DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0550
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0550
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 1) the dining room at the resident’s table and did not re-adjust the resident’s clothing to cover his/her skin. 4. During an interview on 7/13/18 at 8:01 A.M., the Acting Director of Nurses said: – Staff should eye ball each resident to make sure they are dressed for the day in the mornings; – Skin should not be showing in the dining room; – When passing by residents in the dining room, if the resident allows, staff should assist the resident out of the dining room to adjust the resident’s clothing, otherwise do what they can to make the needed adjustments there in the dining room; – Staff should let social services know if a resident’s clothing is too small and social services would then notify the family or the guardian to provide larger clothing. |
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F 0570
Level of harm – Potential for minimal harm Residents Affected – Some |
Assure the security of all personal funds of residents deposited with the facility.
Based on interview and record review, the facility failed to purchase a surety bond in an |
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F 0578
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0578
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 2) Review of Resident 902’s admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: – Moderate cognitive impairment; – Required extensive staff assistance for hygiene and toileting; – Frequently incontinent of bladder; – Occasionally incontinent of bowel; – [DIAGNOSES REDACTED]. Review of the resident’s out of hospital DNR, dated [DATE], showed: – The form was signed by the resident’s public administrator (PA); – The resident’s PA requested DNR status. Review of the resident’s order sheet (POS), dated (MONTH) (YEAR), showed the resident was a full code (in case the resident’s heart stopped beating and/or the resident stopped breathing staff must perform CPR). During an interview on [DATE] at 1:00 P.M., regarding a resident’s code status, Licensed Practical Nurse (LPN) A said: – He/she would look at the chart for the out of hospital DNR; – He/she would check the resident’s POS; – If they did not match, he/she would perform CPR. During an interview on [DATE] at 1:30 P.M., the Director of Nursing (DON) said: – The resident’s PA signed an out of hospital DNR; – The resident’s POS stated a full code; – Staff checked each resident’s POS, but missed the discrepancy. |
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F 0584
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0584
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 3) Observation on 7/12/18 at 8:37 A.M., showed the resident was not in the room, and the room had a strong odor of urine. During an interview on 7/12/18 at 8:37 A.M., the Director of Nursing (DON) said: – He/she was unaware that the resident’s room had a persistent odor; – Staff must investigate room odors; – Staff must ensure resident rooms are odor free. 2. Observation on 7/10/18 at 1:30 P.M., showed the following: -Cobwebs, and dead bugs by the bookshelf in the family room at the end of the 300 hall; -room [ROOM NUMBER] wall heating unit was rusted and cracked all along the top; -room [ROOM NUMBER] wall heating unit was falling off and partially hanging on the floor, a piece of two by four was underneath it to keep it from completely falling off; -room [ROOM NUMBER] bottom of door frame scuffed and chipped up; -Bottoms of door frames on both sides of the double doors leading into the dining room were scuffed and chipped; -Rooms 103, 104, 105, 106, 108, 111, and 113 bottom of door frames were scuffed and chipped; -Door frame to the shower room on 100 hall was covered with scuff and chipped marks. During an interview on 7/13/18 at 8:40 A.M., the Maintenance Director said he checks doors at least once a month and makes weekly rounds of the facility. He said he is aware of the condition of the wall heating units in rooms [ROOM NUMBERS] and put the two by four piece of wood there to keep it from falling down completely. He said he fixes things when he can. |
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F 0657
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0657
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 4) result of an overwhelming external force (i.e. resident pushes another resident). An episode where a resident lost his/her balance and would have fallen if not for staff intervention, is considered a fall. A fall without injury is still a fall. 2. Review of Resident #24’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 8/14/18, showed: – Severely impaired cognitive skills; – Required extensive assistance of one staff for bed mobility, transfers and toilet use; – Frequently incontinent of bowel and bladder; – Had two falls since admission without injury; – [DIAGNOSES REDACTED]. Review of the resident’s fall scale, dated 8/15/18, showed: – A score of 80 (scores of 45 and higher are considered high risk for falls). Review of the resident’s care plan, revised 9/18/18, showed: – The resident had a potential to fall; – Interventions: be sure pathways are kept clear and room is free of clutter; the resident is receiving [MEDICATION NAME] (medication used to treat depression), and could put him/her at a higher fall risk; remind resident to walk up into his/her walker, otherwise he/she becomes very stooped over; keep resident’s walker close to him/her; help resident wear well-fitting footwear with nonskid soles; the resident is being evaluated and treated by therapy department; keep call light close to the resident and remind him/her to use it if he/she needs assistance as he/she may not remember this; the resident has a wheelchair for optional mobility; foot rests are not to be used with the wheelchair. Review of the resident’s nurse’s notes showed: – 10/6/18 at 9:34 P.M.: At 6:30 P.M., the resident’s roommate was in the hallway outside their door and yelled for help. Resident #24 was on the floor. Resident assessed and neuros (neurological assessment, an assessment of the motor responses to determine if the nervous system is impaired) started. Redirected resident to ask for help, but he/she is forgetful; – 10/6/18 at 10:27 P.M.: At 10:00 P.M., Certified Nurse Aide (CNA) reported the resident fell and cut his/her forehead. The resident was on the floor. Resident assessed and neuro assessment started. Treatment ordered for skin tear; – 10/7/18 at 2:36 A.M.: At 2:00 A.M., the laceration over the resident’s right eye continued to bleed. The resident was transferred to the hospital; – 10/7/18 at 6:06 A.M.: The hospital called with report. Placed three stitches on laceration over right eye. CAT (CT) scan on head, face, cervical and neck were negative. Awaiting transportation back to the facility; – 10/7/18 at 8:45 A.M.: The resident returned to the facility. Neuros started. The resident educated to ask for assistance when needed; – 10/7/18 at 9:40 A.M.: The resident found sitting on the floor in the hallway beside his/her wheelchair. Resident assessed and neuros started; – 10/8/18 at 9:42 P.M.: Nurse in the hall outside the resident’s room and heard a loud noise in the resident’s room and saw the resident on the floor in front of his/her TV, with new skin tears to his/her right inner forearm. Resident redirected to ask for help when getting up, but he/she is very forgetful and does not ask. Family contacted but were unable to come and sit with the resident. Observation and interview on 10/10/18 at 10:50 A.M., showed: – The resident sat on the side of his/her bed and was wearing hipsters (padded garment worn to protect the hips); – CNA E said the resident started wearing them on 10/9/18 after he/she fell ; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0657
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 5) – The resident’s bed was raised and the brakes were not locked; – After CNA E provided incontinent care, CNA E transferred the resident into his/her wheelchair; – CNA E placed the foot rests on the wheelchair and took the resident to the dining room. Review of the resident’s care plan, revised 9/18/18, showed: – The care plan was not updated with current falls and did not include any new interventions. During an interview on 10/11/18 at 2:25 P.M., the DON said: – The care plans are updated by the social worker and the MDS Coordinator, but the MDS coordinator left last week; – The care plans should be updated with a change in condition; – There should be new interventions on the care plan related to each fall; – The resident’s bed should be in a low position and locked; – The resident should not have the foot rests on his/her wheelchair; – The hipsters should have been care planned. |
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F 0658
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Ensure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0658
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 6) instructions; – If a resident refused to allow staff to alter sites, staff should educate the resident; – If the resident still refused to allow staff to alternate patch sites, staff should care plan the resident’s refusal to alternate sites. 2. Review of the insert for [MEDICATION NAME] Ophthalmic solution, 0.3%, showed, in part: – Do not touch the dropper tip to the surface of the eye. Review of Resident #13’s physician order sheet (POS), dated (MONTH) (YEAR), showed: – an order for [REDACTED]. Observation on 7/11/18 at 9:28 A.M., showed: – LPN B placed tissues, eye drop bottle and gloves on a paper towel and washed his/her hands and applied gloves; – LPN B touched the tip of the eye dropper to the resident’s upper eyelid and instilled one drop in the resident’s right eye. During an interview on 7/12/18 at 9:15 A.M., LPN B said: – The eye dropper should not touch the resident’s eyelid. During an interview on 7/13/18 at 8:01 A.M., the DON said: – Staff should not touch the eye dropper to the eyelid. 3. Review of the facility policy, dated 1/1/2014, on oxygen concentrators showed the policy did not address changing tubing and humidifiers. Review of Resident #15’s admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 4/22/18, showed staff assessed the resident as: – Cognitively impaired; – Dependent upon staff for transfers, dressing, toileting, and hygiene; – Shortness of breath when lying down and upon exertion; – Received oxygen therapy. Review of the resident’s care plan, dated 5/17/18, showed staff: – Did not document the resident received oxygen therapy; – Did not address changing the resident’s oxygen tubing and oxygen humidifier. Observations on 7/10/18 at 9:06 A.M. and 7/11/18 at 8:36 A.M., showed: – The resident received oxygen through a humidifier; – Staff did not label the resident’s oxygen tubing with the date it was last changed. 4. Review of Resident #21’s care plan, dated 7/10/18, showed: – The resident received oxygen therapy as needed; – Did not address changing the resident’s oxygen tubing and humidifier. Review of the resident’s admission MDS, dated [DATE], showed staff assessed the resident as: – Cognitively impaired; – Totally dependent on staff for transfers, hygiene, and toileting; – [DIAGNOSES REDACTED]. Review of the resident’s POS, dated 7/2/18, showed an order for [REDACTED].>Observations on 7/10/18 at 10:24 A.M. and 7/11/18 at 1:44 P.M., showed staff did not label the resident’s oxygen tubing and humidifier with the date it was last changed. During an interview on 7/11/18 at 3:10 P.M., the DON said: – Oxygen tubing and humidifiers should be changed and dated by the evening staff every Sunday; – He/she worked the evening shift last Sunday and did not change the oxygen tubing and humidifiers. 5. Review of Resident #9’s MAR, dated (MONTH) (YEAR), showed: |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0658
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 7) – an order for [REDACTED].>- Staff to ensure medication is given 12 hours apart. Review of the resident’s MAR, dated (MONTH) (YEAR), showed staff administered the medication as follows: – 7/1/18, no time for the morning dose and the evening dose at 8:00 P.M.; – 7/3/18, morning dose 8:00 A.M. and no time for the evening dose; – 7/4/18, morning dose 7:00 A.M. and no time for the evening dose; – 7/5/18, morning dose no time and evening dose 8:00 P.M.; – 7/6/18, morning dose at 7:00 A.M. and evening dose 8:00 P.M.; – 7/7/18, morning dose 7:00 A.M. and evening dose 8:00 P.M.; – 7/9/18, morning dose no given and evening dose 8:00 P.M.; – 7/10/18, morning dose 7:00 A.M. and evening dose 8:00 P.M.; – 7/11/18, morning dose 7:00 A.M. and evening dose no time given; – 7/12/18, morning dose 9:00 A.M. Observation on 7/12/18 at 9:10 A.M., showed LPN A administered the resident’s [MEDICATION NAME] 46 units subcutaneously (under the skin). During an interview on 7/12/18 at 9:10 A.M., LPN A said that he/she did not realize the medication should be administered 12 hours apart. During an interview on 7/12/18 at 10:00 A.M., the DON said staff should administer insulin as ordered. 6. Review of Resident #13’s face sheet, showed an admission date of [DATE]. |
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F 0677
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0677
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 8) – Totally dependent on staff for transfers, personal hygiene, and toileting; – [DIAGNOSES REDACTED]. – Received hospice care. Review of the resident’s care plan, dated 7/10/18, showed: – The resident required extensive staff assistance for care; – Did not address perineal care. Observation on 7/11/18 at 10:26 A.M., showed Certified Nurse Assistant (CNA) A and CNA B: – Removed the resident’s brief, which was soaked with urine from front and back; – CNA A cleaned the front perineal area of the resident; – Without cleaning the back of the resident, CNA A placed a clean brief on the resident. During an interview on 7/11/18 at 10:30 A.M., CNA A said he/she should have cleaned the back of the resident. 3. Review of Resident #10’s urinalysis report, dated 3/15/18, showed: – The presence of a UTI; – The resident’s physician started the resident on an antibiotic. Review of the resident’s care plan, dated 2/28/18, showed staff should assist the resident with perineal care as needed. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 4/19/18, showed staff assessed the resident as: – Cognitively impaired; – Required extensive staff assistance for toileting and hygiene; – Frequently incontinent of bladder; – Occasionally incontinent of bowel. Observation on 7/11/18 at 9:34 A.M., showed: – CNA A provided perineal care and cleaned both groins; – He/she did not spread the resident’s perineal folds and clean in between the folds. During an interview on 7/11/18 at 9:40 A.M., CNA A said he/she should have spread the resident’s perineal folds and cleaned between them. During an interview on 7/11/18 at 3:10 P.M., the Director of Nursing (DON) said staff must always spread the perineal folds and clean between them. Staff should always clean the front and the back of the resident. 4. Review of Resident #236’s admission MDS, dated [DATE], showed staff assessed the resident as: – Moderately impaired cognitive skills; – Dependent on two staff for bed mobility and toilet use; – Required extensive assistance of two staff for transfers; – Required extensive assistance of one staff for dressing and personal hygiene; – Occasionally incontinent of bowel and bladder; – [DIAGNOSES REDACTED]. Review of the resident’s care plan, initiated on 5/21/18, showed: – The resident is a two person assist with the Hoyer (mechanical lift) at all times for nursing staff; – The care plan did not address personal hygiene. Observation on 7/11/18 at 8:35 A.M., showed: – CNA D assisted the resident from bed into his/her wheelchair and the resident propelled him/herself down the hall and was weighed; – The resident’s hair was matted; – Staff did not comb the resident’s hair, provide or offer oral care or wash his/her face before leaving his/her room; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0677
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 9) – The resident passed several staff and other residents in the hall. Observation on 7/12/18 at 9:43 A.M., showed: – CNA D used the gait belt and assisted the resident with the use of his/her walker and ambulated to the bedside commode; – The resident’s pants were wet; – CNA D assisted the resident onto the bedside commode, removed the resident’s incontinent brief, which was saturated with urine and removed the resident’s wet pants; – The resident urinated on his/her hand and the floor; – CNA D did not clean the resident’s hand or clean the resident’s feet before he/she applied clean non-skid socks; – CNA D and Licensed Practical Nurse (LPN) B used the gait belt and assisted the resident to stand; – CNA D did not clean the entire buttocks that had been in contact with urine; – CNA D applied skin barrier cream to the resident’s buttocks; – LPN B pulled the resident’s incontinent brief up; – CNA D reminded LPN B he/she still needed to clean the front; – LPN B pulled the incontinent brief down and cleaned the front perineal folds; – LPN B used a new wipe and used the same area to clean the front perineal folds and did not manipulate and thoroughly cleanse all the perineal folds; – CNA D and LPN B pulled the resident’s incontinent brief and pants up and assisted him/her into the wheelchair. During an interview on 7/12/18 at 12:02 P.M., LPN B said he/she: – Should not use the same area of the wipe to clean different areas of the skin; – Should clean all areas of the of the skin in contact with urine or feces. During an interview on 7/12/18 at 1:03 P.M., CNA D said he/she: – Should clean all areas of the skin where urine or feces has touched the skin; – Should not use the same area of the wipe to clean different areas of the skin; – Should have made sure the resident had his/her hair combed before he/she left the room and offered to brush the resident’s teeth or swab their mouth. 5. During an interview on 7/13/18 at 8:01 A.M., the DON said: – She expected staff to wash the resident’s face, hands, use deodorant, good oral care and comb hair when staff assisted the resident to get up in the morning; – If the resident was incontinent of urine, staff should clean all areas of the skin where urine has touched; – Staff should not use the same area of the wipe to clean different areas of the skin. |
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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 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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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 10) policy showed staff were instructed to place the gait belt around the resident’s waist, snug but not tight, avoiding ribs, hipbone or breast. The policy did not indicate where the staff should place their hands on the gait belt. 2. Review of Resident #10’s care plan, dated 4/13/18, showed: – [DIAGNOSES REDACTED]. – Staff should use a gait belt for transfers. Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/19/18, showed: – Cognitively impaired; – Required staff assistance for transfers; – Not steady with transfers; – Used a wheelchair. Observation on 7/11/18 at 9:34 A.M., showed: – Without locking the wheelchair, Certified Nurse Assistant (CNA) A transferred the resident using a gait belt from the wheelchair to the toilet; – Without locking the wheelchair, CNA A transferred the resident from the toilet to his/her wheelchair. During an interview on 7/11/18 at 9:40 A.M., CNA A said he/she should have locked the wheelchair before transferring the resident. During an interview on 7/11/18 at 3:10 P.M., the Director of Nursing (DON) said staff should always lock wheelchairs when transferring a resident. 3. Review of Resident #236’s admission MDS, dated [DATE], showed: – Cognitive skills moderately impaired; – Dependent on two staff for bed mobility; – Required extensive assistance of two staff for transfers; – [DIAGNOSES REDACTED]. Review of the resident’s care plan, initiated on 5/21/18, showed; – The resident is a two person assist for transfers. Observation on 7/12/18 at 9:43 A.M., showed: – CNA D placed the gait belt around the resident’s waist and placed the walker in front of him/her; – CNA D grabbed the back of the gait belt and the front of the gait belt because the resident had difficulty standing; – The gait belt was loose and slid up under the resident’s arm pits; – The resident ambulated to the bedside commode; – After CNA D and LPN B provided incontinent care, LPN B grabbed the side of the gait belt with one hand and placed his/her hand under the resident’s arm and CNA D grabbed the other side of the gait belt; – The gait belt was loose and slid up under the resident’s arm pits; – CNA D and LPN B grabbed the back of the resident’s pants and assisted the resident to transfer into his/her wheelchair. During an interview on 7/12/18 at 12:02 P.M., LPN B said: – He/she tried not to grab the resident’s pants or arm during transfers but sometimes they do so the resident’s pants do not fall down, but we should try to use the gait belt. During an interview on 7/12/18 at 1:03 P.M., CNA D said: – The gait belt should not slide up, if it does, it should be tightened up; – He/she should not grab a hold of the resident’s arm or the resident’s pants during transfers. During an interview on 7/13/18 at 8:01 A.M., the DON said: |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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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 11) – The gait belt should not slide up under the resident’s arm pits, if it slides up, staff should stop the transfer and readjust it; – Staff should not grab the back of the resident’s pants or the resident’s arm during transfers. 4. Review of the policy, dated 1/1/2014, on mechanical lift transfers showed: – Did not address leaving the casters on the lift unlocked; – Did not address keeping the lift legs spread; – Did not address adhering to manufacturer’s instructions. Review of the undated user manual for the Invacare lift, the facility’s mechanical lift, showed: – When lifting a resident, staff should never lock the casters; – When lifting and transferring a resident, staff should always keep the legs spread. 5. Review of Resident #18’s quarterly MDS, dated [DATE], showed: – Severe cognitive impairment; – Total dependence upon staff for transfers; – [DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 5/3/18, showed staff should use a mechanical lift to transfer the resident. Observation on 7/10/18 at 8:43 A.M., showed: – CNA D locked the casters on the mechanical lift and lifted the resident from his/her wheelchair; – CNA D unlocked the casters; – Both CNAs moved the resident over his/her bed; – CNA D locked the mechanical lift casters and lowered the resident. During an interview at the time of the observation, both CNA’s said they thought they were supposed to lock the mechanical lift casters when lifting or lowering a resident. 6. Review of Resident #21’s admission MDS, dated [DATE], showed: – Cognitively impaired; – Total dependence upon staff for transfers, hygiene, and toileting; – [DIAGNOSES REDACTED]. – Received hospice care. Review of the resident’s care plan, dated 6/12/18, showed staff should transfer the resident using a mechanical lift. Observation on 7/11/18 at 10:26 A.M., showed: – Without spreading the mechanical lift legs, CNA A raised the resident from his/her bed; – Without spreading the mechanical lift legs, CNA A and CNA B moved the resident over the wheelchair; – Without locking the wheelchair, CNA B lowered the resident into the wheelchair. During an interview on 7/11/18 at 10:30 A.M., both CNAs said: – They thought they should not spread the lift legs when lifting, lowering, and transferring a resident; – They should have locked the resident’s wheelchair before lowering the resident. 7. Review of Resident #34’s quarterly MDS, dated [DATE], showed: – Cognitive skills intact; – Required extensive assistance of one staff for bed mobility; – Dependent on the assistance of two staff for transfers; – No impairment to upper or lower extremities; – [DIAGNOSES REDACTED]. The resident’s care plan, dated 6/12/18, did not address how the resident was to be |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
|||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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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 12) transferred. Observation on 7/12/18 at 9:15 A.M., showed: – LPN A and CNA B placed the lift pad under the resident; – LPN A moved the mechanical lift under the bed with the legs of the lift closed; – CNA B and LPN A hooked the lift sling up to the lift; – LPN A opened the legs of the mechanical lift, locked the the rear casters, and raised the resident up from the bed; – LPN A unlocked the rear casters and backed the lift away from the bed; – CNA B placed the resident’s wheelchair between the legs of the lift; – LPN A locked the rear casters on the mechanical lift and CNA B locked the brakes on the resident’s wheelchair; – LPN A lowered the resident into his/her wheelchair and CNA B and LPN A unhooked the lift sling from the lift. During an interview on 7/12/18 at 12:19 P.M., CNA B said: – The brakes should be locked on the mechanical lift. During an interview on 7/12/18 at 12:25 P.M., LPN B said: – The casters or brakes should be locked when raising or lowering the resident. During an interview on 7/13/18 at 8:01 A.M., the DON said: – Per the manufacturer’s guidelines, the brakes should not be locked on the mechanical lift; – He/she thought staff should not spread the mechanical lift legs when transferring a resident; – Staff should always lock a resident’s wheelchair when transferring a resident. 8. Review of the manufacturer’s guideline for the Invacare Stand Up Lift showed: – Invacare does NOT recommend locking the rear swivel casters of the Stand Up Lift when lifting and lowering an individual. Doing so could cause the lift to tip and endanger the resident and the assistants. – Invacare DOES recommend that the rear swivel casters be left unlocked during lifting and transferring procedures to allow the Stand Up Lift to stabilize itself when the patient is initially lifted from and transferred to a stationary object (bed or chair). 9. Review of Resident #30’s MDS, dated [DATE], showed: – Able to make daily decisions; – Dependent on staff for transfers; – Limited range of motion to both sides upper and lower extremities; – [DIAGNOSES REDACTED]. Review of the resident’s care plan, revised on 6/5/18, showed: – Transfer the resident to the toilet and shower chair with the Stand Up Lift and two staff assist at all times. Observation on 7/11/18 at 1:46 P.M., showed CNA B and CNA D transferred the resident from his/her wheelchair to the shower chair with the Stand Up Lift. CNA B locked the rear casters of the lift as he/she lifted the resident from the wheelchair and lowered the resident on to the shower chair. During an interview on 7/11/18 at 2:37 P.M., CNA B said: – He/she received CNA training at the facility. He/she was trained to lock the back casters on the Stand Up Lift while lifting and lowering the resident. During an interview on 7/13/18 at 8:01 A.M., the acting DON said she did not know what the manufacturer’s guideline for the Stand Up Lift directed regarding the rear casters being locked or unlocked during lifting and lowering the resident. 10. Review of Resident #14’s Smoking Safety Screen, effective date 3/25/18, showed 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: 265728 |
|
(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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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 13) facility team determined the resident was safe to smoke with supervision. Review of the resident’s MDS, dated [DATE], showed: – Moderately impaired decision making skills; – Required extensive assistance for activities of daily living; – [DIAGNOSES REDACTED]. Review of the resident’s care plan, revised 5/16/18, showed – The resident is a smoker and can smoke unassisted. The resident should always wear a smoking apron. Review of the resident’s smoking care plan, initiated on 7/11/18, showed the resident is able to smoke unsupervised with his/her smoking apron on. Observation on 7/11/18 at 10:24 A.M., the resident sat on the front porch unattended, smoking a cigarette without wearing a smoking apron. At 10:30 A.M., the resident lit a second cigarette without wearing a smoking apron. As he/she lit the second cigarette, the resident’s forearm jerked up and down. LPN B came out to the front porch and held the resident’s hand for a minute, then returned inside the facility. LPN B did not take a smoking apron out to the resident. During an interview on 7/11/18 at 11:42 A.M., the acting Director of Nurses said: – The resident was supposed to wear a smoking apron when he/she smoked; – The Smoking Assessment directed staff to ensure the resident was supervised; – She interpreted supervision as the staff knowing the resident needed an apron on when he/she went out to smoke. |
|
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 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
|
---|---|---|
F 0690
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 14) catheter tubing rested on the floor (about 10 inches), the dignity bag that held the urinary drainage bag also rested on the floor; – 7/11/18 at 08:49 A.M., the resident sat in his/her wheelchair with the catheter tubing under the resident’s foot on the foot pedal, and the dignity bag touched the floor; – 7/11/18 at 11:59 A.M., the resident sat in the dining room, his/her dignity bag and tubing dragged the floor; – 7/11/18 at 1:46 P.M., CNA B and CNA D transferred the resident from the wheelchair to the shower chair with the sit-to-stand lift. CNA D placed the dignity bag on the floor of the lift. The floor of the lift had dirt and debris on it. After staff transferred the resident to the shower chair, two to three inches of the dignity bag lay on the floor. CNA B took the urinary drainage bag out of the dignity bag and hung the drainage bag back on the lower bar of the shower chair. Two to three inches of the drainage bag rested on the shower room floor. The urine in the drainage bag was reddish amber in color. The drainage bag rested on the the shower stall floor during the resident’s shower. CNA B attempted to get urine in the tubing to drain into drainage bag. He/she held the tubing high above the resident’s bladder, the urine ran backwards up tubing. CNA B emptied 300 cc of amber urine, he/she did not clean the drainage spout before he/she placed the spout back inside the holder on the drainage bag. The resident expressed the desire to use the toilet. CNA B moved the shower chair, the drainage bag fell to the floor, and the wheel of the shower chair rolled across the drainage bag. The resident had a bowel movement, CNA B provided perineal care. CNA B changed gloves, did not wash hands, and used a new wipe to clean down the catheter tubing. During an interview on 7/11/18 at 2:37 P.M., CNA B said: – The catheter tubing, drainage bag and dignity bag could not touch the floor; – He/she was not taught to clean the drainage spout with alcohol pads. During an interview on 7/13/18 at 8:01 A.M., the acting Director of Nurses said: – Staff should not allow the catheter tubing, drainage bag or dignity bag to ever touch the floor; – Staff should clean the drainage spout with alcohol pads when they remove it from the holder on the catheter drainage bag and before they replace it in the holder. 2. Review of Resident #30’s POS, dated 7/2018, showed the physician ordered a 20 french Foley catheter, change every month on the 13th (original order on 3/22/18). Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as: – Able to make daily decisions; – Had an indwelling catheter; – [DIAGNOSES REDACTED]. Record review of the resident’s May, (MONTH) and (MONTH) (YEAR) treatment administration records (TAR’s), showed: – Month of (MONTH) – staff did not initial they changed the resident’s catheter; – Month of (MONTH) – staff initialed on 6/24 they changed the resident’s catheter, but drew a line through the initial to indicate they documented in error; – Month of (MONTH) – staff did not initial they changed the resident’s catheter. Observation and interview on 7/10/18 at 1:38 P.M., showed the resident sat in his/her room in his/her wheelchair. The catheter tubing lay on the floor under the wheelchair and the urinary drainage bag was in the dignity bag that rested on the floor. The resident said he/she did not remember the last time staff changed his/her catheter. Review of the resident’s care plan, initiated 7/11/18, directed staff to change catheter as ordered. During an interview on 7/13/18 at 8:01 A.M., the acting Director of Nursing said staff |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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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 15) should follow the physician’s orders [REDACTED]. 3. Review of Resident #34’s quarterly MDS, dated [DATE], showed staff assessed the resident as: – Cognitive skills intact; – No impairment to upper or lower extremities; – Frequently incontinent of bladder; – Occasionally incontinent of bowel; – [DIAGNOSES REDACTED]. Observation on 7/10/18 at 9:24 A.M., showed: – The resident sat in his/her wheelchair on the front porch and the dignity bag rested on the ground. Observation on 7/11/18 at 1:20 P.M., showed: – The resident’s dignity bag rested on the floor; – CNA A placed a trash bag on the floor and sat the graduate on it; – CNA A unclamped the drainage spout, did not clean it and emptied the urine into the graduate, dumped the graduate in the toilet then emptied more urine from the drainage bag; – CNA A did not clean the drainage spout after he/she emptied the urine and replaced it in the sleeve. During an interview on 7/11/18 at 1:40 P.M., CNA A said: – He/she was not taught to clean the port when emptying the drainage bag; – The drainage bag should not rest or drag on the floor. Observation on 7/11/18 at various times showed: – The resident’s dignity bag rested or dragged on the floor as the resident propelled him/herself in his/her wheelchair. Review of the resident’s care plan, initiated on 7/11/18, showed: – The resident had a Foley catheter related to urinary obstruction; – Catheter care as ordered. Observation on 7/12/18 at 6:43 A.M., showed: – The resident’s dignity bag rested on the floor; – CNA E placed the graduate directly on the floor; – CNA E opened the clamp on the drainage spout and emptied the urine then placed the drainage bag back in the dignity bag and hung it on the side of the bed; – CNA E did not clean the drainage spout. During an interview on 7/12/18 at 6:49 A.M., CNA E said: – He/she was not trained to clean the drainage spout; – He/she should have placed the graduate in a trash bag and not on the floor. – The drainage bag or the dignity bag should not be on the floor. During an interview on 7/13/18 at 8:01 A.M., the DON said: – The drainage bag nor the catheter bag should rest on the floor or drag on the floor; – The drainage spout should be cleaned before and after emptying it. |
|
F 0756
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
|
---|---|---|
F 0756
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 16) pharmacist’s (PharmD) recommendations to residents’ physicians for three residents (Residents #5, #21 and #25) out of 12 sampled residents. The facility census was 35. 1. Review of Resident #21’s admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/8/18 showed: – Cognitively impaired; – Total dependence upon staff for transfers, hygiene, and toileting; – [DIAGNOSES REDACTED]. – Received hospice care. Review of the resident’s Drug Regimen Review (DRR), dated 5/24/18, showed PharmD documented: – A recommendation to add blood pressure parameters to the resident’s [MEDICATION NAME] (used to treat high blood pressure (BP), [MEDICATION NAME] (used to treat high BP), [MEDICATION NAME] (used to treat high BP), [MEDICATION NAME] (used to treat high BP), and [MEDICATION NAME] (used to treat high BP); – A recommendation for pulse parameters for [MEDICATION NAME] (may cause a slow heart rate); – There was no documentation indicating the recommendations were relayed to the resident’s physician. Review of the resident’s physician’s orders [REDACTED]. – No BP parameters for [MEDICATION NAME], or [MEDICATION NAME]; – No pulse parameters for [MEDICATION NAME]. 2. Review of Resident #25’s care plan, revised on 2/20/18, showed: – The resident received [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] (antidepressant) routinely. Review of the resident’s quarterly MDS, dated [DATE], showed: – Cognitively intact; – [DIAGNOSES REDACTED]. Review of the resident’s DRR, dated 6/29/18, showed PharmD documented: – The resident has been on [MEDICATION NAME] 10 mg. daily and [MEDICATION NAME] 10 mg. (note; error by PharmD, should be 150mg) daily for some time; – Quarterly dose reduction trials must be attempted to minimize or discontinue medications that are unnecessary; – Did not show any documentation the information was sent to the physician or if the physician responded. Review of the resident’s POS, dated (MONTH) (YEAR), showed: – an order for [REDACTED].>- an order for [REDACTED].>3. Review of Resident #5’s DRR, dated 3/27/18, showed PharmD documented: -A recommendation for Gradual Does Reduction (GDR) [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] (antidepressant); -No documentation to show this was communicated with the physician or his/her response. Review of the resident’s quarterly MDS, dated [DATE], showed: – admission date of [DATE]; – [DIAGNOSES REDACTED]. – Cognitively impaired; – Antipsychotic medication received on a routine basis; – A GDR has not been attempted. Review of residents POS, dated (MONTH) (YEAR), showed: -[MEDICATION NAME] 25 mg tab, one tab at bedtime, started 8/26/16; -[MEDICATION NAME] 25 mg tab, .5 tab in the morning, started 8/26/16; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
|
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F 0756
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 17) -[MEDICATION NAME] HCL 25 mg tab, (generic for [MEDICATION NAME]), one daily, started 1/29/17. 4. During an interview on 7/11/18 at 11:00 A.M., the Director of Nursing (DON) said: – He/she recently assumed the position of DON; – He/she had never seen a DRR sheet; – He/she did not know what to do with the DRRs. During an interview on 7/11/18 at 11:10 A.M., the Regional Nurse Consultant (RNC) said staff must communicate the DRR with the residents’ physicians. The RNC did not know who is responsible for this. |
|
F 0759
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Ensure medication error rates are not 5 percent or greater.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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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 0759
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 18) – Hold the dropper directly over the eye and place one drop into the eye; – Look downward and gently close eyes for one to two minutes; – Place one finger at the corner of the eye (near the nose) and apply gentle pressure for one to two minutes. This will prevent the medication from draining out; – Try not to blink and do not rub the eye. Review of Resident #13’s POS, dated (MONTH) (YEAR), showed: – an order for [REDACTED]. Observation on 7/11/18 at 9:28 A.M., showed: – LPN B placed tissues, eye drop bottle and gloves on a paper towel and washed his/her hands and applied gloves; – LPN B touched the tip of the eye dropper to the resident’s upper eyelid and instilled one drop in the resident’s right eye; – LPN B placed his/her finger in the middle of the resident’s closed upper eye for 30 seconds, removed gloves and washed his/her hands. During an interview on 7/12/18 at 9:15 A.M., LPN B said: – The eye dropper should not touch the resident’s eyelid; – He/she should have applied lacrimal pressure to the inner eye by the resident’s nose for one minute. During an interview on 7/13/18 at 8:01 A.M., the DON said: – Staff should not touch the the eye drop to the eyelid and should apply lacrimal pressure to the corner of the eye for one minute. |
|
F 0761
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0761
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 19) Tresiba insulin pens belonged to. LPN A said all nurses and CMT’s should check for outdated medications, staff should not use outdated medications, and medications should be labeled with the date they are opened. During an interview on 7/13/18 at 8:01 A.M., the Director of Nursing (DON) said: – She thought a nurse had been assigned to check for expired medications but did not know who it was; – Staff should not administer medications that are expired or use treatment medications that are expired; – Medications and insulin pens should be dated when opened. |
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F 0809
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation and interview, the facility failed to ensure staff offered HS |
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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 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0880
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 20) used proper infection control when staff failed to wear gloves when administering insulin and failed to clean the glucometer after use for one of 12 sampled residents (Resident #25). Additionally, the facility did not ensure staff who provided care for two residents (Residents #29 and #236) in isolation washed their hands between dirty and clean tasks and before they left the residents’ rooms. The facility census was 35. 1. Review of the undated manufacturer’s instructions for the facility’s Assure Platinum glucometer showed: – Contact with blood represented a potential infection risk; – Staff should clean and disinfect the meter after use. Review of the facility policy, dated 1/1/2014, on cleaning glucometers showed staff should clean and disinfect all glucometers after each use. Review of Resident #25’s physician order sheet (POS), dated (MONTH) (YEAR), showed an order for [REDACTED]. Observation on 7/11/18 at 10:55 A.M., showed: – Licensed Practical Nurse (LPN) B performed a blood glucose for Resident #25; – After performing the blood glucose, he/she put the used glucometer in a bag labeled with the resident’s name. During an interview on 7/11/18 at 10:55 A.M., LPN B said: – Each resident had his/her own bag containing his/her glucometer machine and glucometer supplies; – According to facility policy, the night shift cleaned each resident’s glucometer machine every night. During an interview on 7/11/18 at 3:10 P.M., the Director of Nursing (DON) said staff should always disinfect every glucometer after use. 2. Observation on 7/11/18 at 9:51 A.M., showed Licensed Practical Nurse (LPN) B administered an insulin injection to Resident #25 without wearing gloves. During an interview on 7/11/18 at 9:51 A.M., LPN B said he/she always gave injections without wearing gloves. During an interview on 7/11/18 at 3:10 P.M., the Director of Nursing (DON) said staff should always wear gloves when administering injections. 3. Review of the facility’s Handwashing policy, issued 2/16, showed: – To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections; – Staff will perform hand hygiene by washing hands for at least 15 seconds with anti- or non-antimicrobial soap and water should be performed under the following conditions: – When hands are visibly dirty or soiled with blood or other body substances; – Before entering and leaving an isolation room; – Before applying gloves and after removing gloves or other personal protective equipment; – After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; – After handling items potentially contaminated with blood, body fluids, or secretions; – Before moving from a contaminated body site to a clean body site during resident care; example: after providing perineal care, before applying moisture barrier cream or other treatments; – After providing direct resident care; – If exposure to an infectious disease is suspected or proven. Review of the facility’s Isolation Precautions policy, dated 1/1/14, showed: – To establish transmission based precautions for residents who are suspected or confirmed to have communicable diseases/infections that could be transmitted to others; – Appropriate communication/notices will identify the resident/room with isolation |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0880
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 21) precautions implemented; – Contact Precautions – Prior to entering the isolation room, the following steps are required, perform hand hygiene and apply gloves and gown prior to entering the room; – While providing direct resident care, remove gloves and wash hands after coming in contact with infectious material; – Remove gloves and perform hand-hygiene before leaving the room (do not use alcohol-based hand gels for isolation due to suspected or confirmed [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacterium that can cause symptoms ranging from diarrhea to a life threatening inflammation of the colon). 4. Review of Resident #30’s MDS, dated [DATE], showed: – Able to make daily decisions; – Required extensive assistance of staff with toilet use, personal hygiene and bathing; – Indwelling catheter and occasionally incontinent of bowel. Review of the resident’s care plan, revised 6/5/18, showed: – Please offer the toilet before and after meals, activities, and before going to bed; – Required extensive assist with bathing as scheduled; – Please be sure to provide proper catheter care every shift. Observation on 07/11/18 01:46 P.M., showed CNA B assisted the resident with his/her shower as needed. The resident expressed he/she needed to use the toilet. CNA B moved the shower chair over to the toilet. CNA B wiped fecal matter from the rectal area with four wipes, changed gloves but did not wash his/her hands, used a wipe and cleaned the tip of the perineal fold which had bright red blood. CNA B changed his/her gloves, did not wash hands and cleaned down the resident’s catheter tubing. CNA B changed his/her gloves, did not wash hands and proceeded to dress the resident. During an interview on 7/11/18 at 2:37 P.M., CNA B said he/she should wash hands: – When entering the resident’s room; – Before and after he/she provided care and in between glove changes; – During a shower, he/she should wash his/her hands every time he/she changed his/her gloves to clean another area of the resident’s body. 5. Review of Resident #29’s MDS, dated [DATE], showed: – Unable to make daily decisions; – Required assistance of staff with toilet use, personal hygiene and dressing; – Indwelling catheter; – Frequently incontinent of bowel; – [DIAGNOSES REDACTED]. Review of the resident’s current care plan showed no care plan for [MEDICAL CONDITION] or [MEDICAL CONDITION]. Review of the resident’s current POS, dated (MONTH) (YEAR), showed the physician ordered [MEDICATION NAME] 125 mg./ per 5 ml, suspension , give 5 ml every 6 hrs for[DIAGNOSES REDACTED]. Observation on 7/10/18 at 1:07 P.M., showed a plastic three-drawer container outside the resident’s door that held personal protective equipment (PPE) used for residents on isolation precautions. There was no notification posted to direct visitors to see the nurse to see if it was alright to enter the resident’s room. The resident lay in his/her low bed with a catheter drainage bag inside a dignity bag, the bottom of which rested on the floor. CNA A and CNA C did not wash their hands. CNA A provided perineal care and catheter care, assisted CNA C to roll the resident to his/her side and cleaned fecal material from the resident’s rectum. Without changing his/her gloves or washing his/her hands, CNA A wiped moisture barrier cream on the resident’s buttocks and genitalia. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
|||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0880
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 22) Without changing his/her gloves or washing his/her hands, CNA A proceeded to place a clean brief on the resident, pulled the resident’s gown down, positioned a pillow behind the resident’s back and underneath the resident’s head. CNA A retrieved a graduate from the bathroom, drained the urinary drainage bag of 300 cc of amber colored urine. CNA A placed the used graduate in a plastic bag and told CNA C he/she would hand the bag to CNA C at the resident’s doorway. CNA C bagged up soiled linens and trash and placed them in the biohazard receptacles, removed his/her PPE, retrieved a clean plastic bag and without washing his/her hands opened the resident’s door, held the plastic bag open for CNA A to place the bagged graduate into. CNA C carried the plastic bag down the hallway. CNA A removed his/her PPE, did not wash his/her hands and reopened the resident’s door, grabbed a clean pair of gloves, picked up the remote to lower the resident’s bed and touched buttons on the resident’s television before he/she removed his/her gloves and washed his/her hands. During an interview on 7/11/18 at 9:18 A.M., CNA A said the resident was on isolation because he/she had [MEDICAL CONDITION]. During an interview on 7/11/18 at 11:10 A.M., LPN A said staff should have placed a sign on the door for visitors to see the nurse before entering the resident’s room. During an interview on 7/11/18 at 2:25 P.M., CNA A said he/she should wash his/her hands: – Before gloving and when changing gloves; – Before and after resident care; – Anytime he/she touches a resident or touches anything soiled; – After cleaning fecal matter, before applying cream to the resident’s bottom or before repositioning a resident in his/her bed. During an interview on 7/13/18 at 8:01 A.M., the DON said: – Staff should wash their hands when they enter the resident’s room; – Staff should wash their hands if they get their gloves soiled while giving care, they should change gloves and wash their hands and put on new gloves; – Staff should wash hands between dirty and clean tasks; – Before they leave a resident’s room and when they reenter a resident’s room; – If staff provided care for a resident on isolation, they should remove their gown and gloves, then their mask and wash their hands before they leave the room; – Resident #29 had a [DIAGNOSES REDACTED]. 6. Review of Resident #236’s admission MDS, dated , 4/16/18, showed: – Cognitive skills moderately impaired; – Dependent on two staff for bed mobility, transfers and toilet use; – Occasionally incontinent of bowel and bladder. Review of the resident’s care plan, revised on 7/10/18, showed: – The resident had [MEDICAL CONDITION] infection, (MRSA, a type of staph bacteria resistant to the antibiotic [MEDICAL CONDITION]); – Administer antibiotics per physician’s orders; – The resident was on contact precautions [MEDICAL CONDITION]; – Contact isolation precautions [MEDICAL CONDITION] in nares (nose). Review of the physician’s order sheet (POS), dated (MONTH) (YEAR), showed: – 7/3/18: an order for [REDACTED].>- 7/10/18: an order for [REDACTED].>Observation on 7/10/18 at 8:38 A.M., showed: – The resident was in a low bed; – The door was half way open; – A plastic three drawer cart on wheels was placed outside the resident’s room which contained PPE to be used prior to entering the resident’s room; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0880
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 23) – The facility did not have a sign posted on the outside of the resident’s door informing visitors about the isolation precautions. Observation on 7/11/18 at 8:19 A.M., showed: – The resident’s door was open; – CNA D applied gloves, gown and mask then entered the resident’s room. He/she did not wash his/her hands; – CNA D transferred the resident from his/her bed to his/her wheelchair; – CNA D removed the gloves, gown and mask and left the room to get a portable oxygen canister; – CNA D did not wash his/her hands before leaving the resident’s room; – CNA D did not wash his/her hands, applied gloves, gown and mask and brought a portable oxygen canister in the resident’s room; – CNA D gave the resident a mask to wear in the hallway and instructed him/her to go down the hall and get weighed; – CNA D removed his/her gloves, gown and mask, did not wash his/her hands and left the room. Observation on 7/12/18 at 9:43 A.M., showed: – The resident’s door was open; – CNA D applied gloves, gown and mask and entered the resident’s room; – CNA D transferred the resident from his/her chair to the bedside commode; – The resident was incontinent of urine and his/her pants were wet; – CNA D removed the resident’s wet incontinent brief and wet pants; – CNA D removed gloves, did not wash his/her hands and applied gloves; – The resident urinated on the floor; – CNA D cleaned the urine with a towel; – CNA D removed his/her gloves, did not wash his/her hands and applied new gloves; – CNA D put a clean incontinent brief on the resident and clean pants; – CNA D provided incontinent care and applied skin barrier cream to the resident’s buttocks; – CNA D removed gloves, did not wash his/her hands and applied new gloves; – CNA D assisted the resident with dressing and the resident put a mask on and left the room; – CNA D removed his/her gloves, gown and mask and did not wash his/her hands before leaving the room. Observation at different times throughout the survey from 7/10/18 – 7/13/18, showed: – The resident’s door was left open and did not have a sign instructing visitors to see the nurse before entering the resident’s room. During an interview on 7/12/18 at 1:03 P.M., CNA D said: – He/she should wash hands before care, between clean and dirty tasks, between glove changes, when entering and leaving residents’ rooms; – He/she should have washed his/her hands before entering the isolation room; – He/she thought there should have been a sign on the resident’s door about him/her being in isolation; – The resident’s door should have been closed. During an interview on 7/13/18 at 8:01 A.M., the DON said: – Staff should wash their hands when they enter the resident’s room, if the gloves get soiled, between clean and dirty tasks, between glove changes and if they leave the room and reenter; – Staff should wash their hands when removing PPE; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0880
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
(continued… from page 24) – When a resident was in isolation, staff should post a sign on the resident’s door. |
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F 0881
Level of harm – Potential for minimal harm Residents Affected – Many |
Implement a program that monitors antibiotic use.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
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F 0883
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Based on interview and record review, the facility failed to ensure all residents were |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES |
PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 |
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265728 |
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(X3) DATE SURVEY COMPLETED
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NAME OF PROVIDER OF SUPPLIER
KING CITY MANOR |
STREET ADDRESS, CITY, STATE, ZIP
300 WEST FAIRVIEW |
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For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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F 0883
Level of harm – Minimal harm or potential for actual harm Residents Affected – Few |
(continued… from page 25) – No record that staff offered the flu vaccine in (YEAR). 3. Review of Resident #21’s medical records showed: – Date of admission was 4/26/18; – Staff did not assess the resident’s immunization status on admission; – Staff did not offer the resident any immunizations. During an interview on 7/12/18 at 10:00 A.M., the Director of Nursing said: – Staff should offer residents immunizations according to the Center for Disease Control Guidelines; – The facility does not have a mechanism to monitor offering residents immunizations. |
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F 0925
Level of harm – Minimal harm or potential for actual harm Residents Affected – Some |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
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