lower dentures and kept them in a box in the top dresser drawer and sometimes will put them in. 7. During interview on 09/21/18 at 2:07 PM, the director of nursing said she would expect staff to provide morning cares which included washing a resident’s face and hands, and providing oral care such as brushing teeth and putting in their dentures. 8. During interview on 09/21/18 at 2:07 PM, the director of nursing said she would expect staff to provide morning cares including washing a resident’s face and hands, and providing oral care such as brushing teeth or putting in their dentures. | |
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide activities to meet all resident’s needs. **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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) -Activities are a way for individuals to establish meaning in their lives, and the need for enjoyable activities and pastimes does not change on admission to a nursing home; -A lack of opportunity to engage in meaningful and enjoyable activities can result in boredom, depression, and behavior disturbances; -Individuals vary in the activities they prefer, reflecting unique personalities, past interests, perceived environmental constraints, religious and cultural background, and changing physical and mental abilities. 4. Review of Resident #84’s Activities Evaluation, dated 7/21/18, showed the following: -admitted was 7/20/18; -Short and long-term memory problem, decision making skills severely impaired, rarely makes self-understood, speech clarity unclear; -Needs assistance from two staff for ambulation; -Finds strength in his/her faith, actively participates; -Activity pursuit patterns and preferences: current includes animal/pets, current events and news, family/friend visits, music/radio and religious services; -Interest in life/activities: interested; -Motivation: motivated -Family/friends involvement: A handwritten note completed by the activity director said the resident’s family member helped complete the assessment and is highly involved in the resident’s care. Review of the resident’s care plan, last revised on 7/23/18, showed the following: -The resident had little or no activity involvement related to major [MEDICAL CONDITION]; -Will not exhibit isolation or boredom through review date; -Preferred activities are listening to music; -Prefers the following radio stations 99.1; -Staff will implement one-on-one visits with the resident once a week; -Staff will inform the resident of current news and events; -Provide a program of activities that accommodates the resident’s communication abilities; -Be conscious of resident position when in groups, activities, dining room to promote proper communication with others; -The resident was dependent on all staff for locomotion. Review of the resident’s admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/27/18, showed the following: -Long and short-term memory problems; -Daily decision making skills severely impaired; -It was very important to listen to music he/she liked and being around animals such as pets; -It was somewhat important to do things with a group; -It was important but can’t do or no choice to do favorite activities of his/her choice, go outside to get fresh air when the weather is good, and participate in religious services or practices. Review of the resident’s One-on-One Activity/Recreation Program Documentation for (MONTH) (YEAR) showed the following: -On 8/1/18, olfactory stimulation and reading/writing, passive participation; -On 8/10/18, tactile stimulation and current news and events, passive participation; -On 8/15/18, visual stimulation, participation; -On 8/23/18, current news and events, passive participation; -On 8/29/18, tactile stimulation, passive participation and current news and events, |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) active participation. Review of the resident’s activity notes for (MONTH) (YEAR) showed the resident participated in a group activity on 8/15/18. The resident sat and watched an arts and crafts activities and was shown pictures of flowers and houses for visual stimulation. There was no further documentation to show the resident participated in other group activities during the month. Review of the resident’s One-on-One Activity/Recreation Program Documentation for (MONTH) (YEAR) showed the following: -On 9/7/18, active tactile simulation, passive participation current news/events; -On 9/12/18, active participation exercise/sports and tactile stimulation, passive participation, music, reading/writing; -On 9/17/18, active participation auditory stimulation, passive participation stimulation in reading/writing and in current/news and events. Review of the resident’s activity notes for (MONTH) (YEAR) showed no documentation the resident participated in group activities during the month. Observation on 9/18/18 at 10:55 A.M. showed the resident lay in bed. The resident’s television and radio were turned off and the room was quiet. Observations on 9/19/18 at 8:18 A.M., 10:00 A.M. 11:30 A.M., 3:00 P.M. and 5:00 P.M. showed the resident lay in bed. His/her roommate’s television was turned on behind the privacy curtain and not visible to the resident. Observation on 9/20/18 at 7:06 A.M. showed the resident lay in bed with his/her eyes open. His/her roommate’s television was turned on behind the privacy curtain and not visible to the resident. Observation on 9/20/18 at 10:07 A.M. showed the resident lay in bed and faced the door, with his/her eyes open. The radio and television that sat on the bedside table were turned off. The resident’s roommate’s television played quietly on his/her side of the room and not visible to the resident. Observation on 9/20/18 at 12:50 P.M. showed the resident lay in bed with his/her eyes open. The resident’s television and radio were turned off and the was room quiet. During interview on 9/21/18 at 10:00 A.M., Certified Nurse Assistant (CNA) T said he/she had worked in this area of the facility for around a month and he/she had not assisted the resident out of bed during that time period. During interview on 9/21/18 at 11:56 A.M., CNA P said he/she worked the day shift in this area routinely. He/she had not assisted the resident out of bed before today. He/she did not know of any activities the resident was involved in or liked. The resident’s television or radio could not be turned on because the wound vac equipment was plugged into the outlet. During interview on 9/21/18 at 11:05 A.M., CNA R said he/she had worked in the facility for close to six months and during that time period, the resident had only been out of bed a couple times. He/she was not sure why the resident never got out of bed. He/she just followed the lead of others. Staff fed the resident his/her meals in bed. He/she just made sure the resident was changed, repositioned and kept clean. During interview on 10/1/18 at 2:05 P.M., the resident’s family said the following: -The facility got the resident up out of bed at one time but after the resident stopped physical therapy he/she seemed to not get out of bed anymore; -He/she was not sure why the resident did not get out of bed anymore; -He/she had Christian music tapes he/she played for the resident, but he/she wasn’t able to play them now because the wound vac and breathing treatment equipment were plugged into the outlets and left nowhere to plug anything in. |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) 5. Review of the Resident #38’s annual MDS, dated [DATE], showed the following: -Rarely/never understands others; -Absence of speech; -Preferences for customary routine and activities was not completed. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Persistent vegetative state; -Total dependence of two staff member with transfers; -Required extensive assistance from one staff member with locomotion on and off the unit. Record review of the resident’s care plan, last reviewed on 7/13/18, showed the following: -The resident is in a semi-vegetative type state, but occasionally opens his/her eyes and tends to track with his/her eyes; -Per family, he/she enjoys listening to music, being read to, and having the television on at times; -The resident will not exhibit boredom or isolation; -Provide one-on-one sessions one time a week; -The resident has impaired cognition because of Alzheimer’s and is unable to speak or communicate; -Assist the resident to and from low functioning activities, music, parties and movies; -Speak to the resident when in the room. Play television, radio, music if available. -The resident has Alzheimer’s and is dependent with all activities of daily living. Review of the resident’s One-on-One Activity/Recreation Program Documentation for (MONTH) (YEAR) showed the following: -On 8/3/18, current news and events, active participation; -On 8/6/18, reading/writing, passive participation; -On 8/13/18, exercise/sports, passive participation; -On 8/21/18, visual stimulation, passive participation; -On 8/29/18, music/current news and events, active participation. Record review of the resident’s activity notes for (MONTH) (YEAR) showed no evidence the resident participated in any group activities. Review of the resident’s One-on-One Activity/Recreation Program Documentation for (MONTH) (YEAR): -On 9/5/18, music, passive participation; -On 9/12/18, music, olfactory stimulation, reading/writing, tactile stimulation (touch) television and current news and events, passive stimulation; -On 9/17/18, auditory stimulation, active stimulation, music, reading/writing and current news and events, passive stimulation. Record review of the resident’s activity notes for (MONTH) of (YEAR) showed no evidence the resident participated in any group activities. Observations on 9/18/18 at 11:30 A.M., 12:45 P.M., and 4:44 P.M., showed the resident lay in bed. The television in his/her room was turned off and the room was quiet. Observations on 9/19/18 at 8:30 A.M., 10:09 A.M., 11:30 A.M., 3:00 P.M. and 5:00 P.M. showed the resident lay in bed. The television was turned off and the room was quiet. Observations on 9/20/18 at 6:00 A.M., 8:08 A.M. and 1:00 P.M. showed the resident lay in bed. The resident’s room was quiet, the lights were turned off, and the door was closed. Observations on 9/21/18 at 9:30 A.M. showed the resident lay in bed. The room was quiet. During interview on 9/21/18 at 11:56 A.M., Certified Nurse Assistant (CNA) P said he/she was not sure if the resident’s television worked because it was never turned on. He/she |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) was not sure of any activities the resident liked. He/she worked in this area routinely on the day shift and had not assisted the resident out of bed before today. During interview on 9/21/18 at 11:05 A.M., CNA R said he/she had worked in the facility for close to six months and during that time period, the resident had only been up out of bed three or four times. He/she was not sure why the resident never got out of bed. He/she just followed the lead of others. He/she just made sure the resident was changed, repositioned and kept clean. During interview on 9/27/18 at 2:30 P.M., the resident’s family member said the following: -He/she had not observed the resident out of bed for a long time; -The resident listened to music and watched the television at one time, but he/she had not seen the television or radio on in a long time; -The resident had friends and enjoyed visiting at one time. 6. During interview on 9/28/18 at 11:00 A.M., the activity director said the following: -He/she was unable to locate the activity evaluation that was completed on Resident #38; -He/she set up one-on-one activities for some of the residents one time a week who also went to attend group activities throughout the week. If the residents were not able to attend group activities, those residents should receive one-on-one activities three times a week per the facility policy; -If a resident participated in a group activity, he/she documented it on the activity notes; -He/she thought Resident #38 had been up one time in the last couple months for a group activity; -Resident #84 had been up a couple times in the past month and a half for a group activity; -He/she had asked the nurses if there was a reason Resident #38 and Resident #84 could not get out of bed. He/she was told there was no reason the residents could not get out of bed; -The staff don’t get Resident #38 and Resident #84 up out of bed for group activities and he/she is not sure why. 7. During interview on 9/21/18 at 2:06 P.M., the director of nursing said one-on-one activities should be conducted at least three times a week. He/she would expect staff to turn on the residents’ televisions for stimulation. Staff should follow each resident’s activity preferences and those should be included on the care plan. | |
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 18) system; -Drainage tubing/bags must not touch the floor; -The drainage bag should always be below the level of the bladder. If moved above, urine could flow back into the bladder. 2. Review of Resident #84’s urinalysis (the physical, microscopic, or chemical examination of urine), dated 7/25/18, showed the following: -Clarity: turbid (normal: clear); -Leukocyte Esterase (the detection of leukocytes in urine usually points to the presence of a health abnormality such as infection of the urinary system by bacteria): large (normal: 0-4); -White blood cell: too numerous to count per high power field (HPF, area visible under the maximum magnification power) (normal: 0-4)); -Red blood cell: 16-25/HPF (normal: 0-4); -Mucous: moderate (normal: none/small); -Culture indicated: yes; -Culture report (test to identify bacteria or fungus that can cause an infection), dated 7/27/18, showed greater than 100,000 colony forming unit (CFU) milliliter (ml) proteus mirabilis (a gram- negative bacterium frequently a pathogen of the urinary tract) -On the bottom of the form was a hand written physician order [REDACTED]. Review of the resident’s admission Minimum Data Set (MDS), a federally mandated assessment completed by facility, dated 7/27/18, showed the following: -Daily decision making skills severely impaired; -Indwelling urinary catheter. Review of the resident’s care plan, last revised 8/2/18, showed the following: -[DIAGNOSES REDACTED]. -He/she was incontinent of bowel and bladder and is dependent on staff for care; -His/her mobility is limited; -At risk for infection; -The care plan did not address the resident’s urinary catheter. Observation on 9/18/18 at 2:42 P.M. showed the resident lay in a low positioned bed. The resident’s urinary catheter drainage bag hung on the side of the bed and was not contained within a privacy bag. The catheter drainage bag rested directly on the floor. Observation on 9/18/18 at 4:44 P.M. showed the resident lay in a low positioned bed. The resident’s urinary catheter drainage bag hung on the side of the bed and was not contained within a privacy bag. The catheter drainage bag rested directly on the floor. Observation on 9/19/18 at 8:11 A.M. showed the resident lay in a low positioned bed. The resident’s urinary catheter drainage bag hung on the side of the bed and was not contained within a privacy bag. The catheter drainage bag rested directly on the floor. Observation on 9/19/18 at 3:33 P.M. showed the resident lay in a low positioned bed. The resident’s urinary catheter drainage bag hung on the side of the bed and was not contained within a privacy bag. The catheter drainage bag rested directly on the floor. Observation on 9/20/18 at 5:22 A.M. showed the resident lay in a low positioned bed. The resident’s catheter drainage bag hung on the side of the bed and was not contained within a privacy bag. The catheter drainage bag rested directly on the floor. Observation on 9/21/18 at approximately 11:00 A.M. showed the following: -Licensed Practical Nurse (LPN) Q, Certified Nurse Assistant (CNA) P, and CNA T transferred the resident to his/her wheelchair; -The resident’s urinary catheter drainage bag (not contained within a privacy bag) dropped onto the floor; |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) -The drainage bag remained on the floor as the three staff members adjusted the resident in the wheelchair, applied foot pedals to the wheelchair and heel protectors to the resident’s feet; -LPN Q picked up the catheter drainage bag and passed the bag under the wheelchair to CNA T who attached it to the back of the wheelchair. During interview on 9/21/18 at 11:05 A.M., CNA T said he/she does not normally put the urinary drainage bag on the floor but there were a lot of tubes to handle during the resident’s transfer. During interview on 9/21/18 at 12:55 P.M., CNA P said the urinary catheter drainage bag should not be on the floor because it was dirty. He/she did not know it was on the floor when he/she assisted the resident to transfer. During interview on 9/21/18 at 2:06 P.M., the director of nursing said the urinary catheter drainage bag should not touch the floor due to causing infections. If the resident is in a low bed, the bed should be lowered to a point where the urinary catheter drainage bag is off the floor. He/she would not expect the urinary catheter drainage bag to be on the floor during transfers. Staff should hold on to the catheter drainage bag during transfers and then place it in a privacy bag. | |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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) (3) times: -Before moving the medication from the drawer; -Before pouring the medication; -After pouring the medication; -The authorized licensed/certified staff member seeks assistance from the nursing supervisor/designee and consulting pharmacy when any aspect of medication administration is in question. 2. Review of the facility policy Medication Shortages and Unavailable Medications, dated 11/1/17, showed the following:: -Policy: The facility shall ensure there is always an adequate supply of medication to administer to a resident on hand at all times and facility staff should immediately initiate action to obtain medication from the pharmacy once a potential medication shortage has been identified; -Procedures: Upon discovery that the facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from the pharmacy. If the medication shortage is discovered at the time of medication administration, the nurse will immediately take the action; -The nurse should contact the pharmacy to determine the status of the order. If the medication has not been ordered, the licensed nurse should place the order or reorder for the next scheduled delivery; -If the next available delivery causes delay or a missed dose in the resident’s medication schedule, the nurse should check to see if the dose can be removed from the on-site store or the emergency medication supply to administer the dose; -If the medication is not available in the emergency medical supply, the nurse should notify the pharmacy and arrange for an emergency STAT delivery; -If an emergency STAT delivery will not be in time for the next dose, or if the medication is not in the on-site supply or emergency medication supply, the nurse should contact the attending physician to obtain orders for directions; -When a missed dose is unavoidable, the nurse should notify the physician and document the missed dose on the medication administration record (MAR) or treatment administration record (TAR) 3. Review of Resident #2’s physician’s orders, dated 8/30/18 to 9/30/18, showed the following: -Focus select eye vitamin with [MEDICATION NAME], take one every day at 9:00 A.M.; -[MEDICATION NAME] (an [MEDICATION NAME]), take one tablet daily; -[MEDICATION NAME] Propionate (an inhaled steroid) 50 microgram (mcg), one spray in each nostril every morning at 9:00 A.M. for allergies [REDACTED].>-Losartan potassium (used to treat high blood pressure) 25 milligrams (mg), take one tablet every day at 9:00 A.M. for HTN; -Polyethylene [MEDICATION NAME] (used to treat constipation) 3350, mix 17 grams (one capful) in 8 ounces of liquid and take by mouth every day at 9:00 A.M. for constipation; -[MEDICATION NAME] (nerve pain medication and used to treat [MEDICAL CONDITION]) 100 mg, take two capsules (200 mg) three times a day at 8:00 A.M., 12:00 P.M. and 9:00 P.M; -[MEDICATION NAME] HCL ER (extended release antidepressant medication) 150 mg, take one capsule every morning with breakfast at 9:00 A.M.; -Vitamin B12 (B12 supplement) 1,000 mcg, take one tablet every day at 9:00 A.M.; -Vitamin D-3 (D-3 supplement) 2000 units, take one tablet every day at 9:00 A. M; -[MEDICATION NAME] (used to treat pain) 5% patch, apply one patch topically to left side/back every morning and remove at bedtime, on at 8:00 A.M. and off at 8:00 P.M.; |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 21) -[MEDICATION NAME] (used to treat high blood pressure, chest pain and heart failure) 25 mg, take one tablet twice daily; -[MEDICATION NAME] ([MEDICATION NAME], pain reliever) 325 mg, take two tablets (650 mg) three times a day at 9:00 A.M., 3:00 P.M. and 9:00 P.M.; -[MEDICATION NAME] 7.5 mg with a line drawn through it and a hand written note to discontinue the medication on 7/18/18. Review of the resident’s medication administration record (MAR), dated (MONTH) (YEAR), showed the following: -Focus select eye vitamin with [MEDICATION NAME], take one every day at 9:00 A.M.; -[MEDICATION NAME] HCL 10 mg, take one tablet by mouth daily; -[MEDICATION NAME] Propionate 50 microgram (mcg), one spray in each nostril every morning at 9:00 A.M. for allergies [REDACTED].>-Losartan potassium 25 mg, take one tablet every day at 9:00 A.M. for HTN; -Polyethylene [MEDICATION NAME] 3350, mix 17 grams (one capful) in 8 ounces of liquid and take by mouth every day at 9:00 A.M. for constipation; -[MEDICATION NAME] 100 mg, take two capsules (200 mg) by mouth three times a day at 8:00 A.M., 12:00 P.M. and 9:00 P.M; -[MEDICATION NAME] HCL ER 150 mg, take one capsule every morning with breakfast at 9:00 A.M.; -Vitamin B12 1,000 mcg, take one tablet every day at 9:00 A.M.; -Vitamin D-3 2000 units, take one tablet every day at 9:00 A.M.; -[MEDICATION NAME] 5% patch, apply one patch topically to left side/back every morning and remove at bedtime, on at 8:00 A.M. and off at 8:00 P.M. (the dose was circled indicating not available on 9/1/18, 9/2/18, 9/3/18, and from 9/8/18 to 9/19/18); -[MEDICATION NAME] 25 mg, take one tablet twice daily; -[MEDICATION NAME] 325 mg, take two tablets (650 mg) three times a day. -[MEDICATION NAME] (used to treat pain and inflammation caused by arthritis) 7.5 mg, take one tablet every day at 9:00 A.M. (The resident’s (MONTH) POS did not show a current order for [MEDICATION NAME]). Observation on 9/19/18 at 8:13 A.M. showed Certified Medication Technician (CMT) S prepared the following medications: [REDACTED] -One tablet of focus select eye vitamin with [MEDICATION NAME]; -One 10 mg tablet of [MEDICATION NAME] HCL; -One 25 mg tablet of Losartan potassium; -Two 100 mg capsules of [MEDICATION NAME]; -One 150 mg capsule of [MEDICATION NAME]; -One 1000 mcg tablet of Vitamin B12; -One 25 mg tablet of [MEDICATION NAME]; -Two 325 mg tablets of [MEDICATION NAME]; -One 7.5 mg tablet of [MEDICATION NAME] 7.5 mg (the resident’s (MONTH) POS did not show a current order for [MEDICATION NAME]); -17 grams or Polyethylene [MEDICATION NAME] 3350 in 8 ounces of liquid; -[MEDICATION NAME] Propionate 50 mcg nasal spray. During interview on 9/19/18 a 8:16 A.M., CMT S said the resident’s [MEDICATION NAME] 5% patch was not available. Observation on 9/19/18 at 8:18 A.M. showed the following: -CMT S entered Resident #102’s room (the door was labeled with Resident #102’s name); -CMT S said I have your medications, Resident #2 as he/she prepared to administer the medications to Resident #102; |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 22) -The surveyor questioned Resident #102 on his/her name prior to CMT S administering the medications to the resident. The resident said he/she was Resident #102 (not Resident #2); -CMT S exited the room and questioned staff in the hall where Resident #2 had been moved; -CMT S then entered Resident #2’s (the door was labeled with Resident #2’s name) and administered the medications to Resident #2. During interview on 9/19/18 at 8:49 A.M., CMT S said the following: -The MAR for Resident #2 had the wrong room number and there was not a picture on the MAR indicating who the resident was. He/she was not sure when Resident #2 had been moved to a different room. It was his/her error that he/she almost gave Resident #102 Resident #2’s medications; -Resident #2’s [MEDICATION NAME] had not been available for nine days. During interview on 10/1/18 at 11:35 A.M., the administrator said the [MEDICATION NAME] order was put on the resident’s MAR in error on 9/1/18 when the facility changed pharmacies. The medication was discontinued on 7/18/18. During interview on 9/21/18 at 2:06 P.M., the director of nursing said the following: -Resident #2’s [MEDICATION NAME] was not available for nine days. She would have expected staff to have notified the physician. -Staff is to address resident’s by name when giving medications. The resident’s room change should be conveyed in report. During interview on 10/1/18 at 1:08 P.M., the Physician Assistant to the Medical Director said the following: -He/she would expect staff to notify him/her if a medication was not available so a medication could be given to the resident during the interim; -He/she would expect the facility to have a physician’s order to administer a medication. | |
| F 0805 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0805 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) residents with a physician’s orders [REDACTED]. Review of the undated Pureed Food Guidelines, provided by the dietary manager, showed the following directions regarding preparation of pureed entrees: -Product Amount: 3 ounces cooked or ½ cup cooked (ground); -1/2 slice bread; -Broth (use beef broth for beef, pork for pork, pork for ham, chicken for poultry, fish for fish); -Place bread, then food to be pureed in blender or food processor. Begin with ½ cup liquid, puree; then continue to alternate adding liquid and pureeing until product is correct consistency. During an interview on 9/19/18 at 10:14 A.M., the Dietary Manager said the facility had 11 residents on a pureed diet. Bread was added during the preparation of the pureed items by adding a half slice of bread to the mixture per serving per resident. Observation and interview on 9/19/18 at 10:16 A.M. showed the dietary manager gathered items to puree the Salisbury steak. She said she planned to prepare 18 servings of Salisbury steak so there was extra leftover. She would use nine pieces of bread for the puree preparation. The dietary manager added 11 mostly full 4-ounce ladles of broth to five slices of bread and nine torn up Salisbury steak patties and pureed the mixture together. The mixture was thin and chunky. She placed this mixture in a steam table pan and started a second batch of pureed Salisbury steak in the food processor. She used nine Salisbury steak patties, four slices of bread and ten mostly-full ladles of broth. She pureed this mixture and added it to the steam table pan. Both final products were thin and chunky with visible chunks of meat/bread and were not smooth. She said the puree should be between a pudding and mashed potato consistency and not too thick and not too runny. Purees should be smooth in texture. Observation on 9/19/18 at 12:31 P.M. showed the pureed test tray contained pureed Salisbury steak. The consistency of the pureed steak was very thick and chunky. The mixture was difficult to swallow without trying to chew the bite of food. 3. During an interview on 9/19/18 at 3:30 P.M., the consultant dietician said pureed items such as vegetables and meat should be pudding or mashed potato consistency and preferably smooth in texture. She did not typically get a modified diet tray to sample during her visits to the facility. During an interview on 9/20/18 at 9:05 A.M., the dietary manager said staff should follow the Pureed Food Guidelines when preparing pureed items. She would expect staff to follow the spreadsheet and would expect all items to be prepared appropriately. Meat that was grittier in texture, like the pork steak, was harder to get to a smooth consistency. The pork steak was stringier and doesn’t puree as well. The mixed vegetables that have hulls also don’t puree as well. | |
| 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 and interview, the facility failed to ensure the range hood was free |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 24) and not towel dried. The facility census was 109. 1. Observation on 9/18/18 at 10:50 A.M. showed the range hood had an accumulation of yellow grease with a buildup of dark-colored debris over the fryer and griddle. Observation and interview on 9/19/18 at 10:35 A.M. showed the range hood baffles had accumulated yellow grease over the fryer and griddle. Clear grease was visible on the other remaining baffle filters. Further observation showed the range hood sticker on the outside of the hood indicated the hood was last professionally cleaned 8/28/18 and was due again to be cleaned in December. The dietary manager said staff cleaned the range hood baffles weekly by running them through the dish machine. The dishwasher staff person was supposed to clean them yesterday. Observation on 9/20/18 at 9:02 A.M. showed the range hood baffles had accumulated yellow grease over the fryer and the griddle. Yellow drip formations were visible on the fire suppression piping and shielded lights inside the hood. 2. Observation on 9/18/18 at 11:14 A.M. and on 9/19/18 at 8:52 A.M. showed the dish machine room was empty and no staff was present. A large gray rolling trash can sat uncovered and was halfway full of food waste and paper trash. Observation on 9/19/18 at 10:51 A.M. showed the trash can in the dish machine room was uncovered and no staff was present in the room. Observation on 9/19/18 at 11:55 A.M. of the dish machine room showed the trash can was 1/4 full of food waste and trash. Gray-colored liquid was present in the bottom of the trash can. The trash can was uncovered. No staff was present in the dish room. The lunch meal service was in progress. 3. Observation on 9/18/18 at 10:56 A.M. and on 9/19/18 at 8:58 A.M. showed the walk-in cooler had a large amount of wet yellow-colored liquid on the floor of the cooler. Numerous onion skins/peels were visible on the metal floor and under the metal shelves. Observation on 9/20/18 at 9:02 A.M. showed the floor inside the walk-in cooler had dried yellow liquid and onion skins under the shelving. 4. Observation on 9/18/18 at 12:31 P.M. showed two residents’ lunch trays were prepared and the plates were covered with a dome lids. The lids were wet and had an accumulation of wet food debris on the inside and outside of the covers. Observation on 9/18/18 at 12:41 P.M. showed dietary staff covered two test tray plates with dome lids. The inside and outside of the two plate covers were dirty with wet food debris and water droplets. During an interview on 9/18/18 at 12:42 P.M., Dietary Staff W said the facility does not have enough trays or tray covers for all the residents, so the kitchen has to get them back and wash them to be able to serve the rest of the residents. 5. Observation on 9/19/18 at 9:25 A.M. showed Dietary Staff W dried two large steam table pans with a white cloth. He/she stacked and stored the pans on the storage rack. 6. During an interview on 9/20/18 at 9:05 A.M., the dietary manager said the following: -The evening cook mopped the walk-in cooler floor daily. She doesn’t know what the yellow debris is on the walk-in cooler floor and can’t get it up off the floor. -She would expect the trash cans to be covered. She was not aware the can in the dish room needed to be covered. -Dishware should be air dried and not towel dried. Staff was trying to dry the dishware before storing it; -Plate domes and bases should be clean without food debris. The facility is running short on lids and bases and sometimes have to reuse them during a meal. The lids and bases need to be clean when used. -The dishwasher staff cleaned the range hood baffles weekly on Tuesdays. The baffles had |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 25) not been cleaned this week. Maintenance staff wiped down/cleaned the inside of the hood weekly when the baffles were out of the hood. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 26) Procedures, revised 4/23/12, showed the following: -Soiled linen is held away from the body; -Soiled linen is bagged or put into carts at the location where it is used, like in the resident’s room or in containers directly outside the resident’s room; -Linen is transported and stored in a manner that maintains cleanliness. 4. Review of Resident #68’s annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/7/18, showed the resident required extensive assistance of one staff for personal hygiene. Observation on 9/20/18 at 10:21 A.M., showed the following: -Registered Nurse (RN) D and Certified Nurse Assistant (CNA) O entered the resident’s room; -CNA O transferred the resident from his/her wheelchair to his/her bed; -Without washing his/her hands, RN D put on gloves, removed the resident’s pants and incontinence brief, and positioned the resident on his/her right side; -The resident was incontinent of bowel; -RN D cleansed the resident’s rectal area and buttocks, rolled up the soiled incontinence brief, and tucked it under the resident; -RN D removed his/her gloves, and without washing his/her hands, put on new gloves, picked up a tube of barrier cream, squeezed out a small amount of cream onto his/her left hand, and applied the cream to the resident’s buttock/rectal area; -RN D removed his/her gloves, and without washing his/her hands, put on new gloves, and put a new incontinence brief behind the resident; -RN removed his/her gloves, and without washing his/her hands, put on new gloves, and applied a dressing to the resident’s coccyx (tailbone) wound; -RN D removed his/her gloves, and without washing his/her hands, put on new gloves, removed the soiled incontinence brief that was tucked under the resident’s right hip, and rolled the resident back and forth to position the clean brief; -RN D removed his/her gloves, and without washing hands, put on new gloves, assisted the resident to pull up his/her pants and transferred the resident back to his/her wheelchair. During interview on 9/21/18 at 7:54 A.M., RN D said staff should wash their hands before and after cares and in between glove changes. Staff should not touch anything after removing their gloves and before washing their hands. 5. Review of Resident #57’s admission MDS, dated [DATE], showed the resident required limited assistance from one staff for personal hygiene. Review of the resident’s care plan, dated 8/2/18, showed the resident required limited assistance from one staff for personal hygiene. Observation on 09/20/18 at 6:00 A.M. showed the following: -CNA L and CNA K entered the room; -The resident wore a hospital gown and incontinence brief and sat on the edge of the bed; -CNA K washed his/her hands, put on gloves, and assisted the resident to lay down on the bed; -CNA K placed wash cloths in the resident’s sink and ran water over them. CNA L put on gloves without washing his/her hands. CNA K squeezed skin cleanser soap on the washcloths that lay in the sink basin; -CNA K removed the resident’s wet incontinence brief and cleansed the resident; -Without removing his/her soiled gloves, CNA K assisted CNA L to dress the resident, and to assist the resident to sit on the side of the bed; -CNA K and CNA L transferred the resident from the bed to the wheelchair; -Without removing his/her soiled gloves, CNA K combed the resident’s hair; |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 27) -CNA L removed the resident’s bed sheets and linens and put them in a trash bag. He/she left the room without removing gloves. CNA L touched the key pad and put in the code to go out of the unit door and to the soiled utility room to deposit the soiled linen bag, touching the soiled utility room door, and then came back inside the unit door. 6. Review of Resident #80’s admission MDS, dated [DATE], showed the resident required limited assistance from one staff for personal hygiene; Review of the resident’s care plan, dated 8/12/18, showed the resident required limited assistance of one to two staff for personal hygiene. Observation on 09/20/18 at 6:14 A.M., showed the following: -CNA L and CNA K were in the resident’s room after assisting the resident’s roommate Resident #57 with personal cares; -CNA K removed his/her gloves, put on new pair of gloves without washing his/her hands, placed clean washcloths into the sink to wet them, squeezed soap on the washcloths, and left the washcloths inside the sink while CNA L and CNA K assisted the resident to dress; -CNA K performed perineal care, and without removing his/her gloves, assisted the resident to the wheelchair; -CNA K removed his/her gloves, did not wash his/her hands, placed the resident’s soiled linens into a trash bag, and gave the bag with soiled linens to CNA L; -CNA L removed his/her gloves, did not wash his/her hands, and held the bag of soiled linens against the side of his/her body, picked up another bag of trash, and pushed the resident in the wheelchair to the dining room; -CNA L took the two bags of soiled linens, pressed the key pad to release the unit door, walked out of the unit to the soiled utility room to deposit the linens and trash, touched the door knob and key hanging above the door, opened the unit door and came back inside. During interview on 9/20/18 at 6:55 A.M., CNA L said the following: -He/she was to wash his/her hands when he/she came into the facility from outside, when he/she dumped trash/linens, when he/she changed gloves, and before putting on gloves; -There was no soiled linen cart for soiled linens on the special care unit. -After providing care to Resident #80, he/she carried the two bags of soiled linens to the soiled linen room. He/she didn’t think about the bag up against his/her clothing, but should not have done this. During interview on 8/20/18 at 7:10 A.M., CNA K said he/she was to wash his/her hands before entering and leaving a resident’s room, after removing his/her gloves, and when he/she used the bathroom; 7. During interview on 09/21/18 at 2:07 PM, the director of nursing said the following: -She expected staff to wash their hands and put on gloves as soon as they enter a resident’s room; -She expected staff to remove gloves and wash hands before leaving the room; -She expected staff to wash hands before, during, and after perineal care; -She expected staff to remove their gloves and wash their hands when they take trash and soiled linens out of the unit to the dirty utility room; -Staff should not wear gloves in the hall, should not touch things with soiled gloves, and should not place soiled linens against their body. | |
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement policies and procedures for flu and pneumonia vaccinations. **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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 28) Based on interview and record review, the facility failed to vaccinate eligible residents with the pneumococcal vaccine as indicated by the current Centers for Disease Control (CDC) guidelines, unless the resident had previously received the vaccine, refused, or had a medical contraindication present for four residents (Residents #23, #57, #62 and #99), in a review of 28 sampled residents. The facility failed to develop policies and procedures in accordance with the current CDC guidelines for administering the pneumococcal vaccine. The facility census was 109. 1. Review of the facility policy Pneumococcal Disease: Prevention and Control, and Use of Pneumococcal [MEDICATION NAME] Vaccine, revised 12/19/11, showed the following: -Residents who are at risk of pneumococcal diseases will be offered the pneumococcal vaccine as part of their therapeutic regimen unless the vaccine is contraindicated; -Pneumococcal vaccine will be offered to all new residents upon admission after determining, if possible, whether they have previously received the vaccine; -Residents who refuse to accept the vaccine will be asked to sign a declination form after the risks and benefits of receiving the pneumococcal vaccine have been fully explained to them, or their responsible party; -Documentation of the education provided concerning the risks/benefits of receiving the pneumococcal vaccine, and the resident’s decision regarding whether to accept or decline the vaccine will be entered into their medical record; -Standing orders will be used for administration of vaccines, unless specific orders are required per state regulations; -Pneumococcal [MEDICATION NAME] Vaccine: there are currently two available pneumococcal vaccines, [MEDICATION NAME] 23 and PnuImmune 23; -Persons who should be vaccinated: Persons [AGE] years and older, persons aged 2-64 who have chronic illness, persons aged 2-64 who are living in special environments or social setting such as nursing homes; -Immuno-compromised person for the potential benefits and safety of the vaccine justify its use; -Order vaccine and maintain a supply of pneumococcal vaccine in order to be prepared for new admissions needing vaccination; -The policy did not address the current Centers for Disease Control (CDC) guidelines for the pneumococcal vaccine. 2. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Time for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR 13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23): -One dose of PCV13 was recommended for adults [AGE] years or older who had not previously received PCV13; -One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered; -For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history, administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions; -For those age [AGE] years or older who previously received one dose of PPSV23 and no doses of PCV13, administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions; |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 29) -For residents age 19-[AGE] years, administer one dose of PPSV23 at 19 through [AGE] years. This includes adults with chronic heart or lung disease, diabetes mellitus, alcoholism, chronic liver disease and adults who smoke; -For residents age 19-[AGE] years, administer one dose of PCV13 then administer PPSV23 at least eight weeks apart from the PCV13 (at 19-[AGE] years). Administer another PPSV23 at least five years after the first dose of PPSV23(at 19-[AGE] years). 3. Review of Resident #23’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/18/18, showed the following: -Cognitively intact; -Pneumococcal vaccine was up to date. Review of the resident’s undated face sheet showed the resident was under age 65. Review of the resident’s Physician Order Sheet, dated (MONTH) (YEAR), showed an order that the resident may have [MEDICATION NAME] as indicated. Review of the resident’s Informed Consent for Pneumococcal Vaccine, undated, showed no evidence the pneumonia education had been addressed with the resident/representative and the box indicating permission to receive or refuse the vaccination was left blank. Review of the resident’s immunization record showed the following: -The resident had received the PPSV 23 vaccination on 9/19/14; -No evidence the resident received the Prevnar 13 vaccination. During interview on 9/21/18 at 1:41 P.M., the resident said if his/her physician recommended he/she should receive another vaccination for pneumonia, he/she would be agreeable to receiving the vaccine. 4. Review of Resident #57’s face sheet showed the resident was admitted on [DATE]. The resident was over age 65. Review of the Pneumococcal Consent/Refusal Form showed the family representative signed the consent form on 7/25/18 for the resident to receive the pneumococcal vaccine. Review of the resident’s immunization record showed no pneumonia vaccine history. Review of the resident’s admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Pneumonia vaccine offered and declined. During interview on 9/21/18 at 11:05 A.M., the administrator and Director of Nursing said they had trouble receiving the pneumonia vaccine PPSV 23 when it was ordered in (MONTH) (YEAR). They would have administered the pneumonia vaccine to this resident within a day or two when the consent form was signed by the family representative if the vaccine was available. They would administer the vaccine within 24 to 48 hours of the family giving consent. 5. Review of Resident #62’s face sheet showed the resident was admitted on [DATE]. The resident was over age 65. Review of the resident’s admission MDS, dated [DATE], showed the following: -Intact cognition; -The pneumococcal vaccine was not marked and left blank. Review of the Pneumococcal Consent/Refusal form showed the resident signed the consent form on 7/26/18, to receive the pneumococcal vaccine. Review of the resident’s immunization record showed no pneumonia vaccine history. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -Pneumococcal vaccine was not up to date; -Reason: not offered. During interview on 9/21/18 at 11:05 A.M., the administrator and Director of Nursing said |
| 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: 265118 |
| (X3) DATE SURVEY COMPLETED 09/21/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER FRONTIER HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 2840 WEST CLAY ST | |||||||||
| 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 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 30) they had trouble receiving the pneumonia vaccine PPSV 23 when it was ordered in (MONTH) (YEAR). They would have administered the pneumonia vaccine to any residents within a day or two when the consent form was signed by the resident and/or family representative if the vaccine was available. They would administer the vaccine within 24 to 48 hours of the family giving consent. 6. Review of Resident #99’s medical record showed the resident was admitted to the facility on [DATE]. Review of the resident’s informed consent for pneumococcal vaccine, signed on 8/25/18, showed the resident’s representative gave the facility permission to administer a pneumococcal vaccination. Review of the resident’s immunization record showed no evidence the resident had received a pneumococcal vaccine. Review of the resident’s admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Pneumococcal vaccine not up to date; -Reason: not offered. 7. During interview on 9/21/18 at 2:06 P.M., the DON said the following: -The facility followed the CDC guidelines for vaccinations. -If a consent form was blank, then the vaccine had not been addressed; -The admitting nurse should be addressing vaccinations on admission; -Staff should follow-up with the resident/responsible party, hospital or physicians office to find out immunization history; -If a resident/representative has signed a consent, then staff should be giving the vaccination; -The pneumonia vaccination should be given within 24 to 48 hours after admission. During interview on 10/1/18 at 1:08 P.M., the Physician Assistant to the Medical Director said the following: -He/she would expect the facility policy to include and follow the CDC guidelines for administering the pneumonia vaccines; -He/she would expect the facility staff to seek him/her for a resource if the pneumonia vaccines were not available so they could discuss other possible options available. | |
