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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
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 – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
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 – Some | (continued… from page 1) -Eight ceiling vents in the laundry room were covered with a thick layer of dust; -A ceiling vent in the service corridor was covered with a thick layer of dust; -The ceiling vent in the janitor’s closet in the service corridor was covered with a thick layer of dust. During interview on 02/06/19 at 2:26 P.M., the maintenance supervisor said maintenance was responsible for ensuring the ceiling vents were clean. He said staff checked the vents monthly. He was not aware the ones found during the inspection needed cleaning. During interview on 02/06/19 at 3:41 P.M., the administrator said she expected the ceiling vents to be clean and dust free. | |
F 0659 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide care by qualified persons according to each resident’s written plan of 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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
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 0659 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) that were CPR certified; -[DATE] LPN G worked from 10:00 P.M. to 6:00 A.M. (eight hours) without any other staff that were CPR certified; -[DATE] LPN G worked from 10:00 P.M. to 6:00 A.M. (eight hours) without any other staff that were CPR certified; -[DATE] LPN G worked from 5:00 P.M. to 10:00 P.M. (five hours) without any other staff that were CPR certified. During interview on [DATE] at 7:50 A.M. the DON said LPN G worked [DATE], [DATE], [DATE], and [DATE] without current CPR certified and without any other CPR certified staff in the building. 5. Review of Resident #6’s physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -admission date of [DATE]; -Code status: full code. Review of the the facility’s transportation schedule report showed the facility transported the resident in the facility van to appointments out of town on [DATE], [DATE], [DATE], [DATE] and [DATE]. 6. Review of Resident #9’s physician orders [REDACTED]. -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Code status: full code. Review of the facility’s transportation schedule report showed the facility provided transportation of the resident in the facility van to appointments on [DATE] and [DATE]. 7. Review of Resident #31’s physician’s orders [REDACTED]. -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Code status: full code. Review of the facility’s transportation schedule report showed the the facility provided transportation for the resident to an appointment on [DATE]. 6. During interview on [DATE] at 10:11 A.M., the transporter said the following: -He/she was hired in ,[DATE] as the transporter to take residents to and from physician appointments and occasionally to the store; -He/she had been CPR certified back in 2010 or 2011 and it was different process back then; -He/she would call 911 if a resident was non-responsive; -He/she might check a resident’s pulse before performing CPR; -He/she never had to perform CPR on a real person before. During interview on [DATE] 10:36 A.M., the administrator said all the licensed staff were CPR certified. She just found out that staff that transported the residents also needed to be CPR certified. | |
F 0661 Level of harm – Potential for minimal harm Residents Affected – Many | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
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 0661 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 3) of three closed records, and one additional resident (Resident #100). The facility census was 43. 1. During interview on 2/11/19 at 1:48 P.M., the Director of Nursing (DON) said the facility did not have a discharge or recapitulation policy. 2. Review of Resident #48’s medical record showed the following: -admitted to the facility on [DATE]; -discharged home with family member on 11/26/18. Staff sent all medications with the resident’s family member; -The medical record contained no discharge summary or recapitulation of stay. 3. Review of Resident #100’s medical record showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -discharged home 6/29/18; -The medical record contained no discharge summary or recapitulation of stay. 4. During interview on 2/6/19 at 4:36 P.M., the DON said the following: -The charge nurse is responsible for completing discharge summaries; -The staff just found out they needed to complete a summary of residents’ stays; -The staff have not been completing discharge summaries or recapitulation of the residents’ stay. -Resident #48 was a respite care resident for the holidays and she was not aware staff needed to complete a recapitulation summary for respite care residents. | |
F 0678 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
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 0678 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) admission; -Code status will be updated on the resident’s chart when/if changed; -When a resident is found to be unresponsive: staff will call for help using call system or verbally alerting other staff on duty; -Verify code status (full code or DNR). If code status is not known and cannot be immediately determined, assume full code; -Initiate emergency procedures. Example, call 911, physician, obtain equipment, etc.; -If a resident is a full code, a staff person initiates CPR according to current BLS (basic life support) guidelines and a second person acts as a messenger to assist first staff person; -Messenger ensures Code Blue is announced overhead and emergency personnel and physician is notified; -CPR will continue until emergency personnel arrive and take over the process. 2. Review of the resident listing report supplied by the Director of Nursing (DON) on [DATE] at 3:25 P.M. showed the following: -Resident #6 was a full code; -Resident #46 was a full code. 3. Review of Resident #6’s medical record showed an outside the hospital DNR request dated [DATE] showed the resident requested to have a DNR put into place and did not want staff performing CPR. Review of the resident’s face sheet showed DNR highlighted. Review of the resident’s physician orders (POS) dated [DATE] showed CPR, indicating the resident was a full code. Review of the resident’s care plan last updated [DATE], showed the resident’s code status was not addressed on the care plan. Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed the following: -admission date of [DATE]; -Cognitively intact; -Understood others and made self understood; -[DIAGNOSES REDACTED]. Observation on [DATE] to [DATE] of the resident’s hard chart showed a green sticker indicating the resident was a full code. Review of the resident’s POS dated [DATE] showed CPR, indicating the resident was a full code. Observation on [DATE], at 12:33 P.M., of the resident’s door showed a red sticker on his/her name tag, indicating DNR status. 3. Review of Resident #46’s hard chart showed a red sticker indicating the resident was a DNR. Review of the resident’s care plan last updated [DATE], showed the resident’s code status was not addressed. Record review of the resident’s quarterly MDS dated [DATE], showed the following: -admission date of [DATE]; -Cognition intact; -[DIAGNOSES REDACTED]. Review of the resident’s physician orders (POS) on the electronic medical record (EMR) dated (MONTH) 2019, showed the code status was blank. Observation on [DATE] at 2:30 P.M. of the resident’s door showed a green sticker on his/her name tag indicating full code status. |
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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
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 0678 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) 5. During interview on [DATE] at 5:54 A.M., Certified Nurse Aide (CNA) C said he/she finds out a resident’s code status by looking at the computer under the Kardex by the resident’s name. During interview on [DATE] at 5:56 A.M., CNA D said he/she knows resident code status from the stickers on the resident’s hard chart and the sticker on the outside of the resident’s room on their picture. The stickers should match, with red dot sticker being DNR and the green dot sticker being full code. The code status is also in the resident’s EMR charted by the allergies [REDACTED]. During an interview on [DATE] at 9:45 A.M. Licensed Practical Nurse (LPN) A said the following: -He/she had worked at the facility long enough to know the residents’ code status; -A green dot on the resident name plate on the door and resident’s chart meant the resident was a full code; -A red dot on the resident’s name plate on the door and spine of the chart meant the resident was DNR; -He/she would also look at the EMR top right corner which tells the resident code status but he/she didn’t always have a computer available. During an interview on [DATE] at 6:11 A.M. LPN E said the following: -He/she would look for the red or green dot outside on the spine of the resident’s chart to know the resident’s code status; -If the resident had a green dot it meant the resident was a full code; -If the resident’s chart had a red dot on the outside spine it meant the resident was a DNR; -He/she would also check the resident’s face sheet for the code status. During an interview on [DATE] at 7:50 A.M. the DON said the following; -The facility has full code and DNR residents in the building; -The facility did not have a policy for the red and green dot system for resident code status; -The admitting nurse was responsible for getting the resident’s wishes for code status from the resident and/or the resident’s guardian and the physician; -Each resident should have a red or green dot on the spine of their hard chart indicating code status; -A red dot meany the resident was a DNR and a green dot meant the resident was a full code; -The dots outside the residents’ rooms were not used anymore because they were too hard to keep up with; -He/she was not sure why some of the residents have dots outside their door on their name plate and some do not because they have not used that system for at least a year; -She expected staff to refer to the resident’s spine of their hard chart, face sheet, and POS for code status; -If there was no code status indicated, the resident is a full code; -She would expect the resident’s POS, face sheet, and chart to all match on code status. | |
F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure medication error rates are not 5 percent or greater. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) medication error rate was less than five percent. Twenty-six opportunities were observed with five medication errors, resulting in a medication error rate of 19.23 percent. The facility census was 43. 1. Review of the facility’s policy, Medication Pass Times, implemented 7/1/13, showed the following: -Purpose was to ensure medications were administered as ordered in a safe and effective manner that meets standards of practice according to Centers for Medicare and Medicaid Service’s guidelines; -Time frame for the evening medication pass was 3:00 P.M. to 6:00 P.M., and the time frame for the bedtime (HS) pass was 7:00 P.M. to 10:00 P.M. 2. Review of the facility’s policy Eye Drop Administration, revised (MONTH) 2011, showed the following: -Administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner; -Tilt the resident’s head slightly back; -With a gloved finger, gently pull down lower eyelid to form a pouch while instructing the resident to look up. Place other hand against the resident’s forehead to steady; -Hold inverted medication bottle between the thumb and index finger, press gently, and instill prescribed number of drops into the pouch near outer the corner of the resident’s eye; -If resident blinks or a drop lands on the resident’s cheek, repeat administration. 3. Review of Resident #101’s physician order, dated 2/4/19, showed an order for [REDACTED]. Observation on 2/5/19 at 11:35 A.M., showed the resident lay in bed with the head of his/her bed slightly elevated. Licensed Practical Nurse (LPN) A did not tilt the resident’s head back before he/she instilled one drop of the [MEDICATION NAME] B solution into the resident’s right eye. LPN A did not instill the eye drop into a pouch in the resident’s lower lid but instilled the drop into the corner of the eye. The drop immediately rolled out of the resident’s eye and down the resident’s cheek. LPN A wiped the drop from the resident’s face. LPN A did not instill another eye drop into the resident’s eye. During interview on 2/13/19 at 1:17 P.M. and on 2/21/19 at 11:10 A.M., LPN A said he/she was rushed and nervous and knew right away, he/she did not administer the eye drop correctly. He/she was to instill the drop by making a pouch in the lower eyelid. He/she should have re-administered the eye drop to the resident. During interview on 2/21/19 at 10:58 A.M., the director of nursing (DON) said she expected staff to re-administer the eye drop if it immediately rolled out of the resident’s eye upon administration. Staff was to make a pouch in the lower eye lid to instill the eye drop. 4. Review of Resident #37’s physician orders, dated 2/6/19, showed the following: -[MEDICATION NAME] (a natural hormone that helps maintain daily cycle of sleep and wakefulness) 5 milligram (mg), administer one tablet at bedtime for sleeplessness; -[MEDICATION NAME] (antidepressant) 30 mg, administer one tablet at bedtime for chronic depression. Review of the resident’s electronic Medication Administration Record [REDACTED] -[MEDICATION NAME] 5 mg, give one tablet at bedtime for sleeplessness; -[MEDICATION NAME] 30 mg, give one tablet at bedtime for chronic depression; -These medications were on the list of medications for staff to administer to the resident during the 1700 (5:00 P.M.) medication pass. |
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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) Observation on 2/5/19 at 4:05 P.M., showed Certified Medication Technician (CMT) B reviewed the resident’s eMAR, which highlighted medications to be administered for the 5:00 medication pass. CMT B administered the [MEDICATION NAME] 5 mg and [MEDICATION NAME] 30 mg to the resident during the evening medication pass scheduled for 5:00 P.M. per the eMAR. (Both medications were ordered to be given at bedtime.) 5. Review of Resident #1’s physician’s orders [REDACTED]. -[MEDICATION NAME] (anticonvulsant) 100 mg, administer one tablet at bedtime; -Donepezil (cognition-enhancing medication) 10 mg, administer one tablet at bedtime. Review of the resident’s eMAR showed [MEDICATION NAME] and donepezil were scheduled for the evening medication pass (5:00 P.M.), however, the eMAR showed the medications were ordered to be administered at bedtime. Observation on 2/5/19 at 4:15 P.M. showed CMT B administered the [MEDICATION NAME] 100 mg and donepezil 10 mg to the resident during the evening medication pass. (Both medications were ordered to be given at bedtime.) 6. During interview on 2/13/18 at 1:56 P.M., CMT B said he/she followed the eMAR when administering medications. The eMAR said the medications for Resident #1 and Resident #37 were to be given during the 5:00 P.M. medication pass. 7. During interviews on 2/11/19 at 1:48 P.M. and on 2/13/19 at 2:09 P.M., the DON said the following: -The nurse, who receives a physician’s orders [REDACTED]. The nurse on the next shift was to review the new order and eMAR to ensure it was correct; -Staff were to administer Resident #1 and Resident #37’s bedtime medications no earlier than 7:00 P.M. Staff administering bedtime medications at 4:00 P.M. or 5:00 P.M. was too early; -Staff were to administer medications ordered specifically at HS as listed on the physician’s orders [REDACTED].>-She expected staff to follow physician’s orders [REDACTED]. | |
F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure 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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
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 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 8) supports and ran up into the ceiling also were covered in dusty and debris. White PVC piping and black wiring underneath the unit had a buildup of dark fuzzy debris. Observation on 2/5/19 at 10:46 A.M. showed Dietary Staff A removed frozen chicken livers from plastic bags under the ceiling mounted air conditioning ventilation unit. Three small empty steamtable pans sat underneath the unit and were not covered. Two open bags of frozen chicken livers sat underneath the air conditioning unit. During an interview on 2/5/19 at 10:55 A.M., the dietary manager said dietary staff cleaned the air conditioning ventilation unit monthly. The unit cleaning was not listed on the daily, weekly or monthly cleaning lists for December. The unit cleaning was listed on the (MONTH) monthly cleaning log, but the task had not been documented as being completed for (MONTH) and was left blank. She was unable to provide documentation to show when the unit had been cleaned previously. During an interview on 2/5/19 11:36 A.M., the maintenance supervisor said dietary staff was responsible for cleaning the air conditioning ventilation unit in the kitchen. Maintenance staff changed the filters in the kitchen on a monthly basis. During an interview on 2/5/19 at 12:17 P.M., the dietary manager said staff should prepare food at the end of the food preparation metal counter that doesn’t have the air conditioning unit over the top. She was aware the dietician had concerns with the cleanliness of the unit. The dietician reviewed her report with dietary staff at the end of the visit, so dietary had been made aware of the dirty unit. The dietician also emailed her reports to the assistant dietary manager. 2. Observations on 2/4/19 at 10:48 A.M. and on 2/4/19 at 2:26 P.M. showed the range hood in the kitchen had a buildup of fuzzy, stringy dark-colored debris on the baffle filters and the fire suppression piping and nozzles. Observation on 2/4/19 at 3:15 P.M. of the kitchen range hood showed the filters were covered with a moderate amount of clear grease and debris. During an interview on 2/4/19 at 2:27 P.M., the dietary manager said maintenance staff was responsible for cleaning the baffle filters monthly. An outside vendor professionally cleaned the range hood a few months ago. During an interview on 2/5/19 at 8:18 A.M., the maintenance supervisor said he cleaned the baffle filters monthly. | |
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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
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 – Some | (continued… from page 9) -If a resident, staff, family and/or responsible party refuses pneumonia vaccine, other than for allergy to vaccination, and/or the resident has previously been vaccinated, further education will be provided and documented. The facility policy did not address following the current CDC guidelines for administering the pneumococcal vaccinations. 2. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Time for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR 13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23): -One dose of PCV13 was recommended for adults [AGE] years or older who had not previously received PCV13; -One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered; -For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history, administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions; -For those age [AGE] years or older who previously received one dose of PPSV23 and no doses of PCV13, administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions. 3. Review of Resident #1’s immunization record showed the following: -The resident received the pneumococcal conjugate vaccine (PCV13) on 12/31/16; -Consent status: historically. (The resident did not receive this vaccine in the facility.) Review of the resident’s face sheet, showed the following: -He/she was admitted to the facility on [DATE]; -The resident was over age 65. Review of the resident’s medical record showed no evidence a current pneumococcal vaccine consent form or educational information was provided to the resident and/or his/her representative. Further review showed no evidence staff offered or administered the PPSV23 vaccine to the resident. During interview on 2/21/19 at 9:56 A.M., the resident’s guardian said the resident was admitted to the facility from a residential care facility. The guardian signed the pneumonia consent and told the facility to give the pneumonia vaccine as long as the record showed it was required at this time. He/she expected the facility to follow the guidelines for administration of the pneumococcal vaccine. During interview on 2/21/19 at 10:50 A.M., the director of nursing (DON) said the facility did not offer the pneumococcal vaccine when the resident was admitted since the resident had the PCV13 vaccine in the hospital in (YEAR). 4. Review of Resident #25’s face sheet, showed the following: -He/she was admitted to the facility on [DATE]; -The resident was over age 65. Review of the resident’s influenza and pneumococcal vaccine consent form, dated 10/12/16, showed the following: -The resident’s guardian gave consent for the resident to receive the pneumococcal vaccination; -The consent form did not provide information related to the PCV13 and PPSV23 |
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: 265646 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER LA BELLE MANOR CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 1002 CENTRAL | |||||||||
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 – Some | (continued… from page 10) vaccinations. Review of the resident’s medical record showed no evidence staff provided educational material regarding the PPSV23 and PCV13 pneumococcal vaccinations to the resident and/or his/her representative. Further review showed no evidence staff administered the pneumococcal vaccine to the resident after the guardian gave consent on 10/12/16. During interview on 2/21/19 at 10:10 A.M., the resident’s guardian said he/she would have consented to administering the pneumonia vaccine to the resident upon admission. He/she expected the facility to follow the guidelines for administering the pneumococcal vaccine. During interview on 2/21/19 at 10:50 A.M., the DON said even though the resident’s pneumococcal vaccination consent form was dated 10/12/16, she didn’t think staff administered the pneumococcal vaccine to the resident. She thought it was probably overlooked. 5. Review of Resident #37’s face sheet, showed the following: -He/she was admitted to the facility on [DATE]; -The resident was over age 65. Review of the resident’s influenza and pneumococcal vaccine consent form, dated 9/24/18, showed the following: -The resident’s responsible party gave consent for the resident to receive the pneumococcal vaccination; -The consent form did not provide information related to the PCV13 and PPSV23 vaccinations. Review of the resident’s medical record showed no evidence staff provided educational material regarding the PPSV23 and PCV13 pneumococcal vaccinations to the resident and/or his/her representative. Further review showed no evidence the resident received the pneumococcal vaccination after his/her responsible party gave consent on 9/24/18. During interview on 2/21/19 at 10:15 A.M., the resident’s responsible party said he/she was not sure if he/she signed a consent for the pneumonia vaccine but would have given consent for the facility to administer the pneumonia vaccine to the resident. He/she was not sure if the resident received the pneumonia vaccine. During interview on 2/21/19 at 10:50 A.M., the DON said staff had not yet administered the pneumococcal vaccine to the resident. 6. During interview on 2/11/19 at 1:48 P.M., the DON said the following: -The facility only administered the PCV13 pneumococcal vaccine to residents at this time; -She had to review all the residents and their pneumococcal vaccination status, and was administering the PCV13 to the residents in alphabetical order. Staff had not yet administered the PCV13 vaccination to all the residents who provided consent; -Staff did not administer the PPSV23 pneumococcal vaccination to any residents, including Resident #1; -She was just learning the CDC guidelines for the pneumococcal vaccines. | |