| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on record review and interview, the facility failed to timely provide a Skilled |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) memo (S&C-09-20), dated 1/9/09, showed the following: -The NOMNC, form CMS- is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident’s stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary’s potential liability for payment for the non-covered services. The SNF’s responsibility to provide notice to the resident can be fulfilled by the use of either the SNFABN (form CMS- ) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met is obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. 1. Record review of Resident #169’s SNF ABN and NOMNC showed the resident was notified on 8/30/18 that coverage of services was ending 8/31/18. During an interview on 9/21/18 at 2:19 P.M., the Social Services Director said he/she knew the regulation required more advance notice of services ending. | |
| F 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Based on interview and record review, the facility failed to check the Nurse Aide (NA) |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | ||
| F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) showed he/she was readmitted from the hospital. Record review of the resident’s medical record showed there were no letters notifying the resident and/or the resident’s representative(s) of transfers/discharges and the reasons for the transfers/discharges. Record review of resident’s Nurses Notes dated 8/7/18 at 7:51 P.M., showed he/she was sent to hospital 6:10 P.M. Record review of resident’s Nurses Notes dated 8/15/18 at 2:44 P.M., showed he/she returned to the facility. Record review of the resident’s medical record showed there were no letters notifying the resident and/or the resident’s representative(s) of transfers/discharges and the reasons for the transfers/discharges. 5. Record review of Resident # 112’s Nurses Notes dated 7/18/18 at 10:56 A.M., showed he/she was sent to hospital at 9:45 A.M. Record review of resident’s Nurses Notes dated 7/24/18 at 7:51 P.M., showed he/she returned to facility. Record review of the resident’s medical record showed there were no letters notifying the resident and/or the resident’s representative(s) of transfers/discharges and the reasons for the transfers/discharges. 6. Record review of Resident # 74’s Nurses Notes dated 9/12/18 at 6:41 P.M. showed he/she was sent to hospital at 6:20 P.M. Record review of the resident’s Admission Record showed he/she was readmitted on [DATE] at 6:00 A.M. Record review of the resident’s medical record showed there were no letters notifying the resident and/or the resident’s representative(s) of transfers/discharges and the reasons for the transfers/discharges. 7. During an interview on 9/27/18 at 10:00 A.M., the Director of Nursing (DON) said they are not doing transfer, discharge letters and they are not sent to the Ombudsman. During an interview on 9/27/18 at 1:10 P.M., the Administrator said he/she does not do transfer/discharge letters. | |
| F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) Record review of the resident’s medical record showed there was no letter notifying the resident and/or the resident’s representative(s) of the bed hold policy upon transferred/discharge from the facility. 2. Record review of Resident #109’s entry tracking records and discharge assessments showed he/she: -Entered the facility on 12/16/17; -discharged from the facility on 4/3/18; -Returned to the facility on [DATE]; -discharged from the facility on 8/1/18; -Returned to the facility on [DATE]; -discharged from the facility on 8/15/18; -Returned to the facility on [DATE]. Record review of the resident’s medical record showed there was no letter notifying the resident and/or the resident’s representative(s) of the bed hold policy upon transferred/discharge from the facility. 3. Record review of Resident #45’s entry tracking records and discharge assessments showed he/she: -Entered the facility on 4/20/18; -discharged from the facility on 5/6/18; -Returned to the facility on [DATE]; -discharged from the facility on 8/9/18; -Returned to the facility on [DATE]; -discharged from the facility on 9/17/18 and -Returned to the facility on [DATE]. Record review of the resident’s medical record showed there was no letter notifying the resident and/or the resident’s representative(s) of the bed hold policy upon transferred/discharge from the facility. 4. Record review of Resident # 30’s Nurses Notes dated 6/6/18 6:38 P.M., showed an order for [REDACTED].>Record review of resident’s Nurses Notes dated 6/13/18 1:47 A.M., showed he/she was readmitted from the hospital. Record review of the resident’s medical record showed there was no letter notifying the resident and/or the resident’s representative(s) of a bed hold policy. Record review of resident’s Nurses Notes dated 8/7/18 at 7:51 P.M., showed he/she was sent to hospital 6:10 P.M. Record review of resident’s Nurses Notes dated 8/15/18 at 2:44 P.M., showed he/she returned to facility. Record review of the resident’s medical record showed there was no letter notifying the resident and/or the resident’s representative(s) of a bed hold policy. 5. Record review of Resident # 112’s Nurses Notes dated 7/18/18 at 10:56 A.M., showed he/she was sent to hospital at 9:45 A.M. Record review of resident’s Nurses Notes dated 7/24/18 at 7:51 P.M., showed he/she returned to facility. Record review of the resident’s medical record showed there was no letter notifying the resident and/or the resident’s representative(s) of a bed hold policy. 6. Record review of Resident # 74’s Nurses Notes dated 9/12/18 at 6:41 P.M. showed he/she was sent to hospital at 6:20 P.M. Record review of resident’s Admission Record showed he/she was readmitted on [DATE] at 6:00 A.M. Record review of the resident’s medical record showed there was no letter notifying 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) resident and/or the resident’s representative(s) of a bed hold policy. 7. During an interview on 9/27/18 at 10:00 A.M., the Director of Nursing (DON) said they are not doing bedhold letters. During an interview on 9/27/18 at 1:10 P.M., the Administrator said he/she does not do bedhold letters. | |
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives an accurate assessment. **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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) over six months) and -The resident had not fallen since his/her last MDS assessment (5/4/18). Record review of the resident’s dietary notes from 2/1/18 through 9/25/18 at 9:41 AM showed a dietary note dated 8/9/18 that the resident had lost weight but remained overweight. During an interview on 9/28/18 10:18 at A.M., the MDS Coordinator said: -Their system didn’t automatically trigger weight loss; -She uses the facility’s weight tracking form which shows dates, weights and calculates weight loss and -The resident’s quarterly MDS dated [DATE] should have indicated weight loss and a fall. During an interview on 9/28/18 at 12:00 P.M., the DON said he/she expected the MDS to be accurate. | |
| F 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | PASARR screening for Mental disorders or Intellectual Disabilities **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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) transferred. If a legible copy is not maintained, the facility must complete and submit a new set of DA124A/B and C forms to COMRU, – If a resident is discharged to a new nursing home, the receiving facility is responsible for assuring the DA124C and Level II screening results are included in the transfer packet, and – Should the DA124C not be included in the packet, admission should not be completed. The DA124C and Level II screening results should be requested from the prior facility by the receiving facility. 1. Record review of Resident #63’s annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 2/5/18 showed: -The resident had [DIAGNOSES REDACTED]. severe loss of contact with reality) and -The resident was not evaluated by a Level II PASRR and determined to have a serious mental illness. Record review of the resident’s medical record showed no DA124C. 2. Record review of Resident #109’s Admission MDS dated [DATE] showed: -The resident was admitted to the facility on [DATE]; -The resident had [DIAGNOSES REDACTED]. -The resident was not evaluated by a Level II PASRR and determined to have a serious mental illness. Record review of the resident’s medical record showed no DA124C. 3. During an interview on 9/27/18 at 9:32 A.M., the Social Services Director said: -Currently the Admission Coordinator is responsible for the PASRRs; -The PASRRs should be in the chart; -Social Services will be responsible for the PASRRs; -They keep a copy in the front office and -He/she was not able to locate a PASRR for Residents #63 or #109. | |
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted **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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) -Had no diagnoses listed. Record review of the resident’s Admission Minimum Data Set (MDS – a federally mandated assessment tool completed by the facility staff for care planning) dated 9/25/18 showed he/she had a cognitive loss/dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning). Record review of the resident’s undated Nutrition data Collection/Assessment record showed he/she had the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] reflux disease (GERD – back up of stomach acid/heartburn); -Hypertension (HTN- high blood pressure) and -[MEDICAL CONDITION] Fibrillation (A-Fib – abnormal heart rhythm). Record review of the resident’s medical record chart showed: -A blank paper baseline care plan; -A computer generated care plan dated 9/13/18 for risk for developing a Pressure Ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and -No other type of care plan found. Record review of the resident’s Nurses Notes dated 9/15/18 at 2:10 P.M., showed he/she: -Had right sided weakness; -Requires two-person assist with transfers and -Receives Physical Therapy, Occupational Therapy, and Speech Therapy. Record review of the resident’s Nurses Notes dated 9/16/18 at 7:33 A.M., showed he/she: -Was [MEDICAL CONDITION] left sided weakness; -Was a fall risk and -Was unaware of safety needs. Record review of the resident’s Nurses Notes dated 9/16/18 at 1:13 P.M., showed he/she: -Was leaning to the left side and -Had pillows for positioning, comfort and safety needs. Record review of the resident’s Nurses Notes dated 9/17/18 at 4:38 P.M., showed he/she: -Had left sided flaccidness and -Had a bolster (a mattress cover with padded raised sections on both sides at the top and bottom) added to his/her mattress for positioning. Record review of the resident’s Nurses Notes dated 9/18/18 at 7:23 A.M., showed the bolstered mattress did help the resident with positioning. Record Review of the resident’s Nurses Notes dated 9/18/18 at 11:39 A.M., showed he/she: -Received maximum assistance of two staff members to transfer to a wheelchair and -Was propelled in the wheelchair by a staff member. 2. Record review of Resident #45’s entry tracking record showed he/she admitted to the facility on [DATE]. Record review of the resident’s baseline care plan showed: -It was not dated; -It listed the resident’s allergies [REDACTED].>-The resident received [MEDICAL TREATMENT]; -Everything else was left blank and -No documentation that the baseline care plan was given to the resident and/or the resident’s representative. 3. Record review of Resident #109’s entry tracking record showed he/she was admitted to the facility on [DATE]. Record review of the resident’s medical record showed there was no baseline care plan. |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) 4. During an interview on 9/28/18 at 11:59 A.M., the Director of Nursing DON) said a baseline care plan should be completed as soon as the resident is admitted , possibly in 24 hours and by the Charge Nurse. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) –Keep bed in lowest position. –Provide resident/family teaching to include: —Safety measures to reduce fall risk; —What to do if a fall occurs; —Remind resident and reinforce safety awareness; —Lock brakes on bed, chair, etc., before transferring; —Appropriate foot wear; —Transfer with assist; —Keep bed at appropriate height for transfers and -Risk for falls and possible related injury. -Goals: –Injury due to falls will be minimized related to fall interventions through next review date 10/12/18. -Interventions: – Fall risk assessment per protocol or as warranted. Record review of the resident’s Quarterly Minimum Data Set (MDS – a federally mandated assessment tool completed by the facility staff for care planning) dated 7/10/18 showed: -The resident’s cognition was severely impaired and -History of falls in the last six months with one major injury fall. Record review of the resident’s Incident/Accident Data Entry Questionnaire dated 4/21/18 at 6:15 A.M., showed: -Unwitnessed fall. -Incident follow-up and recommendation form showed: –Therapy services. –Floor mat. –Google eye sign (for fall risk). –Neurological checks (Neuro checks – neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs). -Care Plan updated. -No documentation of a fall or updates noted on the resident’s Fall Care Plan for this fall. Record review of the resident’s Incident follow-up and recommendation form for an unwitnessed fall on 4/26/18 showed: -Therapy services; -Floor mat; -Google eye sign; -Neuro checks; -Care plan updated and -No documentation of a fall or updates noted on the resident’s Fall Care Plan for this fall. Record review of the resident’s Nurses notes dated 6/1/18 at 9:12 P.M., showed he/she had an unwitnessed fall. Record review of the resident’s Fall Care Plan showed no documentation of a fall or any updates for a fall on 6/1/18. Record review of the resident’s Nurses notes dated 6/18/18 at 5:27 P.M., showed the resident had a [DIAGNOSES REDACTED]. Record review of the resident’s Fall Care Plan showed no documentation of a fall or updates showing a [MEDICAL CONDITION] for 6/18/18. |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) Record review of the resident’s Neurological Assessment Flow Sheet showed 72 hour charting from 8/2/18 through 8/5/18 shifts. Record review of the resident’s Nurses notes dated 8/3/18 at 3:53 P.M., showed fall follow-up charting with Neuro checks. Record review of the resident’s Fall Care Plan showed no documentation of a fall or updates for a fall on 8/2/18. Record review of the resident’s Incident/Accident Data Entry Questionnaire dated 8/7/18 at 3:30 A.M., showed an unwitnessed fall with no injury. Record review of the resident’s Fall Care Plan showed no documentation of a fall or updates for a fall on 8/7/18. 2. Record review of Resident #110’s Admission Record showed he/she was admitted on [DATE] with the following Diagnoses: [REDACTED]. -Difficulty walking; -[MEDICAL CONDITION] (a common, potentially serious bacterial infection of the skin and the soft tissues underneath) of the left and right lower limbs; -Chronic [MEDICAL CONDITION] (also known as [MEDICAL CONDITION] – [MEDICAL CONDITION] – inadequate flow of blood to the extremities) and -[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability of the lungs to perform ventilation). Record review of the resident’s Care Plans dated 8/24/18 showed he/she had: -A risk for falls. –Goal: will have no serious injuries related to falls through next review 11/24/18. –Interventions: —Fall risk assessment per protocol or as warranted. —Provide environmental adaptations as needed. —Keep frequently used items close to resident. —Report falls to physician and responsible party. Record review of the Resident’s Admission MDS dated [DATE] showed that: -That there was no cognition level recorded for the resident. -The resident had a history of [REDACTED]. -The resident used [MEDICAL CONDITION] medications. Record review of the resident’s Incident/Accident Data Entry Questionnaire dated 8/25/18 at 6:00 P.M., showed he/she had an unwitnessed fall in his/her room. Record review of the resident’s Fall Care Plan showed no documentation of a fall or updates for his/her fall on 8/25/18. Record review of the resident’s Nurses Notes dated 9/3/18 at 3:54 A.M., showed evening shift on 9/2/18 reported he/she had a fall around 8:15 P.M. Record review of the resident’s Fall Care Plan showed no documentation of a fall or updates for his/her fall on 9/2/18. Record review of the resident’s Incident/Accident Data Entry Questionnaire dated 9/4/18 at 5:30 A.M., showed he/she had an unwitnessed fall in his/her room. Record review of the resident’s Fall Care Plan showed no documentation of his/her fall or updates for a fall on 9/4/18. 3. During an interview on 09/28/18 at 11:59 A.M., The Director of Nursing (DON) said: -Each resident fall should be listed on his/her Care Plan and -Each resident fall should have new interventions added to his/her Care Plan. |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 | 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 13) showed [MEDICATION NAME] (an antiseptic-inhibits the growth and development of microorganisms) to the resident’s 1st and 2nd toe of his/her left foot was not initialed as completed seven out of 17 opportunities. Record review of the resident’s (MONTH) (YEAR) TAR showed [MEDICATION NAME] to the resident’s 1st and 2nd toe of his/her left foot was not initialed as completed seven out of 11 out of 30 opportunities and one time it was documented that the resident refused. Record review of the resident’s Physician’s Assistant’s note dated 6/6/18 showed the resident’s gangrenous 2nd toe on his/her left foot was arterial in nature (caused by poor circulation). Record review of the resident’s (MONTH) (YEAR) TAR showed [MEDICATION NAME] to the resident’s 1st and 2nd toe of his/her left foot was not initialed as completed three out of 31 opportunities. Record review of the resident’s (MONTH) (YEAR) TAR showed [MEDICATION NAME] to the resident’s 1st and 2nd toe of his/her left foot was not completed at all that month. Two lines were drawn through the order and healed was written on it. Record review of the resident’s non-pressure skin condition sheet dated 8/13/18 showed the resident’s 2nd toe on his/her left foot was dry gangrene. Record review of the resident’s Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility staff for care planning) dated 8/15/18 showed an arterial wound was not marked on the MDS. Record review of the resident’s (MONTH) (YEAR) POS showed the resident had a physician’s orders [REDACTED]. Record review of the resident’s (MONTH) (YEAR) TAR was initialed as only being completed on 9/1/18. The rest of dates had two wavy lines drawn over them. Observation and interview on 9/26/18 at 1:27 P.M. showed: -The resident’s 2nd toe on his/her left foot was black. -The wound nurse said: –The resident came from the hospital with her toe like that and –The resident is on Hospice (end of life care), the toe does not have any drainage, and it does not have any open areas. During an interview on 9/26/18 01:54 P.M., the wound nurse said [MEDICATION NAME] was still an active order for the resident’s 2nd toe on his/her left foot and he/she did not know why that order was not being followed. During an interview on 9/28/18 at 10:18 A.M., the MDS Coordinator said an arterial wound should have been documented on the quarterly MDS dated [DATE]. During an interview on 9/28/18 at 9:55 A.M., Licensed Practical Nurse (LPN) D said they should document the completion of the treatment and if it was not done, they should initial the TAR, circle their initials on the date and document the reason it was not done. During an interview on 9/28/18 at 12:00 P.M., the DON said they should follow physician’s orders [REDACTED]. | |
| F 0685 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Assist a resident in gaining access to vision and hearing services. **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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0685 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) out of 23 sampled residents. The facility census was 114 residents. 1. Record review of Resident #109’s quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/3/18 showed the following staff assessment of the resident: -Had vision that was adequate to complete the assessment without corrective lenses and -It was marked that the staff should assess the resident’s mental status but then it was left blank as to whether the resident had memory problems or not. Record review of the resident’s 30 day MDS dated [DATE] showed he/she was moderately cognitively impaired. Record review of the resident’s medical record showed no documented vision exams. Record review of the resident’s progress notes (social service, physicians’ and nurses’) showed no documentation regarding the resident’s glasses from 12/1/17-9/27/18 at 12:49 P.M. other than on 4/6/18, the resident was going to be at the hospital for awhile so the resident’s glasses were left at front desk for someone to pick up and take to the resident. Observation and interview on 9/18/18 2:07 P.M. showed: -The resident said he/she liked to read and -The resident’s glasses were broken with one ear piece missing. Record review of the resident’s current care plan showed no care plan regarding glasses or vision impairment. During an interview on 9/27/18 at 9:32 A.M., the Social Services Director said he/she doesn’t remember if he/she has ever seen the resident wear glasses. During an interview on 9/28/18 at 9:42 A.M., Certified Nursing Assistant CNA) C said: -The resident does wear glasses; -He/she doesn’t think he/she’s seen the resident wear his/her glasses lately; -The resident has asked him/her to get the resident’s glasses out of the drawer or wherever they were and give them to the resident and -He/she did not know the resident’s glasses were broken. During an interview on 9/28/18 at 9:55 A.M., Licensed Practical Nurse (LPN) D said he/she has not seen the resident wear glasses. During an interview on 9/28/18 at 10:18 A.M., the MDS Coordinator said there should be a care plan for glasses if the resident wears glasses. During an interview on 9/28/18 at 12:00 P.M., the Director of Nursing (DON) said: -He/she has not seen the resident wear glasses and -He/she was not aware the resident’s glasses were broken. | |
| F 0686 Level of harm – Actual harm Residents Affected – Few | Provide appropriate pressure ulcer care and prevent new ulcers from developing. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 15) four Stage 3 pressure ulcers (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed) to his/her coccyx area, Deep Tissue Pressure Injuries (DTPI-may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to his/her right upper thigh, caused by the ace wrap being wrapped tightly around his/her thigh after he/she had destroyed the plaster cast/long leg splint that was applied to his/her right leg; failed to ensure the resident’s [DEVICE] (machine that applies negative pressure to an area to promote healing in acute or chronic wounds) dressing was maintaining an airtight seal, and did not address the loud noise that the [DEVICE] machine was making to ensure it was functioning properly for one sampled resident (Resident #17); and failed to do pressure ulcer dressing changes and [DEVICE] dressing changes for one sampled resident (Resident #115) out of 23 sampled residents. The facility census was 114 residents. Record review of the facility’s treatment of [REDACTED]. -Care of wounds involve the cleansing and application of dressings and possible adjuvant therapies (i.e., electrical stimulation) as appropriate. -Dressings are chosen based upon: –The presentation of the wound. –The desired dressing function. –The patient’s medical condition. –The cardinal rule is to keep the ulcer moist and the surrounding skin dry and intact. -Adjuvant therapies may be considered when wounds have proven unresponsive to conventional therapy and in keeping with patient goal and medical condition. Record review of the facility’s Pressure Ulcer/Injury Prevention policy dated as revised (MONTH) (YEAR) showed: -A comprehensive skin assessment should be completed on admission and re-admission; -A weekly skin assessment should be conducted; -A plan should be developed to maintain and improve the resident’s skin integrity such as skin inspections and encouraging food and fluid intake; -Measures should be put in place to protect the resident’s skin integrity such as repositioning at least every two to four hours, utilizing positioning devices, ensure proper body alignment, maintain the head of the bed at the lowest degree of elevation, pressure reduction mattresses and proper wheelchair positioning and -Develop a change in the care plan when skin breakdown does occur. Record review of the facility’s policy dated 12/29/14 Negative Pressure Wound Therapy ([DEVICE]), said: -The wound must be surrounded by enough intact periwound skin (tissue surrounding a wound) to ensure an airtight seal of the occulsive dressing; -The nurse should check that the dressing is fully sealed at the beginning of each shift and every four hours after; -To be effective, the machine must be on at least 22 hours per day; -The nurse must check and document that the clamps are open; -The dressing is fully contracted at the beginning of each shift and every four hours thereafter; and -The policy does not instruct the staff to check the machine to see if it is working correctly. 1. Record review of Resident #34’s care plan dated 4/21/16 showed: -The resident was at risk for developing a pressure ulcer and -The care plan was not updated for the resident’s tibia (shin bone) and fibula (calf bone) |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 16) fracture on 9/7/18. Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/10/18 showed the following staff assessment of the resident: -Was severely cognitively impaired; -Required extensive assistance with bed mobility, transferring from one surface to another, locomotion on the unit, dressing and hygiene; -Did not walk; -Used a wheelchair; -Had [DIAGNOSES REDACTED]. -Did not have any pressure ulcers. Record review of the resident’s most recent bath sheet provided dated 8/21/18 showed the resident had a brace on his/her leg and there were scratches on his/her right inner thigh. Record review of the resident’s weekly skin integrity data collection sheet dated 9/6/18, 9/13/18 and 9/20/18 show the resident’s skin was intact. Record review of the resident’s nurse’s note dated 9/7/18 at 11:12 P.M., showed: -The resident’s family member reported to the nurse that the resident’s right knee looked swollen and the resident was in pain; -The nurse assessed the resident’s right knee and it was swollen and -The resident was sent to the emergency room . Record review of the resident’s nurse’s note dated 9/8/18 at 8:03 A.M., showed: -The resident was sent out to the hospital by the evening shift the prior evening due to a tibia and fibula fracture and -The resident returned from the hospital at 6:00 A.M. Record review of the resident’s nurse’s note dated 9/8/18 at 5:24 P.M., showed the resident was in bed with his/her right leg elevated on a pillow and had a splint on his/her right leg. Record review of the resident’s nurse’s note dated 9/8/18 at 11:47 P.M. showed the resident was in bed and had a splint on his/her right leg. Record review of the resident’s nurse’s note dated 9/10/18 at 5:17 P.M. showed the resident had a splint on his/her right leg. Record review of the resident’s nurse’s note dated 9/11/18 showed a follow-up appointment was scheduled with the resident’s orthopedic physician for 9/21/18. Record review of the resident’s physician’s progress note dated 9/11/18 showed: -The resident had a recent right leg fracture which is currently wrapped with ace wrap and has a soft cast. The resident constantly pulls at the ace wrap and it gets very tangled and pulled off; -The resident has an appointment with an orthopedist this week to have the soft cast removed and a hard cast placed and -The plan was to re-wrap the resident’s right leg. Record review of the resident’s nurse’s note dated 9/13/18 at 11:57 P.M. showed the resident’s family member requested the resident be out of bed and up in his/her wheelchair daily. Record review of the resident’s nurse’s note dated 9/16/18 at 9:52 A.M., showed: -The resident took apart his/her cast on his/her right leg; -The resident took the soft fluffy material out of upper part of his/her cast, unwrapped the ace bandage and snapped apart the plaster splinted areas and -A family member reported that the resident says the cast itches and he/she wants it off. Record review of the resident’s nurse’s note dated 9/17/18 at 8:00 P.M. showed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 17) resident’s splint on his/her right leg was intact. Observation on 9/18/18 at 10:00 A.M., showed the resident was asleep in bed. Observation on 9/18/18 at 1:28 P.M., showed the resident was in his/her wheelchair in his/her room. There was an ace wrap and a soft-cast on the resident’s right leg. Observation on 9/20/18 at 11:45 A.M., showed the resident was in his/her room sitting in his/her wheelchair. The resident’s position in the wheelchair was: the resident was sitting at the very edge of the wheelchair seat. The resident’s left leg was bent with his/her left heel resting against the footrest. The resident’s right mid-calf was resting against the front part of the footrest. Record review of the resident’s nurse’s note dated 9/21/18 at 3:12 P.M. showed: -Staff reported to the nurse that the resident’s eyes appeared to rolled back and he/she was not responding; -The resident’s blood pressure was low at 85/44 and -The nurse practitioner was at the facility and gave an order to send the resident to the emergency room . Record review of the resident’s hospital orthopedic consult dated 9/21/18 at 7:14 P.M. showed: -The resident’s right leg was in a long-leg splint. -The lateral (away from the midline of the body) portion of the plaster was broken at the level of the proximal (near the center) tibia and the ace bandages were tightly wrapped around the right thigh. There were ecchymoses (discoloration of the skin that occurs when blood leaks from a broken capillary into surrounding tissue under the skin) and blisters about the right mid-thigh as well as the right lateral shin in the region where the plaster was broken. There was exposed plaster over the medial (toward the middle) and lateral aspects of the right knee, as the padding was removed at those sights. The right knee was swollen as it was the only portion of the right leg that was not wrapped with ace bandage. Record review of the resident’s hospital wound notes dated 9/21/18 showed: -The resident had a Stage 3 pressure ulcer on his/her sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) that was present upon admission; -The resident had a DTPI on below his/her right, distal (away from the point of attachment or origin) knee that was present upon admission and -The resident had DTPI on both heels. Record review of the hand-written report called from the hospital note dated 9/26/18 showed the following: -The resident was returning to the facility with Hospice services (end of life care); -Instructions to turn the resident right to left every two hours and do not lay the resident on his/her back; -The resident had a Stage 3 pressure ulcer on his/her sacrum; -The resident had DTPIs from his/her cast and -The resident had wounds on his/her right and left heels and right ankle. Record review of the resident’s baseline care plan dated 9/26/18 showed: -The resident had a break in skin integrity and -Instructions for staff to reposition the resident every two hours. Record review of the resident’s weekly skin integrity data collection dated 9/26/18 showed the resident had boggy (spongy) heels, blisters on his/her right upper thigh, bruising on his/her ankle and an open area on his/her sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity). |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 18) Record review of the resident’s Braden Scale for predicting pressure ulcer risk dated 9/26/18 showed the resident was at high risk. Record review of the resident’s physician’s orders [REDACTED].>-Lay down after lunch; -Cleanse Stage 3 sacral wound with normal saline, cover with Allevyn (a wound healing product that provides a moist wound environment) foam every three days until healed; -Cover right ankle with Allevyn foam every three days until healed and -Cover right upper thigh and right upper shin with Allevyn foam every three days until healed and as needed. Record review of the resident’s Pressure Ulcer Status Records dated 9/27/18 showed the resident had the following pressure ulcers that were all first observed on 9/27/18: -A Stage III pressure ulcer on his/her left distal sacrum. –It measured 1.7 centimeters (cm) x 0.7 cm x 0.1 cm. –It was 100% granulation. -A Stage 3 pressure ulcer on his/her left, proximal sacrum. –It measured 2.0 cm x 0.3 cm x 0.1 cm. –It was 100% granulation. -A Stage 3 pressure ulcer on his/her right distal sacrum. –It measured 2.5 cm x 2.5 cm x 0.1 cm. –It was 50% slough and 50% granulation. -A Stage 3 pressure ulcer on his/her right proximal sacrum. Record review of the resident’s non-pressure skin condition records dated 9/27/18 showed the resident had had the following what the facility called blood blisters (a blister containing blood or bloody serum usually caused by an injury) that were all first observed on 9/27/18: -Right thigh that measured 30.0 cm x 1.5 cm x unknown depth; -Right thigh that measured 1.0 cm x 8.0 cm x unknown depth; -Right thigh that measured 0.5 cm x 8.0 cm x unknown depth and -Right shin that measured 4.0 cm x 6.0 cm x unknown depth. Observation on 9/27/18 at 7:45 A.M. showed the resident: -Was on his/her back with a wedge pillow under his/her right knee in bed; -Had waffle boots (cushioned foot protector) on both feet and -Had a regular mattress (not a low air-loss mattress). During an interview on 9/27/18 at 8:15 A.M., Registered Nurse (RN) A said new admissions and residents returning from the hospital have wounds measured by the wound nurse. Continuous observation on 9/27/18 showed: -At 8:20 A.M.: –The resident was in bed and was on his/her back with a wedge pillow under his/her right knee. –The resident had waffle boots on both feet. –The resident’s right leg was in a soft blue splint. -At 8:43 A.M., the resident was on his/her back. A staff member elevated the resident’s head to sitting up in bed. -At 9:17 A.M., Certified Medication Technician (CMT) A removed the resident’s meal tray and the resident remained on his/her back with his/her head elevated. Observation on 9/27/18 at 9:45 A.M. showed: -The resident had a linear blister across the top and around the resident’s upper right thigh and had two additional blisters on his/her upper right thigh; -The resident had two blisters on his/her right shin and -The resident had multiple wounds on his/her coccyx. |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 19) During an interview on 9/27/18 at 10:02 A.M., the wound nurse said he/she was not aware of the resident having any wounds prior to going out to the hospital. Observation on 9/27/18 at 9:45 A.M. showed the resident remained on his/her back with a wedge cushion by the resident’s right side. Observation on 9/28/18 showed: -At 7:55 A.M., the resident was in bed, on a regular mattress, on his/her back with a wedge cushion by the resident’s right side; -At 9:10 A.M., the resident was lying on his/her back with the head of his/her bed elevated; -At 9:40 A.M., the resident remained positioned on his/her back with a wedge pillow on his/her right side and the head of the bed elevated and -At 10:05 A.M., the resident was positioned on his/her back. During an interview on 9/28/18 at 8:00 A.M., CMT B said: -If a resident was supposed to be turned from side to side, the resident should not be on his/her back; -If a resident had a pressure ulcer/injury on his/her bottom, the resident should be positioned on his/her side with a pillow to support him/her on his/her side and -A resident should not be positioned on his/her back if he/she had a wound on his/her bottom. During an interview on 9/28/18 at 9:25 A.M., Certified Nursing Assistant (CNA) D said: -Residents are supposed to be turned and repositioned every two hours; -Residents who have a wound on his/her bottom should be positioned on his/her side with a pillow behind him/her to help hold them on his/her side; -If a resident had specific instructions to keep off his/her back, the resident should not be positioned on his/her back; -No one told him/her to keep the resident off of his/her back; -No one told him/her the resident had pressure ulcers on his/her bottom; -If he/she had known the resident had pressure ulcers on his/her bottom, the resident would not be positioned on his/her back but would be positioned on his/her side; -The resident is not able to re-position himself/herself and -Was not aware that the resident had pressure ulcers anywhere. During an interview on 9/28/18 at 9:50 A.M., CNA E said: -Residents are turned and repositioned every two hours; -If a resident had a wound, the resident would be positioned so the wound was not getting any pressure to it; -The nurses will report to the CNAs if there is anything going on with the residents; -Was informed of the cares of all the residents on the wing currently working.; -Was not told the resident had any wounds; -Had not performed any incontinent care to the resident since the beginning of his/her shift (7:00 A.M.); -Residents are to be changed every two hours; -The resident is currently positioned on his/her back; -The resident should have been turned side to side while in bed, but he/she had breakfast so he/she was on his/ her back; -The resident was positioned on his/her back at the beginning of his/her shift and -The resident is not able to re-position himself/herself. During an interview on 9/28/18 at 10:10 A.M. RN A said: -Residents are repositioned every two hours; -CNAs are present for morning shift report; |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 20) -CNAs can get information about the resident off the assignment sheet and the resident list; -The information shared with the CNA’s included any wounds residents’ had and how the residents should be positioned; -The resident should be repositioned at least every two hours; -The resident should be positioned from side to side with a pillow to keep him/her on his/her side; -The resident is able to reposition himself/herself and favors his/her back; -RN A does a walk through at the beginning of his/her shift between 6:45 A.M. and 7:00 A.M; -The resident was positioned was on his/her right side during the walk through that morning; -The wedge pillow should be behind him/her by the wall; -The resident had a popped blister where the adult brief was placed and it healed quickly; -The resident had no other wounds; |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 21) -Had [DIAGNOSES REDACTED]. Record review of the resident’s care plan dated 7/15/16 for pressure ulcers showed he/she had a pressure ulcer on his/her buttocks and left ankle. No other skin alterations were on the care plan. There were no care plan updates since 7/15/16. Record review of the resident’s nurse’s note dated 8/26/18 showed he/she returned to facility (from the hospital) with a knee splint on his/her right leg. Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED]. -There were treatment orders for the resident’s left and right ischium (forms the lower and back part of the hip bone).treatment orders; -9/19/18: Right inner ankle: Clean with normal saline, apply [MEDICATION NAME] AG (a dressing that is indicated for moderate to high exuding wounds which are infected or at risk of infection), secure with bordered foam and change daily and as needed if soiled and -9/19/18: Right shin: Clean with normal saline, apply [MEDICATION NAME] AG, secure with bordered foam and change daily and as needed if soiled. Observation on 9/18/18 at 1:52 P.M. showed the resident had visible bandages on his/her left ankle and left shin. The resident said he/she did not know how he/she got them Record review of the resident’s non-pressure skin condition record completed by the facility wound nurse dated 9/20/18 showed: -Site A: –Was an abrasion on the resident’s left shin; –Was first observed on 9/19/18 (bandages were observed in place on 9/18/18); –The abrasion was 1.5 cm x 0.5 cm x 0.1 cm; –The tissue was 50% granulation (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) and 50% slough (dead tissue that is in the process of separating from the viable portions of the body); –Did not have any drainage and -The documentation did not specify why the wound was documented to be an abrasion and not a pressure ulcer. Record review of the resident’s facility’s wound nurse’s note dated 9/19/18 showed: -The resident had two new wounds on his/her left leg; -The wounds corresponded with the metal on the leg brace the resident wore on his/her right leg for his/her fractured kneecap and -Treatment orders were written for wound care for the two new wounds. Record review of the resident’s nurses’ notes dated 9/19/18 through 9/28/18 at 9:33 A.M. showed no further documentation regarding the resident’s brace or new wounds. Record review of the resident’s consulting wound company’s physician’s assistant’s wound note dated 9/20/18 at 11:20 A.M. showed: -The resident had a pressure ulcer on his/her left ischium. -The resident had a wound caused by pressure from a brace on his/her left, medial ankle that: –Was a Stage 3 pressure ulcer; –Measured 1.0 cm x 1.0 cm x 0.2 cm; –Had no drainage; and –Was 100% granulation. -There was no documentation regarding the resident’s shin wound. During an interview and observation on 9/24/18 at 10:28 A.M.: -The wound nurse said: –The resident has two areas, one on his/her left shin and one on his/her left ankle that were caused by the resident’s brace on his/her right leg; |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 22) –The joints of the brace rub on the rsident’s left leg; –The resident had a brace on his/her right leg due to a fractured kneecap; –The resident had recurring wound areas on his/her ischium; –The resident had [DIAGNOSES REDACTED] (a birth defect that occurs when the spine and spinal cord do not form properly); -The resident’s legs were together with the left side of the brace on the resident’s right leg being directly up against the right side of the resident’s left leg; -The wound nurse had to pull the resident’s legs apart to separate them; -The wound nurse removed the bandages on the resident’s left leg and there were red open areas on the resident’s left shin and left ankle; -When the wound nurse was asked if therapy had looked at the resident’s brace, he/she said the brace was for the resident’s fractured patella (kneecap); -When the wound nurse was asked if they tried to put something between the resident’s legs to prevent the brace from rubbing on his/her left leg, he/she said no, that the resident was up most of the time during the day and -The resident had a dressing on his/her left ischium. Observation on 9/25/18 at 2:50 P.M. showed the resident was sitting in his/her wheelchair in his/her room. His/her right foot was on the floor. His/her left foot was partially on the foot rest. The resident’s left ankle was touching the brace on the resident’s right leg. During an interview on 9/26/18 at 8:30 A.M., the DON said: -They tried pillows to keep his/her legs apart and -They did not refer the resident to therapy because he/she was not able to stand on his/her right leg. During an interview on 9/28/18 at 9:42 A.M., CNA C said: -The resident’s wounds on his/her left leg were from his/her brace rubbing against his/her skin and -The resident has had the same brace since he/she first broke his/her kneecap. During an interview on 9/28/18 at 9:55 A.M., Licensed Practical Nurse (LPN) D said: -The resident’s wounds on his/her left leg were from the brace rubbing on it and -They tried using towels and pillow cases to position the resident’s legs in the past but not specifically since he/she started wearing the brace. During an interview on 9/28/18 at 11:04 A.M., the facility’s wound nurse said: -The wound on the resident’s left shin was healed and -They received a physician’s orders [REDACTED]. During an interview on 9/28/18 at 12:00 P.M., the DON said: -The staff should document any preventative measures they put in place for the resident’s brace rubbing on his/her skin and -They did not refer the resident to therapy to evaluate the positioning of the brace. During an interview on 9/28/18 at 12:10 P.M., the resident’s physician’s nurse practitioner said: -The resident is constantly moving himself/herself; -The resident is in his/her wheelchair a lot; -A pillow probably would not stayed between the resident’s legs and -If the resident had been referred to therapy, therapy could have looked at the resident to make sure the brace fit well, to make sure the brace was on properly and for positioning of the brace. 3. Record review of the facility’s inservice sign in sheet on 6/26/18 showed LPN D had attended an inservice on the Wound Vac (vacuum). |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 23) Record review of Resident 17’s admission MDS dated [DATE] said the resident had the following Diagnoses: [REDACTED]. -Pressure ulcer. Record review of the resident’s medical record showed he/she was admitted to the facility on [DATE] from a hospital with a Stage 4 ulcer (wound that exposes bone, muscle, or tissue). The resident was unable to make decisions for his/her self. During an observation on initial tour on 9/18/18 at 10:00 A.M. the resident was observed to have: -A [DEVICE] attached to his/her lower back; -The collection canister was half full with a yellow colored drainage; -The [DEVICE] machine was making a very loud noise indicating a malfunction; and -The seal on the dressing covering the wound and [DEVICE] was stuck to itself not flat to the skin. During an observation and interview on 9/18/18 at 10:33 A.M. with LPN D said: -The resident had a bridge in the [DEVICE] system (an extension to the system); -The nurse was able to stick his/her fingers in the dressing and said that was ok; -The noise was ok; and -According to the facility’s policy it said the wound vac should be sealed to create a vacuum. During an observation on 9/18/18 at 12:44 P.M., showed: -The resident’s dressing covering the wound and [DEVICE] was stuck to itself not flat to the skin; and -The [DEVICE] machine was still making a loud noise indicating it was not working properly. During an observation and interview on 09/18/18 at 02:32 P.M. with the DON and LPN D: -Turned the resident so his/her lower back wound site could be more observable; -The seal on the low back [DEVICE] dressing was stuck to itself not flat to the skin; and -LPN D said the dressing and noise from the machine were ok. During an interview on 09/18/18 at 2:45 P.M. with the DON said: -The [DEVICE] noise and the dressing was not attached correctly; and -He/she would make sure it was fixed. Record review on 09/25/18 at 2:32 P.M., showed the resident’s POS dated 09/04/18 directed the staff to monitor the function of the [DEVICE] every shift. 4. Record review of Resident #115’s Admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. -PU of the left hip, unspecified stage. -Unspecified open wound of the resident’s left foot, sequela (a condition that is the consequence of a previous disease or injury). -Unspecified injury at T11-T12 level of [MEDICATION NAME] spinal cord, sequela. -[MEDICAL CONDITION]. -Diabetes II with diabetic peripheral angiopathy (generic term for a disease of the blood vessels, a common complication of chronic diabetes) without gangrene (dead tissue caused by an infection or lack of blood flow). Record review of Resident’s POS dated 8/2/18 showed physician’s orders [REDACTED].>-Change the resident’s Wound Vac dressing on Monday, Wednesday, and Friday on the 7:00 A.M.-3:00 P.M. shift. -Monitor Wound Vac function every shift and as needed. Record review of the Resident’s Treatment Administration Record (TAR) dated (MONTH) (YEAR) |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0686 Level of harm – Actual harm Residents Affected – Few | (continued… from page 24) showed that the PU and wound vac dressings were not changed on the following dates: -Wednesday 8/8/18. -Monday 8/13/18. -Wednesday 8/15/18. -Wednesday 8/22/18. -Monday 8/27/18. -Friday 8/31/18. Record review of Resident’s POS dated (MONTH) (YEAR) showed: -No order for a Wound Vac machine to wounds. Record review of the Resident’s TAR dated (MONTH) (YEAR) showed that the PU dressings were not changed on Monday 9/3/18. Record review of the Resident’s medical record showed only one entry for a missed dressing change on 9/3/18 as follows: -Dressing changes not done this shift. -Nurse told resident several times that he/she was ready to change the dressings. -The resident was either in another resident’s room or outside each time the nurse went to do the dressing changes. -The on-coming nurse was informed. Record review of Resident’s Care Plan (written out plan for the care of the resident) dated 9/7/18 showed: -Risk for developing a pressure ulcer, currently has PU. -Goal: will have intact skin by next review of 12/31/18. -Interventions: –Reposition/shift weight to relieve pressure. –Minimize pressure over bony prominences. –Provide pressure relieving or reduction device: —Low air loss mattress. —Chair cushion. —Pressure reduction device in wheelchair. —Reposition. Record review of Resident’s medical record showed no Care Plan for the care of the Resident’s wounds or the use of a Wound Vac. Record review of the Resident’s Wound Rounds charting dated 8/28/18 at 1:38 P.M. showed: -Physician here for rounds. -Resident non-compliant with wound care/dressing changes. -While changing his/her dressing he/she would not roll to the right side to allow access to the wound on the left great trochanter (a part of the thigh bone). -While taping the bridge (connects two or more dressings to a wound vac) down he/she continued to state the tape was tight and to remove it. -Resident continu | |
| F 0692 Level of harm – 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0692 Level of harm – Actual harm Residents Affected – Few | (continued… from page 25) it easier for the heart to pump), high blood pressure medications and was sent to the hospital emergency room for a very low pulse and blood pressure and for critical lab results which resulted in the resident to have poor kidney function and was placed on hospice (end of life care); and to assist the resident with his/her meals after being readmitted to the facility after a hospital stay with a significant change in condition for one sampled resident (Resident #34) out of 23 sampled residents. The facility census was 114 residents. Record review of the facility’s hydration policy dated as revised 3/1/13 showed: -Instructions for staff to staff to watch for risk factors for dehydration such as insufficient fluids, loss of appetite, the use of diuretics refusal of fluids and Dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes) and -Clinical symptoms of a deficit of fluids include decreased blood pressure. 1. Record review of Resident #34’s care plan dated 4/21/16 showed instructions to staff to encourage the resident to eat and drink. Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/10/18 showed the following staff assessment of the resident: -Was severely cognitively impaired; -Required supervision, encouragement or cueing with eating and -Had [DIAGNOSES REDACTED]. Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED]. -A diet order of mechanical soft and discontinued on 9/21/18; -A physician’s orders [REDACTED]. – A physician order [REDACTED].>-A physician orders [REDACTED]. Notify MD if any BP meds are held) and discontinued on 9/21/18; -Please encourage po fluids at all meals dated 2/28/17 and discontinued on 9/21/18; -Monitor BP and pulse weekly. Notify MD is SBP is less than 90 or above 200 or if pulse is less than 50 every day dated 7/18/17 and discontinued on 9/21/18 and -[MEDICATION NAME] 30 mg daily dated 7/3/18 (hold if SBP is below 100. Notify MD if any BP meds are held) and discontinued 9/21/18. Record review of the resident’s nurse’s note dated 9/8/18 at 5:24 P.M. showed he/she consumed 75% of breakfast and 50% of lunch. Record review of the resident’s Nurse’s Note dated 9/8/18 at 11:47 P.M. showed he/she was fed dinner by a Certified Nursing Assistant (CNA). Record review of the resident’s Nurse’s Note dated 9/10/18 at 5:17 P.M. showed: -The resident was fed breakfast by staff; -The resident’s family member fed the resident lunch and -The resident’s family member reported that the resident ate 100% of the food they brought from home. Record review of the resident’s physician’s progress note dated 9/11/18 showed: -The resident’s heart rate was low at 47 beats per minute (normal is 60-100); -The resident was seen urgently for low heart rate and low blood pressure; -The resident has a very dry mouth; -Nursing stated the resident refuses to drink regular water and likes sweets and -The resident’s family brought the resident in [MEDICATION NAME] flavored water to drink. Record review of the resident’s Nurse’s Note dated 9/17/18 at 12:50 P.M. showed the resident’s blood pressure was low at 115/46 ( normal range is 120/80) and the resident’s pulse was low 47. |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0692 Level of harm – Actual harm Residents Affected – Few | (continued… from page 26) Observation on 9/18/18 at 10:00 A.M. showed the resident was asleep in bed. Observation on 9/18/18 at 1:28 P.M. showed the resident was in his/her wheelchair in his/her room. Record review of the resident’s Nurse’s Note dated 9/18/18 at 4:54 P.M. showed the resident’s blood pressure medication was held due to a low blood pressure of 84/44. Record review of the resident’s Nurses’ Notes showed there were no nurses’ notes dated 9/19/18-9/20/18. Observation on 9/20/18 at 11:45 A.M. showed the resident was in his/her room in his/her wheelchair. Record review of the resident’s Nurse’s Note dated 9/21/18 at 12:55 A.M. showed the resident’s blood pressure medication was held due to a low blood pressure of 97/37. The physician was informed. The physician ordered a Basic Metabolic Panel (a blood test that measures sugar levels, electrolytes, fluid balance, and kidney function), Urinary Analysis and a Complete Blood Count (a test that gives information about blood cells) in the morning. Record review of the resident’s lab results dated 9/21/18 at 11:38 A.M. showed: -The resident’s white blood cell count was elevated at 11.0 (normal range 4.5-10.5) which can indicate an infection; -The resident’s red blood cell count was low at 3.45 (normal range 3.9-5.2) which can indicate [MEDICAL CONDITION] (when one doesn’t have enough healthy red blood cells to carry adequate oxygen to the body’s tissues), kidney disease and other conditions; -The resident’s potassium level was elevated at 5.4 (normal range 3.5-5.1) which can indicate kidney disease; -The resident’s blood urea nitrogen (BUN-A measurement of the amount of nitrogen in the blood. A high BUN may indicate heart failure or dehydration) was elevated at 71 (normal range 7-25); -The resident’s Creatinine (blood test is used to assess kidney function) was elevated at 3.7 (normal range 0.6-1.3) which can indicate dehydration and/or impaired kidney function; -The resident’s hemoglobin level (the protein molecule in red blood cells) was low at 8.4 (normal range is 12.0-16.0) which can indicate [MEDICAL CONDITION]; -The resident’s Hematocrit (a blood test that measures the percentage of red blood cells found in whole blood) was low at 27.8 (normal range is 36.0-48.0) which can indicate conditions such as [MEDICAL CONDITION] or blood loss and -The lab was dated, initialed and it was hand-written on the lab results that the resident was sent to the emergency room . Record review of the resident’s Nurse’s Note dated 9/21/18 at 3:12 P.M. showed: -Staff reported to the nurse that the resident’s eyes appeared to roll back and he/she was not responding; -The resident’s blood pressure was 85/44 and -The Nurse Practitioner was at the facility and gave an order to send the resident to the emergency room . Record review of the resident’s hospital notes dated 9/21/18-9/26/18 showed the resident had [DIAGNOSES REDACTED]. Hypovolemia occurs with dehydration or bleeding). Record review of the hand-written report called from the hospital note dated 9/26/18 showed the following: -The resident was returning to the facility with hospice services and -A diet order of puree food with thin liquids. Record review of the resident’s POS dated 9/26/18 showed physician orders: -[MEDICATION NAME] CD 240 mg daily dated 9/26/18 (hold if SBP is less than 90 or pulse is |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0692 Level of harm – Actual harm Residents Affected – Few | (continued… from page 27) less than 50. Notify MD if any BP meds are held); -Please encourage po fluids at all meals dated 9/26/18; -Monitor BP and pulse weekly and notify MD if SBP is less than 90 or above 200 or pulse is less than 50 every day dated 9/26/18; -[MEDICATION NAME] 12.5 mg twice a day dated 9/26/18 and -[MEDICATION NAME] 25 mg three times a day, date 9/26/18. Record review of the resident’s baseline care plan dated 9/26/18 showed: -The resident required some or total assistance to eat/drink and he/she had a chewing, swallowing or choking problem and -Instructions for staff to assist the resident with eating. Record review of the resident’s initial data collection tool/nursing service dated 9/26/18 showed the resident: -Eats poorly; -Has trouble swallowing; -Has choking problems; -Accepts fluids when offered and -Had a [DIAGNOSES REDACTED]. Observation on 9/26/18 at 2:40 P.M. showed: -There were five bottles of flavored water in the resident’s room. One of the bottles had been opened and about 1/4 of it was gone and -There was an insulated mug that had water in it by his/her television. During an interview on 9/26/18 at 2:45 P.M., CNA G said: -The resident’s family brings bottled water; -They put the flavored water in her pitcher in the resident’s room; -They give the resident flavored water at meals and -The resident’s family member comes every day at lunch and gives the resident flavored water when he/she’s here. Record review of the resident’s POS upon return from the hospital on [DATE] showed diet orders for puree food (food that is ground and altered into a consistency of a soft, smooth, thick paste (similar to a thick pudding) that requires very little or no chewing) and to encourage beverages with all meals. Observation on 9/27/18 at 7:45 A.M. showed the resident(‘s): -Tongue was coated with a white substance that was cracked in appearance; -Water pitcher was on his/her bedside table; -Flavored water bottle was half full and – A sucker was on the open wrapper on the bedside table. Continuous observation on 9/27/18 showed: -At 8:20 A.M.: –The resident was in bed. –The resident’s water pitcher was on his/her bedside table. –The resident’s flavored water bottle was half full. –The resident’s sucker was on the open wrapper on the bedside table. -At 8:24 A.M., housekeeping was cleaning the resident’s room. -At 8:41 A.M., the housekeeper left the resident’s room. -At 8:43 A.M., the resident was served a breakfast tray in his/her room that consisted of eggs, oatmeal, bread, 1/2 a glass of orange juice, [MEDICATION NAME] water, unopened butter and jelly. Certified Medication Technician (CMT) A elevated the resident’s head to sitting up in bed. Staff did not assist the resident with his/her breakfast. The resident was not able to feed himself/herself. |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0692 Level of harm – Actual harm Residents Affected – Few | (continued… from page 28) -At 8:54 A.M., the resident was crying out. -At 8:56 A.M., the charge nurse walked by the resident’s room. -At 9:01 A.M., the resident was crying out. The resident cried out my leg. -At 9:05 A.M., the resident’s breakfast tray remained untouched on a bedside tray. -At 9:15 A.M., the resident’s breakfast tray remained untouched on a bedside tray. No staff entered the resident’s room since his/her breakfast tray was delivered. The resident’s food and drink remained untouched. -At 9:17 A.M., staff were picking up room trays. CMT A offered the resident a sip of orange juice. The resident shook his/her head no. The resident was offered flavored water. The resident took a sip of flavored water. CMT A removed the resident’s meal tray. The resident was not offered any food. The resident’s glass of orange juice and flavored water were left for the resident. During an interview on 9/27/18 at 10:10 A.M., the resident’s family member said: -The resident’s appetite declined around the same time he/she complained of knee pain on 9/7/18; -The resident began pocketing food in his/her cheeks and not eating and -He/she noticed the resident was more lethargic recently. Record review of the resident’s Nurse’s Note dated 9/27/18 at 3:23 P.M. showed Registered Nurse (RN) A documented: -The resident ate a few bites for breakfast; -The resident’s family member brought the resident lunch and -The resident’s family member reported to RN A that the resident ate two bites and refused to eat or drink. Record review of the resident’s Nurse’s Note dated 9/27/18 at 6:56 P.M. showed RN A documented: -CNA F reported to RN A that he/she served the resident dinner and -CNA F reported to RN A that the resident’s family member asked CNA F to take away the resident’s dinner as the family member was bringing the resident soup. Continuous observation on 9/28/18 showed: -At 9:10 A.M.: –The resident was in bed. –A breakfast tray was in the resident’s room uncovered. It included pureed eggs, oatmeal, bread, water and orange juice. The resident was not feeding himself/herself and staff were not in the room assisting the resident. None of the food and/or drinks were consumed. -At 9:15 A.M., a housekeeper began cleaning the resident’s room. -At 9:20 A.M.: –The resident had not eaten any food. –A CNA removed the resident’s breakfast tray without offering the resident any food or drink. During an interview on 9/28/18 at 8:00 A.M., CMT B said: -The resident drinks flavored water when taking his/her medications; -The resident will drink orange juice when he/she is in the dining room; -The resident will eat cereal for breakfast and -The resident will feed himself/herself. During an interview on 9/28/18 at 9:25 A.M., CNA D said: -The resident was able to feed himself/herself and -He/she would encourage the resident to eat and then inform the charge nurse. During an interview on 9/28/18 at 9:50 A.M., CNA E said: -The nurses will report to the CNAs if there is anything going on with the residents; |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0692 Level of harm – Actual harm Residents Affected – Few | (continued… from page 29) -He/she was informed of the cares of all the residents on the wing currently working; -The resident was able to feed himself/herself but required a lot of cueing and -The meal tray should be covered until the staff are sitting next to him/her and assisting/cueing him/her to eat or feeding him/her. During an interview on 9/28/18 at 10:10 A.M. RN A said: -CNAs are present for morning shift report; -CNAs can get information about the resident off the assignment sheet and the resident list; -The resident was able to feed himself/herself with verbal cueing; -The resident would eat what he/she wants to eat and if he/she doesn’t want to eat it, he/she won’t; -Family have been coming in and bringing food for the resident; -The resident does not drink regular water but will drink flavored water his/her family brings in; -He/she attempted to feed the resident but he/she would not eat anything; -The resident had always been a picky eater but it has been decreasing recently and -He/she would expect staff to assist the resident with meals. During an interview on 9/28/18 at 12:00 P.M. the Director of Nursing (DON) said: -He/she expected staff to assist residents with meals as needed; -He/she expected staff to feed residents when needed; -He/she did not expect staff to place a room tray in the room, uncover the meal and leave the room if the resident was unable to feed himself/herself; -The resident was able to feed himself/herself when he/she wants to eat; -The resident does need assistance with meals; -The resident would eat the dessert first; -The resident doesn’t have the appetite so he/she is not eating as much as he/she was before; -The resident will only drink flavored water and will not drink orange juice and -The resident’s family said the resident will eat sweets. During an interview on 9/28/18 at 12:10 P.M. the resident’s physician’s Nurse Practitioner said: -He/she would expect the staff to feed the resident if he/she was unable to feed himself/herself and -He/she would expect staff to notify him/her of a resident refusing to eat if the resident was refusing to eat on a regular basis. MO 871 | |
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 30) -Resident #106’s quarterly MDS dated [DATE] showed the resident was cognitively intact; -Resident #37’s quarterly MDS dated [DATE] showed the resident was cognitively intact; -Resident #48’s quarterly MDS dated [DATE] showed the resident was cognitively intact; -Resident #2’s quarterly MDS dated [DATE] showed the resident was cognitively intact; -Resident #14’s annual MDS dated [DATE] showed the resident was cognitively intact; -Resident #39’s quarterly MDS dated [DATE] showed the resident was cognitively intact and -Resident #15’s quarterly MDS dated [DATE] showed the resident was cognitively intact. During the resident group meeting on 9/18/18 at 10:22 A.M.: -Resident #15 said staff tell the residents they are short-staffed and that they are tired; -Resident #37 said he/she doesn’t get his/her medication timely; -Resident #14 said he/she has to bang on the walls in the morning to get someone to come get him/her out of bed; -Resident #6 arrived to the meeting at 10:25 A.M. and said they were just getting his/her spouse up out of bed; -Resident #15 and #48 said staff often tell them that they can get up after breakfast, so they have to eat breakfast in their rooms because staff don’t get them up before breakfast; -Residents #14, #15, #48 and #106 said it frequently takes an hour for staff to answer their call lights; -Residents #2, #14, #15, #37, #39, #48 and #106 said: –The facility is short-staffed and because of the facility being short-staffed, they are not gotten out of bed timely, not put to bed timely, they get medications late, the call light response time is very long and their beds don’t get made. 2. Record review of the facility staffing sheets from 9/10/18 through 9/27/18 showed that the facility was below the facility staffing ratios for the nursing staff on these days for he entire building: – On 9/10/18 the facility was short three licensed nurses and three CNA’s; -On 9/11/18, the facility was short two licensed nurses and four CNA’s; -On 9/12/18, the facility was short two licensed nurses and two CNA’s; -On9/13/18, the facility was short two licensed nurses and three CNA’s; -On 9/14/18, the facility was short six CNA’s; -On 9/15/18, the facility was short eight CNA’s; -On 9/16/18, the facility was short nine CNA’s; -On 9/17/18, the facility was short one licensed nurses and three CNA’s; -On 9/18/18, the facility was short seven CNA’s; -On 9/19/18, the facility was short four CNA’s; -On 9/20/18, the facility was short five CNA’s; -On 9/21/18, the facility was short seven CNA’s; -On 9/22/18, the facility was short seven CNA’s; -On 9/23/18, the facility was short seven CNA’s; -On 9/24/18, the facility was short six CNA’s; -On 9/25/18, the facility was short three CNA’s; -On 9/26/18, the facility was short five CNA’s and -On 9/27/18, the facility was short two CNA’s. 3. Record review of Resident #16’s medical record showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Nocturia (frequent urination at night); -High blood pressure and |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 31) -The resident is not able to make decisions about his/her cares. During an observation and family interview on 09/17/18 at 2:00 P.M. the spouse said: -They live together in the same room; -The spouse has written a blue sheet (grievance) almost every month since he/she has lived here and would like both of them to move to a different facility; -He/she said the staff will put his/her spouse to bed at 8:30 P.M.; -The staff will not check on him/her all night; -The resident is not able to toilet himself/herself; -The spouse has talked to the Administrator about getting more help especially on the evening and night shifts and -The resident was not able to use the call light or answer a question with more than a one word answer. During an observation on 09/22/18 at 11:15 P.M. the evening charge nurse had called two of the night shift CNAs (Certified Nurse Assistant) who had been scheduled for the night shift and were more than 30 minutes late; -One CNA said he/she was not scheduled for that shift; -The charge nurse was not able to contact the other CNA and -The night shift worked without two of the CNAs that had been scheduled. During an interview on 09/27/18 at 11:00 A.M. the Director of Nursing (DON) said: -The facility has open positions for five full time CNA’s and five full time nurses; -The facility is currently working with a local college to try to hire more help. -The CNA’s that work here have several issues: -They have limited resources such as transportation and daycare; -They have little family support and -They are frequently late or don’t show up; -He/she has had to come in and work on the floor as a CNA and -He/she has given himself/herself 18 months to try to resolve this issue. During an interview on 09/28/18 at 07:00 A.M. Licensed Practical Nurse (LPN) E said: -In the last 30 days the night shift is short staffed 50% of the time; -He/she frequently has to work extra shifts; -The night shift is short five full time positions; -As a result of not having enough staff the residents are left wet longer and -The residents do not get turned every two hours like they should be. During an interview on 09/28/18 at 11:00 A.M. with the Administrator he/she said: -The parent company of the facility has a good staffing budget and -The facility is currently working with an online employee recruiting tool. 4. During an observation on 9/18/18 the following employees were observed to be on their personal cell phones: -Two on the 100 hallway; -Three on the 300 hallway and -Two on the 400 hallway were looking at pictures. During an interview on 9/23/18 at 10:00 A.M., the Administrator said: -He/she knows there’s a problem with staff being on their cell phones during work hours; -It’s hard to get the employees to stop using their cell phones and -When the new Director of Nursing (DON) was hired he/she has been slowly working on this problem. During an interview on 9/27/18 at 8:23 A.M. LPN E said: -He/she works the night shift; -He/she is in charge of the 600 hallway and locked unit with 13 and 30 residents |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 32) respectively; -The facility should have one nurse and one Certified Nurse Assistant (CNA) to work on each hallway; -In the past month he/she said they were short staffed 50% of the time; -At times there is a Certified Medication Technician (CMT) in charge of the locked unit with a CNA with the nurse being the only staff on the other hallway; -That has happened twice this last month; -Over the last 30 days there were 10 times that people could not get up when they wanted to because there was not enough staff and -It takes longer to get to each resident if there is only one staff so they are wet longer. During an observation on 9/27/18 at 12:37 P.M. the following employees were observed to be talking on their personal cell phones: -One on the 100 hallway; -One on the 200 hallway and -One on the 400 hallway. During an observation on 9/27/18 at 1:15 P.M. one employee on the 200 hallway was observed on his/her personal cell phone looking at pictures. 5. During an interview on 9/28/18 at 9:00 A.M. LPN C said: -He/she works his/her regular shift plus two extra most weeks because of shortages or call ins and -Record review of the staffing sheet showed in the last 17 days he/she has worked 20 shifts. During an interview on 9/28/18 at 9:15 A.M. Registered Nurse (RN) A said: -He/she works here full time and an extra two to three shifts a week; -If he/she doesn’t work extra when there is a call in he/she will get complaints the next day from the residents about cares not having been done and -Record review of the staffing sheet showed he/she had worked 24 shifts in the last 17 days. MO 055, MO 371, MO 094 and MO 416 | |
| F 0730 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Observe each nurse aide’s job performance and give regular training. Based on interview and record review, the facility failed to provide the annual 12 hours |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0730 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 33) -The staff should have 12 hours of training; and -Training should be annually. During an interview on 9/28/18 at 9:00 A.M. LPN C said: -He/she takes the facility training whenever it is offered; -He/she does not do any outside training or classes; and -He/she does not think the amount of training the facility provided equaled 12 hours. During an interview on 9/28/18 at 9:15 A.M. RN A said: -He/she does not do any training outside of the facility; and -He/she did not think the amount of training would equal 12 hours. During an interview on 9/28/18 at 11:59 A.M., the Director of Nursing (DON) said: -Staff education is done throughout the year; -Monthly inservices cover different categories; -Staff receive a minimum of 12 hours a year; and -He/she believes that dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) care is covered yearly. | |
| F 0741 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 34) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document indications, symptoms, reason or [DIAGNOSES REDACTED].#80) out of 23 sampled residents. The facility census was 114 residents. 1. Record review of Resident #80’s nurses’ notes dated (MONTH) (YEAR)-September (YEAR) showed no documentation regarding symptoms or indications for the use of [MEDICATION NAME] (an antidepressant that has a sedating effect). Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].>-Dated 7/31/18 for [MEDICATION NAME] (an antidepressant) 20 milligrams (mg) for Depression (a mental disorder in which the individual has intense sadness or despair that affects their daily life) and -Dated 8/3/18 for [MEDICATION NAME] 25 mg at bedtime and there was not a [DIAGNOSES REDACTED]. Record review of the resident’s care plan dated 9/18/17 with a goal date of 6/13/18 showed: -The resident made negative statements about himself/herself; -The resident made negative statements about life; -The goals were that the resident would allow basic cares and not harm himself/herself or others; -The resident was at risk of mood and/or behavior changes related to depression and -The care plan did not include the use of [MEDICAL CONDITION] medication. Record review of the resident’s annual Minimum Data Set ( MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/10/18 showed the following staff assessment of the resident: -Was cognitively intact; -The resident’s self-reported mood symptoms indicated mild depression; -Had no behaviors and -Had a [DIAGNOSES REDACTED]. Observation during an initial tour conducted on 9/17/18 at 10:39 A.M. showed the resident was lying in bed watching television. Observation on 9/24/18 at 6:21 A.M. showed the resident was asleep in bed. During an interview on 9/28/18 at 9:42 A.M., Certified Nursing Assistant C said the resident had not said anything about having trouble sleeping. During an interview on 9/28/18 at 12:00 P.M., the Director of Nursing (DON) said: -There should be a [DIAGNOSES REDACTED]. -There should be documentation of symptoms indicating the need for [MEDICATION NAME]. | |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 35) oxygen tubing off the floor for one sampled resident (Resident #269) and to keep oxygen tubing bagged when not in use for two sampled residents (Resident’s #269 and #110) out 23 sampled residents. The facility census was 114 residents. Respiratory Therapy Policy and Procedure Manual; Chapter 1 Oxygen Therapy; Infection control dated 3/28/16 showed: -Change oxygen supplies weekly and when visibly soiled. -Humidifier/Aerosol bottles should be dated and replaced every seven days regardless of water level; -Store oxygen and respiratory supplies in bag labeled with resident’s name when not in use and -Licensed healthcare providers are responsible for seeing that oxygen equipment/supplies are setup and cared for and for the removal of the equipment from rooms when the oxygen is discontinued. Record review of the facility’s policy dated 05/01/2015 Central Vascular Access Device said: -Central vascular access devices includes peripherally inserted central catheter (PICC) lines; -Nurses caring for patients receiving infusion therapies are expected to follow infection control and safety compliance procedures; -The catheter insertion site (where the tubing enters the skin) is a potential entry site for bacteria that may cause a catheter-related infection; -A transparent dressing is the preferred dressing; -Dressing change is performed if the integrity of the dressing has been compromised (wet, loose, or soiled); -The staff is directed to apply the transparent dressing, according to the manufacturers’s instructions, smoothing around the catheter starting at the insertion site and moving to the periphery (outer edge); and -The staff is directed to observe the site with intermittent therapy or when not in use. Record review of the facility’s policy dated 12/29/2014 Negative Pressure Wound Therapy (a [DEVICE] is a machine that helps to heal a wound with negative pressure), said: -The wound must be surrounded by enough intact periwound skin (tissue surrounding a wound) to ensure an airtight seal (of the occlusive seal); and -The nurse should check that the dressing is fully sealed at the beginning of each shift and every four hours after. 1. Record review of the Resident #269’s Admission record showed he/she: -Was admitted on [DATE]; -Was a Full Code status; -Had no known drug allergies [REDACTED].>-Had a diet of pureed food and pudding thick liquids and -Had no diagnoses listed. Record review of the resident’s undated Nutrition data Collection/Assessment record showed the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] reflux disease (GERD – back up of stomach acid/heartburn); -Hypertension (HTN- high blood pressure) and -[MEDICAL CONDITION] Fibrillation (A-Fib – abnormal heart rhythm). Record review of the resident’s Admission Minimum Data Set (MDS – a federally mandated assessment tool completed by the facility staff for care planning) dated 9/25/18 showed he/she has cognitive loss/dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 36) functioning). Observation on 9/17/18 10:35 A.M., showed the resident’s oxygen tubing lying on floor behind the concentrator not bagged. Observation on 9/25/18 03:00 P.M., showed the resident’s oxygen tubing laying on floor behind concentrator not bagged and a family member was in room and said he/she had used it once since being admitted to the facility. Record review of the resident’s Physicians Order Sheet (POS) dated (MONTH) (YEAR) showed: -No physician’s order for oxygen and -No order for C-Pap (a ventilation device that blows a gentle stream of air into the nose during sleep to keep the airway open). 2. Record review of Resident #110’s Admission record showed he/she was admitted on [DATE] with [MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability of the lungs to perform ventilation). Record Review of the Resident’s POS dated (MONTH) (YEAR) showed: – Oxygen at 3 Liters (L) per Nasal Cannula continuously each shift; -No orders for the C-Pap machine. Record review of the resident’s Care Plan (written out plan for the care of the resident) dated 8/24/28 showed no care plan for oxygen usage. Record review of the resident’s 14-Day MDS dated [DATE] showed he/she had [MEDICAL CONDITION] and [MEDICAL CONDITION]. Observation on 9/18/17/18 10:40 A.M., showed: -The resident not wearing oxygen; -Oxygen concentrator settings were 3.5 lpm (liters/per minute); -Oxygen tubing not bagged lying on the concentrator and -C-pap mask lying on nightstand not bagged. 3. During an interview on 9/28/18 11:59 A.M., the Director of Nursing (DON) said: -Oxygen tubing should be bagged if the resident is not using it and -C-Pap mask should be bagged when not being used by a resident. 4. Record review of Resident’s #17 MDS dated [DATE] showed the resident had the following Diagnoses: [REDACTED]. -Pressure ulcer (wound that is an opening in the skin) and -The resident was not able to make decisions about his/her cares. Record review of the resident’s medical record showed: -He/she was admitted to the facility on [DATE] from a hospital with a Stage 4 ulcer (wound that exposes bone, muscle, or tissue); -The resident was on an antibiotic (Memperim) intermittently to be given through his/her PICC line; -The resident was to receive [MEDICATION NAME] (a liquid food substitute) through a feeding tube as well as pureed food and -He/she had a [DEVICE] dressing to his/her lower back. Observation on initial tour on 9/18/18 at 10:00 A.M. showed the resident: – Had a [DEVICE] attached to his/her lower back; -The seal on the dressing covering the wound and [DEVICE] was stuck to itself not sealed flat to the skin; -The occlusive dressing covering the PICC line was loose not covering the insertion site; -The antibiotic with tubing was not dated with the date it was hung and -The [MEDICATION NAME] bottle and tubing were not dated with the date it was hung. During an observation and interview on 9/18/18 at 10:33 A.M. with Licensed Practical Nurse (LPN) D he/she said: |
| 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: 265355 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LIFE CARE CENTER OF GRANDVIEW | STREET ADDRESS, CITY, STATE, ZIP 6301 EAST 125TH 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 37) -The nurse was able to stick his/her fingers in the dressing but that was ok; -The occlusive dressing covering the PICC line was loose and not covering the insertion site; -The antibiotic with tubing was not dated; -The [MEDICATION NAME] bottle and tubing were not dated. -LPN D said he/she thought the antibiotic may have been discontinued but the resident may need a lab sample before he/she could take out the PICC line. Observation on 9/18/18 at 12:44 P.M. showed the resident: -The [DEVICE] dressing was still stuck to itself and not flat to the skin; -The occlusive dressing covering the PICC line was loose not covering the insertion site; -The antibiotic with tubing was not dated and -The [MEDICATION NAME] bottle and tubing were not dated. During an observation and interview on 09/18/18 at 02:32 P.M. the DON said: -The [DEVICE] dressing was still stuck to itself not sealed flat to the skin; -The occlusive dressing covering the PICC line was loose and not covering the insertion site; -The antibiotic with tubing was not dated and -The [MEDICATION NAME] bottle and tubing were not dated. During an interview on 09/18/18 at 2:45 P.M. the DON said: -The [DEVICE] dressing, and the PICC line dressing were not correct; -The antibiotic bottle and tubing were not dated when opened; -The [MEDICATION NAME] bottle and tubing were not dated when opened; and -He/she would make sure it was fixed. Observation on 9/22/18 at 10:30 A.M. showed the resident: -The [MEDICATION NAME] bottle was not dated and -The feeding tube tubing was not dated. 5. Record review of Resident #46’s face sheet showed he/she was admitted on [DATE] with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] (impaired lung function that leads to a decreased oxygen uptake). Record review of the resident’s medical record showed he/she was not able to make his/her needs known. Record review of the resident’s (MONTH) (YEAR) POS showed he/she had an order for [REDACTED].>During an observation and interview on 9/20/18 at 09:30 A.M. with Registered Nurse (RN A): -A [MEDICATION NAME] tube feeding was infusing the bottle nor the tubing were dated; -RN A said the [MEDICATION NAME] container and the tubing should be dated and -The tubing and the bottle should be dated showing when it was opened. | |
