| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 – Few | 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 – Few | (continued… from page 1) to install a more durable wall material to prevent holes but it is expensive. He/She said the missing baseboards and dented holes in walls are due to wheelchairs and he/she is constantly working to repair them. During an interview on 08/30/18 at 10:25 A.M., Certified Nursing Aide (CNA) I said staff report needed repairs to maintenance verbally or via a note in writing. He/She said he/she usually fixes minor issues the same day and more time consuming issues he/she will repair as soon as possible. During an interview on 08/30/18 at 10:54 A.M., Licensed Practical Nurse (LPN) B said he/she notifies maintenance verbally if he/she needs something to be repaired. He/She said maintenance usually fixes things as soon as he/she can. He/She said he/she is not aware of any non-repaired issues. He/She said he/she has not noticed any missing drawers or holes in the walls because it is not his/her job. He/She said housekeeping and maintenance are responsible for making sure resident rooms do not need any repairs. During an interview on 08/30/18 at 1:02 P.M., the Director of Nursing (DON) said staff should inform maintenance verbally or in a note if they notice something that needs repaired. He/She said the administrator should monitor to make sure things are repaired. He/She said maintenance said he/she had ordered new drawers. He/She said he/she is unsure how long ago it was. He/She said he/she has noticed areas in the building that need to be repaired. He/She said maintenance is repairing stuff as requested. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) 2. Review of Resident #5’s comprehensive Minimum Data Set (MDS), a federally mandated assessment, dated 5/12/18, showed staff assessed the resident as follows: -Moderately impaired cognition; -No mood symptoms; -No behaviors or rejection of care; -Received antipsychotic and antidepressant medications for seven days during the review period. Review of the resident’s care plan, dated 7/18/18, showed staff did not develop the comprehensive care plan within seven days of completion of the comprehensive MDS. Staff documented the following to address the dementia care needs of the resident: -Assist of 1 with bathing, dressing, toileting, and personal hygiene. Keep all personal items in reach, provide non-distracting environment for grooming/personal hygiene; -Assess/record effectiveness of drug treatment. monitor and report signs of sedation, [MEDICATION NAME] and extrapyramidal symptoms; -Administer meds crushed, will not take in multiple attempts due to dementia. 3. Review of Resident #8’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Poor appetite on several days; -No behaviors or rejection of care; -Oxygen therapy. Review of the resident’s care plan, dated 7/24/18, showed staff did not address the resident’s oxygen use or tubing changes. Review of the resident’s physician’s orders [REDACTED]. Further review showed staff are directed to change oxygen tubing monthly. 4. Review of Resident #11’s face sheet showed he/she admitted to facility on 11/22/17, with [DIAGNOSES REDACTED]. Review of the resident’s admission pain assessment, completed by staff on 11/23/17, showed staff documented the following: -Vocal complaints of pain, rated as severe; -Pain in legs; -Almost constantly, on scale 6 out of 10; -Pain limited daily activities over the past 5 days; -Pain comes and goes; -Measures previously used to alleviate pain: [MEDICATION NAME], rest, relaxation techniques; -Initiate plan of care. Review of the resident’s baseline care plan, signed completed by staff on 11/23/17, showed pain was not identified as an area of concern. Review of the resident’s comprehensive care plan, dated 11/23/17, showed staff did not document any directions or interventions to address the resident’s pain. Review of the resident’s admission MDS, dated [DATE], showed staff documented resident was admitted [DATE], and assessed the resident as follows: -Not on a scheduled pain medication regimen; -Received as needed (PRN) pain medications; -Did not receive non-medication intervention for pain; -Vocal complaints of pain (that hurts, ouch, stop); -Indicators of pain or possible pain observed daily. Further review of the resident’s records, showed staff did not develop and implement |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) interventions to address the resident’s pain until 4/9/18. Staff were directed: -Problem: Resident has chronic complaints of pain and history of opioid abuse per guardian; -Goal: Pain will be monitored and treated within parameters set by guardian and physician; -Interventions: Update guardian on pain complaints, follow up with pain specialist. Make guardian aware of pain specialist prior to visit. During an interview on 8/27/18 at 11:56 A.M., the resident said he/she has pain on a scale of 7 out of 10 to his/her lower back, but had not asked staff at this time for pain medication. During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said if a resident complains of pain on admission, he/she expects staff to document care plan interventions for the pain, and staff should always attempt non-pharmacological interventions for pain. 5. Review of Resident #17’s MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two or more staff with bed mobility, dressing, and toileting; -Use of walker and wheelchair. Review of the resident’s care plan, last updated 8/16/18, showed staff are directed to do the following: -Assist the resident with activities of daily living (ADLs) with three staff for pericare, bed mobility, and dressing; -Stand by assist with two staff with walker for transfers. Further review showed staff did not develop and implement measurable goals and interventions to address the resident’s use of side rails or grab bars. Observation on 8/27/18 at 11:27 A.M., showed the resident in his/her bed with a half side rail in the raised position on the left and right side at the head of his/her bed. Observation on 8/28/18 at 11:32 A.M., showed the resident in his/her bed with a half side rail in the raised position on the left and right side at the head of his/her bed. Observation on 8/29/18 at 11:19 A.M., showed the resident in his/her bed with a half side rail in the raised position on the left and right side at the head of his/her bed. 6. Review of Resident #28’s comprehensive admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -No mood; -No behaviors or rejection of care; -Oxygen therapy. Review of the resident’s care plan, dated 4/12/18, showed staff did not address when to administer oxygen or the flow rate ordered for the resident. Further review showed staff are directed to change the resident’s oxygen tubing weekly. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -No mood; -No behaviors or rejection of care; -Oxygen therapy. Review of the resident’s POS, dated 08/01/18, showed staff are directed to administer 2 liters of oxygen per minute per nasal cannula at night and PRN for shortness of breath. |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) Further review showed staff are directed to change oxygen tubing monthly. Observation on 08/27/18 at 10:22 A.M., showed the resident’s oxygen tubing dated 08/07/18. Staff did not change the resident’s oxygen tubing weekly, as directed by the physician’s Staff did not change the resident’s oxygen tubing weekly, as directed by the physician’s Observation on 08/28/18 at 12:48 P.M. showed the resident’s oxygen tubing dated 07/27/18. 8. Review of Resident #41’s quarterly MDS, dated [DATE], showed staff assessed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) Observation on 08/29/18 at 2:12 P.M. showed the resident in bed with half rails on each side. Further observation showed resident on oxygen via nasal cannula set at 2 liters. Additional review showed the oxygen tubing was not dated. 9. Review of Resident #69’s significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -No impairments to upper or lower extremities; -No behavior or rejection of care; -Limited assist of one with dressing, and toileting, and set-up help with eating; -Extensive assist of one with personal hygiene. Review of the resident’s comprehensive care plan, dated 8/29/18, showed staff are directed: -Assist of one with all ADLs except resident is able to feed self; -Offer turning and peri care frequently throughout shift -Check for incontinence in morning, before and after meals, at bed time, and frequently throughout shift; -Offer to perform personal hygiene, (washing face, combing hair, dressing) every morning. Staff did not develop the comprehensive care plan within seven days of completion of the comprehensive MDS. During an interview on 8/27/18 at 2:45 P.M., Certified Nursing Assistant (CNA) N said the resident became incontinent of bowel and bladder about 2 weeks ago, has gotten weaker, and needs more assistance from staff with his/her ADLs. 10. During an interview on 8/30/18 at 10:32 A.M., CNA D said staff use information from each resident’s care plan to provide care for the resident. He/She said residents’ care plans are located in their charts, and in the wall kiosks. 11. During an interview on 8/30/18 at 10:54 A.M., Licensed Practical Nurse (LPN) B said the MDS coordinator creates care plans and they should be created to meet the residents needs and staff should follow the care plans and interventions. 12. During an interview on 8/30/18 at 11:21 A.M., the MDS Coordinator said he/she creates the care plans based on the residents care area assessment off the MDS and through interviews from residents and family members, and the care plan should accurately reflect the resident. 13. During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said the MDS Coordinator creates the care plans and they should reflect the residents. The DON said things like side rail use, Activities of Daily living, dementia, weight loss, pain, and oxygen use should be on the care plan. The DON said he/she expects staff to follow the care plans and interventions. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) assessment, dated 03/20/18, showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Required total dependence of one or more staff for eating, toileting, and personal hygiene; -Required extensive assistance of two or more staff for bed mobility and transfers; -Required extensive assistance of one staff for dressing; -No falls during lookback period. Review of the resident’s care plan, last updated 03/23/18, showed facility staff are directed to do the following: -Assist to bed when tired/sleeping; -Apply foot buddy for leg support; -Provide individualized toileting interventions based on needs and patterns. Review of the resident’s comprehensive significant change MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance of two or more staff for bed mobility; -Required extensive assistance of one staff for transfers, dressing, eating, toileting, and personal hygiene; -No falls during lookback period. Review of the resident’s internal incident report, dated 08/23/18, showed staff documented the resident fell on [DATE] and staff are following up on it through interdisciplinary team meetings. Review of the resident’s nurses’ notes, dated 08/23/18 showed staff documented they conducted neurological checks and the resident denied pain. Further review of the resident’s care plan, last updated 03/23/18, showed staff did not update the resident’s care plan with fall interventions following the fall with injury on 08/23/18. 2. Review of Resident #62’s MDS, dated [DATE], showed facility staff assessed the resident as follows: -Sever cognitive impairment; -Required total assistance of two or more staff for bed mobility, transfer, dressing; and toileting; -Required total assistance of one staff for eating, personal hygiene, and bathing; -Limited range of motion in both upper and lower extremities. Review of the resident’s Monthly Summary, dated 8/1/18, showed staff documented the resident had limitations of range of motion in both upper and lower extremities. Review of the resident’s care plan, last updated 8/9/18, showed facility staff are directed to do the following: -Use appropriate staff member for activities of daily living, -Toilet and reposition before and after meals, at bed time and as needed; -Bilateral lower extremities impaired; -Assess lower extremities every day for skin condition; -Maintain upright position in wheelchair. Further review of the resident’s care plan, last updated 8/9/18, showed staff did not update the resident’s care plan with the limitation in range of motion limitation in upper extremities. Observation on 8/27/18 at 11:49 A.M., showed the resident’s hands in a fist. Observation on 8/28/18 at 10:36 A.M., showed the resident in bed with both his/her hands in a fist. |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) Observation on 8/28/18 at 2:15 P.M., showed the resident in his/her wheelchair with his/her hands in a fist. Observation on 8/30/18 at 10:26 A.M., showed the resident in his/her bed with his/her hands in a fist. 3. Review of Resident #73’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance of two or more staff for bed mobility, transfers, and toileting; -Required extensive assistance of one staff for dressing and personal hygiene; -One fall with no injury after admission; -No weight loss of 5% or more in the last 6 months. Review of the resident’s care plan, last updated 02/06/18, showed facility staff are directed to do the following: -Two staff present for transfers, personal hygiene, and toileting; -Provide appropriate fitting wheelchair; -Assess pain; -Provide special boots to be worn; -Proper catheter placement; -Monitor diabetes; -Monthly weights; -Report weight gain or loss; -Provide alternates for food dislikes; -Offer snacks. Review of the resident’s quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance of two or more staff for bed mobility, transfers, and toileting; -Required extensive assistance of one staff for dressing and personal hygiene; -One fall with no injury after admission; -No weight loss of 5% or more in the last 6 months. Review of the resident’s notes, dated 05/21/2018, showed the Registered Dietician documented the resident’s weight increase by 11% in 180 days from 207.2 to 229.4. He/She recommended no changes. Review of the resident’s nurses’ notes, dated 05/22/18, showed staff documented the resident was in his/her wheelchair in the dining room after lunch when he/she reached for something on the ground and fell on to the floor. Staff noted the resident did not hit his/her head, denies pain, and had no visible injuries. Further review of the resident’s care plan, last updated 02/06/18, showed facility staff did not update the care plan with the fall, review of current fall interventions or new fall interventions. Additional review showed staff did not update the care plan with the weight gain or add any weight monitoring. 4. Review of Resident #122’s face sheet, showed the resident was admitted on [DATE]. Review of the resident’s Admission assessment, dated 8/16/18, showed facility staff assessed the resident’s skin as buttocks and buttocks cleft red, irritated, and fragile. Skin is intact. Review of the resident’s skin assessments, dated 8/17/18, showed staff documented the resident had an excoriated area to coccyx. |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two or more staff for bed mobility and transfers; -Required extensive assistance of one staff member for dressing and bathing; -No pressure ulcers; -No skin issues. Review of the resident’s Nurses Notes, dated 8/27/18, showed facility staff documented wound one to right buttock measures 2.6 cm x 3.0 cm x 0.1 cm onset on 8/16/18 upon admission to facility with denudation and excoriation (reddened skin). Wound two to left buttock measuring 1.5 cm x 1.5 cm x 0.1 cm with onset on 8/16/18 of excoriation. Both wounds were cleaned with wound cleanser and applied barrier (cream used to provide a barrier from being wet) cream twice and day and as needed for soiling. Measurements were completed 8/23/18. Review of the resident’s care plan, last updated 8/27/18, showed the resident was at risk for pressure ulcers and staff were directed to do the following: -Consider speciality bed; -Elevate heels off bed or use heel protectors; -Position with pillows to elevate pressure points off bed; -Skin assessments and inspection every shift with close attention to heels by Certified Nurse Assistant (CNA) and weekly by nurses; -Do frequent small shift of body weight, turn and reposition frequently throughout shift and as needed. Further review of the resident’s care plan showed staff did not update the care plan to address the open areas on the resident’s buttocks. Observation on 8/23/18 at 1:55 P.M., showed Licensed Practical Nurse (LPN) J entered the resident’s room. Observation showed the resident had an open area on the right buttock and three open areas on the resident’s left buttock. LPN J said he/she is not sure how the are categorized, but the wounds are open and have serosanguineous drainage (clear, thin, watery drainage) and the wound bed is red and raw. Observation on 8/29/18 at 11:52 A.M., showed the Assistant Director of Nursing (ADON) entered the residents room. Observation showed the ADON rolled the resident to the left. Observation showed the resident had an open area on the right buttock and three open areas on the left buttock. The ADON said the resident’s bottom has denuded skin. The ADON said the resident’s had one open area on the right bottom that measured 2.3 centimeter (cm) x 2.5 cm x 0.1 cm. The ADON said the wound has was 70 percent (%) [MEDICATION NAME] tissue (thin tissue that cover all exposed surface of body) and 30% granulation tissues (new connective tissue in the surface of the wound). ADON said the resident’s left buttock wound measured 1.6 cm x 1 cm x 0.1 cm with 10% granulation tissue and 90% [MEDICATION NAME] tissue with two satiate open area that are less than 1 cm one is 5% granulation and 95% [MEDICATION NAME] tissues. 5. During an interview on 8/30/18 at 10:54 A.M., LPN B said the MDS coordinator and nurses can update resident’s care plans. Care plans should be updated with any change of condition such as falls, personal preference, weight loss, new skin issues or wounds. 6. During an interview on 8/30/18 at 11:21 A.M., the MDS Coordinator said he/she updates care plans as well as nurses. The MDS coordinator said care plans should be updated with any change in condition, activity of daily living changes, weight loss, falls, antibiotics, hospitzation, and new skin issues or wounds. The MDS Coordinator said he/she gets the information by staff passing the word along, reviewing charts quarterly, and weekly risk meetings. |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) 7. During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said nurses and the MDS coordinator can update care plans. The DON said falls, open areas, and limitations in range of motion should be updated in the residents’ care plans. The DON said Resident’s #25’s fall should be on the care plan within the first 24 hours. The DON said he/she updated Resident’s #122 care plan with a fall on 8/29/18. The DON said wounds should be updated on the residents care plan. The DON said Resident’s #73’s fall should have been updated on the care plan. | |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 10) -Saturday 7/28/18: Word finds, read a good book, and cards with friends (no time scheduled); -Sunday 7/29/18: Movie of choice at 10:00 A.M., and Church at 2:30 P.M.; -Staff did not schedule any activities after 3:30 P.M., for the entire month of July. 4. Review of the Activity calendar, dated (MONTH) (YEAR), showed the following: -Saturday 8/4/18: Music and relaxation at 7:00 A.M., Movie and popcorn at 10:00 A.M., and Front Porch Pickers at 2:00 P.M.; -Sunday 8/5/18: Visit with others (no time scheduled), and Church at 2:30 P.M.; -Saturday 8/11/18: Cards with friends, puzzles, and music (no time scheduled); -Sunday 8/12/18: Talk with a veteran (no time scheduled), and Church at 2:30 P.M.; -Saturday 8/18/18: Puzzle, music, cards, and board games (no time scheduled); -Sunday 8/19/18: Reminisce with friends about school (no time scheduled), and Church at 2:30 P.M.; -Saturday 8/25/18: Puzzles, cards, sewing (no time scheduled); -Sunday 8/26/18: Sing old songs (no time scheduled), and Church at 2:30 P.M. -Staff only scheduled two evening activities for the entire month of (MONTH) (8/17/18 and 8/28/18). 5. Review of Resident #11’s admission Minimum Data Set (MDS), a federally mandated assessment, dated 12/1/17 showed staff assessed the resident with moderate cognitive impairment, required extensive assist of one staff with locomotion on and off unit, and prefers to spend time away from nursing home. Review of the resident’s activity participation log dated (MONTH) (YEAR), showed staff did not document the resident participated in any activities. Staff documented the resident likes to stay in his/her room, is very talkative, loves his/her coffee, and likes bingo, which is the only game he/she will come out to play. Review of the resident’s activity participation log dated (MONTH) (YEAR), showed staff documented the resident attended the following activities: -7/3/18: Bingo and popcorn; -7/6/18: Enjoyed ice cream that was brought to him/her; -7/11/18: Came to the band in the North dining room; -7/23/18: Enjoyed the children reading to him/her; -7/26/18: Went to Country Store for the first time. Review of the resident’s activity participation log dated (MONTH) (YEAR), showed staff documented the resident attended the following activities: -8/3/18: Talked with him/her about raising children; -8/18/18: Enjoyed ice cream and two cups of coffee; -8/20/18: Bingo and popcorn; -8/26/18: Visited with peers outside, watched Cardinals baseball game on TV; -8/29/18: Visited with peers outside. Review of the resident’s care plan last updated 8/28/18, showed staff are directed: -Resident will not leave facility without presence of staff or family member; -Provide supervision with transfers, independent with all other ADLs; -Uses wheelchair for locomotion, may need assistance for long distances; -Ensure resident is aware of activities, allowed to decorate room, and voice feelings to staff. Review of the resident’s activities assessment dated [DATE] showed staff documented: -Prefers his/her own room for independent leisure; -Prefers music, watching TV, people watch, and bingo; -Will play bingo twice a week, rest of time spent in room. |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 11) During an interview on 8/27/18 at 11:56 A.M., the resident said he/she likes to play Bingo, but staff doesn’t offer it that often. He/She said there is not much to do on the weekends either, and he/she would love if staff offered even Bingo on the weekends, because he/she would participate. 6. Review of Resident #25’s quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance of two or more staff for bed mobility, transfers, and toileting; -Required extensive assistance of one staff for eating, dressing, and personal hygiene. Review of the resident’s activity participation log, dated 06/2018, showed staff did not document the resident attended any facility activities. Review of the resident’s activity participation log, dated 07/2018, showed staff documented the resident attended the following activities: -7/09/18 reading with kids; -7/11/18 watched a band; -7/16/18 reading with kids; -7/24/18 tell a joke day; -7/27/18 watched a band. Review of the resident’s activity participation log, dated 08/2018, showed staff documented the resident attended the following activities; -8/04/18 listened to music; -8/08/18 watched a band; -8/14/18 listened to the piano; -8/28/18 supper with youth group. Review of the resident’s comprehensive significant change MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Customary routine activities include: receiving shower, snacks between meals, listening to music, being around animals, doing group activities, and participating in favorite activities; -Required extensive assistance of two or more staff for bed mobility; -Required extensive assistance of one staff for transfers, dressing, eating, toileting, and personal hygiene. Review of the resident’s care plan, last updated 08/29/18, showed staff are directed to provide a setting in which activities are preferred: by the nurse’s station or in the dining room so the resident can people watch. Review of the resident’s activity assessment, dated 08/29/18, showed staff assessed the resident as: -Alertness varies by day; -Prefers his/her own room or activity room; -Prefers one on one activities and independent leisure; -Likes to nap frequently, people watch, and reminisce; -Interested in music, watching television, and talking. Observation on 08/27/18 at 2:36 P.M., showed the resident lie in bed and appear to sleep. Further observation showed the light off, the television was not on, and no music was played. Observation on 08/28/18 at 10:41 A.M., showed the resident lie in bed and appear to sleep. Further observation showed the light off, the television was not on, and no music was |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 12) played. Observation on 08/28/18 at 12:57 P.M., showed the resident sit in his/her wheelchair in his/her room. Further observation showed the light off, the television was not on, and no music was played. 7. Review of Resident #29’s comprehensive admission MDS, dated [DATE], showed facility staff assessed the resident as follows: -Cognitively intact; -Activity preferences include music and spiritual service; -Required extensive assistance of two or more staff for bed mobility and transfers; -Required extensive assistance of one staff for dressing, toileting, and personal hygiene. Review of the resident’s care plan, last updated 08/29/18, showed staff are directed to provide the resident with activities that identify with the resident’s prior lifestyle, such as drinking beer as ordered once or twice per week. Review of the resident’s activity participation log, dated 08/2018, showed staff documented the resident attended the following activities; -8/08/18 hospice came in and shaved the resident; -8/16/18 family came to visit; -8/20/18 had coffee and looked at the menu; -8/23/18 came out for both meals; -8/27/18 family came to visit; -8/28/18 enjoyed music at dinner. Review of the resident’s complete medical record showed staff did not complete an activity assessment for the resident and did not complete activity logs for 06/2018 or 07/2018. Observation on 08/27/18 at 10:29 A.M., showed the resident laid in bed and appear to sleep. Observation on 08/28/18 at 12:48 P.M., showed the resident laid in bed and appear to sleep. Observation on 08/29/18 at 2:11 P.M., showed the resident laid in bed and appear to sleep. 8. Review of Resident #33’s significant change MDS, dated [DATE], showed staff assessed |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 13) -8/20/18: Enjoyed popcorn for afternoon snack; -8/21/18: Visited with staff; -8/22/18: Visited with peers outside; -8/26/18: Visited with peers outside; -8/29/18: Visited with peers outside. Review of the resident’s care plan, last updated 8/28/18, showed staff are directed to offer assist of one with transfers, and encourage small group programs. During an interview on 8/30/18 at 10:20 A.M., the resident said he/she loves to play bingo, but they only have it sometimes twice a week. He/She said it would be nice to have bingo on the weekends sometimes to at least give the residents something to do because the weekends are boring. The resident said he/she did not even care if he/she won or not, because it’s just a game. 9. Review of the White Board on the unit, showed the following scheduled activities for Monday 8/27/18: -11:15 A.M.: Roll of the dice; -1:15 P.M.: Crafts for September; -2:00 P.M.: Bingo. Observation on 8/27/18 at 11:38 A.M., showed a total of nine residents in the TV/lobby area. Further observation showed there was no staff-led activity in progress. Observation on 8/27/18 at 2:30 P.M., showed a total of six residents in the TV/lobby area. Further observation showed there was no staff-led activity in progress. Observation and interview on 8/27/18 at 2:38 P.M., showed Resident #11 sat in his/her room in the wheelchair. The resident said staff did not offer him/her to play Bingo today. During an interview on 8/27/18 at 2:30 P.M., Certified Nursing Assistant (CNA) O said according to the board, Bingo was scheduled for 2:00 P.M., but it looks like they didn’t do it back here today. 10. Review of the White Board on the unit, showed the following scheduled activities for Tuesday 8/28/18: -2:00 P.M.: Board game (Sorry) -3:00 P.M.: Baking. Observation on 8/28/18 at 2:08 P.M., showed there was no staff-led activity in progress. Observation on 8/28/18 at 2:20 P.M., showed a total of six residents sat in the TV/lobby area. Further observation showed there was no staff-led activity in progress. 11. Review of the White Board on the unit, showed the following scheduled activities for Wednesday 8/29/18: -11:15 A.M.: Roll the dice; -2:00 P.M.: Mid-week social drink a beer & painting. During an interview on 8/29/18 at 12:02 P.M., Resident #11 said he/she did not play any Bingo this week, and did not do a roll the dice activity today either. He/She said staff usually has activities scheduled on the board, but often cancels the activities, so residents only end up doing something about twice a week back in the locked unit. Observation and interview on 8/29/18 at 12:09 P.M., showed Resident #71 sat in a chair in his/her room. The resident said staff did not do a roll the dice activity today. He/She said there is not usually any activities on the weekends. He/She said sometimes they have church, but that doesn’t interest him/her. He/She would enjoy bowling/fishing or something like that because he/she is from the country. 12. During an interview on 8/29/18 at 2:40 P.M., the AD said he/she had to cancel the beer and painting activity today because the administrative staff said they did not have the time to get the supplies for the activity, and he/she was busy with a transport errand, so |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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) he/she did not get to go shopping for supplies either. He/She said the Roll the dice activity was not held in the morning either, because he/she had to go on a transport. The AD said most of the activities are held in the front of the building (North side), but staff will assist a few residents from the locked unit to scheduled activities. The AD said if he/she has a free moment he/she will go to the unit and play balloons with the residents and they love it. He/She said on weekends when he/she is not at work, the residents do open activities (puzzles, crafts, etc.), and pretty much what the residents want to do. He/She said the CNAs will conduct activities like popcorn and a movie as well when he/she is not there. During an interview on 8/30/18 at 10:25 A.M., CNA D said he/she works every other weekend. The CNA said staff conducts activities on the weekends, based on the calendar (dice, board games, movie), and every once in a while bingo, if the AD has the supplies left out. He/She said there are at least seven residents that play bingo regularly, but thinks it’s only done once a week on the unit. He/She said sometimes staff takes some of the residents on the unit to the front for activities. During an interview on 08/30/18 at 10:25 A.M., CNA I said all staff are technically responsible for doing activities with residents but there is an activities person. He/She said the activities person works day shift five days a week and sometimes on the weekends. He/She said the activities person selects a staff member to help deliver activities when he/she is not here. He/She said sometimes family members volunteer to help with activities. He/She said they try to make sure the more dependent residents have music playing or television on in their rooms. During an interview on 8/30/18 at 10:49 A.M., Licensed Practical Nurse (LPN) C said on Sundays, activities typically include church, puzzles, and sometimes staff paint residents’ nails. On Saturdays, they usually have movie and popcorn, ball/balloon swat, cards, and sometimes music. He/She thinks bingo is held twice a week back in the unit. The LPN said activities are not usually canceled without a replacement, but the mid-week social and beer activity is not usually held for residents on the locked unit, even if they have an order for [REDACTED].>During an interview on 08/30/18 at 10:54 A.M., LPN B said the AD is responsible for doing activities with residents. He/She said on evenings and weekends the CNAs help with activities. He/She said all staff are responsible for inviting residents to activities and all residents should be invited to all activities. He/She said Resident #62 participates in balloon swat and other physical games and Resident #25 sleeps a lot but he/she is rarely in his/her room because he/she is usually sitting at the nurses’ station so they can talk to him/her. | |
| F 0680 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure the activities program is directed by a qualified professional. Based on record review and staff interviews, facility staff failed to ensure the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0680 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) During an interview on 8/29/18 at 2:40 P.M., CNA H said he/she was the AD/CNA and transport person when needed. He/She has not received any formal or online training, and has been the AD since (MONTH) (YEAR). He/She said he/she thinks the Administrator was working on getting him/her to complete a week-long training, but did not know when. He/She said he/she assisted the previous AD with activities about three days per week. During an interview on 8/29/18 at 4:48 P.M., the Administrator said the facility currently does not have an AD until CNA H is trained. He/She said CNA H is an activities aide at this time, and has not completed any formal/online training. The Administrator said there are plans for CNA H to attend a one-week training, but he/she did not have a date planned as yet. | |
| F 0727 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, facility staff failed to provide the services of a |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 0732 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Post nurse staffing information every day. Based on observation, interview and record review, facility staff failed to post the | |
| F 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, licensed facility staff failed to ensure controlled medications were properly stored, failed to routinely conduct a physical inventory of controlled medications, failed to record the number of narcotic cards at the beginning and end of each shift, and failed to ensure change of shift sheets for controlled medications were routinely signed by each on-coming and off-going staff. Additionally, facility staff failed to properly document the as needed (PRN) administration of a controlled medication for one randomly observed resident (Resident #58). The facility census was 69. 1. Review of the facility’s policy on Controlled Substance Storage, revised (MONTH) 2011, showed staff are directed: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations; -The Director of Nursing in collaboration with the consultant pharmacist, maintains the facility’s compliance with federal and state laws and regulations in handling of controlled substances; -Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, (double-locked) compartment separate from all other medications, or per state regulations; -Controlled substances that require refrigeration are stored within a locked box within the refrigerator. The box must be attached to the inside of the refrigerator; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented; -The consultant pharmacist or designee routinely monitors controlled substance storage records (such as change of shift sheets, individual controlled substance accountability sheets, delivery confirmation sheets) and expiration dates, during routine medication storage inspections. 2. Review of the facility’s Narcotics Shift Change sheet, showed staff are directed to document the facility name, hall, date, shift, time, nurse/CMT leaving duty, nurse/CMT arriving, number of cards at start, number of cards added or subtracted, and number of cards remaining. 3. Review of the North side Narcotics Shift Change sheet for (MONTH) (YEAR) showed the following: -8/1/18: on-coming nurse (2pm to 10pm) and off-going nurse (10pm to 6am) did not sign; -8/2/18: on-coming nurse (6am to 2pm) and off-going nurse (2pm to 10pm) did not sign; -8/3/18: on-coming nurse (6am to 2pm) and off-going nurse (10pm to 6am) did not sign; -8/4/18: on-coming nurse (6am to 2pm), off-going nurse (2pm to 10pm), on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/5/18: on-coming nurse (6am to 2pm), off-going nurse (2pm to 10pm), on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/6/18: on-coming nurse (6am to 2pm), and off-going nurse (2pm to 10pm) did not sign; -8/8/18: on-coming nurse (6am to 2pm), and off-going nurse (2pm to 10pm) did not sign; -8/10/18: on-coming nurse (6am to 2pm), and off-going nurse (2pm to 10pm) did not sign; -8/11/18: on-coming nurse (10pm to 6am), and off-going nurse (10pm to 6am) did not sign; -8/12/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/13/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 18) -8/14/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/15/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/16/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/18/18: on-coming nurse (6am to 2pm) did not sign. Staff did not document the number of narcotic cards and bottles remaining at the end of each shift/day for the entire month of August, as directed by the form. 4. Review of the South side Narcotics Shift Change sheet for (MONTH) (YEAR) showed the following: -8/2/18: on-coming nurse (10pm to 6am) did not sign; -8/3/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/5/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/7/18: on-coming nurse (10pm to 6am) did not sign; -8/8/18: off-going nurse (10pm to 6am) did not sign; -8/9/18: on-coming nurse (6am to 2pm), off-going nurse (6am to 2pm), on-coming nurse (2pm to 10pm), off-going nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/10/18: on-coming nurse (2pm to 10pm), off-going nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/13/18: on-coming nurse (6am to 2pm), off-going nurse (6am to 2pm), on-coming nurse (2pm to 10pm), off-going nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/18/18: on-coming nurse (2pm to 10pm), off-going nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign; -8/19/18: on-coming nurse (6am to 2pm) and off-going nurse (2pm to 10pm) did not sign; -8/20/18: on-coming nurse (2pm to 10pm) and off-going nurse (2pm to 10pm) did not sign; -8/21/18: on-coming nurse (2pm to 7:30pm) and off-going nurse (7:30pm to 6am) did not sign; -8/23/18: on-coming nurse (6am to 2pm), off-going nurse (6am to 2pm), and on-coming nurse (2pm to 10pm) did not sign; -8/27/18: staff did not sign the sheet for any shift that day; -8/28/18: on-coming nurse (6am to 2pm), off-going nurse (6am to 2pm), on-coming nurse (2pm to 10pm), and off-going nurse (2pm to 10pm) did not sign. Staff did not document the number of narcotic cards and bottles remaining at the end of each shift/day for 27 out of 28 days reviewed, as directed by the form. 5. Review of Resident #58’s individual controlled substance accountability sheets, showed staff documented a remaining quantity of 3.5 ml (milliliters) of [MEDICATION NAME] (a schedule IV controlled medication). Review of the resident’s electronic Medication Administration Record [REDACTED]. Further review of the narcotic count sheet showed staff documented they administered 0.5 ml of the medication to the resident on 8/17/18, 8/18/18, 8/19/18, 8/20/18, 8/24/18, 8/26/18, and 8/27/18. Staff failed to properly document the time and reason for administration of a controlled medication to a resident for seven days. 6. Observation on 8/27/18 at 9:43 A.M., showed the North Medication storage room unlocked, and unattended. Further observation showed the refrigerator inside the med room also unlocked, unattended, and contained: -an opened bottle of [MEDICATION NAME] 2 milligrams/ milliliters (mg/ml), labeled for Resident #12; -an unopened bottle of [MEDICATION NAME] 2 mg/ml, labeled EKIT (emergency kit). 7. During an interview on 8/27/18 at 10:16 A.M., Licensed Practical Nurse (LPN) B said nurses are expected to reconcile the amount remaining on each card with the individual resident’s controlled medication record, and sign the on-coming and off-going spots on the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) narcotic count sheets in the book. The LPN said staff are expected to lock the medication room at all times when unattended. During an interview on 8/28/18 at 11:21 A.M., LPN C nurses are expected to physically check the quantity of medication left in the bottles and verify with the written amount documented on the individual resident’s controlled medication record sheet, but the nurses don’t always do it. The LPN said he/she did not physically check the amount of medication in the bottles stored in the refrigerator at the beginning of his/her shift. He/She said sometimes it is hard to get the off-going night nurse to come and perform the count with the on-coming nurse. During an interview on 8/30/18 at 10:42 A.M., LPN C said staff are expected to always store narcotic medications under double-lock when not being accessed. During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said he/she expects staff to store narcotic medications (controlled substances) behind two locks. He/She said oncoming and off-going nurses and CMTs are expected to count every container of narcotics each shift, and document the quantities of each. The DON said staff should at a minimum sign the narcotic count sheet at each shift change, but should also document the total number of cards/bottles of narcotic medications in the cart and/ or refrigerator. He/she said staff are expected to physically verify the amount of narcotic liquid medication left inside the bottle with the actual amount documented on the sheet. The DON said he/she also expects staff to document administration of PRN narcotics on the resident’s eMAR, and not just on paper. Additionally, he/she expects the nurse/CMT to document a corresponding note with a reason for the administration of the PRN medication. | |
| F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 20) *As needed (PRN) orders include indications for use; *Indications for use and therapeutic goals are consistent with current medical literature and clinical practice guidelines; *The prescribed dose is appropriate to the resident’s clinical status; *The duration of therapy is indicated and is appropriate for the resident; -Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing (DON), and/or prescriber as appropriate; -Recommendation are acted upon and documented by the facility staff and or the prescriber: *Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing; *If there is potential for serious harm and the attending physician does not concur, or the attending physician refuses to document an explanation for disagreeing, the Director of Nursing and the consultant pharmacist contact the medical director. 2. Review of Resident #5’s annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/12/18, showed staff assessed the resident as follows: -[DIAGNOSES REDACTED]. -Moderate impaired cognition; -No mood symptoms; -No behaviors or rejection of care; -Received antipsychotic medications for 7 days; -Received antidepressant medications for 7 days; -Antipsychotics were received on a routine basis only; Review of the resident’s care plan last updated 8/29/18, showed staff are directed: -Resident receives [MEDICAL CONDITION] medication related to [DIAGNOSES REDACTED]. -Assess/record effectiveness of drug treatment, monitor and report signs of sedation, [MEDICATION NAME] and extrapyramidal symptoms (EPS); -Follow Gradual Dose Reductions (GDR) with physician and pharmacy consult; -Monitor For behaviors every shift. (Listed in eMAR Behavior Monitoring). Review of the monthly MRR documented by the Consultant Pharmacist, showed he/she documented the following: -2/28/18 MRR-complete -3/31/18 MRR-complete -4/30/18 MRR-complete -5/25/18 MRR-no recommendations -6/28/18 MRR-complete -7/31/18 MRR-no recommendations Review of the resident’s physician’s orders [REDACTED]. -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (an antipsychotic medication) 2.5 mg twice daily (BID) for anxiety disorder, begin 1/30/18. The Consultant Pharmacist failed to recognize and notify facility staff and the physician, of the use of an antipsychotic medication for an inappropriate [DIAGNOSES REDACTED]. 3. Review of Resident #12’s MDS, dated [DATE] showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Required total assistance of one staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing; -7 days of antipsychotic medication; |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 21) -7 days of antidepressants medications. Review of the resident’s Physician order [REDACTED]. Review of the resident’s MRR, dated 7/31/18, showed the consultant pharmacist documented [MEDICATION NAME] 0.25 mL hours as needed for anxiety CMS requires that all PRN psychoactive medication orders are to be written for no more than 14 days. If PRN psychoactive are deemed necessary beyond this time, the prescribing practitioner must document a clinical rationale and specify the duration of use. Further review of the resident’s MRR, dated 7/31/18 showed the physician did not check agree, disagree, or other and documented This is for comfort care. The physician did not specify a duration for use. Review of the resident’s care plan, last updated 8/28/18, showed the resident’s is on [MEDICAL CONDITION] medications and staff are directed to monitor for adverse effects and behaviors every shift. During an interview on 8/29/18 at 4:55 P.M., the Director of Nursing (DON) said the physician documented for comfort care because the resident’s is hospice. The DON believes the physician did not agree because of his/her statement. The DON said he/she does not believe hospice patients should be included in the requiment. During an interview on 8/30/18 at 10:45 A.M., Licensed Practical Nurse (LPN) B said PRN [MEDICAL CONDITION] medication should only be ordered for 14 days and if they are ordered for more than 14 days staff should call the physician and get clarification. LPN B said he/she is not sure why the resident’s medication did not have a stop date. 4. Review of Resident #43’s annual MDS, dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED]. -BIMS not assessed; -No mood symptoms or depression; -Rejection of care, and wandering that did not impact others; -Received antipsychotic medications for 7 days; -Received antidepressant medications for 7 days; -Antipsychotics were received on a routine basis only; -Last attempted GDR 9/22/17. Review of the resident’s care plan, dated 7/9/18, showed staff are directed the resident is at risk for falls due to use of [MEDICAL CONDITION] medications and self-ambulatory. Further review of the care plan updated 7/26/18, showed staff are directed to follow GDR by pharmacist review with physician orders, and monitor for behaviors and interventions every shift. Review of the Consultant Pharmacist’s Note to Attending Prescriber, dated 1/26/18, showed he/she documented if clinically appropriate, please consider reducing the current medication dose to [MEDICATION NAME] (an antipsychotic medication) 0.25 mg, take half tablet BID. If a GDR is clinically contraindicated at this time, please document the clinical rationale below. This must address the reason(s) why an attempted dose reduction would likely impair the resident’s function, or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. Further review of the resident’s record showed the physician did not document a response to the Consultant Pharmacist’s recommendation. Additional review of the records showed facility staff did not follow up on the recommendation, or contact the medical director for direction. Additional review of the monthly MRR documented by the Consultant Pharmacist, showed he/she documented 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 22) -2/28/18 MRR-complete -3/31/18 MRR-complete -4/30/18 MRR-complete -5/25/18 MRR-no recommendations -6/28/18 MRR-complete -7/31/18 MRR-no recommendations Review of the POS [REDACTED]. The Consultant Pharmacist and facility staff did not follow up for six months, on a previously recommended GDR for a resident prescribed a routine Antipsychotic medication. 5. During an interview on 8/29/18 at 1:12 P.M., the DON said if the Consultant Pharmacist only documented MRR-complete, he/she did not have any additional documentation to accompany that note. During an interview on 8/29/18 at 4:55 P.M., the DON said the pharmacist reviews residents medications and then he/she sends the recommendation to the DON who will send it to the physician. The DON said he/she expects the physician to review and document agree/disagree and if disagree a rational within 72 hours of receiving the pharmacy recommendation. During an interview on 8/30/18 at 10:45 A.M., LPN B said pharmacist reviews the residents’ medications. The pharmacist send his/her recommendations to staff. LPN B said the nurse sends the recommendation to the physician and the physician will sign if he/she agrees or disagrees. He/She said if the physician disagrees there should be a rationale. The LPN said if the physician does not respond or does not complete all required information staff should call the physician for follow up and clarification. | |
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) -All expired medications will be removed from the active supply and destroyed in the facility regardless of amount remaining. The medication will be destroyed in the usual manner; -When the original seal of a manufacturer’s container or vial is initially broken, the container or vial will be dated: **The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating; 2. Review of the facility’s policy on Storage of Medications, dated (MONTH) (YEAR), showed staff are directed all medications for residents must be stored at or near the nurse’s station in a locked cabinet, a locked medication room, or one or more locked medication carts; and no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. 3. Observation on 8/27/18 at 9:43 A.M., showed the North Medication storage room unlocked, and unattended. Observation showed the cabinet above the sink unlocked and contained the following: -Two bags of 0.9% Sodium Chloride Injection 100 ml (medication administered intravenously), expired 5/2018; -Multiple cards with various pills for different residents, [MEDICATION NAME] vials (inhaled medications), glucose gel (used to treat low blood sugar levels), 1 [MEDICATION NAME] injection pen (used to treat severe low blood sugar levels) labeled EKIT (emergency kit), Carbamezapine liquid (medication to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder), labeled for Resident #62. Further observation showed the refrigerator unlocked and contained multiple insulin pens (used to treat elevated blood sugar levels) labeled for different residents, two vials of pneumonia vaccine, two vials of [MEDICATION NAME] medication (used to test individuals for [MEDICAL CONDITION]-a bacterial lung disease), two bottles of controlled medications, among other medications. Observation showed on top of the refrigerator a red bin labeled overflow with: -Multiple oral medications to include [MEDICATION NAME] 2 milligrams (mg) (antipsychotic medication), [MEDICATION NAME] 80 mg (used to treat heart rhythm problems), [MEDICATION NAME] 25 mg (used to treat high blood pressure), [MEDICATION NAME] 20 mg (used to treat fluid retention); -A box with seven [MEDICATION NAME] injections (medication injected to prevent blood clots) 30 mg/0.3 milliliters (ml), labeled for Resident #70, and another box with 10 injections for the same resident; -A box with two [MEDICATION NAME] injections 40 mg/0.4 ml labeled for Resident #55. Additional observation showed the following underneath the sink: -A spray bottle of Springtime odor counteractant with a warning label to keep out of reach of children; -A plastic cottage cheese container, with a powdered substance inside, and a hand-written label Thickener, dated 4/24/18; -An opened metal container of Sysco Instant food thickener, dated 1/18. During an interview on 8/27/18 at 10:16 A.M., Licensed Practical Nurse (LPN) B said staff are expected to lock the medication room at all times when unattended, because there are medications inside. The LPN said he/she had the keys for the medication room and did not know why the room was left unlocked. The LPN said nurses are responsible to discard expired medications and IV supplies, but do not have a specific schedule. He/She said the Consultant Pharmacist also checks the med room for expired meds, but was not sure how |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) often. He/She said staff just hadn’t tossed the expired IV meds as yet. 4. Observation on 8/27/18 at 10:25 A.M., showed the North Medication/Treatment Cart contained the following: -A Basaglar Kwikpen (medication to lower blood sugar levels), opened and undated, labeled for Resident #26; -A [MEDICATION NAME] (medication to lower blood sugar levels), opened and undated, labeled for Resident #23; -A [MEDICATION NAME] vial 100 units/ml, opened, and unlabeled with a resident name or the date; -A [MEDICATION NAME] vial (medication to lower blood sugar levels), 100 units/ml, opened and undated, labeled for Resident #23; -A [MEDICATION NAME] vial 100 units/ml, opened and undated, labeled for Resident #38; During and interview on 8/27/18 at 10:32 A.M., LPN B said staff are expected to label insulin pens and vials with the resident’s name, opened and expiration dates, and affix the prescription label if available. 5. Observation on 8/28/18 at 10:51 A.M., showed the South Medication Cart contained the following: -A [MEDICATION NAME] labeled for Resident #71, expiration date 8/26/18; -A [MEDICATION NAME] labeled for Resident #63, with an opened date of 7/23/18, another opened date of 8/12/18, and an expiration date of 8/26/18. During an interview on 8/28/18 at 10:59 A.M., LPN C said it was unclear when Resident #63’s [MEDICATION NAME] was expired based on the two different opened dates documented by staff. The LPN said nurses and Certified Medication Technician’s administer insulin to residents at the facility, and they are expected to check the expiration dates on each medication before they administer it to the resident. 6. During an interview on 8/30/18 at 10:42 A.M., LPN C said nurses on the day and evening shift check for expired medications in the med rooms once a month, but with no set schedule. He/She said the Consultant Pharmacist also checks the med rooms once a month for expired medications. The LPN said chemicals should not be stored in the same compartment with thickeners/food products. During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said the med room should be locked at all times when not accessed, and he/she expects staff to store narcotic medications (controlled substances) behind two locks. The DON said the Consultant Pharmacist checks the med rooms monthly for expired medications, and was at the facility the last week of July. He/She said facility staff is ultimately responsible to check for expired medications, and he/she missed the expired IV medications. He/She said thickener (or other foods) should be stored in their original containers, and should not be stored in the same compartment with chemicals inside the medication room. | |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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 25) 1. According to the Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. *Hand washing remains the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and when each resident’s care is completed. 2. Review of the facility’s policy on handwashing, dated (MONTH) (YEAR), showed staff are directed to perform handwashing to reduce transmissions of organisms from resident to resident, nursing staff to resident, and resident to nursing staff. 3. Review of the facility’s policy on Gloves, dated (MONTH) (YEAR), showed staff are directed: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances), and/ or persons with a rash; -Change gloves between contacts with different residents or with different body sites of the same resident. 4. Observation on 8/27/18 at 12:18 P.M., showed Certified Nurse Assistant (CNA) K and CNA L entered Resident’s #7’s room. Observation showed CNA L washed his/her hands and applied gloves and CNA K applied gloves. CNA K removed the resident’s soiled brief. CNA K provided incontinence care to the resident and did not wash his/her hands or change his/her gloves. CNA K applied the resident’s new brief and pants. CNA K touched the resident’s sheets, pillows, clothes, and skin with his/her soiled gloves. CNA K removed his/her gloves and washed his/her hands. CNA K did not wash hands and change gloves in a manner to prevent the spread of bacteria. 5. Observation on 8/28/18 at 1:53 P.M., showed CNA E and CNA F entered Resident #69’s room, washed hands and applied gloves. Observation showed the resident incontinent of urine. CNA E turned the resident side to side, while CNA F provided incontinence care. CNA E applied a cream to the resident’s buttocks and washed hands. CNA F continued to wear his/her contaminated gloves, touched the resident’s clothing and placed a clean brief on the resident before he/she washed hands. CNA F did not change gloves and wash/sanitize hands in a manner to prevent the spread of bacteria. 6. Observation on 8/29/18 at 12:53 P.M., showed the Assistant Director of Nursing (ADON) and CNA N entered Resident #33’s room, washed hands and applied gloves, and assisted the resident to stand. Observation showed the resident incontinent of urine. CNA N provided incontinence care to the resident, while the ADON applied a dressing to the resident’s buttocks, and washed hands. CNA N continued to wear his/her contaminated gloves, placed the clean brief on the resident, and assisted the resident back to the recliner, before he/she washed hands. The CNA did not change gloves and wash/sanitize hands in a manner to prevent the spread of bacteria. During an interview on 8/30/18 at 10:32 A.M., CNA D said staff are expected to wash hands when they enter a room, during and after perineal care, between glove changes, and before they leave the room. 7. Review of Resident #12’s quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/26/18, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required total assistance of one staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing; -Resident had a stage two pressure ulcer that originated in the facility on 3/12/18 with |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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) slough; -Resident’s wound is worsening. Review of the resident’s care plan, last updated on 8/22/18, showed the resident has a pressure ulcer and staff are directed to do the following: -Observe and report signs of infection; -Assess and record the condition of the skin surrounding the pressure ulcer; -Assess the pressure ulcer for location, stage, and size; -Catheter placement to facilitate wound healing; -Conduct a systematic skin inspection weekly; -Keep bony prominence from direct contact with one another; -Turn and reposition every two hours. Review of the resident’s Physician order [REDACTED]. edges. Cover with bordered gauze an change daily as needed. Review of the resident’s wound company documentation, dated 8/16/18, showed the wound care company documented wound continues to decline, significant odor this visit. Further review showed the wound care company talked to hospice and the hospice director [MEDICATION NAME](antibiotic) 250 milligrams (mg) twice a day for 14 days and [MEDICATION NAME] (antibiotic) 500 mg three times a day for 14 days. Observation on 8/29/18 at 2:16 P.M., showed the Assistant Director of Nursing (ADON) entered Resident #12’s room and washed his/her hands and applied gloves. The ADON removed the resident’s brief. Observation showed the resident with a small amount of bowel movement on his/her bottom. Observation showed the ADON removed the resident’s dressing. Observation showed moderate drainage on the soiled dressing. Observation showed the ADON did not wash his/her hands and change gloves before he/she wiped the resident’s wound with gauze. Observation showed the ADON washed his/her hands and changed his/her gloves and applied the treatment and dressing. Observation showed the ADON wiped the bowel movement from the resident’s bottom from his/her bottom toward the clean dressing. The ADON did not clean the resident’s wound in a manner to prevent the spread of bacteria as directed and did not clean the residents bottom in a manner to prevent wound contamination. 8. Review of Resident #60’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two or more staff for bed mobility, transfers, and toilet use; -Required extensive assistance of one or more staff for dressing and personal hygiene; -Resident has a stage four pressure ulcer with slough that was present upon entry. Review of the resident’s care plan, last updated on 8/29/18, showed the resident had a pressure ulcer and staff are directed to do the following: -Administer antibiotics as ordered; -Administer vitamins, minerals, and antibiotics as needed; -Assess the resident for pain related to pressure ulcer and treat pain as indicated; -Conduct a systematic skin inspection daily by certified nurse aide (CNA), weekly by nurse, and report signs of infection; -Provide custom made electric wheelchair with pressure reduction seat; -Provide air mattress on bed; -Provide a regular diet and protein supplements as ordered; -Float heels when in bed; -Provide multi-podus boot to right foot; -Foley catheter to aid in wound healing; |
| 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: 265398 |
| (X3) DATE SURVEY COMPLETED 08/30/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GAMMA ROAD LODGE | STREET ADDRESS, CITY, STATE, ZIP 250 E LOCUST | |||||||||
| 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) -Keep skin clean and dry as possible to minimize skin exposure to moisture; -Keep linens clean, dry, and wrinkle free; -Toilet, turn and reposition as ordered; -Treatment as ordered by wound care plus team; -Use moisture barrier product to perineal area. Review of the resident’s Physician order [REDACTED]. necrosis of bone. Further review showed the resident’s physician ordered staff are directed to cleanse the coccyx wound with wound cleanser (a solution used to clean wounds), apply skin prep (a protective film or barrier) to surrounding area, apply santyl (enzyme used to help heal wounds by breaking up and removing dead skin) and calcium alginate (absorbent dressing) to wound bed and edges, cover with ABD pad (highly absorbent sterile dressing) secure with tape, and change daily and as needed for soiling. Additional review showed the resident’s physician ordered staff to cleanse the left buttocks wound with wound cleanser (a solution used to clean wounds), apply skin prep (a protective film or barrier) to surrounding area, apply hydrogel (highly absorbent gel used to promote wound healing) to wound bed and edges, cover with ABD pad (highly absorbent sterile dressing) secure with tape, and change daily and as needed for soiling. Review of the resident’s wound company documentation, dated 8/23/18, showed the wound care company documented coccyx wound unhealed, improved, with no signs of infection. Further review showed the wound care company documented the left buttocks unhealed, unchanged, with no signs of infection. Observation on 8/27/18 at 3:27 P.M., showed Licensed Practical Nurse (LPN) M entered the resident’s room. LPN M washed his/her hands and applied gloves. LPN G removed the residents brief. Observation noted red drainage from the wound on the resident’s brief. Further observation showed the resident did not have a dressing on his/her wound as directed by physician’s orders [REDACTED]. Observation showed LPN M did not clean the wound as directed before he/she applied the treatment and dressing to the resident’s wound. LPN M removed his/her gloves and washed his/her hands. Observation showed LPN M did not clean the residents wound in order to prevent the spread of bacteria as directed. 9. During an interview on 8/30/18 at 10:54 A.M., LPN B said staff should wash their hands and change gloves when staff enter/exit a room, between dirty/clean tasks, between glove changes, LPN B said staff should clean wounds with every treatment, change gloves between clean and dirty tasks to prevent wound infections. During an interview on 8/30/28 at the Director of Nursing (DON) said staff are expected to wash or sanitize hands between dirty and clean procedures, between glove changes with care or treatments. The DON said staff should clean the wound with each wound treatment to prevent infections The DON said staff should clean any bowel movement from a resident’s bottom prior to starting the wound treatment. | |
