| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 – Few | 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 – Few | (continued… from page 1) -Nursing staff was in-serviced on the bed hold process during the summer of (YEAR) and -The nursing staff were given education on the transfer forms. | |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 2) Record review of the resident’s Medical Record showed there was no PASARR Level II screening in the resident’s medical record. 3. During an interview on 10/1/18 at 1:40 P.M., the Human Resources Manager said: -The former Social Service Director used to ensure that the PASSAR level I and II screenings were completed and in the resident’s medical record; -Since he/she has taken on the role, he/she was not aware that they were supposed to check the Level I screening to see if a Level II was indicated and follow up on that, so the screening on the residents were not completed and -Now that he/she is aware, he/she will make sure to check and follow up on any level II screenings that are required or indicated. | |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 3) Worker, along with discussing what needs to be done related to care plans and -Everyone is responsible for making sure the care plans are updated. During an interview on 10/03/18 at 11:48 A.M., the MDS Coordinator said the resident’s care plan should be reviewed and revised after a Significant Change MDS is completed; and he/she would check the computer to see if the resident’s care plan was updated. During an interview on 10/03/18 at 12:24 P.M., the MDS Coordinator said after checking the computer he/she did not find a revised or updated care plan. During an interview on 10/03/18 at 12:52 P.M., the Director of Nursing (DON) said: -Nursing staff puts orders onto the care plan; -There should have been a revision to the resident’s care plan after the resident significant change and -Training with MDS workers and CNAs for MDS coding and care planning is still taking place all across the board. | |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 4) from prolonged pressure the bony area of the lower spine) and -[MEDICAL CONDITION] ([MEDICAL CONDITION]- an [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs). Record review of the resident’s Admission Minimum Data Sheet (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/3/18 showed he/she: -Was unable to complete the Brief Interview for Mental Status (BIMS); -Needed the staff’s guidance with decisions; -Needed assistance of one to two nursing staff for Activities of Daily Living (ADL’s); -Was frequently incontinent of bowel and -Had an indwelling urinary catheter which drained into a urinary drainage bag. Record review of the resident’s Care plan for ADL’s dated 7/6/18 showed the resident; -Had a urinary indwelling catheter; -The facility nursing staff were to provide care routinely and as needed; -The nursing staff were to notify the residents nurse of leakage around the catheter and -The resident complained of pain or discomfort from the urinary catheter. Record review of the resident’s Nurses Treatment Administration Record (TAR) dated 6/26/18 showed the resident did not have physician’s orders for the care of an indwelling urinary catheter with a urinary drainage bag. Record review of the resident’s (MONTH) (YEAR)’s Physician’s Order Sheet (POS), showed the resident: -Had no physician’s orders for an indwelling urinary catheter; -Had no physician’s orders for changing the urinary catheter and -Had no physician’s orders for care and cleaning of a urinary catheter. Record review of the resident’s nursing progress notes dated 7/1/18 to 7/12/18 showed the resident had an indwelling urinary catheter. Record review of the resident’s a SBAR (acronym for Situation, Background, Assessment, and Recommendation) communication form dated 7/13/18 at 10:00 P.M., showed he/she: -Was found on the floor; -Had [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Vital signs were within normal limits; -Had pulled out the urinary catheter with the indwelling balloon inflated; and -He/she denied pain; -The resident’s physician’s office had been notified; and -The physician’s nurse practitioner responded, and gave an order for [REDACTED]. Record review of the resident’s nursing notes dated 7/13/18 documented during the night shift showe d: -The resident had been found on the floor with her head and shoulders on the bedside fall mat; -He/she had pulled out the indwelling urinary catheter out a second time with the balloon inflated; -He/she had skin tears to both lower legs; -The nurse had assessed the resident; -The nurse initiated neurological checks and vital signs per protocol; -The nurse had found and treated skin tears on the resident’s legs; -The nurses had called the resident’s Physician’s Nurse Practitioner and received an order to replace the urinary catheter; -The nurse had replaced the urinary catheter per the Nurse Practitioner’s order; -The resident was then found at 10:45 P.M. near the door of his/her room; |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 5) -He/she had pulled the urinary catheter out with the balloon inflated a second time; -The resident was taken to the nursing station due to restlessness; -The resident’s responsible party was notified and they said they would discuss what interventions could be used with the resident; -The resident started to get sleepy about 1:00 A.M. on 7/14/18; and the resident was placed back in bed with neurological checks and vital signs continuing. Record review of the resident’s (MONTH) (YEAR)’s POS showed a physicians order to discontinue the Urinary catheter due to the resident’s refusal on 7/23/18. During an interview on 10/3/18 at 8:34 A.M., Licensed Practical Nurse (LPN) A said: -The resident’s Urinary catheter orders should be put on the POS at admission; -The resident should be assessed and if there was no Physician’s order on the transfer document the nurse should request and order from the resident’s physician; and -The admitting nurse should make sure the orders are complete, they should have included the size of the urinary catheter, when it should have been changed, and the care instructions. During an interview on 10/3/18 at 8:50 A.M. Registered Nurse (RN) A said: -A resident with a urinary catheter should have an Physicians order written on the resident’s POS; -Physician’s orders that should have been included on the POS would be the size of the urinary catheter the inflation amount of the indwelling balloon; -The resident then would have orders for the frequency the urinary catheter was to be changed, when the drainage bag should be changed and the types of drainage bags the resident should be using; and -The care instructions should be on the POS also, along with the [DIAGNOSES REDACTED]. During an interview on 10/3/18 at 9:10 A.M., LPN B said: -The nurse should have first the physician’s order for the resident to have a urinary catheter; -The resident should have other orders for the frequency of urinary catheter changes; -There should be a physician’s order for the type of urinary catheter, the size and the amount of sterile water to put into the indwelling balloon; -There should of be a physician’s order for cares and what the physician wants to be used to clean the tubing; -The urinary catheter cares would also needed to be care planned. During an interview on 10/3/18 at 12:26 P.M. the resident’s physician A said, He/She: -Expected to be notified if a resident has transferred to the facility to with a urinary catheter; -When the resident orders needed to be continued, the orders should have been reviewed with him/her, then transcribed to the facilities POS. -The staff did notify him/her that the resident arrived at the facility with a urinary catheter on admission. During an interview on 10/3/18 at 1:28 P.M., the Director of Nursing (DON) said: -Expected the staff to do a head to toe assessment using the check in assessment sheet when doing a new admit; -The check in sheet has a place for the type and size of a urinary catheter; -Expected the nursing staff to transcribe the orders to our POS’s correctly; -If a physician’s order was not on the transfer document for a urinary catheter he/she would expect the staff to notify the resident’s physician and request a physician’s order for the urinary catheter and the cares required for it. 2. Record review of Resident #9’s Admission Face sheet showed the resident was admitted to |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 6) the facility on [DATE] with [DIAGNOSES REDACTED]. and loss of interest),[MEDICAL CONDITION] with septic shock (life threatening infection), Record review of the resident’s care plan dated 3/18/18 showed the resident did not have a care plan for his/her [MEDICAL CONDITION]. Record review of the resident’s discharge MDS dated [DATE] showed the resident; -Was not cognitively impaired and has a BIMS score of 15 and was able to make own discussion, -Had a ostomy -Required limited staff assistance with toileting and cares. Record review of the resident care plan conference summary dated 6/20/18 showed; the staff was to continue with bowel and bladder monitoring. No other care plan updated found related to the resident [MEDICAL CONDITION] in his/her medical chart. Record review of the resident’s Nursing weekly skin integrity tool dated 8/15/18 showed the resident had staples down his/her abdomen, also had redness at the first three staples site, his/her [MEDICAL CONDITION] (a surgical procedure in which a piece of the ileum (lower small intestine) is diverted to an artificial opening in the abdominal wall for the feces to come out instead of the rectum) was on the right side of his/her abdomen. Record review of the resident’s nursing weekly skin integrity tool dated 8/7/18 showed the resident had staples down his/her abdomen staples down abdomen no other documentation noted. Record review of the resident’s readmitting POS dated 8/26/18 showed physician’s orders for; -[MEDICAL CONDITION]/[MEDICAL CONDITION] care was to keep ostomy clean and dry ([MEDICAL CONDITION]). Record review of the resident’s TAR dated (MONTH) (YEAR) showed; -On 8/7/18 the resident’s staples to his/her abdomen, staff are to monitor for signs and symptoms of infection every shift, and -From 8/7/18 to 8/15/18 [MEDICAL CONDITION] care every shift and as needed -On 8/26/18, keep the resident’s ostomy clean and dry and had only been documented on the day shift, -No documentation related to the resident providing self-care of his/her [MEDICAL CONDITION]. Record review of the resident’s Nursing Collection data tool dated 8/26/18 showed the resident was readmitted to the facility, his/her bowel pattern section had documentation that the resident had a [MEDICAL CONDITION], no other documentation related to his/her ostomy. Record review of the resident’s Nursing Collection Data Tool dated 8/30/18 showed the resident was readmitted to the facility, his/her bowel elimination section had documentation that the resident had a ostomy was present – [MEDICAL CONDITION], no other documentation related to his/her ostomy. Record review of the resident’s Physician’s History and Physical assessment dated [DATE] showed the resident; -Had a readmission and was seen 8/27/18, back in facility times 24 hours, -Physician had discussed with the resident the risk of getting dehydrated due to his/her [MEDICAL CONDITION], -On 7/29/18, the nurse had notified the resident’s physician about the resident’s abdomen had been ridged and his/her bowel sounds was hypoactive and the resident had also been in pain, -Had been transferred to the hospital with a [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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 7) -Then transferred to another hospital were he/she had surgery for [REDACTED]. -Problem list showed the resident had an ischemic bowel with a total colectomy on 7/29/18 and the Ostomy bag needed to be change as needed. Record review of the resident’s Nursing Collection Tool dated 9/8/18, showed the resident; -Had been readmitted : and the section on the tool labeled bowel elimination pattern had documentation showing the resident had a ostomy that was present -[MEDICAL CONDITION] medical necessary documentation: please summarize any medical condition that would exceed routine care and require the skills of a licensed nurse. Documentation should include assessment, planning, and any interventions required to administer care: the staff wrote [MEDICAL CONDITION] care, -Under the nurse’s comments was documentation that the resident had been readmitted from the hospital for abnormal labs and had undissolved stitches at the [MEDICAL CONDITION] site, -Had nursing evaluation of his/her bowels dated 9/8/18 showed the resident had recent surgery on 7/29/18 for a right hemicolectomy (is a surgical procedure that involves the removal of the cecum (a pouch connected to the junction of the small and large intestines), the ascending colon (the first part of the large intestine, which passes upward from the cecum on the right side of abdomen), the hepatic colon (where the ascending colon joins the [MEDICATION NAME] colon), the first third of the [MEDICATION NAME] colon, and part of the terminal ileum, along with the fat and lymph nodes) with an [MEDICAL CONDITION]. -Had nursing evaluation of his/her bowels dated 8/26/18 showed the resident had recent surgery on 7/29/18 for a right hemicolectomy with an [MEDICAL CONDITION] -Nursing staff was to change and empty his/her [MEDICAL CONDITION] bag as needed. Record review of the resident’s Certified Nursing Assistant (CNA) daily skin inspection record for (MONTH) (YEAR) showed no documentation of the resident’s [MEDICAL CONDITION] for the three shifts. Record review of the resident’s medical record showed the resident had hospital discharge notes dated from 9/5/18 – 9/8/18. He/she was admitted to the hospital with [REDACTED]. Had increased output of loose stool through his/her [MEDICAL CONDITION], gastric pathogen panel was negative. Had a wound care consulted to manage [MEDICAL CONDITION] due to concerns for leakage of the stool. During an interview on 9/28/18 at 11:42 A.M. the resident said ostomy care was very new for him/her, was not comfortable with the smell from the [MEDICAL CONDITION] and with his/her body image at this time. Denied any complaint of redness or pain at the site. He/she said staff had been providing care for his/her ostomy. During an interview on 9/28/18 at 12:00 P.M., RN A said; -The CNAs provide the care for the residents with [MEDICAL CONDITION], -CNA’s would apply skin prep to the ostomy area and place a new bag as needed, and would also drain or burp the ostomy bag, -The facility was able to obtain [MEDICAL CONDITION]’s bag that did not required to be changed every day, -The resident does not have a physician’s order for the licensed nursing staff to assess the resident stoma or provided [MEDICAL CONDITION] care, -RN A said if he/she happen to be in the resident’s room during [MEDICAL CONDITION] care, then he/she would assess the resident stoma site at that time. Record review of the resident’s POS for 10/18 showed the resident did not have physician’s orders for the care or monitoring of his/her [MEDICAL CONDITION]/[MEDICAL CONDITION]. 3. Record review the Resident #7’s Face sheet showed the resident; |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 8) -Was admitted to the facility on [DATE], -Had a [DIAGNOSES REDACTED]. Record review of the resident’s medical record showed the resident had a letter showing that his/her durable Power of Attorney (DPOA) had been activated on 4/8/18 by two physician’s signature Status, Record review of the resident’s Care Plan dated 5/3/16 and edited on 3/21/18, showed; -On 9/20/18 in a handwritten note showed to continue with the resident current plan of care, -The resident continues to be independent with ADLs care, with supervision as indicated, -Requires supervision for ADLs, the resident has a [MEDICAL CONDITION], he/she has been caring for his/her own [MEDICAL CONDITION] for years without any issue, -The resident’s goal was to maintain current level of independence through next review date, -The care plan intervention included; — Daily skin checks by the CNA’s, –Weekly and as needed skin assessments by the LPNs, Bathing supervision and setup as needed, (MONTH) need extra encouragement to bath, -Nursing staff are to document and report any deterioration in status to the resident’s physician. -Under toileting requires supervision and setup as needed: the staff wrote the resident cares for his/her own [MEDICAL CONDITION]. Record review of the resident’s quarterly MDS dated [DATE] showed the resident; -Was not cognitively impaired and has a BIMS score of 15 and was able to make own discussion, -Had a ostomy -Required no assistance with toileting, -Had a [DIAGNOSES REDACTED]. Record review of the resident’s medical record showed bowel evaluation was done on 9/10/18, showed the resident; -Had short term memory only, -Had been independent with his/her own care of his/her [MEDICAL CONDITION], -Bowel sound had been active time four quad areas, his/her bowel movement had been soft to medium and the color was a light to medium, -Had no documentation showing an evaluation had been done for the resident to provide self-care of his/her [MEDICAL CONDITION], -Had no documentation related physician’s orders for the resident to provide his/her own self-care, -Had no documentation related to physician’s orders for the nursing staff to provide ongoing assessment, monitoring and care of the resident’s [MEDICAL CONDITION] and his/her stoma. Record review of the resident’s Physician’s Progress Note dated 9/20/18, showed the resident; -Had a [MEDICAL CONDITION] located on his /her right lower Quad, -Abdomen was soft, non-tender to touch, and -[MEDICAL CONDITION] was intact, and the resident’s bowels sounds were active. Record review of the residents TAR dated (MONTH) (YEAR), showed; -The resident had no documentation for the care of his/her [MEDICAL CONDITION], or to provide his/her own self care, -Nursing staff were to provide weekly skin assessments. |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) Record review of the resident’s Nursing Skin Checks reviewed for (MONTH) and (MONTH) (YEAR) showed the resident skin assessments had been completed; -Nursing documentation showed the resident had no skin issues, and on some of the skin assessment had documented had a [MEDICAL CONDITION], -Did not have a formal detail assessment of the stoma site or if any issue had related to his/her [MEDICAL CONDITION], -No documentation related to obtain a physician’s order for the resident to provide self-care of his/her [MEDICAL CONDITION]. Record review of the resident’s POS dated 10/1/18 to 10/31/18 showed the resident; -Had a [DIAGNOSES REDACTED]. – Had medication related to the bowels included: [MEDICATION NAME] 2 milligram (mg) capsules, take 2 capsules by mouth after the first loose stool, then take 1 capsule by mouth after every subsequent loose stools, -Had no documentation related to the resident’s having physician’s orders for the resident to provide his/her own self-care, -Had no documentation related to the resident’s having physician’s orders for the nursing staff to provide ongoing assessment, monitoring and care of the resident’s [MEDICAL CONDITION] and of his/her ostomy stoma. -Check for bowel movement (BMs) every shift, and to notify the nurse and the resident’s physician’s if no bowel movements in three days. During an interview on 10/03/18 at 9:43 A.M., LPN F said, The resident does not have any odors or a problem with the [MEDICAL CONDITION], -He/she had never seen the resident dirty or smelling; there has not been no change in resident’s mental capacity, -When the resident had been admitted to the facility, the resident already had the [MEDICAL CONDITION] and was doing his/her own cares, -Nursing staff only have to check the resident’s skin, -CNA’s do daily skin checks and the nursing staff do weekly skin assessments, -There were no physician’s order for treatment because the resident does the treatment himself/herself. During an interview on 10/3/18 at 10:07 A.M. LPN C said; -An outside supplier supplies the resident’s [MEDICAL CONDITION] bag; -Supplier calls to check to see if delivery of bags needed at the regular time periods, -Nursing receives the [MEDICAL CONDITION] bags, and knows when resident needs them, -The resident never has fecal matter or wetness at the site, -The resident had not been formally assessed for his/her ability perform his/her own [MEDICAL CONDITION] care, -The resident continues to prove he/she is capable based on daily CNA’s skin checks and nurse assessments. During an interview on 10/03/18 at 1:01 P.M., DON said; – When you look at the resident’s POS the [MEDICAL CONDITION] is under his/her diagnosis, -There probably should be a physician’s order on the resident’s POS that shows the resident was providing own self-care of his/her [MEDICAL CONDITION]. | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 – Few | (continued… from page 10) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the safety of one sampled resident during a transfer in order to prevent a fall from occurring and to transfer the resident safely after initiating interventions that would prevent further falls from the side of his/her bed (Resident #32) and to provide adequate supervision for a resident who goes through alarmed doors to exit the building to the parking lot that is next to a deep ditch and a busy highway for one sampled resident (Resident #12) out of 21 sampled residents. The facility census was 66 residents. 1. Record review of Resident #32’s Face Sheet showed he/she was admitted on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/20/18, showed he/she: -Was confused with inattention and disorganized thought with behavioral symptoms; -Needed extensive assistance with bathing, dressing toileting, bed mobility, transfers, locomotion and used a wheelchair for mobility and did not ambulate and -had a history of [REDACTED]. Record review of the resident’s Fall Risk assessment dated [DATE] showed a score of 24 (a score of 10 or higher was considered at risk). Record review of the resident’s Nursing Notes showed: -On 7/20/18, the Certified Nursing Assistant (CNA) reported the resident fell from a sitting position on the side of his/her bed to the fall mat while the CNA was raising the resident’s bed to transfer him/her to his/her wheelchair. The CNA reported the resident did not hit his/her head. The nurse documented the resident’s vital signs (blood pressure, temperature, respirations and pulse). The resident sustained [REDACTED]. The nurse cleaned the skin tear with normal saline, and applied opti-foam dressing. There was a small amount of bleeding. The resident’s range of motion was within normal limits and there was no shortening of limbs. The resident denied pain. Nursing staff assisted the resident into his/her wheelchair. The resident’s physician and family were notified. The new intervention to be implemented was for the resident to remain in a lying position when raising or lowering the bed. Record review of the resident’s Fall/Incident Investigation dated 7/20/18, showed: -On 7/20/18 at 4:45 P.M., the CNA witnessed the resident fall in the resident’s room; -The resident was alert and confused. There was no change in the resident’s baseline; -The CNA was raising the resident’s bed while the resident was sitting on the side of his/hr bed. The resident reached for something on the floor and fell from the side of the bed onto the floor mat; -The resident sustained [REDACTED]. -Findings showed the CNA was raising the bed while the resident was sitting on the side of the bed (as the root cause of the resident’s fall); -Follow up to prevent recurrence showed there was a new intervention to have the resident in a lying position while raising and lowering the bed; -The resident’s Fall risk (updated on 7/20/18) was 22. The resident’s Pain Evaluation, dated 7/22/18, showed no pain complaint and -The resident’s Care Plan was updated to show the new intervention that staff should leave resident in a lying position when raising or lowering the bed. It also showed treatment to the resident’s skin tear (Cleanse the resident’s right lateral elbow skin tear with normal saline or wound cleanser, pat it dry, cover it with opti foam or equivalent dressing, and change it every three days and as needed). |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 – Few | (continued… from page 11) Record review of the resident’s Care Plan showed there was no update after the resident’s fall on 7/20/18, showing the new intervention to leave the resident laying down when raising or lowering his/her bed. During an observation and interview on 10/2/18 at 2:55 P.M., showed the resident: -In a low bed (almost to the floor) with a mat on the floor; -CNA C went into the resident’s room, put on gloves and removed the mat from the side of the resident’s bed; -The resident sat up on the side of his/her bed and CNA C began to raise the resident’s bed up; -CNA B entered the resident’s room, put on gloves and began assisting CNA C to place the gait belt around him/her and transfer him/her to his/her wheelchair; -Once they were finished transferring the resident, both CNA C and CNA B said: -They were aware of the resident’s falls; -The resident would often reach and lean forward because he/she was trying to get things; -CNA C said he/she usually would sit the resident up on the side of the bed while they raised the bed up to prepare to transfer; and -CNA C was unaware that the resident was not to sit up on the side of the bed while the bed was being raised. During an interview on 10/3/18 at 2:14 P.M., the Director of Nursing (DON) said: -Nursing staff should not raise the bed while the resident is sitting on the side of the bed; -The resident’s fall was avoidable because staff should not have raised the resident’s bed while the resident was sitting up on the side of the bed and -The resident’s fall interventions should be on the care plan. Record review of the facility’s Elopement Policy dated 7/1/16 showed that residents who eloped should be safely and timely redirected to a safe environment. 2. Record review of Resident #12’s Admission record face sheet showed he/she was initially admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Delusional disorder (an unshakable belief in something untrue or not based on reality); -Conduct disorder (a repetitive and persistent pattern of behavior in which the basic rights of others are violated); –Anxiety disorder (a group of mental disorders characterized by significant feelings of anxiety and fear) and -Restlessness and agitation: a feeling of aggravation, annoyance, or restlessness brought on by little or no provocation). Record review of the resident’s Risk of Elopement/Wandering was completed initially on 12/19/17 and showed: -The resident was assessed to have poor decision making skills; -He/she had a pertinent [DIAGNOSES REDACTED]. -He/she had been admitted or readmitted to the facility within the past 30 days and was not accepting of the situation; -The resident’s family/guardian preferred the resident to be on a locked Unit; -The facility was locked and secured; -The resident did not have a [DIAGNOSES REDACTED]. -The facility’s staff was not to allow the resident to be out of the facility without his/her guardian. Record review of the resident’s care plan dated 1/15/18 showed: -The resident had altered thought processes due to paranoid [MEDICAL CONDITION]; -The resident was a risk for harm to self and others; |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 – Few | (continued… from page 12) -Staff was to monitor the resident for changes in cognition and to notify the resident’s physician of his/her decline and -The staff was to monitor for safety risks and to intervene as needed. Record review of the resident’s Non-Emergency Ambulance Transportation from a local hospital for transportation returning to the facility dated 2/4/18, signed by a Registered Nurse(RN) said: -The resident had a psych condition and was a high elopement risk and -He/she required to be on one to one monitoring by a trained medical personnel. Record review of the resident’s nursing notes dated 7/11/18 at 1:45 P.M. showed: -The resident attempted to open the doors to the solarium; -The resident was unsuccessful in the attempt to open the doors and -He/she returned to his/her room. Record review of the resident’s nursing notes of 7/14/18 at 9:00 P.M. showed: -The resident opened the alarmed door at the end of hallway into the independent living apartments; -The resident went out through the independent living apartment doors to the parking lot; – A staff member followed the resident into the parking lot; -The resident became verbally and physically aggressive toward the staff; -The resident was brought back into the building by the staff member who then escorted the resident to their room; -The on duty nurse notified the Director of Nursing (DON), the resident’s physician, and the resident’s Mental Health provider; -The resident’s physician’s on call nurse practitioner gave an order for [REDACTED].>-The resident accepted the injection of [MEDICATION NAME]; -The resident’s mental health provider had called and had given a medication order for [MEDICATION NAME] 1 mg orally or [MEDICATION NAME] 1 mg by injection intramuscularly ( IM-into a muscle) as needed (PRN) for 14 days and -The resident was put on staff visual safety checks every 15 minutes for 24 hours. Record review of the resident’s Nurse Notes dated 7/22/18 at 12:45 A.M. showed: -The resident left the facility by the door at the end of the resident’s hallway that opens into the independent living facility; -The facility staff went out into the parking lot through the front door and a nurse followed the resident out the door at the end of the hallway; -The resident had a bag and was attempting to get into a car; -The facility staff spoke to the resident and convinced her to return to the building, -The DON was notified of the elopement and -The Mental Health provider was notified of the elopement and gave an order to give the resident an injection of [MEDICATION NAME] 1 mg IM. Record review of the resident’s Nurse Notes dated 7/22/18 at 2:00 P.M., showed: -The resident was on visual safety checks every 15 minutes through the day; -The resident was going from his/her room to the dining room and -The resident had not attempted to elope during the nursing shift. Record review of the resident’s Nurse Notes dated 7/23/18 at 6:16 A.M. showed: -The resident had continued on safety checks through the night and -The resident had left his/her room through the night to go to the dining room. Record review of the resident’s Nursing Notes dated 8/2/18 at 8:53 A.M. showed the resident was repeatedly pushing on the solarium doors. Record review of the resident’s Nursing Notes dated 8/2/18 at 9:15 A.M. showed the resident was redirected by the staff when the resident attempted to leave the facility by |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 – Few | (continued… from page 13) the front door. Record review of the resident’s Nurse Notes dated 8/3/18 at 11:40 A.M. showed: -The resident pushed and hit his/her Mother; -He/she attempted to push through his/her Father to exit the front door; -The resident was brought back into the facility by the staff; and -The resident was verbally abusive to the staff. Record review of the resident’s Nurse Note dated 8/17/18 at 1:45 A.M. showed: -The resident had left the facility through the west hallway door; -The staff redirected the resident back into the facility; -The staff notified the DON, Mental Health provider, the resident’s physician and the resident’s guardian; and -The resident was put on every 15 minute safety checks. Record review of the resident’s Nurse Notes dated 8/19/18 at 12:00 A.M. showed the resident: -Was on 15 minute safety checks; -Was in his/her room packing a bag; and -Had to be convinced it was too late to leave the facility. Record review of the resident’s Quarterly MDS dated [DATE] showed the resident: -Was cognitively intact; -Required supervision or oversight on and off his/her Unit/hallway;-Was continent of bowel and bladder; -Had received antipsychotic (a medication used to treat psychiatric disorders) 7 out of 7 days during the look back period; and -Had received antianxiety (a medication which has a calming effect) medication 7 out of 7 days during the look back period. During a interview on 10/2/18 at 9:48 A.M. Licensed Practical Nurse (LPN) B said; -When facility staff had noticed the resident near a door, the staff had always attempted to redirect the resident; and -Waits until the staff were busy to make his/her attempt to leave the facility. During an interview on 10/2/18 at 10:02 A.M. LPN A said we had not received any special training to care for the resident with the [DIAGNOSES REDACTED]. During an interview on 10/3/18 at 1:28 P.M. with the Director of Nursing (DON) said: -Expected the staff to redirect the resident when they saw him/her near an exit door; -Expected the staff to use the facility’s policy on elopement/wandering when a resident left the facility unattended; -Expected the staff to notify the DON, the resident’s physician and the guardian when a resident elopes; and -Expected the staff to use the interventions in the resident’s care plan to prevent future attempted elopements. | |
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure safe |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 14) expiration dates for 4 out of 9 medication carts. The facility census was 66 residents. 1. Observation on 10/01/18 at 12:17 P.M. of the Certified Medication Technician (CMT) cart on The Memory Care Unit showed one Milk of Magnesia (MOM) had an expiration date of 2/2018 and had an open date of 6/18. During an interview on 10/1/18 at 12:17 P.M. , CMT A said: -The medication carts are checked monthly for expired medication and -The MOM should have been pulled and not used. Observation on 10/01/18 at 12:22 P.M. of the CMT Medication Cart on the East hall showed: -One bottle of liquid tears (eye drops) with no open date on the vial but was dated on box and -One bottle of MOM had an expiration date of 2/2018 and had an open date of 8/18. During an interview on 10/1/18 at 12:22 P.M. , CMT B said: -The medication carts are checked monthly for expired medications and -The MOM should have been pulled and not used. Observation on 10/01/18 on 12:37 P.M. of the CMT Medication Cart on the West hall showed: -Two open bottles of liquid tears with no opened date on the vials and -One open bottle of nasal spray with no opened date on the bottle. During an interview on 10/3/18 at 1:30 P.M., the Director of Nursing (DON) said: -All medications bottles should have dates on the medication bottles and boxes to show the date it was opened; -It was not appropriate to open an expired medication and date that medication bottle with the date it was opened after the expiration date and administer the expired medication to the residents and -The nurses and CMTs medication carts are checked monthly for expired medication and the expired medications are to be removed from the medication cart and disposed of appropriately. | |
| F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Based on observation, interview, and record review the facility failed to 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) -Hold on steam table above 160 degrees Fahrenheit. -Note: use only the amount of liquid necessary to puree the product. Do not increase or decrease the amount of vegetables or bread. Observation of the process of pureeing the vegetables showed the following: -At 11:42 A.M., Dietary Cook (DC) A pureed the vegetables without recipe book open; -At 11:42 A.M., DC A did not add vegetable juice or melted margarine/butter; and -At 11:42 A.M., DC A placed the pureed vegetables in a pan and placed the pan on the steam table without tasting the pureed vegetables. During a taste test on 10/1/18 at 11:49 A.M., the pureed vegetables tasted bland. During an interview on 10/1/18 at 11:51 A.M. DC A said he/she did not add margarine to the pureed veggies which caused them to be bland. During an interview on 10/1/18 at 1:40 P.M., the Dietary Manager (DM) said employees are trained in making pureed foods and using the recipes in the recipe book is a part of that training. | |
| F 0805 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0805 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to prevent 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 17) – At 1:54 P.M., the Activities Assistant said the sherbet in the freezer did not belong to the activities department. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: – In Chapter 3-305.14, During preparation, unpackaged Food shall be protected from environmental sources of contamination. – In Chapter 4-202.11, regarding Food-Contact Surfaces; Multi-use Food-Contact Surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and 4) Finished to have smooth welds and joints; – In 4-203.11 B) Temperature Measuring Devices, Food. Food temperature measuring devices that are scaled only in Fahrenheit shall be accurate to ?2 ?F in the intended range of use. – In Chapter 4-601.11, Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. – In Chapter 4-602.13, non-Food-Contact Surfaces of Equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; – In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean. | |
| F 0814 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Dispose of garbage and refuse properly. Based on observation, interview and record review, the facility failed to ensure the | |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 18) The facility census was 66 residents. Record review of the facility Infection Prevention Hand Hygiene/Handwashing policy and procedure dated 9/2011, showed hand hygiene/handwashing technique will be accomplished at all times that handwashing is indicated. Procedures: -Hand hygiene/Handwashing is done before resident contact, after contact with soiled or contaminated articles, such as articles that are contaminated with bodily fluids, after patient/resident contact, after contact with a contaminated object or source where there is a concentration of micro organisms, such as mucous membranes, non-intact skin, body fluids or wounds. -Handwashing/Hand hygiene is done after removal of medical/surgical or utility gloves, contact with a patient’s/resident’s intact skin, performing physical examinations, lifting residents/patient while in bed, and when in contact with environmental surfaces in the immediate vicinity of patients/residents. -When hands are visibly soiled , wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. -If hands are not visibly soiled, use an alcohol based rub for routinely decontaminating hands in all other clinical situations. Record review of the facility Indications for Glove Use policy and procedure dated 9/2011, showed standard/universal precautions are intended to prevent the exposure of non-intact skin and mucous membranes of health care workers to others blood and body fluids. Personnel will routinely use appropriate precautions when contact with the blood or bodily fluids except sweat of any patient/resident is likely. Gloves are an appropriate barrier for protection from blood or body substances likely to soil the hands. -Gloves are worn when touching blood and body fluids, except sweat; touching mucous membranes or non-intact skin; touching urine, stool or vomit; handling items or environmental surfaces soiled with blood or body fluids, except sweat; when performing venipuncture and other vascular access procedures and anytime required by the facility policy, procedure or regulations. -Gloves are changed between residents/patients, if contaminated with blood or body fluids before touching other parts of the same resident/patient. -Hands are washed immediately after gloves are removed, before contact with another resident/patient or the environment. -Hands are washed or decontaminated prior to donning gloves. 1. Record review of Resident #4’s Face Sheet showed the resident was was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident’s quarterly Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/10/18, showed the resident: -Was alert and oriented with little confusion. -Needed total assistance with bed mobility, transfers, dressing, bathing, toileting and mobilized in a wheelchair. -Had upper and lower extremity limitations. Record review of the resident’s physician’s orders [REDACTED]. Observation on 10/03/18 at 9:18 A.M., showed the resident was sitting up in his/her wheelchair in his/her room. Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B came into the resident’s room and washed their hands, turning off the water with a paper towel. Supplies were laying on a clean towel on the resident’s tray table. RN A laid a sterile towel down on the resident’s bed and laid supplies there (gauze and cotton pads). RN A then: |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 19) -Took out sterile gloves and put them on. He/She poured sterile water in one container and peroxide in another. -He/she then changed sterile gloves and removed the resident’s trachea cannula tube and removed the old dressing (from around the cannula). He/she removed his/her gloves and discarded them. -RN A then, without washing or sanitizing his/her hands, opened a package containing sterile gloves and put them on. He/she then cleaned the cannula tubing in the peroxide solution. LPN B poured saline over and into the cannula tubing as RN A held the cannula tube. -RN A then discarded his/her gloves and without washing or sanitizing his/her hands, opened another package of sterile gloves, put them on and cleaned the resident’s skin around the [MEDICAL CONDITION] (using a cotton gauze) with saline, then cleansed the [MEDICAL CONDITION] itself (the resident began to cough and RN A stopped and allowed the resident to calm). -RN A continued to clean the area using one gauze per swipe and disposed of the gauze. -RN A then, without de-gloving, washing or sanitizing his/her hands, placed a new pad around the [MEDICAL CONDITION] and re-inserted the [MEDICAL CONDITION] tubing cannula. RN A then de-gloved. -RN A discarded his/her gloves, without washing or sanitizing his/her hands, he/she opened another package of sterile gloves and put them on then placed the suction tubing in saline (with the machine turned on ) and began to suction the resident’s [MEDICAL CONDITION]. When the resident said she felt that all of the phlegm was out RN A stopped suctioning. -RN A de-gloved the left hand and placed another glove on it, then changed the resident’s neck strap. -RN A then assisted the resident to leave the room. During an interview on 10/3/18 at 9:40 A.M., RN A said: -He/she brought additional sterile gloves in the room as a precaution. -After he/she cleansed the resident’s tube and after cleaning around the resident’s [MEDICAL CONDITION] site, he/she should have sanitized his/her hands. -When he/she read their policy, the policy did not show that hand washing was necessary, but since it is a sterile procedure, he/she should have used hand sanitizer after changing from a dirty to clean process. -He/she was nervous. During an interview on 10/03/18 at 2:14 P.M., the Director of Nursing (DON) said: -Their policy for [MEDICAL CONDITION] care and his/her expectation is for the nurse to wash hands upon entry. -The RN should have washed or sanitized her hands after cleaning the resident’s [MEDICAL CONDITION] site and after cleansing the cannula, before starting the clean processes. -According to their policy the nurse should have suctioned the resident first, but he/she should have washed his/her hands prior to suctioning the resident and again once the process was completed. 2. Record review of Resident #69’s Face Sheet showed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident’s quarterly MDS dated [DATE], showed the resident: -Was alert with inattention and disorganized thoughts and memory loss. -Needed extensive assistance with bathing, dressing, transfers, toileting and mobilized in a wheelchair. -Was at risk for wounds and had a skin tear that the facility was treating with ointment and dressings. |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) Observation on 9/28/18 at 8:35 A.M., showed RN B brought the resident into the resident’s room to complete wound care. He/She had placed his/her supplies on a barrier on the resident’s tray table and then washed his/her hands, turning the water off with a paper towel and gloved. The resident was sitting up in his/her wheelchair. RN B then: -Took the resident’s sock off of his/her left foot and rolled up the compression sock on the resident’s left leg. There was a bandage on the resident’s anterior left calf that RN B removed. He/she then de-gloved. -Without washing or sanitizing his/her hands, RN B gloved then used wound cleanser to spray onto the resident’s leg wound and wiped it using sterile gauze. -After cleaning the wound and surrounding area, RN B removed his/her gloves. -Without washing or sanitizing his/her hands, RN B opened an alcohol wipe, cleaned a pair of scissors, discarded the wipe, and opened the new dressing. -RN B then gloved, cut the Xeroform dressing (a sterile, non-adhering, protective gauze dressing that provides a moist environment for healing), placed Santyl (an ointment used to help break up and dissolve dead skin) on the Xeroform, then placed the Xeroform on the resident’s wound. -RN B then removed his/her gloves, and without washing or sanitizing, put on another pair of gloves and placed the Xeroform dressing over the resident’s wound. -RN B de-gloved and dated the dressing. -RN B then put on another pair of gloves and without washing or sanitizing his/her hands, placed a dry gauze on a red area on the resident’s skin that was above the dressing and taped the area to hold it down. He/she then removed his her gloves. -RN B then put on another pair of gloves and without washing or sanitizing his/her hands pulled the resident’s compression sock and pant leg down and put his/her sock back on. -RN B then washed his/her hands turning off the water with a paper towel. During an interview on 9/28/18 at 8:50 A.M., RN B said: -He/She should have sanitized his/her hands (or washed them) every time he/she changed his/her gloves. -The reason that he/she did not sanitize his/her hands (during the wound care treatment) was because there was no hand sanitizer in the supplies that he/she brought into the resident’s room and he/she thought about going to get it but did not. 3. Record review of Resident #32’s Face Sheet showed the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident’s quarterly MDS dated [DATE], showed the resident: -Was confused with inattention and disorganized thought with behavioral symptoms. -Needed extensive assistance with bathing, dressing toileting, bed mobility, transfers, locomotion and used a wheelchair for mobility and did not ambulate. During an observation and interview on 10/2/18 at 2:55 P.M., showed the resident was in a low bed (almost to the floor) with a mat on the floor: -Certified Nursing Assistant (CNA) C went into the resident’s room and without washing or sanitizing his/her hands put on gloves and removed the mat from the side of the residents bed. -The resident sat up on the side of his/her bed and CNA C began to raise the resident’s bed up. -CNA B entered the resident’s room and without washing or sanitizing her hands, he/she put on gloves and began assisting CNA C to place the gait belt around him/her and transfer him/her to the wheelchair. -Once they were finished transferring the resident, both CNA C and CNA B said that they were supposed to wash their hands upon entering the resident’s room prior to providing |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) care and after they completed care, before leaving the resident’s room. 4. Record review of the Resident #50 Face sheet showed the resident was readmitted to the facility on [DATE], original date 5/17/13 with [DIAGNOSES REDACTED]. Record review of the resident’s Care Plan dated 4/19/18 showed the resident: -Had excoriation gaulding on buttock was updated on 5/17/18, was started on [MEDICATION NAME] (an antibiotic) 500 milligrams (mg) daily x 10 days for wound infections to his/her coccyx, and [MEDICATION NAME] in place times 4 weeks. -An update on 5/18 showed the resident was sent to the hospital related to a leaking catheter. -On 5/20/18 showed to continue [MEDICATION NAME] until completed. -On 7/8/18 was sent to the hospital for evaluation and treatment. -Goal was: gaulded/excoriated area to buttocks will receive treatment as ordered: –Notify the resident’s physician of decline in condition of his/her skin, any open areas to skin as indicated. –Updated on 7/14/18 -the resident was readmitted : coccyx/bilateral buttocks and left ischial tuberosity (hip), cleanse open areas with normal saline, cleanse intact skin with [MEDICATION NAME] and skin cleanser, then rinse well, pat dry, apply [MEDICATION NAME] to open areas, cover with meplix foam border dressing and sacral border dressing, wound dressing to be changed every two days and as needed. –Nursing staff to apply [MEDICATION NAME] protective ointment as needed to protect surrounding skin. Record review of the resident’s Quarterly MDS dated [DATE] showed the resident: -Was not cognitively impaired and had a BIMs (Brief Interview for Mental Status) score of 15 and was able to make his/her own decisions. -Had an ostomy. -Required extensive staff assistance with toileting and cares. -Had one unhealed stage 4 pressure ulcer. -Had [DIAGNOSES REDACTED]. Record review of the resident’s Treatment Administration Record (TAR) for (MONTH) (YEAR) showed: the resident wound on his/her coccyx/bilateral buttocks and on his/her left ischial tuberosity: -Was to clean the wounds with normal saline (NS) to the open area of the wounds. -Cleanse the surrounding intact skin with [MEDICATION NAME] cleanser (Skin wound and general skin cleanser, will help prevent cross-infection of dangerous staph infections) and skin cleanser, then rinse and pat dry. -Apply [MEDICATION NAME] wound dressing (a type of collagen dressing designed to kick start the healing process while providing protection from infection) inside the wounds and cover with boarder dressing and sacral boarder dressing. -Change the resident’s dressing every two days and as needed, if the dressing was soiled or had fallen off. -Apply [MEDICATION NAME] protective ointment as needed to protect surrounding skin. During an observation of the resident’s mechanical transfer on 9/28/18 at 10:00 A.M., showed: -CNA/RA already in the resident’s room and CNA F enter the resident’s room and obtain pair of gloves without washing his/her hands or using hand sanitizer. – CNA/RA placed the sling under the resident on right side, then rolled the resident to left side to remove the resident’s old brief, then position the shower sling (has hole to wash bottom area. -CNA’s did not change gloves or was theirs hands and continue to connect the sling to 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 22) Hoyer, -Raised the resident up in the air and slowly moved to the shower chair. -CNA/RA guided the resident while LPN A managed the Hoyer. -The resident was transferred to the shower chair. -Nursing Staff removed gloves before leaving the resident’s room and washed their hands with soap and water. During observation of the resident’s wound care on 09/28/18 at 11:05 A.M., showed: -RN A and RA/CNA and CNA G was present in the resident room. -The nursing staff did not wash his/her hand when enter the resident’s room. -The RN A had setup a paper barrier for the resident’s wound care supplies. -The RN A had used hand sanitizer for his/her hands then applied gloves and began wound care for the resident. -He/she had cleaned the resident’s wound on his/her coccyx/bilateral buttocks and then on his/her left hip with normal saline soak gauze pad. -He/she cleaned inside the wound of the coccyx first then with a new gauze wipe cleaned around outside the resident’s coccyx wound, and then repeated the process for all three wounds. RN A did not remove his/her gloves or washed or santitize his/her hands inbetween each of the three wounds. After the last wound was cleaned RN A -Removed his/her gloves and used hand sanitizer on his/her hands, and then placed new gloves on his/her hands. -RN A had cleaned the scissors and then cut the [MEDICATION NAME] dressing to fit each of the three wounds and placed a piece of the [MEDICATION NAME] in each of the resident’s wounds and he/she covered the resident’s wounds with two dressing. -RN A had dated and initials the dressing. -RN A removed his/her gloves and washed his/her hands. During an interview on 9/28/18 at 11:16 A.M. RN A said: -When he/she entered or exited the resident’s room he/she should either wash his/her hands or use hand sanitizer. -Before providing wound care should have washed his/her hands with soap and water then applied a new pair of gloves. -If the residents have more than one wound, should had treated each wound separately to prevent cross contamination. -He/she should have washed his/her hands between each wound. -He/she said that he/she did not follow the resident’s physician order [REDACTED]. -Instead he/she had just used normal saline to clean the intact skin around the resident’s wound. -His/her plan was to redo the dressing change later today. 5. During observation of resident’s blood sugar monitoring on 9/28/18 at 7:26 A.M. with RN B showed for Resident #34 and Resident #15: -RN B entered the residents room and used hand sanitizer for his/her hands, then applied gloves to his/her hands. -Checked the resident’s blood sugar, for Resident #34, RN B had the same gloves on his/her hands used to perform the resident’s blood sugar monitor and then gave the resident’s his/her insulin per multi dose insulin pen with same gloves on his/her hands. -Removed his/her gloves and washed his/her hands before exiting the resident room. -RN B said each resident had their own glucometer in a black cloth case, then RN B had taken the glucometer in the case into the resident’s room and placed onto the resident’s bedside table without a barrier. -After checking the resident’s blood sugar, he/she returned to the medication cart 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 23) without cleaning the glucometer machine and the outside of the glucometer case, had placed each resident’s glucometer machine back into the medication cart drawer, next to the other resident’s glucometer case. During an interview on 9/28/18 at 7:51 P.M., RN B said: -The residents each have their own glucometer and should be cleaned at least every shift. -He/she should have had a barrier for the glucometer bag and should clean the outside with bleach wipe afterwards. 6. During an infection Control interview on 10/02/18 at 2:38 P.M., LPN C /Unit Manager said: -The staff’s hands should be washed before and after providing care, when noticeably soiled, before and after administering eye medication, peg tubes, and other treatments. -Hand sanitizer can be used between residents when passing medication. During an interview on 10/03/18 at 2:14 P.M., the DON said he/she expects nursing staff to wash their hands or use hand sanitizer upon entering the resident’s room, before putting on gloves, with each glove change, when going from dirty to clean processes, and before leaving the room after removing gloves. | |
| F 0923 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Have enough outside ventilation via a window or mechanical ventilation, or both. **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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 0923 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 24) – At 2:02 P.M., there was the absence of negative air flow from the restroom ceiling vent in resident room [ROOM NUMBER]; – At 2:14 P.M., there was the absence of negative air flow from the restroom ceiling vent in resident room [ROOM NUMBER]; and – At 2:16 P.M., there was the absence of negative air flow from the restroom ceiling vent in resident room [ROOM NUMBER]. During an interview on 10/2/18 at 10:01 A.M., the Maintenance Director said they do not let him/her know when there is the absence of negative air flow. There are work order sheets at both nurse’s stations and they (the facility staff) should fill out the work order sheets. | |
| F 0925 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Based on observation, interview and record review, the facility failed to maintain |
| 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: 265362 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB | STREET ADDRESS, CITY, STATE, ZIP 2203 EAST MECHANIC STREET | |||||||||
| 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 0925 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 25) Chapter 6-501.111 Controlling Pests. The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: A) Routinely inspecting incoming shipments of food and supplies; B) Routinely inspecting the premises for evidence of pests; C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and D) Eliminating harborage conditions. 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the premises at a frequency that prevents their accumulation, decomposition, or the attraction of pests. | |
