| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0567 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to manage his or her financial affairs. Based on interview and record review, the facility failed to keep resident’s accounts from | |
| F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) are performed); -A physician order sheet (POS), dated 7/15/18 through 8/14/18, showed a standing emergency order for do not resuscitate (DNR, no life prolonging methods are performed). 2. Review of Resident #82’s electronic medical record, showed: -An admission date of [DATE]; -A signed code status form, dated 7/12/18, for a full code status; -A POS, dated 7/15/18 through 8/14/18, showed no orders for a code status. 3. Review of Resident #39’s electronic medical record, showed: -An admission date of [DATE]; -A signed code status form, dated 5/16/18, for a full code status; -Review of the POS [REDACTED]. 4. During an interview on 7/30/18 at 9:10 A.M., the administrator and the Director of Nurses (DON) said the facility’s policy is that social services is responsible for ensuring the code status sheet is signed and accurate. The code status are then placed on the POS. The administrator would expect the code status to be on the POS and to match the sign code status form. | |
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to provide a safe, clean, |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) on it. The lid was approximately about 4 inches too large (about 2 inches on each side). The handle of the sink showed grimy and dirty. The caulking behind the sink was dirty and stained, and the baseboards around the entire bathroom dirty. A hole was in wall over the baseboard by the sink, the frame of the door cracked and peeled, and baseboards were loose by the shower. No caulking around the bottom of the toilet. A brown substance on the wall by the frame of the door, close to the shower. The shower had a green substance around the drain. The bottom of the door was boarded up. The exhaust vent in the bathroom full of dust and debris. 3. Observation of Resident #41’s room and bathroom on 7/24/18 at 12:04 P.M., 7/25/18 at 2:09 P.M. and 7/26/18 at 9:59 A.M., showed dirty and stained flooring. The main doorframe chipped and missing paint. Behind the bedroom door, the baseboard stuck out from the wall. The wall behind the bed and on the wall by the television missing paint. Nails exposed in the wall behind the TV as well as in the wall over the second bed. A patch approximately 2 feet by 1 foot in length, with missing paint behind the chain by the call light. The door leading to the bathroom was dirty and a brown substance was observed over the bedroom door. Above one bed, the bed curtain hooks were intact, no curtain was attached. In the bathroom, the tank lid on the back of the toilet was the wrong size. The bottom of the toilet had no caulking. The lid was approximately 4 inches too large (about 2 inches on each side). The handle of the sink showed grimy and dirty. The caulking behind the sink was dirty and stained and the baseboards around the entire bathroom were dirty. A hole showed in the wall over the baseboard by the sink, the frame of the door was cracked and peeled, and baseboards were loose by the shower. No caulking around the bottom of the toilet and a brown substance on the wall by the frame of the door, close to the shower. The shower had a green substance around the drain. The exhaust vent in the bathroom was full of dirt and debris. During an interview on 7/24/18 at 12:09 P.M., Housekeeper Q said he/she is responsible for cleaning the rooms on C Hall. He/she cleaned the rooms every day because this is his/her hall. 4. Observation of Resident #14’s bathroom on 7/27/18 at 11:15 A.M., showed: -Bathroom floor dull, dirty and sticky underfoot; -Exposed bolts at the base of the toilet, measured approximately 1 1/2 inches long without any type of cap covering them. 5. Observation of Resident #93’s room on 7/24/18 at 12:55 P.M., 7/25/18 at 8:53 A.M., 12:38 P.M., 1:27 P.M., 2:51 P.M., 7/26/18 at 8:25 A.M. and 12:37 P.M., showed dirt build up on the floor on the right side of the bed. The floor was sticky. A dried brown substance was visible on the floor, wall, and air conditioner. An open trash can had flies swarming around. A dried brown stain was visible on the resident’s linen. Observation on 7/26/18 at 1:48 P.M., Housekeeper P went into the resident’s room with cleaning supplies and paper towels. He/she went into the bathroom and closed the door. At 2:00 P.M., the floor closest to the entrance was cleaned. The right side of the resident’s room not cleaned. The dried brown substance and stains were on the floor, wall, and the air conditioner. 6. Observation of the B-hall on 7/24/18 through 7/27/18 and 7/30/18, showed: -Missing baseboards measured approximately 15 inches and 2 feet; -Torn dry wall on the left side of the common area; -A hole in the door approximately 2 inches, on the left side of the common area; -Brown stains on the door outside the entrance to the unit. During an interview on 7/30/18 at 7:45 A.M., the housekeeping supervisor said he was aware of the condition of the resident’s room. He asked Housekeeper P why it was not cleaned. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) Housekeeper P said he/she could not remove the stains. He would expected the housekeeper to notify him if any stains could not be removed. Housekeeping staff should not ignore any areas of the room that need attention. The linen is removed every day by the certified nurse aides (CNAs). The housekeeping staff wipe down the mattresses before clean linen is placed on the bed. He would expect all residents to have clean linen on a daily basis. There is constant flow on the B-hall. There are a lot of residents that do not leave their room. As soon as staff finishes cleaning the room, it needs attention again. Since there is no wax on the floor of the B-hall, the collection of dark looks darker. 7. Observation of the C hall on 7/24/18 through 7/27/18 and 7/30/18, showed: -All hallway walls appear to have scuff marks of dark blackish and brownish in color, extend from floor up 1 foot throughout unit to include room doors and fire doors; -Hallway baseboards have approximately 2 inches of built up grime, stains and dirt throughout hall; -Fire doors near room C-3 with brown drips and appeared to be a spilled fluid substance; -An electric outlet cover near room C-3 in the hallway, not flush with the wall and stuck out approximately 1/2 of an inch from the wall; -All room doors and door frames with built up dirt and debris and chips of paint missing in various sizes; -The toilet located in the shared bathroom between rooms C-10 and C-12 loose, easily moved side to side, exposed caulk. During an interview on 7/27/18 at 10:43 A.M., the maintenance manager said the toilet’s flange is loose. He/she expected staff to fill out a work order or call him directly with any maintenance needs. 8. Observation of the C-hall on 7/24/18 through 7/27/18 and 7/30/18, approximately 4 feet into the unit, the floor wavy across the hall with a difference of height, 1 to 2 inches. Some of the tiles located over the wavy sections broken. Observed on 7/25/18 at approximately 11:15 A.M., showed Care Tech H propelled a resident in their wheel chair. Care Tech H appeared to struggle at the height difference in floor. During an interview on 7/25/18 at approximately 1:06 P.M., Care Tech H said he/she had difficulty propelling the wheel chairs on the floor in the area with height difference in the floor. During an interview on 7/27/18 at approximately 7:52 A.M., the maintenance manager said there appeared to be a transitional plate under the tile installed improperly. This resulted in an area with height difference on the floor. A transitional plate should be installed over the tile. 9. Observation of the shower room outside of C-Hall, on 7/26/18 at 7:56 A.M. and on 7/30/18 at 7:30 A.M., showed; -Exhaust vent holes clogged with dirt, paint and rust, not working; -A dirty pair of jeans, used towels and washcloths in the tub. 10. Observation of the shower room outside of B-Hall, on 7/26/18 at 8:00 A.M. and on 7/30/18 at 7:30 A.M., showed exhaust vent holes clogged with dirt, paint, rust and not working. 11. During an interview on 7/27/18 at 11:30 A.M., the Maintenance Director said the vents in the bathrooms are exhaust vents and are dirty with dirt, paint and rust. 12. During an interview on 7/30/18 at 7:45 A.M., the housekeeping supervisor said he is responsible for overseeing housekeeping, laundry, and floor technicians. He is responsible for ensuring the housekeeping staff provide a home like, clean environment for all residents in the facility. There are three housekeeping staff on the day shift, one floor tech, and one laundry staff on the day shift. There is one floor technician and one |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) laundry staff during the evening shift. There is laundry staff on all three shifts. The housekeeper is responsible for cleaning all resident rooms and all surfaces including bed frames, walls, baseboards, doors, and the entire bathrooms. The resident’s rooms are cleaned twice during the day shift. Since the housekeeping staff are here until 3:00 P.M., they are expected to constantly monitor the rooms. Housekeeping staff are expected to move beds and dressers out of the way to clean underneath because it helps with the deep clean. The floor technician strips the floor twice a year and put wax on the floor. The linen is expected to be changed once a day. The linen is changed first thing in the morning and evenings for some residents. There are residents who remain in their room all day and will need attention to their room and linen by evening time, so staff will make a second trip. The staff have a daily checklist that show the tasks were completed. He would expect staff to complete the tasks before checking them off. 13. During an interview on 7/30/18 at 9:10 A.M., the administrator and the director of nursing (DON) said they would expect staff to thoroughly clean the resident’s room. The DON would expect resident #93’s linen to be changed three or four times a day due to the body moisture. The administrator said she would expect staff to change the linen twice a week. Anyone can fill out a maintenance request, located at the front desk. The maintenance log is reviewed by the maintenance manager and the Administrator. Housekeeping cleans rooms and halls twice daily. The Housekeeping supervisor does random checks of two rooms on each hall five days a week, to insure cleanliness. MO 234 | |
| F 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives an accurate assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) -Able to report correct year: Correct; -Able to report correct month: Accurate within five days; -Able to report correct day of the month: Correct; -Able to recall sock: Yes, no cue required; -Able to recall blue: Yes, no cue required; -Able to recall bed: Yes, no cue required; -Is there evidence of an acute change in mental status from the resident’s baseline: No. Review of the resident’s care plan, dated 6/24/17, and in use during the survey, showed: -Impaired thought processes due to a [DIAGNOSES REDACTED]. -Resident has difficulty making his/her own decisions related to memory impairment. During an interview on 7/30/18 at 9:10 A.M., the DON said the resident’s MDS should be accurate, and she would expect the resident’s BIMS score to be accurate as well. The DON did not know what the resident’s BIMS would be; however, she did not consider the resident to be cognitively intact. | |
| 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: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 7) A care plan should be patient centered and should list how staff should care for the resident. 2. Review of Resident #51’s face sheet, showed: -Originally admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident’s quarterly minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/1/18, showed: -Cognitively intact without any short or long term memory problems; -No behaviors; -Range of motion limits to both lower extremities; -Supra-pubic catheter (SP catheter, surgically inserted into the bladder through the abdomen for continual drainage of urine); -Required maximum assistance from the staff for transfers, dressing and bathing. Review of the resident’s physician order [REDACTED].#18 French (type and size) with a 10 cubic centimeter (cc) balloon. Change monthly on the 3rd of each month. Review of the resident’s care plan, updated on 7/27/18, and in use during the survey, showed staff had not care planned the resident for the use of the SP catheter. During an interview on 7/30/18 at 9:10 A.M., the DON said she would expect staff to care plan the resident for the use of the SP catheter. 3. Review of Resident #93’s quarterly MDS, dated [DATE], showed the following: -A Brief Interview of Mental Status (BIMS) score of 15 out of 15, shows the resident is cognitively intact; -Independent with dressing, toileting, and hygiene; -Always continent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 10/18/17 and in use at the time of the survey, showed: -Problem: Activity of Daily Living (ADL) performance: Resident requires minimum assistance with his/her ADL task requiring oversight for compliance and safety to ensure completeness of task due to physical and cognitive deficits; -Approaches: Allow resident sufficient time for completion of task/daily routine at his/her own pace, provided with oversight; -Provide and ensure that he/she has necessary tools/items available for use to maintain personal appearance; -Monitor the resident daily for compliance with ADL task and report any decline or lack of participation; -Encourage him/her to maintain his/her highest level of independence with appearance and hygiene maintained; -Further review of the resident’s care plan showed no documentation on the resident’s history of refusing showers or how staff should address issues concerning the resident’s body odor. Observation on 7/25/18 at 9:01 A.M., showed the resident with significant body odor. Review of the resident’s shower sheets, for (MONTH) and (MONTH) (YEAR), showed showers documented as provided on 6/20/18, 7/17/18 and 7/23/18. During an interview on 7/30/18 at 9:10 A.M., the DON said the resident can be resistive to bathing; however, he needs assistance with bathing. The DON bathed him/her in the past, and due to his/her medical diagnoses, he/she cannot adequately bathed him/herself. She would expect his/her care plan to reflect that he/she needs assistance to adequately bath him/herself and he/she refuses to take showers. She would expect his/her linen to be |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 8) changed three to four times a day due to the resident’s body moisture. 4. Review of Resident #33’s quarterly MDS, dated [DATE], showed: -BIMS score of 8 out of 15, shows the resident moderately impaired; -Supervision with hygiene and dressing; -Always continent of bowel; -Occasionally incontinent of urine; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 2/9/18, and in use during the survey, showed: -Problem: Resident is independent with ADLs and continent of bowel and bladder. He/she requires cueing to complete simple tasks; -Approaches: Report any changes in condition to the physician immediately; -Report any decline in physical function to the physician immediately; -Encourage him/her to do as much as possible for him/herself; -Further review of the resident’s care plan showed no documentation on the resident’s choice to wear the same soiled outfit and how should staff address the issue. Observation on 7/24/18 through 7/27/18 and 7/30/18, showed the resident wore a sleeveless blue jersey and red shorts. There were several dried, white stains and grease stains on the front of the sleeveless blue jersey and a dark stain on the front of his/her red shorts. During an interview on 7/30/18 at 7:24 A.M., the resident said he/she wore the same outfit since last week. During an interview on 7/30/18 at 9:10 A.M., the DON said the resident wears the same thing every day. After he/she showers, he/she will put on the same shirt and shorts. The DON would expect the resident’s care plan to reflect wearing the same clothing for long periods of time without washing it, and how staff should address it. | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 – Few | (continued… from page 9) 2. Review of Resident #62’s medical record, showed: -Readmission date of [DATE]; -[DIAGNOSES REDACTED]. Review of the resident’s POS, dated 7/15 through 8/14/18 and in use during the survey, showed: -An undated order to obtain a [MEDICAL CONDITION] stimulating hormone (TSH, laboratory test used to determine the amount of [MEDICAL CONDITION] in the blood) test every six months; -No order to discontinue the TSH level every six months -No order for administration of oxygen. Review of the laboratory section in the medical record, showed a TSH test result of 4.58 (normal range 0.35-4.94) dated 10/24/17, but no other TSH test results found. Observations of the resident during the survey, showed: -On 7/24/18 at 1:12 P.M. and 1:52 P.M., the resident lay in the bed with oxygen infused at 4 liters per oxygen concentrator (device that converts oxygen supply from the surrounding air); -On 7/25/18 at 7:20 A.M., 12:07 P.M. and 2:30 P.M., the resident lay in the bed with oxygen infused at 4 liters per oxygen concentrator; -On 7/26/18 at 6:55 A.M., on 7/27 at 9:00 A.M. and 1:40 P.M. and on 7/30/18 at 8:00 A.M., showed the resident lay in the bed with oxygen infused at 4 liters per oxygen concentrator. During an interview on 7/30/18 at 9:10 A.M., the DON said she expected the nursing staff to have contacted the resident’s physician for an order for [REDACTED]. The DON said the laboratory company came to the facility on [DATE], to obtain the resident’s TSH level, but the resident was in the hospital. She said nursing staff should have contacted the laboratory company when the resident returned from the hospital and obtained the TSH as ordered. The DON said she thought the facility had received an order to discontinue the blood draw for the TSH every six months, but did not find an order to discontinue the TSH level every six months. She said the unit managers are responsible to ensure all laboratory tests are obtained as ordered. 3. Review of Resident #66’s face sheet, showed: -Originally admitted to the facility on [DATE]; -readmitted to facility from a local hospital on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident’s POS, dated 4/15 through 5/14/18, showed an order dated 4/17/18, to arrange for a colonoscopy (an examination of the entire lower bowel); -Staff documented the colonoscopy had been scheduled for 5/23/18 at 10:30 A.M., at a local hospital. Review of the resident’s medical record, showed: -No colonoscopy results; -No documentation the resident had gone for the colonoscopy as late as 7/25/18; -No documentation staff had administered the prescribed prep for the colonoscopy as late as 7/25/18. Review of the resident’s physician progress notes [REDACTED]. -4/17/18 – Discussed colonoscopy. Health maintenance – arrange for colonoscopy; -6/12/18 – Follow up results of colonoscopy. During an interview on 7/24/18 at 10:00 A.M., the resident said his/her doctor had ordered for a colonoscopy to be done, however it hasn’t been done yet, and does not know when it has been scheduled. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 – Few | (continued… from page 10) During an interview on 7/25/18 at 9:28 A.M., Nurse A said the resident had been scheduled for the colonoscopy on 5/23/18. He/She refused to go on that date and went out with his/her family instead. It had been rescheduled, but did not know the date to be done, Nurse A called the local hospital, spoke with the gastro-intestinal laboratory personal and said it was scheduled for 7/26/18 at 9:15 A.M., and would call the physician for orders for the prep. During an interview on 7/25/18 at 2:00 P.M., the resident said he/she did refuse to go for the colonoscopy in May. Staff told him/her the colonoscopy was scheduled for tomorrow, he/she knew would be on clear liquids and would receive medication to clean out his/her bowels. During an observation and interview on 7/26/18 at 6:53 A.M., the resident sat in his/her wheelchair in the hallway, speaking with Nurse A. Nurse A told him/her that he/she could not go for the colonoscopy scheduled for that day because he/she had eaten rice the night before. When questioned by surveyor, Nurse A said the Assistant Director of Nurses (ADON) had ordered the prep (golytly, a liquid that helps to clean out the bowels) from the pharmacy the day before and it still had not been delivered to the facility. During an interview on 7/26/18 at 6:55 A.M., the ADON said the resident was scheduled for a colonoscopy but cannot have it done because he/she ate rice the evening before. She said she had called the pharmacy on 7/25/18, ordered for the golytly to be sent immediately, but it still had not been delivered. During an interview on 7/26/18 at 7:00 A.M., Nurse B said she was the charge nurse for the resident during the night shift. Said the golytly had not been delivered by the pharmacy as of that time and the resident did not receive any bowel prep. The resident had been nothing by mouth (NPO) since midnight. Nurse B said the resident ate some rice around 9:00 P.M. last night and does not know where or how the resident obtained the rice. During an interview on7/27/18 at 9:45 A.M., the DON said the ADON had called for the pharmacy to send the golytly and it was suppose to be delivered to the facility. Around 1:00 A.M., she called the facility and was told it had not been received from the pharmacy and the prep was not started. Staff also told her the resident had eaten rice that evening. She said she could not find any documentation about the resident receiving any bowl prep for the colonoscopy scheduled in May, his/her refusal to go for the colonoscopy in May, or of his/her physician being notified of his/her refusal to go for the colonoscopy. 4. During an interview on 7/30/18 at 9:10 A.M., the DON said she expected nursing staff to follow all physician’s orders [REDACTED]. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) -Independent with dressing, toileting, and hygiene; -Always continent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 10/18/17, and in use at the time of the survey, showed: -Problem: Activity of Daily Living (ADL) performance: Resident requires minimal assistance with his ADL task requiring oversight for compliance and safety to ensure completeness of task due to physical and cognitive deficits; -Approaches: Allow resident sufficient time for completion of task/daily routine at his/her own pace provided with oversight; -Provide and ensure that he/she has the necessary tools/items available for use to maintain personal appearance; -Monitor the resident daily for compliance with ADL task and report any decline or lack of participation; -Encourage him/her to maintain his/her highest level of independence with appearance and hygiene maintained. Review of the resident’s shower sheets, dated 7/1/18 through 7/26/18, showed staff documented the resident received a shower on 7/17/18 and 7/23/18. Observation and interview on 7/25/18 and 7/26/18, showed: -The resident resides on a secured unit; -On 7/25/18 at 9:01 A.M., a pungent body odor present in the resident’s room, outside the resident’s opened door, and into the hallway outside of the room; -On 7/25/18 at 1:27 P.M., the resident said he/she completes his/her hygiene and bathing independently. He/she takes a shower every so often; -On 7/26/18 at 6:50 A.M., a pungent body odor present in the resident’s room, outside the resident’s opened door, and into the hallway outside of the room; -On 7/26/18 at 9:15 A.M., 11:27 A.M., and 12:37 P.M., the resident lay in bed in his/her room. There was a body odor present in the room and became much stronger closer to the resident. The bottom of the resident’s feet appeared black. During an interview on 7/26/18 at 2:15 P.M., the Director of Nursing (DON) said she would expect staff to address any odors from the resident’s room and from the resident. The resident can be resistive to bathing; however, he/she needs assistance for bathing. The DON bathed him/her in the past, and due to his/her mobility and medical diagnoses, he/she cannot adequately bathe him/herself. 2. Review of Resident #33’s quarterly MDS, dated [DATE], showed: -BIMS score of 8 out of 15, shows the resident is moderately impaired; -Supervision with hygiene, and dressing; -Always continent of bowel; -Occasionally incontinent of urine; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 2/9/18, and in use during the survey, showed: -Problem: Resident is independent with ADLs and continent of bowel and bladder. He/she requires cueing to complete simple tasks; -Approaches: Encourage him/her to do as much as possible for him/herself. Review of the resident’s shower sheets, dated 7/1/18 through 7/26/18, showed staff documented the resident received a shower on 7/20/18. Observation on 7/24/18 through 7/27/18 and 7/30/18, showed the resident resided on a secured unit. The resident wore a sleeveless blue jersey and red shorts. There were several dried, white stains and grease stains on the front of the sleeveless blue jersey. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) There was a dark stain on the front of his/her red shorts. The resident had a noticeable body odor. He/she had dried saliva around his/her mouth. His/her lips appeared dry and skin peeling from his/her lips. During an interview on 7/27/18 at 11:00 A.M., Hall Monitor R said they ask each resident every day if they want a shower. Some of the residents say yes and some say no. There are a lot of residents that do not want to take a shower. During an interview on 7/27/18 at 11:10 A.M., Certified Nurse Aide (CNA) S said sometimes staff have to beg the residents to take a shower or buy them a soda. During an interview on 7/30/18 at 7:24 A.M., the resident said he/she wore the same outfit since last week. He/she could not say when the last time he/she had a shower. He/she believed the certified CNA would give him a shower today. During an interview on 7/30/18 at 9:10 A.M., the DON said the resident wears the same thing every day. After he/she showers, he/she will put on the same shirt and shorts. It is his/her favorite outfit to wear. Sometimes staff tries to hand wash the shirt while he/she is in the shower. The DON would expect staff to address any body odor he/she may have and address the stains on the clothes. 3. Review of Resident #41’s care plan, dated 12/6/17, and in use at the time of the survey, showed: -[DIAGNOSES REDACTED].>-Problem: ADL performance: Resident requires assist x 1 with his/her ADLs, dressing, and grooming tasks; -Approaches: Assist with showers two times a week and as needed. Staff will anticipate and address the resident’s needs that require assistance or cannot be met by him/herself; -Encourage the resident to complete task that he/she is capable of completing provided with oversight assistance; -Monitor and assess the resident frequently for any further decline with his/her ADL performance and refer for further evaluation; -Allow Resident to have sufficient time to complete his/her tasks in a timely manner; -Encourage/allow resident to make choices in regards to his/her daily care needs, provide assistance as needed; -Attempt to dress Resident according to season appropriately for comfort and dignity; -Frequently monitor Resident and his/her abilities to participate with ADL tasks, document any changes, and refer as needed for further evaluation. Observation of the resident on 7/24/18 through 7/27/18, showed the resident’s hair long (about four inches in length) and unkempt. The resident’s facial hair was approximately 2 inches in length. During an interview on 7/25/18 at 2:09 P.M., the resident said he/she takes showers and he/she needed a haircut and shaved. It has been about five months since he/she had a haircut. When he/she asks staff for a haircut and a shave, they don’t say nothing. During an interview on 7/27/18 at 1:10 P.M., a CNA I said the resident gets washed up two to three times a day. The resident take showers on Tuesday and Friday evenings. Now the resident had hollered about wanting a haircut. Last night, he/she helped the resident to call his/her family member. The family member informed CNA I to contact someone about getting the resident a haircut. He/she could not remember the last time the resident had a haircut. The resident wears hats a lot and takes his/her hat off when wanting a haircut. The resident has had his/her hat off for the past couple of days and started asking about a haircut last night. 4. Review of Resident #10 care plan, dated 1/29/18 and in use at the time of the survey, showed: -[DIAGNOSES REDACTED].>-Problem: ADL performance: Resident is dependent on staff for |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) completion of ADLs. Resident requires the use of mechanical lift for all transfers; -Approaches: Break ADL tasks into small segments as needed to allow/enhance participation; -Provide assistance with toileting/brief change upon arising, before and after meals, during scheduled rounds, at nighttime, and as needed; -Allow Resident sufficient time to do what he/she is able for completion pf ADL tasks to maintain/enhance independence/self-esteem. Observation on 7/24/18 thru 7/27/18 and 7/30/18, showed the resident’s hair uncombed and long in length, approximately 3 inches. The resident’s facial hair was uncombed and approximately 1/2 in length. During an interview on 7/25/18 at 2:45 P.M., the resident said he/she wanted a haircut and to be shaved. He/she had not asked for a haircut or shave but no one asked if he/she wanted a haircut or to be shaved. During an interview on 7/27/18 at 1:10 P.M., the CNA said the resident is total care. He/she is unsure of when the resident last had a shower, haircut, or a shave. During an interview on 7/30/18 at 9:55 A.M., the Administrator and DON said the resident never expressed wanting a haircut or a shave. The Administrator said that he/she did not know when the last time the resident had a shave or a haircut. The shower sheets would not show both showers and haircuts, as this would be different. In regards to the shaving, the CNAs could do that. Shaving should be routine or part of the residents care/grooming. The beautician does the haircuts as he/she is available, two times a week, but he/she had been out sick for the past three weeks. MO 210 | |
| 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: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 14) the resident lay in bed sleeping. The SP catheter drainage bag lay flat, directly on the floor without any type of barrier between the drainage bag and the floor. The drainage bag contained clear yellow urine. During an interview on 7/30/18 at 9:10 A.M., the Director of Nurses (DON) said urinary catheter drainage bags should never be directly on the floor due to the possibility of an infection. The drainage bag should be hooked onto the side of the bed. | |
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide safe and appropriate respiratory care for a resident when needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) shortness of breath and O2 sat less than 90%; -Further review showed no orders for [MEDICAL CONDITION] and no order to change the oxygen tubing. Review of the resident’s Medication Administration Record [REDACTED]. Review of the resident’s oxygen saturation record, dated 7/1/18 through 7/25/18, showed: -On 7/1/18, 92%; -No further O2 saturation levels documented. Observation and interview on 7/24/18 through 7/26/18, showed: -On 7/24/18 at 10:23 A.M., the oxygen machine and the [MEDICAL CONDITION] were observed in the resident’s room; -On 7/24/18 at 12:55 P.M., the oxygen machine was left on in the room and set at 2 liters. The oxygen tubing was not dated. The resident was not in the room; -On 7/25/18 at 1:27 P.M., the resident sat in the common area of the secured unit. He/she said he/she was not experiencing any shortness of breath. He/she used the oxygen every day. He/she can turn the machine on without any assistance from staff. He/she increased the oxygen to 3 liters PRN. He/she can breathe easier if it is set at 3 [MI] He/she uses a [MEDICAL CONDITION] every night when he/she sleeps. Since there is no setting, he/she can turn the machine on and use it; -On 7/25/18 at 2:51 P.M., the oxygen machine was left on in the room and set between 3-4 liters. The oxygen tubing was not dated. The resident was not in the room; -On 7/26/18 at 6:50 A.M., the resident sat on the bed with his/her back facing the door. He/she turned around and wore a nasal cannula under his/her nose. The oxygen machine was turned on; -On 7/26/18 at 9:15 A.M., the resident lay in bed with his/her eyes closed. The [MEDICAL CONDITION] mask was placed around the resident’s face. The [MEDICAL CONDITION] machine was on. The oxygen machine was on and set between 3-4 liters per nasal cannula. The resident was observed with oxygen tubing and the nasal cannula underneath the [MEDICAL CONDITION] mask. The oxygen tubing was not dated; -On 7/26/18 at 12:37 P.M., the resident lay in bed with the sheets over his/her face. The [MEDICAL CONDITION] machine was on; -On 7/26/18 at 1:48 P.M., the resident lay in bed with his/her eyes closed. The [MEDICAL CONDITION] mask was placed around his/her face. The [MEDICAL CONDITION] machine was on. During interviews on 7/26/18 at 2:15 P.M. and 7/30/18 at 9:10 A.M., the Director of Nursing (DON) said the nurse is responsible for administering the resident’s oxygen and obtaining the resident’s oxygen saturation. The oxygen machine is in the resident’s room, so the resident will turn it on, but she expects staff to document when the resident uses his/her oxygen and ensure it is on the correct setting. The resident went to the hospital and the order for the [MEDICAL CONDITION] dropped off the physician orders. She expects the nurse to obtain an order for [REDACTED]. During an interview on 7/30/18 at 2:00 P.M., the DON confirmed that the facility did not have an oxygen policy. | |
| 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) pharmaceutical services, including failing to follow procedures that ensure accurate acquiring, receiving, dispensing and administering of drugs to meet the needs of the residents, who had medication ordered and not administered. This effected one of 23 sampled residents (Resident #70). The census was 114. Review of facility’s policy, dated (MONTH) 6, (YEAR), titled: Medication Administration and Monitoring, showed nurse or certified medication technician (CMTs) should note that if the medication is not available the nurse or CMT will initial and circle the time of the medication is not available. The Director of Nursing (DON) or nurse designee will be notified immediately, it will then become the nurse or DON’s responsibility to ensure the medication is received and given to the resident. The pharmacy and the physician will be notified. Review of Resident #70’s medical records, showed: -The resident admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -An order dated 6/8/18, for Breo Ellipta (helps relieve breathing problems) 100-25 micrograms (mcg) inhaler, one puff daily. Review of the resident’s (MONTH) (YEAR) and (MONTH) (YEAR) medication administration records (MAR), showed staff did not document they administered the Breo inhaler from 6/8/18 through 7/24/18. Review of the resident’s pharmacy denial form, dated 6/9/18, and provided by the facility on 7/30/18 showed, the resident’s order for Breo Ellipta inhaler was not covered by insurance and should be changed to a suggested covered medication or paid for by facility. During an interview on 7/24/18 at 9:41 A.M., CMT G said circled initials on the MAR indicated [REDACTED]. He/she had told the nurse in the past that the medication was unavailable, and he/she would tell the nurse again today. Observation and interview on 7/24/18 at 9:41 A.M., showed CMT G administered medication to the resident. Breo Ellipta 100-25 mcg inhaler was not given. CMT G said the Breo inhaler was not given, because it was not available. During an interview on 7/25/18 at 9:02 A.M., CMT F said the Brio inhaler for the resident had not been given today because it is not available. He/she reported this to a nurse in (MONTH) when the resident first got here. He/she will tell the nurse again today. During an interview on 7/27/18 at 2:31 P.M., Pharmacy Technician D said an order for [REDACTED]. Notification was sent to facility that insurance denied payment for this medication on 6/9/18, 6/11/18, and 7/25/18. The pharmacy did not receive a response from the facility. During an interview on 7/25/18 at 9:32 A.M., Nurse C said he/she was made aware yesterday that the resident’s medication was not available. He/she has contacted the physician, and the medication has now been discontinued. The resident has not shown any signs or symptoms of respiratory distress. During an interview on 7/30/18 at approximately 1:45 P.M., the DON said he/she would expect the CMT to notify a nurse or the DON if a medication is not available. He/she would then expect the nurse to notify the pharmacy and the physician. He/she would also expect staff to call the physician when receiving a denial fax from pharmacy. | |
| F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Based on observation, interview, and record review, the facility failed to follow three out of three puree recipes for eight residents. The facility failed to serve milk and nutritional health shakes at a temperature of 41 degrees Fahrenheit (F) or lower. The facility also failed to serve water at the appropriate temperature at time of service. The facility census was 114. 1. Review of the facility’s resident food storage policy, dated 11/28/16, showed: -Purpose: To ensure that resident’s food storage is safe with sanitary storage, handling and consumption; -Procedure: Refrigerators will be kept clean and within the regulation temperature guidelines of 32-40 degrees. If the temperature falls beyond the regulated guidelines, the food will be discarded; -Each refrigerator will have a thermometer in the freezer and refrigerated compartments; -Each refrigerator will have a temperature log and will be documented daily; -Prepared food that is dated three days after it is placed in the refrigerator will be discarded. 2. Observation of the kitchen showed: -On 7/24/18 at 9:20 A.M., the refrigerator gauge showed a temperature of 52 degrees F. The inside thermometer showed a temperature of 58 degrees F. The refrigerator contained milk, nutritional drinks, and thickened liquids; -On 7/26/18 at 7:10 A.M., the refrigerator gauge showed a temperature of 54 degrees F. The inside thermometer measured 50 degrees F. The refrigerator contained milk, nutritional drinks, and thickened liquids; -On 7/26/18 at 11:10 A.M., the surveyor’s calibrated digital thermometer was placed inside the refrigerator. At 11:20 A.M., the digital thermometer showed a temperature of 46.2 degrees F; -On 7/27/18 at 9:23 A.M., several containers of milk and nutritional health shakes were inside a metal container filled with ice during meal service in the main dining room and the Happy Cafe. The milk was 48.2 degrees F, a vanilla health shake was 43.4 degrees F, and a chocolate milk was 46.6 degrees F; -On 7/27/18 at 11:10 A.M., the surveyor’s calibrated digital thermometer was placed inside the refrigerator. At 11:15 A.M., the digital thermometer showed a temperature of 49 degrees after five minutes inside the unopened refrigerator. The refrigerator gauge showed a temperature of 52 degrees F. The inside thermometer showed a temperature of 54 degrees F. Observation on 7/27/18 at 1:01 P.M., showed the double refrigerator gauge showed a temperature of 52 degrees F. The inside thermometer showed 52 degrees F. Cook E and surveyor took the temperature of the drinks inside the refrigerator with the surveyor’s calibrated digital thermometer. The vanilla health shake showed a temperature of 52.0 degrees F, lemon flavored thickened water showed a temperature of 47.3 degrees F, and Boost showed a temperature of 54.1 degrees F. A carton of milk was removed from a metal container of during meal service. The milk showed a temperature of 45.8 degrees F. During an interview on 7/27/18 at 1:01 P.M., Cook E said all cold beverages must be 40 degrees F or less. The beverages cannot be served due to the high temperature. Review of the temperature log of the double refrigerator showed staff documented the temperature at 40 degrees F on the following dates and times: -On 7/23/18 AM; -On 7/24/18 AM; -On 7/25/18 AM; -On 7/26/18 AM; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) -On 7/27/18 AM; -On 7/23/18 PM; -On 7/24/18 PM; -On 7/25/18, left blank; -On 7/26/18, left blank . 3. Observation on 7/27/18 at 7:15 A.M., showed Cook E removed a metal container from the oven that contained cooked scrambled eggs. Cook E confirmed there are eight residents that received a puree diet, so he/she will prepare 16 servings. He/she used a large spoon to scoop out the unmeasured cooked eggs from the container and into the blender. He/she poured hot milk into a measuring cup, measured at 3 3/4 cups. He/she said it was four cups of milk. He/she started to blend the cooked scrambled eggs and poured the milk into the blender in small amounts. There was approximately one cup of milk that remained in the measuring cup after he/she finished the puree. The pureed eggs had a thin, cake batter consistency. The puree easily moved up and down the spoon. Cook E did not look at the recipe. Review of the pureed scrambled eggs recipe for 20 servings showed: -1 quart and 2 cups of eggs; -1 cup of milk; -Further review of the puree showed Cook E used an unmeasured amount of cooked eggs and 2 3/4 cups of milk. Observation on 7/27/18 at 2:00 P.M., showed Cook J removed cook grilled ham and cheese sandwiches from a container. Cook J confirmed there are eight residents on a pureed diet and he/she will prepare 14 servings. Cook J placed five sandwiches into the blender. He/she had four cups of milk in the measuring cup. He/she began blending the sandwiches and adding the milk into the blender. There was 1 1/2 cup of milk that remained in the measuring cup. Cook J added six more grilled ham and cheese sandwiches into the blender and poured more milk into the blender. He/she added three more sandwiches to the blender and poured more milk into the blender and mixed it together. There were two sandwiches left inside the container; however, Cook J did not use them because his/her sharpie fell into the container. Cook J continued to blend the mixture. It was thick and did not blend. Cook J poured 3 1/2 cups of milk into the measuring cup and poured the milk into the blender. The milk sat on top of the mixture and did not blend. He/she used a spatula to mix the sandwiches in the blender. The mixture was thick and chunky. Cook J poured more milk into the blender and tried to blend it. The milk continued to sit on top of the mixture. He/she used the spatula to mix the milk into the sandwich mixture. He/she added more milk into the blender mixed it together in the blender for approximately two minutes. Approximately two cups of milk remained in the measuring cup. Cook J poured the grilled ham and cheese sandwich puree into a metal container. The texture was thick pudding consistency. Cook J had the recipe accessible on the preparation table. Review of the pureed grilled ham and cheese sandwich recipe for 20 servings showed: -20 sandwiches; -1 quart (4 cups) and 2 cups milk; -Further review of the puree showed Cook J used 14 sandwiches and 5 1 /2 cups of milk. Observation on 7/30/18 at 10:50 A.M., showed Cook J removed cooked chopped chicken from a metal container. He/she said there were 12 servings inside the container. He/she poured the chicken into the blender where the 12 cup marker line was located. He/she poured 6 1/2 cups of chicken broth into the measuring cup. He/she started to blend the chicken and began to pour the broth into the mixture. Approximately two cups of broth remained in the measuring cup. Cook J poured the pureed chicken into the metal container. Small pieces of |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) chicken were observed in the puree. The puree easily ran down the spoon with a cake batter consistency. There were small pieces of chicken that could be chewed in the puree. Cook J said the puree could have been thicker. Cook J did not look at a recipe. Dietary Aide K said the puree looked like someone could eat it with crackers, like tuna. Review of the pureed chicken recipe for 20 servings showed: -1 tablespoon and 1 teaspoon of chicken base; -1 quart of water; -3 3/4 pounds of roasted chicken; -Further review of the puree showed Cook J used unmeasured amount of chicken and 4 1/2 cups of chicken broth. 4. Observation and interview on 7/30/18 at 8:00 A.M., showed Certified Nurse Aides (CNAs) served hall trays to the residents on the C-hall . The beverage tray showed several cups of frozen water. There were several staff that said the water was frozen. The surveyor’s calibrated thermometer was placed inside the cup. The temperature of the frozen water was 32.0 degree F. CNA L said he/she was aware of the frozen water; however he/she tried to squeeze the cup to break the ice. CNA L went into a resident’s room and picked up the cup. The water was frozen inside the cup. He/she squeezed the cup and the ice did not break. CNA L said frozen water should not be served to the residents. A dietary aide said the refrigerator was not working, so it could have been the reason why the water was frozen. During an interview on 7/30/18 at 8:10 A.M., Dietary Aide K said the cups of water were placed in the freezer to keep the beverages cold, but he/she did not know they were frozen when the tray was served to the C-hall. 5. During an interview on 7/30/18 at 11:30 A.M., the administrator and Cook M said they would expect staff to report low temperatures in the refrigerator and at meal service. They would expect staff to not serve warm drinks or frozen drinks to the residents. The refrigerator was recently repaired and there are no issues with the temperatures. The temperature log on the refrigerator was accurate and was 40 degrees F in the morning and the evening per the gauge and thermometer. They would expect staff to follow the recipe for the puree to ensure residents are served the appropriate texture. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure all |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 20) -Container of raisin bran without a date; -Container of captain crunch without a date; -Container of rice cereal without a date; -Chipped paint on the outside of the door of the walk in cooler; -Cracked, loose tile in the dish machine room; -Brown substance around the caulking underneath the dish machine; -Bug trap on the floor underneath the dish machine. Observation on 7/25/18 at 10:45 A.M., showed: -Container of cheerios without a date; -Container corn flakes without a date; -Container of fruit loops without a date; -Container of raisin bran without a date; -Container of captain crunch without a date; -Container of rice cereal without a date; -Two undated vanilla health shakes in the refrigerator; -Container of corn meal with a scoop inside; -Cracked, loose tile in the dish machine room; -Brown substance around the caulking underneath the dish machine; -Bug trap on the floor underneath the dish machine. Observation on 7/26/18 at 7:10 A.M., showed: -Dust and debris build up on the bottom part of the large fan blowing into the food preparation and cooking area; -Wrapped plate of braunschweiger and a slice of American cheese without a date inside the walk in cooler; -Container of cheerios without a date; -Container corn flakes without a date; -Container of fruit loops without a date; -Container of raisin bran without a date; -Container of captain crunch without a date; -Container of rice cereal without a date; -Container of corn meal with a scoop inside; -Chipped paint on the outside the door of the walk in cooler. -Ceiling vent above the walk in cooler covered with dust and debris; -Large metal pan filled with water under the three sink sanitizer; -Cracked, loose tile in the dish machine room; -Brown substance around the caulking underneath the dish machine; -Bug trap on the floor underneath the dish machine. Observation on 7/26/18 at 11:10 A.M. and 7/27/18 at 7:00 A.M., showed: -Dust and debris build up on the bottom part of the large fan blowing into the kitchen during food preparation; -Stacked wet pans on the shelf in the dish machine room; -Container of cheerios without a date; -Container corn flakes without a date; -Container of fruit loops without a date; -Container of raisin bran without a date; -Container of captain crunch without a date; -Container of rice cereal without a date; -Container of corn meal with a scoop inside; -Chipped paint on the outside the door of the walk in cooler. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 21) -Ceiling vent above the walk in cooler covered with dust and debris; -Large metal pan filled with water under the three sink sanitizer; -Cracked, loose tile in the dish machine room; -Brown substance around the caulking underneath the dish machine; -Bug trap on the floor underneath the dish machine. Observation on 7/30/18 at 6:45 A.M., showed: -Dust and debris build up on the bottom part of the large fan blowing into the kitchen during food preparation; -Chipped paint on the outside the door of the walk in cooler; -Wrapped shredded cheese without a date; -Container of cornmeal with scoop inside; -Container of cheerios without a date; -Container corn flakes without a date; -Container of fruit loops without a date; -Container of raisin bran without a date; -Container of captain crunch without a date; -Container of rice cereal without a date; -Cracked, loose tile in the dish machine room; -Brown substance around the caulking underneath the dish machine; -Bug trap on the floor underneath the dish machine. 2. Observation and interview on 7/27/18 at 7:05 A.M., showed Dietary Aide N tested the dish machine sanitizer. Dietary Aide N confirmed that the dish machine was chemical, so he/she would expect the sanitizer to be at 50 parts per million (ppm). The manufacturer metal sign on the dish machine showed the required sanitization was 50 ppm. He/she removed a clean strip from the container and placed it in the tank during the cycle. The strip did not change colors. He/she placed the used strip onto the bottle of strips to match the examples. The light colored purple on the bottle was 50 ppm and the darker purple was 100 ppm. He/she said it should turn purple which would read 50 ppm. He/she removed another strip from the container and started another cycle on the dish machine. He/she placed the strip into the tank of water. The strip did not change colors. He/she said the strip changed to a light purple. The wet strip was white. Dietary Aide N said the dish machine needed to warm up. He/she had not tested the dish machine today, but it was last tested yesterday morning. He/she tests the sanitizer on the dish machine every morning. He/she started another cycle, and placed a clean strip into the water. The sanitizer cycle turned and the strip did not change colors. He/she said the strip changed from white to purple, but the strip remained white. Cook E arrived to the dish machine room and confirmed that the strip was white. Cook E said the machine should not have to warm up because sanitizer is coming directly from the container along with the detergent. Dietary Aide N removed a clean testing strip from the bottle and started a new cycle. The detergent gauge turned and liquid poured out of the tube into the tank. Cook E confirmed it was the detergent released from the tube. The water inside the tank emptied, and the sanitizer gauge turned and blue liquid poured out of the tube. Cook E confirmed it was the sanitizer released from the tube. Dietary Aide N placed a clean testing strip into the water. The testing strip did not change colors. Cook E confirmed that the testing strip did not change colors and it was possible that there was not enough sanitizer released. Cook E said he/she would get the dish machine repaired. Observation and interview on 7/27/18 at 8:30 A.M., Cook E and Dietary Aide N said the sanitizer container was empty and it was the reason it did not sanitize. Cook E said he/she did not know why liquid came out of the tube before when the sanitizer was |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 22) released, but the container was empty. It could have been left over sanitizer. The dish machine was tested , and a new strip was used. Cook E started a new cycle. The sanitizer was released and blue liquid poured into the water tank. The strip immediately turned purple. The strip was compared to the examples on the bottle of strips and it was between 50 to 100 ppm. Cook E said he/she did not know how long the container was empty, but there was definitely sanitizing solution yesterday. It could have run out after dinner. Cook E later said he/she could not be certain when the dish machine ran out of sanitizer after it was tested yesterday morning. Review of the dish machine testing log, showed: -On 7/20/18, staff did not document the chlorine level; -On 7/21/18, staff documented the chlorine level was 100 ppm; -On 7/22/18, staff documented the chlorine level was 100 ppm; -On 7/23/18, staff did not document the chlorine level; -On 7/24/18, staff documented the chlorine level was 100 ppm; -On 7/25/18, staff documented the chlorine level was 100 ppm; -On 7/26/18, staff documented the chlorine level was 100 ppm; -On 7/27/18, staff did not document the chlorine level; 3. Observation on 7/25/18 at 11:00 A.M., showed Cook E slicing turkey on machine without a facial restraint exposing facial hair on the chin, neck, upper lip, and cheek. Observation on 7/26/18 at 7:10 A.M., showed Dietary Aide K with bangs approximately three inches long outside of the hair restraint. Observation on 7/27/18 at 7:00 A.M., showed Dietary Aide K with bangs outside of the hair restraint. He/she covered the bangs, but left approximately two inches of hair outside of the restraint on both sides of the head. Dietary Aide O had waist length braids outside of the hair restraint. Observation on 7/30/18 at 6:45 A.M., showed Dietary Aide O with waist length braids outside of the hair restraint as he/she prepared the beverages. The braids were around his/her shoulder. The end of the braids touched the rim and inside the cups. 4. During an interview on 7/30/18 at 11:30 A.M., the administrator and Cook M said they expect staff to cover all hair and facial hair in the kitchen. The cereal is filled everyday. The residents go through the cereal quickly. The containers are empty before staff refill it with cereal. All opened foods are expected to be dated. The sanitizer was replaced in the dish machine and is working properly. Staff are expected to test the sanitizer twice a day and documented on the testing sheet. The paint on the outside of the walk in cooler door has been chipping off for a long time. The door was repainted in the past. The fan was recently taken apart and cleaned by staff. Cook M would expect the fan to be free of dust and debris. The tile in the dish machine room is in need of a repair. The brown substance on the caulking underneath the dish machine has been there for a while, and Cook M did not know what it was. The administrator and Cook M expect all areas of the kitchen to be cleaned on a daily basis by the porter. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) for one resident (Resident #93). The census was 114. 1. Review of the quarterly Minimum Data Set (MDS), federally mandated assessment instrument completed by facility staff, dated 7/8/18, showed: -Brief Interview of Mental Status (BIMS) score of 15 out of 15, shows the resident is cognitively intact; -[DIAGNOSES REDACTED]. -Independent with transfers, dressing, eating, toileting, and hygiene; -Receives oxygen therapy; -Bi-pap not selected. Review of the resident’s care plan, dated 10/18/17, and in use during the survey showed: -Problem: Obstructive sleep apnea: Resident requires use of continuous positive airway pressure ([MEDICAL CONDITION], a machine used to treat sleep apnea), due to ineffective breathing pattern with risk of further respiratory complication; -Approaches: Monitor the resident’s compliance with use of [MEDICAL CONDITION] document and follow up and the physician on any concerns; -Perform frequent face and safety checks on the resident as part of daily routine; -Licensed nurse to ensure appropriate set up and use [MEDICAL CONDITION] checks daily/frequently for use; Problem: Due to resident’s experiencing sleep apnea, resident is required to use the [MEDICAL CONDITION] to aid in assisting him/her with sleeping; -Approaches: Ensure the resident is using equipment appropriately; -Assist the resident with [MEDICAL CONDITION]/[MEDICAL CONDITION] equipment each night. Observation and interview on 7/24/18 through 7/26/18, showed: -On 7/24/18 at 12:55 P.M., the oxygen machine was left on in the room and set at 2 liters. The resident was not in the room. The undated oxygen tubing and nasal cannula lay on the dirty floor that was sticky and covered with a dried brown substance. The oxygen machine had dried brown stains on the front; -On 7/25/18 at 8:53 A.M., the undated oxygen tubing and nasal cannula lay on the dirty floor that was sticky and covered with a dried brown substance. The oxygen machine had dried brown stains on the front. The [MEDICAL CONDITION] mask was uncovered and on the floor next to the oxygen tubing; -On 7/25/18 at 12:28 P.M., the undated oxygen tubing and nasal cannula lay on the dirty floor that was sticky and covered with a dried brown substance. There were dried brown stains on the front of the oxygen machine. The [MEDICAL CONDITION] mask was uncovered and on the floor next to the oxygen tubing. There was an open trash can with flies swarming above it. The trash can was next to the tubing, [MEDICAL CONDITION] mask, and oxygen machine; -On 7/25/18 at 1:27 P.M., the resident sat in the common area of the secured unit. The resident said he/she asked for a new filter for the machine two weeks ago because he/she could see that it was dirty. He/she said it feels like there is dirt in his/her throat; -On 7/25/18 at 2:51 P.M., the oxygen machine was left on in the room and set between 3-4 liters. The resident was not in the room. The undated oxygen tubing and nasal cannula lay on the dirty floor that was sticky and covered with a dried brown substance; -On 7/26/18 at 8:25 A.M., the resident was observed in the common area in the unit. The resident’s room had brown stains on the floor, the air conditioner unit, and the wall and oxygen machine. The floor was sticky. The undated oxygen tubing and nasal cannula was on the stained and sticky floor; -On 7/26/18 at 12:37 P.M., the undated oxygen tubing and nasal cannula lay on the dirty floor that was sticky and covered with a dried brown substance; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265534 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER HERITAGE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 4401 NORTH HANLEY 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 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) -On 7/26/18 at 1:48 P.M., the undated oxygen tubing and nasal cannula lay on the dirty floor that was sticky and covered with a dried brown substance. The housekeeper entered the room and mopped one side of the resident’s floor as the oxygen tubing and nasal cannula continued to lay on the floor; -On 7/27/18 at 2:41 P.M., the resident was observed in the common room. The oxygen tubing was dated 7/26/18. The nasal cannula was placed inside the resident’s night table drawer. Inside the drawer was a collection of dirty cup lids and trash. During an interview on 7/26/18 at 2:15 P.M. and 7/30/18 at 9:10 A.M., the Director of Nursing (DON) said it was not acceptable to find the [MEDICAL CONDITION] mask, oxygen tubing and nasal cannula on the resident’s floor. The DON confirmed there were numerous stains on the resident’s floor. The tubing and the [MEDICAL CONDITION] should not be on the floor because of cross contamination and infection control. She would expect the tubing and mask to be dated and covered when it is not in use. She would expect the CNA’s and nursing staff to ensure the tubing was not on the floor. During an interview on 7/30/18 at 2:00 P.M., the DON confirmed that the facility did not have an oxygen policy. | |
| F 0925 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Based on observation and interview, the facility failed to maintain an effective pest | |
