| 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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0577 Level of harm – Potential for minimal harm Residents Affected – Many | Allow residents to easily view the nursing home’s survey results and communicate with advocate agencies. Based on observation, interview and record review, the facility failed to post the most | |
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) handled appropriately and reported to the Complaint Register Unit as necessary; -Procedure: -All employees will be screened for history of abuse, neglect or mistreatment of [REDACTED]. This includes attempting to obtain previous employment references, review of license as appropriate, criminal record checks and employee disqualification registry check; -Employees will be trained during orientation, through in service training’s and ongoing education on appropriate interventions, reporting allegations, what constitutes abuse, recognizing signs of abuse or signs that may lead to abuse, and annually a refresher course will be completed; -Profile adequate staff to meet the needs of residents, supervision of staff to identify inappropriate behaviors, assess and monitor residents with needs and behaviors that may lead to conflict or neglect; -When there is suspicion of abuse an investigation will be initiated; -An investigation form will be completed by the charge nurse. If the charge nurse suspects abuse/neglect, the Director of Nursing (DON) will be notified immediately. The DON will continue the investigation to determine cause and resolution of occurrence. If the DON concurs with the charge nurse, the administrator will be notified immediately; -The facility ensures that all allegations will be reported immediately, but no later than 2 hours if there is serious bodily harm, and no later than 24 hours if there is not serious bodily harm. In addition to reporting to the administrator and other officials, such as the State Survey Agency, and in compliance with the policy on Elder Justice Act Issues as outlined in the facility’s compliance manual; -If during the investigation a specific employee is suspected, they will be put on leave of absence until the investigation is completed; -Any occurrence that needs to be reported to the Complaint Register Unit and any other agencies as required will be reported by the DON or the Administrator. The following may be self reported: -An unexplained injury which require medical attention; -A resident to resident altercation which resulted in injury; -Financial exploitation of a resident; -Any allegation of abuse; -Elopement of a resident in which a resident leaves the facility without any staff knowledge; -Incidents of neglect; -Suspicious deaths. Review of Resident #20’s admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/15/18, showed the following: -admission date of [DATE]; -Severe cognitive impairment; -Required staff assistance for toileting, walking and dressing; -[DIAGNOSES REDACTED]. Review of the resident’s medical record, showed a nurse’s notes on 6/14/18 at 3:30 A.M., which showed the following: -Around 1:30 A.M., Nurse G informed by certified nurse aide (CNA) H the resident was very agitated and cursed at the CNA. The resident yelled he/she did not want CNA H in his/her room and he/she fired the CNA; -Nurse G able to calm the resident down and walked with him/her to his/her bed; -The resident said CNA H slapped him/her on the left side of the face and caused his/her |
| 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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) head to hit the wall. The resident said it hurt; -Nurse G assessed the resident and did not note any injury; -Nurse G was able to calm the resident and get him/her back to bed; -Nurse G did not document if the DON or Administrator were informed of the abuse allegation; -No further notes regarding the allegation. Further review of the resident’s medical record, did not show any additional information regarding the alleged abuse allegation. Review of the facility’s (MONTH) (YEAR) incident/accident log, provided on 7/11/18, showed no documentation regarding the abuse allegation. During an interview on 7/13/18 at 10:53 A.M., the administrator and DON said they were unaware of the incident. If a resident makes an allegation of abuse, staff should notify the DON or administrator immediately. During an interview on 7/16/18 at 7:21 A.M., Nurse G said since the resident did not have an injury, and it was the night shift, he/she left a note for the DON and informed the on-coming nurse of the resident’s allegation. If the resident had an injury, he/she would have notified the DON and the resident’s doctor. Nurse G also made CNA H write a statement regarding the allegation. The nurse’s note and the CNA’s statement were left under the door of the DON’s office. During an interview on 7/16/18 at 9:30 A.M., the DON said she did not have any record of a statement from the CNA. The administrator said DHSS should have been contacted regarding the abuse allegation. | |
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Respond appropriately to all alleged violations. **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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) involved. Statements will be obtained. If there is reasonable suspicion of abuse or neglect the nursing supervisor must be notified immediately; -Procedure: The charge nurse will immediately handle the incident and complete and investigation and/or incident report; -Immediately secure the safety of the resident; -Relocate resident to safe area; -Suspend staff involved until investigation is complete; -Complete and document a physical assessment of the resident; -The investigation should consist of: -Interviews with resident(s) involved, statements taken and documented; -Interviews with staff member(s), statements taken and enclosed; -Interviews with witnesses, statements obtained and documented; -Police report made/obtained if necessary; -Documentation requirements: -Internal incident report filled out; -Documented in chart; -Completed internal investigation report; -Documented plan of correction; -Reporting requirements: -The charge nurse shall notify the nursing supervisor immediately; -The nursing supervisor will make sure the family and doctor have been notified; -The nursing supervisor shall call the police if necessary; -The administrator or his/her designee shall review the file, and will make the final ruling on the plan of correction and agencies to be contacted; -Social services will notify the ombudsmen and DHSS if necessary. Review of Resident #20’s admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/15/18, showed the following: -admission date of [DATE]; -Severe cognitive impairment; -Required staff assistance for toileting, walking and dressing; -[DIAGNOSES REDACTED]. Review of the resident’s medical record, showed a nurse’s notes on 6/14/18 at 3:30 A.M., which showed the following: -Around 1:30 A.M., Certified nurse aide (CNA) H informed Nurse G the resident was very agitated and cursed at the CNA. The resident yelled he/she did not want CNA H in his/her room and he/she fired the CNA. CNA H was not the boss of the resident; -Nurse G calmed the resident down and walked with him/her to his/her bed; -The resident he/she was upset because CNA H slapped him/her on the left side of the face and caused his/her head to hit the wall. The resident said it hurt; -Nurse G assessed the resident and did not note any injury; -Nurse G was able to calm the resident and get him/her back to bed; -Nurse G did not document if the DON or Administrator were informed of the abuse allegation. Review of the resident’s medical record, showed no further notes regarding the alleged incident. During an interview on 7/16/18 at 7:21 A.M., Nurse G said he/she helped CNA H with toileting the resident around 1:30 A.M. on 6/14/18. Nurse G left the room and approximately five minute later, CNA H came to the nurse station and informed Nurse G the resident was agitated and cursing and did not want CAN H to work with him/her. Nurse G |
| 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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) said he/she found the resident in the doorway of his/her room and said the CNA was fired and was not the boss of him/her. Nurse G told the CNA to not work with the resident for the rest of the shift. The resident repeatedly stated CNA H had slapped him/her on the face. The resident was assessed and no injury was noted. The CNA was asked to make a statement regarding the incident. The CNA continued to work with other residents during the shift. The resident is confused at times, but since Nurse G was not in the room, he/she cannot say what did or did not happen. Nurse G put the CNA’s statement under the door of the DON office. The DON never followed up with Nurse G regarding the incident. During an interview on 7/16/18 at 8:18 A.M., CNA H said he/she wrote a statement regarding the incident on 6/14/18 and Nurse G placed it under the door of the DON’s office. Nurse G assisted him/her with toileting the resident and then left the room. CNA H was trying to assist the resident back to bed when the resident became very agitated and began cursing at him/her and attempted to take off his/her brief. CNA H said he/she never got within arm’s reach of the resident once Nurse G left. He/she went and got Nurse G and was reassigned to other residents for the remainder of the shift. CNA H helped the resident get dressed in the morning with no issue. CNA H has worked with the resident since the incident with no issues. The DON never followed up with him/her regarding his/her statement. During an interview on 7/13/18 at 10:53 A.M., the administrator and Director of Nursing (DON) said they were not aware of the resident’s allegation of abuse. Once the allegation was made, one of them should have been contacted immediately. Staff should have been removed and other residents should be interviewed. Despite the resident’s confusion, the allegation should have been investigated. During an interview on 7/16/18 at 9:30 A.M., the DON said she did not receive a statement from CNA H regarding the incident. She denied ever being told about the resident’s allegation. She was told the incident did not happen when she interviewed staff on 7/13/18. If she had known, she would have sent CNA H home and completed an investigation. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) assessments, wander guard (device used to alert staff when resident approaches an exit door) placed on resident, administer medications as needed, provide diet as ordered and approach diet as ordered. Review of the resident’s medical chart on all days of the survey, 7/11, 7/12, 7/13 and 7/16/18, showed only the admission care plan available for staff review. During an interview on 7/16/18 at 9:30 A.M., the administrator said the resident should have a comprehensive care plan which reflects the resident’s current needs by the 14th day. The care plan should be completed by the MDS coordinator and should be kept in the resident’s chart for staff use. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise |
| 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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) -Cognitively intact; -Required assistance of one staff member for transfers and total dependence on staff for locomotion and hygiene; -Utilized walker and wheelchair for mobility; -Unsteady balance during transitions and walking; -[DIAGNOSES REDACTED]. -Sustained two falls without injury and one fall with injury since last assessment. Review of the resident’s progress notes, showed the following: -On 5/21/18 at 12:30 P.M., the resident fell to the floor while walking and had complaints of pain to his/her shoulders and back. The resident sustained [REDACTED]. Resident will now go to meals in his/her wheelchair since this seems to be a continual problem; -On 5/25/18 at 4:15 A.M., staff responded to the resident’s roommate’s call light. The resident was on the floor on his/her left side at the bedside. Resident said he/she was getting up to go to the bathroom. Resident complained of pain to his/her left shoulder. No other injuries noted; -On 6/25/18 at 6:00 P.M., staff called to the resident’s room and found the resident on the floor on his/her buttock in the corner of the room, leaning against the closet door. Staff noted a small white scratch to the right wrist and a small purple bruise; -On 6/26/18 at 2:00 P.M., the resident complained of lower back pain, but no bruising noted. Slight [MEDICAL CONDITION] to the lower back noted, but resident has arthritis and it is a rainy day, which can cause a flare up; -On 6/27/18 at 7:45 P.M., the resident requested pain medication for back pain; -On 6/28/18 at 2:00 P.M., the resident requested pain medication for back pain; -On 7/2/18 at 2:00 P.M., received a new order to complete an x-ray on the resident’s lower back due to pain and a previous fall; -On 7/3/18 at 12:00 P.M., x-ray results showed resident sustained [REDACTED]. Review of the resident’s care plan, last updated on 6/25/18 and in use during the survey, showed the following: -Problem: At risk for falls related to [MEDICAL CONDITION] and scoliosis (sideways curvature of the spine). A hand written note, dated 6/25/18, showed staff found him/her on the floor, leaning against closet; -Goal: Resident will remain free from injury for the next 90 days. A hand written note, showed staff to continue to educate to wait for staff assistance, not reach for things on his/her own or get out of wheelchair without assistance; -Approach: Dated 4/26/18, Resident is a high fall risk due to feeling strong and capable, but his/her legs give out without warning. He/she has been educated on the risk of not asking or waiting for assistance. He/she has verbalized understanding, but will do it anyway. Also, resident has his/her own bed and it is high and does not lower. It has been suggested to use a facility bed. Resident has back problems and his/her bed is special for his/her condition; -Staff did not document any other falls sustained by the resident; -Staff did not document any new interventions. During an interview on 7/11/18 at 3:30 P.M., the resident said he/she fractured his/her back in two places. He/she has to stay in bed mostly now. When he/she gets up, he/she can transfer by himself/herself. He/she now uses the wheelchair to get around, but is doing therapy and hopes to be able to walk again. He/she knows to use his/her call light, but sometimes it can take a while to have someone respond. 3. Review of Resident #9’s quarterly MDS, dated [DATE], showed the following: -Short and long term memory problems; |
| 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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) -Severely impaired cognitive skills for daily decision making; -Extensive assistance of staff required for bathing, eating, dressing, personal hygiene and toileting; -Incontinent of bowel and bladder; -One fall since the last assessment; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, updated 3/22/18 and in use during the survey, showed the following: -Problem: Activities of daily living (ADL) functional/rehabilitation potential-ability for walking with walker has improved, still a high risk for falls related to difficulty when standing and balance and will not further deteriorate in ability to ambulate with walker and ability to transfer for next 90 days; -Approaches: Make sure resident is ambulating with walker, do not rush resident and allow extra time to complete ADLs, have consistent approach amongst caregivers, instruct use of walker, provide adequate rest periods between activities, provide standby assistance when ambulating with walker, report any further deterioration to physician. Review of the resident’s nurses notes, showed the following: -6/21/18 at 12:00 P.M., The resident was found on the floor in the dining area on his/her right side with eyes open, near his/her wheelchair, fully clothed with shoes on. The floor was free from debris. Passive range of motion performed and within normal limits. Resident is alert and oriented to self and unable to describe the incident and denied pain or discomfort. Neuro checks were initiated; -7/6/18 at 4:40 P.M., the resident was in the dining room ambulating with a walker, lost his/her balance and sat down on the floor. Staff witnessed the fall, stated the resident did not hit his/her head and no apparent injuries noted. Further review of the resident’s care plan showed the falls on 6/21/18 and on 7/6/18 not documented and no additional interventions added. 4. During an interview on 7/16/18 at 9:30 A.M., the DON said the care plan should reflect the resident’s current condition and care needs. Any staff member can update the care plan. Every fall should be listed on the care plan with either a new intervention or the decision to continue with existing interventions. | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) cardiopulmonary resuscitation (CPR, life saving measures in the even the heart stops beating); -A (MONTH) (YEAR) physician order [REDACTED]. -No order for code status; -An order, dated [DATE], for [MEDICATION NAME] (medication for high blood pressure) 90 milligram (mg) tablet every eight hours; -A (MONTH) (YEAR) medication administration record (MAR), showed the following: -an order for [REDACTED]. -No documentation the medication had been given on the mornings of [DATE] through [DATE] and [DATE] through [DATE]; -No documentation on the back of the MAR to indicate why the medication had not been administered at those times; -Review of the resident’s nurse’s notes, showed no documentation to indicate why the medication had not been administered. During an interview on [DATE] at 9:30 A.M., the Director of Nursing (DON) said she expected staff to follow physician orders. If a medication is not given, an explanation should be provided on the back of the MAR and in the nurse’s notes. If the MAR is blank, then the medication was not given. The resident’s code status should be on the POS. She completes regular chart audits. 2. Review of Resident #2’s quarterly MDS, dated [DATE], showed the following: -Diagnoses included dementia and diabetes; -Severe cognitive impairment; -Dependent on staff for mobility and personal hygiene; -Incontinent of urine. Review of the POS, dated [DATE], showed an order to administer Z-pak (antibiotic) and take as directed. No diagnosis listed for the use of the antibiotic. Review of the POS, dated [DATE], showed an order to administer [MEDICATION NAME] (antibiotic) 100 milligrams mg twice a day for 10 days. No diagnosis listed for the use of the antibiotic. Review of the POS, dated [DATE], showed an order to discontinue [MEDICATION NAME] and administer [MEDICATION NAME] (antibiotic) 500 mg. twice a day for 10 days. No diagnosis listed for the use of the antibiotic. During an interview on [DATE] at 9:30 A.M., the DON said staff should include a [DIAGNOSES REDACTED]. 3. Review of Resident #15’s quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED].>-Severe cognitive impairment; -Required extensive assistance with all mobility and personal care; -Incontinent of urine. Review of the POS, dated [DATE], showed an order to obtain a urinalysis with culture. Review of the laboratory reports, showed staff did not obtain the specimen until [DATE], the lab did not receive the specimen until [DATE] and the culture completed on [DATE], at which time the physician ordered a course of antibiotics to treat a urinary tract infection During an interview on [DATE] at 9:30 A.M., the DON said if there is a delay in obtaining a specimen it could be due to the resident’s resistance to cooperate. She added that sometimes a resident may refuse care. This should be documented. 4. Review of Resident #8’s admission MDS, dated [DATE], showed the following: -Short and long term memory problems; -Severely impaired cognitive skills for daily decision making; |
| 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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) -Extensive assistance required for dressing, toileting, personal hygiene and bathing; -Incontinent of bowel and bladder; -Diagnoses included high blood pressure, diabetes, dementia, anxiety, depression and [MEDICAL CONDITION] (a-fib, irregular heartbeat). Review of the resident’s care plan, dated [DATE] and in use during the survey, showed the following: -Required a regular diet with finger foods, needed staff assistance with eating and will maintain current weight; -Approaches: Make sure resident receives nutritional health shake every day, obtain dietary consult and follow recommendations, praise for good dietary compliance, provide with as much control as possible in routines, food preferences and try different food choices. Review of the resident’s nutrition progress note, dated [DATE], showed the resident weighed 150.2 pounds, down 6.6 pounds since readmission (4.25%). Suggestion to add super cereal (oatmeal fortified with high calorie ingredients) every morning to maximize calorie intake. Observations of the resident, showed the following: -On [DATE] at 8:17 A.M., the resident sat at the dining room table and a plate in front of him/her contained an omelet, two bacon strips and a donut. The resident ate ,[DATE] of the donut and drank 100% of a glass of orange juice. Staff did not serve the resident super cereal; -On [DATE] at 8:35 A.M., the resident sat at the dining room table with a plate of scrambled eggs and staff did not serve him/her super cereal. Review of the resident’s diet card showed he/she received a regular diet and was updated [DATE], to receive a health shake with meals and at bedtime, with no mention of super cereal at breakfast. During an interview on [DATE] at 9:30 A.M., the DON said the registered dietician (RD) sent recommendations to her by email. The physician should be contacted and if the recommendation is approved, it became an order and was added to the resident’s diet. She would look for follow up to the recommendation to add super cereal. The facility did not provide additional information regarding the RD recommendation as late as 2:30 P.M. on [DATE]. | |
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) the catheter) and to prevent infection of the resident’s urinary tract; -Preparation: -Review the resident’s care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed; -General Guidelines: -Observe the urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report to the supervisor; -If the resident indicates his/her bladder is full or the need to void, report to the supervisor; -Check the urine for unusual appearance (color, blood, etc.); -The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; -Check the resident frequently to be sure the tubing is free of kinks; -Observe the resident for signs and symptoms of a urinary tract infection (UTI, an infection in any part of the urinary system) and [MEDICAL CONDITION]; -Empty the collection bag at least every eight hours; Review of Resident #21’s admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/26/18, showed the following: -[DIAGNOSES REDACTED]. -Moderate cognitive impairment; -Required extensive assistance by staff for all mobility and personal hygiene. Review of the physician order [REDACTED]. -An order dated 7/3/18 to administer [MEDICATION NAME] (antibiotic) 500 milligrams twice a day for seven days for a UTI; -No order for a SP catheter, size or care. During an interview on 7/12/18 at 9:08 A.M., the resident’s spouse said he/she noted the resident’s urine with a cloudy appearance. He/she asked staff to look into it and a specimen was obtained. The resident tested positive for a UTI. He/she is not sure staff are consistently and properly cleaning the site and storing the bag in the appropriate place. The resident did not have any UTIs when at home. The resident wears a leg bag (designed to provide discreet storage of urine under clothing and are secured to the leg) when not in bed. He/she applies the leg bag to the resident’s calf area, but the facility staff apply it to the resident’s mid to upper thigh. The resident’s catheter was changed yesterday. Observation on 7/13/18 at 11:15 A.M., showed the urinary catheter drainage bag hung in a plastic bag on the bathroom handrail. The uncovered connection port lay across the drainage bag and the leg bag lay on top of the resident’s right thigh. During an interview on 7/13/18 at 11:16 A.M., the resident said when he/she is in the chair, the certified nurse aide (CNA) removes the drainage bag and connects the catheter to a leg bag. He/she said the CNA always attaches the leg bag to his/her thigh but at home they connected it to his/her lower leg. During an interview on 7/13/18 at 11:20 A.M., CNA C said he/she always works a different hall and this was his/her first day with the resident. He/she said the nurse did not inform him/her that the resident had a catheter and he/she did not know how to perform care for that particular kind of catheter. Observation of the resident on 7/16/18 at 6:55 A.M., showed the resident in bed with his/her eyes closed. The resident’s catheter drainage bag lay in a privacy bag which rested directly on the floor. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/23/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) Observation on 7/16/18 at 7:54 A.M., showed CNA D and Certified Medication Technician (CMT) E washed their hands and donned gloves. Using a wet cloth, CMT E wiped the catheter from the abdomen to the connection port and removed the drainage bag. With the same cloth, he/she picked up the leg bag that lay uncapped on the bed, wiped the connection port with the cloth and connected the port to the catheter. He/she then secured the leg bag to the right thigh. CNA D took hold of the catheter drainage bag, drained the urine into the toilet and placed the drainage bag in a plastic bag that hung on the grab bar. He/she did not cover the connection port. The catheter insertion site to the lower abdomen did not have a dressing. CNA D nor CMT E cleansed the catheter insertion site. During an interview on 7/16/18 at 8:05 A.M., CNA D and CMT E said catheter care with a SP catheter means to cleanse the insertion site with soap and water and leave it open to air. If it would need a dressing, the nurse does that. They both said the connection port of the drainage bags need to be covered when not in use. During an interview on 7/16/18 at 9:30 A.M., the Director of Nursing said urinary catheter bags should never be allowed to lay on the floor and when not in use, the drainage bag and leg bag connection ports should be covered with a plastic cover. The connection port should always be wiped with an alcohol pad prior to connecting to the catheter, not wiped with a wet cloth. She said it is permissible to wear the leg bag on the thigh when the resident is seated in a chair because she believed the bag would be below the bladder, however if the resident is in bed the leg bag should be removed and changed to the gravity drainage bag. She added that the insertion site should be cleansed daily with soap and water and if there is any drainage around the site, the nurse should apply a gauze dressing. | |
| F 0730 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Observe each nurse aide’s job performance and give regular training. Based on interview and record review, the facility failed to ensure certified nurse |
| 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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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** | |
| F 0805 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and interview, the facility failed to ensure one of one resident on 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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0805 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 13) -On 7/12/18 at 8:40 A.M., Cook N said three residents had puree diets and he/she would make three servings. Cook N placed 2 cups of cooked cabbage into a blender, added ½ cup of the liquid from the cooked cabbage and turned the blender on. Cook N said he/she was not using their usual blender because the blade was broken and a new blade was ordered two to three weeks ago. Cook N spooned the cabbage from the blender onto three divided plates. The texture was coarse and not a pudding-like consistency; -Cook N placed cooked sweet potatoes in the blender, added ½ cup of milk, blended the mixture, added more milk and continued to blend. Cook N spooned the blended sweet potatoes on to three divided plates. The texture was not a smooth, pudding consistency and contained lumps; -Cook N placed three servings of cooked corned beef in the blender, added juice from the cooked cabbage, blended, stirred and continued to blend the mixture for approximately 45 seconds. Cook N spooned the corned beef onto the three divided plates. The texture was very coarse, not smooth and resembled mechanical soft texture. During an interview while preparing the meal on 7/12/18, Cook N said it was the best we can do right now because of the blender. During an interview on 7/12/18 at 9:45 A.M., the Administrator and Dietary Manager (DM) looked at one of the divided plates that contained the puree mixture and agreed the texture was not acceptable and could not be served. The Administrator said she had not heard of any residents having an issue with the puree. Cook N said any meat that is pureed in the blender would come out like the corned beef. During an interview on 7/13/18 at 11:00 A.M., the DM said Cook N told him about the problem with the puree. That is when he ordered the new blade. After the observation on 7/12, they borrowed a blender like the one that was broken from another facility and would use it until the new blade was received and theirs could be repaired. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to date thawed meat and health |
| 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: 265808 |
| (X3) DATE SURVEY COMPLETED 07/16/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY | STREET ADDRESS, CITY, STATE, ZIP 13612 BIG BEND ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 14) one thawed large package of ground beef that had been opened and rewrapped, but not dated, at least 8 undated, thawed packages of bologna and one box contained approximately 25 to 30 undated chocolate health shakes. During an interview on 7/16/18 at 12:15 P.M., the dietary manager (DM) said the meat just came in and was not frozen when it arrived. This surveyor explained the meat was in the refrigerator on the previous Friday. The DM then said thawed meat was good for seven days. The meat should have been dated when it was placed in the walk-in by the staff person who put stock away. Health shakes arrived frozen and were good for one month. | |
