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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice. **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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) 1. Review of Resident #114’s quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 9/22/18, showed: -Clear speech, distinct intelligible words; -Makes self-understood; -Able to understand others; -Extensive assistance required for bed mobility, dressing and toilet use; -Total dependence for personal hygiene; -[DIAGNOSES REDACTED]. Observation on 11/7/18 at 7:24 A.M., showed Certified Nursing Assistant (CNA) A provided care to the resident. CNA A entered the resident’s room and gathered supplies. He/she turned off the resident’s television and provided care to the resident. Several times the resident requested the television be turned back on. CNA A would either not respond to the resident’s request or would tell the resident to wait a minute. CNA A finished providing care to the resident and assisted the resident to his/her wheelchair at 8:07 A.M. CNA A never turned the resident’s television back on or provided a reason why the television could not be on. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said a resident’s choice should be honored. If a resident requested their television be turned on during incontinence care, she would expect staff to turn it on. 2. Review of Resident #11’s quarterly MDS, sated 7/21/18, showed: -A Brief interview of mental status (BIMS) score of 13 out of a possible score of 15; -A BIMS score of 8-15 showed the resident understands and was able to make self-understood; -Expensive assistance required for locomotion off the unit; -[DIAGNOSES REDACTED]. Observation on 11/8/18 at 8:35 A.M., showed the resident sat in a wheelchair at the 2 South nurses’ station. He/she asked Activity Assistant B if he/she could use the phone. Activity Assistant B told the resident he/she could not use the phone and he/she had to go downstairs to use it. He/she would have to wait. CNA C walked past the resident and Activity Assistant B asked CNA C if the resident could use the phone. CNA C said he/she does not usually work on the floor and did not know. CNA C continued to walk past the resident and down the hall. CNA D walked past the resident and Activity Assistant B asked CNA D if the resident could use the phone at the nurses’ station. CNA D said the resident had to go downstairs to use the phone and he/she walked away. Activity Assistant B walked away. No staff assisted the resident to make a phone call and the resident sat alone at the nurses’ station. Several minutes later a nurse came to the nurses’ station. The resident asked if he/she could use the phone and the nurse assisted the resident to use the phone at the nurses’ station. During an interview on 11/13/18 at 9:00 A.M., the DON said residents are allowed to use the phone at the nurses’ station. They also have a resident only phone. If a resident requested to use the phone, she would expect staff to help them. 3. Review of Resident #47’s admission MDS, dated [DATE], showed; -A BIMS score of 12, shows the resident was moderately impaired; -[DIAGNOSES REDACTED]. Observation on 11/6/18 at 12:10 P.M., showed the resident was observed with a bag of chips and a soda in his/her room. Certified Nurses Aide (CNA) M told the resident it was time to go to the dining room. The resident asked if he/she could stay in his/her room. CNA M said he/she had to go to the dining room. The resident walked out of his/her room to the dining room. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) During an interview on 11/6/18 12:15 P.M., CNA M said if the residents are able to go to the dining room, then they go. There is a resident that stays in bed all day, and they serve him/her food, but everyone else would go to the dining room. They are not going to just serve them in their room. During an interview on 11/8/18 at 9:00 A.M., the residents in the group meeting said they CNA’s do not like when the residents eat in their room because they do not like bring them a plate. During an interview on 11/13/18 at 10:37 A.M., the administrator said she would expect the residents to be allowed to eat in their room if they choose to. | |
F 0567 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Honor the resident’s right to manage his or her financial affairs. **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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0567 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 3) $0 to $5 per day, depending on the severity of the situation; -Social services will monitor beneficiary’s spending activity and will notify the business office if they suspect misuse of funds or if they have any concerns regarding the distributed amount. Social services will also determine if a beneficiary’s day to day and personal needs are being met, then let the BOM know. 1. Review of Resident #50’s medical record, showed: -admitted on [DATE]; -Own responsible party. Review of facility’s authorization and agreement to handle resident funds, showed the resident signed on 5/6/15. Review of the resident’s social services notes, showed: -On 1/26/2018, the resident has been reduced to receiving $2.00 day instead of $5.00 due to being observed by the psych social aide and the nurse giving his/her money away to two other residents. Resident was redirected by the aide and was counseled on not giving his/her money away and that he/she will be reduced to $2.00 a day. Resident complied and did not display a negative reaction. Aide informed the business office manager of the change in amount; -On 8/17/2018 at 12:12 P.M., the resident’s family member called to ask social services to provide resident with $50 so that resident can purchase his/her pastor a birthday present. Contact the business office manager who stated per state regulations, residents are not allowed to purchase items with state money for non-immediate family members. State money is for resident’s needs. In addition, business office manager stated the last time resident took money, the family member who was supposed to take him/her shopping never showed up and resident did not return it back to the business office manager and ended up spending all of it. He/she understood and wanted to know if he/she could at least receive $20. Advised the family member that resident could receive $20 but receipts have to be returned along with any change; -On 8/17/18 2:40 P.M., resident’s family called and will be here tomorrow to pick resident up to go shopping and requested the $20. Contacted business office manager who said they need at least one business day notice in advance to make sure we have the money on site; -On 8/23/2018 at 12:00 P.M., resident’s family member left multiple voice mail messages to social services requesting $20 for resident to be taken to the beauty supply. Spoke with the business office manager who said since resident is his/her own responsible party that money request from family is not allowed and that resident has to follow the procedures to request his/her own money. Resident has been informed that he/she is to return with receipts and any unused money. During the resident group interview on 11/8/18 at 9:00 A.M., the residents said they have to provide a receipt to show what they purchased. They are grown men and women, and they want to buy what they want to buy. The facility also has a problem with residents giving each other money. During an interview on 11/8/18 at 11:00 A.M., the business office manager said if the resident wanted to withdrawal money from their resident trust account, they have to sign up the night before on the money sheet. The funds are sent out to the resident the next day before 9:00 A.M. If the resident misses the sheet to fill out, they tell the residents to fill out the sheet next time. If the resident is upset or adamant about their money, then staff will let it go and the resident could have their money. There are no weekend hours. The residents are aware they need to fill out the sheet on Thursday if they want money during the weekend. If a resident needed money during the weekend, they would not be able to receive it until Monday. If the resident is going out with their family, they |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0567 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 4) usually know in advance, so they fill out the money sheet. The business office manager holds on to the money until Friday. If it is a holiday, the residents are aware to request more money the day before. The majority of the residents request money. Today there were 36 residents that requested money from their account. There is a $50.00 limit for the day. If they want more than $50.00, they have to give the business manager manager one business day. The residents are started with a $5.00 starting limit a day, so their money can stretch throughout the month. If they run out of money, they will become upset. The business office manager tried to spread the money out, especially if that resident received $30.00 a month. The resident’s daily limit can be decrease if they are misplacing the money or giving it away. If the resident was their own responsible party, the business office manager does not adjust their funds. If the facility is the resident’s representative payee, the facility is allowed to adjust their money and request a receipt if the resident goes shopping. The resident does not have to submit a receipt; however, social security is concerned about the intent of use. Some residents say it is none of the facility’s business. Staff counsels them to bring back the receipt or they will lower the daily amount. If the resident was observed giving their money away, for example, buying a soda for another resident or if it appeared the resident was being taken advantage of, the amount they are able to receive will decrease. The business office manager started working on a policy, but it had not been passed to the residents. Right now it is communicated verbally. During an interview on 11/13/18 at 9:00 A.M., the administrator said the residents fill out the money sheet and their money is delivered the next day. They do not have access to their money, and there is no system in place for the residents to receive their money on a weekend. If the residents are aware they need more for the weekend, they have to fill out the money sheet in advance. Social security requires the facility to obtain a receipt from the residents only if the facility is the resident’s representative payee. The guidelines state that they are supposed to have the money to spend on themselves. During an interview on 11/13/18 at 12:00 P.M., the business office manager said it is a case by case basis to determine if a receipt had to be provided. The Medicaid office does not like the residents gifting in large amounts. A large amount would be $500, but there are no residents requesting that amount of money. Resident #50 had issues with his/her family members. He/she might have given his/her family money. They have to make sure the residents needs are met. The business office manager depends on social services to inform him/her if there was a problem and if the resident’s amount of money they could receive needed to be adjusted. Resident #50’s documentation is expected to show the concerns that lead to the decrease of the money. If the resident gave another resident $1 or $2, that would not be enough to decrease the amount of money he/she received. The business office manager did not remember saying the resident could not only purchase gifts for non-immediate family members. The aides are not allowed to adjust the amount. The business office manager would expect more communication with him/her before decreasing the daily amount. | |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) Based on interview and record review, the facility failed to obtain a signed code status sheet or failed to obtain physician orders for code status for four of 29 sampled residents (Residents #131, #452, #154 and #70). The census was 148. 1. Review of Resident #131’s electronic and hard copy medical record, showed: -An electronic face sheet, with an admission date of [DATE]; -A signed code status sheet, dated [DATE], with a code status of full code (all life saving methods are preformed); -An electronic physician order sheet (ePOS), dated (MONTH) (YEAR), showed no code status ordered as late as [DATE], at 9:45 A.M. During an interview on [DATE] at 9:45 A.M., the Director of Nurses (DON) verified there was no order for the resident’s code status on the POS. She would expect staff to obtain a physician order for [REDACTED].>2. Review of Resident #452 electronic medical record, showed: -admitted to the facility on [DATE]; -A POS, dated [DATE] through [DATE], showed no physician order of code status; -A face sheet, showed no documentation of code status. Review of the resident’s code status election form, dated [DATE] and signed by the resident, showed the resident wished to have cardiopulmonary resuscitation (CPR). 3. Review of Resident #154’s electronic face sheet, showed the resident a full code. Review of the resident’s electronic medical record, showed: -admitted to the facility on [DATE]; -An active order dated [DATE], for full code status; -A progress noted dated [DATE] at 5:21 A.M., this nurse called to the resident’s room by a certified nursing assistant (CNA). Resident noted unresponsive to the touch, no pulse present, no respirations. Resident is a do not resuscitate (DNR, no life saving measures to be performed); -An active order dated [DATE], for DNR. Review of the resident’s paper chart, showed: -A code status election form, dated [DATE] and signed by the resident, showed the resident wished to have cardiopulmonary resuscitation (CPR); -A code status election form, dated [DATE] and signed by the resident representative, showed no CPR desired; -No code status election form completed from the resident’s date of admission on [DATE] until [DATE]. 4. Review of Resident #70’s medical record, showed: -admitted on [DATE]; -A signed code status form, dated [DATE], with a code status of DNR; -Physician order sheet (POS), dated [DATE] through [DATE], showed an order, dated [DATE] and [DATE], for full code status. 5. During an interview on [DATE] at 9:00 A.M., the Director of Nursing (DON) said it is the responsibility of social services to get a code status election form completed when a resident is admitted to the facility. After that, it goes into the resident’s chart. There should be a physician’s order for code status. The code status on the face sheet and physician order sheet should match. If a resident’s code status were to change, the old code status order should be discontinued. If staff need to know a resident’s code status, they would look in the paper chart. Social services meet with the resident and/or family to determine their wishes. Social services communicate this to the nursing staff. If a resident is admitted on the weekend, the nurse would be responsible to obtain a code status for the resident. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) | |
F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) During an interview on 11/8/18 at 11:39 A.M., Licensed Practical Nurse (LPN)H said the resident wears the safety helmet every day because he/she has [MEDICAL CONDITION] and has a lot of falls. During an interview on 11/13/18 at 9:00 A.M., the DON confirmed that the resident wore a safety helmet to protect him/her in the event of a fall. She would expect it to be assessed for any rips or tears on a daily basis because it is worn every day. She would expect staff to notify her that the helmet is torn, so it can be replaced. | |
F 0585 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to establish a grievance policy | |
F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) the event they become aware or formulate a reasonable suspicion that abuse, neglect, theft or a crime has been committed against a resident of the facility: -Upon receipt of an allegation of abuse, neglect, theft or that a crime has occurred against a resident the facility Administrator or his/her designee will initiate external reports to the department; -The administrator or designee will contact the department immediately but no later than 24 hours following an observed event, allegation or formulation of a reasonable suspicion that a crime occurred against a resident that did not result in serious bodily injury; -In cases of serious bodily injury the administrator will contact the department immediately but no later than 2 hours from the time of the allegation or formulation of the reasonable suspicion that a crime was committed against a resident; -Within 5 business (working) days from the event or report the facility will submit a report to the department that will contain a description of the initial allegation, description of the investigation and the facts obtained, a brief conclusion based on the information obtained during the investigation, a description of any corrective actions taken if necessary; -The policy failed to require that in response to any allegations of abuse the facility must: Ensure all alleged violations are reported immediately. No later than 2 hours if the allegation involve abuse or result in serious bodily injury; -Staff obligations to prevent and report abuse, neglect and theft: Federal and state laws and regulations mandate that a nursing home resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion; -Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means; -It is the policy of this facility that employees must always report allegations of abuse, neglect, theft or crimes committed against its residents; -Resident Protection During Abuse Investigations policy, dated 1/2012, the facility desires to establish a resident secure environment and will take steps to protect residents from exposure to additional acts of mistreatment following an allegation or reported instance of abuse, neglect, theft or criminal action committed against the residents while an investigation is conducted: -Resident to resident events: Residents who allegedly abuse another resident should be removed from contact with other residents until such time that reasonable clinical judgement determines that their behavior no longer poses a significant risk to other residents or until the investigation is concluded. 1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 10/4/18, showed: -Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had moderately impaired cognition; -No behaviors; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 6/30/16, showed: -Focus: Resident gets upset easily and can become verbally & physically aggressive towards others. Resident can be hard to direct at times. Resident is impulsive and likes to hug: -On 4/15/17, aggressive towards peers stating they cannot sit at table with him/her and he/she knocked over a chair; -On 12/24/16, attempting to exit locked doors, staff attempted to redirect. Resident started kicking and rolling around on the floor. History of getting upset when he/she does |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) not win bingo. Will become physical or verbally aggressive; -On 4/24/17, kicking the wall, yelling, and refusing to move to one side of the hall; -On 7/4/18, hit peer after argument. Had a resident to resident altercation; -Resident’s roommate accused him/her of talking about his/her roommate and backed his/her wheechair into the resident; -Interventions: Create a positive environment for the resident to gain socially acceptable patterns of behaviors. Keep resident away from source of agitation. Every 15 min face checks; -Focus: Resident is at risk for injury from other residents: -On 7/24/18, hit by peer and was pulled by purse. No injury; -On 9/13/18, hit by peer. No injury; -Interventions: Assess the resident for injury after any physical incident. Alert physician and responsible party. Remove the resident from the source of aggression; -Focus: Resident has a history of being verbally/physically aggressive towards others. Has a history of resident to resident altercations. Resident can be very hard to redirect at times. Resident needs frequent redirection and supervision; -Focus: He/she pushed a resident in his/her back four times related to anger, history of harm to others, and poor impulse and control; Interventions: The resident’s triggers for physical aggression are (not being allowed to go on outings). The resident’s behaviors is de-escalated by (providing distractions and other activities). Review of the Resident #126’s progress notes, dated 10/30/18, showed he/she was speaking with another resident, when Resident #47 brushed up against Resident #126 in passing. A small verbal commotion followed and Resident #126 yelled, I’m not a boy! Resident #126 moved toward Resident #47 in an aggressive manner, but never raised his/her hands in an attempt to strike. Resident #47 then struck Resident #126 on the right side of his/her face. Residents swiftly separated. Cold compress applied to right side of face. Slight swelling noted. Skin intact. No discoloration noted. Complaints of tenderness to touch. Praised his/her coping skills, of not retaliating physically. Encouraged to walk away from confrontations. Verbalized understanding. Review of Resident #47’s admission MDS, dated [DATE], showed; -A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition; -No behaviors exhibited; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 8/15/18, showed: -Focus: Resident has the potential to be verbally aggressive (screaming, yelling at others) related to dementia and a [DIAGNOSES REDACTED]. -Interventions: Administer antipsychotic medications as ordered. Monitor/document for side effects and effectiveness. Give the resident as many choices as possible about care and activities. Monitor behaviors every 15 minutes. Document observed behavior and attempted interventions; -When resident becomes agitated: Intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later. Review of Resident #47’s progress notes, dated 10/31/18, showed staff reported while in the hallway, another resident was speaking with someone else, when this resident brushed up against the first resident in passing. A small verbal commotion followed and the other resident yelled, I’m not a boy! Staff reports that resident moved toward this resident in an aggressive manner, but never raised his/her hands in an attempt to strike. This |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) resident then struck the other resident on the right side of his/her face. Residents swiftly separated. Encouraged him/her to walk away from confrontations. Verbalized understanding, but still claimed that the other resident is trying to, make you all go against me. Reiterated to him/her there was no need to strike him/her, especially since he/she him/herself had not been hit. Also spoke to him/her about utilizing better conflict resolution techniques during confrontations. During an interview on 11/8/18 at 11:30 A.M., Resident #126 said the altercation was with Resident #47. He/she bumped into the resident and Resident #47 said he/she was going to hit him/her. Observation on 11/8/18 at 12:00 P.M., Resident #126 told Licensed Practical Nurse (LPN) H that Resident #47 was going to hit him/her. The resident was told to sit far away from Resident #47 and he/she would monitor everyone in the dining room. During an interview on 11/8/18 at 12:05 P.M., LPN H said Resident #47 had a history of [REDACTED]. During an interview on 11/9/18 at 12:04 P.M., the Director of Nursing (DON) said if there was an altercation, she would talk to the residents. The DON was not aware that a resident was hit. She would expect staff to report and investigate it the incident. There are systems in place per the facility’s policy if there was a resident to resident altercation. Staff are expected to talk to the residents, notify the physician, and ask for a psych consult to make sure it is an isolated incident. If there was an ongoing problem, they would notify the physician to check labs and medications. During an interview on 11/8/19 at 12:10 P.M., the care coordinator said Resident #126 was upset because Resident #47 called the resident a boy. Resident #47 believed Resident #126 was going to strike him/her, so Resident #47 hit the resident. Resident #47 had a history of [REDACTED]. 2. Review of Resident #12’s electronic face sheet, showed [DIAGNOSES REDACTED].>-Dementia with behavioral disturbances; -[MEDICAL CONDITION]; and -Major [MEDICAL CONDITION]. Review of the resident’s quarterly MDS, dated [DATE], showed: -BIMS score of 8 out of 15, showed moderate cognitive impairment; -Independent with all Activities of Daily Living (ADLs); -Physical behaviors directed toward others: Behavior not exhibited; -Verbal behaviors directed toward others: Behavior not exhibited; -Other behaviors not directed at others including pacing and rummaging: Behavior not exhibited. Review of the resident’s care plan, in use at the time of survey, showed: -Focus: The resident has the potential to be physically injured related to wandering into others rooms and removing their property. He/she takes other residents clothing and other items that he/she likes. He/she has had a recent incident in which another resident hit him/her for coming in his/her room. On 8/10/18 the resident was hit by another resident after entering the resident’s room. No injuries. On 8/24/18 the resident was hit by another resident no injuries; -Goal: The resident will not harm self or others through the review date; -Interventions: Staff will encourage and redirect the resident out of other resident’s rooms/personal space as needed; -Focus: The resident is an elopement risk/wanderer related to disease progression. He/she is at risk for injuries related to wandering into other resident’s rooms. He/she removes their items or gets into their personal things. On 7/9/2018 the resident made a statement |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) that he/she was hit by another resident while in his/her room. Un-witnessed. On 8/2/18 physical aggression was received from another resident. On 8/29/18 the resident exhibited aggressive behaviors toward his/her roommate; -Goal: The resident’s safety will be maintained through the review date; -Interventions: Distract him/her from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers to color in coloring book, talking with staff at times, etc. Monitor location every 15 min every shift. Document wandering behavior and attempted diversional interventions in medical record as needed. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Relocate to another room as needed for safety. Review of Resident #12’s progress notes, showed: -On 7/31/18 at 9:22 A.M., the resident was screaming very loudly and this writer went down the hall to find him/her. He/she was lying on the floor in another resident’s room screaming and moving around on the floor. When asked what happen he/she stated he/she pushed me down. I am hurting. He/she was able to move all extremities without complaints of pain and no difficulties, grimacing or indication of pain exhibited. Assisted off of the floor by two staff and assisted into a wheelchair; -On 8/1/18 at 10:36 P.M., Resident alert to self and is confused, redirected several time throughout shift from other peoples room; -On 8/2/18 at 3:12 A.M., Day 2 of 3 for incident follow up. Resident in bed, no acute distress noted. No signs behavior at this time; -The notes did not show after the initial incident what interventions were put in place to show how the nursing staff was monitoring Resident #12 in order to prevent him/her from coming back into contact with the other resident or notification to the Department of Health and Senior Services (DHSS) of the alleged resident to resident abuse. Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/31/18, showed: -The resident had an unwitnessed fall on 7/31/18; -Upon entering the room, the resident was found lying on his/her back on the ground, screaming he/she pushed me down and moving; -The resident stated that he/she was pushed down while in another resident’s room; -No injuries were observed at the time of the incident; -Pain, consciousness and mobility at the time of the incident: Blank; -Pain, consciousness, mobility and mental status [REDACTED].>-Other information: The resident wanders into other resident’s rooms; -Witnesses: No witnesses; -Agencies/people notified: No notifications found; -No summary of the investigation and no interventions taken at the time of the incident and post incident noted. No behavior incident report provided upon request; -The occurrence report did not identify what monitoring measures the facility staff put in place after the resident first pushed down Resident #12, in order to prevent a second occurrence; -The facility was unable to provide an abuse investigation for this incident. The 7/31/18 incident was reported and investigated as a fall only. Further review of Resident #12’s progress notes, showed: -On 8/2/18 at 3:55 P.M., reported this resident was struck in the chest by another resident. Residents separated. Physical assessment revealed no injury. Physician notified. No new orders; -On 8/3/2018 at 1:53 A.M., resident must be redirected out of other room when awake; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 12) -On 8/3/2018 at 3:39 P.M., no discoloration to chest noted; -On 8/5/2018 at 11:12 A.M., redirected several times throughout shift, resident going through other clothing, lying in their beds, standing in others room; -The notes did not show, after the second incident what interventions (other than separating the residents) were put in place, how the nursing staff was monitoring Resident #12 in order to prevent him/her from coming back into contact with the other resident or notification to the department regarding the alleged resident to resident abuse. Review of the resident’s Physical Altercation Occurrence Report, dated 8/2/18, showed: -The resident stated another resident hit him/her; -The residents were separated and a physical assessment was completed; -No injuries were observed at the time of the incident; -Pain, consciousness and mobility at the time of the incident: Blank; -Mental status at the time of the incident: Blank; -No injuries noted post incident; -Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing environmental factors: Blank; -Predisposing physiological factors: Blank; -Predisposing situation factors: Wanderer; -Other information: Blank; -Witnesses: No witnesses found; -Agencies/people notified: The physician and the Power of Attorney (POA) notified 8/2/18 at 4:30 P.M. No documentation the department notified; -No summary of the investigation, no cause, and no interventions taken at the time of the incident and post incident noted. Review of Resident #143’s electronic face sheet, showed [DIAGNOSES REDACTED].>-Dementia with behavioral disturbances; -Anxiety disorder; -Restlessness and agitation; and -Major [MEDICAL CONDITION]. Review of the resident’s Significant Change MDS, dated [DATE], showed: -BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment); -Physical behaviors directed toward others: Behavior not exhibited; -Verbal behaviors directed toward others: Behavior not exhibited; -Other behaviors not directed at others including pacing and rummaging: Behavior not exhibited. Review of the resident’s care plan, in use at the time of survey, showed: -Focus: The resident has potential to be physically aggressive towards others related to dementia and he/she has recently shown aggression towards one resident. On 7/9/18, accused of hitting another resident. On 8/2/18, physically aggressive towards another resident. On 8/6/18, bruises to the right/left forearm no open areas noted. 8/10/18, hit another resident after he/she entered the resident’s room. No injuries. 8/24/18, hit another resident: -Goal: The resident will not harm self or others through the review date; -Interventions: Administer medication as ordered. Monitor/document for side effects and effectiveness. Assess and anticipate his/her needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Provide physical and verbal cues to alleviate anxiety. Give positive feedback, assist verbalization of source of agitation, and assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Monitor every 15 minutes and Document observed behavior and attempted interventions in his |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 13) medical chart. Monitor other resident’s closely and encourage them from wandering into the resident’s room. Monitor/document/report PRN any signs and symptoms of him/her posing danger to self and others. The resident’s triggers for physical aggression are having personal items removed from his/her room by other residents. The resident’s behaviors is de-escalated by talking to him/her in a calm approach. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of the resident’s Social Services note, dated 8/24/18 at 12:15 P.M., showed: Called and left a voicemail message for the resident’s family member to contact us regarding a meeting needing to be scheduled to discuss resident’s behavior in being physically aggressive toward other residents. Due to the communication barrier, it is best if resident’s family is involved in order to translate the information. Review of Resident #143’s progress notes, showed the resident was in a physical altercation with Resident #12 on 8/10/18 and 8/24/18. During interviews on 11/9/18 at 12:22 P.M. and 11/13/18, the DON said it was Resident #143 that pushed down Resident #12. Resident #12’s Occurrence Reports for the incidents on 7/31/18 and 8/2/18 were the only documentation the facility had for both incidents. During an interview on 11/13/18 at 7:40 A.M., and 11/9/18 at 11:48 A.M., Certified Nursing Assistant (CNA) AA said: -Resident #12 wanders into other resident rooms, once staff hear him/her hollering out staff will go get him/her and take him/her to the day area or dining room; -Resident #143 can be aggressive if someone goes into his/her room. Staff will just remove the other resident from his/her room; -He/she heard it was Resident #143 that pushed down Resident #12; -If a resident accuses another resident of hitting/pushing/kicking/tripping them, staff separate them and take one to another area of the unit or facility. If one of the resident’s is in the wrong room staff will separate them and take the resident out of the other resident’s room. If staff notice anything out of the ordinary, staff will let the nurse know; -Any allegations of abuse need to be reported to the nurse immediately; -There are no residents that require 15 minute checks. During an interview on 11/13/18 at 7:48 A.M., LPN BB said: -Any allegations or suspicions of abuse should be documented and followed up on; -If a resident to resident altercation occurs, staff should immediately separate the residents, notify the DON and Administrator, call both resident’s physicians and family, and both residents should be assessed for injury; -He/she was not present when the incidents occurred between Residents #12 and #143; -Any incidents such as a resident pushing another resident down or hitting another resident is abuse and should be reported to DON and Administrator, an incident report completed, and documented in a nurse’s note; -If a resident said someone pushed him/her down, it would be both a fall and abuse. Documentation should reflect both; -It is not appropriate to just redirect a resident out of the room. There needs to be a thorough investigation completed; -He/she is not aware of any residents that require 15 minute checks for behaviors. 3. Review of Resident #39’s quarterly MDS, dated [DATE], showed: -BIMS score of 15 out of 15, shows the resident is cognitively intact; -[DIAGNOSES REDACTED]. -Has hallucinations. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 14) Review of the resident’s care plan, dated 10/24/18, showed: -Focus: Resident had been struck by peer on 10/21/18; -Interventions: Encourage effective coping skills that help the resident to avoid confrontations; -Separate the resident from source of aggression; -Focus: Resident is verbally aggressive towards staff due to ineffective coping skills; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; -Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document; -Give resident as many choices as possible about care and activities; -Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Review of the resident’s progress notes, showed: -On 10/21/18, resident to resident altercation. A resident hit Resident #39 in the face and knock off his/her glasses. The resident’s face on left side is slightly swollen. Residents sent to their rooms. Ice pack applied to the resident’s face but he/she took it off of his/her face. He/she stated he/she did not want it on his/her face. Physician notified of the altercation between the residents, no new orders given; -On 10/22/2018 at 2:39 P.M., resident continued on observation related to physical aggression. No complaints of pain or discomfort voiced. No swelling to face noted. No mood changes or negative behaviors noted. Resident voiced that yesterday he/she wanted to hit the other resident with his/her cup but didn’t because staff told him/her not to. Resident made aware that staff told him/her correctly and that it is inappropriate to retaliate. Resident voiced understanding. During an interview on 11/9/18 at 12:14 P.M., the DON said she was not aware of the altercation. She would expect staff to notify her. During an interview on 11/9/18 at 12:20 P.M., Care Coordinator I said he/she remembered the incident was brought up, but could not provide any additional information. 4. Review of Resident #89’s quarterly MDS, dated [DATE], showed: -A BIMS score of 14, showed the resident was cognitively intact; -Physical behaviors in the last one to three days; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 6/4/18, showed: -Focus: The resident has potential to be physically aggressive related/to anger, history of harm to others, and poor impulse control. On 10/19/18, struck peer when he/she touched him/her; -Interventions: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; -Assess and anticipate resident’s needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Review of the resident’s progress notes, dated 10/19/18, showed: -At 7:07 A.M., therapy reported to nurse that the resident hit another resident, unwitnessed by staff, when asked what happen, resident stated, he/she pushed me and he/she hit him/her back. Resident separated, physical assessment performed, no bruising, or discoloration noted. Denies pain; -At 2:59 P.M., continues on observation related to unwitnessed altercation. Resident noted upset with another peer this morning because he/she says that the other resident keeps asking for food and is always coming in the room. Redirection given to calm resident. No |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 15) other mood changes or physical aggression noted; -At 3:19 P.M., nurse practitioner aware of altercation. No new orders received. During an interview on 11/9/18 at 12:18 P.M., the DON said if there was an unwitnessed altercation, he/she would expect there to be an investigation. If resident said someone hit him/her, they would investigate to make sure it really happen. The DON was not aware of the altercation that involved the resident. She would have expected staff to report all altercations to her. 5. During an interview on 11/13/18 at 9:05 A.M., the DON said: -With resident to resident altercations, he/she would expect nursing staff to separate the residents, the nurse to complete a physical assessment of each resident, notify the residents physicians and family and follow any physician’s orders [REDACTED]. -He/she would also expect the nursing staff to monitor the residents to ensure their safety and well-being and the safety and well-being of other residents; -He/she expects the resident’s care plan interventions to be implemented to help manage the resident’s behaviors; -The facility wouldn’t investigate the incident as abuse due to confusion if the resident alleging the push is confused and so is the resident that pushed him/her down; -It would be appropriate to separate and monitor to make sure residents are kept away from each other; -The incident should be reported to the state agency (the department) as an FYI (for your information), if nothing else; -He/she doesn’t know why the incidents were not reported; -Policy is to notify the DON and Administrator immediately of any abuse allegations or suspicions; -He/she expects staff to follow the abuse policy; -All staff has been educated on the abuse policy; -He/she knows what abuse is and what to investigate; -He/she does report abuse to the state agency. | |
F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 16) -The administrator or designee will contact the department immediately but no later than 24 hours following an observed event, allegation or formulation of a reasonable suspicion that a crime occurred against a resident that did not result in serious bodily injury; -In cases of serious bodily injury the administrator will contact the department immediately but no later than 2 hours from the time of the allegation or formulation of the reasonable suspicion that a crime was committed against a resident; -Within 5 business (working) days from the event or report the facility will submit a report to the department that will contain a description of the initial allegation, description of the investigation and the facts obtained, a brief conclusion based on the information obtained during the investigation, a description of any corrective actions taken if necessary; -The policy failed to require that in response to any allegations of abuse the facility must: Ensure all alleged violations are reported immediately. No later than 2 hours if the allegation involve abuse or result in serious bodily injury. 1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 10/4/18, showed: -Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had moderately impaired cognition; -No behaviors; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 6/30/16, showed: -Focus: Resident gets upset easily and can become verbally & physically aggressive towards others. Resident can be hard to direct at times. Resident is impulsive and likes to hug. On 4/15/17 aggressive towards peers stating they cannot sit at table with him/her and he/she knocked over a chair. On 12/24/16 attempting to exit locked doors, staff attempted to redirect. Resident started kicking and rolling around on the floor. History of getting upset when he/she does not win bingo. Will become physical or verbally aggressive. On 4/24/17, kicking the wall, yelling, and refusing to move to one side of the hall. On 7/4/18, hit peer after argument. Had a resident to resident altercation. Resident’s roommate accused him/her of talking about his/her roommate and backed his/her wheel chair into the resident; -Focus: Resident is at risk for injury from other residents: On 7/24/18, hit by peer and was pulled by purse. No injury. On 9/13/18, hit by peer. No injury; -Focus: Resident has a history of being verbally/physically aggressive towards others. Has a history of resident to resident altercations. Resident can be very hard to redirect at times. Resident needs frequent redirection and supervision; -Focus: He/she pushed a resident in his/her back four times related to anger, history of harm to others, and poor impulse and control. Review of Resident #126’s progress notes, dated 10/30/18, showed Resident #126 was speaking with another resident, when Resident #47 brushed up against Resident #126 in passing. A small verbal commotion followed and Resident #126 yelled, I’m not a boy! Resident #126 moved toward Resident #47 in an aggressive manner, but never raised his/her hands in an attempt to strike. Resident #47 then struck Resident #126 on the right side of his/her face. Residents swiftly separated. Cold compress applied to right side of face. Slight swelling noted. Skin intact. No discoloration noted. Complaints of tenderness to touch. Praised his/her coping skills, of not retaliating physically. Encouraged to walk away from confrontations. Verbalized understanding. Review of Resident #47’s admission MDS, dated [DATE], showed; -A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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 – Some | (continued… from page 17) -No behaviors exhibited; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 8/15/18, showed the resident has the potential to be verbally aggressive (screaming, yelling at others) related to dementia and a [DIAGNOSES REDACTED]. Review of Resident #47’s progress notes, dated 10/31/18, showed staff reported while in the hallway, another resident was speaking with someone else, when this resident brushed up against the first resident in passing. A small verbal commotion followed and the other resident yelled, I’m not a boy! Staff reports that resident moved toward this resident in an aggressive manner, but never raised his/her hands in an attempt to strike. This resident then struck the other resident on the right side of his/her face. Residents swiftly separated. Encouraged him/her to walk away from confrontations. Verbalized understanding, but still claimed that the other resident is trying to, make you all go against me. Reiterated to him/her there was no need to strike him/her, especially since he/she him/herself had not been hit. Also spoke to him/her about utilizing better conflict resolution techniques during confrontations. Review of DHSS records, showed the facility did not report the 10/30/18 resident to resident abuse. During an interview on 11/9/18 at 12:04 P.M., the Director of Nursing (DON) said if there was an altercation, she would talk to the residents. The DON was not aware that a resident was hit. She would expect staff to report and investigate it the incident. There are systems in place per the facility’s policy if there was a resident to resident altercation. Staff are expected to talk to the residents, notify the physician, and ask for a psych consult to make sure it is an isolated incident. If there was an ongoing problem, they would notify the physician to check labs and medications. 2. Review of Resident #12’s quarterly MDS, dated [DATE], showed: -BIMS score of 8 out of 15, showed moderate cognitive impairment; -Independent with all Activities of Daily Living (ADLs); -Physical behaviors directed toward others: Behavior not exhibited; -Verbal behaviors directed toward others: Behavior not exhibited; -Other behaviors not directed at others including pacing and rummaging: Behavior not exhibited. Review of the resident’s care plan, in use at the time of survey, showed: -Focus: The resident has the potential to be physically injured related to wandering into others rooms and removing their property. He/she takes other residents clothing and other items that he/she likes. He/she has had a recent incident in which another resident hit him/her for coming in his/her room. On 8/10/18 the resident was hit by another resident after entering the resident’s room. No injuries. On 8/24/18 the resident was hit by another resident no injuries; -Focus: The resident is an elopement risk/wanderer related to disease progression. He/she is at risk for injuries related to wandering into other resident’s rooms. He/she removes their items or gets into their personal things. On 7/9/2018 the resident made a statement that he/she was hit by another resident while in his/her room. Un-witnessed. On 8/2/18 physical aggression was received from another resident. On 8/29/18 the resident exhibited aggressive behaviors toward his/her roommate. Review of Resident #12’s progress notes, showed: -On 7/31/18 at 9:22 A.M., the resident was screaming very loudly and this writer went down the hall to find him/her. He/she was lying on the floor in another resident’s room screaming and moving around on the floor. When asked what happen he/she stated he/she |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) pushed me down. I am hurting. He/she was able to move all extremities without complaints of pain and no difficulties, grimacing or indication of pain exhibited. Assisted off of the floor by two staff and assisted into a wheelchair; -The notes did not show notification to the department of the alleged resident to resident abuse. Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/31/18, showed: -The resident had an unwitnessed fall on 7/31/18; -Upon entering the room, the resident was found lying on his/her back on the ground, screaming he/she pushed me down and moving; -The resident stated that he/she was pushed down while in another resident’s room; -Agencies/people notified: No notifications found. Further review of Resident #12’s progress notes, showed: -On 8/2/18 at 3:55 P.M., reported this resident was struck in the chest by another resident. Residents separated. Physical assessment revealed no injury. Physician notified. No new orders; -The notes did not show notification to the department regarding the alleged resident to resident abuse. Review of the resident’s Physical Altercation Occurrence Report, dated 8/2/18, showed: -The resident stated another resident hit him/her; -The residents were separated and a physical assessment was completed; -Agencies/people notified: The physician and the Power of Attorney (POA) notified 8/2/18 at 4:30 P.M. No documentation the department notified. Review of Resident #143’s Significant Change MDS, dated [DATE], showed: -BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment); -Physical behaviors directed toward others: Behavior not exhibited; -Verbal behaviors directed toward others: Behavior not exhibited; -Other behaviors not directed at others including pacing and rummaging: Behavior not exhibited. Review of the resident’s care plan, in use at the time of survey, showed the resident has potential to be physically aggressive towards others related to dementia and he/she has recently shown aggression towards one resident. On 7/9/18, accused of hitting another resident. On 8/2/18, physically aggressive towards another resident. On 8/6/18, bruises to the right/left forearm no open areas noted. 8/10/18, hit another resident after he/she entered the resident’s room. No injuries. 8/24/18, hit another resident. Review of DHSS records, showed the facility did not report the 7/31/18 and 8/2/18 resident to resident abuse. During interviews on 11/9/18 at 12:22 P.M. and 11/13/18, the DON said it was Resident #143 that pushed down Resident #12. Resident #12’s Occurrence Reports for the incidents on 7/31/18 and 8/2/18 were the only documentation the facility had for both incidents. During an interview on 11/13/18 at 7:48 A.M., Licensed Practical Nurse (LPN) BB said: -Any allegations or suspicions of abuse should be documented and followed up on; -If a resident to resident altercation occurs, staff should immediately separate the residents, notify the DON and Administrator, call both resident’s physicians and family, and both residents should be assessed for injury; -Any incidents such as a resident pushing another resident down or hitting another resident is abuse and should be reported to DON and Administrator, an incident report completed, and documented in a nurse’s note. 3. Review of Resident #50’s quarterly MDS, dated [DATE], showed: -A BIMS score of 15, showed the resident was cognitively intact; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) -Had hallucinations and delusions; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 5/23/16, showed the resident has a history of making false accusations towards other residents and staff. Observation on 11/6/18 at 9:56 A.M., showed the resident reported to Certified Nursing Assistant (CNA) W that LPN X and LPN Y pulled his/her hair and poked him/her in the stomach on a different day. CNA W was observed writing the resident’s interview. During an interview 11/7/18 at 8:39 A.M., the resident said LPN Y pulled his/her hair and poked him/her in the stomach. The incident occurred two weeks ago. The resident confirmed he/she reported it to CNA W, but no one had come to talk to him/her about it. The resident said LPN Y was working today in the same unit the resident resides in on the 3 South unit. Review of DHSS records, showed the facility did not report the 11/6/18 allegation 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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) -Focus: Resident is verbally aggressive towards staff due to ineffective coping skills. Review of the resident’s progress notes, showed on 10/21/18, resident to resident altercation. A resident hit Resident #39 in the face and knock off his/her glasses. The resident’s face on left side is slightly swollen. Residents sent to their rooms. Ice pack applied to the resident’s face but he/she took it off of his/her face. He/she stated he/she did not want it on his/her face. Physician notified of the altercation between the residents, no new orders given. Review of DHSS records, showed the facility did not report the 10/21/18 resident to resident abuse. During an interview on 11/9/18 at 12:14 P.M., the DON said she was not aware of the altercation. She would expect staff to notify her. 6. During an interview on 11/13/18 at 9:05 A.M., the DON said: -With resident to resident altercations, he/she would expect nursing staff to separate the residents, the nurse to complete a physical assessment of each resident, notify the residents physicians and family and follow any physician’s orders [REDACTED]. -The facility would not investigate the incident as abuse due to confusion if the resident alleging the push is confused and so is the resident that pushed him/her down; -The incident should be reported to the state agency (the department) as an FYI (for your information), if nothing else; -He/she doesn’t know why the incidents were not reported; -Policy is to notify the DON and Administrator immediately of any abuse allegations or suspicions; -He/she expects staff to follow the abuse policy; -All staff has been educated on the abuse policy; -He/she knows what abuse is and what to investigate; -He/she does report abuse to the state agency. | |
F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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 – Some | (continued… from page 21) investigation of all allegations of abuse, neglect, theft or crimes occurring against a resident of the facility: -Investigations will be conducted in a systematic and timely manner. Investigations should begin as soon as practicable but no later than 24 hours following the report of an abuse, neglect, theft or crime committed against a resident; -Investigations will be documented, all documentation will be retained in a separate file and retained in the administrator’s office. After one year, files may be stored in a remote location, however, they should be retained for a minimum of 3 years following the discharge of the resident, who was the subject of the investigation. 1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 10/4/18, showed: -Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had moderately impaired cognition; -No behaviors; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 6/30/16, showed: -Focus: Resident gets upset easily and can become verbally & physically aggressive towards others. Resident can be hard to direct at times. Resident is impulsive and likes to hug. On 4/15/17 aggressive towards peers stating they cannot sit at table with him/her and he/she knocked over a chair. On 12/24/16 attempting to exit locked doors, staff attempted to redirect. Resident started kicking and rolling around on the floor. History of getting upset when he/she does not win bingo. Will become physical or verbally aggressive. On 4/24/17, kicking the wall, yelling, and refusing to move to one side of the hall. On 7/4/18, hit peer after argument. Had a resident to resident altercation. Resident’s roommate accused him/her of talking about his/her roommate and backed his/her wheel chair into the resident; -Focus: Resident is at risk for injury from other residents: On 7/24/18, hit by peer and was pulled by purse. No injury. On 9/13/18, hit by peer. No injury; -Focus: Resident has a history of being verbally/physically aggressive towards others. Has a history of resident to resident altercations. Resident can be very hard to redirect at times. Resident needs frequent redirection and supervision; -Focus: He/she pushed a resident in his/her back four times related to anger, history of harm to others, and poor impulse and control. Review of the Resident #126’s progress notes, dated 10/30/18, showed Resident #126 was speaking with another resident, when Resident #47 brushed up against Resident #126 in passing. A small verbal commotion followed and Resident #126 yelled, I’m not a boy! Resident #126 moved toward Resident #47 in an aggressive manner, but never raised his/her hands in an attempt to strike. Resident #47 then struck Resident #126 on the right side of his/her face. Residents swiftly separated. Cold compress applied to right side of face. Slight swelling noted. Skin intact. No discoloration noted. Complaints of tenderness to touch. Praised his/her coping skills, of not retaliating physically. Encouraged to walk away from confrontations. Verbalized understanding. Review of Resident #47’s admission MDS, dated [DATE], showed; -A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition; -No behaviors exhibited; -[DIAGNOSES REDACTED]. Review of theh resident’s care plan, dated 8/15/18, showed the resident has the potential to be verbally aggressive (screaming, yelling at others) related to dementia and a [DIAGNOSES REDACTED]. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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 – Some | (continued… from page 22) Review of Resident #47’s progress notes, dated 10/31/18, showed staff reported while in the hallway, another resident was speaking with someone else, when this resident brushed up against the first resident in passing. A small verbal commotion followed and the other resident yelled, I’m not a boy! Staff reports that resident moved toward this resident in an aggressive manner, but never raised his/her hands in an attempt to strike. This resident then struck the other resident on the right side of his/her face. Residents swiftly separated. Encouraged him/her to walk away from confrontations. Verbalized understanding, but still claimed that the other resident is trying to, make you all go against me. Reiterated to him/her there was no need to strike him/her, especially since he/she him/herself had not been hit. Also spoke to him/her about utilizing better conflict resolution techniques during confrontations. Review of DHSS records, showed no investigation provided for the 10/30/18 resident to resident abuse. During an interview on 11/9/18 at 12:04 P.M., the Director of Nursing (DON) said if there was an altercation, she would talk to the residents. The DON was not aware that a resident was hit. She would expect staff to report and investigate it the incident. There are systems in place per the facility’s policy if there was a resident to resident altercation. 2. Review of Resident #12’s quarterly MDS, dated [DATE], showed: -BIMS score of 8 out of 15, showed moderate cognitive impairment; -Independent with all Activities of Daily Living (ADLs); -Physical behaviors directed toward others: Behavior not exhibited; -Verbal behaviors directed toward others: Behavior not exhibited; -Other behaviors not directed at others including pacing and rummaging: Behavior not exhibited. Review of the resident’s care plan, in use at the time of survey, showed: -Focus: The resident has the potential to be physically injured related to wandering into others rooms and removing their property. He/she takes other residents clothing and other items that he/she likes. He/she has had a recent incident in which another resident hit him/her for coming in his/her room. On 8/10/18 the resident was hit by another resident after entering the resident’s room. No injuries. On 8/24/18 the resident was hit by another resident no injuries; -Focus: The resident is an elopement risk/wanderer related to disease progression. He/she is at risk for injuries related to wandering into other resident’s rooms. He/she removes their items or gets into their personal things. On 7/9/2018 the resident made a statement that he/she was hit by another resident while in his/her room. Un-witnessed. On 8/2/18 physical aggression was received from another resident. On 8/29/18 the resident exhibited aggressive behaviors toward his/her roommate. Review of Resident #12’s progress notes, showed: -On 7/31/18 at 9:22 A.M., the resident was screaming very loudly and this writer went down the hall to find him/her. He/she was lying on the floor in another resident’s room screaming and moving around on the floor. When asked what happen he/she stated he/she pushed me down. I am hurting. He/she was able to move all extremities without complaints of pain and no difficulties, grimacing or indication of pain exhibited. Assisted off of the floor by two staff and assisted into a wheelchair; -The notes did not show notification to the department of the alleged resident to resident abuse. Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/31/18, showed: -The resident had an unwitnessed fall on 7/31/18; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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 – Some | (continued… from page 23) -Upon entering the room, the resident was found lying on his/her back on the ground, screaming he/she pushed me down and moving; -The resident stated that he/she was pushed down while in another resident’s room; -No injuries were observed at the time of the incident; -Pain, consciousness and mobility at the time of the incident: Blank; -Pain, consciousness, mobility and mental status [REDACTED].>-Other information: The resident wanders into other resident’s rooms; -Witnesses: No witnesses; -Agencies/people notified: No notifications found; -No summary of the investigation and no interventions taken at the time of the incident and post incident noted. No behavior incident report provided upon request; -The occurrence report did not identify what monitoring measures the facility staff put in place after the resident first pushed down Resident #12, in order to prevent a second occurrence; -The facility was unable to provide an abuse investigation for this incident. The 7/31/18 incident was reported and investigated as a fall only. Further review of Resident #12’s progress notes, showed: -On 8/2/18 at 3:55 P.M., reported this resident was struck in the chest by another resident. Residents separated. Physical assessment revealed no injury. Physician notified. No new orders; -The notes did not show notification to the department regarding the alleged resident to resident abuse. Review of the resident’s Physical Altercation Occurrence Report, dated 8/2/18, showed: -The resident stated another resident hit him/her; -The residents were separated and a physical assessment was completed; -No injuries were observed at the time of the incident; -Pain, consciousness and mobility at the time of the incident: Blank; -Mental status at the time of the incident: Blank; -No injuries noted post incident; -Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing environmental factors: Blank; -Predisposing physiological factors: Blank; -Predisposing situation factors: Wanderer; -Other information: Blank; -Witnesses: No witnesses found; -Agencies/people notified: The physician and the Power of Attorney (POA) notified 8/2/18 at 4:30 P.M. No documentation the department notified; -No summary of the investigation, no cause, and no interventions taken at the time of the incident and post incident noted. Review of Resident #143’s Significant Change MDS, dated [DATE], showed: -BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment); -Physical behaviors directed toward others: Behavior not exhibited; -Verbal behaviors directed toward others: Behavior not exhibited; -Other behaviors not directed at others including pacing and rummaging: Behavior not exhibited. Review of the resident’s care plan, in use at the time of survey, showed the resident has potential to be physically aggressive towards others related to dementia and he/she has recently shown aggression towards one resident. On 7/9/18, accused of hitting another resident. On 8/2/18, physically aggressive towards another resident. On 8/6/18, bruises to |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 24) the right/left forearm no open areas noted. 8/10/18, hit another resident after he/she entered the resident’s room. No injuries. 8/24/18, hit another resident. Review of DHSS records, showed no investigation provided for the 7/31/18 and 8/2/18 resident to resident abuse. During interviews on 11/9/18 at 12:22 P.M. and 11/13/18, the DON said it was Resident #143 that pushed down Resident #12. Resident #12’s Occurrence Reports for the incidents on 7/31/18 and 8/2/18 were the only documentation the facility had for both incidents. During an interview on 11/13/18 at 7:48 A.M., Licensed Practical Nurse (LPN) BB said: -Any allegations or suspicions of abuse should be documented and followed up on; -If a resident to resident altercation occurs, staff should immediately separate the residents, notify the DON and Administrator, call both resident’s physicians and family, and both residents should be assessed for injury; -Any incidents such as a resident pushing another resident down or hitting another resident is abuse and should be reported to DON and Administrator, an incident report completed, and documented in a nurse’s note. 3. Review of Resident #50’s quarterly MDS, dated [DATE], showed: -A BIMS score of 15, showed the resident was cognitively intact; -Had hallucinations and delusions; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 5/23/16, showed the resident has a history of making false accusations towards other residents and staff. Observation on 11/6/18 at 9:56 A.M., showed the resident reported to Certified Nursing Assistant (CNA) W that LPN X and LPN Y pulled his/her hair and poked him/her in the stomach on a different day. CNA W was observed writing the resident’s interview. During an interview 11/7/18 at 8:39 A.M., the resident said LPN Y pulled his/her hair and poked him/her in the stomach. The incident occurred two weeks ago. The resident confirmed he/she reported it to CNA W, but no one had come to talk to him/her about it. The resident said LPN Y was working today in the same unit the resident resides in on the 3 South unit. Observation on 11/7/18 at 8:40 A.M., 12:41 P.M., and 1:17 P.M., showed LPN Y at the |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 25) pain. Review of DHSS records, showed no investigation provided for the 10/19/18 resident to resident abuse. During an interview on 11/9/18 at 12:18 P.M., the DON said if there was an unwitnessed altercation, he/she would expect there to be an investigation. If resident said someone hit him/her, they would investigate to make sure it really happen. The DON was not aware of the altercation that involved the resident. She would have expected staff to report all altercations to her. 5. Review of Resident #39’s quarterly MDS, dated [DATE], showed: -BIMS score of 15 out of 15, shows the resident is cognitively intact; -[DIAGNOSES REDACTED]. -Has hallucinations. Review of the resident’s care plan, dated 10/24/18, showed: -Focus: Resident had been struck by peer on 10/21/18; -Focus: Resident is verbally aggressive towards staff due to ineffective coping skills. Review of the resident’s progress notes, showed on 10/21/18, resident to resident altercation. Resident hit resident in the face and knock off his/her glasses. The resident’s face on left side is slightly swollen. Residents sent to their rooms. Ice pack applied to the resident’s face but he/she took it off of his/her face. He/she stated he/she did not want it on his/her face. Physician notified of the altercation between the residents, no new orders given. Review of DHSS records, showed no investigation provided for the 10/21/18 resident to resident abuse. During an interview on 11/9/18 at 12:14 P.M., the DON said she was not aware of the altercation. She would expect staff to notify her. 6. During an interview on 11/13/18 at 9:05 A.M., the DON said: -With resident to resident altercations, he/she would expect nursing staff to separate the residents, the nurse to complete a physical assessment of each resident, notify the residents physicians and family and follow any physician’s orders [REDACTED]. -The facility would not investigate the incident as abuse due to confusion if the resident alleging the push is confused and so is the resident that pushed him/her down; -The incident should be reported to the state agency (the department) as an FYI (for your information), if nothing else; -Policy is to notify the DON and Administrator immediately of any abuse allegations or suspicions; -He/she expects staff to follow the abuse policy; -All staff has been educated on the abuse policy; -He/she knows what abuse is and what to investigate; -He/she does report abuse to the state agency. | |
F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 26) discharged to a hospital for various medical reasons, all were expected to return, and none of those six had been issued a written transfer notice upon leaving the facility (Residents #124, #112, #57, #84, #143 and #150). The census was 148. 1. Review of Resident #124’s medical record showed: -discharged to the hospital on [DATE]; -Returned to facility from the hospital on [DATE]; -No documentation the resident was provided a notice upon discharge. 2. Review of Resident #112’s medical record showed: -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident was provided a notice upon discharge. During an interview on 11/6/18 at 10:48 A.M., the resident said he/she was in the hospital recently and does not remember receiving any discharge notice from the facility. 3. Review of Resident #57’s medical record showed: -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation of dischage notices were provided to the resident by the facility for the 5/31/18 and 8/12/18 discharges. During an interview on 11/6/18 at 12:30 P.M., the resident said he/she had been admitted to the hospital several times recently and does not remember receiving any discharge notice from the facility. 4. Review of Resident #84’s medical record showed: -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation of discharge notices were provided to the resident by the facility for the 9/1/18 and 10/17/18 discharges. During an interview on 11/7/18 at 7:00 A.M., the resident said he.she had been in the hospital several times recently for back surgery and does not remember receiving any discharge notices from the facility. 5. Review of Resident #143’s medical record showed: -The resident was discharged to the hospital on [DATE]. -Resident returned to the facility from the hospital on [DATE]. -No documentation of a discharge notice was provided to the resident by the facility for the 10/31/18 discharge. 6. Review of Resident #150’s medical record showed: -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to hospital on [DATE]; -Returned to facility from the hospital on [DATE]; -No documentation of discharge notices were provided to the resident by the facility for the 6/12/18 and 10/1/18 discharges. During an interview on 11/7/18 at 6:53 A.M., the resident said he/she had been in the hospital recently and does not rember receiving any discharge notices from the facility. 7. During an interview on 11/13/18 at 7:06 A.M., the Administrator said the facility had not been issuing any discharge notices whenever a resident was discharged to the hospital |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 27) with return anticipated. At 9:05 A.M., she said she was unaware the facility needed to issue a discharge notice upon discharge to hospital with return anticipated and they do not have any policy. | |
F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 28) During an interview on 11/7/18 at 7:00 A.M., the resident said he/she had been in the hospital several times recently for back surgery and does not remember receiving any bed hold policy from the facility. 5. Review of Resident #143’s medical record showed: -The resident was discharged to the hospital on [DATE]. -Returned to the facility from the hospital on [DATE]. Review of the resident’s medical record, showed no documentation the resident or the resident’s representative received information in writing of the facility’s bed hold policy at the time of transfer on 10/31/18. 6. Review of Resident #150’s medical record showed: -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to hospital on [DATE]; -Returned to facility from the hospital on [DATE]. Review of the resident’s medical record, showed no documentation the resident or the resident’s representative received information in writing of the facility’s bed hold policy at the time of transfer on 6/12/18 or 10/1/18. During an interview on 11/7/18 at 6:53 A.M., the resident said he/she had been in the hospital recently and does not remember receiving any bed hold policy from the facility. 7. During an interview on 11/13/18 at 7:06 A.M., the Administrator said the facility had not been issuing any written bed hold policy whenever a resident was discharged to the hospital with return anticipated. At 9:05 A.M., she said she was unaware the facility needed to issue a written bed hold policy upon discharge to hospital with return anticipated and they do not have any policy. | |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 29) -[DIAGNOSES REDACTED]. Review of Resident #126’s care plan, dated 6/30/16, showed: -Focus: Resident gets upset easily and can become verbally & physically aggressive towards others. Resident can be hard to direct at times. Resident is impulsive and likes to hug: -On 4/15/17 aggressive towards peers stating they cannot sit at table with him/her and he/she knocked over a chair; -On 12/24/16 attempting to exit locked doors, staff attempted to redirect. Resident started kicking and rolling around on the floor. History of getting upset when he/she does not win bingo. Will become physical or verbally aggressive; -On 4/24/17, kicking the wall, yelling, and refusing to move to one side of the hall; -On 7/4/18, hit peer after argument. Had a resident to resident altercation; -Resident’s roommate accused him/her of talking about his/her roommate and backed his/her wheel chair into the resident; -Interventions: Create a positive environment for the resident to gain socially acceptable patterns of behaviors. Keep resident away from source of agitation. Every 15 min face checks; -Focus: Resident is at risk for injury from other residents: -On 7/24/18, hit by peer and was pulled by purse. No injury; -On 9/13/18, hit by peer. No injury; -Interventions: Assess the resident for injury after any physical incident. Alert physician and responsible party. Remove the resident from the source of aggression; -Focus: Resident has a history of being verbally/physically aggressive towards others. Has a history of resident to resident altercations. Resident can be very hard to redirect at times. Resident needs frequent redirection and supervision; -Focus: He/she pushed a resident in his/her back four times related to anger, history of harm to others, and poor impulse and control; Interventions: The resident’s triggers for physical aggression are (not being allowed to go on outings). The resident’s behaviors is de-escalated by (providing distractions and other activities). During an interview on 11/8/18 at 11:30 A.M., Resident #126 said he/she had an altercation with another resident. 2. Review of Resident #47’s admission MDS, dated [DATE], showed; -A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition; -Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing): Behavior not exhibited; -Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others): Behavior not exhibited; -Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, rummaging, disrobing in public, screaming, disruptive sounds): Behavior not exhibited; -Rejection of care: Behavior not exhibited; -Wandering: Behavior not exhibited;-[DIAGNOSES REDACTED]. Review of Resident #47’s care plan, dated 8/15/18, showed: -Focus: Resident has the potential to be verbally aggressive (screaming, yelling at others) related to dementia and a [DIAGNOSES REDACTED]. -Interventions: Administer antipsychotic medications as ordered. Monitor/document for side effects and effectiveness. Give the resident as many choices as possible about care and activities. Monitor behaviors every 15 minutes. Document observed behavior and attempted |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 30) interventions; -When resident becomes agitated: Intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later. During an interview on 11/8/18 at 12:05 P.M., Licensed Practical Nurse (LPN) H said Resident #47 had a history of [REDACTED]. 3. Review of Resident #12’s quarterly MDS, dated [DATE], showed: -BIMS score of 8 out of 15, showed moderate cognitive impairment; -Independent with all Activities of Daily Living (ADLs); -Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing): Behavior not exhibited; -Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others): Behavior not exhibited; -Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, rummaging, disrobing in public, screaming, disruptive sounds): Behavior not exhibited; -Rejection of care: Behavior not exhibited; -Wandering: Behavior occurred 1 to 3 days. Review of the resident’s care plan, in use at the time of survey, showed: -Focus: The resident has the potential to be physically injured related to wandering into others rooms and removing their property. He/she takes other residents clothing and other items that he/she likes. He/she has had a recent incident in which another resident hit him/her for coming in his/her room. On 8/10/18 the resident was hit by another resident after entering the resident’s room. No injuries. On 8/24/18 the resident was hit by another resident no injuries; -Goal: The resident will not harm self or others through the review date; -Interventions: Staff will encourage and redirect the resident out of other resident’s rooms/personal space as needed; -Focus: The resident is an elopement risk/wanderer related to disease progression. He/she is at risk for injuries related to wandering into other resident’s rooms. He/she removes their items or gets into their personal things. On 7/9/2018 the resident made a statement that he/she was hit by another resident while in his/her room. Un-witnessed. On 8/2/18 physical aggression was received from another resident. On 8/29/18 the resident exhibited aggressive behaviors toward his/her roommate; -Goal: The resident’s safety will be maintained through the review date; -Interventions: Distract him/her from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers to color in coloring book, talking with staff at times, etc. Monitor location every 15 min every shift. Document wandering behavior and attempted diversional interventions in medical record as needed. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Relocate to another room as needed for safety. During an interview on 11/13/18 at 7:40 A.M., Certified Nursing Assistant (CNA) AA said Resident #12 wanders into other resident rooms, once staff hear him/her hollering out staff will go get him/her and take him/her to the day area or dining room. 4. Review of Resident #143’s Significant Change MDS, dated [DATE], showed: -BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment); -Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing): Behavior not exhibited; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 31) -Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others): Behavior not exhibited; -Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, rummaging, disrobing in public, screaming, disruptive sounds): Behavior not exhibited; -Rejection of care: Behavior not exhibited; -Wandering: Behavior not exhibited. Review of the resident’s care plan, in use at the time of survey, showed: -Focus: The resident has potential to be physically aggressive towards others related to dementia and he/she has recently shown aggression towards one resident. On 7/9/18, accused of hitting another resident. On 8/2/18, physically aggressive towards another resident. On 8/6/18, bruises to the right/left forearm no open areas noted. 8/10/18, hit another resident after he/she entered the resident’s room. No injuries. 8/24/18, hit another resident: -Goal: The resident will not harm self or others through the review date; -Interventions: Administer medication as ordered. Monitor/document for side effects and effectiveness. Assess and anticipate his/her needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Provide physical and verbal cues to alleviate anxiety. Give positive feedback, assist verbalization of source of agitation, and assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Monitor every 15 minutes and Document observed behavior and attempted interventions in his medical chart. Monitor other resident’s closely and encourage them from wandering into the resident’s room. Monitor/document/report PRN any signs and symptoms of him/her posing danger to self and others. The resident’s triggers for physical aggression are having personal items removed from his/her room by other residents. The resident’s behaviors is de-escalated by talking to him/her in a calm approach. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. During an interview on 11/13/18 at 7:40 A.M., CNA AA said Resident #143 can be aggressive if someone goes into his/her room. Staff will just remove the other resident from his/her room. 5. During an interview on 11/13/18 at 8:01 A.M., MDS Coordinator K said MDS assessments should be accurate based on the resident’s condition at the time of the assessment. | |
F 0644 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0644 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 32) nursing facility to ensure the client does not trigger a Level II screening. A Level II screening refers to clients with the [DIAGNOSES REDACTED]. -A client that requires a Level II screening cannot be admitted to the nursing facility prior to the determination of the Level II; -The triggers for the Level II screening are: -The client has had inpatient psychiatric treatment in the past two years; -The client was suicidal or homicidal (includes dementia clients); -The client has very aggressive behavior (includes dementia clients); -The client has a [DIAGNOSES REDACTED]. 1. Review of Resident #1’s medical record showed: -admitted to the facility on [DATE] and readmitted on [DATE]; -[DIAGNOSES REDACTED]. -No DA 124 level I screen found. 2. Review of Resident #78’s medical record showed: -admitted to facility on 4/10/14; -Resides in a Medicaid Certified bed; -[DIAGNOSES REDACTED]. -No DA 124 level I screen found. During an interview on 11/09/18 at 8:40 A.M., the facility staff development coordinator said the facility does not have a PASARR for this resident and he/she will be working on re-submitting it today. The goal is to have it done by the end of the day. 3. Review of Resident #124’s medical record showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Resides in a Medicaid Certified bed; -No DA 124 level I screen found. 4. Review of Resident #150’s medical record showed; -admitted to the facility on [DATE] and readmitted on [DATE]; -Resides in a Medicaid Certified bed; -[DIAGNOSES REDACTED]. -No DA 124 level I screen found. 5. During an interview on 11/8/18 at 8:47 A.M., the Staff Develpoment Coordinator said she is responsible for the DA124 level I and Level II screen, could not find any DA124 level I screen for Resident’s #1, #78, #124, or #150. | |
F 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | PASARR screening for Mental disorders or Intellectual Disabilities **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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 33) -The DA-124 application will assist in identifying a client that requires a Level II screening. The DA-124 C form must be completed prior to admitting the client to the a nursing facility to ensure the client does not trigger a Level II screening. A Level II screening refers to clients with the [DIAGNOSES REDACTED]. -A client that requires a Level II screening cannot be admitted to the nursing facility prior to the determination of the Level II; -The triggers for the Level II screening are: -The client has had inpatient psychiatric treatment in the past two years; -The client was suicidal or homicidal (includes dementia clients); -The client has very aggressive behavior (includes dementia clients); -The client has a [DIAGNOSES REDACTED]. 1. Review of Resident #1’s medical record, showed: -admitted to the facility on [DATE] and readmitted on [DATE]; -[DIAGNOSES REDACTED]. -No DA 124 Level I or Level II screen found. 2. Review of Resident #78’s medical record showed: -admitted to facility on 4/10/14; -Resided in a Medicaid Certified bed; -[DIAGNOSES REDACTED]. -No DA 124 Level I screen found. During an interview on 11/09/18 at 8:40 A.M., the facility staff development coordinator said the facility does not have a PASARR for this resident and he/she will be working on re-submitting it today. The goal is to have it done by the end of the day. 3. Review of Resident #124’s medical record showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Resided in a Medicaid Certified bed; -No PASSAR Level II screen found. 4. Review of Resident #150’s medical record showed; -admitted to the facility on [DATE] and readmitted on [DATE]; -Resided in a Medicaid certified bed; -[DIAGNOSES REDACTED]. -No PASSAR Level II screen found. 5. Review of Resident #32’s medical record showed: -admitted to facility on 3/30/04; -Resided in a Medicaid Certified bed; -[DIAGNOSES REDACTED]. -No PASSAR Level II screen found. 6. Review of Resident #109’s medical record, showed: -admitted to the facility on [DATE] and readmitted on [DATE]; -[DIAGNOSES REDACTED]. -No DA 124 Level I screen found. 7. During an interview on 11/8/18 at 8:47 A.M., the Staff Development Coordinator said she is responsible for the DA-124 Level I and Level II screens, could not find any Level II screen for Resident’s #1, #78, #124, #150, #32, or #109. At 10:28 A.M., she said she had called the agencies where the screenings go to and neither of them had any Level II screen on the residents. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | ||
F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 35) transfers; -The care plan failed to correctly identify the resident’s transfer status. Review of the resident’s electronic medical record activity of daily living (ADL) transfer documentation, dated 10/31/2018 to 11/12/18, showed: -No order for transfer status; -Staff documented extensive assistance (resident involved in activity, staff provide weight bearing assistance) for transfers. Observation on 11/07/18 at 10:16 A.M., showed Certified Nursing Assistant (CNA) T and CNA U transferred the resident from the bed to the shower chair using a mechanical lift. Observation on 11/07/18 at 3:33 P.M., showed CNA J and CNA V transferred the resident from the wheelchair to the bed using a mechanical lift. During an interview on 11/07/18 at 7:23 A.M., CNA D said the resident is the only resident transferred with a mechanical lift on the floor. During an interview on 11/09/18 at 9:00 A.M., the Director of Nursing (DON) said if a resident requires a mechanical lift it should be in the care plan. The care coordinator updates all care plans and informs staff of changes. The expectation is that care plans are accurate. Transfer orders are noted for resident in the ADLs found in the electronic medical record for the resident. Resident’s transfer status is determined based on their needs and abilities. The DON expects nursing staff to notice change in ADLs and report it to the nurse. 2. Review of Resident #114’s quarterly MDS, dated [DATE], showed: -Extensive assistance of two-person physical assist required for transfers; -Mobility devices: Wheelchair. Review of the resident’s care plan, in use at the time of the survey, showed: -Problem: ADL self-care performance deficit related to [MEDICAL CONDITION] and limited mobility. He/she requires assist with transfers and mobility; -Goal: Be clean, odor free and well groomed; -The care plan failed to identify the resident’s transfer status. During an interview on 11/7/18 at 7:20 A.M., CNA A said he/she just knows how to care for residents. He/she knows how to care for the resident because he/she had worked at the facility for four years. Observation on 11/7/18 at 7:24 A.M., showed CNA A provided care to the resident and transferred the resident to his/her wheelchair. CNA A transferred the resident to his/her wheelchair with the use of a gait belt. The resident not able to bear weight or assist in the transfer. 3. Review of Resident #139’s annual MDS, dated [DATE], showed: -Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 0 out of a possible score of 15; -A score of 0-7, showed the resident had severe cognitive impairment; -Total dependence on two-person physical assist for transfers; -Functional limitation in range of motion; -Upper extremity: Impairment on one side; -Lower extremity: Impairment on both sides; -Mobility devices: Wheelchair; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Physical therapy end date, 6/7/18; -Restorative nursing program: Not performed. Review of the resident’s care plan, in use at the time of the survey, showed: |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 36) -Problem: Resident is nonverbal and is provided socialization by staff and family to provide socialization and conversations. He/she calms down when talked to by others. He/she screams and yells a lot when he/she does not have attention provided or is attempting to communicate with others; -Goal: Psychosocial needs will be met and anticipated by staff and family; -Approach: Talk with the resident while providing care; -Problem: Resident required total care with activities of daily living (ADLs) related to stroke; -Goal: Be clean, odor free and well groomed; -Approach: Total care in all aspects of ADL care; -Resident has contractures (chronic loss of joint motion due to structural changes in non-bony tissue. These non-bony tissues include muscle, ligaments and tendons) of the right arm and hand; -Range of motion (ROM) to be provided with daily care as tolerated; -Totally dependent on one staff for transferring; -Problem: Risk for falls: Limitations with lower extremities related to contractures: -Goal: Remain free from injuries related to falls; -Approach: Staff will assist the resident with transfers to bed within an hour of meals; -The care plan failed to identify the resident’s transfer status; -Activities not care planned. Review of the medical record, showed no documentation staff assisted the resident with ROM with daily care as tolerated or how the resident tolerated ROM. Observations on 11/6/18 at 9:44 A.M. and 10:59 A.M., 11/9/18 at 6:31 AM., showed the resident sat in his/her room in his/her wheelchair. All extremities were contracted and the resident yelled out. Observation on 11/6/18 at 11:05 A.M., showed a music activity taking place on the floor for the residents. No staff assisted the resident to the activity and the resident remained in his/her room. Observation on 11/7/18 at 3:47 P.M., showed CNA E and CNA J transferred the resident from bed to the wheelchair. Without the use of a gait belt, CNA E stood on one side of the resident and CNA J stood on the other side. Staff placed one arm under the resident’s arm and grabbed onto the resident’s waste band with the other hand and picked the resident up out of the bed. The resident’s extremities contracted and pulled into the resident’s core. During the transfer, the resident’s legs remained contracted up and did not touch the floor. Staff placed the resident in the wheelchair. Observation on 11/13/18 at 6:57 A.M., showed the resident sat in a wheelchair in the hall. Laundry staff passed out clean laundry to resident rooms. The resident yelled out as a CNA walked by. The CNA failed to stop to acknowledge the resident. Laundry staff stopped to talk to the resident and the resident stopped yelling and appeared to watch the laundry staff with a relaxed look on his/her face. As the laundry staff continued down the hall to pass out clean laundry, the resident again started to yell. During an interview on 11/13/18 at 8:01 A.M., MDS Coordinator K said he/she was not the MDS coordinator who completed the annual MDS for the resident. The MDS coordinator before him/her completed the MDS and he/she is not sure why they chose not to care plan activities. The resident would benefit from care planned activities. During an interview on 11/13/18 at 8:10 A.M., the activity director said the resident likes television and the radio. He/she does not come down for group activities much because he/she appears to become anxious in groups. It is hard to say if the resident would benefit from one on one activities. The resident does enjoy when staff propel |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 37) him/her up and down the hall and sitting at the nurse’s station. 4. Review of Resident #150’s significant change MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -BIMS score of 12 out of a possible 15 ( no cognitive impairment); -Required minimal assistance from staff for ambulation and eating. Required maximum assistance from staff for transfers, dressing, hygiene and bathing. Review of the residents electronic POS, in use during the survey, showed an order dated 10/19/18, for hospice to evaluate, admit and treat the resident. Review of the resident’s medical record, showed a signed agreement between the resident and the hospice company, dated 10/11/18. Review of the residents care plan, in use during the survey, showed staff did not care plan the resident for hospice. During an interview on 11/8/18 at 7:31 A.M., the resident said he/she does receive hospice benefits and someone from the hospice company does come to see him/her several times a week. During an interview on 11/13/18 at 9:05 A.M., the Director of Nurses (DON) said she would expect staff to care plan the resident for hospice. 5. Review of Resident #39’s quarterly MDS, dated [DATE], showed: -A BIMS score of 15 out of 15, shows the resident is cognitively intact; -[DIAGNOSES REDACTED]. -Antipsychotics, antianxiety, and antidepressants administered in the last seven days; -No documentation of a [DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 8/9/17, showed: -Focus: Resident uses anti-anxiety medications related to anxiety disorder and antidepressants due to depression and antipsychotic medication use; -Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift; -Monitor/document/report PRN any adverse reactions to anti-anxiety: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, and hallucination; -Monitor/record occurrence of for target behavior symptoms (specify pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol; -Further review of the resident’s care plan, showed no documentation of a [DIAGNOSES REDACTED]. Review the resident’s medical record, showed: -[DIAGNOSES REDACTED]. -POS, dated 11/1/18 through 11/30/18, showed an order dated 11/8/17, for [MEDICATION NAME] tablet 10 mg, give one tablet by mouth at bedtime for Alzheimer’s; -MAR, dated 11/1/18 through 11/9/18, showed an order dated, 11/8/17, for [MEDICATION NAME] 10 mg was administered as ordered. During an interview on 11/13/18 at 9:00 A.M., the DON said she would expect the resident’s care plan to be person centered. If there was a [DIAGNOSES REDACTED]. 6. Review of Resident #102’s medical record, showed: -admitted [DATE]; -[DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 38) -An order, dated 12/6/16, [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) 3 milligram (mg) tablet at bedtime (HS) for [MEDICAL CONDITION]; -An order, dated 5/27/18, for [MEDICATION NAME] (medication used to treat depression and [MEDICAL CONDITION]) HCI tablet 150 mg HS for [MEDICAL CONDITION]; -An order, dated 6/27/18, [MEDICATION NAME] Capsule ([MEDICATION NAME][MEDICATION NAME] HCl, [MEDICATION NAME] used to treat allergy symptoms) 50 mg by mouth (PO) for [MEDICAL CONDITION] at HS. Review of the resident’s Medication Administration Record [REDACTED] -An order, dated 12/6/16, for [MEDICATION NAME] 3 mg HS for [MEDICAL CONDITION] was administered as ordered; -An order, dated 5/27/18, for [MEDICATION NAME] 150 mg HS was administered as ordered; -An order, dated 6/27/18, for [MEDICATION NAME] Capsule 50 mg HS was administered as ordered. Review of the resident’s care plan, reviewed 11/9/18, showed no documentation of the resident’s [MEDICAL CONDITION] or sleep habits and concerns. Observation of the resident on 11/8/18 at 11:30 A.M., 11/8/18 at 4:41 P.M., showed the resident in bed with his/her eyes closed. During an interview on 11/8/18 at 4:46 P.M., Licensed Practical Nurse (LPN) H said the resident sleeps a lot. He/she is only up for meals. That is his/her routine. Observation on 11/8/18 at 5:57 P.M., showed the resident in the dining room during meal service. He/she sat at the table with his/her eyes closed. Staff asked the residents in the dining room if anyone else needed to be served. The resident continued to sit at the table with his/her eyes closed. Other residents in the dining room pointed out that the resident needed to be served before the dietary staff left the room. During an interview on 11/13/18 at 9:00 A.M., the DON said she would expect the resident’s [DIAGNOSES REDACTED]. 7. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said care plans should be resident centered. It should include pertinent care information and resident wishes. A resident’s transfer status should be included in the care plan. | |
F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 39) -Activities of Daily Living (ADL) Functional/Rehabilitation Potential; -Communication; -Behavioral symptoms; -Falls; -Nutritional Status; -Dental Care; -Pain; -Return to Community Referral. Record review of the resident’s electronic and paper medical record, reviewed on 11/13/18, showed no comprehensive care plan found. Observation on 11/7/18 at 6:59 A.M., showed the resident sat on the edge of his/her bed, awake, call light in reach. The resident could not hear this surveyor ask him/her questions. The resident shook his/her head at this surveyor and declined to interact. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said: -Comprehensive care plans are expected to be developed within 21 days of admission; -The MDS coordinators are responsible for completing the care plans. | |
F 0661 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on interview and record review, the facility staff failed to complete a | |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 40) census was 148. Review of the facility’s Perineal Incontinence Care policy, dated 1/1/06, showed the following: -Standard: To provide cleanliness and comfort, prevent irritation and infection in the perineal area during the daily bath and after voiding or defecating; -Wash, rinse and dry the resident; -More than one wash or rinse may be necessary to clean the area thoroughly; -Remove the protective pad from the bed and dispose of it appropriately, if soiled. 1. Review of Resident #1’s annual Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 10/21/18, showed the following: -Total dependence on staff for toilet use; -Always incontinent of bowel and bladder. Review of the resident’s care plan, in use at time of the survey, showed the following: -Problem: Resident requires total care with activities of daily living (ADLs) due to [DIAGNOSES REDACTED]. -Goal: Staff will continue to provide total care with ADLs through next review; -Approach: Skin assessment as needed. Observation on 11/7/18 at 9:57 A.M., showed Certified Nursing Assistant (CNA) T in the resident’s room provided incontinence care to the resident. A strong urine odor permeated the room. CNA T removed the urine soaked brief from the resident. The urine soaked brief had disintegrated. Small, white, gel-like particles of debris from the brief clung to the resident’s buttocks. CNA T commented that the brief had fallen apart. The resident stated his/her buttocks hurt. Observation on 11/7/18 at 3:24 P.M., showed the resident in his/her room. The resident sat in his/her wheelchair with a mechanical lift pad and folded blanket underneath him/her. The resident said nursing staff had not checked his/her brief since his/her shower this morning at 10:00 A.M. The resident said he/she was wet. Observation on 11/7/18 at 3:34 P.M. showed CNA J and CNA V provided incontinence care to the resident. CNA J removed the urine soaked brief from the resident and performed perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks). CNA J put a clean brief on the resident and then pulled the resident’s pants up. CNA V said the resident’s pants were soaked with urine and removed them. CNA J and CNA V put clean pants on the resident without cleaning the resident’s thighs of urine. CNA J and CNA V repositioned the resident on his/her bed. CNA J and CNA V left the resident lying on the urine soaked mechanical lift pad that he/she had been sitting on since the completion of his/her shower at 10:00 A.M. that morning. CNA J and CNA V left the urine soaked folded blanket on the seat of the resident’s wheel chair and left the room. 2. Review of Resident #139’s annual MDS, dated [DATE], showed the following: -Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 0 out of a possible score of 15; -A score of 0-7, showed the resident had severe cognitive impairment; -Total dependence required for toilet use and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident’s care plan, in use at the time of the survey, showed: -Problem: Resident requires total care with ADLs related to stroke: -Goal: Be clean, odor free and well groomed; -Approach: Total care in all aspects of ADL care. Observation on 11/7/18 at 3:43 P.M., showed CNA E entered the resident’s room and said he/she needed to check to see if the resident was clean. He/she placed an ungloved hand |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 41) down the front of the resident’s brief, said the resident was dry, removed his/her hand and exited the resident’s room. At 3:47 P.M., Licensed Practical Nurse (LPN) L entered the resident’s room to complete a skin assessment. He/she unsecured the resident’s brief. The resident was wet with urine and had a soft, partially liquid bowel movement. LPN L used the resident’s brief to wipe away the majority of the bowel movement, rolled it up to contain the stool in the brief and removed the brief. Smears of stool remained on the resident’s buttocks. He/she then called for CNAs to come and finish cleaning the resident. CNA E and CNA J entered the resident’s room. LPN L said the resident needed to be cleaned up and then transferred to his/her wheelchair. Neither CNA acknowledged LPN L and LPN L did not verify the CNAs heard him/her before he/she left the room. CNA E and CNA J placed a clean brief on the resident without cleaning the urine and/or stool off the resident’s skin. They then assisted the resident to transfer to his/her wheelchair. During an interview on 11/7/18 at 4:25 P.M., the administrator said it was not acceptable to check for incontinence by sticking a hand down the front of a resident’s brief. 3. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said staff should check residents who are known to be incontinent every two hours. If a resident is soiled, they should be cleaned. Residents should be cleaned before they get to the point the brief, pants, blanket or transfer pad become soiled. If the resident’s paints, blanket and transfer pad does become soiled, the resident should not be allowed to continue to use them without them being cleaned. 4. Review of Resident #89’s quarterly MDS, dated [DATE], showed the following: -BIMS score of 14, which shows the resident is cognitively intact; -[DIAGNOSES REDACTED]. -Limited assistance required for transfers, dressing and hygiene. Observation on 11/6/18 at 3:53 P.M., 11/7/18 at 8:53 A.M. and 12:52 P.M., and 11/8/18 at 9:51 A.M., showed the resident had gray facial hair on his/her upper lip, chin, and on both sides of the lower cheeks. The facial hair was approximately 1/2 inch long. During an interview on 11/9/18 at 8:51 A.M., the resident said staff used to shave him/her, but not anymore. They no longer offer to shave or do anything outside of bathing. He/she would like for staff to shave his/her facial hair again. During an interview on 11/13/18 at 9:00 A.M., the DON said she would expect staff to ask all residents if they would like to be shaved. In addition to bathing, the residents are expected to be groomed. MO 762 MO 873 | |
F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide activities to meet all resident’s needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 42) -Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 0 out of a possible score of 15, which showed severe cognitive impairment; -Mobility devices: Wheelchair; -[DIAGNOSES REDACTED]. -Care Area Assessment (CAA) Summary Care Planning: Activities triggered, not care planned. Review of the resident’s Pre-Admission Screening and Resident Review (PASRR, used to |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 43) Review of the resident’s one on one room visit documentation, dated 10/29/18 from 3:15 P.M. through 3:30 P.M., showed: -Resident asleep; -Woke up when music played; -Eye contact-watch; facial expression; movement of shifting, nodding, shaking head or participating. Review of the resident’s (MONTH) (YEAR) activity participation documentation, reviewed on 11/9/18, showed the following activities: -Coffee/news: 11/5/18; -No documentation if the resident’s participation was active or passive. Review of the resident’s one on one room visit documentation, dated 11/6/18 from 11:45 A.M. through 12:05 P.M., showed: -Talked with the resident and fed him/her ice-cream; -Eye contact. Observations on 11/6/18 at 9:44 A.M. and 10:59 A.M. and 11/9/18 at 6:31 AM., showed the resident in his/her room in his/her wheelchair and the resident yelled out. The television on. Observation on 11/6/18 at 11:05 A.M., showed a music activity taking place on the floor for the residents. No staff assisted the resident to the activity and the resident remained in his/her room and yelled out. Observation on 11/7/18 at 3:47 P.M., showed the resident in his/her room in bed and yelled out. The television on. Observation on 11/13/18 at 6:57 A.M., showed the resident sat in a wheelchair in the hall. Laundry staff passed out clean laundry to resident rooms. The resident yelled out as a certified nursing assistant (CNA) walked by. The CNA failed to stop to acknowledge the resident. Laundry staff stopped to talk to the resident and the resident stopped yelling and appeared to watch the laundry staff with a relaxed look on his/her face. As the laundry staff continued down the hall to pass out clean laundry, the resident again started to yell. At 7:09 A.M., staff propelled the resident to the nurses’ station where the radio was on behind the nurses’ desk. The resident stopped yelling and had a relaxed look on his/her face. During an interview on 11/13/18 at 8:01 A.M., MDS Coordinator K said he/she was not the MDS coordinator who completed the annual MDS for the resident. The MDS coordinator before him/her completed the MDS and he/she is not sure why they chose not to care plan activities. The resident would benefit from care planned activities. During an interview on 11/13/18 at 8:10 A.M., the activity director said the resident likes television and the radio. He/she does not come down for group activities much because he/she appears to become anxious in groups. It is hard to say if the resident would benefit from one on one activities. The resident does enjoy when staff propel him/her up and down the hall and sitting at the nurse’s station. Activity staff do provide one on one on activities for the resident, sometimes. These are documented on the one on one forms. The resident cannot communicate, but he/she will track staff with his/her eyes. When activity staff visit with him/her they talk to him/her and ask him/her how his/her day is going. | |
F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide restorative therapy (RT, exercises, braces or splints used to main flexibility or movement) as recommended by physical, occupational therapy to residents with limited mobility for two of three sampled residents investigated for positioning and mobility (Residents #1 and #139). In addition, the facility failed to develop and implement policies on restorative/rehabilitative treatments/services, based on professional standards of practice, including who may provide specific treatments and modalities. The census was 148. 1. Review of Resident #1’s annual Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 10/21/18, showed: -Total dependence on two person physical assist for transfers; -Functional limitations in range of motion: -Upper extremity: Impairment on one side; -Lower extremity: Impairment on both sides; -Mobility devices: Wheelchair; -[DIAGNOSES REDACTED]. -Physical therapy end date, 9/20/18. Review of the resident’s electronic medical record, showed; -Medical [DIAGNOSES REDACTED]. -Physician order [REDACTED]. Review of the resident’s care plan, in use at the time of the survey, showed: -Problem: The resident requires total care with activities of daily living (ADLs) [DIAGNOSES REDACTED]. -Goal: Staff will continue to provide total care with ADLs thru next review; -Approach: Allow the resident to choose clothing appropriate for the season (there is no approach related to range of motion (ROM); -Restorative nursing not care planned. Observation on 11/7/18 at 8:42 A.M., showed the resident lay in bed slightly on his/her right side. The resident ate breakfast from his/her bedside table, using only his/her left hand. The resident’s right arm contracted. Observation on 11/7/18 at 3:43 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident watched his/her T.V. with the remote control in his/her left hand. The resident’s right arm contracted. 2. Review of Resident #139 annual MDS, dated [DATE], showed: -Functional limitation in range of motion: -Upper extremity: Impairment on one side; -Lower extremity: Impairment on both sides; -Mobility devices: Wheelchair; -[DIAGNOSES REDACTED]. -Physical therapy end date, 6/7/2018; -Restorative nursing program: Not performed. Review of the resident’s electronic and paper medical records, showed: -Medical [DIAGNOSES REDACTED]. These non-bony tissues include muscle, ligaments, and tendons) of muscle right upper arm; -Occupational therapy (OT) discharge instructions dated 6/21/18, showed the resident will remain in this facility with assistance from staff for ADLs and functional transfers. Resident will continue with restorative nursing program 3 times a week as tolerated for ROM and skin hygiene; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 45) -PT discharge instructions, dated 6/15/18, showed the resident discharged to same location with recommendations including establish restorative nursing program. Review of the resident’s care plan, in use at time of the survey, showed: -Problem: Resident requires total care with ADLs related to stroke; -Approach: Total care in all aspects of ADL care; -Resident has contractures of the right arm and hand; -ROM to be provided with daily care as tolerated. Review of the resident’s electronic and paper medical record showed, no documentation staff assisted the resident with ROM with daily care as tolerated or how the resident tolerated ROM. Observation on 11/6/18 at 9:44 A.M. and 10:59 A.M., and 11/9/19 at 6:31 A.M., showed the resident in his/her room in his/her wheelchair. All extremities contracted and the resident yelled out. 3. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said: -A resident’s care plan should reflect a process to prevent further decline in a resident’s condition when a medical [DIAGNOSES REDACTED]. -The Assistant Director of Nursing (ADON) is responsible for looking at the PT, OT discharge reports for recommendations; -Currently, staff are not monitored to ensure they are accurately implementing ROM exercises during care; -Nursing staff is not documenting when assisting residents with ROM exercises during care, nor how residents tolerate ROM; -There is no restorative nursing program in place currently and she cannot recall the last time the facility had a restorative therapist; -The facility does not have a policy for Restorative/Rehabilitative treatments/services; -Facility just became aware of the new requirement, which took effect last year in (MONTH) (YEAR), that facility must develop restorative care policies on Restorative/Rehabilitative treatments/Services, including who may provide specific treatments and modalities. As of 11/12/18, the facility is working on developing a new restorative program that has not yet been implemented. | |
F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 46) -Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 0 out of a possible score of 15; -A score of 0-7, showed severe cognitive impairment; -Total dependence on two-person physical assist for transfers; -Functional limitation in range of motion: –Upper extremity: Impairment on one side; –Lower extremity: Impairment on both sides; -Mobility devices: Wheelchair; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s current care plan, in use at the time of the survey, showed: -Problem: Resident requires total care with activities of daily living (ADLs) related to stroke: –Goal: Be clean, odor free and well groomed; –Approach: Total care in all aspects of ADL care; —Resident has contractures (chronic loss of joint motion due to structural changes in non-bony tissue. These non-bony tissues include muscle, ligaments and tendons) of the right arm and hand; —Range of motion (ROM) to be provided with daily care as tolerated; —Totally dependent on one staff for transferring; -Problem: Risk for falls: Limitations with lower extremities related to contractures: –Goal: Remain free from injuries related to falls; –Approach: Staff will assist the resident with transfers to bed within an hour of meals; -The care plan failed to identify the resident’s transfer status. Review of the resident’s physician order [REDACTED]. Review of the electronic medical record, showed the ADL: Transfers failed to identify the resident’s transfer status and only indicated if staff transferred the resident. Observation on 11/7/18 at 3:47 P.M., showed Certified Nursing Assistant (CNA) E and CNA J transfer the resident from bed to the wheelchair. Without the use of a gait belt, CNA E stood on one side of the resident and CNA J stood on the other side. Staff placed one arm under the resident’s arm and grabbed onto the resident’s waste band with the other hand, CNA E said one, two, three and staff picked the resident up out of the bed. The resident’s extremities remained contracted. His/her knees bent in a sitting position and arms pulled inward. During the transfer, the resident’s legs remained contracted up and his/her feed did not touch the floor. Staff placed the resident in the wheelchair. CNA J said the resident is supposed to be a two person assist, but staff can do it with one person if needed. 2. Review of Resident #114’s quarterly MDS, dated [DATE], showed: -Extensive assistance of two-person physical assist required for transfers; -Mobility devices: Wheelchair. Review of the resident’s care plan, in use at the time of the survey, showed: -Problem: ADL self-care performance deficit related to [MEDICAL CONDITION] and limited mobility. He/she requires assist with transfers and mobility; -The care plan failed to identify the resident’s transfer status. Review of the resident’s POS, showed no order for transfer status. Review of the electronic medical record, showed the ADL: Transfers failed to identify the resident’s transfer status and only indicated if staff transferred the resident. During an interview on 11/7/18 at 7:20 A.M., CNA A said he/she just knows how to care for residents. He/she knows how to care for resident because he/she had worked at the facility |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 47) for four years. The facility does not utilize care cards. Observation on 11/7/18 at 7:24 A.M., showed CNA A provided care to the resident and transferred the resident to his/her wheelchair. CNA A assisted the resident to sit on the edge of his/her bed by pulling on the resident’s hands and sat the resident on the side of the bed. The resident unable to remain in a seated position and started to fall back and to the side. CNA A grabbed the resident by the back of his/her neck and pulled the resident up into a sitting position. CNA A placed a gait belt around the resident’s waste. As he/she did this, the resident began to slouch and fall over to the side. The resident remained in a tilted slouched position in the bed as CNA A placed the resident’s wheelchair against the wall and said the resident’s wheelchair don’t lock so he/she has to prop it against the wall. CNA A said he/she put in a requested for maintenance to fix it yesterday, but it had been broken for one or two weeks. CNA A straddled the resident and instructed the resident to hold on to his/her waste and picked up the resident with the use of the gait belt. The resident did not bear weight. CNA A twisted the resident and the tips of the resident’s feet remained on the floor, twisted slightly from the direction of his/her legs and body. After several prompts from CNA A, given as he/she held the resident up with the use of the gait belt, the resident was able to pivot his/her feet so they were no longer twisted. CNA A placed the resident in the wheelchair. He/she then placed the left foot rest on the resident’s wheelchair, placed his/her left foot on the foot rest and then placed the right foot on top of the left foot. CNA A said the wheelchair was broken and the right foot rest no longer connected to the wheelchair. CNA A propelled the resident out of the room and into the hall with both feet on one foot rest. 3. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said a resident’s transfer status should be included in the care plan. A resident’s transfer status is based on the resident’s physical ability to transfer. Staff know how to transfer a resident by looking in the ADL section of the electronic medical record. This is also passed on in report. For a gait belt transfer, residents should be able to bear weight. Staff should use a gait belt. If a resident is unable to bear weight, she would expect staff to get them in a safe position and get help. Staff should not pull on a resident’s hands or neck to assist to sit them to sit up. A resident’s feet should touch the floor during a transfer unless they are contracted. Then two people can just lift them. Everyone is responsible to make sure residents can be transferred safely. Staff should not pick residents up by their waste band. Staff should not pick residents up under their arms because this could cause injury to the residents or staff. She was not aware that acceptable standards of practice indicate a resident should be able to bear weight and assist in transfers to qualify for a gait belt transfer. 4. Review of the facility’s Lifting and Transferring Residents policy, dated 1/1/06, showed: -All residents requiring assistance with mobility should be lifted and transferred safely; -Members of the nursing staff are responsible for using good body mechanics, knowing the proper transfer procedures and properly operating assistive devices. Residents are assessed by the nursing and/or therapy departments for lifting and transfer needs and for the most appropriate transfer method(s); -For residents requiring assistance in lifts and transfers, a gait/transfer belt or mechanical lift should be used; -Assess the resident to determine physical limitations and ability to follow directions; -The method for transfer and/or lift that is appropriate for each resident can be found in individual resident care plans; -Lock wheels on bed and/or wheelchair; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 48) -The resident’s hands should remain free during the transfer; -Staff should not place their hands under a resident’s arms or shoulders in order to prevent shoulder injury; -Grasp transfer belt from underneath; -The policy failed to identify that residents transferred with the use of a gait belt must be able to bear weight or what qualified or disqualified a resident from using a gait belt transfer. 5. Review of Resident #1’s annual MDS, dated [DATE], showed: -Total dependence on two person physical assist for transfers; -Functional limitations in range of motion: -Upper extremity: Impairment on one side; -Lower extremity: Impairment on both sides; -Mobility devices: Wheelchair; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, in use at the time of the survey, showed: -Problem: Resident has a habit of removing his/her seatbelt while propelling himself/herself throughout unit and with family; -Goal: The resident will have no major injuries related to non-compliance of seatbelt use; -Approach: Staff will reinforce the resident to use his/her seatbelt properly; -Problem: Resident is at risk for falls due to [DIAGNOSES REDACTED].>-Goal: Resident will not sustain serious injury through the review date; -Approach: Frequently check to see if self-release belt is in place; -Approach: Educate staff to use gait belt during transfers and assist of 2 person for all transfers; -The care plan failed to identify the resident’s transfer status. Review of the resident’s electronic and paper medical records, showed: -Incident note dated 5/20/18, showed, the resident was observed laying on the ground on the outside patio. Resident laying on his/her left side, with his/her feet entangled in the footrest of his/her wheelchair. Another resident was pushing the resident in his/her wheelchair when he/she fell out; -Fall investigation report dated 5/20/18, showed the fall was witnessed by a resident; -No neurological checks (neuro-checks) an assessment completed by nursing staff to monitor for changes in the resident’s neurological (nervous system) status) for the fall on 5/20/18; -The outcome of the fall investigation report not documented; -Incident note dated 6/26/18, showed, the resident was observed lying on his/her right side on ground in front of the activity room. The resident was being propelled in a wheelchair when he/she fell forward. Safety belt was unattached. The resident stated he/she hit his/her head. There was a dime sized raise area on the resident’s right brow and forehead; -No fall investigation report for 6/26/18; -No neuro-checks for 6/26/18; -Incident note dated 9/13/18, showed, the resident was lowered to the floor and sat on his/her buttocks by nursing staff while performing a two person transfer from the wheel chair to the floor for safety; -The care plan was not updated after the fall during transfer on 9/13/18; -The outcome of the fall investigation report was not documented. Review of the resident’s electronic medical record ADL transfer documentation, dated 10/31 to 11/12/18, showed: |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 49) -No order for transfer status; -Staff documented extensive assistance (resident involved in activity, staff provide weight bearing assistance) for transfers. Observation on 11/7/18 at 10:16 A.M., showed CNA T and CNA U transferred the resident from the bed to the shower chair using a mechanical lift. Observation on 11/7/18 at 3:33 P.M., showed CNA J and CNA V transferred the resident from the wheelchair to the bed using a mechanical lift. During an interview on 11/7/18 at 7:23 A.M., CNA D said the resident is the only resident transferred with a mechanical lift on the unit. Further review of the resident’s care plan, in use at the time of the survey, showed: -Problem: Resident smokes daily, is at risk for burns/injuries and has been noted to remove his/her safety apron while smoking causing [MEDICAL CONDITION] his/her skin; -Goal: Resident will not smoke without supervision through the next review date; -Approach: Resident requires supervision while smoking. Review of the resident’s electronic and paper medical records, showed: -Incident note dated 5/4/18, showed, the resident was in the smoking room when he/she removed his/her smoking apron thinking the cigarette was out and burned his/her right thigh. Upon assessment, blistering was found to his/her right thigh; -Smoking investigation report dated 5/4/18, showed: -No witnesses found to incident; -Resident has short attention and memory span; -Resident dropped lit ash from cigarette onto his/her right thigh; -The outcome of the smoking investigation report was not documented. During an interview on 11/9/18 at 9:00 A.M., the DON said she expects nursing staff to read and follow resident’s care plans regarding need of supervision during smoking. Nursing staff are expected to know each resident’s care plan and they can access care plans in the electronic medical record. Care plans are person centered, and based on medical needs and personal wishes. Review of the facility’s Smoking policy, dated 8/20/15, showed: -All residents must be supervised while smoking, therefore smoking activity will be conducted in designated areas during designated times, as assigned by the facility. 6. Review of Resident #123’s electronic face sheet, showed [DIAGNOSES REDACTED]. Review of the resident’s annual MDS, dated [DATE], showed: -BIMS score of 00 out of 15, showed the resident with severe cognitive impairment; -Had two non-injury falls since last assessment; -Required limited assist of one staff for bed mobility and locomotion on the unit; -Required extensive assist of two staff for transfers and toileting; -Totally dependent on staff for dressing and bathing. Review of the resident’s care plan, in use at the time of the survey, showed: -Focus: At risk for falls. Unaware of safety needs. Ambulates with a forward bent posture. At risk for falls related to history of falls. History of falls in room related to ambulating without assistance and will also get out of the wheelchair and ambulate in the hall without assistance; -Goal: Be free of serious injuries related to falls; -Approach: Anticipate needs, call light in reach and encourage use. Ensure appropriate footwear. Follow fall protocol. Uses wheelchair for mobility. Provide activities that minimize the potential for falls while providing diversion and distraction. Review of the facility’s incident list for last 6 months, provided on 11/6/18 at 3:18 P.M., showed the following for the resident un-witnessed falls on 7/3/18, 7/15/18 and |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 50) 9/10/18. Review of the resident’s progress notes, showed: -On 7/3/16 at 8:27 A.M., The resident was alert and oriented to self. Resident remains on observation charting. Resident was asleep halfway through the night then the resident was found on floor. Range of motion performed on all four extremities passively and actively. No facial grimacing noted and no moaning at this time. Non-compliant with vital signs for neuro-checks. Resident up to wheel chair at the nurse’s station. Resident said his/her bottom hurt. Pain medication provided; -On 7/15/18 at 14:32, Resident found on the floor in another residents room around 11:00 A.M. today. No apparent injuries observed. Found on his/her buttocks, legs extended out in front of him/her. Remains alert to self, unable to describe how he/she got onto the floor. Active range of motion remains to all extremities. No bruising or open areas observed. The resident’s nurse practitioner notified, no new orders. Neuro-checks initiated. Call placed and message left for the resident’s family member; -9/10/8 at 5:25 A.M., at 3:45 A.M., the resident was observed sitting on floor next to bed on pad leaning back. Neuro-checks adequate, vital signs, range of motion are all within the resident’s normal limits. Respiration are even non-labored. Skin warm and dry to touch. Resident refused as needed pain medications resident denies pain at this time. The physician and resident’s family member aware of above. During an interview on 11/13/18 at 8:43 A.M., the DON said the fall documentation that had been provided was the only fall documentation the facility had for this resident. There was no fall occurrence report for the 7/3/18 fall. Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/15/18 showed: -The resident had an unwitnessed fall on 7/15/18; -Upon entering the room, the resident was found sitting on the ground, with his/her legs extended out in front of him/her; -The resident was unable to state what occurred; -ROM was performed and the resident was assisted into a wheelchair; -No injuries were observed at the time of the incident; -The resident was alert at the time of the incident; -The resident used a wheelchair for mobility at the time of the incident; -Mental status at the time of the incident: Oriented to person; -No injuries noted post incident; -The resident was alert and wheelchair bound post incident; -Predisposing environmental factors: Wet floor; -Predisposing physiological factors: Confused, impaired memory and weakness/fainted; -Predisposing situation factors: Wanderer; -Witnesses: No witnesses; -No cause determination, and no interventions taken at the time of the incident and/or post incident noted. During an interview on 11/8/18, the DON said she did not know how the floor was determined to be wet, the nurse must have seen water on the floor or they would not have put it in the report. During an interview on 11/13/18 at 7:40 A.M., CNA AA said he/she was not present at the time of the fall and did not know any information, including how the facility determined the floor was wet. During an interview on 11/13/18 at 7:48 A.M., Nurse BB said he/she was not present and does not know any information on the fall, including how they facility determined the floor was wet. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 51) Record review of the resident’s Unwitnessed Fall Occurrence Report, dated 9/10/18, showed: -The resident had an unwitnessed fall on 9/10/18; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 52) Review of the resident’s progress notes, showed: -On 7/31/2018 at 9:22 A.M., the resident was screaming very loudly and this writer went down the hall to find him/her. He/she was lying on the floor in another resident’s room screaming and moving around on the floor. When asked what happen he/she stated he/she pushed me down. I am hurting. ROM initiated and he/she was able to move all extremities without complaints of pain and no difficulties, grimacing or indication of pain exhibited. Assisted off of the floor by two staff and assisted into a wheelchair; -On 8/1/2018 at 10:36 P.M., Resident alert to self and is confused, redirected several time throughout shift from other peoples room. -On 8/2/2018 at 3:12 A.M., day 2/3 Incident follow up: Resident in bed, no acute distress noted. No signs behavior at this time. Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/31/18, showed: -The resident had an unwitnessed fall on 7/31/18; -Upon entering the room, the resident was found lying on his/her back on the ground, screaming he/she pushed me down and moving; -The resident stated that he/she was pushed down while in another resident’s room; -ROM was performed and the resident was assisted into a wheelchair by two staff members; -No injuries were observed at the time of the incident; -Pain, consciousness and mobility at the time of the incident: Blank; -Mental status at the time of the incident: Oriented to person; -No injuries noted post incident; -Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing environmental factors: Wet floor; -Predisposing physiological factors: Confused, impaired memory and weakness/fainted; -Predisposing situation factors: Wanderer and ambulating without assistance; -Other information: The resident wanders into other resident’s rooms; -Witnesses: No witnesses; -No cause determination, and no interventions taken at the time of the incident and/or post incident noted. Record review of the resident’s progress notes, showed: -On 8/11/18 at 1:16 P.M.: Reported this resident was observed sitting on the floor in his/her room. Denies any pain, no signs or symptoms of distress or discomfort. ROM within normal limits, skin warm dry and intact. No discoloration noted. Able to and ambulate with no assistance. Neuro checks started. The physician was notified with no new orders receive. The resident’s family called, message left. Review of the resident’s Unwitnessed Fall Occurrence Report, dated 8/11/18 showed: -The resident had an unwitnessed fall on 8/11/18; -Observed sitting on the floor in his/her room; -The resident was unable to state what occurred; -Physical assessment complete. Neuro checks started; -No injuries were observed at the time of the incident; -The resident was alert and ambulatory without assistance; -Mental status at the time of the incident: Oriented to person; -No injuries noted post incident; -Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing environmental factors: Blank; -Predisposing physiological factors: confused and incontinent; -Predisposing situation factors: Blank; -Witnesses: No witnesses; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 53) -No cause determination, and no interventions taken at the time of the incident and/or post incident noted. Review of the resident’s current care plan, in use at time of the survey, showed no updated interventions after the fall on 7/31 and 8/11/18. Review of the medical record, showed no neurological flow sheets completed for the resident’s unwitnessed falls on 7/31 and 8/11/18. Observation on 11/07/18 at 7:38 A.M., showed the resident sat at a table in the dining room. Another resident kept repeating the same phrase over and over. The resident appeared to get agitated and yelled at the other resident. Numerous staff attempted to calm the resident. The resident’s meal was served, the resident ate fast and left the dining room. During an interview on 11/13/18 at 7:40 A.M., CNA AA said the resident wanders into other resident rooms, once staff hear him/her hollering out, staff will go get him/her and take him/her to the day area or dining room. During an interview on 11/13/18 at 8:43 A.M., the DON said the fall documentation, including neuro checks that had been provided was the only fall documentation the facility had for this resident. 8. During an interview on 11/9/18 at 9:00 A.M., the DON said if a resident requires a mechanical lift it should be in the care plan. The care coordinator updates all care plans and informs staff of changes. The expectation is for care plans are accurate. Transfer orders are noted for resident in the ADLs found in the electronic medical record. Resident’s transfer status is determined based on their needs and abilities. The DON expects nursing staff to notice change in ADLs and report it to the nurse. The expectation of nursing staff regarding unwitnessed falls is to for the nurse to assess the environment to find the cause for the fall, ask the resident what happened, and monitor for injury and conduct neuro checks for 72 hours. The outcome of an investigation should be in the investigation report and then updated in the resident’s care plan. 9. Review of the facility’s Neurological Observations policy, dated 8/5/13, showed: -The purpose of this procedure is to provide guidelines for neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition; -Any change in neurological status should be reported to the physician immediately; -Documentation of neurological assessment and observations should be documented in the resident’s medical record. A flow sheet designated to record pertinent assessment information may be used and placed in the resident’s medical record upon completion; -Neurological assessments implemented in response to an unwitnessed fall or a fall with a suspected head injury will be performed for at least 48 hours; -If a resident refuses to participate or allow a neurological assessment to be completed, refusal should be documented in the resident’s record and the physician notified; -Procedure: -Obtain a copy of the Neurological Observation Flow Sheet for guidance; -On the initial assessment, obtain a full set of vital signs, to include orthostatic blood pressure and pulse and check the resident’s blood sugar level; -Document in the clinical nurses notes every shift x72 hours. Review of the Neurological Observation Flow Sheet, showed: -A neurological observation includes the date, time, temperature, respirations, pulse, blood pressure, level of consciousness, orientation, pupil reaction, extremity motor functions, pain response, observations and nurse initials; -Neurological observations scheduled to be completed initially, every 15 minute times three, every 30 minutes times two, every four hours times four and every eight hours times |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 54) four. 10. Review of the facility’s Fall Prevention policy, dated 10/28/03, showed: -This facility is committed to establishing guidelines to minimize falls and their effects so as to maximize every resident’s wellbeing; -The care plan coordinator is responsible for all care plan updates related to fall prevention efforts; -A narrative summary, written in the nurses notes, shall follow each fall event and shall include at a minimum: Date and time, brief narrative that describes the details of the incident, vital signs, level of consciousness/emotional state of the resident at the time of the fall, reports of pain, any injuries, assistance or care given in response to the fall, the residents response to this care, notification to the physician and responsible party; -Follow-up documentation for each separate fall event shall, at a minimum, be completed once each shift for 72 hours post fall. This should include at a minimum: Vital signs, level of consciousness/emotional state, assessment and description of any previous injuries and/or new injuries; -Within 24-48 hours of a fall event, facility nursing administrative personnel will review the fall risk assessment in conjunction with the fall event documentation to verify that the assessment remains an accurate reflection of the resident’s risk factors; -Care plans for any resident experiencing a fall event will be updated to reflect the fall, any newly identified risk factors and interventions designed to prevent reoccurrences. 11. Observation on the second floor locked unit, on 11/8/18 at 4:27 P.M., showed Licensed Practical Nurse (LPN) CC at a medication cart. A pack of resident medications sat on the top of the cart. LPN CC took a resident into the shower room to provide care and left the medication unattended and on top of the medication cart. Residents moved independently throughout the unit. He/she returned to the medication cart after providing care, gathered supplies and took another resident to the shower room to provide care. The medications remained unattended on the medication cart. During an interview on 11/9/18 at 9:00 A.M., the DON said medications should be locked inside the medication cart and should not be left unattended. 12. Observation of the second floor locked unit shower room, on 11/8/18 at 4:27 P.M., showed LPN CC entered the shower room to provide care to a resident. The shower room unlocked and accessible to residents who resided on the locked unit. Three used razors located in the sink and accessible to residents. After providing care, LPN CC assisted the resident out of the shower room. The razors remained in the sink. Residents moved independently throughout the unit. At 4:43 P.M., LPN CC returned to the shower room with another resident to provide care. After providing care to the resident, LPN CC exited the shower room with the resident. The razors remained in the sink. During an interview on 11/9/18 at 9:00 A.M., the DON said used razors should be placed in the sharps container and should not be accessible to residents. | |
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. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 55) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain proper insertion of an indwelling urinary catheter (a tube inserted into the bladder for the purpose of continual urine drainage). The facility identified one resident with an indwelling urinary catheter. That one resident was chosen for the sample and did not receive the appropriate indwelling catheter as ordered (Resident #64). In addition, the facility failed to provide appropriate perineal care for one of six residents observed during personal care who had been incontinent of urine (Resident #114). The sample was 29. The census was 148. 1. Review of Resident #64’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/30/18, showed: -[DIAGNOSES REDACTED]. -Cognitively intact; -No behaviors; -Indwelling urinary catheter; -Range of motion impairments on both sides of upper and lower extremities; -Required total assistance from the staff for transfers, dressing, hygiene and bathing. Review of the resident’s electronic physician order [REDACTED]. -An order dated 3/26/18, to flush and irrigate the indwelling urinary catheter with 60 cubic centimeters (cc) of normal saline twice a day; -An order dated 4/6/18, to change the indwelling urinary catheter monthly on the 6th and as necessary. Place a French #16 (size) catheter with a 10 cc balloon (amount of fluid used to inflate the balloon which holds the catheter in the bladder); -An order dated 10/6/18, to change the indwelling urinary catheter monthly on the 6th and as needed with a #16 French catheter with a 10 cc balloon. Review of the resident’s undated care plan, in use during the survey, showed: -Problem: Resident has an indwelling catheter in place. Has [DIAGNOSES REDACTED]. -Goal: Resident will show no signs or symptoms of urinary infection; -Interventions included: Change Foley catheter monthly and as needed, irrigate Foley daily with 60 cc normal saline, monitor document for pain or discomfort due to catheter and monitor and report to physician for signs/symptoms of urinary tract infection. Review of the resident’s progress notes, showed: -On 7/22/18 at 6:00 P.M., Foley catheter has been replaced, #16 French with a 30 cc balloon, resident tolerated well; -On 10/5/18 at 4:23 P.M., #17 French catheter was accidentally pulled out during transfer from chair to bed. #17 French intact and balloon was still inflated with 2 cc of saline. #18 French catheter inserted without difficulty at 4:20 P.M.; -On 10/17/18 at 4:43 A.M., Returned from hospital emergency room . New [DIAGNOSES REDACTED].#16 French catheter to gravity and draining yellowish – red cloudy urine; -On 10/21/18 at 10:16 P.M., Resident complained of pressure and discomfort at 3:45 P.M. Resident catheter flushed with 60 cc normal saline, 30 cc instilled with difficulty and 30 cc spilled out. Removed catheter with a 5 cc balloon. Inserted a #18 French catheter with 10 cc of normal saline in the balloon; -On 11/6/18 at 11:03 A.M., withdrew 5 cc of clear liquid from balloon of Foley catheter, removed a #18 French catheter without difficulties using sterile technique. Inserted a #18 French with a 5 cc balloon without difficulties. Catheter draining yellow urine to gravity without difficulties. Observation on 11/6/18 at 10:22 A.M., on 11/7/18 at 7:10 A.M., and on 11/8/18 at 7:53 A.M., showed the resident lay in bed. An indwelling urinary catheter tubing hung over the |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 56) side of the bed and went into a drainage bag inside a blue privacy bag on the side of the bed. The tubing contained a clear, light yellow colored urine. During an interview on 11/9/18 at 9:45 A.M., the Director of Nurses (DON) looked at the resident’s indwelling urinary catheter orders and verified the order was for staff to insert a #16 French Foley catheter with a 10 cc balloon. She looked at the progress notes and verified staff documented they inserted a French #16 with a 30 cc balloon, a French #17 and a French #18 with a 5 cc and a 10 cc balloon. She said staff do not have any #17 French Foley catheters in the facility and was not aware that there was such a size. She verified that Nurse P had changed the resident’s indwelling catheter on 11/6/18. During an interview on 11/9/18 at 10:10 A.M., Nurse P said he/she changed the resident’s indwelling urinary catheter on 11/6/18, inserted a #18 French Foley with a 10 cc balloon. He/she thought the order was for a #18 French, then said they did not have any #16 French Foley catheters and he/she forgot to call the physician to get the order changed. During an interview on 11/13/18 at 9:05 A.M., the DON said she would expect staff to follow the physician orders [REDACTED]. 2. Review of Resident #114’s quarterly MDS, dated [DATE], showed: -Extensive assistance of two-person physical assist required for transfers; -Mobility devices: Wheelchair. Review of the resident’s care plan, in use at the time of the survey, showed: -Problem: Activities of Daily Living (ADL) self-care performance deficit related to [MEDICAL CONDITION] and limited mobility. He/she requires assist with transfers and mobility; -Goal: Be clean, odor free and well groomed; -Approach: Clean and bathe daily and as necessary. Observation on 11/7/18 at 7:24 A.M., showed Certified Nursing Assistant (CNA) A provided care to the resident. The resident incontinent of urine. CNA A said the resident did not have a wash basin and there were no extra ones on the floor, so he/she would have to prepare the washcloths in the resident’s bathroom. CNA A used soap and water to wash the resident’s abdominal folds and groin, rinsed with water and dried with a towel. He/she then used water only to cleanse the resident’s genitals. No soap used. CNA A assisted the resident to reposition and used soap and water cleanse the resident’s buttocks, rinsed with water and dried with a towel. During an interview on 11/13/18 at 9:00 A.M., the DON said when providing care, she would expect staff to use soap and water, not just water. All soiled areas should be cleaned. Review of the facility’s Perineal Incontinence Care policy, dated 1/1/06, showed: -Standard: To provide cleanliness and comfort, prevent irritation and infection in the perineal area during the daily bath and after voiding or defecating; -Wet washcloth in the basin and then add a small amount of soap or perineal wash; -Cleanse with the washcloth; -If soap was used, rinse the washcloth and rinse all areas of soap thoroughly; -Pat the area dry. | |
F 0693 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0693 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 57) provided care and services to a resident who has a feeding tube, utilizing facility protocols and staff were competent in the facility protocols to prevent potential complications, to include occlusion of the tube. During medication administration through a gastrostomy tube ([DEVICE], a tube that is placed directly into the stomach through an abdomen wall incision for administration of food, fluids and medications), staff failed to ensure medications were diluted and a flush administered between medications. This resulted in the [DEVICE] becoming clogged and staff forcing medications through the tube with a syringe for one resident observed to receive medications through a [DEVICE] of the two residents the facility identified as receiving tube feedings (Resident #131). The census was 148. Review of Resident #131’s physician order [REDACTED]. Observation on 11/7/18 at 8:12 A.M., showed Licensed Practical Nurse (LPN) G administered medications to the resident through the resident’s [DEVICE]. LPN G pulled up vitamin C 500 mg one tablet, [MEDICATION NAME] 10 mg two tablets, [MEDICATION NAME] 600 mg one tablet, [MEDICATION NAME] 500 mg one tablet and Tylenol 325 mg two tablets. LPN G crushed each individual medication and placed each medication in an individual plastic medication cup. He/she opened the Juven packet and poured the powdered supplement into a small drink cup. LPN G added approximately 90 milliliters (ml) of water to the Juven powder. He/she failed to dilute the crushed pills. LPN G entered the resident’s room, disconnected the tube feeding, checked placement and flushed the [DEVICE] with approximately 30 ml of water per gravity. He/she then administered the first medication, in powder form, into the syringe that was connected to the [DEVICE], followed by approximately 30 ml of water. He/she swirled the medication several times until the pill was diluted enough to administer per gravity. LPN G used the same technique for the second medication. After pouring the third powder medication into the syringe, adding approximately 30 ml of water and swirling the syringe, LPN G said I have to shake it up so it don’t settle. I don’t think the vitamin C likes us today, it won’t go down. It is stuck in the tip of the syringe. LPN G used the syringe plunger to force the medication through the [DEVICE]. LPN G used the same techniques of adding the powder medication, adding approximately 30 ml of water, swirling the syringe and then using the plunger to force the fourth medication. After pouring the powdered medication, adding approximately 30 ml of water and swirling the syringe for the fifth medication, LPN G flicked the syringe, which contained an occlusion of thick powder in the tip of the syringe and said why does it have to get stuck? We have this problem every day. He/she used the plunger to force the medication down the [DEVICE]. LPN G administered the diluted Juven. The Juven did not easily flow into the [DEVICE]. LPN G said Seriously! Now this will clog up? After swirling the Juven, the supplement eventually went into the [DEVICE] per gravity. LPN G flushed the [DEVICE] with approximately 60 ml of water and reconnected the tube feeding. LPN G failed to flush the [DEVICE] with water between medications. During an interview on 11/8/18 at 9:56 A.M., the Director of Nursing said when administering medications through a [DEVICE], medications should be diluted in water prior to administering. A flush should be given between medications. A plunger should not be used to force medications in the [DEVICE]. Review of the facility’s undated Medication Administration Enteral Medications policy, showed: -Policy: All enteral medications will be administered in a safe, efficient and accurate manner to residents for whom they are prescribed and in accordance with current acceptable nursing practice; -Medications administered via enteral tube should be diluted with warm liquids; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0693 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 58) -Crushed medications should be as finely pulverized as possible and should be diluted with 5 to 10 ml of warm water for instillation into the tube; -Instill the medication into the syringe, hold it slightly above the level of the abdomen and unclamp the tube, allowing the fluid to flow by gravity into the stomach; -If more than one medication is being administered, then give each medication separately and flush the tube with approximately 5 ml of warm water between each medication. | |
F 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Past noncompliance – remedy proposed **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 59) -The resident has a history of refusing to go to [MEDICAL TREATMENT] which increases his/her risk for complications such as fluid overload and toxicity; -The resident also has a history of refusing his medications; -Goal: The resident will have no signs or symptoms of complications from [MEDICAL TREATMENT]; -Interventions: Do not draw blood or take a blood pressure in the arm with the shunt. Educate the resident on the importance of keeping his/her [MEDICAL TREATMENT] schedule. Monitor and document bruit and thrill at [MEDICAL TREATMENT] shunt. Notify the physician of any abnormalities. Monitor for dehydration signs and symptoms such as tenting skin, abnormal labs, dry mucus membranes, decrease intake and output, and increase in confusion. Notify the physician if present. Monitor for dry skin and apply lotion as needed. Monitor labs and report to the physician as needed. Monitor vital signs. Notify the physician of significant abnormalities. Monitor/document/report, as needed, any new or worsening [MEDICAL CONDITION]. Review of the resident’s nursing notes, dated 10/1/18 through 11/9/18, showed no notes indicating results of the thrill and bruit checks, shunt site assessments, intake and output amounts, pain related to [MEDICAL TREATMENT], pre and post [MEDICAL TREATMENT] vital signs and pre and post [MEDICAL TREATMENT] weights. During an interview on 11/7/18 at 10:18 A.M., the resident said: -Staff does check his/her shunt. He/she does not know how often; -The facility does not weigh him/her before or after [MEDICAL TREATMENT]; -Staff does not check his/her vital signs before or after [MEDICAL TREATMENT]; -Observation of the resident’s left AV shunt showed no redness, and the dressing was clean, dry and intact. Review of the resident’s [MEDICAL TREATMENT] communication forms for 10/1/18 through 11/7/18, showed the facility sent the paperwork to the [MEDICAL TREATMENT] clinic for some visits but not all visits. The [MEDICAL TREATMENT] clinic did not fill out their section and returned it with just the information the facility placed on it prior to [MEDICAL TREATMENT]. 3. During an interview on 11/9/18 at 9:45 A.M., the Director of Nurses (DON) said she could not find any documentation for assessment of the residents’ AV fistula, would expect staff to document in the progress notes every shift for thrill, bruit, any signs or symptoms of bleeding, infection, or pain. The POS should include how often and time for [MEDICAL TREATMENT] as well as for the assessment. She would also expect staff to care plan the resident for [MEDICAL TREATMENT] treatment. | |
F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident’s well being. **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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 60) This affected six of 29 sampled residents and three expanded sampled residents (Residents #126, #47, #50, #12, #143, #39, #89, #139 and #114). The census was 148. Review of the facility’s External Reporting of Abuse, Neglect, theft and Crimes policy, dated 1/2012, showed: -It is the policy of this facility to establish external reporting guidelines for facility staff in the event they become aware or formulate a reasonable suspicion that abuse, neglect, theft or a crime has been committed against a resident of the facility: -Upon receipt of an allegation of abuse, neglect, theft or that a crime has occurred against a resident the facility Administrator or his/her designee will initiate external reports to the department; -The administrator or designee will contact the department immediately but no later than 24 hours following an observed event, allegation or formulation of a reasonable suspicion that a crime occurred against a resident that did not result in serious bodily injury; -In cases of serious bodily injury the administrator will contact the department immediately but no later than 2 hours from the time of the allegation or formulation of the reasonable suspicion that a crime was committed against a resident; -Within 5 business (working) days from the event or report the facility will submit a report to the department that will contain a description of the initial allegation, description of the investigation and the facts obtained, a brief conclusion based on the information obtained during the investigation, a description of any corrective actions taken if necessary; -The policy failed to require that in response to any allegations of abuse the facility must: Ensure all alleged violations are reported immediately. No later than 2 hours if the allegation involve abuse or result in serious bodily injury. Review of the facility’s Resident Protection During Abuse Investigations policy, dated 1/2012, the facility desires to establish a resident secure environment and will take steps to protect residents from exposure to additional acts of mistreatment following an allegation or reported instance of abuse, neglect, theft or criminal action committed against the residents while an investigation is conducted: -Resident to resident events: Residents who allegedly abuse another resident should be removed from contact with other residents until such time that reasonable clinical judgement determines that their behavior no longer poses a significant risk to other residents or until the investigation is concluded. 1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 10/4/18, showed: -Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had moderately impaired cognition; -No behaviors; -[DIAGNOSES REDACTED]. Review of the Resident #126’s progress notes, dated 10/30/18, showed Resident A was speaking with another resident, when Resident B brushed up against Resident A in passing. A small verbal commotion followed and Resident A yelled, I’m not a boy! Resident A moved toward Resident B in an aggressive manner, but never raised his/her hands in an attempt to strike. Resident B then struck Resident A on the right side of his/her face. Residents swiftly separated. Cold compress applied to right side of face. Slight swelling noted. Skin intact. No discoloration noted. Complaints of tenderness to touch. Praised his/her coping skills, of not retaliating physically. Encouraged to walk away from confrontations. Verbalized understanding. Review of Resident #47’s admission MDS, dated [DATE], showed; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 61) -A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition; -No behaviors exhibited; -[DIAGNOSES REDACTED]. Review of Resident #47’s progress notes, dated 10/31/18, showed staff reported while in the hallway, another resident was speaking with someone else, when this resident brushed up against the first resident in passing. A small verbal commotion followed and the other resident yelled, I’m not a boy! Staff reports that resident moved toward this resident in an aggressive manner, but never raised his/her hands in an attempt to strike. This resident then struck the other resident on the right side of his/her face. Residents swiftly separated. Encouraged him/her to walk away from confrontations. Verbalized understanding, but still claimed that the other resident is trying to, make you all go against me. Reiterated to him/her there was no need to strike him/her, especially since he/she him/herself had not been hit. Also spoke to him/her about utilizing better conflict resolution techniques during confrontations. Observation on 11/8/18 at 12:00 P.M., Resident #126 told Licensed Practical Nurse (LPN) H that resident #47 was going to hit him/her. The resident was told to sit far away from Resident #47 and he/she would monitor everyone in the dining room. During an interview on 11/9/18 at 12:04 P.M., the Director of Nursing (DON) said if there was an altercation, she would talk to the residents. The DON was not aware that a resident was hit. She would expect staff to report and investigate it the incident. There are systems in place per the facility’s policy if there was a resident to resident altercation. Staff are expected to talk to the residents, notify the physician, and ask for a psych consult to make sure it is an isolated incident. If there was an ongoing problem, they would notify the physician to check labs and medications. 2. Review of Resident #50’s quarterly MDS, dated [DATE], showed: -A BIMS score of 15, showed the resident was cognitively intact; -Had hallucinations and delusions; -[DIAGNOSES REDACTED]. Observation on 11/6/18 at 9:56 A.M., the resident reported to Certified Nursing Assistant (CNA) W that LPN X and LPN Y pulled his/her hair and poked him/her in the stomach on a different day. CNA W was observed writing the resident’s interview. During an interview on 11/7/18 at 12:05 P.M., the administrator said if a resident reported abuse, it would be the facility’s policy to investigate, find out which staff member and if the person was here, they would be suspended the staff member pending the investigation. They would do a skin assessment to check for injury. Staff did not report the incident to the administrator. She would expect CNA W to report it to the nurse manager and it would be reported to the administrator. She would expect them to follow the facility’s policy. If abuse occurred, they would contact the department within two hours. 3. Review of Resident #12’s quarterly MDS, dated [DATE], showed: -BIMS score of 8 out of 15, showed moderate cognitive impairment; -Independent with all Activities of Daily Living (ADLs); -Physical behaviors directed toward others: Behavior not exhibited; -Verbal behaviors directed toward others: Behavior not exhibited; -Other behaviors not directed at others including pacing and rummaging: Behavior not exhibited. Review of Resident #12’s progress notes, showed: -On 7/31/18 at 9:22 A.M., the resident was screaming very loudly and this writer went down the hall to find him/her. He/she was lying on the floor in another resident’s room screaming and moving around on the floor. When asked what happen he/she stated he/she |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 62) pushed me down. I am hurting. He/she was able to move all extremities without complaints of pain and no difficulties, grimacing or indication of pain exhibited. Assisted off of the floor by two staff and assisted into a wheelchair.; -On 8/1/18 at 10:36 P.M., Resident alert to self and is confused, redirected several time throughout shift from other peoples room. -On 8/2/18 at 3:12 A.M., Day 2 of 3 for incident follow up. Resident in bed, no acute distress noted. No signs behavior at this time; -The notes did not show after the initial incident what interventions were put in place to show how the nursing staff was monitoring Resident #12 in order to prevent him/her from coming back into contact with the other resident or notification to the department of the alleged resident to resident abuse. Review of Resident #12’s Unwitnessed Fall Occurrence Report, dated 7/31/18 showed: -The resident had an unwitnessed fall on 7/31/18; -Upon entering the room, the resident was found lying on his/her back on the ground, screaming he/she pushed me down and moving; -The resident stated that he/she was pushed down while in another resident’s room; -No injuries were observed at the time of the incident; -Pain, consciousness and mobility at the time of the incident were left blank; -Pain, consciousness, mobility and mental status [REDACTED]. -Other information: the resident wanders into other resident’s rooms; -Witnesses: no witnesses; -Agencies/people notified: No notifications found; -No summary of the investigation, no cause, and no interventions taken at the time of the incident and post incident noted. No behavior incident report provided upon request; -The occurrence report did not identify what monitoring measures the facility staff put in place after the resident first pushed down Resident #12, in order to prevent the second occurrence 2 days later; -The facility was unable to provide an abuse investigation for this incident. The 7/31/18 incident was reported and investigated as a fall only. Further review of Resident #12’s progress notes, showed: -On 8/2/18 at 3:55 P.M., reported this resident was struck in the chest by another resident. Residents separated. Physical assessment revealed no injury. Physician notified. No new orders; -On 8/3/2018 at 1:53 A.M., resident must be redirected out of other room when awake; -On 8/3/2018 at 3:39 P.M., no discoloration to chest noted; -On 8/5/2018 at 11:12 A.M., redirected several times throughout shift, resident going through other clothing, lying in their beds, standing in others room; -The notes did not show, after the second incident what interventions (other than separating the residents) were put in place to show how the nursing staff was monitoring Resident #12 in order to prevent him/her from coming back into contact with the other resident or notification to the department regarding the alleged resident to resident abuse. Review of Resident #12’s Physical Altercation Occurrence Report, dated 8/2/18, showed: -The resident stated another resident hit him/her; -The residents were separated and a physical assessment was completed; -No injuries were observed at the time of the incident; -Pain, consciousness and mobility at the time of the incident: Blank; -Mental status at the time of the incident: Blank; -No injuries noted post incident; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 63) -Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing environmental factors: Blank; -Predisposing physiological factors: Blank; -Predisposing situation factors: Wanderer; -Other information: Blank; -Witnesses: No witnesses found; -Agencies/people notified: The physician and the Power of Attorney (POA) notified 8/2/18 at 4:30 P.M. No documentation the department notified; -No summary of the investigation, no cause, and no interventions taken at the time of the incident and post incident noted. Review of Resident #143’s Significant Change MDS, dated [DATE], showed: -BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment); -Physical behaviors directed toward others: Behavior not exhibited; -Verbal behaviors directed toward others: Behavior not exhibited; -Other behaviors not directed at others including pacing and rummaging: Behavior not exhibited. Review of the Resident #143’s Social Services Note, dated 8/24/18 at 12:15 P.M., showed: Called and left a voicemail message for the resident’s family member to contact us regarding a meeting needing to be scheduled to discuss resident’s behavior in being physically aggressive toward other residents. Due to the communication barrier, it is best if resident’s family is involved in order to translate the information. Review of Resident #143’s progress notes, showed the resident was in a physical altercation with Resident #12 on 8/10/18 and 8/24/18. When asked, on 11/13/18, if Resident #12’s Occurrence Reports for the incidents on 7/31/18 and 8/2/18 were the only documentation the facility had for both incidents, the DON said yes. During an interview on 11/13/18 at 7:40 A.M., CNA AA said: -Resident #12 wanders into other resident rooms, once we hear him/her hollering out we will go get him/her and take him/her to the day area or dining room; -Resident #143 can be aggressive if someone goes into his/her room. Staff will just remove the other resident from his/her room; -If a resident accuses another resident of hitting/pushing/kicking/tripping them, we separate them and take one to another area of the unit or facility. If one of the resident’s is in the wrong room staff will separate them and take the resident out of the other resident’s room. If staff notice anything out of the ordinary, staff will let the nurse know; -Any allegations of abuse need to be reported to the nurse immediately; -There are no residents that require 15 minute checks. During an interview on 11/13/18 at 7:48 A.M., LPN BB said: -Any allegations or suspicions of abuse should be documented and followed up on. -If a resident to resident altercation occurs, staff should immediately separate the residents, notify the DON and Administrator, call both resident’s physicians and family, and both residents should be assessed for injury; -He/she was not present when the incidents occurred between Residents #12 and #143; -Any incidents such as a resident pushing another resident down or hitting another resident is abuse and should be reported to DON and Administrator, an incident report completed, and documented in a nurse’s note; -If a resident said someone pushed him/her down, it would be both fall and abuse. Documentation should reflect both; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 64) -It is not appropriate to just redirect a resident out of the room. There needs to be a thorough investigation completed; -He/she is not aware of any residents that require 15 minute checks for behaviors. 4. Review of Resident #39’s quarterly MDS, dated [DATE], showed: -BIMS score of 15 out of 15, shows the resident is cognitively intact; -[DIAGNOSES REDACTED]. -Has hallucinations. Review of the resident’s progress notes, showed: -On 10/21/18, resident to resident altercation. Resident hit another resident in the face and knock off his/her glasses. The resident’s face on left side is slightly swollen. Residents sent to their rooms. Ice pack applied to the resident’s face but he/she took it off of his/her face. He/she stated he/she did not want it on his/her face. Physician notified of the altercation between the residents, no new orders given. During an interview on 11/9/18 at 12:14 P.M., the Director of Nursing said she was not aware of the altercation. She would expect staff to notify her. 5. Review of Resident #89’s quarterly MDS, dated [DATE], showed: -A BIMS score of 14, showed the resident was cognitively intact; -Physical behaviors in the last one to three days; -[DIAGNOSES REDACTED]. Review of the resident’s progress notes, dated 10/19/18, showed: -At 7:07 A.M., therapy reported to nurse that the resident hit another resident, unwitnessed by staff, when asked what happen, resident stated, he/she pushed me and he/she hit him/her back. Resident separated, physical assessment performed, no bruising, or discoloration noted. Denies pain; -At 2:59 P.M., continues on observation related to unwitnessed altercation. Resident noted upset with another peer this morning because he/she says that the other resident keeps asking for food and is always coming in the room. Redirection given to calm resident. No other mood changes or physical aggression noted; -At 3:19 P.M., nurse practitioner aware of altercation. No new orders received. During an interview on 11/09/18 at 12:18 P.M., the DON said if there was an unwitnessed altercation, he/she would expect there to be an investigation. If resident said someone hit him/her, they would investigate to make sure it really happen. The DON was not aware of the altercation that involved the resident. She would have expected staff to report all altercations to her. 6. During an interview on 11/13/18 at 9:05 A.M., the DON said: -With resident to resident altercations, he/she would expect nursing staff to separate the residents, the nurse to complete a physical assessment of each resident, notify the residents physicians and family and follow any physician’s orders [REDACTED]. -He/she would also expect the nursing staff to monitor the residents to ensure their safety and well-being and the safety and well-being of other residents; -He/she expects the resident’s care plan interventions to be implemented to help manage the resident’s behaviors; -The facility wouldn’t investigate the incident as abuse due to confusion if the resident alleging the push is confused and so is the resident that pushed him/her down; -It would be appropriate to separate and monitor to make sure residents are kept away from each other; -The incident should be reported to the state agency (the department) as an FYI (for your information), if nothing else; -He/she doesn’t know why the incidents were not reported; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 65) -Policy is to notify the DON and Administrator immediately of any abuse allegations or suspicions; -He/she expects staff to follow the abuse policy; -All staff has been educated on the abuse policy; -He/she knows what abuse is and what to investigate; -He/she does report abuse to the state agency. 7. Review of the facility’s most recent training on resident to resident altercations, dated 2/26/18, showed: -The facility desires to establish a resident secure environment and will take steps to protect residents from exposure to additional acts of mistreatment following an allegation or reported instance of abuse while an investigation is conducted; -Resident to resident events: Residents who allegedly abuse another resident should be removed from contact with other residents until such time that reasonable clinical judgement determines that their behavior no longer poses a significant risk to other residents or until the investigation is concluded; -The in-service failed to clearly train staff that resident to resident altercations should be reviewed as a potential situation of abuse. 8. Review of the facility’s most recent abuse training, dated 10/5, 10/6, 10/8, 10/16, 10/18, 10/22 and 10/31/18, showed: -It is the policy of the facility to develop mechanism to reduce the risk of abuse, neglect, misappropriation of resident property and/or crimes from being committed against the residents of this facility. This will be done by implementing the following systems and/or practices; -Facility staff will investigate and report any allegations of abuse within timeframes required by Federal law; -Residents will be protected from harm and/or further abuse during an abuse investigation; -Any allegation of abuse will be reported immediately to the facility administrator or designee; -Report violations of the regulations or facility policy, report any resident abuse, document care timely; -Upon receipt of an allegation or upon the formation of a reasonable suspicion that abuse occurred, the administrator or designee will report to Missouri’s complaint hotline; -The in-service failed to train staff on resident to resident abuse. 9. Review of Resident #139’s annual Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 10/13/18, showed: -Total dependence on two-person physical assist for transfers; -[DIAGNOSES REDACTED]. Observation on 11/7/18 at 3:47 P.M., showed Certified Nursing Assistant (CNA) E and CNA J transfer the resident from bed to the wheelchair. Without the use of a gait belt, CNA E stood on one side of the resident and CNA J stood on the other side. Staff placed one arm under the resident’s arm and grabbed onto the resident’s waste band with the other hand, CNA E said one, two, three and staff picked the resident up out of the bed. The resident’s extremities remained contracted. His/her knees bent in a sitting position and arms pulled inward. During the transfer, the resident’s legs remained contracted up and his/her feed did not touch the floor. Staff placed the resident in the wheelchair. CNA J said the resident is supposed to be a two person assist, but staff can do it with one person if needed. 10. Review of Resident #114’s quarterly MDS, dated [DATE], showed: -Extensive assistance of two-person physical assist required for transfers; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 66) -Mobility devices: Wheelchair. Observation on 11/7/18 at 7:24 A.M., showed CNA A provided care to the resident and transferred the resident to his/her wheelchair. CNA A assisted the resident to sit on the edge of his/her bed by pulling on the resident’s hands and sat the resident on the side of the bed. The resident unable to remain in a seated position and started to fall back and to the side. CNA A grabbed the resident by the back of his/her neck and pulled the resident up into a sitting position. CNA A placed a gait belt around the resident’s waste. As he/she did this, the resident began to slouch and fall over to the side. The resident remained in a tilted slouched position in the bed as CNA A placed the resident’s wheelchair against the wall and said the resident’s wheelchair don’t lock so he/she has to prop it against the wall. CNA A said he/she put in a requested for maintenance to fix it yesterday, but it had been broken for one or two weeks. CNA A straddled the resident and instructed the resident to hold on to his/her waste and picked up the resident with the use of the gait belt. The resident did not bear weight. CNA A twisted the resident and the tips of the resident’s feet remained on the floor, twisted slightly from the direction of his/her legs and body. After several prompts from CNA A, given as he/she held the resident up with the use of the gait belt, the resident was able to pivot his/her feet so they were no longer twisted. CNA A placed the resident in the wheelchair. He/she then placed the left foot rest on the resident’s wheelchair, placed his/her left foot on the foot rest and then placed the right foot on top of the left foot. CNA A said the wheelchair was broken and the right foot rest no longer connected to the wheelchair. CNA A propelled the resident out of the room and into the hall with both feet on one foot rest. 11. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said a resident’s transfer status should be included in the care plan. A resident’s transfer status is based on the resident’s physical ability to transfer. Staff know how to transfer a resident by looking in the ADL section of the electronic medical record. This is also passed on in report. For a gait belt transfer, residents should be able to bear weight. Staff should use a gait belt. If a resident is unable to bear weight, she would expect staff to get them in a safe position and get help. Staff should not pull on a resident’s hands or neck to assist to sit them to sit up. A resident’s feet should touch the floor during a transfer unless they are contracted. Then two people can just lift them. Everyone is responsible to make sure residents can be transferred safely. Staff should not pick residents up by their waste band. Staff should not pick residents up under their arms because this could cause injury to the residents or staff. She was not aware that acceptable standards of practice indicate a resident should be able to bear weight and assist in transfers to qualify for a gait belt transfer. 12. Review of the facility’s Lifting and Transferring Residents policy, dated 1/1/06, showed: -All residents requiring assistance with mobility should be lifted and transferred safely; -Members of the nursing staff are responsible for using good body mechanics, knowing the proper transfer procedures and properly operating assistive devices. Residents are assessed by the nursing and/or therapy departments for lifting and transfer needs and for the most appropriate transfer method(s); -For residents requiring assistance in lifts and transfers, a gait/transfer belt or mechanical lift should be used; -Assess the resident to determine physical limitations and ability to follow directions; -The method for transfer and/or lift that is appropriate for each resident can be found in individual resident care plans; -Lock wheels on bed and/or wheelchair; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 67) -The resident’s hands should remain free during the transfer; -Staff should not place their hands under a resident’s arms or shoulders in order to prevent shoulder injury; -Grasp transfer belt from underneath; -The policy failed to identify that residents transferred with the use of a gait belt must be able to bear weight or what qualified or disqualified a resident from using a gait belt transfer. 13. Review of the facility’s most recent in-service attendance record for transfers, dated 10/31/18, showed: -Assume for most lifts you will need help or mechanical assistance; -Definitely get help if the resident is immobile, heavy, uncooperative or attached to tubes and wires; -It is sometimes safe to lift residents alone or with minimal help. These situations include residents who are mobile and require just a little assistance, residents who are already standing and situations where you can safely perform the lift alone, with the aid of a mechanical device such as a belt. 14. During an interview on 11/13/18 at 7:53 A.M., the staff development coordinator said she is responsible for staff training. Staff determine a resident’s transfer status during the clinical meetings. In-servicing is completed every two weeks. She would expect staff to be able to recognize when a resident is unable to be transferred with a gait belt assist. Training is provided in classroom settings. Demonstrations are completed as well. | |
F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 68) Review of the resident’s medical record, showed the following: -An admission date of [DATE]; -[DIAGNOSES REDACTED]. -A physician order [REDACTED]. -A Medication Administration Record [REDACTED]. Review of the resident’s care plan, dated 12/14/17, showed: -Focus: Resident uses anti-anxiety medications; -Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift; -Consult with pharmacy and physician to consider dosage reduction to [MEDICATION NAME]; -The resident is taking anti-anxiety medications which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs; -Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, and hallucinations. Review of the resident’s medication regimen review, dated 5/25/18, 7/19/18, and 9/29/18, showed: -Discontinue PRN [MEDICATION NAME]. These medications are only valid for 14 days and require extensive documentation to be continued beyond that window. Please discontinue or schedule; -No physician response. 2. Review of the Resident #123’s electronic Face Sheet, showed [DIAGNOSES REDACTED]. Review of the resident’s POS, showed an order, dated 7/30/17, for [MEDICATION NAME] solution 2 mg per milliliter (ml), inject 0.25 mg IM every six hours PRN for agitation. Review of the resident’s MAR, dated 10/1/18 through 11/8/18, showed [MEDICATION NAME] 0.25 mg PRN was not administered. Review of the resident’s medication regimen review, dated 7/19/18, showed: -Discontinue PRN [MEDICATION NAME]. Please remember this order is only good for 14 days and requires documentation on behaviors to be continued; -No physician response. 3. During an interview on 11/09/18 at 11:57 A.M., the Director of Nursing (DON) said if pharmacy has a recommendation, the written report is given to the DON. Depending on the recommendation, she will forward it to the physician. She would expect the physician to respond within seven days. The DON is responsible for ensuring the pharmacy recommendations are followed through with an answer from the physician and any changes made to the resident’s medications. The DON was aware PRN [MEDICAL CONDITION] medications can only be ordered for 14 days. She would expect to have new physician orders [REDACTED]. The facility does not have a pharmacy recommendation review policy. | |
F 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident’s drug regimen must be free from unnecessary drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 69) to have ongoing monitoring of the effectiveness of the [MEDICAL CONDITION] medications. This affected one out of eight residents investigated for unnecessary medications (Resident #102). The census was 148. Review of Resident #102’s medical record, showed: -admitted [DATE]; -[DIAGNOSES REDACTED]. Review of the resident’s physician order [REDACTED]. -An order, dated 12/6/16, for [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) 3 milligram (mg) tablet at bedtime (HS) for [MEDICAL CONDITION]; -An order, dated 5/27/18, for [MEDICATION NAME] HCI (medication used to treat depression and [MEDICAL CONDITION]) tablet 150 mg HS for [MEDICAL CONDITION]; -An order, dated 6/27/18, for [MEDICATION NAME] Capsule (used to treat allergy symptoms and can be used for [MEDICAL CONDITION]) 50 mg for [MEDICAL CONDITION] at HS. Review of the resident’s Medication Administration Record [REDACTED] -An order, dated 12/6/16, for [MEDICATION NAME] 3 mg HS for [MEDICAL CONDITION] was administered as ordered; -An order, dated 5/27/18, for [MEDICATION NAME] 150 mg HS was administered as ordered; -An order, dated 6/27/18, for [MEDICATION NAME] Capsule 50 mg HS was administered as ordered. Review of the resident’s care plan, reviewed 11/9/18 and in use at the time of the survey, showed no documentation of the resident’s [MEDICAL CONDITION]. Observation of the resident on 11/8/18 at 11:30 A.M. and 11/8/18 at 4:41 P.M., showed the resident in bed with his/her eyes closed. During an interview on 11/8/18 at 4:46 P.M., Licensed Practical Nurse (LPN) H said the resident sleeps a lot. He/she is only up for meals. That is his/her routine. Observation on 11/8/18 at 5:57 P.M., showed the resident in the dining room during meal service. He/she sat at the table with his/her eyes closed. Staff asked the residents in the dining room if anyone else needed to be served. The resident continued to sit at the table with his/her eyes closed. Other residents in the dining room pointed out that the resident needed to be served before the dietary staff left the room. Review of the resident’s progress notes, showed no documentation of the monitoring the resident’s [MEDICAL CONDITION], non-pharmological interventions attempted or gradual dose reduction (GDR) attempted for the use of the [MEDICAL CONDITION] medications. During an interview on 11/9/18 at 9:00 A.M., the Director of Nursing (DON) said the facility does not have a pharmacy recommendation review policy. At 11:43 A.M., the DON said if a resident had [MEDICAL CONDITION] and was alert and oriented enough, they would tell the staff they were having trouble sleeping. Staff would complete rounds to identify if a resident was experiencing [MEDICAL CONDITION]. Once there are physician’s orders [REDACTED]. If a resident was sleeping all day, they would look at other issues to make sure there was not a new disease process. The nurse practitioner prescribed the medications. The DON was not familiar with the resident’s sleep habits. During an interview on 11/9/18 at 11:45 A.M., Care Coordinator I said the resident’s [MEDICAL CONDITION] could be related to [MEDICAL CONDITION]. His/her behavior cycles and he/she can be more engaged, pace, and make rounds in the hallway. There is a three month quarterly evaluation when the medications are reviewed. They discuss the resident’s medications with the physician and they determine if a GDR is appropriate or if the resident is stable. During an interview on 11/9/18 at 11:50 A.M., the resident’s nurse practitioner said the resident had chronic [MEDICAL CONDITION]. He/she slept 1 or 2 hours and he/she was then |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0757 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 70) awake. The nurse practitioner did not want to give a larger dose of [MEDICATION NAME], so the resident was prescribed [MEDICATION NAME]. | |
F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 71) -Discontinue PRN [MEDICATION NAME]. These medications are only valid for 14 days and require extensive documentation to be continued beyond that window. Please discontinue or schedule; -No physician response. Observation on 11/6/18 at 1:52 P.M., showed the resident wore a safety helmet as he/she sat in the dining room. During an interview on 11/9/18 at 11:57 A.M., the Director of Nursing (DON) said she was aware PRN [MEDICAL CONDITION] medications can only be ordered for 14 days. Medications should have an indication for use and staff should be documenting the effectiveness of medications. 2. Review of the Resident #123’s electronic Face Sheet, showed [DIAGNOSES REDACTED]. Review of the resident’s POS, showed an order, dated 7/30/17, for [MEDICATION NAME] solution 2 mg per milliliter (ml), inject 0.25 mg IM every six hours PRN for agitation. Review of the resident’s MAR, dated 10/1/18 through 11/8/18, showed [MEDICATION NAME] 0.25 mg PRN was not administered. Review of the resident’s medication regimen review, dated 7/19/18, showed: -Discontinue PRN [MEDICATION NAME]. Please remember this order is only good for 14 days and requires documentation on behaviors to be continued; -No physician response. Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/17/18, showed: -BIMS score of 00 out of 15, which showed severely cognitively impaired. -[DIAGNOSES REDACTED]. -Displays little interest or pleasure in doing things and is short-tempered and easily annoyed; -Displays physical and verbal behaviors directed at others; -Antipsychotics and antidepressants administered in the last seven days; -Antipsychotics used on a routine basis; -No GDR attempted; -GDR has been documented by a physician as clinically contraindicated; -Medication follow-up: not assessed/no information. Review of the resident’s current care plan, in use at time of the survey, showed no care plan for anti-anxiety medications. Review of the resident’s medical record, showed no physician documented rationale in the resident’s medical record and indicate the duration for the PRN order. Observation on 11/06/18 at 12:38 P.M. showed the resident sat in his/her wheelchair in the dining room feeding himself/herself meatloaf, mixed vegetables and mashed potatoes without difficulty. The resident appeared calm and pleasant. No signs of anxiety or agitation noted. On 11/7/18 at 10:18 A.M., the resident sat in his/her wheelchair in his/her room. The resident appeared calm with no signs of agitation or anxiety. The resident was pleasant and said he/she was doing good and had not had any feelings of anxiety that day. During an interview on 11/9/18 at 11:57 A.M., the DON said she was aware PRN [MEDICAL CONDITION] medications can only be ordered for 14 days. Medications should have an indication for use and staff should be documenting the effectiveness of medications. 3. Review of Resident #39’s quarterly MDS, dated [DATE], showed: -A BIMS score of 15 out of 15, which showed the resident is cognitively intact; -[DIAGNOSES REDACTED]. -Antipsychotics, antianxiety and antidepressants administered in the last seven days; -Antipsychotics used on a routine basis; |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 72) -No GDR attempted; -GDR has not been documented by a physician as clinically contraindicated; -No documentation of a [DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 8/9/17, showed: -Focus: Resident uses anti-anxiety medications related to anxiety disorder and antidepressants due to depression and antipsychotic medication use; -Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift; -Monitor/document/report PRN any adverse reactions to anti-anxiety: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, and hallucination; -Monitor/record occurrence of for target behavior symptoms (specify pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol; -Further review of the resident’s care plan, showed no documentation of a [DIAGNOSES REDACTED]. Review the resident’s medical record, showed: -[DIAGNOSES REDACTED]. -A POS, dated 11/1/18 through 11/30/18, showed an order dated 11/8/17, for [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) tablet 10 mg, give one tablet by mouth at bedtime for Alzheimer’s; -A MAR, dated 11/1/18 through 11/9/18, showed an order dated, 11/8/17, for [MEDICATION NAME] 10 mg, documented administered as ordered. During an interview on 11/13/18 at 9:00 A.M., the DON said she was not sure if the resident had a [DIAGNOSES REDACTED]. 4. During an interview on 1/13/18 at 9:00 A.M., the DON said the facility does not have a pharmacy regimen review policy. | |
F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure medication error rates are not 5 percent or greater. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 73) resident. He/she administered lactose enzyme supplement dietary aide one tablet, [MEDICATION NAME] 1 mg tablet and [MEDICATION NAME] 150 mg tablet. He/she did not administer [MEDICATION NAME] to the resident. During an interview on 11/7/18 at 3:21 P.M., LPN F said the [MEDICATION NAME] was not administered because it was not available in the facility. Review of the resident’s progress notes, reviewed on 11/8/18 at 10:19 A.M., showed no documentation of the physician contacted regarding the medications not administered before meals as ordered. During an interview on 11/8/18 at 9:56 A.M., the Director of Nursing said medications should be administered as ordered. If a medication is ordered to be administered before meals, she would expect staff to follow these instructions. If a resident is going out for a scheduled lunch outing, staff should administer the medications before the resident leaves or they should contact the physician. [MEDICATION NAME] is not a stock medication, but LPN F said he/she did administer the medication on 11/7/18 because it was available in the medication dispensing machine. It was administered 2:30 P.M. | |
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. **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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0805 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 74) 2/7/18, for a regular diet, mechanical soft texture, regular consistency. Observation on 11/6/18 at 12:46 A.M., showed the dietary staff served residents lunch in the main dining area. The dietary staff had several plates of food on a serving cart. The dietary staff served the resident a plate of food that consisted of a smothered pork chop, mashed potatoes and mixed vegetables. There were no observed meal tickets used by dietary staff when serving the residents lunch to alert dietary staff to the residents’ diet orders. 4. During an interview on 11/13/18 at 10:37 A.M., the dietary manager said the dietary aides should know which residents are ordered a mechanical soft diet. There is a list in the office, so they know how many they have. They had meal tickets, but she wanted to change to the laminated diet cards. The staff generally know the residents. | |
F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 75) the potatoes based on the type of meat requested. Staff brought out several more carts of plates which contained the same food options and passed plates of food until all residents were served. During an interview on 11/13/18 at 10:38 A.M., the dietary manager said residents should be given choices for meals. When staff take the carts with food out, they ask residents what they want to eat. All residents on a regular diet should be offered the same choice of sides. 5. Observation on 11/6/18 at 12:42 P.M., showed the residents in the 3 South dining room were all served meatloaf or smothered pork chops. The sides served were new potatoes and mixed vegetables. The residents were also served juice, coffee, bread and a chocolate cake. Resident #74 asked Certified Nurse Aide (CNA) M for more butter. CNA M said, We don’t have anymore. Resident #74 walked around the dining room and asked another resident if they had extra butter, but the resident said he/she did not have any. Resident #74 asked another resident for butter and received one slice of butter. Resident #50 asked CNA M for ice cream. CNA M said, We’re not serving ice cream today. CNA M served the residents juice after their meals were served. CNA M poured juice into the residents’ glasses until the three pitchers of juice were empty. CNA said, We ran out of juice. A resident yelled out for coffee and CNA M said, There’s no more. The same resident asked for more juice, and the CNA M said, There’s no more. A resident was observed offering his/her slices of butter to another resident after he/she finished the meal. 6. Review of Resident #66’s quarterly MDS, dated [DATE], showed a BIMS score of 15 out of a possible score of 15, which showed the resident cognitively intact. During an interview on 11/6/18 at 12:56 P.M., the resident said there is not enough food that he/she likes. A few days ago, the facility served hotdogs and all the residents were given was one hotdog. Residents were not given the option to have seconds. 7. Observation on 11/7/18 at 8:00 A.M., showed the residents sat in the dining room on 3 South. CNA M served the residents their meal. A resident was observed asking for more coffee and CNA M said there was no more coffee. There were two empty coffee pitchers on the cart. A resident asked if there was more cereal. CNA M said no. 8. Observation on 11/7/18 at 12:39 A.M., showed the residents in the dining room on 3 South were served taco bake or fried chicken. Residents served taco bake received only broccoli as the side dish. Residents served fried chicken also received broccoli, rice and a biscuit. 9. Review of Resident #2’s annual MDS, dated [DATE], showed a BIMS score of 12 out of a possible score of 15, which showed the resident cognitively intact. Observation on 11/7/18 at 12:57 P.M., showed the resident sat in the hall outside the 2 South nurses’ station. He/she said the food is dry and flavorless. Staff do not serve the type of food he/she likes. He/she wants to be served food like greens and cornbread. He/she does not want what is served and will not eat it. A staff person walked by and asked the resident if he/she wanted a sub sandwich for a substitute. The resident told the staff person that he/she could not chew that. The staff person continued to walk down the hall and did not offer to provide any further food alternatives. 10. During the resident group meeting on 11/8/18 at 9:00 A.M., the residents said dietary staff make just enough for all the residents to receive one plate. Sometimes seconds are not served because they run out. Some aides do not want to go to the kitchen to get more food or beverages. Milk and chocolate milk isn’t served consistently. Sometimes the residents are not served milk for breakfast and sometimes chocolate milk is served during lunch or dinner, but not all the time. French fries are always served with burgers or hotdogs. There are no other options, especially for residents who are diabetic and want to |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 76) watch their carbohydrate intake. They were served one hotdog for dinner last weekend. The residents said they should have received two hotdogs. French fries were served with the hotdogs. 11. Observation on 11/8/18 at 12:25 P.M., 12:39 P.M. and 12:45 P.M., showed: -At 12:25 P.M., there were approximately 45 residents in the main dining room. The residents in the main dining room were served milk, chocolate milk, water, coffee and juice. Each table had a pitcher of coffee and juice. At 12:39 P.M., the residents in the main dining room had a choice of ravioli and salad or cheeseburger and French fries. Country fried steak was not an option provided; -At 12:45 P.M., the residents in the dining room on 3 South were served their meal. The residents were served ravioli and the substitute was country fried steak. The residents were not served milk or chocolate milk. Cheeseburger was not an option provided. 12. Observation and interview on 11/8/18 at 5:29 P.M., showed: -The residents in the dining room on 3 South were served beverages. There were three pitchers of coffee and three pitchers of juice. There were no observations of the residents served milk or chocolate milk. Resident #74 said they only receive milk and chocolate milk for breakfast and dinner; -The board outside the main dining room showed the substitute was hamburger and sweet potato fries. The residents in the main dining room received grilled turkey melt sandwich with sweet potato fries. The substitute was cheese burger with French fries. The residents in the main dining were served milk and chocolate milk with their meal. The residents were not offered the option between sweet potato fries or French fries; -At 5:40 P.M., the residents in the dining room on 3 South were served milk and chocolate milk with their meal. The residents were served a grilled turkey melt sandwich with sweet potato fries or a cheeseburger with French fries. The residents were not offered the option between sweet potato fries or French fries; -At 6:00 P.M., the residents on 3 Main were served chocolate milk and milk. The residents were served grilled turkey melt sandwiches with sweet potato fries or a cheeseburger with French fries. After half of the residents were served their meal, Dietary Aide N said they ran out of hamburger buns and French fries. There were approximately 12 residents that had not received their meal. At 6:08 P.M., Dietary Aide M returned to the dining room with French fries and hamburger buns. There were no more sweet potato fries. Dietary Aide N said they ran out of hamburgers, so the rest of the residents received the grilled turkey melt sandwiches with French fries. Resident #94 asked for a hamburger, but was told there was no more. The resident was served a mechanical soft turkey melt. 13. During an interview on 11/9/18 at 2:27 P.M., Cook O said they never run out of food. The substitutes are decided by how much food is left over. If there was a lot left over from dinner, then it would be served as an alternate for lunch on the next day. 14. During an interview on 11/13/18 at 10:37 A.M., the dietary manager said if there was a substantial amount of the main meal left over from the day before, they would use that as a substitute. If they have extra hotdogs or hamburgers, they would serve that. She wanted to serve what the residents like. The residents on the third floor are served a different substitute than the residents eating in the main dining room, but not all the time. Sometimes there isn’t enough of one item. They will receive something different on another floor. Sometimes the substitute outweighs the main meal. The turkey melt was the main meal, but the dietary manager did not prepare enough hamburgers for the residents. She did not expect the majority of the residents to ask for hamburgers. She would expect the residents to be aware there are other options for substitutes, not just what is taken to the third floor. She would expect the residents to have a choice of the side dish. |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 77) Residents are able to receive seconds. If they ask for milk, she would expect staff serve the residents a beverage of their preference. She was not aware of the residents not offered milk for all three meals, or milk taken to the third floor for the residents. If the residents wanted chocolate milk, she would expect it to be served. She was aware of the issue of the residents receiving one hotdog over the weekend. The residents should have receive two hotdogs if they wanted two. She was told they ran out, but when she checked, there were plenty of hotdogs left. There were no issues of running out of food. | |
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 all health shakes and |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0813 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Based on interview and record review, the facility failed to produce an on-site policy | |
F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 79) Review of the facility’s Perineal Incontinence Care policy, dated 1/1/06, showed: -Standard: To provide cleanliness and comfort, prevent irritation and infection in the perineal area during the daily bath and after voiding or defecating; -Assemble equipment at bedside; -Wash hands; -Put on gloves; -Cleanse the genital area; -Use different sections of the washcloth with each downward stroke; -Wash the buttocks area; -Remove gloves; -Wash hands; -The policy failed to address removing gloves when changing from cleansing of the genitals to the buttocks and/or washing or sanitizing hand after glove changes. 1. Review of Resident #114’s quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 9/22/18, showed: -Clear speech, distinct intelligible words; -Makes self-understood; -Able to understand others; -Extensive assistance required for bed mobility, dressing and toilet use; -Total dependence for personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, in use at the time of the survey, showed: -Problem: Activity of daily living (ADL) care deficit related to [MEDICAL CONDITION] and limited mobility; -Goal: To be clean, odor free and well-groomed on a daily basis; -Approach: Bathe daily and as necessary. Observation on 11/7/18 at 7:24 A.M., showed Certified Nursing Assistant (CNA) A provided care to the resident. CNA A entered the resident’s room and gathered supplies. He/she placed gloves on and failed to wash or sanitize his/her hands prior to placing gloves on. CNA A said he/she needed to get more supplies, removed his/her gloves, left the room, returned and placed new glove on. CNA A failed to wash or sanitize his/her hands after returning to the room and before placing new gloves on. CNA A unsecured the resident’s brief. The resident brief wet with urine. CNA A cleansed the resident’s abdominal folds and pubic area. He/she then cleansed the resident’s genitalia. While wearing the same gloves CNA A obtained a new washcloth and washed the resident’s underarms. CNA A said he/she needed to get more supplies and, while wearing the same gloves, opened the resident’s dresser and searched through the resident’s belongings in the dresser. He/she then removed his/her gloves and left the resident’s room. He/she returned to the room and without washing or sanitizing his/her hands, CNA A placed new gloves on. CNA A assisted the resident to reposition in bed and washed the resident’s buttocks. While wearing the same gloves, CNA A applied barrier cream to the resident’s buttocks, obtained a clean brief and placed it under the resident, repositioning the resident by pushing and pulling on the resident’s knees, hips arms and back. CNA A secured the brief, put deodorant on the resident, moved the resident’s bedside table, turned on the sink, moistened a new rag and wiped the resident’s chest area. CNA A continued to wear the same gloves while he/she put powder on the resident’s chest and rub it into skin folds, grabbed some slacks and assisted the resident to place them on, assisted the resident to roll side to side, and touched the resident’s gastric tube (a tube surgically inserted into the stomach for the |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 80) purpose of providing food, fluid and medications). CNA A assisted the resident to put on shoes and a shirt. CNA A, while wearing the same gloves, assisted the resident to sit up in bed by pulling on the resident’s hands and back of his/her neck. CNA A transferred the resident to his/her wheelchair before removing his/her gloves and washing his/her hands. 2. Review of Resident #139’s annual MDS, dated [DATE], showed: -BIMS score of 0 out of a possible score of 15; -A score of 0-7 showed the resident rarely or never understood; -Extensive assistance required for bed mobility; -Total dependence for transfers, toilet use and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, in use at the time of the survey, showed: -Problem: The resident requires total care with ADLs related to stroke; -Goal: The resident will be clean, odor free and well-groomed and neat on a daily basis; -Approach: Resident totally depending on one staff for repositioning and turning in bed at least every 2 hours and as necessary. Resident has contractures (loss of muscle tone and range of motion due to loss of flexibility of the muscles and tendons) of the right arm and hand. Provide skin care daily and as needed to keep clean and prevent skin breakdown. Observation on 11/7/18 at 3:43 P.M., showed CNA E entered the resident’s room and said he/she needed to check to see if the resident was clean. He/she placed an ungloved hand down the front of the resident’s brief, said the resident was dry, removed his/her hand and exited the resident’s room. CNA E immediately entered another resident’s room. CNA E failed to wear gloves, wash or sanitize his/her hands before placing his/her hand inside the resident’s brief or before leaving the resident’s room and entering another resident’s room. During an interview on 11/7/18 at 4:25 P.M., the administrator said it was not acceptable to check for incontinence by sticking a hand down the front of a resident’s brief. 3. Review of Resident #58’s quarterly MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Severe cognitive impairment with short and long term memory problems; -No behaviors; -Range of motion impairment on one side upper and lower extremities; -Required maximum assistance from staff for transfers, dressing and bathing. Observation on 11/7/18 at 7:15 A.M., showed the resident lay in bed. CNA S went into the resident’s room and told the resident he/she was going to get him/her dressed. CNA S washed his/her hands, put on gloves and picked up a wash basin from directly off the floor. The wash basin did not have any type of covering and was not on any type of barrier. Without sanitizing or cleaning the wash basin, he/she filled the wash basin with water, placed it directly on top of the resident’s dresser, provided the resident with perineal care, dressed and transferred the resident into his/her wheelchair. After the CNA had provided care to the resident, he/she rinsed out the inside of the wash basin and placed it directly on top of the sink counter top. At 7:42 A.M., the CNA left the resident’s room. The wash basin remained on top of the sink counter top without any type of covering or barrier. During an interview on 11/13/18 at 9:05 A.M., the Director of Nursing (DON) said it would never be appropriate to store or use a wash basin that had been sitting directly on the floor without any type of covering or barrier due to infection control issues. 4. During an interview on 11/13/18 at 9:00 A.M., the DON said while providing incontinence care, she would expect staff to change gloves when going from the front area to the back |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 81) and when the gloves are potentially contaminated. Staff should sanitize their hands when changing gloves. Staff should not touch the resident or resident surfaces with soiled gloves. Urine collection devices should be stored in bags and labeled with the resident’s name. 5. Review of Resident #29’s electronic face sheet, showed [DIAGNOSES REDACTED]. Review of the resident’s physician order [REDACTED]. -[MEDICATION NAME] (short acting insulin) Pen Fill Solution Cartridge 100 units/milliliter (ml) for diabetes. -Inject subcutaneously (under the skin) before meals as per sliding scale. Observation of a blood sugar check, on 11/08/18 at 4:27 P.M., showed Licensed Practical Nurse (LPN) CC: -Gathered supplies and had the resident follow him/her into the second floor shower room; -Placed the glucometer (machine used to sets blood sugar levels) onto the dirty shower room sink with no barrier. He/she failed to sanitize the glucometer prior to placing it on the sink. Three used razors sat inside the sink. LPN CC placed gloves on and did not wash his/her hands prior to placing gloves on, picked up the glucometer and performed the blood sugar check; -Walked out of the shower room into the dining room and placed the dirty glucometer on the medication cart, removed and disposed of his/her gloves and did not wash his/her hands. LPN CC placed the glucometer into the top drawer of the cart without sanitizing it. 6. Review of Resident #111’s electronic face sheet, showed [DIAGNOSES REDACTED]. Review of the resident’s POS, showed: -Humalog Solution (fast acting insulin) 100 units/ml for diabetes; -Inject subcutaneously three times a day as per sliding scale. Observation on 11/8/18 at 4:43 P.M., LPN CC: -Gathered the supplies and had the resident follow him/her into the second floor shower room; -Placed the glucometer (un-sanitized) onto the dirty shower room sink with no barrier. Three used razors sat inside the sink. He/she placed gloves on and did not wash his/her hands. He/she picked up the glucometer and performed the blood sugar check; -He/she walked out of the shower room and into the dining room, placed the dirty glucometer on the resident’s mediation packages that were sitting on top of the cart, removed and disposed of his/her gloves and did not wash his/her hands; -Cleaned the top rubber [MEDICATION NAME] of the insulin bottle and drew up 3 units of Humalog insulin; -Placed the glucometer into the top drawer of the cart without sanitizing it. 7. Review of Resident #142’s electronic face sheet, showed [DIAGNOSES REDACTED].>-End stage [MEDICAL CONDITION] (condition in which a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term [MEDICAL TREATMENT] or a kidney transplant to maintain life); -Dementia with behaviors; and -Need for assistance with personal care. Review of the resident’s care plan, in use during this survey, showed: -The resident had an ADL self-care performance deficit related to Dementia and decrease in areas of physical functioning; -The resident required extensive assistance by one staff for toileting; -The resident required assistance by one staff member with personal hygiene Observation on 11/6/18 at 8:48 A.M., 11/8/18 at 4:21 P.M., and 11/13/18 at 8:01 A.M., showed: |
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: 265585 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER HILLSIDE MANOR HEALTHCARE AND REHAB CENTER | STREET ADDRESS, CITY, STATE, ZIP 1265 MCLARAN AVENUE | |||||||||
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) | |
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F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 82) -A urinal hung on the bathroom handrail with a dried yellow substance in the bottom. The urinal was uncovered and unlabeled; -A urine hat hung on the bathroom wall rack that was uncovered and unlabeled. 8. Observation of the bathroom for room [ROOM NUMBER], on 11/6/18 at 9:21 A.M. and 11/7/18 at 7:04 A.M., showed 2 urine collection hats located on the left and right handrail of a resident’s shared bathroom. The collection hats not stored in a bag. One collection hat labeled the name of a resident who did not reside in the room. The other collection hat not labeled. 9. During an interview on 11/13/18 at 7:40 A.M., CNA AA said: -Urinals and urine hats should be cleaned after each use; -Urinals and urine hats should be stored in a plastic bag and be labeled with the resident’s name, room number and date opened. During an interview on 11/13/18 at 7:48 A.M., LPN BB said: -He/she expected staff to keep urinals and urine hats covered at all times when not in use; -Urinals and urine hats should be labeled with the resident’s name, room number and the date opened. During an interview on 11/13/18 at 9:05 A.M., the DON said: -He/she expected staff to keep urinals and urine hats covered at all times when not in use; -He/she expected staff to clean urinals and urine hats after each use; -He/she expected staff to label urinals and urine hats with the resident’s name, room and the date opened. | |