| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0567 Level of harm – Potential for minimal harm Residents Affected – Many | Honor the resident’s right to manage his or her financial affairs. Based on interview and record review, the facility failed to ensure each resident was |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0567 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 1) His/her sister managed most of his/her money. He/she did not know how to get cash from the trust fund. He/she had not asked the BOM for any cash yet. 5. Review of the facility Trust Fund Statement Register dated (MONTH) 2109 showed the following residents with fund balances: -Resident #15: $50.48; -Resident #3: $1.00; -Resident #9: $261.40; -Resident #23: $30.09; -Resident #8: $665.75; -Resident #17: $547.48; -Resident #6: $40.00. 6. During interview Resident #15 said it was hard to get cash from his/her account for anything. It usually took five days to obtain cash from the account. He/she felt like he/she was begging for his/her own money. During interview on 1/17/19 at 11:30 A.M. the BOM said he/she told the administrator in writing when a resident asked for cash from their Trust Fund Account. The administrator was the only person who could withdraw funds from the resident Trust Fund Account. The administrator went to the bank, obtained the cash, returned to the facility and gave him/her the cash and the receipt. He/she then gave the cash to the resident and the resident signed a receipt for the cash. The process was usually completed the same day or within 24 hours. If the resident requested funds on the weekends or holidays, no funds were available. If the administrator was away from the facility, no funds were available. The facility did not keep petty cash at the facility. During interview on 1/18/19 at 6:10 P.M. the administrator said the following: -Staff should obtain signed permission forms from residents or their legal representatives before depositing resident funds in the trust fund account; -The BOM requested a resident’s funds from the trust fund and she obtained the requested cash from the bank. She went to the bank as soon as she was aware of the resident’s request for funds within the same day unless she was unavailable; -She was the only person on the account and only person allowed to withdrawal funds from the trust fund account at the bank. The facility did not keep petty cash on hand; -She obtained the requested cash at the bank, gave the cash to the BOM who dispersed the funds to the resident. | |
| F 0568 Level of harm – Potential for minimal harm Residents Affected – Many | Properly hold, secure, and manage each resident’s personal money which is deposited with the nursing home. Based on interview and record review, the facility failed to maintain a system to ensure |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0568 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 2) according to generally accepted accounting principles, for each resident’s funds entrusted to the facility on the resident’s behalf. The systems precludes and commingling of resident funds with facility funds unless instruction has been obtained and authorized by the resident/responsible party. Policy Interpretation and Implementation 1. The individual financial records are available through quarterly statements and upon request by the resident/responsible party; 5 c. All written accounts of resident funds shall be reconciled monthly and written statements showing the current balance and all transactions, shall be given to the resident, hi/her designee, guardian, and/or conservator on a quarterly basis and upon request by the resident/responsible party. 2. Review of the facility’s monthly receipts folders labeled (MONTH) (YEAR) through (MONTH) (YEAR) provided by the Business Office Manager (BOM) showed an unsealed bank envelope contained $2.07 in the (MONTH) (YEAR) receipts folder. A receipt for the purchase of cigarettes with cash returned in the amount of $2.07 was in the envelope. Resident #8’s name was written on the outside of the bank envelope. During interview on 1/17/19 at 11:30 A.M. the Business Office Manager said the following: -He/she could not find resident receipts folders for (MONTH) and (MONTH) (YEAR); -He/she thought the $2.07 in the (MONTH) (YEAR) resident receipt folder belonged to Resident #8 and was the change from purchase of cigarettes for the resident. Resident #8 had funds in the resident trust fund and the $2.07 should have gone to the resident or deposited in the trust fund account. The $2.07 should not be in a bank envelope in the BOM files; -He/she started working as the facility BOM in (MONTH) (YEAR); -In (MONTH) (YEAR) he/she found three lock boxes and bank deposit bags containing cash and change in the BOM’s office some of which had notes attached and some were loose in the bags and lock boxes. The cash and change was petty cash; -The cash and change was counted and totaled $287.21; -$238.00 was deposited in the operating account as money received from families and visitors for meals purchased at the facility and for stamps purchased from the facility; -$49.21 was deposited in the operating account as money received from residents for purchases made by the facility for residents. He/she was unsure what the purchases were and did not have a receipt for those purchases; -The facility had petty cash from (MONTH) (YEAR) through (MONTH) (YEAR). No accounting of the petty cash was documented or reconciled; -In (MONTH) (YEAR), the facility no longer had petty cash. Review of the facility’s monthly bank statements and resident trust fund records for (MONTH) (YEAR) through (MONTH) (YEAR) showed from (MONTH) (YEAR) through (MONTH) (YEAR) no reconciliation of petty cash or the amount of petty cash kept at the facility. During interview on 1/18/19 at 8:50 A.M. Resident #15 said he/she did not know the balance of his/her trust fund account. The facility did not send out quarterly statements. During interview on 1/18/19 at 9:15 A.M. Resident #10 said the facility did not send him/her a trust fund account statement. He/she asked the BOM for the current amount in his/her account. The BOM manager wrote the account balance on a piece of paper for him/her. During interview on 01/17/19 at 4:35 P.M. the Business Office Manager said no petty cash reconciliation was found from (MONTH) (YEAR) through (MONTH) (YEAR). The facility did not send out quarterly statements to residents or resident representatives with funds in the facility trust fund. |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0568 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 3) During interview on 1/18/19 at 6:10 P.M. the administrator said the BOM should send out quarterly statements to all residents or resident representatives with funds in the facility trust fund account. A resident’s cash funds should not be in a bank envelope in the BOM office since (MONTH) (YEAR). Any change from a purchase should be returned to the resident or deposited in the resident’s trust fund account. The facility no longer kept petty cash. Previous petty cash should be reconciled on the facility monthly reconciliation form. | |
| 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. Based on observation and interview the facility failed to provide a clean and comfortable |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) paper holder was broken and the toilet paper roll was propped up on the grab bar next to the toilet. A clear plastic bag of feces soiled clothing lay on top of the dirty linen cart parked next to the sink area and visible from the door. 3. Observation of the Presley Hall common bathroom/shower room showed the following: -On 1/17/19 at 6:55 A.M. two sink areas, one on each side of a floor to ceiling cabinet. One sink area counter was stacked with two large boxes labeled with a resident’s name and contained incontinence briefs. Under the same sink on the floor were two additional boxes of incontinence briefs labeled with the same resident’s name. A stack of wheelchair cushions and other medical equipment sat on the floor under the same sink; -On 1/18/19 at 8:55 A.M. two sink areas, one on each side of a floor to ceiling cabinet. One sink area counter was stacked with two large boxes labeled with a resident’s name and contained incontinence briefs. Under the same sink on the floor were two additional boxes of incontinence briefs labeled with the same resident’s name. A stack of wheelchair cushions and other medical equipment sat on the floor under the same sink. A mechanical lift (used for resident care and transfers), was parked in front of the sink area and was soiled with brown dirt and grime across the lifting bar (area where the resident’s lift pad was attached to the mechanical lift), and across the base metal support legs. 4. Observation of the Twitty Hall common bathroom/shower room showed the following: -On 1/17/19 at 8:00 A.M. dirt and debris around the baseboard corner near the sink area. Shower stall base board edges were soiled with dirt and debris, a black substance was present on the bottom edge of the wall under the faucet area, a broken sliver of bar soap was present in the shower stall drain with hair and debris and a soiled wound dressing lay in the corner of the shower stall on the floor next to a gallon container of shower soap. The shower chair seat contained a dark brown substance on the inside edge. The window contained a window blind with two broken slats. The facility front entry way and resident smoking area were visible through the broken window blind slats; -On 1/18/19 at 8:35 A.M. dirt and debris around the baseboard corner near the sink area. Shower stall base board edges soiled with dirt and debris, a black substance was present on the bottom edge of the wall under the faucet area, the same broken sliver of bar soap was present in the shower stall drain with hair and debris, the same soiled wound dressing lay in the corner of the shower stall on the floor with a pile of dirt, hair and debris next to a squeegee mop propped against the wall. The gallon container of shower soap sat on the floor near a shower chair placed in the center of the shower stall covered with a towel. The window contained a window blind with two broken slats. The facility front entry way and residents smoking area were visible through the broken window blind slats. The tub area and central walking area contained one large upright shower chair, two wheelchairs, two bedside commodes and a wide shower chair. 5. During interview on 1/18/19 at 9:00 A.M. the Maintenance/Housekeeping Director said the following: – The housekeeping staff should clean the common bathroom/shower rooms daily; -The Twitty Hall bathroom/shower room was not homelike and not clean. The baseboards were rusty and soiled, the shower stall should not contain dirt, debris, or soiled wound dressings on the floor. There was too much equipment stored in the Twitty Hall bathroom/shower room. The blinds were broken and needed replaced to provide privacy; -The Cash Hall bathroom/shower room bathtub contained dried dirty mop water where a staff member emptied a mop bucket. Staff needed to clean the bathtub. The baseboards were soiled with rust and needed cleaned. The window blinds were broken and needed replaced to provide privacy; -The Presley Hall was recently remodeled and meant for one resident at a time. No privacy |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) curtains were provided for the jetted tub area. Staff stored a resident’s boxes of incontinence briefs on the sink counter and under the sink on the floor. He/she did not know where else to store the resident’s supplies. The medical equipment stacked under the sink blocked the use of the sink. There was another sink for resident use. The mechanical lift was soiled and dirty. Staff needed to clean the lift. During interview on 1/18/19 at 6:10 P.M. the administrator said housekeeping staff should clean all three common bathroom/shower rooms daily. The facility should not have dirty bathrooms, shower rooms, bathtubs and shower stalls. The shower stalls should not contain soiled wound dressings. The shower rooms should not have broken blinds. Staff should not store medical equipment in the common bathrooms/shower rooms and staff should not store a resident’s boxes of incontinence briefs in the bathroom/shower room. She expected staff to keep the common bathroom/shower rooms clean as well as the rest of the facility. | |
| F 0606 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Based on interview and record review, the facility failed to screen three new employees, |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0606 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | ||
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 – Few | (continued… from page 7) eating, Resident #21’s call light came on and CNA I answered the call light. CNA I came back to the area where CNA J was eating in five to ten minutes and said don’t be surprised if Resident #21 said I threw him/her into bed; -CNA J came back to work at 6:00 A.M. on 1/10/19; -The night shift staff said something happened with Resident #21. CNA K from night shift told the day shift during rounds Resident #21 said a staff member slapped him/her; -The night shift and day shift staff were talking about the incident during rounds at the change of shift. The night shift charge nurse, LPN L, was aware of the incident. The day shift nurse, LPN M, heard about the incident from LPN L during change of shift; -CNA J should have told the charge nurse the previous evening about the situation with Resident #21 and CNA I. It was his/her responsibility to report potential abusive situations immediately. During interview on 1/16/19 at 12:20 P.M. LPN M said the following: -He/she worked the day shift from 6:00 A.M. to 2:00 P.M. on 1/10/19; -He/she went to assess the resident at approximately 7:00 A.M. The resident said when he/she went to bed last night a staff member was rough with him/her. The resident said he/she called the staff member a [***] and slapped the staff member. The staff member slapped him/her back and held the right side of his/her right face; -The night shift nurse, LPN L, mentioned it to LPN M during report. LPN L said the resident told him/her about it while passing the resident’s 5:30 A.M. medications; -LPN M did not know if LPN L reported the allegation to anyone else. LPN L should have called the DON. During interview on 1/17/19 at 5:50 A.M. LPN L said the following: -He/she was the night shift charge nurse on 1/9/19; -CNA staff told LPN L on 1/10/19 at about 6:30 A.M. or 6:45 A.M. Resident #21 said a staff member slapped him/her the evening before while getting ready for bed. During interview on 1/18/19 at 7:00 P.M. the Director of Nursing said the following -He/she was unaware the night shift staff knew of Resident # 21’s allegations a staff member slapped him/her; -The night shift staff should have reported the allegation to the DON immediately and an investigation should have started immediately; -Staff should have reported the allegation of abuse to the state agency within two hours; -The facility did not report the allegation of abuse within two hours of knowing about the allegation. | |
| F 0625 Level of harm – Potential for minimal harm Residents Affected – Many | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0625 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 8) -When a resident is scheduled for a transfer or discharge, the business office and/or Social Services will notify Nursing Service of the transfer or discharge so that appropriate procedures can be implemented. 2. Review of the facility’s Admission Agreement revised 2019 showed the following under Bed Reservation section: -All residents were notified upon admission of the Bed Hold Policy. Please review the explanation and initial your request to identify how you would like your bed managed while you are out of the facility on temporary/therapeutic leave or at the hospital; -Three sections followed one each for Private Pay, Medicare and Medicaid payment source; -The resident or responsible party was asked to choose if they requested the facility to hold the resident’s bed or not while the resident was out of the facility on temporary/therapeutic leave or at the hospital; -If the resident or representative requested the resident’s bed not be reserved the resident or representative could still request the bed be reserved but must do so in writing within 24 hours of the resident’s departure from the facility. 3. Review of Resident #24’s Face Sheet showed admitted [DATE]. Review of the resident’s Nurses Notes showed the following: -On 12/19/18 transferred to the hospital; -On 12/20/18 readmitted to the facility. Record review showed no documentation the resident was informed in writing of the facility’s bed hold policy at the time of transfer on 12/19/18. 4. Review of Resident #30’s Face Sheet showed the following: -admitted [DATE]; -discharge date [DATE] with return anticipated. Review of the resident’s closed record showed on 12/12/18 the resident was taken to a physician appointment and admitted to the hospital. Record review showed no documentation the resident was informed in writing of the facility’s bed hold policy at the time of transfer on 12/12/18 with return anticipated. 5. During interview on 1/15/19 at 3:20 P.M. the Social Services Designee said the following: -He/she reviewed the facility bed hold policy with residents and responsible parties at the time of admission; -He/she had not provided written bed hold policy information to residents or responsible parties when the resident was transferred out of the facility; -He/she needed to start sending out the bed hold policy letters at the time of a resident’s transfer. He/she had the letters but had not sent any out yet. During interview on 1/18/19 at 6:10 P.M. the administrator said staff should notify residents and responsible parties in writing at the time of admission and again when transferred out of the facility of the facility’s bed hold policy. | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) medications were not crushed during medication administration for one additional resident (Resident #6). The facility census was 31. 1. Review of the facility policy Crushing Medications, dated 2001 and last revised 4/07 showed the following: Policy Statement: Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders; 1.) The nursing staff and/or Consultant Pharmacist shall notify any practitioner who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or [MEDICATION NAME] coated medications); The practitioner or Consultant Pharmacist must identify an alternative or the practitioner must document (or provide the nurses with a clinically pertinent reason to document) why crushing the medication will not adversely affect the resident. 2. Review of the facility policy Instillation of Eye Drops, dated 2001 and last revised 1/14 showed the following:Purpose: The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes; Preparation: Review the resident’s care plan to assess for any special needs of the resident; Assemble the equipment and supplies as needed; Steps in the procedure: Place the equipment on the bedside stand or over-bed table. Arrange the supplies so they can be easily reached; Wash and dry our hands thoroughly; Put on gloves; If the resident is sitting up, tilt his/her head backward slightly; If the resident is bedfast, position the resident’s head on the pillow and tilt the head backward slightly; Draw medication into the dropper; Gently pull the lower eyelid down and instruct the resident to look up; Drop the medication into the mid lower eyelid (fornix). (Note: Do not touch the eye or eyelid with the dropper.) Recap the medication bottle; instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops. Instruct the resident not to blink or squeeze the eyelids shut, which forces the medication out. 3. Review of [MEDICATION NAME] ocular lubricant (used to relieve burning, irritation and discomfort from dry eyes) manufacturer’s guidelines showed the following: To apply the eye drops: Tilt head, create pocket by pulling the lower eyelid down, instill the eye drop, close your eyes for two or three minutes with your head tipped down, without blinking or squinting. Gently press your finger to the inside corner of the eye for about one minute to keep the liquid from draining into the tear duct. 4. Review of www.drugs.com showed the following: -[MEDICATION NAME]-[MEDICATION NAME] (used to treat [MEDICAL CONDITION]) (disorder of the central nervous system that affects movement, often including tremors) extended release (ER): Do not crush, chew, break, or open a [MEDICATION NAME] and [MEDICATION NAME] capsule. Swallow it whole. The tablet is sometimes broken in half to give the correct dose. Always swallow a whole or half tablet without chewing or crushing; -Potassium chloride (CL) ER (supplement): do not crush, chew, break, or suck on an extended-release tablet or capsule. Swallow the pill whole. Breaking or crushing the pill may cause too much of the drug to be released at one time. 5. Review of Resident #6’s Physician Order Sheet (POS) dated 1/19, showed the following: -[DIAGNOSES REDACTED]. -May crush medications unless contraindicated; -Potassium Cl ER 20 Meq (milliequivalants) PO (by mouth) three times daily (1/31/18); -[MEDICATION NAME]-[MEDICATION NAME] ER ,[DATE] milligrams one PO three times daily; -Pureed diet with nectar thickened liquids. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) Observation on 1/15/19 at 12:35 A.M. showed the following:-The resident sat in his/her wheelchair in the dining room; -Licensed Practical Nurse (LPN) M retrieved and dispensed the resident’s medications, crushed the Potassium CL ER and the [MEDICATION NAME]-[MEDICATION NAME] ER, placed them in applesauce and administered the crushed medications to the resident. 6. Review of Resident # 11’s POS, dated 1/19 showed the following:-[DIAGNOSES REDACTED]. -[MEDICATION NAME] 0.3-0.4% eye drops-one drop both eyes three times daily. Observation on 1/15/19 at 12:35 P.M., showed LPN M administered the resident’s eye drops as the resident sat upright in his/her wheelchair. LPN M administered one drop of [MEDICATION NAME] eye drops into each of the resident’s eyes. Staff handed the resident a Kleenex but did not hold pressure to the lacrimal duct after administration and did not instruct the resident to do so. During interview on 1/30/19 at 10:20 A.M. LPN M said the following: -Medications that should not be crushed are potassium and extended release medications; -Pressure should be applied to the lacrimal duct after instillation of [MEDICATION NAME] eye drops. During interview on 1/18/19 at 5:50 P.M. the Director Of Nursing said the following: -He/she would not expect [MEDICATION NAME]-[MEDICATION NAME] ER or potassium to be crushed; -He/she would expect staff to administer eye drops according to the manufacturer’s guidelines, holding pressure to the lacrimal duct if instructed to do so. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) resident’s mouth; Thoroughly wipe the roof of the resident’s mouth, inside the cheeks, the tongue, and the teeth with the applicator; Place all used applicators into the emesis basin; Rinse the resident’s mouth by using clear (fresh) water on the applicators; Dry the resident’s face and chin area, Remove the towel; Moisten the inside of the resident’s mouth, tongue and lips. Use a prepared swab or a water soluble lubricant; Remove gloves and discard into designated container. Wash your hands; Clean your equipment and return to designated storage area; Discard disposable equipment and supplies in designated containers; Discard towels in soiled laundry hamper; Reposition the bed covers and make the resident comfortable; Place call light within easy reach of the resident; Wash and dry your hands thoroughly. 2. Review of the Nurse Assistant in a Long Term Care Facility manual, Revision (MONTH) 2001, showed the following: -Purposes of oral hygiene (mouth care): A clean mouth and properly functioning teeth are essential for physical and mental well-being of the resident, prevent infections in mouth, remove food particles and plaque, stimulate circulation of gums, eliminate bad taste in mouth, thus food is more appetizing; -Give oral care before breakfast, after meals, and also at bedtime; -Specific observations to make: tooth decay, any loose or broken teeth, red or swollen gums, sores or white patches in the mouth or on the tongue, changes in eating habits, and poorly fitting dentures; -A clean mouth is very important to the physical and mental well-being of the resident. Oral care can prevent infections, the buildup of plaque, and bad breath. It can even influence the resident’s appetite. Remember to observe the resident during oral care to identify potential problems. 3. Review of Resident #19’s significant change Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 12/10/18 showed the following: -[DIAGNOSES REDACTED]. -Short and long term memory problem; -Required total assistance of one staff member with eating and personal hygiene. Review of the resident’s care plan dated 12/11/2018 showed the resident had his/her own teeth and required assistance with brushing teeth. Staff should assist the resident with brushing his/her teeth after meals, monitor for completeness and assist as needed. Staff should monitor for any signs of discomfort, sores or irritation in and around mouth and report to charge nurse. Observation on 1/17/19 at 6:55 A.M. showed the following: -Certified Nurse Assistant (CNA) D and CNA E provided the resident incontinence care, dressed the resident in a clean incontinence brief, pants and shirt and transferred the resident from the bed to a wheelchair; -The resident’s lips were dry and peeling; -His/her mouth was dry, tongue coated with white substance and teeth with white debris; -CNA E brushed the resident’s hair and took the resident to the dining room for breakfast; -CNA D and CNA E did not provide oral care. |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) peeling lips. His/her teeth with debris and food particles. During interview on 1/17/19 at 11:55 A.M. the resident’s family member said the following: -He/she visited the resident almost every day and came to the facility early in the mornings. He/she assisted the resident with almost every meal; -The resident drank a lot of fluids at meal times to assist with swallowing foods; -Staff did not brush the resident’s teeth very often; -Staff did not brush the resident’s teeth this morning or following breakfast. Observation on 1/17/19 at 11:55 A.M. showed the resident’s teeth with debris and a white coating. 4. Review Resident #4’s care plan dated 8/7/18, showed the following: -Problem: Blind and needs guidance with cares; Goal: Resident will be able to navigate and assist with Activities of Daily Living (ADLs) at his/her optimal ability with the help of staff; Approaches: Provide assistance with ADLs; -Problem: Edentulous; Goal: Oral care daily; Approaches: Assist resident with maintaining good oral hygiene care, hand him/her his/her toothbrush and have him/her brush his/her teeth at the wheelchair level in front of the sink. Review of the resident’s quarterly MDS, dated [DATE] showed the following: -Severely impaired vision: no vision or sees only light, colors or shapes, eyes do not appear to follow objects; -Extensive assist of one for personal hygiene: -No impairment of upper extremities. Review of the resident’s POS dated 1/19 showed the following: -[DIAGNOSES REDACTED]. -Fluid restriction of 2000 milliliters/24 hours. Observation on 1/17/19 at 7:32 A.M., showed the following: -The resident lay on the bed; -CNA D and CNA E entered the room, checked the resident for incontinence, dressed the resident and transferred him/her to the wheelchair; -Staff assisted the resident to the dining room; -Staff did not offer oral care to the resident. During interview on 1/24/19 at 11:09 A.M., CNA D said that oral care should be offered when residents rise in the morning, after meals and before bed. During interview on 1/24/19 at 11:38 A.M., CNA E said that oral care should be offered before and after meals but he/she had not completed. 5. During interview on 1/181/9 at 3:00 P.M. the Director of Nursing said the following: -Staff should wash resident’s hands, face, brush teeth, provide oral care, and brush hair in the mornings before breakfast; -Staff should brush residents’ teeth after meals, after sleeping or naps and before bed every day; -Staff saying not enough time was not a good reason for not providing the residents morning cares and brushing residents’ teeth. | |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0678 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 13) accurately and consistently indicated resident’s code status for three residents (Resident #4, #7 and #15) in a review of 12 sampled residents. The facility census was 31. 1. Review of the facility policy Do Not Resuscitate Order and Notification, last revised ,[DATE] showed the following: -Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Our staff will be able to easily identify a resident code status to provide care as ordered; 1. Do not resuscitate orders must be signed by the resident’s Attending Physician on the physician’s order maintained in the resident’s record; 8. Resident code status is entered into the computer at time of admission. The Code Status is entered on the face sheet and the Care Guide ADL. These two points of entry allow the staff to quickly access a resident’s Code Status anywhere in the facility by viewing the Kiosk (smart charting), Order Administration (MAR) or Face sheet. 2. Review of Resident #4’s chart showed the front had a sticker which read Full Code. Review of the resident’s care plan dated [DATE] showed the resident wanted to be a Do Not Resuscitate (DNR). Review of the resident’s face sheet showed the following: -Re-admission of [DATE]; -Full Code. Review of the resident’s Physician Order Sheer dated ,[DATE], showed the resident had an order for [REDACTED]. Review of the resident’s emergency health care directive (purple sheet) showed the following:-Resident was a DNR; -The resident representative signed and dated the request for DNR on [DATE]; -The resident’s physician signed and dated the request for DNR on [DATE]. 3. Review of Resident #7’s emergency health care directive (purple sheet) located in the front of the resident’s medical record showed the following: -The resident signed and dated the request for Do Not Resuscitate on [DATE]; -The resident’s physician signed the request for Do Not Resuscitate on [DATE] ; -The resident signed and revoked Do Not Resuscitate and requested a full code status on [DATE]. Review of the resident’s face sheet showed the following: -admitted [DATE]; -Do Not Resuscitate. Review of the resident’s admission MDS dated [DATE] showed the following: -Cognitively intact; -[DIAGNOSES REDACTED]. Review of the resident’s care plan dated [DATE] showed the resident was a full code. Review of the resident’s medical record front hard cover showed a sign identifying the resident was a full code. Review of the resident’s Physicians Order Sheet showed the resident was a full code. During interview on [DATE] at 3:00 P.M. the Director of Nursing said the resident’s code status documentation was mixed up. The purple emergency health care directive was the rule. The resident had revoked the Do Not Resuscitate and was a Full Code. Staff would not notice the revocation on the form in the case of an emergency and would not provide CPR and a full code. The purple form should be removed from the resident’s chart since the resident desired Full Code status. The resident’s face sheet was filled out incorrectly. 4. Review of Resident #15’s face sheet 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0678 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 14) -admission date of [DATE]; -Full Code. Review of the resident’s hard chart showed the front had a sticker which read DNR. Review of the resident’s emergency healthcare directive (purple sheet) located in the front of the resident’s chart showed:-Resident was a DNR; -The resident’s Durable Power of Attorney signed and dated the request for DNR on [DATE]; -The resident’s physician signed and dated the request for DNR on [DATE]. Review of the resident’s care plan dated [DATE] showed the resident’s annual review of code status for the resident was a DNR. Review of the resident’s POS, dated ,[DATE] showed the resident had an order for [REDACTED].>5. During interview on [DATE] at 10:50 A.M. Certified Nurse Aide (CNA) D said he/she did not know if a resident was a Full Code or a Do Not Resuscitate. He/she did not know where to find the resident’s code status information. If he/she found a resident unresponsive he/she would pull the resident’s call light and call for help. During interview on [DATE] at 2:00 P.M. CNA H said if he/she found a resident unresponsive he/she would call for help. He/she would check the resident’s care plan for their code status. During interview on [DATE] at 11:05 A.M., Licensed Practical Nurse (LPN) M said the following: -There was a message board on the computer screen which had a list of full code residents and if a resident was not listed, they were a DNR; -The front of the charts also had the code status listed; -The Director of Nurses (DON) was responsible for updating the message board. During interview on [DATE] at 3:10 P.M. the DON said the following: -The emergency health care directive (purple sheet) located in the front of the resident’s medical record was the rule. If the resident had a signed purple sheet the resident was a Do Not Resuscitate; -If the resident did not have a signed purple sheet in the front of their chart, they were a full code; -The front hard cover of the chart, the face sheet, the physician’s order sheet and the emergency health care directive (purple sheet) should all match; -If a resident’s code status changed, all documents should change to indicate the correct wishes of the resident; -All staff should know the residents’ code status and where to locate each resident’s code status; -The licensed nurses had a message board on the front screen of electronic medical record system. The message board listed all full code residents. If the resident’s name was not on the message board, they were a Do Not Resuscitate; -He/she was responsible for updating the resident’s POS, the Social Service Director was responsible for updating the face sheet and the MDS Coordinator was responsible for updating the hard chart. During interview on [DATE] at 6:10 P.M. the administrator said staff should know every residents’ code status and know what to do in the event a resident was unresponsive. Each resident’s facesheet, front of the chart, physician order sheet and emergency health care directive (purple sheet) should all match with the same code status information. | |
| F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) During an interview on 1/16/19 at 11:30 A.M., the nutrition services director said there were no recipes for pureed bread in the recipe book or directions anywhere else that indicated how pureed bread was to be prepared or served. | |
| F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Based on observation, interview, and record review, the facility failed to serve food at a | |
| F 0805 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 0805 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 17) 3. Review of the facility’s Physician Orders List, dated 1/15/19, showed three residents had an order for [REDACTED].>Review of the facility diet spreadsheet (Fall/Winter (YEAR)-2019, Week 4, Day 24) for lunch on 1/15/19 showed residents on a physician-ordered pureed diet were to receive a #8 scoop of pureed baked potato with sour cream. Review of the recipe for pureed baked potato with sour cream showed the following: -Remove skin from baked potatoes and place in a food processor along with sour cream. Blend until smooth. Add small amounts of hot milk as needed until desired consistency is achieved; -Top pureed foods with appropriate sauces or gravies, as needed to ensure adequate moisture for safe consumption and enhance flavor. Observation 1/15/19 between 12:58 P.M. and 1:06 P.M. during the meal service, showed the three residents on a pureed diet received pureed baked potatoes. The pureed baked potatoes appeared chunky with large pieces of potato skins throughout the mixture. Observation on 1/15/19 at 1:43 P.M. of the pureed foods test tray, showed the pureed baked potato was chunky with large pieces of potato skin throughout the mixture. The pureed baked potato was extremely thick and paste-like and stuck to the spoon. The item was difficult to swallow without chewing. During an interview on 1/16/19 at 11:30 A.M., the nutrition services director said she used a real baked potatoes in the pureed baked potato recipe. The whole baked potato, including the potato skin, was cut up, and butter, milk and sour cream were added to the mixture. 4. Review of the facility’s Physician Orders List, dated 1/15/19, showed six residents had an order for [REDACTED].>Review of the facility diet spreadsheet (Fall/Winter (YEAR)-2019, Week 4, Day 24) for lunch on 1/15/19 showed residents on a mechanical soft diet were to receive gravy on top of the ground meatloaf. Review of the recipe for ground meatloaf showed the following: -Place portions of meatloaf in a food processor. Pulse/grind until meatloaf is finely ground. Transfer to steamtable pan and add enough broth to keep meat moist; -Serve ground meatloaf with a #8 dip. Top with 1 to 2 ounces of additional broth. Observation on 1/15/19 between 12:41 P.M. and 1:34 P.M. during the meal service, showed staff served all residents on a mechanical soft diet ground meatloaf without any gravy. No gravy was prepared or served during the meal service. Observation on 1/15/19 at 1:43 P.M. of the mechanical soft test tray, showed the ground meatloaf served without gravy. No gravy was served on the sample test tray. During an interview on 1/16/19 at 11:30 A.M., the nutrition services director said no gravy was prepared or served with the mechanical soft items. | |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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) 1. Record review of the facility policy, Food Storage (Dry/Refrigerated/Frozen), dated 2011, showed discard food that has passed the expiration date. 2. Record review of the facility policy, Handling Leftover Foods, dated 2011, showed refrigerated leftovers stored beyond 72 hours shall be discarded. 3. Observation on [DATE] at 3:00 P.M. of the reach-in cooler in the kitchen showed the following: -A tall clear round container labeled gravy for breakfast sausage made ,[DATE]; -A tall white round container labeled turkey gravy dated ,[DATE]; -A tall white round container labeled carrots dated ,[DATE]; -A tall white round container labeled cinnamon apples dated [DATE]; -A tall white round container labeled carmel sauce dated ,[DATE]; -A tall round container labeled applesauce dated ,[DATE]; -A tall round container labeled tomato sauce dated ,[DATE]; -A tall container labeled sauerkraut dated ,[DATE]. -A tall clear container was not labeled or dated and contained sliced peaches. Observation on [DATE] at 3:15 P.M. of the refrigerator labeled fridge#3 in the service hallway behind the kitchen showed the following: -A partial bag of iceberg lettuce in the door was not dated and had watery brown lettuce and brown liquid in the bottom corners of the bag; -A vacuum-sealed bag, labeled romaine lettuce had a manufacturer’s use by date of [DATE] and contained brown lettuce and brownish liquid in the bag. Observation on [DATE] at 3:45 P.M., showed Dietary Staff A retrieved the bag of romaine lettuce out of the refrigerator in the service hall and used the lettuce to make the tossed salad for the evening meal. The bag showed the lettuce expired on [DATE]. The salad was to be used for residents that received regular and low-concentrated sweet diets. During an interview on [DATE] at 11:30 A.M., the nutrition services director said food items should be labeled and dated and were good for three days. After three days, staff should discard the item. Staff should follow manufacturer’s use by dates if applicable. Staff should use items or discard them by the expiration date. All cooks were responsible for checking the refrigerators and cleaning them out every other day. 4. Observation on [DATE] at 3:20 P.M. and on [DATE] at 8:10 A.M. showed a black measuring cup stored inside a bulk storage bin of flour in the dry storage room. The measuring cup lay directly on top of the flour. Observation on [DATE] at 3:30 P.M. and on [DATE] at 8:10 A.M. showed a measuring scoop stored inside a bulk storage container of sugar, located under a metal preparation counter in the kitchen. The measuring scoop lay directly on top of the sugar. During an interview on [DATE] at 11:30 A.M., the nutrition services director said she was not aware scoops were not supposed to be stored inside a bulk food storage container. 5. Record review of the facility policy, Cleaning Rotation, dated 2011, showed the can opener should be cleaned after each use. Observation on [DATE] at 3:31 P.M. showed dark and white colored debris on the blade of the counter-mounted can opener. Dietary Staff A used the mounted can opener to open a large can of spaghetti sauce. He/she did not clean the blade prior to utilizing the can opener. After the can was opened, red spaghetti sauce was visible on the blade. Dietary Staff A did not clean the blade after opening the can of spaghetti sauce. Observation on [DATE] at 8:10 A.M. showed white-colored debris on the can opener blade. During an interview on [DATE] at 11:30 A.M., the nutrition services director said staff cleaned the can opener blade monthly by running it through the dish machine. 6. Record review of the facility policy, Guidelines for Dining Servers, Fundamentals to |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| 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 19) Prevent Food Borne Illness, dated 2011, showed the following guidelines for Gloves Used Correctly: -Gloves are changed anytime they become soiled and between tasks; -Gloves are treated like a food contact surface; -Gloves are used anytime ready to eat foods must be touched by a hand and are changed if they come in contact with an unclean surface, door or piece of equipment. Observation on [DATE] between 12:41 P.M. and 1:34 P.M. during the lunch meal service showed the nutrition services director placed food items on all residents’ meal plates. She wore gloves and handled each resident’s diet card before preparing the resident’s plate. After touching the diet cards, the nutrition services director placed a baked potato on the resident’s plate, sliced it and used both of his/her hands to squeeze the potato open. The nutrition services director proceeded with this process wearing the same gloves through the entire meal service. During an interview on [DATE] at 11:30 A.M., the nutrition services director said staff should change gloves between clean and dirty processes. 7. Observation on [DATE] at 3:21 P.M. showed a stack of five large steam table pans stored on a rack in the kitchen. When the pans were separated, there were water droplets in between the pans. Observation on [DATE] at 8:10 A.M. showed a stack of three small steam table pans stored on the storage rack in the kitchen and had water droplets in between the pans when separated. During an interview on [DATE] at 11:30 A.M., the nutrition services director said dishware should be air dried before staff stack them. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) Before and after direct contact with residents; Before preparing or handling medications; Before and after handling and invasive device (e.g., urinary catheters, IV access sites); Before handling clean or soiled dressings, gauze pads, etc .; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident’s intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, etc.; After removing gloves. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections; Applying and Removing Gloves-Perform hand hygiene before applying non-sterile gloves; Perform hand hygiene after removing gloves. 2. Review of the facility Departmental Laundry and Linen policy, dated 2001 and last revised 1/14 showed: The purpose of this procedure is to provide a process for the safe and aseptic handling of linen; -Standard Precautions: Separate soiled and clean linens at all times, Wash hands after handling soiled linen and before handling clean linen, Consider all soiled linen to be potentially infectious and handle with standard precautions; -Bagging and Handling Soiled Linens: All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. Place any linen saturated with blood or body fluids into a leak-resistant bag before placing it into the hamper. Handle soiled linen as little as possible to prevent agitation. 3. Review of the facility policy [MEDICAL CONDITION] Screening-Administration and Interpretation of [MEDICATION NAME] Skin Tests, dated 2001 and last revised 2/14 showed: The facility will administer and interpret [MEDICATION NAME] skin tests (TST) in accordance with recognized guidelines and pertinent regulations. After obtaining a physician order, a qualified nurse or a healthcare practitioner will inject 0.1 milliliters (ml) (five [MEDICATION NAME] units) of purified protein derivative (PPD) intradermally on the forearm. Individuals with less than ten millimeters (mm) of duration, unless otherwise indicated, will receive a booster of 0.1 ml of PPD one to two weeks after the initial TST. A qualified nurse or healthcare practitioner will interpret the TST forty-eight to seventy-two hours after administration. All test results must be read in mm. 4 . Review of the Infection Control Guidelines for Long Term Care Facilities, (MONTH) 2005 edition showed: -Place all soiled linens in laundry bags provided at the point of use; -Avoid contact with your uniform/clothing and surrounding patient care equipment; -Do not shake or place linen directly on the floor; -For linens lightly to moderately moist, fold and/or roll in such a way as to contain the moist area in the center of the soiled linen; -For soiled linens that are saturated with moisture, place them in a plastic bag followed by tying or knotting the open end. The plastic bag containing wet linens should then be placed in an approved laundry bag and closed before transporting to the proper designated area. 5. Review of the TB Screening for Long Term Care Residents flowchart, revised 3/11/14, provided by the Department of Health and Senior Services, showed the following: -When a resident is admitted to a long term care facility and has no documentation of a two-step TST, the facility must administer the first step TST within one month prior to or one week after admission; |
| 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) -Staff is to read the results of the first step TST within 48 to 72 hours after administration; -If the results were negative, staff must administer the second step TST within one to three weeks; -Staff is to read the results of the second step TST within 48 to 72 hours. -Results must be read and documented in millimeters; -The facility must complete an annual evaluation of residents to rule out signs and symptoms of [MEDICAL CONDITION]. 6. Review of Resident #4’s Immunization and [MEDICAL CONDITION] screening showed the following:-Admission of 7/27/18; -First TST administered on 8/12/18; -No documentation of read date or results for first TST; -Second TST administered on 8/14/18; -Second TST read on 8/16/18 with a 0 negative result; -Second TST administered too soon after first TST and not measured in mm. 4. Review of Resident #20’s Immunization and [MEDICAL CONDITION] screening showed the following: -Admission of 11/5/18; -First TST administered on 11/5/18 to right forearm; -Read on 11/8/18 as 0 negative to left forearm and not measured in mm; -No evidence of second TST documented. 5. Review of Resident #15’s care plan dated 8/30/18, showed the following: -Problem: Frequently incontinent of bladder and bowel and dependent for peri-care; -Approach: Provide help with peri-care and changing of clothing. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, and dated 11/28/18 showed the following: -Extensive assist of two staff for bed mobility; -Extensive assist of one staff for personal hygiene; -Always incontinent of bladder and bowel. Observation on 1/17/19 at 5:45 A.M. showed the following: -The resident lay in his/her bed; -Certified Nurse Assistant (CNA) F and CNA G entered the room and pulled the resident’s linens back to perform perineal care on the resident who had been incontinent of urine; -The resident’s top sheet and blanket touched the floor; -CNA G unfastened the urine soiled incontinent brief and completed peri care. CNA G then tucked the bottom, urine soiled sheet under the resident and placed and tucked the clean, incontinent brief under the soiled linens; -CNA G and CNA F rolled the resident to his/her side; -CNA F untucked and removed the soiled linens from under the resident and placed them directly on the floor. CNA G then pulled the clean brief through; -CNA F and CNA G, wearing the same soiled gloves, rolled the resident to his/her back and both CNA F and CNA G fastened the clean brief; -CNA G removed his/her gloves, washed his/her hands and exited the room; -CNA G returned to the room with clean linens and applied gloves without washing hands; -CNA G placed a clean fitted sheet on one side of the bed and rolled the resident to his/her side; -CNA F wearing the same soiled gloves pulled the bottom sheet through, secured it to the mattress, exited the room, returned with a clean draw sheet in his/her hand wearing 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: 265508 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEGENDARY NURSING & REHABILITATION LLC | STREET ADDRESS, CITY, STATE, ZIP 809 EAST GORDON ST | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 22) same soiled gloves and placed it on the bed; -CNA F and CNA G rolled the resident and CNA G pulled the sheet; -CNA F and CNA G covered the resident with the soiled linens which touched and lay on the floor. During interview on 1/17/19 at 6:05 A.M., CNA G said the following: -Hands should be washed upon entering and exiting the room, when they become soiled and with glove changes; -Gloves should be changed when they become soiled; -Clean items or surfaces touched by soiled hands would be considered contaminated; -When linens touch or lay on the floor, they would be soiled and should not be placed back on the bed; -They had not completed the resident’s care following these principles. During interview on 1/17/19 at 6:53 A.M., CNA F said the following:-Hands should be washed when entering a resident’s room, when exiting and with glove changes; -Gloves should be changed every time they are soiled; -Soiled linens should not be placed on the floor; -Resident linens should not touch or lay on the floor and if they did, they would be contaminated -They had not completed the resident’s care following these principles. 6. During interview on 1/18/19 at 5:50 P.M. the Director Of Nursing said the following: -He/she would expect staff to give the first step followed by the second step ten days later. Read each in 72 hours, and document the date and results in millimeters; -Staff should wash their hands upon entering and exiting a resident’s room, anytime they become soiled, when moving from dirty to clean tasks and with glove changes; -Gloves should be changed when they become soiled; -Resident bed linens should not touch the floor; -Soiled linens should not be thrown on the floor, they should be placed in a bag; -If and when linens become contaminated, they should be bagged and replaced with clean linens; -Staff should not touch clean items or surfaces with soiled hands/gloves. | |
