| 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: 265364 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LINN OAK REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 196 HIGHWAY CC | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| 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: 265364 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LINN OAK REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 196 HIGHWAY CC | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Based on record review, observation, and interview, facility staff failed to ensure the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265364 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LINN OAK REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 196 HIGHWAY CC | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) During an interview on 3/21/19 at 3:01 P.M., Certified Nursing Assistant (CNA) B said staff use the disinfectant spray to clean the shower rooms. Furthermore, he/she said disinfectants, razors, and ointments should be stored in locked cabinets in the shower rooms. He/she said the shower room doors do not automatically lock, and that is why staff should lock the items in the cabinets. During an interview on 3/21/19 3:02 P.M., Licensed Practical Nurse (LPN) C said staff are expected to store all disinfectants, razors, and ointments in locked cabinets out of reach of residents. Furthermore, he/she said staff should dispose of sharps only containers when they get to the fill line. LPN C said he/she expects the person who filled the sharps container to get a new one, and dispose of the full one. He/she said nothing should be above the full line, and staff should not remove the top of the container. During an interview on 3/21/19 at 4:15 P.M., the Director of Nursing (DON) said staff are expected to dispose of razors properly, and he/she expects staff to alert someone if the sharps only container needs to be disposed of. He/She said staff should not remove the top of the sharps only container. Furthermore, he/she said staff are expected to store chemicals and new razors locked in cabinets in the shower room, and kept out of reach of residents. | |
| F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, facility staff failed to serve food |
| 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: 265364 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LINN OAK REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 196 HIGHWAY CC | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 3) chicken broth and blended. Observation showed the cook added three and one half slices of bread to the pureed product and blended. Observation showed the cook poured unmeasured amounts of the pureed pork into five divided plates. Observation showed the consistency of the pureed pork to be thin like soup. Observation on 03/19/19 at 1:09 P.M., showed Cook H prepared pureed stuffing in the food processor. Further observation showed the cook scooped unmeasured amounts of the pureed stuffing into five divided plates. Observation on 03/19/19 at 1:20 P.M., showed Cook H prepared pureed yams in the food processor. Further observation showed the cook scooped unmeasured amounts of the pureed yams into five divided plates. Further observation at this time, showed the DM wrapped the divided plates of pureed foods with foil and delivered the plates to staff in the assisted dining room for service to residents on pureed diets. Further observation showed staff did not prepare or offer the pureed bread to the residents. During an interview on 03/19/19 at 1:16 P.M., Cook H said it is his/her usual practice to divide the pureed products out from the food processor onto the divided plates without the use of measured serving utensils. They cook said the food items are portioned when placed into the food processor so he/she does not measure them again. 3. During an interview on 03/21/19 at 8:51 A.M., the Dietary Manager (DM) said staff should serve meals in accordance with the menus. The DM said the the menus should be reviewed prior to service by staff that serve the meal. The DM said bread should be served with meals when on the menu and by resident choice. 4. During an interview on 03/21/19 at 12:10 P.M., the administrator said staff should prepare foods in accordance with the recipes, serve food items in accordance with the menus and all staff are trained on this requirement. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, facility staff failed to store food in |
| 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: 265364 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LINN OAK REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 196 HIGHWAY CC | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 4) -a 32 oz. box of baking soda open to the air and undated; -a 28 oz. box of cream of wheat opened to air and undated; -an opened and undated 12 oz. bottle of mustard; -an opened and undated 16 oz. bottle of low sodium vegetable base; -an opened and undated one pound jar of chicken stock base; -an opened and undated 42 oz. carton of old fashioned oats; -an opened and undated one gallon bottle of soy sauce; -two opened and undated 14 oz. bottles of ketchup; -an opened and undated 48 oz. container of vegetable shortening; -an opened and undated 48 oz. bottle of vegetable oil. 4. Observation on 03/21/19 at 7:43 A.M., showed the following on the lower shelf in the cook’s station: -a 32 oz. box of baking soda open to the air and undated; -a 28 oz. box of cream of wheat opened to air and undated; -an opened and undated 12 oz. bottle of mustard; -an opened and undated 16 oz. bottle of low sodium vegetable base; -an opened and undated one pound jar of chicken stock base; -an opened and undated one gallon bottle of soy sauce; -two opened and undated 14 oz. bottles of ketchup; -an opened and undated 48 oz. bottle of vegetable oil. 5. Observation on 03/21/19 at 7:46 A.M., showed an opened and undated 46 oz. carton of honey thickened water and an opened and undated 32 oz. bag of smoked ham slices in the glass front reach-in cooler in the cooks’s station. 6. During an interview on 03/21/19 7:51 A.M., Cook G said opened food items should be dated and resealed. 7. Observation on 03/21/19 at 8:26 A.M., showed the following in the main dining room refrigerator: -an opened and undated 46 oz. carton of honey thickened water; -an opened and undated 22 oz. bottle of caramel syrup; -an opened 46 oz. carton of kiwi strawberry nectar thickened juice dated 12-19. Review of the product label showed instruction to discard the juice within 10 days after opening. 8. Observation on 03/21/19 at 8:31 A.M., showed the following in the assisted dining room refrigerator: -an opened and undated 46 oz. carton of honey thickened iced tea; -an opened and undated 46 oz. carton honey thickened golden fruit punch; -an opened and undated 46 oz. carton of honey thickened water; -an opened and undated 46 oz. carton of honey thickened orange juice. Further observation showed staff poured the juice into a glass and served the juice to Resident #40; -an opened and undated 46 oz. carton of honey thickened cranberry juice cocktail. Further observation showed staff poured the juice into two glasses and served the juice to Residents #40 and #46. 9. During an interview on 03/21/19 at 8:51 A.M., the Dietary Manager (DM) said opened food items should be resealed in appropriate containers, labeled and dated. The DM said the dietary aides are responsible for monitoring the refrigerators daily and he/she would expect staff to remove anything that is not dated. The DM said he/she instructed staff to clean out the main dining room refrigerator the day before and he/she would have expected staff to remove the outdated thickened juice. The DM said the facility had not had any residents who required nectar thickened liquids in quite some time and the date written on the carton would be the date the staff opened the carton. 10. Review of the facility’s Dishwashing Machine Use policy dated (MONTH) 2010, showed |
| 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: 265364 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LINN OAK REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 196 HIGHWAY CC | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 5) instruction to allow dishes to air dry after running items through the entire cycle of the dishwashing machine. Review of a sign posted on the clean side of the mechanical dishwashing station showed instruction to allow all dishes to dry before they are removed from the station. Observation on 03/19/19 from 12:56 P.M. to 1:30 P.M., showed Cook H prepared pureed pork roast in the food processor and then washed the food processor in the chemical sanitizing mechanical dishwasher. Observation showed the cook removed the food processor from the clean side of the dishwashing station while wet and used the food processor to prepare pureed stuffing. Observation showed the cook washed the food processor in the mechanical dishwasher, removed the food processor while wet from the clean side of the dishwashing station and used the food processor to prepare pureed yams. Observation showed the cook placed portions of the pureed food items onto divided plates, wrapped the plates with foil and delivered the plates for service to the residents in the assisted dining room. During an interview on 03/21/19 11:45 A.M., the DM said all dishes should be allowed to air dry after they are washed and all staff are trained on this requirement. 11. During an interview on 03/21/19 at 12:10 P.M., the Administrator said staff should reseal and date opened food items before they are put away. The Administrator also said all dishes should be air dried after being washed and before they are used or put into storage and all staff are trained on these requirements. The Administrator said the DM is responsible to monitor food storage and dishwashing when he/she is in the building. | |
| F 0920 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. **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: 265364 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LINN OAK REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 196 HIGHWAY CC | |||||||||
| 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 0920 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) Observation on 3/19/19 at 11:51 A.M., showed the resident sat at a bedside table in the assisted dining room. Staff assisted him/her with the meal. Additional observation showed the two dining room tables full. Observation on 3/20/19 at 12:11 P.M., showed the resident sat at a bedside table near the wall in the assisted dining room. Staff assisted him/her with the meal. Additional observation showed the two dining room tables full. 4. Review of Resident #9’s quarterly MDS, dated [DATE], showed staff assessed the resident as: – Severe cognitive impairment; -Total physical assistance of one person for toileting and bathing; -Extensive physical assistance of one person for bed mobility, dressing, and personal hygiene; -Extensive physical assistance of two persons for transfers; -Limited physical assistance of one person for eating; and -[DIAGNOSES REDACTED]. -Uses a wheelchair (w/c) for mobility. Observation on 03/19/19 at 11:57 A.M., showed the resident sat sideways and back away from the dining table in the ADR. Observation on 3/21/19 at 12:41 P.M., showed the resident sat sideways at the dining room table in the ADR. 5. Review of Resident #40’s significant change MDS, dated [DATE], showed staff assessed the resident as: – Severe cognitive impairment; -Total physical assistance of one person for dressing, eating, personal hygiene, and bathing; -Total physical assistance of two person for bed mobility, and transfers; -[DIAGNOSES REDACTED]. -Uses a wheelchair (w/c) for mobility. Observation on 3/19/19 at 12:47 P.M., showed the resident sat at a bedside table in the assisted dining room. Staff assisted him/her with the meal. Additional observation showed the two dining room tables full. Observation on 3/20/19 at 12:13 P.M., showed the resident sat at a bedside table near the wall in the assisted dining room. Staff assisted him/her with the meal. Additional observation showed the two dining room tables full. Observation on 3/21/19 at 12:18 P.M., showed the resident sat at a bedside table near the wall in the assisted dining room. Staff assisted him/her with the meal. Additional observation showed the two dining room tables full. During an interview on 3/19/19 at 12:48 P.M., the resident’s family member said he/she comes in to assist during the meals and it is always full in the dining room. He/She said often there are two more residents in the dining room that are not in the dining room today. He/She said staff provide the bedside tables but there are no other extra tables available in the dining room. 6. Review of Resident #46’s significant change MDS, dated [DATE], showed staff assessed the resident as: – Severe cognitive impairment; -Extensive physical assistance of one person for transfers, toileting, personal hygiene, and bathing; -Limited physical assistance of one person for bed mobility, dressing, and eating; -[DIAGNOSES REDACTED]. |
| 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: 265364 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LINN OAK REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 196 HIGHWAY CC | |||||||||
| 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 0920 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) -Uses a w/c for mobility. Observation on 03/19/19 at 11:57 A.M., showed Resident #46 propelled himself/herself in his/her wheelchair past Resident #9. Resident #46 could not navigate his/her wheelchair through the area and attempted to back up his/her wheelchair, became entangled with Resident #9’s wheelchair and drug his/her wheelchair along as well. Further observation showed staff came over and removed the foot pedals from the wheelchairs and attempted to center both residents at the table but had to go around and remove all the residents’ foot pedals from their wheelchairs for all the residents to fit at the table. Observation on 3/21/19 at 12:19 P.M., showed Resident #46 sat at a bedside table near the wall in the assisted dining room. Staff assisted him/her with the meal. Additional observation showed the two dining room tables full. 7. Review of Resident #49’s quarterly MDS, dated [DATE], showed staff assessed the resident as: – Mild cognitive impairment; -Total physical assistance of one person for toileting, personal hygiene, and dressing; -Total physical assistance of two person for bathing, -Extensive physical assistance of two person for bed mobility, and transfers; -[DIAGNOSES REDACTED]. -Uses a wheelchair (w/c) for mobility. 8. Observation on 3/19/19 at 12:39 P.M., showed an unidentified resident sat sideways at the dining room table in the ADR. 9. During an interview on 3/21/19 at 12:23 P.M., Certified Medication Technician (CMT) F said he/she feels the dining room is too small for the residents who eat in there right now. He/She said staff have to remove the leg rests to even get the chairs to fit under the tables and prevent injuries from the residents hitting their legs on each other’s leg rests. During an interview on 3/21/19 at 12:49 P.M., Certified Nursing Assistant (CNA) D said staff have discussed how packed the room is lately and they think it is just because they have so many heavy care residents in the ADR. He/She said staff have to remove all the residents’ leg rests from their wheelchairs to even get the residents into the dining room. During an interview on 3/21/19 at 12:56 P.M., CNA B said there are too many residents in the ADR and it isn’t safe. He/She said many times they aren’t able to sit them in there appropriately because of the leg rests so then they have to be moved. During an interview on 3/21/19 at 12:59 P.M., Licensed Practical Nurse (LPN) C said the ADR is pretty crowded right now and there are a lot of heavy care residents in there. He/She said if there were an emergency that required evacuation it would not be done efficiently as it could due to all the leg rests and equipment in there. During an interview on 3/21/19 at 4:20 P.M. the Director of Nursing (DON) said the ADR is small, and does get crowded. He/she said facility staff knows it is a problem. | |
