| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) previous roommate. The resident indicated he/she was at the breaking point and would resort to hurting his/her self through nervous picking at his/her skin. The resident was jiggling his/her legs to indicate how nervous he/she had become. He/She recommended the resident move back in with his/her previous roommate if there is no known reason why he/she could not. Meeting the resident’s requests will reduce anxiety and conflict with roommate. Record review of the resident’s progress note dated 2/28/19, at 12:53 P.M., showed SW U documented the resident had stated concerns regarding his/her roommate. The roommate is making him/her anxious by watching television during late hours at night and making phone calls late at night. He/She educated both residents regarding compromising. The psychologist contacted the SSD that the resident said that he/she would resort to nervous picking at his/her skin if his/her desires were not met. Record review of the resident’s psychology progress note dated 3/29/19, at 5:20 P.M., showed the psychologist documented the resident’s affect was distressed. The resident is not happy and continues to have conflict with roommate. Record review of the resident’s progress note dated 4/2/19, at 12:15 P.M., showed SW U documented the resident has struggled to integrate with his/her roommate. He/She has been looking into transferring to an assisted living community. Record review of the resident’s psychology progress note dated 4/3/19, at 3:00 P.M., showed the psychologist documented the resident continued to be discontented with the facility and his/her roommate. The resident feels that moving would help him/her. During an interview on 4/17/19, at 2:41 P.M., the resident said the following: -He/She has asked many times to have a different roommate or room due to being unhappy with the current situation; -He/She feels degraded by his/her roommate (Resident #21); -Resident #21 tells the resident he/she smells and blocks him/her from coming into the room with his/her bedside table on purpose; -Resident #21’s television is on all the time; -Resident #21 does not respect or communicate with him/her and yells at him/her for taking up too much space; -There are empty rooms, but the facility won’t let him/her move into it because the facility gets more money if a resident needing therapy moves into the room. 3. Record review of Resident #21’s face sheet showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors exhibited; -Extensive staff assistance required for transfers; -Use of a wheelchair. Record review of the resident’s progress note dated 2/11/19, at 12:05 P.M., showed SW U documented the resident moved to room a new room. Record review of the resident’s progress notes, dated 2/25/19, showed SW U documented the following: -At 9:39 A.M., the resident was dissatisfied with his/her roommate/room; -At 4:41 P.M., he/she spoke with the resident and the resident’s significant other about roommate issues. The resident agreed to work on a compromise with the roommate. Record review of the resident’s progress note dated 2/28/19, at 1:00 P.M., showed SW U documented the resident had concerns regarding his/her roommate. The resident was given |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) education on coping skills and compromising. Record review of the resident’s psychology progress note dated 3/6/19, at 4:20 P.M., showed the psychologist documented the resident’s affect was distressed. The resident is upset because his/her roommate has been talking about him/her and wants to move out of the room. The resident tends to blame his/her roommate for all the problems. Record review of the resident’s progress note dated 3/12/19, at 4:45 P.M., showed SW U documented the resident’s significant other expressed concerns regarding the resident’s roommate encroaching on visits with Resident #21. Record review of the resident’s psychology progress note dated 3/14/19, at 6:40 P.M., showed the psychologist documented the resident’s affect was distressed. The resident reported there had been no progress with his/her roommate, they still don’t get along. The resident feels targeted. The resident seems reluctant to accept his/her part of the conflict. Record review of the resident’s psychology progress note dated 3/29/19, at 5:20 P.M., showed the psychologist documented the resident’s affect was distressed. The resident was unhappy and continued to complain about his/her roommate. The resident was paranoid and said people are talking about him/her. Record review of the resident’s psychology progress note dated 4/3/19, at 4:00 P.M., showed the psychologist documented the resident’s affect was sad and distressed. The resident was unable to resolve conflict with his/her roommate and continued to be paranoid. During an interview on 4/17/19, at 3:13 P.M., the resident said the following: -He/She wants a new roommate; -He/She shares a room with Resident #74; -Resident #74 has an odor and takes up more space in the room because he/she uses bariatric equipment; -He/She has talked to SW U about being unhappy with his/her roommate and wanting to change rooms; -He/She does not get along with Resident #74. During an interview on 4/18/19, at 12:17 P.M., Certified Medication Technician (CMT) G said the following: -Resident #21 stated Resident #74 was bossy and would try to control the volume level on the television; -Resident #74 came to the nurse’s desk a few weeks ago crying because Resident #21 was giving him/her the silent treatment and he/she felt upset and anxious; -Resident #74 stated Resident #21 was a bully; -He/She reported to the charge nurse and social services; -The conflict between the two residents has been going on a few months since they moved in together. During an interview on 4/18/19, at 12:32 P.M., Licensed Practical Nurse (LPN) D said Resident #74 complained Resident # 21 would not move his/her bedside table to let him/her in the room. During an interview on 4/18/19, at 2:30 P.M., SW U said the following: -He/She tries to resolve disputes before room changes occur; -He/she tried to resolve conflicts with Resident #74 and #21 by shutting off the television by 10:00 P.M., and giving Resident #74 ear plugs; -He/She was aware of the psychology notes indicating Resident #74 was unhappy with current living situation and the resident possibly harming him/her self; -He/She was not aware Resident #21 said anything mean to Resident #74; |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) -Resident #74 said he/she was uncomfortable in the room with his/her roommate and had been spending most of his/her time out of the room; -Both of the residents have been on the list to change rooms for a while; -Due to Resident #74’s increased anxiety, verbalization of self-harm and psychologist recommendations, the resident should have been moved; however, there was an issue with availability of another room on the long-term hall; -He/she as not sure if he/she could have been moved to a different hall. During an interview on 4/19/19, at 10:53 A.M., SW T said the following: -The facility is transitioning all of the long-term residents to the B hall; -The social services department tried to work on compromising with Resident #21 and #74; -He/She thought Resident #74 should have been moved to a different room; -The residents should feel safe and comfortable in their room; -He/She is not allowed to put a long-term resident on the skilled hall; -He/She brings up room change requests in the morning meeting and a decision is made as a group. During an interview on 4/22/19, at 3:22 P.M., the Administrator said the following: -The facility staff try to help resident’s compromise when they do not get along to see if there is a solution; -The facility involves the Ombudsman and psychologist if appropriate; -Resident #74 and #21 asked to move in together, but then it was not working out; -Resident #74 complained the television was too loud; -He/She was not aware of the psychologist recommendations for Resident #74 to move back in with his/her prior roommate or the resident talking about harming him/her self due to anxiety; -He/She would have moved Resident #74 if he/she had known; -Psychology notes are usually reviewed by the Director of Nursing. 4. Record review of Resident #63’s face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s admission nutrition review dated 3/27/19, at 8:26 A.M., showed the dietary manager documented the location of most of the resident’s meals was the resident’s room. The dietary manager documented the resident as independent in his/her ability to eat and drink. Record review of the resident’s baseline care plan, dated 3/28/19, showed the following information: -Alert/cognitively intact; -Communicated verbally; -Encourage self-care/participation; -Monitor resident routines and preferences to anticipate needs; -Encourage resident to make needs known; -Required set up for eating; -Staff did not document the resident’s preference to eat meals in the dining room or the resident room; -Monitor for safety and assist with eating/drinking as needed Record review of the resident’s progress note dated 3/29/19, at 12:20 P.M., showed Registered Nurse (RN) V documented the resident in his/her room and eating a meal. The resident required assistance for set up the meals. Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) assessment instrument completed by facility staff, dated 4/2/19, showed the following information: -Resident able to make self understood and able to understand others without difficulty; -Resident required oversight for meals; -Staff did not document any signs and symptoms of possible swallowing disorder. Record review of the resident’s care plan, last revised 4/8/19, showed the following information; -At risk for inadequate nutrition related to poor intake, and disease process; -Communicate with family regarding any food and weight issues; -Create a pleasant and relaxing atmosphere while eating to increase intake; -Discuss likes and dislikes of food; -The care plan did not address the resident’s preference for location of meals. Observation on 04/16/19, at 12:31 P.M., showed the resident ate the meal with his/her right hand unassisted in the dining room. Staff were not in the dining room as the resident ate his/her meal. During an interview on 4/17/19, at 11:22 A.M., the resident’s family member said the resident can mostly eat by him/her self. The resident had an observation with swallowing study at the hospital. He/she said the new rule is the resident has to be in the dining room for meals to be monitored while eating. The hospital said the resident was cleared for any food he/she wanted. Resident cannot cut up food with one hand. This past weekend was the first time someone cut up his/her food. This week was the first time, the resident was required to go to the dining room. The resident’s family member brought pizza for the resident and he/she was told he/she could no longer do that. The resident had to be in the dining room. Observation on 4/17/19, showed the following: -At 6:21 P.M., RN V entered the resident’s room. The resident said he/she did not get a supper tray. CNA S said the resident is not allowed to eat alone in the room. RN V and CNA S prepared to transfer the resident to the wheelchair and take him/her into the dining room. RN V explained to the resident why he/she cannot eat in the room alone. CNA S explained they needed two staff to get the resident up. RN V washed his/her hands and left the room. The resident said he/she never had a problem with swallowing before; -At 6:40 P.M., CNA S said the resident would not get up for dinner earlier. The aides said staff requested the resident to get up for supper at about 23 minutes to 5 P.M., but he/she wanted to eat in his/her room and did not want to get up to the wheelchair. The aide said he/she told the LPN at that time. The nurse talked to the resident’s family member on the phone, explaining the resident was never supposed to eat in his/her room alone. The resident can not eat in the room by him/her self if the resident needs assistance or supervision. Staff cannot assist one resident in their room to eat. They don’t have the staff for that. RN V explained to the resident, you aren’t the only one who needs watched. CNA R said staff would bring a tray into the room when the resident’s family member arrived. The resident will eat in his/her room when the family member arrives to the facility; -At 7:43 P.M., the resident sat in the wheelchair in his/her room, eating supper. The resident’s family member stayed in the room with the resident. During an interview on 04/22/19, at 7:40 A.M., CNA N said the resident needs his/her meals set up, but is able to eat by self with the right hand, but should have somebody sitting at the table while eating. Staff prefers the resident to eat in the dining room. Therapy prefers the resident to eat in the dining room so they can watch him/her. If the resident wanted to eat in his/her room, he/she could. Staff just have to watch and check on |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) him/her. During an interview on 4/22/19, at 8:36 A.M., CNA A said the resident is able to eat by self and used his/her one good arm to cut up food, unless it is really hard, then staff will cut it up for the resident. Staff make sure the resident is in the dining room to monitor for choking. During an interview on 04/22/19, at 9:24 A.M., LPN O said the resident eats in the dining room when I am working. When the resident first admitted to the facility, speech therapy evaluated him/her and said he/she was a choke hazard so they wanted the resident to eat with supervision. If residents need to eat in their room, they have to wait until all hall trays are passed and then staff could assist in resident rooms if needed. The resident did need help to cut meat due to the left side weakness, but once food is cut up he/she can eat on own. During an interview on 04/23/19, at 10:02 A.M., the dietary manager said the resident eats in his/her room most of the time, with a daily intake of meals at 25 – 50%. The resident receives Ensure twice per day, at breakfast and dinner. The resident said he/she likes them. During an interview on 04/23/19, at 1:53 P.M., the DON said from what she understood, it is the resident’s preference where they want to eat. Staff will encourage a resident to get up, but it is a resident’s choice. During an interview on 4/23/19, at 3:37 P.M., the administrator said they encourage residents to come out of their rooms for socialization and to decrease depression, and the best time to encourage this is at meals. Overall, it is the resident’s choice where to eat. When a resident is a new admission, they try to highly encourage residents in coming out of their rooms for meals. 5. Record review of the facility’s policy title Smoking- Resident, dated 12/2016, showed the following: -The facility shall establish and maintain safe resident smoking practices. The procedure will cover all types of smoking devices; -Residents have the potential for obtaining independent smoking privileges; -The resident’s personalized care plan will address if the resident is an independent smoker or other requirements for smoking. Record review of the facility’s current Smoking policy, undated, included the following information: -Smoking restrictions are strictly enforced in all non-smoking areas; -Residents may not keep any smoking articles in their possession. Residents are responsible for all cigarettes and the facility is not liable for any reported lost or stolen; -Residents may not have nor keep any types of lighters, lighter fluids, including butane gas or any other forms of gas or fluids at any time; -Residents are requested to not give smoking articles to other residents; -Smoking is not permitted in any area other than the designated smoking areas; -Smoking is permitted under direct staff supervision during designated smoking times; -Staff members and volunteer workers shall not purchase and/or provide any smoking articles for residents unless approved by the charge nurse; -This facility may check periodically to determine if residents have any smoking articles in violation of our smoking policies. Staff shall confiscate any such articles and shall notify the charge nurse; -Designated smoking area is under the pavilion in the courtyard. Only during inclement weather, residents may smoke under the awning by A-wing. |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) Record review of a memorandum located in the B-wing in-services book at the B-wing nurses’ station, showed the following information: -As of 4/12/19, evening shift, the facility will become a supervised smoking facility. No resident is to smoke unsupervised. Smoking times have been provided to each resident. Residents are not to keep any smoking materials on their person or in their rooms. All cigarettes, pipes, cigars, lighters et cetera are kept at the nurses’ desk. -The designated smoking area is under the pavilion in the center of the courtyard unless it is raining or below 32 degrees (Fahrenheit). Record review of the smoking times and responsible staff, posted at the B-wing nurses’ station, showed the following information: -From 6:30 A.M. to 6:45 A.M., nursing staff supervises residents smoking Sunday through Saturday; -From 9:00 A.M. to 9:15 A.M., laundry staff supervises residents smoking Saturday, Sunday and Monday; -From 9:00 A.M. to 9:15 A.M., nursing staff supervises residents smoking Tuesday through Friday; -From 11:00 A.M. to 11:15 A.M., Business Office Manager (BOM) supervises residents smoking Monday through Friday; -From 11:00 A.M. to 11:15 A.M., nursing staff supervises residents smoking Friday and Saturday; -From 1:30 P.M. to 1:45 P.M., housekeeping staff supervises residents smoking Sunday through Thursday; -From 1:30 P.M. to 1:45 P.M., nursing staff supervises residents smoking Friday and Saturday; -From 3:30 P.M. to 3:45 P.M., BOM staff supervises residents smoking Monday through Friday; -From 3:30 P.M. to 3:45 P.M., nursing staff supervises residents smoking Friday and Saturday; -From 7:00 P.M. to 7:15 P.M., nursing staff supervises residents smoking Sunday through Saturday; -From 9:00 P.M. to 9:15 P.M., nursing staff supervises residents smoking Sunday through Saturday; -From 11:00 P.M. to 11:15 P.M., nursing staff supervises residents smoking Sunday through Saturday. 6. Record review of Resident #24’s face sheet showed staff admitted the resident to the facility on [DATE]. Record review of the resident’s smoking risk assessment, dated 11/1/18, showed the following information: -The resident smoked cigarettes more than once per hour; -The resident did not smoke in unauthorized areas; was not careless with smoking materials; did not smoke cigarettes from ash trays; did not inappropriately provide smoking materials to others; did not beg or steal smoking materials from others; had general awareness and orientation; and no problems with general behavior and interpersonal interaction; -Moderate problem with mobility; -Capable to follow facility safe smoking guidelines; -Calculated smoking risk: 2 (0-9 safe smoker). Record review of the resident’s admission MDS, dated [DATE], showed the following information: |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) -Cognitively intact; -Required supervision for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene; -Used a wheelchair for mobility. Record review of the resident’s care plan, last reviewed 11/21/18, showed the following information: -Category: Behavioral symptoms; -Problem: Although the resident was not allowed to smoke in his/her room, he/she could smoke without staff supervision, in the designated smoking area, and may take smoking materials with him/her on leave of absences (LOA); -Goal: The resident will smoke safely without staff supervision in designated area; -Approach: Complete a smoking safety assessment within 14 days of admission and quarterly; observe routinely to ensure the resident is safe while smoking. Smoking is allowed during designated times or individual preference. Smoking materials are monitored and stored by nursing staff and are inaccessible to any resident. Lighters and other materials should be surrendered to nursing staff upon returning from LOA. The resident is able to keep cigarettes in his/her room; smoking with or without staff supervision is allowed in designated area only (central courtyard). Record review of the resident’s progress notes showed the following information: -On 2/13/19, at 10:42 A.M., a social services designee (SSD) documented the facility held a care plan meeting for the resident. The resident and his/her family, including his/her spouse, attended the meeting. Staff reviewed the resident’s medical record, care plan, face sheet, and contacts with the resident and family and made no changes. The resident was alert and oriented, used a wheelchair for long distances and was up in his/her room as he/she wished. The resident was independent with his/her activities of daily living. His/her activity level remained the same; he/she enjoyed going outside to smoke. -On 4/12/19, at 5:08 P.M., a SSD documented the resident attended a smokers meeting regarding the new supervised smoking policy. The resident was educated verbally and in writing regarding smoking policy. The resident placed his/her cigarettes and lighter in the smoking box located at the A-wing nurses’ desk. Staff labeled the resident’s cigarette packs and lighters with his/her name. Staff gave the resident a copy of the new policy and smoking times. Record review of the resident’s current medical record showed no indication the resident violated any of the facility’s unsupervised smoking policy. During an interview conducted on 4/18/19, at 1:06 P.M., the resident said he/she did not like the new smoking policy. He/she did not like the scheduled smoking times because he/she like to smoke when his/her spouse was resting and did not need him/her. Now, the resident had to stop what he/she was doing to smoke or he/she had to wait until the next scheduled smoking time. During an interview conducted on 4/18/19, at 4:15 P.M., Registered Nurse (RN) J said the resident did not require staff supervision when smoking because the resident no longer smoked. During an interview conducted on 4/22/19, at 9:58 A.M., Certified Nurse Aide (CNA) Y said he/she knew of only one resident (Resident #24) who was upset with the new smoking policy. The resident said when staff supervised his/her smoking; it felt like they were babysitting him/her. 7. Record review of Resident #72’s face sheet showed staff admitted the resident to the facility on [DATE]. Record review of the resident’s progress note dated 3/25/19, at 2:01 P.M., showed an |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) activity assistant documented the resident resided at this facility in the past and was very familiar with the activity program. The resident preferred to stay in his/her room most of the day and would get up around noon to smoke and socialize with peers. Record review of the resident’s admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Independent with bed mobility, transfers and locomotion; Required staff supervision with eating and personal hygiene; -Required limited assistance with dressing; -Used a wheelchair for mobility. Record review of the resident’s care plan, last reviewed 4/1/19, showed the following information: -The resident wished to maintain as much independence, autonomy, and personal preference as possible, which influences the choices he/she made regarding his/her care; -Staff did not identify, develop or implement interventions regarding the resident smoking. Record review of the resident’s smoking risk assessment dated [DATE], at 12:08 P.M., showed the following information: -The resident smoked a pipe hourly and he/she carried his/her matches/lighter; -The resident did not smoke in unauthorized areas; was not careless with smoking materials; did not smoke cigarettes from ash trays; did not inappropriately provide smoking materials to others; did not beg or steal smoking materials from others; had general awareness and orientation; no problems with general behavior and interpersonal interaction; -No problem with mobility; -Capable to follow facility safe smoking guidelines; -Calculated smoking risk: 0 (0-9 safe smoker). Record review of the resident’s progress note dated 4/12/19, at 5:08 P.M., showed a SSD documented the resident attended a smokers meeting regarding the new supervised smoking policy. The resident was educated verbally and in writing regarding smoking policy. The resident placed his/her cigarettes and lighter in the smoking box located at the A-wing nurses’ desk. Staff labeled the resident’s cigarette packs and lighters with his/her name. Staff gave the resident a copy of the new policy and smoking times. Record review of the resident’s current medical record showed no indication the resident violated any of the facility’s unsupervised smoking policy. During an interview conducted on 4/18/19, at 12:50 P.M., the resident said the facility recently changed their smoking policy. Now residents are only allowed to smoke with staff at designated times. Because of the new policy, staff took the resident’s expensive pipes and they would not give them back until the resident signed a paper that stated he/she would not use those pipes to smoke, ever. The facility should not punish the group for one resident’s actions. During an interview conducted on 4/18/19, at 4:15 P.M., RN J said the resident smoked unsupervised. 8. During an interview conducted on 4/18/19, at 4:15 P.M., RN J said staff did not supervise residents when they smoked unless the resident tried to light a cigarette in the building, took too many cigarette breaks, staff could not find them, or the resident was not safe. If a resident did any of the above, he/she asked the resident if he/she wanted staff to supervise him/her or not. If a resident did not want supervised smoke breaks, he/she told the resident he/she had to abide by the rules, and there were consequences for |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) not following the rules. The facility did have a list of residents who required staff supervision, but at this time, no residents required staff supervision when smoking. 9. During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said staff supervised residents when they smoked. Residents smoking times are scheduled. Before the policy change (4/12/19), residents could smoke independently, any time they wanted. They just could not keep their lighter in their room. Now staff supervised all residents’ smoking. The CNA did not know exactly what happened, but staff told him/her there was a fire or an almost a fire with oxygen. 10. During an interview conducted on 4/22/19, at 11:34 A.M., SSD U said the facility recently changed the residents’ smoking policy due to resident non-compliance. Staff should document in the resident chart when a resident was noncompliant with the smoking policy. After implementing the new policy, staff went to each resident room to collect smoking materials. Residents had lighters in rooms, which made them non-compliant with the (old) policy. If a confused resident entered a resident’s room who had a lighter, the confused resident could find the lighter, posing a safety risk to all residents. Prior to change (4/12/19), three resident required staff to supervise their smoking. All residents were supposed to keep their lighters in desk drawer at nurse’s sta (TRUNCATED) | |
| F 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. **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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) -Required oversight with encouragement or cueing and one person assist for eating; -Coughing or choking during meals; -Mechanically altered diet. Record review of the resident’s care plan, last reviewed 3/18/19, showed the following information: -Set up trays at meals and assist as needed. -Encourage fluid intake; -Allow sufficient time to eat; -Currently on a mechanical soft diet, with honey thick liquids. Observation on 04/17/19 showed the following: -At 5:31 P.M., staff served the resident’s supper tray. Staff did not assist the resident to eat. -At 5:37 P.M., staff were not present in the dining room assisting or cueing residents to eat; -At 5:38 P.M., staff were not present in the dining room to monitor or assist residents. The resident poured drinks into his/her plate and table, placed napkin into food, and tried to eat the napkin. The resident put napkin back on table, used hands to eat food. The resident spilled food and liquid off table and onto resident clothing. The resident placed his/her spoon in juice, moved the napkin around table wiping table. The resident tried to eat the napkin a second time; -At 5:58 P.M., another resident requested that Resident #55 be helped with his/her meal. The Licensed Practical Nurse (LPN) V directed a passing aide to help the Resident #55. CNA N sat with the resident and began to assist the resident with bites of food. During an interview on 04/22/19, at 7:40 A.M., CNA R said some days, the resident can get the food to his/her mouth okay by his/her self. If staff put food in front of the resident and leave, the resident will spill. Some days, he/she can do okay with just cueing only, other times the resident needs staff to assist him/her with eating. The resident has to have someone by him/her to cue and assist. During an interview on 04/22/19, at 8:36 A.M., CNA A said the resident needed direct assistance for meals and needed someone to sit with him/her. A family member usually came at lunch to assist the resident. Staff usually helped the resident at breakfast and supper. If no one helped or sat with the resident, he/she will knock the plate over and spill drinks. During an interview on 04/22/19, at 9:24 A.M., LPN O said the resident had days he/she could eat on own, some days needed assistance. The resident always needed set up. One staff should be in the dining room every meal until all residents are finished eating. 2. Record review of Resident #22’s face sheet showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/7/19 showed the following: -Severely impaired cognition and vision; -Extensive staff assistance of two required for transfers; -Extensive staff assistance of one required for toileting and hygiene; -Set up and supervision required for eating; -The resident did not reject care. Record review of the resident’s care plan, last reviewed 3/27/19, showed the following: -Instructed staff to set up the resident’s tray at meals and assist as needed; -Instructed staff to frequently check on 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) -Instructed staff to encourage the resident with his/her fluid intake; -Identified the resident was on a mechanically altered diet. Observations on 4/15/19, at 12:46 P.M., showed the resident in the dining area across from the nurses’ station sitting in a high-back wheelchair, facing the wall with his/her back towards the nurse’s station. A staff member set a meal tray on the table in front of the resident. The staff member did not inform the resident what food was served or where on the plate each food was located. The staff left the dining area. The resident sat and did not begin eating. There were no staff members in the dining room. The resident drank a few sips of a shake but did not eat. Observations on 4/16/19, at 12:26 P.M., showed an unidentified certified nurse assistant (CNA) set a meal tray in front of the resident. The CNA told the resident what foods were served, but did not provide guidance for the location of the foods on the plate. The resident picked up a hot dog bun with ground meat and the meat fell on to the resident’s lap then onto the floor. The resident ate the bun without the meat. The resident picked up the edge of his/her clothing protector to wipe his/her mouth and the clothing protector dropped over the food tray and covered the resident’s food. The resident took a spoon to get a bite and the spoon lifted the clothing protector, but did not allow the resident to get a bite of food from under the clothing protector. There were no staff members in the dining room to assist the resident. During an interview on 4/22/19, at 8:15 A.M., MDS Coordinator LL said the resident does fairly well eating independently. The resident needs supervision because some days he/she needs encouragement or assistance. Staff should tell the resident what food is served and the location of the food on the plate. During an interview on 4/22/19, at 11:00 A.M., CNA A said the resident is blind. He/she said staff should explain what is on the resident’s tray and where the food is located. He/she said a staff member should be in the dining room during the entire meal time and staff should assist the resident if he/she is not eating or having difficulties. During an interview on 4/22/19, at 12:42 P.M., Licensed Practical Nurse (LPN) B said the resident is independent with eating at most times. He/she said staff should be available in the dining room at meal times and help the resident if he/she is not eating. 3. Record review of Resident #26’s face sheet showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s progress notes showed the following information: -On 1/16/19, at 1:49 P.M., the Registered Dietician (RD) documented the resident ate hot cereal and drank his/her shake at lunch, but ate little of the rest of his/her meal. The resident received a mechanical soft diet (foods are soft, and easy to chew and swallow), offer cereal with each meal, and house shake three times a day with meals. He/she also received Boost VHC (a high calorie supplement) three times a day with medications. His/her weight was the same as it was a month ago. Staff reported the resident’s intake varied, but seemed somewhat decreased recently. Dietary to continue to provide diet with supplementation as ordered. Staff to continue to honor food preferences and provide foods and beverages he/she enjoyed and was most likely to accept. Staff to continue to encourage intake and monitor weights. No new recommendations at this time; -On 2/6/19, at 2:11 P.M., the Dietary Services Manager (DSM) documented the resident ate, independently, a mechanical soft diet in the assisted dining room. He/she ate an average of 25-50% of his/her meals. Record review of the resident’s annual MDS, dated [DATE], showed the following information: |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 12) -Severe cognitive impairment; -There was evidence the resident had an acute (sudden onset) change in his/her mental status from his/her baseline; -Inattention behavior occurred and fluctuated (came and went, changed in severity); -Disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) occurred and fluctuated; -Required supervision with eating; -Used a wheelchair for mobility. Record review of the resident’s care plan, last reviewed 2/15/19, showed the following information: -The resident had difficulty focusing his/her attention at times related to disease process. -Ensure the resident received adequate nutrition and fluids; -Use a calm and reassuring approach; -The resident was at risk for inadequate nutrition related to poor intake, need for mechanically altered diet and disease process; -Create a pleasant and relaxing atmosphere while eating to increase intake; -Discuss like and dislikes of foods with the resident; -Resident received a mechanical soft diet; -Nutritional supplements as appropriate; -Encourage fluid intake; -Snacks as appropriate; -Set up resident’s tray at meals and assist him/her as appropriate. Observation on 4/18/19 showed the following: -At 12:05 P.M., several residents sat at five tables in the assisted dining room. Two staff members sat at two of the five tables assisting residents to eat. Resident #26 sat, in his/her wheelchair, at a dining table with two other residents. Staff served the resident cornbread, chicken and dumplings, green beans, and mandarin oranges. The resident ate some of his/her cornbread, unassisted; -At 12:12 P.M., the resident wheeled himself/herself out of the dining room. Staff did not acknowledge the resident left the dining room and did not encourage the resident to eat. The resident ate a few bites of his/her cornbread, a few bites of his/her green beans, and drank a small amount of water. The resident did not eat any of his/her chicken and dumplings and did not drink any of his/her shake; -At 12:39 P.M., a staff member wheeled the resident into the dining room and said to CNA JJ, maybe he/she needs to eat. CNA JJ said the resident already ate. Observation on 4/19/19, at 11:49 P.M., showed the resident sat in the assisted dining room eating apple crisp with ice cream. Staff served the resident macaroni salad, a chopped hamburger on a bun, a strawberry shake, water, and Kool aid. After a few minutes, the resident placed his/her bowl of apple crisp on the table. The resident ate a few bites of the hamburger and none of the macaroni salad. A staff member encouraged the resident to drink his/her shake. He/she told the resident the doctor wanted him/her to drink it. The resident drank more than half of the shake before leaving the dining room. During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said when staff serve the resident a meal, the resident usually knew immediately if he/she did not want the food staff served. When this occurred, staff offered the resident something else to eat. The resident typically ate about 50% of his/her meals. Staff tried to encourage the resident to eat. During an interview conducted on 4/22/19, at 1:39 P.M., LPN D said the resident ate in 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 13) assisted dining room. Staff set up his/her meal tray (open silverware, take off lids, cut up food (if needed)) and with a little encouragement he/she ate pretty well. Sometimes the resident left the dining room to go to the bathroom, he/she may get distracted before coming back, but he/she usually came back to the dining room to finish eating. During an interview conducted on 4/22/19, at 3:31 P.M., CNA EE said the resident ate independently after staff set-up his/her meal tray. Sometimes staff had to encourage the resident to eat, other times he/she just needed supervision. During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said the resident needed staff to set-up his/her meal tray, but he/she ate without staff assistance. He/she ate well, but was specific on what he/she wanted. The resident was not easily distracted unless someone else distracted him/her. He/she only left the dining room table, during a meal, to go to the bathroom. The resident usually returned to the dining room, but if he/she did not staff would get him/her. If the resident left without eating, staff encouraged him/her to stay, and might offer him/her other foods. During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said she did not know if the resident struggled with eating 4. Record review of Resident #50’s face sheet showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s physician order [REDACTED]. -An order dated 2/28/17, for a regular diet with mechanical soft texture; -An order dated 9/28/17, for house shakes three times a day with meals. Record review of the resident’s annual MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required supervision with transfers, walking and eating; -[DIAGNOSES REDACTED]. Record review of the resident’s progress note dated 3/19/19, at 11:42 P.M., showed a Social Services Designee (SSD) documented a care plan meeting was held for the resident. The resident ate his/her meals in the assisted dining room. His/her appetite was poor. His/her vision was poor. He/she requires cataract removal pending guardian approval. Record review of the resident’s physician’s orders [REDACTED]. Record review of the resident’s care plan, last reviewed 3/21/19, showed the following information: -The resident was at risk for inadequate nutrition related to fluctuating intake, disease process and mechanically altered diet; -Create a pleasant and relaxing atmosphere while eating to increase intake; -Discuss like and dislikes of foods with the resident; -Resident received a mechanical soft diet; -Encourage fluid intake; -Snacks as appropriate; -The resident was a slow eater. Allow the resident sufficient time to feed himself/herself; -The resident preferred to eat his/her meals in the main dining room; -Set up resident’s tray at meals and assist him/her as appropriate. Observations on 4/18/19 showed the following information: -At 12:05 P.M., the resident walked out of the assisted dining room towards his/her room. The resident’s silverware was wrapped with a paper towel and the resident did not eat any food or drink any fluids. Staff did not encouraged the resident to eat, offer any |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 14) substitutions, or encourage the resident to drink his/her shake since he/she did not eat his/her entr?e; -At 12:20 P.M., the resident laid in bed with his/her eyes closed. Observations on 4/19/19, at 11:49 A.M., showed the resident sat at a dining room table in the assisted dining room. The resident removed his/her top dentures, removed the food debris from his/her gums, and put his/her dentures into his/her mouth. The resident drank his/her house shake then removed his/her top dentures and placed them on his/her plate, then placed his/her dentures into his/her mouth. The resident did this several times. The resident took a drink of water, and said yuck. CNA KK stood next to him/her briefly then walked away. The CNA did not encourage the resident to eat and did not say anything to the resident about his/her dentures on his/her plate. A few minutes later, CNA KK returned to the resident and asked if he/she lost his/her teeth. The CNA placed a chair next to the resident and assisted him/her to eat. After assisting the resident a while, the CNA left. CNA KK did not ask the resident if he/she was finished with his/her meal, if he/she wanted more food, and did not offer the resident an additional shake. The resident ate as long as staff assisted. Without staff assistance, the resident only drank fluids. The resident ate less than 25% of his/her lunch. During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said if staff handed the resident what he/she needed or told the resident what food was on his/her plate the resident would attempt to eat. If the resident did not eat, staff encouraged him/her to eat. The resident needed staff to set-up his/her meal tray and explain what was on the plate because the resident did not see very well. If he/she left the dining room, staff encouraged him/her to eat. The resident often left the dining room to wheel his/her tablemate to his/her room. During an interview on 4/22/19, at 1:39 P.M., LPN D said the resident would not let staff assist him/her. Staff needed to encourage the resident to eat. He/she gets up at night hungry. He/she liked to snack and it was a challenge for staff to get him/her to eat in the dining room. The resident required staff to set-up his/her meal tray. The physician ordered supplements and staff offered substitutions if the resident did not like served food. During an interview conducted on 4/22/19, at 3:31 P.M., CNA EE said the resident required encouragement or guidance to eat. If the resident did not eat well, staff redirects the resident back to his/her table. During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said the resident did not eat anything. Staff tried to give him/her bites of foods. The resident could hardly see his/her plate. The resident will eat a few bites of food, but then would stop eating. If the resident really liked the food, he/she would eat unassisted, but usually after a few bites, staff either had to encourage him/her to eat or assist him/her to eat. During an interview conducted on 4/23/19, at 12:40 P.M., CNA X said the resident could not see very well. Staff tried to walk with him/her to and from meals and activities. Today at breakfast, the CNA gave the resident his/her yogurt and a spoon and the resident ate all of the yogurt, unassisted. The resident had a hard time seeing what was on his/her plate. If there were enough staff in the dining room, CNA X sat next to the resident and assisted him/her to eat. The resident did not eat much by himself/herself. The resident would let the CNA assist him/her to eat, but other staff said the resident would not let them assist him/her. During an interview conducted on 4/23/19, at 1:54 P.M., the administrator said she did not know if the resident struggled with eating. 5. During an interview on 4/22/19, at 1:11 P.M., the Director of Nursing (DON) said 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 15) expects a staff member to be available in the dining rooms to monitor. She said she expects staff to assist residents if not eating and having problems eating. The DON said interventions with eating soul be addressed on the residents’ care plan. 6. During an interview conducted on 4/22/19, at 1:39 P.M., CNA JJ said there were always at least two staff in the B-wing assisted dining room. 7. During an interview conducted on 4/22/19, at 3:31 P.M., CNA EE said two to three staff members assisted in the B-wing assisted dining room. 8. During an interview on 04/23/19, at 10:02 A.M., the dietary manager said they document meal intakes for all residents in the A wing assist dining room. If a resident is in that dining room, they need supervision, cueing, or assistance for eating. 9. During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said there were usually three staff in the B-wing assisted dining room. Two staff to assist resident to eat and one staff to chart residents’ meal intake. 10. During an interview conducted on 4/23/19, at 12:40 P.M., CNA X said two staff assist in the B-wing assisted dining room. After the third staff member passed hall trays, he/she also assisted in the dining room. And if a restorative nurses’ aide (RNA) was available, he/she too assisted in the dining room. 11. During an interview on 04/23/19, at 1:53 P.M., the DON said staff should be in the A wing and B wing dining rooms because all those residents need cueing or assisting with eating. Staff should be supervising in the dining room as long as residents are in there eating. If there are three restorative staff scheduled, they are supposed to spread out to all three dining rooms and supervise. If not, the aides should be in the dining rooms supervising. 12. During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said at least two staff, if not more, should be assisting in the assisted dining room. If a resident did not eat, staff should encourage the resident and offer substitutes. They should find out why the resident did not want to eat. | |
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate treatment and care according to orders, resident’s preferences and goals. **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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s progress note dated 3/26/19, at 7:53 P.M., showed the resident admitted to the facility on [DATE]. The nurse documented left sided weakness in both upper and lower extremity. The nurse documented no skin breakdown. Record review of the resident’s baseline care plan, dated 3/28/19, showed the following information: -Alert/cognitively intact; -Required assistance of two staff for bed mobility, transfers, and toileting; -Staff did not identify any skin concerns; -Staff did not include any skin prevention interventions. Record review of the resident’s skin monitoring certified nursing assistant (CNA) shower review sheet, dated 3/29/19, the resident had a bandage over a wound that needed replacing. The nurse documented under the intervention the resident had a 1 centimeter (cm) skin tear on the left upper arm. New order entered for daily dressing. The charge nurse signed and dated the sheet on 3/29/19. The Director of Nursing (DON) signed and dated the sheet on 4/2/19. Record review of the resident’s physician order [REDACTED]. Record review of the resident’s progress note dated 3/29/19, at 10:09 P.M., showed a 1 cm skin tear noted to left upper arm (LUA) during bath. Staff cleansed wound and applied triple antibiotic ointment (TAO) and [MEDICATION NAME] dressing (a non-stick dressing). Staff entered new order for daily dressing change. Record review of the resident’s nurses’ (MONTH) 2019 treatment administration record (TAR) showed on 3/30/19 and 3/31/19, the nurse documented completion of a LUA TAO and bandage dressing change daily. Record review of the resident’s progress note dated 3/31/19, at 8:55 P.M., showed the nurse documented dressing changed to left upper arm, healing without signs or symptoms of infection. The nurse did not document any further assessment or measurements of the wound. Record review of the resident’s nurses’ TAR, dated 4/1/19 to 4/22/19, showed staff did not |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) -On 4/3/19, staff added approach of weekly skin assessments by licensed nurse; -The resident’s care plan did not address any current skin wounds. Record review of the resident’s weekly skin assessment dated [DATE], at 11:30 A.M., showed the resident had an existing skin issue. Staff did not document a description of the existing skin issue or measurements on the assessment. Record review of resident’s nurses’ TAR, dated 4/1/19 – 4/22/19, showed staff did not document changing the resident’s dressing on 4/5/19. Record review of the resident’s weekly skin assessment dated [DATE], at 9:00 A.M., showed the resident had an existing skin issue. The resident had an area above the left elbow that currently had a treatment order. Staff did not include any further description or measurements of the existing skin issue on the assessment. During an interview on 04/16/19, at 11:26 A.M., the resident said the left upper arm dressing had been there about a week. It was a skin tear and he/she did not know how it happened. Record review of resident’s nurses’ TAR, dated 4/1/19 to 4/22/19, showed staff did not document changing the dressing on 4/17/19 or 4/20/19. During an interview on 04/22/19, at 9:24 A.M., Licensed Practical Nurse (LPN) O said the resident had a skin tear on the left arm that keeps coming open, it kind of heals, but then comes back open. He/she did not know for sure when it occurred, but it had been there for awhile. There is a treatment in place, but it might be on the evening shift. Staff that finds an area starts order on that shift and the treatment plan only shows up on the shift when the treatment is due. The nurse was unsure what caused the skin tear. The nurse did not know if the resident came with the skin tear. Staff document skin assessments under the observation tab in the computer or under clinical assessment. The weekly skin assessment might just show existing skin issue with treatment. If there is treatment order, it will be on the nurse TAR. If it is an actual wound, it is documented on a wound assessment. The MDS Coordinator MM does the weekly wound assessments. During an interview on 04/22/19, at 11:10 A.M., the MDS Coordinator MM said she did not know anything about resident’s left upper arm wound area. But, when the resident admitted to the facility, there were many wraps from the hospital that appeared to be preventative. She is not doing any assessment or monitoring of the resident’s skin tears/wounds. During an interview and observation on 04/22/19, at 1:17 P.M., the resident said he/she did not know what happened to his/her left arm. The resident had two bandages on his/her left arm above the elbow with drainage visible through the dressing. The bandages did not have any dates showing when staff changed the dressing. Observation on 04/22/19, at 1:23 P.M., showed LPN O entered the resident room, washed hands and applied gloves. The nurse removed two bandages, showing two open areas above the resident’s left elbow. The resident said sometimes they are sore, but do not hurt. One superficial open area had yellow/white macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) skin. The other had a bruised appearance. One area had clear drainage and one area had a small amount of blood. Each area measured less than 1 centimeter (cm) in diameter. The nurse placed wound cleanser on gauze, patted the wounds with the gauze, and used two smaller bandages to cover the open areas. The nurse applied triple antibiotic ointment with his/her gloved finger, and applied two smaller adhesive [MEDICATION NAME] bandages. The nurse dated the bandage. During an interview on 04/23/19, at 1:53 P.M., the DON said she did not know of any wounds on the resident. 2. Record review of Resident #28’s face sheet showed the following information: -Readmitted to the facility on [DATE]; |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 18) -[DIAGNOSES REDACTED]. Record review of the resident’s significant change MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Staff documented the resident not at risk for pressure ulcer development; -Staff did not document the presence of any ulcers or skin concerns. Record review of the resident’s progress note dated 3/1/19, at 9:08 P.M., showed the nurse documented a skin tear had resolved and treatment discontinued today. Record review of the resident’s weekly skin assessment, dated 3/7/19, showed skin intact with no skin issues. Record review of the resident’s physician order [REDACTED]. -On 3/12/19, the physician ordered staff to clean the lower bilateral legs with soap and water, pat dry, apply balm wrap with kerlix (cotton gauze wrap) every day until resolved. Record review of the resident’s weekly skin assessment showed the following information: -On 3/15/19, new skin issue of wound to right calf. Order received to clean the wound, apply medi honey (gel/ointment ) to the wound bed, cover with pad, and secure with gauze wrap. Staff to change every 3 days and as needed (PRN). The nurse did not document any a description or measurement of the wound. Record review of the resident’s progress note dated 3/16/19, at 12:20 A.M., showed new skin treatment order received for the wound to the right calf. The nurse did not document any description or measurement of the wound. Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following information: -On 3/16/19, the physician ordered to clean the wound to the right outer calf with wound cleanser, apply [MEDICATION NAME] to the wound bed, cover with absorbant pad and secure with gauze wrap. Staff to change every three days and PRN. Record review of the resident’s weekly skin assessment showed the following information: -On 3/21/19, skin assessment completed on 3/22/19. Existing skin issue of wound to the right calf. Order for treatment continues with no new concerns from last assessment. The nurse did not document any description of the wound or measurements of the wound. Record review of the resident’s progress note dated 3/25/19, at 1:38 P.M., showed the resident continued on antibiotics and received whirlpool by hospice nurse. Treatments completed as ordered. Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following information: -On 3/27/19, the physician discontinued the order to clean the wound to the right outer calf with wound cleanser, apply [MEDICATION NAME] to the wound bed, and cover with absorbant pad; -On 3/27/19, the physician discontinued the order to clean lower bilateral legs with soap and water, pat dry, apply balm wrap with kerlix every day until resolved; -On 3/27/19, the physician ordered treatment to the wound to right and left outer calf of clean with wound cleanser, apply medi-honey to wound bed; cover with absorbent pad, and secure with gauze wrap. Staff to change every three days and PRN. Record review of the resident’s progress note, dated 4/2/19, showed the resident’s [MEDICAL CONDITION] was showing some clinical improvement. The nurse did not document any further assessment of the resident’s skin on his/her legs. Record review of the TAR, dated 4/1/19 to 4/22/19, showed the following: |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) -Staff did not complete the treatment on 4/2/19, as evidenced by parentheses around the staff initials; -On 4/5/19, staff left the box empty, indicating treatment not completed. Record review of the resident’s weekly skin assessment showed the following information: -On 4/12/19 the nurse completed the skin assessment from 4/11/19. Existing skin issue, areas on both legs, and currently receiving treatment. No reports of any other skin issues at this time. The nurse did not document any further assessment of the wounds or measurements of the wounds. Observation on 04/17/19, at 2:01 P.M., showed CNA S and CNA R provided personal care for the resident. The resident’s right lower leg had a dressing, dated 4/8/19 (nine days prior). Observation on 04/18/19, at 10:13 A.M., showed CNA A entered the resident’s room. The aide checked the resident for incontinence. The resident’s left lower leg had a dressing dated 4/27/18 and a right lower leg dressing dated 4/8 (ten days prior). Record review of the TAR, dated 4/1/19-4/22/19, showed on 4/20/19 staff left the box empty indicating treatment not completed. During an interview on 04/22/19, at 9:24 A.M., LPN O said the resident’s two areas were maybe skin tears. The nurse did not know for sure. He/she said the treatment is completed on evening shift. The nurse thought the resident maybe bumped his/her leg on the wheelchair. The date on the dressing would be the date the dressing change was completed by staff. Observation with LPN O showed the resident’s left leg wrapped with no date on the dressing and the right leg dressing with the date of 4/8 (14 days prior). During an interview on 04/22/19, at 11:10 A.M., the MDS Coordinator MM said she is responsible for all wound assessments in the facility and monitor the wounds once per week. She said the resident’s legs will swell and get blisters and then pop. Usually, a wrap is done and some kind of treatment. This was not usually something staff would document as it is on such a grand scale. She would not know what to say about them, whole bunch of tiny ones from knee to ankle. The nurse does not do any monitoring or assessments of the resident’s wounds. During an interview on 04/22/19, at 2:22 P.M., LPN M said awhile back, hospice had an order for [REDACTED]. He/she had not done a treatment since the end of March. He/she did not know who was doing the treatment. He/she puts a smiley face on the dressing, not a date. The nurse started working at the facility on 3/20/19. Observation on 04/22/19, at 3:20 P.M., showed LPN M prepared wound care supplies at the medication cart in hall and entered the resident’s room. The LPN removed a gauze bandage with scissors from the right leg dated 4/8 with staff initials. The nurse said this was LPN GG based on the initials. The area measured approximately 1 cm in diameter with 1 cm line x 1/8 cm wide (like a key shape but smooth edges), area open and red, but no redness surrounding the wound. A small about of drainage was the gauze pad removed from wound. The nurse removed the left leg wrap that had no date or initials on gauze. The left leg wound measured 1 cm open, red with minimal drainage on dressing, no red streaks, and not warm to touch per the LPN. During an interview on 04/23/19, at 1:53 P.M., the DON said she did not know about any wounds on the resident’s legs. 3. During an interview on 04/22/19, at 11:10 A.M., MDS Coordinator MM said he/she is responsible for wound assessments for the whole facility. She monitors everything from skin tears, pressure ulcers, surgical wounds, and non-pressure wounds. She monitors them once a week and documents on the computer program under the observations tab. They are labeled initial and weekly wound documentation. She sometimes looks at referrals, if |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 20) someone is a new admission for any wounds. She looks to see if a resident had a wound at the hospital prior to admission. Some wounds she catches from the clinical assessment that nurses complete on admission. Aides complete a shower sheet with each shower or bath and turn the sheet in at the nurses’ station. The administrator, DON, or the MDS Coordinator MM look through the shower sheets, depending on who has time. Nurses sign off on the the shower sheets before the end of the shift. Nurses call the physician for a treatment order. The MDS Coordinator MM runs a facility activity report of notes, vital signs, and observations every morning. She finds out about wounds from the documentation, or day shift or evening shift staff come tell her. Staff will also put a note under door. The nurses do the skin assessments on a weekly rotation. It pops up on their TAR. If a resident has a wound, the skin assessment just tells if the resident has a wound, It does not contain any description or measurement of the wound. That information would be documented in a wound assessment. 4. During an interview on 04/23/19, at 1:53 P.M., the DON said in general, if skin concern found by staff, it should be written on skin assessment sheets, DON notified, and the physician notified there is a problem. The nurse should document in a progress note. If there was an incident, that should be documented. When documenting the wound, it should have the cause of the wound if known, description of the wound, and measurements. The nurse should notify obtain treatment orders. | |
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate pressure ulcer care and prevent new ulcers from developing. **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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 21) -Use a bed cradle (a frame used to keep the sheets and blankets from laying directly on a person’s skin while in bed) to relieve pressure of bed clothing, if needed. -Assist resident at mealtime to assure adequate nutrition. -Offer fluids frequently for adequate hydration. 1. Record review of Resident #26’s face sheet (a summary of important information about a resident) showed the following: -Readmitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s pressure ulcer risk assessment, dated 1/23/18, showed the staff scored the resident as an 18, which indicated the resident was at risk for pressure ulcer development. Record review of resident’s annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/11/19, showed the following information: -Severe cognitive impairment; -Required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene; -Used a wheelchair for mobility; -Always continent of bowel and bladder; -At risk for developing pressure ulcers; -No pressure ulcers; Pressure-reducing device for his/her chair; -Pressure-relieving device for his/her bed. Record review of the resident’s care plan, last updated 2/15/19 showed the following information: -Urinary Incontinence: the resident was at risk for complications related to incontinence of bowel and/or bladder; -Give the resident good perineal care after each incontinent episode; -Observe for redness and breakdown in the resident’s perineal area when the resident toileted; -Weekly skin assessment by licensed nurse. -At risk for skin breakdown related to history of pressure ulcers, impaired mobility, incontinence, and disease process; -Apply moisture barrier as appropriate; -Check the resident’s position in the wheelchair and bed regularly. Assist the resident to make changes as needed. -Clean and dry the resident’s skin after each incontinent episode. -During my staff assisted shower, document and report any areas of redness or breakdown to the charge nurse. -Report any areas of skin breakdown to the physician as needed for appropriate treatment orders. -Weekly skin checks by the licensed nurse with quarterly pressure ulcer risk assessments; -Required assistance of one staff for all of his/her activities of daily living related to weakness, impaired mobility and disease process, including transfers and toileting; -Up in a wheelchair daily, assist of one staff to transfer. Record review of the resident’s (MONTH) 2019 physician’s orders [REDACTED]. Record review of resident’s progress note, dated 4/9/19, showed a social services designee (SSD) documented the resident would discharged from Hospice services at midnight on 4/11/19 as the resident no longer met hospice criteria for services. Record review of the resident’s weekly skin assessment, dated 4/16/19, showed a nurse |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 22) documented the resident’s skin was intact, no skin issues. Observations on 4/15/19 and 4/16/19 showed the resident propelled himself/herself in a wheelchair throughout the facility. The resident sat up in his/her wheelchair all day. He/she did not have a pressure reducing cushion in his/her wheelchair. He/she sat on a folded blanket. An observation and interview on 4/17/19 on 7:39 P.M., showed Certified Nurse Aide (CNA) Q wheeled the resident to his/her room. The resident stood up from his/her wheelchair and showed a visible dark yellow ring of wetness in the center of the folded blanket where he/she sat. The resident did not have a pressure relieving cushion in his/her wheelchair. The CNA pulled down the resident’s pants and incontinent brief. The resident was incontinent of urine, visible in his/her saturated brief. Urine leaked from the resident brief through his/her pants onto the folded blanket in his/her wheelchair. The brief was so full of urine, it caused his/her pants and folded blanket to be wet. The strong urine odor from the resident brief permeated the bathroom. CNA Q took off the resident’s pants and said they were wet and he/she retrieved a clean pair of pants from the resident’s closet. After the resident finished, he/she stood up for the CNA to clean him/her. The resident had three apple seed-sized raised areas on his/her left inner buttock and his/her perineal area was reddened. The CNA said one of the raised areas was soft, one was hard and the third looked like a bite. He/she also said the resident’s perineal area was reddened. The CNA wiped the resident’s inner buttocks, one time, with a disposable wipe, and dressed the resident in a new brief and pants. Observations on 4/18/19 showed the resident sat in his/her wheelchair all day. He/she did not have a pressure-reducing cushion and sat on a folded blanket. An observation on 4/19/19, at 12:30 P.M., showed CNA X assisted the resident with a shower. The CNA dried off the resident’s feet and showed a small circular scabbed area on the fourth toe of his/her right foot. The resident stood up and showed on circular, dark red area, a little smaller than a pencil eraser, on his/her left inner buttock. The resident’s perineal area was reddened with peeling skin. After the CNA dressed the resident, he/she transferred him/her to the wheelchair. The resident’s wheelchair did not have a pressure re cushion for the resident to sit on. Record review of Skin Monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review sheet, dated 4/19/19, showed the following information: -A CNA documented the resident had reddened and peeling skin on his/her buttocks. -On 4/19/19, the charge nurse signed the sheet indicating he/she reviewed it; -On 4/22/19, administrator signed the sheet, indicating she reviewed it; -A staff member documented was also given to MDS coordinator (MM)/ wound nurse to assess. (The staff member did not document the date he/she gave MDS coordinator MM the shower sheet). During an interview on 4/19/19, at 2:18 P.M., LPN D said the resident had a pressure reducing cushion in his/her wheelchair. When Hospice discharged the resident, they probably took it when they picked up their equipment. He/she should have noticed the resident did not have a pressure reducing cushion in his/her wheelchair, before now. An observation on 4/22/19, at approximately 9:30 A.M., showed the resident sat in his/her wheelchair. The resident did not have a pressure reducing cushion in his/her wheelchair. During an interview conducted on 4/22/19, at 11:18 A.M., the Rehabilitation Director said the physician had to write an order for [REDACTED]. He randomly screened residents throughout the week for positioning devices. If a resident had a pressure ulcer or complained of pain in his/her buttocks, he completed a screen on that resident as well. The rehabilitation director did not know if the resident continued to receive Hospice |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) services but he thought Hospice provided the resident with a pressure-reducing cushion. He wanted to screen the resident for the last two to three weeks but he was waiting for resident Hospice to discharge him/her. The rehabilitation services director found out about new wounds through daily morning meetings, as well as, during the weekly residents at risk (RAR) meeting. During an interview conducted on 4/22/19, at 1:39 P.M., LPN D said the resident now had a Roho cushion. The resident received Hospice services and recently they discharged him/her from services. Hospice staff took the resident’s cushion when he/she discharges and we did not catch that until last Friday afternoon (4/19/19). Therapy screened residents for positioning devices but they probably did not screen the resident because he/she received Hospice services. The LPN had not recently observed the resident’s skin. If a CNA found a skin concern when assisting a resident with a shower, the CNA would report the issue to the charge nurse. An onservation on 4/22/19, at 1:56 P.M., the resident sat, with his/her eyes closed, in his/her wheelchair in the B-wing dining room. The resident sat on a pressure-reducing cushion. Record review of the resident’s Medication Administration Record [REDACTED] -An order, dated 3/14/19, for a ROHO cushion to the resident’s wheelchair each shift; -Day shift (6:00 A.M.-2:00 P.M.) staff documented the item was unavailable on 4/1/19 through 4/8/19, 4/10/19, 4/11/19, 4/14/19, 4/18/19, 4/19/19, and 4/22/19. -Evening shift (2:00 P.M.-10:00 P.M.) staff documented the item was unavailable on 4/1/19 through 4/4/19, 4/6/19 through 4/8/19, 4/10/19, 4/14/19, 4/15/19, 4/16/19, 04/19/19, 04/22/19. On 4/18/19, evening shift staff documented the resident refused the item; -Night shift staff (10:00 P.M.-6:00 A.M.) documented the item was unavailable on 4/1/19 through 4/3/19. On 4/4/19, night shift staff did not document if the resident had the cushion or not. On 4/18/19, night shift staff documented the resident refused the item. Review of the resident’s progress notes, 4/17/19-4/22/19 showed no documentation a nurse assessed the reddened areas on the resident’s buttocks or the small scab on the resident fourth toe. Record review of the weekly skin assessment, dated 4/23/19, at 1:00 A.M., showed a nurse documented the resident’s skin was intact. An observation on 4/23/19, at 9:26 A.M., showed the following: The DON and MDS coordinator MM removed the resident’s house shoes and observed his/her feet. The resident had a small circular area on the fourth toe of his/her right foot. The MDS Coordinator said she did not know what to call the area, maybe an abrasion or pressure area from his/her shoes. The resident had issues with his/her feet, off and on. His/her shoes were tight and he/she had a lot of swelling in his/her feet. -The DON and MDS Coordinator MM assisted the resident to the bathroom. The MDS Coordinator said the resident had a pea-sized, Stage II pressure ulcer, with flaky skin, on his/her left buttock. The resident had a pressure ulcer in this area before and she considered this a reopening of an old pressure area. The resident’s inner buttocks were reddened. Record review of the resident’s weekly initial and weekly wound documentation, dated 4/23/19, at 1:00 A.M., showed a nurse documented the resident’s skin was intact. Record review of resident’s initial and weekly wound documentation, dated 4/23/19, showed the following information: -Date of onset: 2/23/19, new area; -Acquired at the facility; -Left inner, mid buttock, pressure ulcer Stage II (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) that measured 0.5 centimeters |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) (cm) X 0.3 cm X 0.1 cm. -Granulation (pink or red tissue with a shiny, most, granular appearance) tissue present in the wound bed -Scant amount of bloody drainage and no foul odor. -Surrounding tissue intact; -Interventions: Pressure reducing device for bed, pressure ulcer care (no pressure ulcer device for chair). Record review of the resident’s medical record showed no documentation of the small pressure area on the resident fourth toe, right foot. During an interview conducted on 4/22/19, at 4:05 P.M., CNA Q said the resident’s skin was fragile. He/she had not seen the resident’s skin since last week, but he/she remembered the resident had three little bumps on his/her inner left buttocks that were firm but not fluid-filled. His/her buttocks were not red at that time. The CNA knew he/she told the charge nurse about the three small bumps but he/she did not remember whom he/she told. During an interview conducted on 4/22/19, at 9:20 P.M., Registered Nurse (RN) J said he/she did not know the resident had three small raised areas on his/her inner left buttock. Social services staff asked him/her, today, to assess the resident’s buttocks. During an interview conducted on 4/23/19, at 12:39 P.M., CNA X said the CNAs completed a shower sheet with each resident shower. The CNAs gave the sheets to the nurse, the nurse then reviewed it, signed it, and placed it in the medical records tray at the nurses’ station. If the CNA found something concerning, he/she would report it to the nurse. During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said MDS Coordinator MM told her about resident’s pressure ulcer today. The administrator reviewed the resident’s shower sheet yesterday and she asked RN J to complete a skin assessment on the resident. During an interview conducted on 4/23/19, at 3:38 P.M., the DON said if an aide observed a new skin issue, he/she should report it to the charge nurse. The nurse should assess the area, document the assessment in the progress notes and weekly skin assessment and notify the physician. The nurse should also report the skin issue to the DON and MDS coordinator MM. 2. Record review of Resident #10’s face sheet showed the following: -Readmitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of resident’s quarterly MDS, dated [DATE], showed the following information: -No cognitive impairment; -Independent with bed mobility, transfers, dressing, eating. Toileting and personal and hygiene; -Used a wheelchair for mobility; -At risk for pressure ulcers; -No pressure ulcers; -Pressure-reducing device for his/her bed; -Application of ointments/medications other than to feet. Record review of the resident’s care plan, last reviewed 1/23/19 showed the following information: -The resident was risk for skin breakdown related to obesity and disease process; -Apply moisture barrier as appropriate; -Check the resident’s position in his/her wheelchair and bed regularly. Assist him/her to make changes as needed. -Clean and dry his/her skin if he/she should have an incontinent episode. |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 25) -Complete his/her Braden scale (a tool used to help determine a resident’s risk of developing a pressure ulcer) quarterly and as needed. -During staff assisted showers, document and report any areas of redness/breakdown to the charge nurse. -Report any areas of skin breakdown to the physician as needed for appropriate treatment orders. -Weekly skin checks by the licensed nurse with quarterly pressure ulcer risk assessments. Record review of the resident’s progress notes, dated 4/9/19, showed a nurse documented the resident returned from the hospital and had a Stage I pressure ulcer to his/her right coccyx. The nurse did not document a description of the area including size and surrounding tissue. Record review of the resident’s physician order, dated 4/9/19, showed an order to clean the right coccyx (tailbone) Stage I pressure ulcer with wound cleanser and apply a [MEDICATION NAME] (an adhesive dressing) every other day and as needed. Record review of the resident’s (MONTH) 2019 treatment administration record (TAR) showed the following information: -an order for [REDACTED].>-Staff documented they did not change the dressing on 4/11/19, the resident was unavailable; 4/13/19, the resident was unavailable; 4/15/19, due to time constraints; 4/17/19, the resident was unavailable; and 4/19/19, due to time issues. Record review of the resident’s Skin Monitoring: Comprehensive CNA Shower Review forms showed the following information: -On 4/16/19, at 5:15 A.M., a CNA documented the resident received a shower. On 4/16/19, a nurse documented no skin issues reported to this nurse. On 4/16/19, the DON signed the form; -On 4/16/19 a CNA (a different CNA than who documented on the above shower sheet) documented the resident received a shower. The resident had a reddened area on his/her buttocks. On 4/16/19 a nurse (a different nurse than who signed the above shower sheet) documented he/she reviewed the shower sheet. On 4/17/19, the administrator signed the form. During an interview conducted on 4/17/19, at 2:06 P.M., the resident said he/she had a dressing on his/her buttocks but he/she removed it yesterday (4/16/19) when he/she took a shower. He/she removed it because he/she in case it had fecal material on it. Staff placed the dressing on his/her buttocks the day he/she readmitted to the facility (4/9/19). During an interview conducted on 4/18/19, at 4:20 PM RN J said the Stage I pressure ulcer on the resident’s buttocks was healing well. He/she observed it a long time ago. The resident said he/she did not want staff messing with it, so he/she backed off the treatment. The resident had an air mattress but it staff took it off his/her bed because another resident needed it more. The RN did not know why staff would document they did not complete the treatment because the resident was unavailable. Ig the RN did not complete a treatment, he/she would always document why he/she did not complete it on the TAR. An interview and observation on 4/19/19, at 8:33 A.M. and 10:55 A.M., showed the following information: -At 8:33 A.M., a CNA walked with the resident as he/she propelled his/her wheelchair into his/her room. The resident stood up and pulled down his/her pants and showed, on his/her right buttock, an apple seed-sized open area with white flaky skin surrounding and partly covering the wound bed. On his/her left buttock, the resident had a pea-sized white, flaky scabbed area. His/her perineal area was reddened. The resident did not have a pressure reducing cushion in his/her wheelchair. He/she sat on three folded cloth pads. |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 26) -The resident said he/she had a history of [REDACTED]. In the past, therapy staff placed a pressure-reducing cushion in his/her wheelchair but it was too thick and his/her feet did not reach the ground to propel his/her wheelchair. The resident got the wheelchair he/she currently sat in seven or eight years ago. The wheelchair was broken; the seat sagged so if he/she placed a smaller cushion in the wheelchair, it slid out the back of the chair. -The resident said about four or five months ago, staff placed an air mattress on his/her bed. The resident asked staff to remove it one to two weeks later due to severe back pain. He/she thought the air mattress caused his/her back pain and a regular mattress would help. The staff removed the air mattress but his/her back pain remained. The resident recently found out he/she had a broken back. The resident wished he/she never asked staff to remove the air mattress. At the beginning of (MONTH) 2019, the resident asked a nurse if he/she could have the air mattress back. The nurse said the physician would have to write an order for [REDACTED]. The resident did not talk to the nurse practitioner about an air mattress because he/she it was a moot point; he/she did not have a big enough issue to get one. -The resident pointed to his/her bed and said he/she placed a pillow, under mattress, and positioned several folded blankets under his/her bottom and upper legs to hopefully avoid developing any more sores. The resident had a history of [REDACTED]. Record review of a psychiatric consult, dated 2/20/19, showed the psychologist documented the resident reported he/she could not sleep through the night due to extreme pain. He/she was waiting to get the (air) mattress back. During an interview conducted on 4/19/19, at 2:18 P.M., LPN D said in the past, the resident had an air mattress and a pressure reducing cushion in his/her wheelchair. The LPN did not know the resident currently wanted either of those items. If a nurse could not complete a treatment because a resident was unavailable, the nurse would report this to the oncoming shift to complete. If staff already documented completing the treatment, but was actually unable to complete the treatment, staff should add an addendum describing the situation, but he/she did not know if staff knew how to do that. During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said the resident sat on a green folded pad instead of a wheelchair cushion because the cushion the resident tried was too thick and the resident’s feet did not reach the floor. The CNA did not know what resident’s skin looked like since resident took himself/herself to the bathroom. The CNA thought the nurse checked the resident’s skin. The resident used to have an air mattress on his/her bed, but the CNA did not know if he/she still had one. He/she thought the resident wanted the mattress removed because it hurt his/her back. An observation and interview conducted on 4/22/19, at approximately 10:00 A.M., showed the resident propelling his/her wheelchair down the hall, towards the main dining room. The resident said, in an irritated tone, he/she did not need staff (LPN D) to look at his/her skin; it was fine. During an interview conducted on 4/22/19, at 11:18 A.M., the Rehabilitation Director said the resident did have a cushion but he had not looked at the resident recently because the resident was good about talking to him when he/she needed something. The rehabilitation director did not know the resident’s wheelchair was broken. In terms of a properly fitting cushion, he would assess the resident’s wheelchair to ensure it was in the lowest position. During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said she did not know resident had skin issues. If staff were unable to complete a physician’s orders [REDACTED]. 3. During an interview on 4/19/19, at 2:18 P.M., LPN D said the nurses completed skin |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 27) assessments weekly for each resident. The physician determined and ordered interventions related to residents’ skin issues. During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said pressure ulcer interventions included consistently turning and repositioning residents and placing pillows between their knees. All residents should have a cushion in their wheelchair unless they requested not to. During an interview conducted on 4/22/19, at 1:39 P.M., LPN D said to prevent pressure ulcers staff reposition residents, provide skin care, and apply barrier cream, if needed. Ideally, all residents who use a wheelchair for mobility should have a cushion. During an interview conducted on 4/22/19, at 9:20 P.M., RN J said if he/she found or if staff reported a new skin issue, he/she assessed the area, documented the assessment in the nurse’s notes and notified the doctor. During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said when a CNA assisted a resident with a shower, he/she completed a shower sheet and gave the sheet to the nurse to review. If a CNA documented a skin issue on the shower sheet, the nurse compared the sheet to what he/she knew about the resident, he/she signed the sheet and placed it in medical records’ tray at the nurses’ desk. If the CNA found a new area on a resident’s skin, he/she reported the area to the nurse. If a resident’s perineal area were reddened, he/she would first perform perineal care on the resident; if it were still red, he/she would report the redness to the nurse. During an interview conducted on 4/23/19, at 12:49 P.M. and 1:43 P.M., LPN D said the following: -After the CNA gave the shower sheet to the nurse to review the nurse signed the sheet and placed it in the tray at the nurses’ station for the administrator to review; -If a resident had a new wound, he/she would notify the physician and wound nurse. If the wound nurse was at the facility, she would assess the wound. If the wound nurse was not at the facility, the LPN would assess the wound and document the assessment in the progress notes. During an interview conducted on 4/23/19, at 1:54 P.M., the administrator said interventions for pressure ulcer prevention and treatment included turning and repositioning, and a pressure-reducing cushion in the wheelchair. Staff should report any new skin areas to the nurse and the nurse should assess and document the assessment in the progress note or on a skin assessment. The nurse then should give a copy of the progress note or skin assessment to MDS Coordinator MM, who was the wound nurse at this time. The administrator said they did needed to do a better job following up on skin concerns. | |
| F 0687 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate foot care. **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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0687 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 28) Record review of resident’s annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/11/19 showed the following information: -Severe cognitive impairment; -Required supervision for locomotion throughout the facility; -Required extensive assistance with transfers and dressing; -Used a wheelchair for mobility. Record review of the resident’s care plan, reviewed 2/15/19, showed the following information: -The resident’s nails should be cut routinely by licensed staff only; -Observe my skin for impairment in integrity. Weekly skin assessments by licensed nurse; -Ensure the resident wears appropriate footwear to minimize trauma to his/her feet. Record review of the resident’s (MONTH) 2019 physician order [REDACTED]. Record review of resident’s progress note, dated 4/9/19, showed a social services designee (SSD) documented the resident would discharged from Hospice services at midnight on 4/11/19 as the resident no longer met hospice criteria for services. Observations on 4/17/19 showed the following information: -At 6:38 P.M. and 7:18 P.M., the resident propelled his/her wheelchair up and down the halls of the facility. Resident wore house shoes and nonskid socks. The resident’s house shoes were not completely on the resident’s feet causing the resident to step on the sides of the house shoes when he/she propelled his/her wheelchair; -At 7:39 P.M., Certified Nurse Aide (CNA) Q assisted resident to bathroom. The resident continued to wear nonskid socks and house shoes, stepping on the sides of the house shoe. When the CNA removed the resident’s house shoes and socks, the resident told the CNA to be careful; his/her feet were sore. The resident’s feet were swollen and reddish purple. The CNA placed the resident’s feet properly into the house shoes, without the nonskid socks. An observation on 4/19/19, at 12:30 P.M., showed CNA X assisting the resident with a shower. The resident’s feet were swollen and bluish purple in color. The CNA lifted the resident left foot and showed a garbanzo-sized, hard, white area, approximately two inches below his/her great toe, and pea-sized, hard, white area approximately one inch below his/her fourth toe. The resident said his/her foot was tender to the touch, and then he/she said both of his/her feet were tender. The toenails on the resident’s feet were yellowish, long and thickened. Record review of Skin Monitoring: Comprehensive CNA Shower Review sheet, dated 4/19/19, showed the CNA documented the resident’s feet were blue/purple. On 4/19/19, a nurse signed the shower sheet indicating he/she reviewed it. On 4/22/19, the administrator signed on the form. An interview conducted on 4/22/19, at 1:39 P.M., Licensed Practical Nurse (LPN) D said the resident complained of foot pain, in the past, but it had been awhile. Social services staff schedule resident visits with the podiatrist. If a resident had thick nails or complained of foot pain, he/she might see the podiatrist. An observation on 4/22/19, at 3:51 P.M., the resident propelled his/her wheelchair up and down the halls of the facility. Resident wore house shoes and nonskid socks. The resident’s house shoes were not completely on the resident’s feet causing the resident to step on the sides of the house shoes when he/she propelled his/her wheelchair. An observation on 4/23/19, at 9:26 A.M., the Director of Nursing (DON) and MDS coordinator MM wheeled the resident into his/her room and asked if his/her feet hurt. The resident said no and lifted his/her feet up and down as if he/she was running, but he/she did not touch his/her left foot to the floor. The MDS coordinator removed the resident’s house shoes; his/her feet were swollen and reddish purple. On his/her left foot he/she had a |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0687 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 29) garbanzo-sized, hard, white area, approximately two inches below his/her great toe, and pea-sized, hard, white area approximately one inch below his/her fourth toe. The MDS Coordinator said the resident had two callous’ on the bottom his/her left foot. The resident had issues, off and on, with his/her feet. His/her feet swelled and his/her shoes were tight. The DON said the resident’s toenails were a little thick. The MDS coordinator found a pair of slip on shoes in the resident’s closet and brought them to him/her. The resident said those shoes hurt his/her feet. The DON said the shoes might cut into the sides of the resident’s foot (due to swelling). The resident said he/she tried to wear the shoes yesterday but took them off because they hurt his/her feet. The DON and MDS coordinator assisted the resident to the bathroom. During the transfer, the res did not step down or put pressure on his/her toes and the ball of her right and left foot; when he/she walked he/she walked on his/her heels. The MDS coordinator said she noticed how the resident walked during the transfer and she figured those calluses were pretty sore. The resident said his/her toes and feet hurt badly. He/she placed his/her left foot on his/her right leg and rubbed it multiple times. The DON wondered if the podiatrist had seen the resident and MDS coordinator MM said she did not know, but she would ask SSD T if the resident was on the podiatrist’s list. During an interview conducted on 4/23/19, at 10:45 A.M., SSD T and SSD U said a podiatrist came to the facility every three months. The SSDs determined who saw the podiatrist and wrote a list. They announced the upcoming podiatry visit in resident council and if any of those residents wanted to see the podiatrist, he/she told one of the SSDs and she would write the resident’s name on the list. The SSDs also included residents with diabetes and those who had a specific physician’s orders [REDACTED]. If a resident did not attend resident council meetings, did not have a specific physician’s orders [REDACTED]. The SSDs did not know why the podiatrist had not seen the resident and they were unable to locate podiatrist’s list at that time. One of the SSDs said the resident did not want fitted for shoes, but it depended on the day. The SSDs did not have any documentation that showed they offered to fit the resident for shoes. A short time later, at approximately 11:00 A.M., one of the SSDs said the podiatrist did not fit the resident for shoes because the resident received Hospice services. During an interview conducted on 4/23/19, at 12:39 P.M., CNA X said the resident often complained of foot pain. He/she would tell staff to be careful, his/her feet were tender he/she would say he/she needed a physician to check his/her feet. The CNA did not report the resident’s complaints of foot pain to the nurses because the nurses were already aware of the resident’s foot pain. The CNA did not know specifically how the nurses knew, however, the nurses kept up on things regarding the residents. The resident complaints of foot pain was not new. The CNA started working with the resident around (MONTH) (YEAR). The first time he/she observed the resident’s feet, he/she was surprised by the color (reddish blue), the temperature (cool to touch) and the amount of swelling. This was a regular issue for the resident, at least for a few months. During an interview conducted on 4/23/19, at 1:54 P.M., the administrator said the podiatrist saw residents based on a list. Staff wrote a resident’s name on the list if the resident was diabetic, if the resident requested to be seen or if nursing thought the resident needed seen. The podiatrist came to facility every three months to cut toenails and to check for and treat callouses. When the resident first admitted to the facility, he/she had several wounds on his/her feet, but they healed. The resident recently discharge from Hospice, but when he/she received Hospice services, he/she could not see the podiatrist because Hospice would not pay for it Record review of the resident’s progress notes, from 1/2/19 to 4/23/19, showed 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0687 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 30) documentation regarding the condition of the resident’s feet or his/her complaints of foot pain. | |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 31) -Alert/cognitively intact; -Required assistance of two staff for bed mobility, transfers, and toileting; -Safety concerns included: fall risk, ambulation difficulties, unsteady/unsafe independent transfers, balance/gait unsteady, muscle weakness, fatigue/endurance concerns; -Manual wheelchair. Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by the facility staff, dated 4/2/19, showed the following information: -Entered facility on 3/26/19; -Required extensive physical assistance, two or more staff, when transferring from bed, chair, wheelchair, standing position; -Walked only one or two times in room and required two or more staff for physical assistance; -Did not walk in hallways. Record review of the resident’s care plan, last revised 4/3/19, showed the following information: -At risk for falls related to left sided neglect and [MEDICAL CONDITION] post-[MEDICAL CONDITION] (left sided lack of awareness and weakness after a stroke), impaired safety awareness, impaired mobility, general debility, and disease processes; -Ensure positioned properly; -Keep call light within reach in room; -Keep needed items within easy reach. During an interview on 04/17/19, at 11:36 A.M., the resident’s family member said staff almost dropped the resident one day last week. While he/she was transferred, his/her chest was at the level of bed before the staff got the resident safely onto the bed. The family member said he/she was in the room during that transfer. Observation on 04/17/19, at 6:41 P.M., showed Certified Nursing Assistant (CNA) S and CNA R entered the resident’s room. CNA R assisted the resident to sit on the side of the bed. The aides put shoes on the resident’s feet. The aides placed the gait belt on the resident’s waist. The aides moved the wheelchair to the right side of the resident’s bed. CNA S held and lifted under the resident’s arm and pants during the transfer. CNA R held the gait belt and lifted under the resident’s arm. The aides assisted the resident to a standing position. CNA S moved to the resident’s right side and CNA R moved to the resident’s left side. They assisted the resident to pivot with his/her right foot, the bed moved away from the resident and the aides as the transfer took place. CNA S said, don’t move the bed, and CNA R said that he/she did not move it. At 6:48 P.M., CNA S said this is taking entirely too long. The aides transferred the resident from the bed to the wheelchair, with extensive assistance. Observation on 04/18/19, at 10:00 A.M., showed CNA N and CNA A in the resident’s room. The aides had the resident standing at the side of the bed, with staff on each side of the resident. The two aides pivot transferred the resident to the recliner. The aides did not have a gait belt on the resident’s waist during the transfer. The aides lifted the resident under his/her arms during the transfer. During an interview on 04/22/19, at 7:40 A.M., CNA N said he/she uses a gait belt for everybody. The gait belt goes around the resident’s waist, especially if the resident had any chest surgery and around the chest if the resident had any abdominal surgery. Staff should never transfer a resident by holding under the arms. Staff should hold on to the gait belt. If a resident is able, the resident can hold onto staff to help. Resident #63 is a two person transfer with gait belt, left side is weak, he/she is a pivot transfer, |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 32) and requires one staff on each side. During an interview on 04/22/19, at 8:36 A.M., CNA A said he/she would ask another staff that had transferred a new resident before or get therapy to help with the transfer. He/she did not know if there was somewhere to look for transfer plan. Resident #63 is a two person extensive assistance with a gait belt put around the chest and hold gait belt while lifting transfer. The resident can only bear full weight on one side. The resident pivots on his/her good leg as much as he/she can. Sometimes, staff have to hold under the resident’s arm to help steady the resident. During an interview on 04/23/2019, at 1:53 P.M., the Director of Nursing (DON) said there are specific orders for transfers with the Hoyer lift or sit to stand with two staff. If a resident is new admission from the hospital then therapy will advise how much assistance a resident needs. Usually therapy will make recommendations to restorative. B-Wing residents that have been here a long time just continue the same type of transfers. During a transfer the gait belt goes around the resident. Staff should be sure they are able to hold gait belt with transfer and use proper body mechanics. The gait belt needs to be tight enough to stay in place, but able to get hands under belt. Gait belt should be used for anybody that requires assistance. Staff should not grab or pull under arms. During an interview on 04/23/19, at 3:36 P.M., the administrator and the quality assurance (QA) support nurse said staff should look at the care plan for how to transfer a resident. All staff have access to the care plan. For a new admission, they try to look at the hospital paperwork. Therapy completes an evaluation for transfer assistance needed and therapy communicates pretty well with staff. 2. Record review of Resident #26’s face sheet showed the resident admitted to the facility on [DATE]. The resident’s [DIAGNOSES REDACTED]. Record review of the resident’s annual MDS, dated [DATE], showed the following information; -Severe cognitive impairment; -Required extensive assistance with bed mobility and transfers; -Did not walk; -Required supervision for locomotion throughout the facility; -Not steady, only able to stabilize with human assistance; -Used a wheelchair for mobility. Record review of the resident’s care plan, updated 2/15/19, showed the following information: -The resident required assistance of one staff for all of his/her activities of daily living due to weakness, impaired mobility and disease process, including transfers and toileting; -The resident was up in a wheelchair daily with assistance from one staff to transfer. A observation on 4/17/19, at 7:39 P.M., showed CNA Q wheeled the resident into his/her room to assist him/her to the bathroom. The resident stood up from his/her wheelchair; the CNA did not lock the resident’s wheelchair brakes. The resident placed his/her hands on the sink and stood up. He/she then walked into the bathroom, unassisted, using the sink and wall to steady himself/herself. While the resident walked into the bathroom, the CNA stood near the sink, watching the resident. He/she did not apply a gait belt around the resident’s waist and did not assist the resident with the transfer. An observation on 4/23/19, at 9:26 A.M., showed the DON and MDS Coordinator MM wheeled the resident into his/her room. The DON and MDS Coordinator wheeled the resident to the bathroom door and assisted the resident into the bathroom by placing one of their arms underneath the resident’s armpit. The DON and MDS coordinator did not use a gait belt 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 33) transfer the resident. After the resident finished toileting, the DON and MDS coordinator assisted the resident to his/her wheelchair by placing one of their arms underneath the resident’s armpit. During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said staff should use a gait belt when transferring a resident unless a nurse or physician instructed them otherwise. If they were not supposed to use a gait belt, it would be documented in the resident’s care plan. The resident required assistance of one staff for transfers but at times, he/she transferred himself/herself without assistance. During an interview conducted on 4/22/19, at 9:15 P.M., CNA Q said the following: -The resident required limited assistance from staff to transfer for balance, especially with transfers from his/her bed to the bathroom, and the toilet to his/her bed. -The resident sometimes transferred himself/herself, which was scary because resident could lose his/her balance; -The resident stood, most of the time, unassisted, and he/she used the wall, and available furniture, to keep his/her balance; -The CNA knew how a resident transferred by asking the resident what he/she could do. Although the resident’s legs were strong, the resident had problems with balance; -CNA Q used a gait belt every time he/she assisted a resident to transfer, if he/she had one available, which he/she always did. If he/she did not have one with him/her, he/she kept one at the nurses’ station; -Last Wednesday (4/17/19), around 9:00 P.M., the CNA was checking on residents and found Resident #26 sitting on the toilet. The resident transferred himself/herself. When the resident finished, the CNA stood near the bathroom door talking to the resident. The resident stood using the bathroom bar to steady himself/herself for a good couple of minutes, then his/her legs buckled. The CNA rushed to the resident and caught him/her before he/she fell to the ground. The resident did not have a gait belt on. The CNA told the charge nurse of the resident’s almost fall, but he/she could not remember which charge nurse he/she told. During an interview conducted on 4/22/19, at 9:20 P.M., Registered Nurse (RN) J said he/she knew how to transfer a resident by assessing the resident himself/herself. The first time he/she assisted a resident to transfer, he/she had an aide with him/her to assist if needed. Although you could ask a resident how he/she transferred, you could not always take someone’s word on how he/she transferred. The RN worked the evening shift on 4/17/19. No staff told him/her Resident #26 almost fell . During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said he/she used a gait belt if a resident was wobbly, he/she would not stand, or if he/she was not familiar with the resident. All of the aides had a gait belt. Resident #26 transferred himself/herself. He/she could stand and transfer to the toilet, but he/she needed staff assistance to wipe and pull up his/her pants after he/she toileted. During an interview conducted on 4/23/19, at 12:40 P.M., CNA X said Resident #26 transferred pretty well independently, but he/she needed assistance pulling up his/her pants and he/she wanted someone to talk to. Staff used a gait belt to assist him/her occasionally, depending on the day. Resident was sometimes unsteady and sometimes steady. Staff should use a gait belt anytime they transferred a resident. If the aide did not know the resident or did not know how that resident transferred, the aide either asked the nurse or asked the resident if he/she could stand on his/her own, and did he/she use a walker. These questions helped the aide to determine how much assistance the resident needed. The first time CNA X transferred a resident, he/she had a second person with him/her in care he/she needed assistance. |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 34) During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said staff should use a gait belt any time they transferred a resident. During an interview conducted on 4/23/19, at 3:38 P.M., the DON said staff should use a gait belt with all transfers, especially if the resident needed assistance getting up. The DON and MDS Coordinator MM should have used a gait belt to transfer Resident #26 to the toilet. 3. Record review of Resident #22’s face sheet showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s fall risk assessment, dated 8/21/17, and completed by facility staff, showed staff identified the resident to be at high risk for falls. (Staff did not complete additional fall risk assessments after 8/21/17.) Record review the resident’s nurses’ progress noted, dated 1/27/19, showed staff documented the resident fell , hitting his/her left arm, and causing a three inch by one inch skin tear with total skin loss. (Staff did not document a root cause of the fall, or what new interventions were put in place.) Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated assessment instrument completed by facility staff), dated 2/7/19 showed the following: -Severely impaired cognition and vision; -Extensive staff assistance of two required for transfers; -Use of a chair alarm and bed alarm daily; -Two or more non-injury falls since the previous assessment; -The resident did not receive restorative or other therapy’s during the previous seven days. Record review the resident’s nurses’ progress notes showed the following: -On 2/21/19, staff documented the resident fell with no apparent injury; -On 3/20/19, staff documented the resident fell , hit his/her head, and caused an abrasion to the top of his/her head; -On 3/26/19, staff documented the resident fell injuring his/her left hand. (Staff did not document a root cause of the fall, or what new interventions were put in place.) Record review of the resident’s left hand radiology (x-ray) report, dated 3/27/19, showed an acute (sudden onset) fracture to the resident’s 5th finger (pinky). Record review of the resident’s care plan, last reviewed date 3/27/19, showed the following: -Staff identified the resident as at risk for falls; -Instructed staff to check on the resident frequently; -Instructed staff to complete a fall risk assessment quarterly and as needed; -Instructed staff to toilet the resident every morning then take the resident to the nurse’s station. During an interview on 4/22/19, at 8:15 A.M., the MDS Coordinator LL said the following: -The residents’ care plans should be updated with every fall and additional interventions should be added to prevent further falls; -Resident #22 is very difficult because he/she is blind and impulsive. The resident had a recent hand fracture and previous rib fractures related to falls; -The charge nurse should complete a fall risk assessment quarterly and the MDS Coordinator reviews the assessment when it is completed; -Resident #22’s last fall risk assessment was completed on 8/21/17 which was the resident’s admission assessment; |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 35) -The resident’s falls could be related to toileting. Staff should toilet the resident every two hours and it should be addressed in the resident’s care plan. During an interview on 4/22/19, at 11:00 A.M., Certified Nurse Assistant (CNA) A said Resident #22 has had a lot of falls. The resident recently fractured his/her hand and has fractured ribs in the past. Whenever the resident falls he/she is usually needing to toilet or looking for something like cigarettes. The resident can ambulate, but is very unsteady and will fall within a few steps. Staff should respond to the resident and not the alarm. Staff have not been told to do anything different to prevent Resident #22’s falls, just to monitor. During an interview on 4/22/19 at 12:42 P.M., Licensed Practical Nurse (LPN) B said the following: -Dependent residents should be toileted every 2 hours; -Resident #22 gets really agitated so staff just wait until he/she asks to go to the bathroom; -The resident will try to get up on his/her own and will fall. He/she has an alarm to let staff know when the resident attempts to stand. The resident has had a lot of falls with multiple abrasions and skin tears and a recent fracture to his/her left hand and previous rib fractures; -He/She is not aware of any new interventions put in place to prevent falls for Resident #22. The only intervention is for staff to monitor the resident. The resident sits in the dining room or nurses station all day so staff can see him/her. During an interview on 4/22/19, at 1:11 P.M., the DON said she expects staff to toilet dependent residents at least every two hours. The resident’s toileting needs should be addressed in the resident’s care plan. The resident’s toileting needs puts them at risk for falls. She expects staff to assess the resident after each fall and update the care plan with interventions to prevent further falls. 4. An observation on 4/15/19, of the main dining room, showed the following information: -At 11:30 A.M., staff served 24 residents their lunch trays. After staff served the resident, they left the dining room; -At 12:07 P.M., 16 residents ate their meal without staff present; -At 12:20 P.M., eight residents remained in the dining room eating their meal. A staff member entered the dining room, removed soiled clothing protectors from empty tables, then left the dining room; -At 12:27 P.M., two residents continued eating their meal, no staff present in the dining room; -At 12:33 P.M., the last resident finished his/her meal; -At 12:34 P.M., the resident left the dining room. During an interview conducted on 4/15/19, at 1:18 P.M., Resident #41 said staff did not stay in the main dining room, especially for the evening meal. Sometimes, a supervisor or aide might enter the dining room for a short time, but most of the time no one was in there. This concerned Resident #41 because he/she witnessed a resident choke in the dining room. No staff was in the dining room at the time so he/she had to find staff to help. The resident asked staff why someone could not stay in the main dining room and staff told him/her they did not have enough staff. Observations on 4/17/19 showed the following information: -At 5:17 P.M., staff finished serving residents’ meals and left dining room. Residents continued to eat the evening meal without any staff present; -At 5:31 P.M., two residents continue to eat their meals with no staff present in 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 36) During an interview conducted during the resident council meeting, on 4/17/19, at 9:57 A.M., the residents said the following information: -Ten residents attended the resident council meeting. All ten residents ate their meals in the main dining room. All ten residents said after staff served residents their meals they left the dining room. Not only was there no staff supervision in case of a resident emergency, there were no staff available to give residents more drinks or an alternate meal if the resident did not like what staff served. The residents thought that after kitchen staff plated their meals, they took a break. Several residents said they attempted to get the attention of the kitchen staff by knocking on the door, but no one ever answered; -Resident #41 said after staff served the residents their meals, staff left the dining room. This happens mostly in the evening and on the weekends. A few months ago, a resident choked and LPN D had to perform the [MEDICATION NAME] maneuver. That resident now ate in one of the assisted dining rooms. During an interview conducted on 4/18/19, at 12:31 P.M., CNA Z said staff used to be assigned to the main dining room during mealtime, but now staff are not assigned due to the new schedule change. During an interview conducted on 4/18/19, at 4:15 P.M., RN J said the residents who sit in the main dining room ate without staff assistance. Residents, who required staff assistance to eat, ate in the assisted dining room. Staff did not have to supervise the main dining room, but he/she thought they should to assist residents and in case, a resident choked. RN J did not think staff stayed in the main dining room for the entire meal, they left after they served all the residents their meals During an interview conducted on 4/19/19, at 12:00 P.M., CNA DD said if three Restorative Nurses’ Aides (RNA) worked, one would go to each of the dining rooms (the main dining room, A-wing assisted dining room and B-wing ding room). The charge nurse assigned staff to the assisted dining rooms, but there was not always enough staff to assign to the main dining room. During an interview conducted on 4/22/19, at 3:31 P.M., CNA EE said usually two to three aides assisted residents who ate in the assisted dining rooms and whoever was available would supervise the main dining room. During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said they, for the most part, tried to ensure staff supervised residents’ meals in the main dining room. Normally, restorative staff assisted in the main dining room and the department heads assisted during the evening meal. Two RNAs worked from 6:00 A.M. to 2:00 P.M. and two RNAs worked 2:00 P.M. to 6:00 P.M. Technically, the charge nurses did not assign staff to supervise the main dining room, but if one of the restorative aides were not available, the charge nurse should send one aide from the A-wing or B-wing to assist. A resident did have a choking incident in the main dining room about 6 months ago. During an interview conducted on 4/23/19, at 3:38 P.M., the DON said staff should supervise and assist residents eating in main dining room. The RNAs should take turns on assisting in the main dining room and if an RNA was not available, an aide should assist and monitor residents. The RNAs knew to go to the dining room, but the charge nurses needed to assign the aide. 5. Record review of Resident #26’s face sheet showed the resident admitted to the facility on [DATE]. The resident’s [DIAGNOSES REDACTED]. Record review of the resident’s annual MDS, dated [DATE], showed the following information; -Severe cognitive impairment; |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 37) -Required extensive assistance with bed mobility and transfers; -Did not walk; -Required supervision for locomotion throughout the facility; -Not steady, only able to stabilize with human assistance; -Used a wheelchair for mobility. Record review of the resident’s care plan, updated 2/15/19, showed the following information: -The resident required assistance of one staff for all of his/her activities of daily living due to weakness, impaired mobility and disease process, including transfers and toileting; -The resident was up in a wheelchair daily with assistance from one staff to transfer. An observation on 4/17/19 07:39 PM CNA Q wheeled the resident into his/her room to assist him/her to the bathroom. The resident stood up from his/her wheelchair; the CNA did not lock the resident’s wheelchair brakes. The resident placed his/her hands on the sink and stood up. He/she then walked into the bathroom, unassisted, using the sink and wall to steady himself/herself. While the resident walked into the bathroom, the CNA stood near the sink, watching the resident. He/she did not apply a gait belt around the resident’s waist and did not assist the resident with the transfer. An observation on 4/23/19, at 9:26 A.M., the DON and MDS coordinator MM wheeled the resident into his/her room. The DON and MDS coordinator wheeled the resident to the bathroom door and assisted the resident into the bathroom by placing one of their arms underneath the resident’s armpit. The DON and MDS coordinator did not use a gait belt to transfer the resident. After the resident finished toileting, the DON and MDS coordinator again assisted the resident to his/her wheelchair by placing one of their arms underneath the resident’s armpit. During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said staff should use a gait belt when transferring a resident unless a nurse or physician instructed them otherwise. If they were not supposed to use a gait belt, it would be documented in the resident’s care plan. The resident required assistance of one staff for transfers but at times, he/she transferred himself/herself without assistance. During an interview conducted on 4/22/19, at 9:15 P.M., CNA Q said the following: -The resident required limited assistance from staff to transfer for balance, especially with transfers from his/her bed to the bathroom, and the toilet to his/her bed. -The resident sometimes transferred himself/herself, which was scary because resident could lose his/her balance. -The resident stood, most of the time, unassisted, and he/she used the wall, and available furniture, to keep his/her balance. -The CNA knew how a resident transferred by asking the resident what he/she could do. Resident #26 looked frail and you would think he/she was unable to walk, but if you looked at his/her legs, you could see they were not atrophied (muscle loss due to underuse) at all, his/her legs were still strong. Although the resident’s legs were strong, the resident had problems with balance. -CNA Q used a gait belt every time he/she assisted a resident to transfer, if he/she had one available, which he/she always did. If he/she did not have one with him/her, he/she kept one at the nurses’ station. -Last Wednesday (4/17/19), around 9:00 P.M., the CNA was checking on residents and found Resident #26 sitting on the toilet. The resident transferred himself/herself. When the resident finished, the CNA stood near the bathroom door talking to the resident. The resident stood using the bathroom bar to steady himself/herself for a good couple 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 38) minutes, then his/her legs buckled. The CNA rushed to the resident and caught him/her before he/she fell to the ground. The resident did not have a gait belt on. The CNA told the charge nurse of the resident’s almost fall, but he/she could not remember which charge nurse he/she told. During an interview conducted on 4/22/19, at 9:20 P.M., RN J said he/she knew how to transfer a resident by assessing the resident himself/herself. The first time he/she assisted a resident to transfer, he/she had an aide with him/her to assist if needed. Although you could ask a resident how he/she transferred, you could not always take someone’s word on how he/she transferred. The RN worked the evening shift on 4/17/19. No staff told him/her Resident #26 almost fell . During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said he/she used a gait belt if a resident was wobbly, he/she would not stand, or if he/she was not familiar with the resident. All of the aides had a gait belt. Resident #26 transferred himself/herself. He/she could stand and transfer to the toilet but he/she needed staff assistance to wipe and pull up his/her pants after he/she toileted. During an interview conducted on 4/23/19, at 12:40 P.M., CNA X said Resident #26 transferred pretty well independently, but he/she needed assistance pulling up his/her pants and he/she wanted someone to talk to. Staff used a gait belt to assist him/her occasionally, depending on the day. Resident was sometimes unsteady and sometimes steady. Staff should use a gait belt anytime they transferred a resident. If the aide did not know the resident or did not know how that resident transferred, the aide either asked the nurse or asked the resident if he/she could stand on his/her own, and did he/she use a walker. These questions helped the aide to determine how much assistance the resident needed. The first time CNA X transferred a resident, he/she had a second person with him/her in care he/she needed assistance. During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said staff should use a gait belt any time they transferred a resident. During an interview conducted on 4/23/19, at 3:38 P.M., the DON said staff should use a gait belt with all transfers, especially if the resident needed assistance getting up. The DON and MDS coordinator MM should have used a gait belt to transfer Resident #26 to the toilet. | |
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 39) -Guidelines included options for managing urinary incontinence include primary toileting plans and medication therapy; -Types of programs, assess the resident for appropriateness of toileting plans being considered; -Bladder rehabilitation/bladder training may not be appropriate for the resident with cognitive impairment or those who are frail or dependent on staff for assistance with activities of daily living (ADLs); -Incontinent management, if the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own named, staff will use an incontinent management program; -An incontinent management program involves checking the resident’s continence status at regular intervals and providing incontinent care and garments as indicated by individual need. The primary goals are to maintain dignity and comfort and to protect the skin. 1. Record review of Resident #63’s face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s baseline care plan, dated 3/28/19, showed the following information: -Alert/cognitively intact; -Communicates verbally; -Assist of two staff for toileting; -Assist of one staff for hygiene; -Sometimes incontinent of bowel; -Sometimes incontinent of bladder; -Bowel and bladder interventions included incontinence briefs or pads; -Urinal within reach. Record review of the resident’s bowel/bladder assessment, dated 3/28/19, showed the following information: -Occasionally bowel incontinence (one episode of bowel incontinence); -Constipation not present; -Occasionally incontinent of urine (less than 7 episodes of incontinence); -No trial of toileting program attempted; -Extensive assistance required for toilet use; -Moderately cognitively impaired for daily decision-making; -Resident usually aware of toileting needs; -No redness noted to perineal (residents’ genitalia) and buttocks area; -Contributing factors present:[MEDICAL CONDITION](stroke); -Resident appeared to be good candidate for retraining; -Will continue to work with therapy to build up strength. Record review of the resident’s progress note dated 3/28/19, at 6:53 P.M., showed Licensed Practical Nurse (LPN) M documented the resident up in the wheelchair, sitting in the dining room. Therapy completed with assessment, resident will require two assist with transfers and needed someone with him/her while using the commode due to resident leaning backwards and unable to hold self in sitting position for a long period of time. Resident able to make needs known to staff. Record review of the resident’s admission Minimum Data Set (MDS – a federally mandated comprehensive assessment instrument completed by facility staff), dated 4/2/19, showed the following information: |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 40) -Required extensive assistance with bed mobility, transfers, toileting, and dressing; -Occasional urine incontinence (less than seven episodes); -Occasional bowel incontinence (less than one episode); -Wheelchair required for mobility; -Fall risk assessment showed moderate fall risk; -No falls since admission. Record review of the resident’s care plan, last revised 04/08/19, showed the following information: -Problem start date 03/26/19; -At risk for complications related to incontinence of bowel and/or bladder; -Give resident good pericare after each incontinent episode; -Modify resident clothing as need to provide easy access to toilet; -Observe for increased incontinence and report to the physician as needed; -Observe for redness and breakdown in the perineal area when toileted; -Observe for signs and symptoms of urinary tract infection [MEDICAL CONDITION] such as fever, increased frequency of urination, hematuria, sediment in urine, cloudy or odorous urine; -Weekly skin assessments by licensed nurse. During an interview on 04/16/19, at 2:43 P.M., the resident said he/she needed to go to the bathroom, but did not want to tell anybody because he/she was in so much trouble. During an interview on 04/17/19, at 11:21 A.M., the resident’s family member said staff had not helped the resident to the bathroom at any time during visits and said he/she visited with the resident every day for 3 to 4 hours and sometimes longer. The resident wears diapers. He/she had not seen the resident be changed or diaper checked, or seen any staff take the resident to the bathroom or offer a bedside commode during visits. Observation on 04/17/19 showed the following: -At 6:21 P.M., Registered Nurse (RN) V entered the resident’s room and checked the resident for incontinence. The nurse said the resident was wet. RN V left the room; -At 6:33 P.M., CNA S and CNA R entered the room, both put gloves on and pulled down the resident’s pants. CNA S took trash bags out of his/her pocket. CNA R unfastened the resident’s brief and rolled the resident to the side. The resident was incontinent of bowel movement and urine. CNA S wiped the resident’s bottom and placed a new clean brief under the resident (without performing hand hygiene or changing gloves). CNA R cleaned the resident’s front area with a front and back, back and forth and around motion (potentially introducing bacteria into the urinary tract). The aide fastened the brief and put the resident’s pants back on; -Staff did not offer to take the resident to the toilet or bedside commode. Observation on 04/18/19, at 11:49 A.M., showed CNA A entered the resident room and closed the door. The resident said he/she needed changed. CNA A had gloves on hands and put gait belt on resident waist. CNA P entered the room, washed hands, and put gloves on hands. CNA A prepared wash cloth, prepared trash bags and placed on empty bed. CNA P held gait belt and had resident stand from recliner with extensive assistance from aide. CNA A pulled resident’s pants down, removed the brief, wiped resident, disposed of the brief, wipes, and gloves into the trash bag. CNA A placed new brief and pulled up the resident’s pants. CNA A said the brief was dry, but changed it any way. The aides did not offer to take the resident to the commode or urinal. CNA A and CNA P transferred the resident to the wheelchair for lunch. During an interview on 04/22/19, at 7:40 A.M., CNA N said the resident will let staff know when he/she needed to go to the bathroom and when he/she wanted to lay down. When 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 41) notified staff of needs, the staff went to change and clean the resident. He/she had never personally taken the resident to the bathroom. The resident will say he/she needs changed. During an interview on 04/22/19, at 8:36 A.M., CNA A said the resident would let staff | |
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide enough food/fluids to maintain a resident’s health. **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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 42) and encourage use of adaptive equipment as necessary; -Allow resident to enjoy his/her meal after you are sure adequate assistance provided; -Return periodically to determine if the resident requires further assistance; -Remove tray as appropriate area when the resident has finished eating, but do not rush them; -Take note of the percentage of food consumed. 1. Record review of Resident #63’s face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s care plan, problem start date of 3/26/19, showed the following information: -Encourage resident to have adequate hydration to promote skin integrity; -Observe the resident’s nutritional status for weight loss and signs of dehydration; -At risk for constipation related to decreased mobility, use of pain medications, and poor dietary intake; -Observe the resident’s dietary intake; -Provide the resident with encouragement and gentle verbal cues; -Set up trays at meals and assist the resident as needed. Record review of the resident’s physician order [REDACTED]. -Order start date 3/26/19, for regular diet; -Order start date of 3/26/19, for weigh monthly unless otherwise indicated; -Order start date of 3/27/19, for speech language pathologist (SLP) to evaluate and treat as indicated. SLP treatment five times a week for four weeks for dysphagia and cognitive communication. Record review of the resident’s nutrition preliminary/admission review, dated 3/27/19, completed by the dietary manager, showed the following information: -Weight 137 pounds; -Current diet orders, to include supplements: regular diet; -Staff did not document any food preferences/likes/dislikes/religious/cultural/ethnic food needs; -Location of most meals was in resident room; -Independent in ability to eat/drink; -New resident admitted with a regular diet, admission height 68 inches, weight 137 pounds. Record review of the resident’s comprehensive nutrition initial assessment, dated 3/27/19, completed by the registered dietitian (RD), showed the following information: -[DIAGNOSES REDACTED]. -Current diet orders, including supplements: regular diet; -The RD did not document any food preferences, likes/dislikes, religious/cultural/ethnic food needs; -Current weight of 137 pounds; -Independent in ability to eat/drink; -The RD did not document any oral problems, such as chewing problems; -The RD documented the resident is a new admission with stroke diagnosis. The resident’s weight was 137 pounds. Resident eats a regular diet by self. The resident is alert and able to make wants known. Resident reports some trouble chewing chicken, but doesn’t want meat ground up. Resident reports enjoying a cheeseburger at lunch today. Resident reports likes Ensure (supplement) and agrees to an Ensure or other nutritious shake three times a day with meals. The RD recommended Ensure or other nutritional shake three times a day |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 43) with meals. Record review of the resident’s baseline care plan (plan of care required to be completed within 48 hours of admission), dated 3/28/19, showed the following information: -Alert and cognitively intact; -Disease management concerns included diabetic, high blood pressure, [MEDICAL CONDITION], pneumonia, and post stroke; -Staff did not identify any nutrition deficiency concern; -Required set up for eating; -Regular diet order; -Boost supplement twice a day (breakfast and lunch); -Dietary goal was to maintain weight through nutritional intake that is consistent with preferences and overall health goals; -Interventions included assess dietary preferences, monitor for safety and assist with eating/drinking as needed. Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following information: -An order, with a start date of 3/28/19, for Boost supplement twice a day, 8 A.M. and 12:00 P.M. Record review of the resident’s progress notes, dated 3/28/19, showed new order received for dietary supplements twice a day (breakfast and lunch) from the resident’s physician. Staff entered new order into the computer system. Record review of the resident’s medication administration history, dated 3/1/19 through 3/31/19, showed staff administered the Boost supplement twice a day as ordered, starting on 3/28/19. Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following information: -Order start date of 3/29/19, for snack three times a day between meals for [DIAGNOSES REDACTED]. Record review of the resident’s progress note dated 3/29/19, at 12:20 P.M., showed the resident in his/her room eating his/her meal. The resident required set up for meals. Resident receiving physical therapy to strengthen his/her arms and legs. The resident able to make needs known and had water within reach. Record review of the medication administration history, dated 3/1/19 through 3/31/19, showed the following information: -Staff documented administration of the resident’s snacks three times a day between meals, starting on 3/29/19. Record review of the resident’s progress note dated 3/30/19, at 7:32 P.M., showed the resident refused supper, but ate two other meals today and half eaten protein snack lay on the bedside table. Record review of the resident’s medication administration history, dated 3/1/19 through 3/31/19, showed the resident refused the 3/31/19, 10:00 A.M. and 2:00 P.M., snacks. Record review of the resident’s progress note dated 3/31/19, at 8:55 P.M., showed the resident’s appetite as fair. The resident enjoys snacking on the facility monster cookies with protein. Record review of the resident’s vitals report showed staff did not document meal intakes for (MONTH) 2019. Record review of the resident’s medication administration history, dated 4/1/19 through 4/23/19, showed staff documented the resident refused one snack on 4/1/19. Record review of the weekly Resident at Risk (RAR) review dated 4/2/19, at 8:55 A.M., |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 44) showed the resident admitted to the facility recently. RD consulted and recommended shakes three times a day. Staff to continue to monitor. Record review of the resident’s medication administration history, dated 4/1/19 through 4/23/19, showed the following information: -Staff documented the resident refused two snacks on 4/3/19; -Staff documented the resident refused two snacks on 4/4/19. Record review of the resident’s progress note, dated 4/5/19, showed a RD recommendation noted. Per the dietary director, the resident prefers Ensure and refuses to drink Boost at this time. Family has provided Ensure until the facility supply arrives. A new order received for Ensure three times a day with meals entered into the computer. Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following information: -On 4/5/19, Boost supplement twice a day discontinued; -Order start date of 4/5/19, for Ensure nutritional drink three times a day with meals per RD recommendation. Record review of the resident’s medication administration history, dated 4/1/19 through 4/23/19, showed the following information: -Staff documented administration of the Boost supplement, twice a day, from 4/1/19 through 4/5/19. Record review of the resident’s medication administration history, dated 4/1/19 through 4/23/19, showed the following information: -Staff documented the resident refused one snack on 4/5/19; -Staff documented the resident refused one snack on 4/6/19. Record review of the resident’s care plan, revised 4/8/19, showed the following information: -Problem start date 4/8/19 of at risk for inadequate nutrition related to poor intake, and disease process; -Communicate with the resident’s family regarding any food and weight issues; -Discuss likes and dislikes of food with resident; -Encourage fluid intake; -Give nutritional supplements as appropriate; -Snacks as appropriate; -Weigh the resident monthly and inform the physician of any significant changes. Record review of the resident’s progress note dated 4/7/19, at 12:45 P.M., showed the resident sitting up in bed, eating lunch at this time, visitor at bedside. Record review of the resident’s medication administration history, dated 4/1/19 through 4/23/19, showed the following information: -Staff documented the resident refused one snack on 4/7/19; -Staff documented the resident refused one snack on 4/8/19. Record review of the resident’s progress notes dated 4/9/19, at 8:31 A.M., showed the weekly RAR review showed the resident has adjusted well to the facility. The resident to be removed from weekly review. Record review of the resident’s progress notes, dated 4/10/19, showed care plan meeting completed. The resident attended the meeting and the resident’s weight remains stable. Record review of the resident’s medication administration history, dated 4/1/19 through 4/23/19, showed staff documented the resident refused one snack on 4/11/19. Record review of the resident’s vital report, showed staff documented the resident ate 26-50% of lunch on 4/11/19. Staff did not document any other meal intakes for (MONTH) 2019. |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 45) Record review of the resident’s medication administration history, dated 4/1/19 through 4/23/19, showed the following information: -Staff documented the resident refused two snacks on 4/12/19; -Staff documented the resident refused one snack on 4/13/19, 4/14/19, 4/15/19, and 4/16/19. Record review of the progress notes, dated 4/16/19, showed the resident up in the wheelchair for meals. Record review of the resident’s vital signs, dated 4/16/19, showed the resident weighed 128 pounds (a 9 pound weight loss, 6.5% in three week time period). Observation on 04/16/19 showed the following: -At 12:21 P.M., the resident sat at the dining room table with water, milk, and coffee cup for drinks; -At 12:26 P.M., staff served the resident lunch. It included salad in a foam bowl, chili in a regular bowl and hot dog on bun on regular plate. Staff placed the utensils on the table and put the dressing on the salad and cut the hot dog into large bite size pieces. The meal tray did not include an Ensure or Boost supplement; -At 12:31 P.M., the resident ate the meal unassisted with his/her right hand, no staff remained in the dining room for any assistance or supervision; -At 12:48 P.M., the resident remained in the dining room, he/she ate less than one half of the meal. The resident removed the clothing protector and his/her bottom dentures and set them on the table; -At 1:00 P.M., Licensed Practical Nurse (LPN) O pushed the resident in his/her wheelchair to the resident room and stopped at the sink for the resident to rinse the bottom denture and placed it in the denture cup. The nurse left the resident in front of the TV in the resident room. Observation on 04/17/19, at 8:16 A.M., showed the resident sat at the dining room table and staff put butter and jelly on toast for the resident. Staff served the resident eggs, sausage links, and a cup of juice. The meal tray did not include an Ensure or Boost supplement. No staff remained in the dining room to assist or cue residents. During an interview on 04/17/19, at 11:22 A.M., the resident’s family member said the resident cannot cut up the food with one hand. The staff would leave the food without cutting up meat. This past weekend was the first time a staff member had cut up the food while the family member was there. This week was the first time the resident had been required to go to the dining room. He/she had brought pizza to eat with the resident and was told he/she could not do that because the resident had to go to the dining room for meals. The family member said he/she has occasionally seen a small cookie given for a snack but not every time he/she visited. Observation on 04/17/19 showed the following: -At 5:31 P.M., staff serving supper trays in the A wing assistive dining room. No staff in the dining room supervising or cueing residents to eat. Certified Nursing Assistant (CNA) R served meal trays and then left the A wing assistive dining room. Observation on 04/17/19, at 5:37 P.M., showed a certified medication technician (CMT) left the resident’s room. The CMT told the resident they will be bringing supper any time. Observation on 04/17/19, at 5:58 P.M., showed the resident lay in bed. Staff had not served the resident supper at that time. Observation and interview on 04/17/19, at 6:21 P.M., showed the surveyor asked Registered Nurse (RN) V about the resident’s supper tray or if the resident did not want a meal tray or supper. RN V said, let’s go find out. The RN went to the resident’s room and asked him/her if the resident did not want dinner. The resident said he/she did not get a meal |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 46) tray. The RN notified a nurse aide. CNA S said the resident needed to get up in order to have the meal. He/she said the resident needed to get up for the meal and the resident did not want to leave his/her room, and the resident was required to eat in the dining room; -At 6:24 P.M., the RN advised he/she would call the family member per the resident’s request to sit with the resident as he/she ate in the resident room; -At 6:27 P.M., the resident said the food is good, but he/she wanted to eat in his/her room and would like to talk to the therapist about why he/she cannot eat in the room; -At 6:41 P.M., the nurse aides transferred the resident to the wheelchair for supper. CNA A said to RN V that the aides tried to get the resident up about 23 minutes to 5:00 P.M., but the resident wanted to eat in his/her room and did not want to get up. They did not have two staff to get the resident up; -At 6:48 P.M., RN V told the resident the family member will be in shortly to sit with the resident while he/she eats in his/her room; -At 7:13 P.M., the resident’s family member came to the nurses’ station and requested the supper tray. The nurse said supper was a cold supper today, so do not have to re-heat. The nurse gave the supper tray to the family member to take to the resident room. The staff removed the milk from the supper tray to get a cold milk from the refrigerator. The meal tray included a sandwich, cold salad, and milk. The meal tray did not include an Ensure or Boost supplement; -At 7:29 P.M., the resident ate the sandwich and the family member remained in the room. Observation on 04/18/19, at 10:00 A.M., showed staff transferred the resident from the bed to the recliner. The CNA asked if the resident would like a snack, the aide opened a honey bun and gave it to the resident in the recliner, then left the room. The resident began to eat the snack with no staff in the room. Observation and interview on 04/18/19 showed the following: -At 12:29 P.M., CNA A served the resident his/her lunch last in the dining room. The aide asked the resident if he/she wanted salt and pepper and sprinkled salt and pepper on the resident’s food. The resident had a bowl of chicken and dumplings, cornbread, okra, bowl of oranges, cup of water, and cup of coffee. The meal tray did not include an Ensure or Boost supplement. The resident began eating and drinking using his/her right hand to crumble the cornbread into the chicken and dumplings. The resident stopped eating the chicken and dumpling and cornbread and ate the oranges. The resident stopped eating and began putting all the different food containers on his/her plate. Staff did not cue or assist the resident to eat any additional food; -At 12:41 P.M., the resident did not eat and continued to sit in the dining room; -At 1:18 P.M., the administrator said she could wheel the resident to his/her room, but would have to get help to transfer him/her. The administrator wheeled the resident into his/her room. Staff did not offer any other option of food for the resident. Staff did not attempted to cue or encourage the resident to eat any additional food; -At 1:24 P.M., the resident sat in the wheelchair in room. The resident said lunch was no good, hard okra, oranges ok, dumplings had weird taste. Record review of the resident’s medication administration history, dated 4/1/19 through 4/23/19, showed the following information: -Staff documented the resident refused two snacks on 4/21/19; -Staff documented the resident refused two snacks on 4/23/19. During an interview on 04/22/19, at 7:40 A.M., CNA N said the resident could eat with his/her right hand but needed meal set up and should have somebody sitting at the table. During an interview on 04/22/19, at 8:36 A.M., CNA A said the resident does pretty good and eats by him/her self. Staff just make sure they have him/her in the dining room 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 47) monitor for choking. The resident uses his/her one good arm to cut up the meat unless it is really hard, then staff cut it up for him/her. During an interview on 04/22/19, at 9:24 A.M., Licensed Practical Nurse (LPN) N said the resident does need help to cut meat due to the left sided weakness, but once the meat is cut up the resident can eat on his/her own. During an interview on 4/23/19, at 10:34 A.M., CMT BB said the resident received house shakes with meals and boost for snacks, he/she offered the boost when passing medications. The resident took the shakes on occasion, but today he/she did not want the shake offered for the morning snack and did not eat much for breakfast. Observation on 04/23/19, at 12:25 P.M., showed the resident in bed with the head of bed elevated almost 90 degrees. The bed level was in the high position. The resident said the staff came and told him/her he/she had to get up for lunch. The resident said the therapist had said he/she could have meals in his/her own room if the resident wanted. Restorative therapy aide entered the resident room with the resident’s lunch tray. The tray included a bottle of Ensure for the drink. The tray did not contain any other drinks. The therapy aide said he/she was there to assist the resident to eat in his/her room today. During an interview on 04/23/19, at 10:02 A.M., the Dietary Manager said she looks at the weight report every week and all weight loss is covered in RAR weekly meeting. When indicated, residents are added to the dietitian weekly list, she usually comes on Wednesday. Usually any resident with 7.5 %-10% weight loss or intake of less than 25% is placed on the dietitian list. Anybody that is a high risk for nutrition concerns has meal intakes reported in the main dining room. A-wing staff documents intake on all residents and those are entered on each resident matrix. All residents in A and B wing need assistance or cueing for meals. There are a couple of residents that eat on B wing because they don’t like the larger dining room. The resident eats in his/her room most of the time, and intake is usually 25 – 50%. The resident receives Ensure twice per day, at breakfast and dinner. Nursing staff documents the Ensure and shake intakes under the supplements. He/she is on the weight list as weight risk. Dietitian saw the resident on 3/27/19. The resident had a seven pound weight loss since admission. The resident weighed 130 pounds today and weighed 137 pounds on admission. The dietary manager added the resident to the dietitian list to be seen tomorrow. The dietary manager said she did not know if the resident needed assistance with meals. The resident receives super cereal at breakfast because he/she requested sweetened cereal when first admitted to the facility. So, the dietitian recommended super cereal. During an interview on 4/23/19, at 10:34 A.M., CMT BB said supplement intakes are documented under observations on the computer. During an interview on 04/23/19, at 1:53 P.M., the Director of Nursing (DON) said she did not know if the resident had weight loss, but will be sure he/she was listed on the RAR. Diets are recommended by the RD and staff notify the physician to receive the orders for the diet. Staff should be monitoring meal intake on every resident, especially if at risk for weight loss. During an interview on 04/23/19, at 3:36 P.M., the administrator and Quality Assurance (QA) support nurse said the RD sees new residents every Wednesday. If a resident triggers for weight loss, the dietary manager lets the RD know. | |
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide safe and appropriate respiratory care for a resident when needed. |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff cleaned and maintained a continuous positive airway pressure ([MEDICAL CONDITION] – treatment for [REDACTED]. for a [MEDICAL CONDITION], and failed to care plan the use of the [MEDICAL CONDITION] for one resident (Resident #74) out of a sample of 20 residents. The census was 84. Record review of the facility’s policy titled, Continuous Positive Airway Pressure ([MEDICAL CONDITION]) Administration, dated (MONTH) 2019, showed the following: -Check the physician’s order for pressure setting and method of administration; -The [MEDICAL CONDITION] machine should be placed on the table near the bed; -Fill the humidifier with water to the appropriate level; -Assist the resident as needed with applying and adjusting the [MEDICAL CONDITION] mask and head strap; -Use a wet cloth or cleaning wipe to clean the outside surface of the [MEDICAL CONDITION] machine; -Clean the back filter weekly by running it under warm tap water; -Replace the filter with a new one once a year; -The tubing should be cleaned weekly: -The mask and nasal pillows can be wiped with a damp cloth. 1. Record review of Resident #74’s face sheet (a document that gives a resident’s information at a quick glance) showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/10/18, showed the following: -Cognitively intact; -Limited staff assistance required for transfers; -Use of a wheelchair for mobility; -Respiratory treatment included a [MEDICAL CONDITION] machine. Record review of the resident’s quarterly MDS, dated [DATE], showed staff did not document use of a [MEDICAL CONDITION] machine. Record review of the residents’ nurses’ progress note, dated 4/8/19, showed Licensed Practical Nurse (LPN) D documented the resident was resting in the bed with the [MEDICAL CONDITION] mask in place. Record review of the resident’s care plan, last revised 4/9/19, showed staff did not care plan interventions for the [MEDICAL CONDITION] machine use. Record review of the resident’s (MONTH) 2019 physician order sheet (POS) showed no order for a [MEDICAL CONDITION] machine. Observation on 4/17/19, at 2:40 P.M., showed a [MEDICAL CONDITION] machine on the floor next to the resident’s bed with the mask hanging from the side of the bed. The [MEDICAL CONDITION] mask had a white film on it. During an interview on 4/17/19, at 2:41 P.M., the resident said the following: -He/She has had the [MEDICAL CONDITION] machine since admission to the facility; -The facility staff has never cleaned the [MEDICAL CONDITION] machine since he/she has been at the facility; -He/She wishes staff would help him/her clean the [MEDICAL CONDITION] machine; -He/She cleans the mask the best he/she can with a wet wipe after each use. During an interview on 4/17/19, at 6:30 P.M., Certified Nurse Assistant (CNA) Q said he/she does not know who cleans or takes care of the resident’s [MEDICAL CONDITION] |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 49) machines. He/She was never trained how to use or clean the [MEDICAL CONDITION] machines. During an interview on 4/22/19, at 11:00 A.M., Certified Medication Technician (CMT) G said the following: -He/She is not sure who is responsible for cleaning and maintaining the resident’s [MEDICAL CONDITION] machine; -He/She assumes that it is not being done due to it not being documented on the resident’s treatment administration record (TAR); -If the [MEDICAL CONDITION] was being cleaned it should be documented on the TAR. During an interview on 4/22/19, at 11:26 A.M., Licensed Practical Nurse (LPN) D said the following: -The evening shift nurse should be cleaning the resident’s [MEDICAL CONDITION] machine once a week; -The [MEDICAL CONDITION] machine cleaning should be documented on the resident’s TAR; -He/She was unable to locate a physician’s order for the [MEDICAL CONDITION] machine or documention on the resident’s TAR pertaining to the [MEDICAL CONDITION]. During an interview on 4/22/19, at 1:36 P.M., the Director of Nursing (DON) said the following: -He/She would expect there to be a physician’s order for the use of [REDACTED] -The [MEDICAL CONDITION] machine should be cleaned weekly by nursing staff and documented on the resident’s TAR and on the resident’s care plan; – He/She does not know why there were no physician’s order for the resident’s [MEDICAL CONDITION] or why it was not documented on the resident’s TAR. During an interview on 4/22/19, at 2:42 P.M., Registered Nurse (RN) J said the following: -He/She was not aware the resident used a [MEDICAL CONDITION] machine; -The night nurse is supposed to clean the [MEDICAL CONDITION] machines weekly and it should be documented on the resident’s TAR. During an interview on 4/22/19, at 3:47 P.M., the Administrator said the following: -He/She would expect a physician’s order for the [MEDICAL CONDITION] machine with the appropriate settings to be in the resident’s chart; -Nursing staff should clean the [MEDICAL CONDITION] machine and should document it on the resident’s TAR; -He/She would expect the [MEDICAL CONDITION] machine to be included in the resident’s care plan. | |
| F 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 50) 84. Record review of the facility’s policy titled, Bed Rail Policy, dated (YEAR), showed the following: -The objective of the policy is to determine if resident use is safe and appropriate; -It is the policy of the facility to prevent entrapment and other safety hazards associated with bed rail use; -The facility’s leadership will be responsible for completing individual bed rail evaluations on a regular basis, providing employees appropriate education related to the risks and benefits of bed rail usage, and education pertaining to specific risks and care needs associated with bed rail use; – Before admission, prospective residents will be screened to help determine if care needs necessitate the use for bed rails; -Upon admission, readmission or change in condition, residents will be assessed for the need of bed rails, including identifying an appropriate alternate prior to installation; -The resident will be assessed for risk of entrapment prior to installation; -The facility staff will document the bed rail is the least restrictive alternative for the least amount of time; -The facility staff will document the ongoing need for the bed rail; -The facility staff will review the risk and benefits with the resident and resident representative and obtain informed consent; -There will be a physician order [REDACTED].>-The resident’s care plan will include use of the bed rails as assessed; -When installing or maintaining bedrails, the maintenance department staff will follow the manufacturer’s recommendations and specifications; -The maintenance department will conduct regular inspection of bed frames, mattresses, and bedrails, as part of a regular maintenance program to identify areas of possible entrapment. 1. Record review of Resident #20’s face sheet (a document that gives a resident’s information at a quick glance) showed the following: -Readmission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/4/19, showed the following: -Moderately impaired cognition; -Extensive staff assistance required for transfers and bed mobility; -Use of a wheelchair. Observation on 4/16/19, at 8:56 A.M., showed the resident’s bed with a quarter bed rail on both sides of the bed in the up position. Record review of the resident’s (MONTH) 2019 physician order [REDACTED]. Record review of the resident’s care plan, review dated 2/4/19, showed staff did not care plan the use of bed rails. Record review of the resident’s medical record, on 4/22/19, showed the record did not include the following: -A bed rail assessment/evaluation; -A bed rail consent form; -A bed rail safety check form or completion of a regular inspection of the bed frame or bed rails. During an interview on 4/22/19, at 11:00 A.M., Certified Medication Technician (CMT) G said the resident uses the side rails to get in and out of bed. |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 51) During an interview on 4/23/19, at 11:59 A.M., the administrator said the following she could not find side rail assessments or signed consent forms for the resident. During an interview on 4/23/19, at 12:28 P.M., the resident said the following: -He/She uses the bed rails to get in and out of the bed; -The facility got him/her a new bed frame and the side rails were already on it. 2. Record review of Resident #63’s face sheet showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s admission MDS, dated [DATE], showed the following information: -Required extensive assistance with bed mobility, transfers, toileting, and dressing; -Wheelchair required for mobility; -Fall risk assessment showed moderate fall risk; -No falls since admission; -Staff did not document the use of side rails. Observation on 4/23/19, at 12:25 P.M., showed the head of bed elevated to almost 90 degrees, round side rails on both sides of the resident’s bed in the up position. Record review of the resident’s care plan, last revised 04/08/19, showed staff did not care plan the use of side rails. Record review of the resident’s (MONTH) to (MONTH) 2019 POS showed no order for side rails in place. Record review of the resident’s medical record showed the record did not include the following: -Bed rail assessment/evaluation; -Bed rail consent form; -Bed rail safety check form or completion of a regular inspection of the bed frame or bed rails. During an interview on 4/23/19, at 12:25 P.M., the resident said the bed rails had been on the bed since he/she arrived to the facility. The staff tied the call light on the left side rail and he/she could usually reach it there. The left rail stayed up, but staff would put the right side rail up and down when they provided cares to him/her. The resident would hold on to the rails when staff rolled him/her to the side. During an interview on 4/23/19, at 11:59 A.M., the administrator said she could not find side rail assessments or signed consent forms for the resident. 3. During an interview on 4/22/19, at 11:00 A.M., Certified Nurse Aide (CNA) A said the following: -Side rails can be considered a restraint; -Residents should be assessed for the use of side rails. 4. During an interview on 4/22/19, at 11:26 A.M., Licensed Practical Nurse (LPN) D said the following: -Residents should be assessed for the use of side rails; -The assessment is used to evaluate if side rails are appropriate for the resident. 5. During an interview on 4/23/19, at 11:57 A.M., the Director of Nursing (DON) said he/she did not know for sure what was expected in regards to the use of side rails with residents. 6. During an interview on 4/23/19, at 11:59 A.M., the Quality Assurance Nurse said the following: -If a resident is using a side rail there should be an assessment completed to assess the need and if the bed rail is a hazard; |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 52) -There should be a consent form signed by the resident or resident’s representative in the chart. 7. During an interview on 4/23/19, at 11:59 A.M., the administrator said the following: -The facility is currently not completing assessments or reassessing the use of side rails with residents; -A side rail assessment should be completed to ensure that the bed rail will not be a hazard or may cause entrapment; -The previous DON was responsible for completing assessments and measuring to ensure safety with side rails. | |
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to store drugs and biologicals in | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Based on observation, interview, and record review, the facility failed to store food in a | |
| F 0825 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide or get specialized rehabilitative services as required for a resident. **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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0825 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 54) -Cognitively intact; -Limited staff assistance required for transfers; -Extensive staff assistance required for toileting; -Resident did not receive therapy in the previous seven days; -Use of a wheelchair for mobility. Record review of the resident’s care plan, last revised on 4/9/19, showed the following: -Identified the resident as at risk for falls due to impaired mobility, weakness, and disease process; -Provide two staff for transfers due to a fall on 7/19/18; -Provide assistance of one to two staff for activities for daily living (ADL – dressing, grooming, bathing, eating, and toileting) due to impaired mobility, weakness, and disease process. Record review of the residents’ physician’s note, dated 4/10/19, showed the following: -The resident has a tremor and does not know why; -The resident is reporting leg weakness and short-term memory loss; -Recommendation of physical therapy, occupational therapy, and speech therapy to address the resident’s physical inability and short-term memory loss. Record review of the resident’s physician order, dated 4/10/19. showed direction for occupational therapy, physical therapy, and speech therapy to evaluate and treat the resident due to weakness. Record review of the resident’s medical record showed staff did not complete occupational therapy, physical therapy, or speech therapy evaluations. During an interview on 4/17/19, at 2:37 P.M., the resident said the following; -He/She wanted to be on therapy so he/she could get stronger and be more independent; -He/She talked to the physician about getting therapy to get stronger; -He/She is supposed to be getting therapy. but is not. During an interview on 4/18/19, at 10:59 A.M., the Director of Rehabilitation (DOR) said the following: -Nursing staff notify therapy when there are new physician’s orders [REDACTED].>-Resident #74 is not currently receiving therapy; -He/She was not aware the resident’s physician ordered therapy. During an interview on 4/22/19, at 11:26 A.M., Licensed Practical Nurse (LPN) D said the following: -He/she was not aware Resident #74 had a physician order [REDACTED].>-He/She checked and confirmed there were physician order’s for occupational therapy, physical therapy, and speech therapy; -Therapy should have been notified of the physician’s therapy orders so the resident could be evaluated. During an interview on 4/22/19, at 1:36 P.M., the Director of Nursing (DON) said the following: -He/She would expect Resident #74 to be evaluated by therapy if there were physician orders [REDACTED].>-He/She was not sure why the resident was not evaluated by therapy; -Nursing staff should notify the DOR when the physician puts in therapy orders. During an interview on 4/23/19, at 2:34 P.M., Registered Nurse (RN) J said the following: -When the physician orders [REDACTED]. -He/She did not remember entering a therapy order for Resident #74 in the electronic chart and did not give the order to therapy. During an interview on 4/22/19, at 3:50 P.M., the Administrator said the following: -There needs to be better communication with therapy to make sure residents get therapy as |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| 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 0825 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 55) ordered by the physician; -The nurse is expected to put the physician’s therapy orders into the resident’s chart and then give the order to the DOR; -Resident #74 should have been evaluated for therapy as the physician ordered. | |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 56) returned to the medication cart wearing the same gloves and placed the possibly contaminated glucometer on top of the medication cart. The LPN did not clean or disinfect the top of the medication cart. 4. During an interview on 4/22/19, at 12:42 P.M., LPN B said the following: -Glucometers should be cleaned with disinfectant wipes before and after each use; -Staff should place a barrier underneath the glucometer if it is laid down in a resident’s room; -He/She said a nurse should wear gloves whenever cleaning the glucometer, then the gloves should be removed and hand hygiene performed before obtaining a test strip from the container and administering a glucometer test to a resident; -Gloves should be removed and hands washed before leaving the residents room after performing a fingerstick on a resident. 5. During an interview on 4/22/19, at 1:11 P.M., the Director of Nursing (DON) said the following: -She was not sure of the glucometer cleaning policy; -Staff should be cleaning the glucometer with bleach and water every night; -A barrier to lay the glucometer on would not be necessary whenever placing the glucometer down in the resident’s room; -She would expect staff to wash their hands before performing blood glucose tests. Gloves should be removed and hands washed before leaving the resident’s room. 6. Record review of Resident #63’s face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 4/2/19, showed the following information: -Required extensive assistance with bed mobility, transfers, toileting, and dressing; -Wheelchair required for mobility. Observation on 04/17/19 showed the following: -At 6:33 P.M., CNA S and CNA R left the resident room across the hall and had wipes in hand. The aides entered the resident’s room. The aides washed their hands and pulled the resident’s privacy curtain around the bed. The aides put on gloves. The aides prepared the trash bag for soiled items. The aides pulled down the resident’s pants and placed the wet pants in the bag. The aides assisted the resident to roll to his/her left side, CNA S used wipes to clean the front. CNA R held the resident on his/her side. CNA S placed a new incontinent brief under the resident and assisted the resident to roll back to the right side. CNA R finished wiping the resident’s perineal region and sealed the trash bag; -At 6:37 P.M., a staff member, with no name tag, entered the room and picked up the resident’s cell phone and said he/she was taking the phone to call the resident’s family member. The staff then returned to the room and said the call went to voice mail. The cell phone rang as the aides finished dressing the resident. CNA S picked up the cell phone, still wearing the same contaminated gloves, then handed the phone to CNA R, still wearing the same contaminated gloves. CNA R removed one glove, but did not perform hand hygiene, to answer the phone, but held the phone with the gloved hand first. The aide gave the phone to the resident to talk to the family member; -At 6:41 P.M., RN V entered the room with a shot. After administration of the shot, the nurse took the resident’s cell phone with a gloved hand and the syringe in the same hand and spoke with the resident’s family member. CNA S assisted the resident out of the bed; |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 57) -At 6:48 P.M., CNA S removed the bed linens and took the trash. CNA R placed a new trash liner in the trash can. -At 6:53 P.M., the aides left the room after washing their hands. Observation on 04/18/19, at 11:49 A.M., showed CNA A entered the resident’s room, closed the door, and the resident said he/she needed his/her diaper changed. CNA A wore gloves, but did not use hand sanitizer or wash his/her hands in the resident room. The aide put shoes on the resident, lowered the recliner leg rest, and placed a gait belt on the resident’s waist. CNA P entered the room, washed hands at the sink, and put on gloves. CNA A prepared the wash cloth and trash bags and placed them on the second bed in the room. CNA P assisted the resident to stand, requiring extensive assistance. CNA A pulled down the resident’s pants, and provided front perineal care. The aide threw the depends, wipes, and gloves into the trash bag on the second bed. CNA A obtained a new pair of gloves, but did not wash his/her hands or use hand sanitizer. CNA P continued holding the resident up with the gait belt, CNA A placed a new depends on the resident and pulled up the resident’s pants. The aides transferred the resident to the wheelchair. The aides placed the wheelchair foot rests and wheelchair table for the left arm on the wheelchair. The aides placed the resident’s glasses on the resident’s face. CNA A placed a full trash bag on the recliner while plugging in the resident’s cell phone to charge. The aide took the trash, removed his/her gloves and washed his/her hands at the sink as he/she left the room. 7. Record review of Resident #28’s face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. organs), difficulty with walking, [MEDICAL CONDITION] (infection on skin), rash and other non-specific skin eruption, multiple fractures of pelvis, history of fracture of right humerus (right upper arm), and [MEDICATION NAME] (inflammation of the digestive tract) due to [MEDICAL CONDITION] (bacterial infection in the colon). Record review of the resident’s significant change MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Always incontinent of bladder; -Frequently incontinent of bowel; -[DIAGNOSES REDACTED]. During an interview and observation on 04/15/19, at 1:38 P.M., the resident’s room had isolation personal protective equipment (PPE) items in hall, including gowns and gloves in a small three drawer plastic container. The resident said he/she had [MEDICAL CONDITION] (an infection of the colon), said some staff wear gloves and some do not, the staff had been wearing gowns but not any longer. The resident said he/she had only an occasionally loose stool now, but did not know if he/she still had a [DIAGNOSES REDACTED]. Observation on 04/17/19, at 2:01 P.M., showed two nurse aides entered the resident room. CNA S removed the resident’s top sheet and gown. The aide donned gloves and wiped the resident’s face with bath wipes and wiped the oxygen tubing with the wipe. The aide placed the resident’s gown and top sheet into the red biohazard containers. The aide placed the wipes in a second red container. CNA R wiped down the resident table with wipes. CNA S left the room. At 2:06 P.M., CNA S returned to the room with clean pillowcases and said they would get the resident fresh water shortly. The aides left the room without washing his/her hands or using hand sanitizer. |
| 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 58) Observation on 04/18/19, at 10:12 A.M., showed CNA A entered the room and closed the door. The aide removed the disposable meal items and placed them in a trash bag. The aide moved the juice and coffee cup from the bedside table to the resident room sink. CNA A pulled the privacy curtain. The aide applied gloves on his/her hands and removed the top sheet and the resident’s incontinent brief. The aide provided perineal care for the resident. CNA A changed gloves without washing hands. The aide assisted the resident to roll to the right side to remove the wet brief and place a new brief under the resident. The aide assisted the resident to roll to the left side and then to his/her back. The aide fastened the new incontinent brief. The aide put a new gown on the resident. The aide changed gloves without washing hands. With the potentially contaminated hands, the aide replaced the pillows under the legs, and covered the resident with a top sheet. With potentially contaminated hands, the aide raised the head of the bed, adjusted the nasal cannula for the resident’s oxygen, and the pillow under the resident’s head. 8. During an interview on 4/22/19, at 1:11 P.M., the DON said the following: -Gloves should be removed and hands washed before leaving the resident’s room; -Touching items with soiled gloves would contaminate anything touched. | |
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement policies and procedures for flu and pneumonia vaccinations. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 59) -[DIAGNOSES REDACTED]. -No known allergies [REDACTED].>Record review of the resident’s physician order, dated 8/22/16, showed instruction for staff to administer the pneumonia vaccine as needed unless contraindicated or refused. Record review of the resident’s immunization record, dated 10/21/16, showed staff documented the resident received a PCV13. Staff did not document the resident received a PPSV23. Record review of the resident’s immunization consent or refusal form, dated 9/3/18, showed the resident requested to be vaccinated with the PCV13 and the PPSV23. During an interview on 4/17/19, at 11:25 A.M., the resident said he/she wanted to take the pneumonia vaccines as recommended. He/She has [MEDICAL CONDITION] (one of the diseases that comprises [MEDICAL CONDITION], with gradual damage of lung tissue) and uses oxygen therapy at all times in order to breath. His/Her physician told him/her it is important for him/her to take the vaccines. 2. Record review of Resident #22’s face sheet showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s immunization consent or refusal form, dated 8/21/17, showed the resident’s responsible party requested the resident be vaccinated with the PCV13 and the PPSV23. Record review the resident’s immunization record, dated 8/21/17, showed staff documented the following: -The resident received a pneumonia vaccine about four years ago, and will need another vaccine in the next year; -No education material was provided; -Staff did not document the type of pneumonia vaccine received or needed; -Staff did not document further pneumonia vaccines administered. 3. Record review of Resident #42’s face sheet showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s immunization record, dated 1/1/13, showed the resident received a PPSV23. Record review of the resident’s immunization consent or refusal form, dated 3/5/19, showed the influenza vaccine checked and the resident’s signature. The pneumonia section was blank. Record review of the resident’s physician order, dated 4/2/19, showed instruction for staff to administer the pneumonia vaccine as needed unless contraindicated or refused. During an interview on 4/18/19, at 10:30 A.M., Resident #42 said he/she did have one pneumonia vaccine years ago. The facility staff have not offered or provided any education on the pneumonia vaccine. He/She would like to receive all the recommended pneumonia vaccines. He/She has respiratory problems and should take steps to prevent complications. He/She has heart failure, [MEDICAL CONDITION], diabetes, and smokes cigarettes and understands he/she is at risk for pneumonia. 4. During an interview on 4/19/19, at 8:26 A.M., Registered Nurse (RN) C said the facility follows the CDC guidelines for pneumonia vaccines. All residents should be offered the PCV13 and the PPSV23 and immunizations should be provided if the resident or responsible party gives consent. Staff document the pneumonia vaccine on the resident’s preventive health/immunization record. 5. During an interview on 4/22/19, at 9:00 A.M., Social Worker T said he/she provides 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: 265394 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JORDAN CREEK NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 910 SOUTH WEST AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 60) residents or their responsible party the pneumonia consent upon their admission. The nurses follow-up and explain the risks and benefits of the vaccines and administer the vaccines. The nurses track the vaccine due dates. He/She said the social workers should review the consent form to assure they are complete. 6. During an interview on 4/22/19, at 12:42 P.M., Licensed Practical Nurse (LPN) B said the social workers let the nurses know when a resident has consented for the pneumonia vaccines and the nurse will administer the vaccine at that time. The nurse documents the pneumonia vaccines on the preventative health/immunization record and adds the follow up date on the resident’s Medication Administration Record [REDACTED] 7. During an interview on 4/22/19, at 1:11 P.M., the Director of Nursing (DON) said she expects staff to follow the facility policy and CDC guidelines for pneumonia vaccines. The residents should receive all vaccinations consented for unless the vaccine is contraindicated. | |