| 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) television and cracking the screen; -On 5/19/18 at 7:00 P.M., a nurse documented another resident reported after a verbal altercation in the smoking courtyard, Resident #3 propelled his/her wheel chair over to the other resident and struck him/her on the right arm. The nurse reported the incident to the administrator, Director of Nursing (DON), and left a message for the resident’s physician and guardian. The nurse received instructions from the administrator to start 30 minute checks on Resident #3. -On 5/20/18, staff observed the resident coming down the hall, cursing at other residents; -On 6/0718 at 10:06 A.M., a nurse documented the resident had a verbal altercation yelling at another resident. The staff intervened before physical actions were made. The physician gave an order for [REDACTED].>-On 7/11/18 at 4:09 P.M., a nurse documented he/she notified the nurse practitioner that social services had made multiple attempts for an inpatient psychiatric evaluation and was unsuccessful. The physician order [REDACTED].>Record review of the resident’s medical record showed the following information: -On 5/19/18, staff did not document 30 minute checks; -On 5/20/18, from 6:00 A.M. until 3:00 PM, staff documented every 30 minute checks. Staff did not document 30 minute checks from 3:30 P.M. to 6:30 P.M. From 7:00 P.M. until 5:30 A.M. on 5/21/18, staff documented the 30 minute checks were completed. Record review of the social service progress notes dated 5/22/18 at 1:51 P.M., showed the residents’ behaviors were worsening. The resident had been cussing at other residents, calling them inappropriate names and also became physically aggressive with another resident. Record review of the residents’ physician’s monthly progress notes dated 1/15/18 through 7/17/18 showed the physician documented the resident had displayed no new behaviors. Observation on 7/23/18 at 8:57 A.M., showed Resident #3 in bed watching television. The resident’s roommate was in the room. During an interview on 7/25/18 at 10:45 A.M., Resident #3 said he/she has had physical altercations with other residents. He/she got mad at his/her roommate and hit the roommate in the back. He/she also hit another resident in the arm. Staff were aware of both incidences and staff didn’t do anything about it. During an interview on 7/27/18 at 9:43 A.M., CNA C said the following: -All types of abuse should be reported immediately to the charge nurse and to administration; -Resident-to-resident altercations are abuse and need to be reported to the charge nurse and other residents need to be protected; -He/She was aware of Resident #3 hitting another resident but is unsure who the other resident was; -Resident #3 has a history of physical altercations, and it is not the first time Resident #3 hit another resident; -Resident #3 is frequently verbally abusive; -The charge nurse lets staff know what interventions need to be implemented; -When frequent resident checks are done, the staff should document those on a form kept at the nursing station. During an interview on 7/27/19 at 9:55 A.M., LPN D said all abuse should be reported. He/She is not aware of any resident-to-resident altercations involving Resident #3 because he/she does not work on the resident’s hall. He/She is familiar with Resident #3 and the resident does have frequent verbal outbursts directed towards others. During an interview on 7/27/18 at 2:49 P.M., the DON said she can only find one day of 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) 30 minute check sheets related to Resident #3’s 5/19/18 incident. 3. Record review of Resident# 10’s face sheet showed the following information: -admitted [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s significant change MDS dated [DATE] showed staff documented the following: -Moderately impaired cognition; -No behaviors were present in the past seven days; -Received an anti-depressant medication six of the previous seven days. Record review of the resident’s care plan last updated 05/16/18, showed the following information: -Notify the charge nurse when the resident becomes agitated or combative; -Report any change of behavior to the resident’s physician; -Document behaviors every shift. Record review of the physician progress notes [REDACTED]. -On 4/20/18, an Advanced Practice Registered Nurse (APRN) documented he/she saw the resident for an evaluation of recent behaviors of trying to escape through the front door, attempting to assault other residents and staff members; -On 6/4/18, an Adult Gerontology Nurse Practitioner (AGNP) documented the resident had a long history of [MEDICAL CONDITION] (extreme mood swings) manic (emotional highs) behaviors with violent behaviors. The goal was to educate the resident to demonstrate self-control and reduce impulsivity. Record review of the residents’ nurse’s progress notes showed the following: -On 7/10/18 at 4:54 P.M., a nurse documented the resident was readmitted from an in-patient psychiatric hospital for dementia with behaviors: -On 7/21/18, at 8:00 A.M., a nurse documented he/she heard the resident yelling and observed him fall in the hall outside of his/her room door. The resident reported he/she and his/her roommate had a fist fight. The nurse found water all over the resident’s room floor and the room mate in the room. Staff moved Resident #10 to the room next door with a different roommate. Staff notified the administrator, the physician, the nursing supervisor, and the resident’s spouse. Record review of the resident’s behavioral monitoring record dated 7/1/18 to 7/31/18 showed staff did not document the resident’s 7/21/18 behaviors or interventions. During an interview on 7/23/18 at 3:17 P.M., LPN A said on Saturday, 7/21/18, there was an altercation between Resident #10 and Resident #54. Resident #10 was temporarily moved to another room with a new roommate. Resident #10 reported he/she and his/her roommate got in a fist fight. Resident #10 had a recent inpatient stay in a psychiatric hospital because of severe aggressiveness towards other residents and the staff. Resident #10 had a history of [REDACTED]. Resident #10 does wander and probably went back into his/her previous room by mistake. During an interview on 7/24/18 at 2:47 P.M., Resident #10 said he/she and his room mate (Resident #54) had an altercation on Saturday, 7/21/18. He/She did not like the fact the roommate wore a pony tail, that is not the way it is done in the military. The resident people don’t look like that in my army. Him/Her and his/her roommate started yelling and cursing at each other. He/She walked over to the roommate and pushed and struck him on the side of the head. The staff moved him/her to the room next door with another roommate after the incident happened. During an interview on 7/24/18 at 3:03 P.M., Resident #54 said the following: -There was an altercation with his/her room mate (Resident #10) on 7/21/18; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) -He/She and Resident #10 began yelling and cursing at each other; -Resident #10 hit him/her on the side of the head and knocked his/her hat off; -Resident #10 spilled water on the floor during the altercation. -Staff moved his/her roommate (Resident #10) out of his/her room; -Resident #10 came back in the room a few times since then. Observation on 7/25/2018 at 3:41 P.M., showed Resident #10 walking in the hallway asking for assistance to find his/her room. During an interview on 7/27/18 at 8:45 A.M., CNA B said the following: -He/she considers resident-to-resident altercations to be abuse and should be reported immediately; -All observed or suspected abuse should be reported immediately to the charge nurse;-Staff need to intervene and protect the residents; -He/She is aware of the resident-to-resident altercation on Saturday 7/21/18, between Resident #10 and Resident #54; -Resident #10 reported him/her and Resident #54 were yelling and cursing at each other and he/she hit Resident #54; -The resident’s room had water all over the floor and staff had heard the yelling so they knew there was an altercation; -Resident #10 was taken to the room next door with another roommate after the incident; -Resident #10 has had aggressive behaviors before and recently been in a behavior hospital. During an interview on 7/27/18 at 9:55 A.M., LPN D said he/she was the charge nurse on-duty when the altercation between Resident #10 and Resident #54 happened. He/She heard Resident #10 yelling loudly. He/She looked up and saw Resident #10 fall in the hall outside his/her door. Resident #10 reported he/she and the roommate Resident #54 had been in a fist fight. There was water all over the floor and Resident #54 reported the two residents had got into it and Resident #10 hit him and knocked his hat off. Resident #10 was moved to the room next door with another roommate. He/she informed the facility administration and he/she was not informed to do anything more. During an interview on 7/27/18 at 10:29 A.M., the MDS Coordinator said resident’s who have a history of resident-to-resident altercations should have the behavior identified on the residents’ care plan. Staff should update the care plan with the information as soon as staff are aware. During an interview on 7/27/18 at 1:27 P.M., the DON said the following: -The administrator investigates all resident-to-resident altercations; -How the altercations are handled depended on the residents degree of confusion; -The administrator contacts the state and it is the administrators call whether it is called in; -When a resident has an altercation with another resident the violator should be separated to another area and staff try to deescalate the situation; -Staff should stay with the violator and the other residents should be protected; -She was unaware of an altercation involving Resident #10 and Resident # 54; -She would expect staff to notify her of any resident-to-resident altercations; -She does have some remembrance of an altercation involving Resident #3 that took place in May, (YEAR); -Resident #3 has a history of altercations with other residents. The altercations are usually more verbal but Resident #3 has hit other residents before. If the incident was investigated and called in, the administrator would have done the investigation. Staff should have protected the other residents during the investigation. |
| 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) During an interview on 7/27/18 at 3:55 P.M., the administrator said the following: -All allegations of abuse should be called into the state no later than 2 hours from the time of the incident; -He expects staff to report all incidents of abuse to him immediately; -All allegations of abuse should be investigated to include witness statements and interviews to include other residents and the staff; -He is responsible for contacting the state and completing the investigations; -He came to the facility for the resident-to-resident altercations involving Resident #3 on (MONTH) 19. (YEAR), and for the the altercation involving Resident #10 on 7/21/18; -Reported the incident to the state depends on the resident and their cognition, and if the potential abuse was intentional; -He investigated the incidents but did not feel the incidents were abusive so the incidents were not called in; -Resident # 3 has a history of physical altercations with other residents; -He did tell staff to put Resident #3 on 30 minute checks at the time of the incident; -He was aware Resident #10 has a history of aggression and the resident was in a behavioral hospital recently but has been better since returning; -The altercation between Resident #10 and Resident #54 took place after Resident #10 returned for the hospitalization ; -He was aware of Resident #10 being moved into another room with another resident after the altercation; -No other interventions were put in place for either incident; -Residents with potential for abusive behaviors should be identified on the resident’s care plan. | |
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) 2. Record review of Resident #3’s face sheet (a document that gives a resident’s information at a quick glance) showed the following information: -admitted [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 04/03/18, showed the resident exhibited verbal behaviors directed towards others for one to three days (out of the previous seven days). Record review of the resident’s care plan, dated 01/01/18 and last update 4/16/18, showed direction for staff to do the following: -Notify the charge nurse if the resident becomes agitated or combative; -Document behaviors every shift; -Psychological Services will continue to consult with the resident due to his/her emotional and behavioral concerns; -The goal is the resident will verbalize his/her feelings of anger and depression in an appropriate manner rather than getting verbally upset and aggressive. Record review of the resident’s behavior monitoring record showed staff documented the following information: -On 5/19/18, the resident exhibited a behavior of hitting; -The intervention was redirection. Record review of the residents’ progress notes showed the following information: -On 5/19/18 at 2:10 P.M., a nurse documented the resident was sitting in the dining room before lunch, became angry, threw a butter knife bouncing it off the table, hitting the television and cracking the screen; -On 5/19/18 at 7:00 P.M., a nurse documented another resident reported after a verbal altercation in the smoking courtyard, Resident #3 propelled his/her wheel chair over to the other resident and struck him/her on the right arm. The nurse reported the incident to the administrator, Director of Nursing (DON), and left a message for the resident’s physician and guardian. The nurse received instructions from the administrator to start 30 minute checks on Resident #3. -On 5/20/18, staff observed the resident coming down the hall, cursing at other residents; -On 6/0718 at 10:06 A.M., a nurse documented the resident had a verbal altercation yelling at another resident. The staff intervened before physical actions were made. The physician gave an order for [REDACTED].>-On 7/11/18 at 4:09 P.M., a nurse documented he/she notified the nurse practitioner that social services had made multiple attempts for an inpatient psychiatric evaluation and was unsuccessful. The physician order [REDACTED].>Record review of the social service progress notes dated 5/22/18 at 1:51 P.M., showed the residents’ behaviors were worsening. The resident had been cussing at other residents, calling them inappropriate names and also became physically aggressive with another resident. During an interview on 7/25/18 at 10:45 A.M., Resident #3 said he/she has had physical altercations with other residents. He/she got mad at his/her roommate and hit the roommate in the back. He/she also hit another resident in the arm. Staff were aware of both times incidences and staff didn’t do anything about it. During an interview on 7/27/18 at 9:43 A.M., CNA C said the following: -All types of abuse should be reported immediately to the charge nurse and to administration; -Resident-to-resident altercations are abuse and need to be reported to the charge nurse and other residents need to be protected; |
| 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) -He/She was aware of Resident #3 hitting another resident but is unsure who the other resident was; -Resident #3 has a history of physical altercations, and it is not the first time Resident #3 hit another resident; -Resident #3 is frequently verbally abusive; -The charge nurse lets staff know what interventions need to be implemented; During an interview on 7/27/19 at 9:55 A.M., LPN D said all abuse should be reported. He/She is familiar with Resident #3 and the resident does have frequent verbal outbursts directed towards others. Review of the Department of Health and Senior Services (DHSS) record did not show staff notified DHSS of the resident-to-resident abusive incidents. 3. Record review of Resident# 10’s face sheet showed the following information: -admitted [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s significant change MDS dated [DATE] showed staff documented the following: -Moderately impaired cognition; -No behaviors were present in the past seven days. Record review of the resident’s care plan last updated 05/16/18, showed the following information: -Notify the charge nurse when the resident becomes agitated or combative; -Report any change of behavior to the resident’s physician; -Document behaviors every shift. Record review of the physician progress notes [REDACTED]. -On 4/20/18, an Advanced Practice Registered Nurse (APRN) documented he/she saw the resident for an evaluation of recent behaviors of trying to escape through the front door, attempting to assault other residents and staff members; -On 6/4/18, an Adult Gerontology Nurse Practitioner (AGNP) documented the resident had a long history of [MEDICAL CONDITION] (extreme mood swings) manic (emotional highs) behaviors with violent behaviors. Record review of the residents’ nurse’s progress notes showed the following: -On 7/10/18 at 4:54 P.M., a nurse documented the resident was readmitted from an in-patient psychiatric hospital for dementia with behaviors: -On 7/21/18, at 8:00 A.M., a nurse documented he/she heard the resident yelling. The resident reported he/she and his/her roommate had a fist fight. Staff moved Resident #10 to the room next door with a different roommate. Staff notified the administrator, the physician, the nursing supervisor, and the resident’s spouse. During an interview on 7/23/18 at 3:17 P.M., LPN A said on Saturday, 7/21/18, there was an altercation between Resident #10 and Resident #54. Resident #10 was temporarily moved to another room with a new roommate. Resident #10 reported he/she and his/her roommate got in a fist fight. Resident #10 had a recent inpatient stay in a psychiatric hospital because of severe aggressiveness towards other residents and the staff. Resident #10 had a history of [REDACTED]. Resident #10 does wander and probably went back into his/her previous room by mistake. During an interview on 7/24/18 at 2:47 P.M., Resident #10 said he/she and his room mate (Resident #54) had an altercation on Saturday, 7/21/18. He/She and his/her roommate started yelling and cursing at each other. He/She walked over to the roommate and pushed and struck the roommate. The staff moved him/her to the room next door with another roommate after the incident happened. |
| 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) During an interview on 7/24/18 at 3:03 P.M., Resident #54 said the following: -There was an altercation with his/her room mate (Resident #10) on 7/21/18; -Resident #10 and he/she began yelling and cursing at each other; -Resident #10 hit him/her on the side of the head and knocked his/her hat off. During an interview on 7/27/18 at 8:45 A.M., CNA B said the following: -He/she considers resident-to-resident altercations to be abuse and should be reported immediately; -All observed or suspected abuse should be reported immediately to the charge nurse;-Staff need to intervene and protect the residents; -He/She is aware of the resident-to-resident altercation on Saturday 7/21/18, between Resident #10 and Resident #54; -Resident #10 reported him/her and Resident #54 were yelling and cursing at each other and he/she hit Resident #54; -Resident #10 has had aggressive behaviors before and recently been in a behavior hospital. During an interview on 7/27/18 at 9:55 A.M., LPN D said he/she was the charge nurse on-duty when the altercation between Resident #10 and Resident #54 happened. He/She heard Resident #10 yelling loudly. He/She looked up and saw Resident #10 fall in the hall outside his/her door. Resident #10 reported he/she and the roommate Resident #54 had been in a fist fight. Resident #54 reported the two residents had got into it and Resident #10 hit him and knocked his hat off. He/she informed the facility administration and he/she was not informed to do anything more. During an interview on 7/27/18 at 1:27 P.M., the DON said the following: -The administrator investigates all resident-to-resident altercations; -How the altercations are handled depended on the resident’s degree of confusion; -The administrator contacts DHSS and it is the administrators call whether it is called in; -She was unaware of an altercation involving Resident #10 and Resident # 54; -She would expect staff to notify her of any resident-to-resident altercations; -She does have some remembrance of an altercation involving Resident #3 that took place in May, (YEAR); -Resident #3 has a history of altercations with other residents. The altercations are usually more verbal but Resident #3 has hit other residents before. If the incident was investigated and called in, the administrator would have done the investigation. During an interview on 7/27/18 at 3:55 P.M., the administrator said the following: -All allegations of abuse should be called into the state no later than 2 hours from the time of the incident; -He expects staff to report all incidents of abuse to him immediately; -All allegations of abuse should be investigated to include witness statements and interviews to include other residents and the staff; -He is responsible for contacting DHSS and completing the investigations; -He came to the facility for the resident-to-resident altercations involving Resident #3 on (MONTH) 19. (YEAR), and for the the altercation involving Resident #10 on 7/21/18; -Reporting the incident to DHSS depends on the resident and their cognition, and if the potential abuse was intentional; -He investigated the incidents but did not feel the incidents were abusive so the incidents were not called in; -Resident # 3 has a history of physical altercations with other residents; -The altercation between Resident #10 and Resident #54 took place after Resident #10 |
| 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) returned for the hospitalization . | |
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Respond appropriately to all alleged violations. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) Record review of the facility investigation report for an allegation of abuse on 5/19/18 involving Resident #3 showed the following: -An unusual occurrence investigation report with names of two resident witnesses; -Staff noted no abuse on the resident abuse report summary and to monitor and redirect the resident; -A copy of the resident’s physician order [REDACTED]. -A copy of nurse’s notes documenting the abuse incident; -The report did not include witness interviews; -The report did not include staff interviews; -The report did not include the residents’ assessment’s. Record review of the residents’ progress notes dated 5/20/18, showed staff observed the resident coming down the hall, cursing at other residents. Record review of the social service progress notes dated 5/22/18 at 1:51 P.M., showed the residents’ behaviors were worsening. The resident had been cussing at other residents, calling them inappropriate names and also became physically aggressive with another resident. Record review of the residents’ progress notes showed the following information: -On 6/0718 at 10:06 A.M., a nurse documented the resident had a verbal altercation yelling at another resident. The staff intervened before physical actions were made. The physician gave an order for [REDACTED].>-On 7/11/18 at 4:09 P.M., a nurse documented he/she notified the nurse practitioner that social services had made multiple attempts for an inpatient psychiatric evaluation and was unsuccessful. The physician order [REDACTED].>Record review of the residents’ physician’s monthly progress notes dated 1/15/18 through 7/17/18 showed the physician documented the resident had no new behaviors. During an interview on 7/25/18 at 10:45 A.M., Resident #3 said he/she has had physical altercations with other residents. He/she got mad at his/her roommate and hit the roommate in the back. He/she also hit another resident in the arm. Staff were aware of both incidences and staff didn’t do anything about it. During an interview on 7/27/18 at 9:43 A.M., CNA C said the following: -Resident-to-resident altercations are abuse and need to be reported to the charge nurse and other residents need to be protected; -He/She was aware of Resident #3 hitting another resident but is unsure who the other resident was; -Resident #3 has a history of physical altercations, and it is not the first time Resident #3 hit another resident; -Resident #3 is frequently verbally abusive; -The charge nurse lets staff know what interventions need to be implemented. During an interview on 7/27/19 at 9:55 A.M., LPN D said all abuse should be reported. He/She is familiar with Resident #3 and the resident does have frequent verbal outbursts directed towards others. 3. Record review of Resident# 10’s face sheet showed the following information: -admitted [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s significant change MDS dated [DATE] showed staff documented the following: -Moderately impaired cognition; -No behaviors were present in the past seven days; -Received an anti-depressant medication six of the previous seven days. Record review of the resident’s care plan last updated 05/16/18, showed the following |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) information: -Notify the charge nurse when the resident becomes agitated or combative; -Report any change of behavior to the resident’s physician; -Document behaviors every shift. Record review of the resident’s physician progress notes [REDACTED]. -On 4/20/18, an Advanced Practice Registered Nurse (APRN) documented he/she saw the resident for an evaluation of recent behaviors of trying to escape through the front door, attempting to assault other residents and staff members; -On 6/4/18, an Adult Gerontology Nurse Practitioner (AGNP) documented the resident had a long history of [MEDICAL CONDITION] (extreme mood swings) manic (emotional highs) behaviors with violent behaviors. The goal was to educate the resident to demonstrate self-control and reduce impulsivity. Record review of the residents’ nurse’s progress notes showed the following information: -On 7/10/18 at 4:54 P.M., a nurse documents the resident was readmitted from an in-patient psychiatric hospital for skilled dementia with behaviors: -On 7/21/18 a nurse documents at 8:00 A.M., he/she heard the resident yelling and observed him fall in the hall outside of door to room. The resident states he/she and their room mate had a fist fight. The nurse entered the room to find water allover the floor and the room mate in room. Resident #10 was moved to room next door with another room mate. The administrator , physician, nursing supervisor, and spouse were notified. Record review of the resident’s behavioral monitoring record dated July, (YEAR), showed staff did not document behaviors or interventions on 7/21/18. Record review of the facility investigation report for an allegation of abuse on 7/21/18 involving Resident #10 showed the following: -An unusual occurrence investigation report with names of two resident witnesses; -Staff noted no abuse on the resident abuse report summary and to monitor and redirect the resident; -A copy of the resident’s physician order [REDACTED]. -A copy of nurse’s notes documenting the abuse incident; -The report did not include witness interviews; -The report did not include staff interviews; -The report did not include the residents’ assessment’s. During an interview on 7/23/18 at 3:17 P.M., LPN A said on Saturday, 7/21/18, there was an altercation between Resident #10 and Resident #54. Resident #10 was temporarily moved to another room with a new roommate. Resident #10 reported he/she and his/her roommate got in a fist fight. Resident #10 had a recent inpatient stay in a psychiatric hospital because of severe aggressiveness towards other residents and the staff. Resident #10 had a history of [REDACTED]. Resident #10 does wander and probably went back into his/her previous room by mistake. During an interview on 7/24/18 at 2:47 P.M., Resident #10 said he/she and his room mate (Resident #54) had an altercation on Saturday, 7/21/18. He/She did not like the fact the roommate wore a pony tail, that is not the way it is done in the military. The resident people don’t look like that in my army. Him/Her and his/her roommate started yelling and cursing at each other. He/She walked over to the roommate and pushed and struck him on the side of the head. The staff moved him/her to the room next door with another roommate after the incident happened. During an interview on 7/24/18 at 3:03 P.M., Resident #54 said the following: -There was an altercation with his/her room mate (Resident #10) on 7/21/18; -Resident #10 and he/she began yelling and cursing at each other; |
| 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) -Resident #10 hit him/her on the side of the head and knocked his/her hat off; -Resident #10 spilled water on the floor during the altercation. -The staff moved the roommate out of his/her room; -Resident #10 came back in the room a few times since then. During an interview on 7/27/18 at 8:45 A.M., CNA B said the following: -He/She considers resident-to-resident altercations to be abuse and should be reported immediately; -Staff need to intervene and protect the residents; -He/She is aware of the resident-to-resident altercation on Saturday 7/21/18, between Resident #10 and Resident #54; -Resident #10 reported him/her and Resident #54 were yelling and cursing at each other and he/she hit Resident #54; -Resident #10 was taken to the room next door with another roommate after the incident; -Resident #10 has had aggressive behaviors before and recently been in a behavior hospital. During an interview on 7/27/18 at 9:55 A.M., LPN D said he/she was the charge nurse on-duty when the altercation between Resident #10 and Resident #54 happened. He/She heard Resident #10 yelling loudly. Resident #10 reported he/she and the roommate Resident #54 had been in a fist fight. Resident #54 reported the two residents had got into it and Resident #10 hit him and knocked his hat off. Resident #10 was moved to the room next door with another roommate. He/She informed the facility administration and he/she was not informed to do anything more. During an interview on 7/27/18 at 1:27 P.M., the DON said the following: -The administrator investigates all resident-to-resident altercations; -How the altercations are handled depended on the residents degree of confusion; -When a resident has an altercation with another resident the violator should be separated to another area and staff try to deescalate the situation; -Staff should stay with the violator and the other residents should be protected; -She was unaware of an altercation involving Resident #10 and Resident # 54; -She would expect staff to notify her of any resident-to-resident altercations; -She does have some remembrance of an altercation involving Resident #3 that took place in May, (YEAR); -Resident #3 has a history of altercations with other residents. The altercations are usually more verbal but Resident #3 has hit other residents before. If the incident was investigated and called in, the administrator would have done the investigation. Staff should have protected the other residents during the investigation. During an interview on 7/27/18 at 3:55 P.M., the administrator said the following: -All allegations of abuse should be investigated to include witness statements and interviews to include other residents and the staff; -He is responsible for contacting the state and completing the investigations; -He came to the facility for the resident-to-resident altercations involving Resident #3 on (MONTH) 19. (YEAR), and for the the altercation involving Resident #10 on 7/21/18; -He investigated the incidents but did not feel the incidents were abusive; -Resident #3 has a history of physical altercations with other residents; -He did tell staff to put Resident #3 on 30 minute checks at the time of the incident; -He was aware Resident #10 has a history of aggression and the resident was in a behavioral hospital recently but has been better since returning; -The altercation between Resident #10 and Resident #54 took place after Resident #10 returned for the hospitalization ; |
| 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 12) -He was aware of Resident #10 being moved into another room with another resident after the altercation; -No other interventions were put in place for either incident. | |
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide enough food/fluids to maintain a resident’s health. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) -Current weight 140 pounds, previous weight 148 pounds; -Resumed fortified foods and ice cream with lunch and supper on readmit 7/10/18 from psychiatric stay; -Weekly weights in place. Record review of the resident’s weight record showed the following information: -Staff did not record weights 7/10/18 to 7/22/18; -Weight 137 pounds on 7/23/18. Observations at the following time and dates showed the following information: -On 7/24/18 at 8:32 A.M., the resident in bed with his/her eyes closed. The resident’s room was dark. A breakfast tray was untouched on the bedside table. The resident was thin with loose fitting clothing; -On 7/26/18 at 8:28 A.M., resident in bed with eyes closed. A breakfast tray was on bedside table. The plate cover was covering plate and bowls were covered with foil wrap; -On 7/26/18 at 12:12 P.M., resident in bed, covered up with blanket and eyes closed. The residents’ lunch tray sat on bedside table with cover in place over the meal. No light was on in the room and the shades were pulled down on the window; -On 7/27/18 at 8:20 A.M., resident in bed with eyes closed. A breakfast tray sat on the bedside table still covered and untouched. The room was dark and no staff was in room. During an interview on 7/27/18 at 8:45 A.M., Certified Nurse Aide (CNA) B said the nurses let the staff know who is at risk for nutrition and weight loss and what interventions are needed. He/she said the resident usually eats in his/her room and has not been eating well. Staff need to wake him/her up frequently to get him/her to eat. He/she is not aware if the residents is receiving any supplements. During an interview on 7/27/18, at 9:55 A.M., Licensed Practical Nurse (LPN) D said the resident required a lot of assistance with activities of daily living (dressing, grooming, bathing, eating, and toileting). He/She said the resident sleeps a lot and staff need to encourage him/her with meals. He/she said the resident is not eating much. He/she is not aware if the resident receives any supplements related to poor nutrition. He/She said staff should cue, encourage, and offer an alternate if the resident is not eating. During an interview on 7/27/18, at 10:29 A.M., the MDS Coordinator said all residents at risk for weight loss should have interventions and assistance needed documented on the care plan. She said she reviews the weekly weight meeting notes and adds any interventions identified to the care plan. She said she does not review each week, but reviews when the resident’s comprehensive assessment is due. During an interview on 7/27/18, at 10:37 A.M., the Dietary Manger (DM) said all residents at risk for nutrition are discussed in a weekly weight meeting with the DON and the DM. She said they decide at the meeting the approaches to be started for the resident. She said the resident has had a significant weight loss. She has not observed the resident eat as he most always eats in his/her room. She said the care plan should address the amount of assistance needed for the resident. She said fortified foods and ice cream would not be appropriate interventions if the resident is not eating. She said the resident should be reassessed. During an interview on 7/27/18, at 1:27 P.M., the DON said if a resident is not eating she would expect the staff to encourage and assist the resident. She said she would expect staff to monitor the residents during meal times that eat in their room. She said she would expect the charge nurse to follow up visually to assure residents are being assisted as needed. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide safe and appropriate respiratory care for a resident when needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) During an observation on 7/26/18, at 8:51 A.M., showed resident’s oxygen concentrator set at 2 liter per minute and nasal cannula in place. During an interview on 7/26/18, at 11:59 A.M., Certified Medication Technician (CMT) N said the facility usually has a physician order [REDACTED]. The physician determines the amount of oxygen and a nurse sets that amount on the oxygen concentrator. Nurses are responsible for cleaning filters and tubing is changed by nurses weekly. During an interview on 7/26/18, at 12:05 P.M., Licensed Practical Nurse (LPN) O said nurses are responsible for setting the oxygen flow and nurses change the oxygen concentrator tubing weekly. A physician orders [REDACTED]. A physician order [REDACTED]. If oxygen is ordered during a hospital stay, it should be on the transfer orders. During an interview on 7/27/18, at 11:10 A.M., the Director of Nurses (DON) said the charge nurses monitor the oxygen equipment by cleaning and changing tubing once per week. The physician order [REDACTED]. A physician order [REDACTED]. The resident did not have an order for [REDACTED]. During an interview on 7/27/18, at 1:46 P.M., the administrator said he would expect a physician order [REDACTED]. Administrator said staff told him that somehow that was missed for the resident. | |
| F 0732 Level of harm – Potential for minimal harm Residents Affected – Many | Post nurse staffing information every day. Based on observation and interview, the facility failed to post the required nurse |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0732 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 16) and visitors. | |
| 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. **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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 17) Observations on [DATE], at 11:20 A.M., of walk-in freezer showed two unsealed pans of lasagna. During an interview on [DATE], at 4:00 P.M., the Housekeeping Supervisor said housekeeping staff cleans the refrigerators in the assisted dining areas and Special Care Unit. Nursing and dietary staff date leftover food and monitors for expired food. Dietary staff marks foods, such as covered puddings and applesauce, with the date it was prepared. Nursing staff label food brought in for residents. During an interviews on [DATE], at 11:20 A.M., and [DATE], at 1:27 P.M., the Dietary Manager (DM) said dietary staff checks all refrigerators daily, or two to three times per week, for out of date food. Nursing staff dates and seals food in assisted dining rooms and Special Care Unit. Leftover food is dated when stored and thrown out within three days. She expects all food stored in sealed containers or packaging. Lunch meat and cheese should be dated with date the package is opened. Lunch meat stored should be thrown out within 6 days of opening. Observations on [DATE], at 11:00 A.M., of the B-Wing assisted dining room refrigerator showed 12 covered, undated, cups of fruit cocktail. During an interview on [DATE] at 11:20 A.M., Director of Nursing, (DON) said nursing staff is responsible for dating food stored in the assisted dining room refrigerators and Special Care Unit. She would expect them to date and seal any food stored in the refrigerators. Dietary staff checks for food that is expired. During an interview on [DATE], at 1:46 P.M., the administrator said he expects that all food, not eaten at a meal, would be dated and stored properly. 2. Record review of the facility’s policy titled Refrigerator and Freezer Temperatures, dated (MONTH) 2011, showed the following: -Temperature of refrigerators should be 33 to 40 degrees F; -There should be a thermometer in all refrigerator and freezers. Thermometers should be located in the front of the unit; -Temperatures should be checked regularly in all refrigerators, at least every morning and every night; -Refrigerator and freezer temperatures will be logged twice daily. Record review of the (MONTH) Daily Refrigerator Temperature Log for the kitchen walk-in cooler showed staff did not document temperatures for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review of the (MONTH) Daily Refrigerator Temperature Log for C-Wing refrigerator/freezer showed staff did not document temperatures for the refrigerator section on [DATE], [DATE], [DATE], and [DATE], and did not document temperatures for the freezer section. Record review of the (MONTH) Daily Refrigerator Temperature Log for B-Wing refrigerator/freezer showed staff did not document temperatures for refrigerator section on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], and did not document temperatures for the freezer section. Record review of the (MONTH) Daily Refrigerator Temperature Log for Special Care Unit showed staff did not document temperatures for [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE], and [DATE]. Observations on [DATE], at 12:00 P.M., of the C-Wing assisted dining room refrigerator/freezer showed no thermometer in the freezer section. Observation on [DATE], at 3:15 P.M., of the B-Wing assisted dining room refrigerator/freezer showed no internal thermometer in the refrigerator or freezer sections. |
| 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 18) During an interview on [DATE], at 3:40 P.M., CNA J said dietary staff logs the temperatures of refrigerator/freezers. During an interview on [DATE], at 8:39 A.M., CNA K said nursing staff monitors refrigerator temperatures. Observation on [DATE], at 11:20 A.M., of the walk-in freezer showed no internal thermometer. During an interview on [DATE], at 4:00 P.M., the Housekeeping Supervisor said he/she receives the temperature logs. There has not been an issue with freezer temperatures so there has not been thermometers placed in the freezer sections. She expects staff to log temperatures using internal thermometers. During an interviews on [DATE], at 11:20 A.M. and [DATE] at 1:27 P.M., the Dietary Manager (DM) said staff use internal thermometers to log refrigerator and freezer temperatures. The DM receives kitchen temperature logs. The housekeeping supervisor receives temperature logs for refrigerators in assisted dining rooms and the Special Care Unit. Temperatures should be checked daily for refrigerators and freezers. She expects a thermometer in each kitchen refrigerator and freezer and expects temperatures logged twice a day. During an interview on [DATE], at 1:46 P.M., the administrator said every refrigerator and freezer should have a thermometer and temperatures logged daily. 3. Record review of the facility’s policy titled Dishwashing, dated (MONTH) 2011, showed the following: -Allow items to thoroughly dry before unloading racks or storing items. Observations on [DATE], at 11:55 A.M., of the C-Wing assisted dining room showed staff served beverages to residents from wet glasses and from coffee cups on a tray with standing water. Observations on [DATE], at 11:10 A.M., of the main dining room, by the coffee and beverage dispenser, showed wet glasses and coffee cups. Observation of a hall cart in the kitchen serving area on [DATE], at 11:35 A.M., showed water standing on tray of coffee cups turned upside down on tray. During an interview on [DATE], at 11:35 A.M., Dietary Aide (DA) M said dishes are dried in the dishwashing area before using them for food or beverages. During an interviews on [DATE], at 11:20 A.M., and [DATE], at 1:27 P.M., the Dietary Manager (DM) said dishes are dried on shelves next to dishwasher until dry. Beverages and food should not be served on wet dishes. During an interview on [DATE], at 1:46 P.M., the administrator said he expected dishes to be dry before residents are served from them. | |
| F 0919 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Make sure that a working call system is available in each resident’s bathroom and bathing area. Based on observation and interview, the facility failed to provide a switch in all toilet |
| 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: 265123 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEBANON NORTH NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 596 MORTON ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0919 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) -The toilet room located near the A wing nurses’ desk remained without a call light activation switch. During an interview on 7/24/18, at 4:30 P.M., the administrator said they had added some call light switches to toilet rooms, but missed those three rooms. | |
