| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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** |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) sink faucet area was soiled and stained black. During interview on 08/08/18 at 1:20 P.M., the maintenance supervisor said he was responsible for cleaning the ceiling vents. He was not aware of the dusty vents or the black fuzzy debris on the wall and ceiling in the mechanical room. He did not monitor the vents. He was responsible to ensure all lights worked, all lights were covered, and the resident dressers worked properly. During interview on 08/08/18 at 1:58 P.M., the administrator said he expected all vents to be clean and free of dust. He expected there to be no black fuzzy debris anywhere in the building. He expected all lights to work, all lights to be covered, and for all the residents’ dressers to be in good repair. Observation on 08/10/18 at 12:11 P.M. showed the following: -The baseboards throughout resident occupied rooms 300, 302, 303, 305, 307, and 309 were discolored and dirty. The floors around the edge of the baseboards and the toilets were dirty; -The baseboards in the shared resident bathrooms between rooms [ROOM NUMBERS], and between 300 and 302, were discolored and dirty, and the floor around the toilet was discolored and dirty; -The floor tile at the entrance to the bathroom in resident room [ROOM NUMBER] was chipped and pieces of the tile was missing; -The bath tub in the bathroom in resident bathroom [ROOM NUMBER] had yellow stains around the edge of the tub, a circular area in the center, and around the drain. -The lower portion of the wood doors to the bathrooms between resident rooms [ROOM NUMBERS], between resident room [ROOM NUMBER] and 311, and in room [ROOM NUMBER] were discolored, broken and peeling. During interview on 08/10/18 at 4:25 P.M., the maintenance supervisor said the maintenance department was responsible for repairing the floors and the doors. He expected staff to report broken doors and tiles that needed to be repaired. He expected doors and floors to be in good repair. During interview on 08/10/18 at 5:15 P.M., the housekeeping supervisor said the housekeeping department was responsible for cleaning the resident rooms, bathrooms and halls throughout the building. He/she would expect staff to clean around the baseboards and toilets. The housekeeping supervisor verified the baseboards were not clean and the bathtub in room [ROOM NUMBER] was not clean. He/she said the baseboards in those rooms needed replaced and the floors around the walls and toilets needed to be cleaned. He/she would expect the floors, baseboards and bathtub to be clean in all the resident rooms. He/she would expect staff to report broken tile and holes in the doors and any repairs that were needed in resident rooms. Surveyor: Cordray, Terri | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 – Some | (continued… from page 2) [MEDICATION NAME] (generic name Levetiracetam, anti-[MEDICAL CONDITION] medication) blood levels (laboratory blood test) as physician ordered; and failed to appropriately transfer Resident #16 during a Hoyer lift transfer (mechanical lift used for non-weight bearing residents). The census was 57. 1. Review of the facility policy Hydraulic Lift (Hoyer lift), dated (MONTH) (YEAR), showed the purpose was to enable one individual to lift and move a resident safely. 2. Review of the undated Invacare manual for Manual/Electric Portable Patient Lift showed adjustments for safety and comfort should be made before moving the patient. 3. Review of the 2001 revision of the Nurse Assistant in a Long Term Care Facility Manual showed the following: -A mechanical lift is a device used to lift and move residents who are unable to do so on their own. -Two people are needed to use this device safely; -Follow manufacturer’s directions regarding safe use; -Check for proper body alignment. 4. Review of Resident #16’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/12/18, showed the following: -Cognitively intact; -Total dependence of two staff for bed mobility and transfers; -Functional range of motion-impairment of both lower extremities. Review of the resident’s care plan, dated 6/25/18, showed the following: -Problem: Bilateral lower extremity paralysis and need for extensive assist with all activities of daily living and transfers; -Approaches: Assist of two staff and Hoyer lift for transfers. Review of the resident’s Physician Order Sheet (POS), dated 8/1/18 to 8/31/18, showed the following: -[DIAGNOSES REDACTED]. -Up with assist of two staff and Hoyer lift. Observation on 8/8/18 at 3:19 P.M., showed the following: -The resident sat on the Hoyer lift sling in his/her electric scooter in his/her room; -The assistant director of nursing (ADON) and Certified Nurse Assistant (CNA) D entered the room with the Hoyer lift and attached the resident’s sling to the mechanical lift; -CNA D operated the remote as the resident was raised into the air. The ADON walked to the other side of the bed. The resident hung freely as he/she was lifted and his/her left foot hit the emergency stop button on the lift bar. CNA D then grabbed the resident’s lower legs and attempted to move the resident’s feet to the other side of the center hydraulic bar, scraping the resident’s bilateral feet on the bar. The resident yelled ouch. CNA D lowered the resident into bed and backed the lift away from the bed; -As ADON and CNA D rolled the resident to remove the sling pad, the resident complained of his/her little toe, stating, It hurt when you lifted me. The ADON exited the room. During interview on 8/9/18 at 5:05 P.M., CNA D said the following: -He/she did know he/she scraped the resident’s feet against the lift bar, he/she did not know the resident’s foot had hit the emergency button; -He/she should have guided the resident’s feet around the bar instead of forcing them or should have had a second staff pull the resident back away from the bar. During interview on 8/10/18 at 2:00 P.M., the resident said he/she knew during the transfer, his/her foot scraped the bar as he/she felt it and that’s why he/she yelled, ouch. During interview on 8/10/18 at 2:45 P.M , Licensed Practical Nurse (LPN) A said two staff |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 – Some | (continued… from page 3) should be present during a Hoyer transfer with one staff driving the lift, the second guiding the resident, and both watching the feet to ensure there are no injuries. During interview on 8/14/18 at 6:50 P.M., the director of nursing (DON) said two staff should assist with Hoyer transfers. One staff should hold feet and ensure the resident does not hit the lift or other surfaces and the second should be at the bedside to assist the resident over the bed. 5. Review of Resident #212’s POS, dated 8/1/18, showed the following: -[DIAGNOSES REDACTED]. -Check and record weight daily (original order dated 7/13/18). Review of the resident’s daily weight sheet showed the following: -Daily weights. Have medication technician give [MEDICATION NAME] (diuretic) for greater than 4 pound weight gain; -Weight on 8/2/18 was 262.2 pounds; -Weight on 8/4/18 was 271.2 pounds, a 9 pound weight gain; -No weights were recorded on 8/6, 8/7, 8/8 or 8/9/18. Review of the resident’s Medication Administration Record [REDACTED]. During interview on 8/10/18 at 3:15 P.M., Certified Medication Technician (CMT) P said the following: -The day shift CNA on the resident’s hall was responsible for obtaining the daily weights; -The CNA on the floor or the restorative aide were responsible for obtaining the weekly |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 – Some | (continued… from page 4) following: -Weigh resident daily. If gains more than three pounds in three days or five pounds in one week, call the physician; -Weight on 8/5/18 was 133.6 pounds; -Weight on 8/10/18 was 138.4 pounds (difference of 4.8 pounds); -No weights were recorded on 8/6, 8/7, 8/8 or 8/9/18. 8. During interview on 8/14/18 at 6:30 P.M., the DON said the following: -Staff should administer resident’s medications as physician ordered; -Staff should obtain resident’s laboratory tests as physicians ordered and report results to the physicians; -She would expect weights to be obtained as ordered by the physician and for nursing to monitor when orders are attached for a weight loss/gain; -Weights should be obtained every morning before meals. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) -Specific observations to make: tooth decay, any loose or broken teeth, red or swollen gums, sores or white patches in the mouth or on the tongue, changes in eating habits, and poorly fitting dentures; -A clean mouth is very important to the physical and mental well-being of the resident. Oral care can prevent infections, the buildup of plaque, and bad breath. It can even influence the resident’s appetite. Remember to observe the resident during oral care to identify potential problems. 4. Review of Resident #10’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/29/18 showed the following: -Short and long term memory problem; -Severely impaired daily decision making ability; -Required extensive assistance of two staff members with bed mobility, dressing and toileting; -Required extensive assistance of one staff member with personal hygiene; -Always incontinent of bowel and bladder. Review of the resident’s care plan revised 8/2/18 showed the following: -[DIAGNOSES REDACTED]. -The resident was incontinent of bowel and bladder. Staff should check the resident every two hours and as needed for incontinent episodes, provide perineal care after each incontinent episode and apply incontinence briefs while up in the wheelchair. The goal was to keep the resident clean, dry and odor free at all times; -The resident had right sided weakness due to a stroke and was dependent on staff for Activities of Daily Living (ADLs). Staff should provide assistance with all ADLs and shower the resident twice weekly. Goal was the resident clean, dry and well-groomed at all times with staff performing ADLs. Observation on 8/9/18 at 7:00 A.M. showed the following: -The resident lay in bed on his/her back; -Nurse Assistant (NA) R turned the resident to his/her side and the resident said he/she was wet; -The resident was incontinent of urine and stool; -NA R obtained wet wipes and removed a small amount of soft feces from the resident’s anal area, obtained a clean wet wipe and wiped the resident’s buttock areas. NA R did not wash the resident’s urine soiled hips, thighs, frontal skin folds or perineal area; -NA R turned the resident side to side and removed the resident’s urine soiled incontinence brief; -NA R dressed the resident and asked the resident if he/she would like a shower. The resident shook head yes. NA R said you smell yourself too, I know you would like a shower; -NA R transferred the resident to a wheelchair and combed his/her hair; -NA R did not provide the resident oral care or wash his/her face. During interview on 8/9/18 at 7:40 A.M. the resident said no staff rinsed his/her mouth or washed his/her face this morning. He/she noticed this morning he/she had an odor and needed a shower. During interview on 8/9/18 at 2:35 P.M. NA R said the following: -He/she changed the resident’s soiled briefs, removed the brief, wiped them down a little and put on a clean brief; -He/she did not know the proper way to provide incontinence care. He/she wiped them down, put on a clean brief and got the resident up in the wheelchair. 5. Review of Resident #18’s significant change MDS dated [DATE], showed the following: -Extensive assist of one staff for transfers, dressing and personal hygiene; |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) -Wheelchair for mobility; -Swallowing disorder: Coughing/choking. Review of the resident’s care plan dated 5/2/18 and last revised 8/2/18, showed the following: -Problems: I have missing teeth and have chewing and swallowing difficulties. I am weak and unsteady and require assist of one with my ADL’s; -Goals: I will be assisted with my ADLs by staff and be clean and well groomed at all times; -Approaches: Assist of one for all ADLs. Observation on 8/9/18 at 6:50 AM showed the following: -The resident lay on his/her back in the bed: -CNA K entered the room and prepared wash cloths. He/she performed personal cares, dressed the resident, transferred him/her to a wheelchair and offered a wash cloth for the resident to wash his/her face. The CNA did not offer to assist the resident with oral care. During interview on 8/21/18 at 2:32 P.M. CNA K said oral care should be offered in the A.M. 6. Review of Resident #8’s quarterly MDS, dated [DATE], showed the following: -Limited assist of one staff for bed mobility; -Extensive assist of one staff for personal hygiene; -Always incontinent of bladder and bowel. Review of the resident #8’s care plan last revised 7/26/18 showed: -Problem: Incontinent of bladder and bowel; -Goal: I will be kept clean, dry and odor free at all times; -Approaches: One assist of staff for personal hygiene. Provide perineal care after each incontinent episode. Review of the resident’s POS dated 8/1/18 included [DIAGNOSES REDACTED]. Observation on 8/9/18 at 5:50 A.M. showed the following: -The resident lay in his/her bed; -CNA M entered the room, prepared to perform perineal care, removed the resident’s urine soiled incontinent brief; -CNA M performed perineal care but did not cleanse the right buttock/hip area. 7. Review of Resident #110’s Admission MDS, dated [DATE] showed the following: -Severely impaired cognition; -Extensive assist of two for bed mobility; -Extensive assist of one for personal hygiene; -Always incontinent of bladder and bowel. Review of the resident’s POS, dated 8/1/18 showed [DIAGNOSES REDACTED]. Observation on 8/9/18 at 5:50 A.M., showed the following: -The resident lay in his/her bed; -CNA M and CNA K entered the room, prepared to perform perineal care and unfastened the resident’s urine soiled incontinent brief; -CNA M performed perineal care to the frontal perineal area and the left hip/buttock areas but did not cleanse the resident’s right hip/buttock areas. During interview on 8/9/18 at 6:25 P.M., CNA M said that all soiled areas of the incontinent resident’s skin should be cleansed. During interview on 8/14/18 at 6:50 P.M. the DON said the following: -Staff should provide resident incontinence care from front to back; -All soiled areas of an incontinent resident should be cleaned which would include thighs, |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) perineal areas, pelvis, buttocks and hips; -He/she would expect oral care to be offered in the morning and anytime it was needed; -Staff should assist residents every morning before breakfast with toileting, incontinence care, oral care, and wash the resident’s face and hands. | |
| F 0684 Level of harm – Actual harm Residents Affected – Few | Provide appropriate treatment and care according to orders, resident’s preferences and goals. **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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 8) 3. Review of Resident #52’s face sheet showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Review of the resident’s Physician Order Sheet (POS) dated 4/26/18 showed the following: -[MEDICATION NAME] (diuretic medication used to remove excess fluid from the body) 20 milligrams (mg) one by mouth as needed for [MEDICAL CONDITION] (swelling of the tissues); -Weekly weights on Thursdays; -Supplemental oxygen at 2 liters per nasal cannula (through the nose), maintain oxygen saturation (oxygen levels in the blood) above 90 percent (normal 92 to 100 percent). Review of the resident’s Baseline Care Plan dated 4/26/18 showed the following: -Disease management concerns included respiratory and pain; -Observation detail list included oxygen therapy; -Monitor medications, condition and report changes to Director of Nursing (DON) and physician as applicable; -Monitor lab values and report to physician; -Intervention of weigh weekly not marked. Review of the resident’s Admission Clinical assessment dated [DATE] showed the following: -Admission weight 231 pounds; -1+ [MEDICAL CONDITION] (the degree of observable swelling of body tissues due to fluid accumulation that may be demonstrated by applying pressure to the swollen area such as by depressing the skin with a finger. Ranges from 1+ up 4+) to both feet; -Regular and unlabored breathing and right and left upper lung fields clear. Right and left lower lung fields diminished. Review of the resident’s Admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 5/3/18 showed the following: -Moderately impaired cognition; -Required extensive assistance of two staff members with bed mobility, dressing and toileting; -Required total assistance of two staff members with transfers; -Received scheduled and as needed pain medication in the last five days; -Frequent presence of pain in the last five days that effected the resident’s sleep and day to day activities rated at 8 on a 0-10 pain scale; -Shortness of breath or trouble breathing when lying flat; -Weight 231 pounds; -Received no diuretic medication in the previous seven days. Review of the resident’s POS dated (MONTH) (YEAR) showed weekly weights on Thursday related to [MEDICAL CONDITION] (a heart condition of the inability or failure of the heart to adequately meet the needs of organs and tissues for oxygen and nutrients causing fluid to leak from capillary blood vessels into the tissues. This leads to symptoms that may include shortness of breath, weakness, and swelling of tissues and fluid in the lungs). Review of the resident’s nurses’ notes showed the following: -On 5/3/18 lung sounds diminished in lower lobes bilaterally; -On 5/5/18 lung sounds diminished; -On 5/8/18 lung sounds diminished throughout. Review of the resident’s MAR indicated [REDACTED]. Review of the resident’s Treatment Administration Record (TAR) dated (MONTH) (YEAR) showed the following: -On 5/10/18 weight 228.6; -Staff documented no other weights for the month of May. |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 9) Review of the resident’s nurses’ notes showed the following: -On 5/13/18 choked on bedtime medication, complained of extreme shortness of breath, oxygen saturation 42 percent on 4 liters of supplemental oxygen. Oxygen changed from nasal cannula to mask with oxygen saturation increased to 73 percent. The physician was notified and resident was transferred to the emergency room by ambulance; -On 5/14/18 resident admitted to the hospital with [REDACTED]. Review of the resident’s POS dated 6/4/18 showed the following: -Readmit to facility; -[DIAGNOSES REDACTED]. -Weekly weights; -[MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]. Review of the resident’s TAR showed on 6/7/18 a weight of 202.6 pounds. Review of the resident’s MAR indicated [REDACTED]. Review of the nurses’ note dated 6/10/18 showed the resident was on [MEDICATION NAME] for 2+ [MEDICAL CONDITION] of bilateral (both) lower extremities (The MAR indicated [REDACTED]. Lungs clear with respirations unlabored. Becomes short of air easily. Review of the resident’s Admission MDS dated [DATE] showed the following: -Severely impaired cognition; -Required total assistance of two staff members with bed mobility, dressing, toileting and transfers; -Received as needed pain medication in the last five days; -Frequent presence of pain in the last five days that effected the resident’s sleep and day to day activities rated at eight on a 0-10 pain scale; -Shortness of breath or trouble breathing when lying flat; -Weight 207 pounds; -Received no diuretic medication in the previous seven days. Review of the nurses’ note dated 6/14/18 showed the resident’s lungs were clear, respirations labored at times with exertion. Review of the resident’s care plan dated 6/15/18 showed the following: -The resident was at risk for pneumonia (lung infection), upper respiratory infection and respiratory distress related to [DIAGNOSES REDACTED]. Staff should administer medications as ordered, monitor supplemental oxygen use at 2 liters per nasal cannula, monitor for peripheral (arms and legs) [MEDICAL CONDITION] and notify physician of increased [MEDICAL CONDITION], monitor weights as ordered and document, monitor for lung congestion, shortness of breath and notify the physician of changes; -The resident had [MEDICAL CONDITION] and was at risk for complications. Staff should monitor for pain and administer pain medications as ordered; -The resident had intermittent complaints of pain. Staff should monitor for signs and symptoms of discomfort, notify the medication nurse of pain and administer pain medications as ordered. Staff should notify the physician if interventions were unsuccessful of if current complaint was a significant change in past experience of pain; -The resident was at risk for cardiac complications. Staff should monitor for increased [MEDICAL CONDITION] and administer [MEDICATION NAME] as ordered, if unresolved notify physician. Staff should monitor weights and vital signs as ordered and notify physician of changes in cognition. Review of the resident’s TAR for (MONTH) (YEAR) showed the following: -Staff documented no assessment of the resident’s weight on 6/11/18 (Physician ordered weekly weights beginning 6/4/18); |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 10) -On 6/18/18 weight of 209.6 pounds, a seven pound weight gain in 11 days; Review of the resident’s nurses’ notes dated 6/18/18 showed no documentation staff notified the resident’s physician of the seven pound weight gain in 11 days. Review of the resident’s nurses’ notes showed on 6/25/18 staff documented the resident was sliding out of his/her wheelchair and unable to go to his/her physician’s appointment. Lung sounds diminished, respirations labored with any exertion, abdomen firm. Review of the resident’s Electronic Medical Record (EMR) showed on 6/25/18 staff documented the resident’s blood pressure was 141/92 millimeters of mercury (mmHg)(normal 120/80). No documentation staff notified the physician of resident’s condition. Review of the resident’s nurses’ notes showed on 6/26/18 staff documented the resident’s lung sounds with expiratory wheezes and diminished breath sounds in posterior bases. Will continue with current plan of care. Review of the resident’s EMR showed on 6/25/18 staff documented the resident’s blood pressure was 89/77 with no documentation staff notified the physician of the resident’s condition. Review of the resident’s nurses’ notes showed on 6/27/18 staff documented the resident’s lungs with faint wheezes in bilateral upper lung fields with no documentation staff notified the resident’s physician. Review of the resident’s computed tomography scan (CT scan) (x-ray measurements taken from different angles to produce cross-sectional images of specific areas of the body) scan of the abdomen and pelvis (related to a groin wound) dated 6/29/18 showed a small right effusion and trace left effusion with bibasilar (both lung bases) subsequent atelectasis (collapsing of part of the lung). Review of the resident’s MAR indicated [REDACTED]. Review of the resident’s electronic medical record vital signs tab dated 7/1/18 showed the resident’s weight as 219.2 pounds, a 10 pound weight gain from the previous weight on 6/18/18 and a 16 pound weight gain from his/her readmission weight on 6/4/18. Review of the resident’s MAR indicated [REDACTED]. Review of the resident’s nurses’ notes showed staff documented on 7/1/18 the resident’s lungs were clear, abdomen slightly distended, no [MEDICAL CONDITION] noted. The resident preferred not to get out of bed. Periods of confusion noted. Review of the resident’s EMR vital signs tab showed staff documented the following: -On 7/1/18 the resident’s blood pressure was 138/52 mmHg and respirations 22 breaths per minute (normal 12-20 breaths per minute); -On 7/2/18 the resident’s blood pressure was 167/77 mmHg. Review of the resident’s nurses’ notes showed staff documented the following: -On 7/3/18 the resident had light wheezes in the upper bilateral lung fields; -On 7/4/18 the resident refused repositioning during the night. Review of the resident’s EMR vital signs tab dated 7/4/18 showed staff documented the resident’s blood pressure was 173/89 mmHg. Review of the resident’s nurses’ notes showed staff documented the following: -On 7/5/18 the resident refused turning side to side, preferred to lay on back at all times; -On 7/6/18 the resident complained of pain at times to feet and back, had a poor appetite, was total assistance with activities of daily living, lungs were clear. Review of a Registered Dietician note dated 7/6/18 showed the resident’s weight was up 16 pounds over the last 30 days. Review of the resident’s MAR indicated [REDACTED]. Review of the resident’s nurses’ notes dated 7/10/18 showed the resident’s skin was moist |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 11) and [MEDICAL CONDITION] from left thigh to foot, from abdomen around to back with bottom part of back hard to touch, and had a weight gain of nine pounds in two days with lung sounds diminished on the right and crackles to the left posterior lung fields. The resident complained of back and abdominal pain. The physician was notified and orders received to send the resident to the emergency room for evaluation. Resident transferred by ambulance. Review of the resident’s hospital transfer form dated 7/10/18 showed the reason for transfer was [MEDICAL CONDITION] and crackles. He/she had low back pain, was on supplemental oxygen at 4 liter/minute by nasal cannula. Review of the resident’s Hospital emergency room record dated 7/10/18 showed the following: -Presented with complaint of leg swelling; -History of [MEDICAL CONDITION]; -On 6/29/18 the resident had a CT of his abdomen and pelvis to evaluate a cutaneous groin abscess. This found [MEDICAL CONDITION] (liver disease) with small volume of ascites (fluid accumulation in the abdominal cavity) in abdomen and pelvis; -Presented with increased abdominal ascites going on for the past five days, increased weight gain from 219 pounds to 228 pounds, crackles in left lung base. Chronically on oxygen at 3 liters by nasal cannula; -Chest x ray showed trace pleural effusions (pleural space or sac around the lung contained fluid) and chronically enlarged cardiac silhouette (enlarged heart); -Medications administered in the emergency department included [MEDICATION NAME] 40 mg intravenous (IV) and [MEDICATION NAME] (narcotic pain medication) 4 mg; -Clinical impression was anasarca (wide spread swelling of the skin due to effusion or spreading of fluid into the extracellular space), [MEDICAL CONDITION] (high potassium blood level), [MEDICAL CONDITION] and acute on chronic [MEDICAL CONDITION]. Review of the resident’s Hospital Inpatient Discharge Summary dated 7/16/18 showed the following: -Discharge [DIAGNOSES REDACTED]. The heart has to work harder to pump the blood), acute kidney injury superimposed on [MEDICAL CONDITION] and [MEDICAL CONDITION] stage five; -Hospital course: admitted for increasing weight gain following discharge to nursing facility. Was found to have acute on chronic diastolic [MEDICAL CONDITION] due to inadequate diuresis (the process of removal of excess fluid from the tissues with medication). The resident was [MEDICATION NAME] with improvement in ascara. Nephrology (kidney specialist) was consulted and resident was placed on [MEDICATION NAME] (diuretic medication used to remove excess fluid from the tissues) 50 mg by mouth daily. Educated extensively regarding monitoring daily weights and titrate diuretics based on fluid status. discharged to skilled nursing facility with new prescription of [MEDICATION NAME]; -Special instructions: Resident started on [MEDICATION NAME] 50 mg daily for diastolic [MEDICAL CONDITION] in the setting of [MEDICAL CONDITION] stage 3. Weight/fluid status as well as electrolytes and renal function (blood tests) should be monitored and [MEDICATION NAME] dose titrated as appropriate. Recommend repeat Basic Metabolic Panel (BMP) (laboratory blood test) in 2-3 days; -Discharge medications included [MEDICATION NAME] 50 mg daily. Review of the resident’s Post-Acute Care Transport Report from the hospital to the facility dated 7/16/18 showed the following: -Weight 213 pounds 10 ounces; -Medication orders included [MEDICATION NAME] 50 mg daily with instructions resident was started on [MEDICATION NAME] 50 mg daily for diastolic [MEDICAL CONDITION] in the setting |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 12) of [MEDICAL CONDITION] stage three. Weight/fluid status as well as electrolytes and renal function should be monitored and [MEDICATION NAME] dose titrated as appropriate. Recommend repeat BMP in two to three days. Review of the resident’s POS showed the following: -On 7/16/18 readmit to facility with previous orders. Add [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -On 7/17/18 daily weights for two weeks. Review of the resident’s MAR indicated [REDACTED] -No administration of [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -No administration of [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician) one time daily (MONTH) 17 through (MONTH) 28. Review of the resident’s nurses’ note dated 7/16/18 showed readmit from the hospital, physician notified of readmission and new orders. Lungs clear. Review of the resident’s TAR dated /18 and 7/18/18 showed no documentation staff obtained daily weights. Review of the resident’s MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. Review of the resident’s nurses’ note dated 7/18/18 showed lungs with expiratory wheezing in lower bases. Review of the resident’s nurses’ note dated 7/19/18 showed [MEDICAL CONDITION] to lower extremities 2+. Review of the resident’s TAR on 7/19/18 showed staff obtained no ordered daily weight. Review of the resident’s MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on the 7/16/18 hospital discharge. Review of the resident’s TAR on 7/20/18 showed no documentation staff obtained the resident’s daily weight. Review of the resident’s MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on the 7/16/18 hospital discharge. Review of the resident’s nurses’ note dated 7/21/18 showed staff documented the resident’s |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 13) lungs were clear, respirations labored with exertion. Review of the resident’s TAR on 7/21/18 and 7/22/18 showed no documentation staff obtained the resident’s daily weight. Review of the resident’s MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. Review of the resident’s TAR showed the following: -On 7/23/18 weight 228.8 pounds. A 15 pound weight gain since 7/16/18; -On 7/24/18 no daily weight obtained. Review of the resident’s MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on the 7/16/18 hospital discharge. Review of the resident’s EMR showed staff documented the following: -On 7/23/18 blood pressure 134/83 mmHg; -On 7/24/18 blood pressure 181/87 mmHg. Review of the resident’s nurses’ notes showed staff documented the following: -On 7/25/18 lungs diminished in bases; -On 7/26/18 lungs diminished, respirations labored with exertion, abdomen distended. Review of the resident’s EMR dated 7/26/18 showed staff documented the the resident’s blood pressure was 135/97 mmHg. Review of the resident’s TAR on 7/25/18 and 7/26/18 showed no documentation staff obtained the resident’s daily weights. Review of the resident’s MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. Review of the resident’s TAR showed on 7/27/18 a weight of 232.6 pounds, a 19 pound weight gain since 7/16/18. Review of the resident’s MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. Review of the resident’s POS dated 7/27/18 showed a new order for [MEDICATION NAME] 10 mg as needed (PRN) for a weight gain of 3 pounds or increased [MEDICAL CONDITION] in addition to the current [MEDICATION NAME] dose. (facility was still giving 10 mg. of [MEDICATION |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 14) NAME] rather than the ordered 50 mg.; this day the resident received a total of 20 mg. [MEDICATION NAME]). Review of the resident’s MAR indicated [REDACTED].M. staff administered an additional [MEDICATION NAME] 10 mg as needed for a weight gain of 3 pounds or increased [MEDICAL CONDITION]. (Total of [MEDICATION NAME] 20mg administered on 7/27/18, 30mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician). Review of the resident’s EMR dated 7/28/18 showed staff documented the resident’s blood pressure was 149/98mmHg. Review of the resident’s nurses’ note dated 7/28/18 showed staff documented the following: -Total dependence on staff with activities of daily living; -Staff turned and repositioned resident. He/she refused to sit up in wheelchair; -Daily weights. Review of the resident’s TAR showed on 7/28/18 a weight of 231.0 pounds; an 18 pound weight gain since 7/16/18. Review of the resident’s MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -[MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician) administered; -No administration of [MEDICATION NAME] 50 mg daily as ordered on the 7/16/18 hospital discharge. Review of the resident’s nurses’ note dated 7/29/18 showed on 7/28/18 the resident was transferred to the hospital via ambulance at 9:00 P.M. Staff noted thick yellow-white urine with thick sediment in urinary catheter. Noted increased abdominal girth, puffy [MEDICAL CONDITION] to bilateral upper extremities, fluid pockets to back of head and neck, [MEDICAL CONDITION] present to face and [MEDICAL CONDITION] to temple. Review of the resident’s hospital transfer form dated 7/28/18 showed reason for transfer was fluid overload, B/P 188/78, pain level 10/10 with pain medication administered at 8:30 P.M. Review of the resident’s Hospital emergency room record dated 7/28/18 showed the following: -Chief compliant of leg swelling, leg, abdomen and facial fluid retention, shortness of breath; -History of [MEDICAL CONDITION] chronically on supplemental oxygen at 3 liters per nasal cannula. Presented to the emergency department with shortness of breath onset yesterday and worsening today as well as extremity [MEDICAL CONDITION] and 8-9 pound weight gain over the last few days (219 pounds on 7/1/18 and 232 pounds today). Recent urinary catheter placed. Past medical history included hosptalized on [DATE] for anasarca; -Respiratory status was shortness of breath with decreased breath sounds in the right lower field; -[MEDICAL CONDITION] with 3+ pitting from feet to groin bilaterally. Swelling of arms and legs; -Abdominal distension and ascites; -Lab results of B-type Natriuretic Peptide (Pro BNP) ( substances that are produced in the heart and released when the heart is stretched and working hard to pump blood. Tests for BNP and NT-proBNP measure the levels in the blood in order to detect and evaluate heart failure with levels above 1200 picogram/ml in a person with kidney disease indicating [MEDICAL CONDITION]). Results of 6,551 pg/ml; -Clinical impression of urinary tract infection associated with indwelling urinary |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 15) catheter, acute [MEDICAL CONDITION] superimposed on [MEDICAL CONDITION], chronic [MEDICAL CONDITION]. Review of the resident’s Hospital History and Physical dated 7/29/18 showed the resident was last seen at the hospital on [DATE] under admission and underwent treatment with diuresis for decompensated heart failure, was transitioned to by mouth diuretics and discharged to skilled nursing facility. Review of the resident’s Hospital Inpatient Discharge Summary dated 8/9/18 showed the following: -[DIAGNOSES REDACTED]. -Resident was discharged from the hospital on [DATE] after treatment of [REDACTED]. -Known diastolic [MEDICAL CONDITION], inadvertently following the last discharge the resident only received 10 mg of [MEDICATION NAME] daily instead of 50 mg of [MEDICATION NAME] daily that was prescribed at the time of discharge and this was likely cause for acute heart failure exacerbation; -On 8/9/18 resident was seen by palliative care and based on 24 hour [MEDICATION NAME] utilization start [MEDICATION NAME] (a long acting narcotic pain medication absorbed through the skin through placement of a patch) 12 microgram (mcg) patch with [MEDICATION NAME] ([MEDICATION NAME] with [MEDICATION NAME] narcotic pain medication) one tablet every four hours as needed for breakthrough pain. Discharge prescriptions provided for facility; -Acute on [MEDICAL CONDITION] stage 3 or 4 likely secondary [MEDICAL CONDITION] as well as acute on chronic diastolic [MEDICAL CONDITION]; -Firm [MEDICAL CONDITION] over bilateral lower abdomen, hips, upper thighs, legs and feet at discharge. Review of the nurses’ note showed on 8/9/18 the resident was admitted to facility. Review of the resident’s POS dated 8/9/18 showed the following: -[MEDICATION NAME] 50 mg daily; -Daily weights; -[MEDICATION NAME] 12 mcg/hour patch, change every third day, placed on 8/9/18, change 8/12/18; -[MEDICATION NAME] 5/325 mg one or two tablets every four hours as needed for pain. Observations of the resident on 8/9/18 at 10:30 A.M. showed the following: -[MEDICAL CONDITION] noted to bilateral feet and legs, arms and hands appear fluid filled and puffy; -Attempted to answer questions and talk with family with repetitive answers and difficulty understanding questions and topic of conversation. During interview on 8/9/18 at 3:00 P.M. the resident’s family said the following: -Staff did not administer the resident’s [MEDICATION NAME] dose correctly. Staff gave [MEDICATION NAME] 10mg daily instead of 50mg daily and the resident filled up with fluid. His/her hands, arms, feet and legs were full of fluid and had areas of fluid weeping out the skin. He/she was transferred to the hospital in respiratory distress; -Staff delayed his/her treatment for [REDACTED]. -The family informed the staff three times the resident needed to go to the hospital before the ambulance was called. Review of the resident’s MAR indicated [REDACTED].M. staff administered [MEDICATION NAME] 5/325 mg one tablet. Review of the nurses’ note showed on 8/10/18 staff documented the resident was on comfort measures. Review of the resident’s MAR indicated [REDACTED] -On the 6:00 A.M. to 2:00 P.M. shift the resident’s pain level was zero on a scale of |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 16) 1-10. At 9:00 A.M. administered [MEDICATION NAME] 5/325 mg one tablet; -On the 2:00 P.M. to 10:00 P.M. shift the resident’s pain level was zero on a scale of 1-10. At 7:30 P.M. administered [MEDICATION NAME] 5/325 mg one tablet; -On the 10:00 P.M. to 6:00 A.M. shift the resident’s pain level was zero on a scale of 1-10. Review of the nurses’ notes dated 8/11/18 showed the resident’s lungs were diminished throughout, abdomen round and firm. Physician notified and ordered comfort medications sublingual only. Discussed with family resident’s current status including multiple organs failing and wish to be comfortable. Several new comfort medication orders received, resident concerned about pain. Review of the resident’s MAR indicated [REDACTED] -On the 6:00 A.M. to 2:00 P.M. shift the resident’s pain level was four on a scale of 1-10. At 9:00 A.M. administered [MEDICATION NAME] 5/325 mg one tablet and documented the resident said he/she felt bad all over; -On the 2:00 P.M. to 10:00 P.M. shift the resident’s pain level was five on a scale of 1-10. At 2:30 P.M. administered [MEDICATION NAME] 5/325 mg one tablet and documented the resident hurt; -On the 10:00 P.M. to 6:00 A.M. shift the resident’s pain level was eight on a scale of 1-10. No documentation of pain medication administered. Review of the nurses’ note dated 8/12/18 showed the resident was concerned about pain. His/her abdomen was distended and tight with absent bowel sounds. Lungs were diminished with bilateral peri | |
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate pressure ulcer care and prevent new ulcers from developing. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound). 2. Review of the facility policy Pressure Ulcer, Care and Prevention of, Nursing Guidelines Manual, (MONTH) (YEAR) showed the following: -Purpose was to prevent and treat further breakdown of pressure sores; -treatment of [REDACTED]. The nurse was responsible for carrying out the treatment as ordered by the physician and for implementing measures to prevent pressure ulcers. 3. Review of the facility policy General Wound and Skin Care Guidelines, MedSupply (YEAR) showed the following: -Wash hands before and after resident contact; -All chronic wounds were contaminated. Chronic wounds should be dressed using a clean technique; -Reevaluate dressing and skin integrity every shift; -Use care when removing dressings and tapes to avoid further damage to fragile skin; -Notify appropriate personnel of all new pressure ulcers, or if have questions; -Educate residents, families, and staff on interventions to prevent skin breakdown. 4. Review of Resident #49’s Braden Scale (scale for predicting pressure ulcer risk) dated 1/4/18 showed the following: -[DIAGNOSES REDACTED]. -Sensory perception was very limited responds only to painful stimuli (score 2); -Occasionally moist skin, required an extra linen change approximately once per day (score 3); -Chairfast, could not bear weight and /or must be assisted into chair or wheelchair (score 2); -Mobility very limited unable to make frequent or significant changes independently (score 2); -Nutrition probably inadequate, rarely ate a complete meal and generally ate only about 1/2 of food offered (score 2); -Friction and shear problem, required moderate to maximum assist in moving, complete lifting without sliding against sheets was impossible, frequently slide down in bed or chair, required frequent repositioning with maximum assist (score 1); -Total Braden Scale Score was 12. Level as HIGH RISK (range 10-12). Review of the resident’s significant change Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 4/30/18 showed the following: -[DIAGNOSES REDACTED]. -Cognitively intact; -Required total assistance of two staff members with transfers; -Required extensive assistance of two staff members with bed mobility and dressing; -Required extensive assistance of one staff member with toileting; -Required an indwelling urinary catheter and an ostomy; -Risk of developing pressure ulcers; -One or more unhealed pressure ulcers at stage 1 or higher; -One stage 3 pressure ulcer present on admission measured 4.5 centimeters (cm) long by 2.5cm wide and 0.2cm deep; -One stage 3 pressure ulcer worsening in status; -Pressure reducing device (equipment that aims to relieve pressure away from areas of high risk for skin breakdown) for chair and bed, turning and repositioning program, pressure |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 18) ulcer care and application of ointments and medications. Review of the resident’s wound management physician note dated 5/31/18 showed the following: -Stage 3 left buttock pressure ulcer measured 5.0 cm long by 5.0 cm wide and 0.2 cm deep with large amount of blood tinged drainage. Facility staff should change the resident’s dressing twice daily and as needed for soiling; -Trauma left ischial (part of the pelvic bone located at the lower buttocks, the sitting bone) wound measured 1.0 cm long by 2.0 cm wide and 1.5 cm deep with moderate amount of pink tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling. Excisional debridement of wound performed; -Considering re-culturing (laboratory test of the wound tissue and drainage for infection) the wound next week if things were not different. Review of the Physician’s Order Sheet (POS) dated 5/31/18 showed the following: -Left buttock pressure ulcer cleanse with wound cleanser, apply Sure Prep on surrounding tissue, apply bio-pad (wound treatment dressing used to control minor bleeding and for management of chronic non-healing wounds) to wound bed, cover with alginate (wound dressing used to maintain a moist microenvironment that promotes healing) and border gauze (absorptive gauze dressing with taped edges placed on top of a wound), change twice daily and as needed for soiling or dislodgement; -Left ischium wound cleanse with wound cleanser, apply sure prep on surrounding tissue, apply bio-pad to wound bed, cover with alginate and border gauze, change daily and as needed for soiling or dislodgement. Review of the POS [REDACTED] -Left buttock pressure ulcer cleanse with wound cleanser, apply sure prep on surrounding tissue, apply alginate to wound bed and cover with border gauze, change daily and as needed for soiling or dislodgement -Left ischium wound cleanse with wound cleanser, apply Sure Prep on surrounding tissue, apply sure prep on surrounding tissue, pack wound with alginate, cover with border gauze and change daily and as needed for soiling or dislodgement. Review of the resident’s wound management physician note dated 6/7/18 showed the following: -Stage 3 left buttock pressure ulcer measured 5.0 cm long by 5.0 cm wide and 0.2 cm deep with evidence of pressure noted, moderate amount of blood tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling; -Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep with moderate amount of pink tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling. Review of the resident’s wound management physician note dated 6/21/18 showed the following: -Stage 3 left buttock pressure ulcer measured 4.0 cm long by 5.0 cm wide and 0.2 cm deep deteriorated wound status, moderate amount of blood tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling; -Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep moderate amount of pink tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling. Review of the POS [REDACTED] -Left buttock pressure ulcer cleanse with wound cleanser, apply sure prep on surrounding tissue, apply bio-pad to wound bed, cover with alginate and border gauze, change daily and as needed for soiling or dislodgement; |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) -Left ischium wound cleanse with wound cleanser, apply sure Prep on surrounding tissue, apply Sure Prep on surrounding tissue, apply bio-pad to wound bed, cover with alginate and border gauze, change daily and as needed for soiling or dislodgement. Review of the resident’s wound management physician note dated 6/28/18 showed the following: -Stage 3 left buttock pressure ulcer measured 3.5 cm long by 4.5 cm wide and 0.2 cm deep, moderate amount of blood tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling; -Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep moderate amount of pink tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling; -Considering re-culture of wounds. Review of the resident’s wound management physician note dated 7/5/18 showed the following: -Stage 3 left buttock pressure ulcer measured 4.0 cm long by 4.0 cm wide and 0.2 cm deep with deteriorated wound status not healthy appearance, moderate amount of blood tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling; -Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep with pink granulating tissue, moderate amount of pink tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling; -Tissue culture and sensitivity sent to laboratory. Review of the resident’s POS showed continue the same wound treatment procedure, increase frequency to twice daily. Review of the resident’s care plan dated 7/19/18 showed the following: -The resident had a stage 3 pressure ulcer on the left buttock and a previous trauma wound that reopened on the left ischium. Staff should turn and reposition the resident every two hours to prevent skin breakdown and utilize wedges and pillows to reduce pressure and provide assistance with all Activities of Daily Living (ADLs), bed mobility, toileting and transfers. Staff should cleanse the stage 3 pressure ulcer of the left buttock with cleanser and physician ordered treatment daily and as needed for soiling or dislodgement. Staff should cleanse the left ischial wound with cleanser and physician ordered treatment daily and as needed for soiling or dislodgement. Staff should monitor for signs and symptoms of non-healing and infection (increased redness, warmth or tenderness, foul smelling or purulent drainage, fever) and notify the physician. Staff should monitor skin for further redness and breakdown, if noted notify the charge nurse. If a decline in skin condition was noted, notify physician and request treatment orders; -The resident was weak with limited range of motion and [DIAGNOSES REDACTED] in legs and was unable to straighten out legs. Required extensive assistance on one or two staff members with all ADLs. Staff should shower the resident twice weekly, provide mechanical lift transfers, and assist with re-positioning every two hours while in bed or out of bed in wheelchair; -The resident had a [MEDICAL CONDITION]. Staff should change the appliance every three days and as needed. Monitor the output and record, observe for leakage and change as needed; -The resident had a suprapubic urinary catheter (sterile tube inserted through the lower abdominal wall into the bladder use to drain the bladder of urine). Staff should monitor placement of the urinary catheter and maintain a closed drainage system. Review of the resident’s wound management physician note dated 7/26/18 showed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 20) following: -Stage 3 left buttock pressure ulcer measured 3.5 cm long by 2.0 cm wide and 0.2 cm deep with deteriorated wound status, small amount of blood tinged drainage. There was an infection in the wound. Facility staff should change the resident’s dressing daily and as needed for soiling; -Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep, small amount of pink tinged drainage. There was an infection in the wound. Facility staff should change the resident’s dressing daily and as needed for soiling; -Wound cultures showed Escherichia coli (bacteria normally present in the intestines, frequent cause of urinary tract and wound infections) and Proteus (bacteria present in the intestines, water and soil), start Bactrim DS (antibiotic medication) twice daily. Review of the POS [REDACTED] -Bactrim DS one tablet twice daily for 14 days; -Left buttock pressure ulcer cleanse with wound cleanser, apply sure prep on surrounding tissue, mix hydrogel (wound treatment gel designed to keep the wound slightly moist) and collagen, place in wound bed and cover with border gauze, change daily and as needed for soiling or dislodgement -Left ischium wound cleanse with wound cleanser, apply sure prep on surrounding tissue, mix hydrogel and collagen, place in wound bed and cover with border gauze, change daily and as needed for soiling or dislodgement. Review of the resident’s wound management physician note dated 8/6/18 showed the following: -Stage 3 left buttock pressure ulcer measured 2.2 cm long by 2.0 cm wide and .02 cm deep, small amount of blood tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling; -Trauma left ischial wound measured 0.5 cm long by 0.3 cm wide and 1.7 cm deep with pink granulating tissue, small amount of blood tinged drainage. Facility staff should change the resident’s dressing daily and as needed for soiling; -Education provided to facility staff regarding proper wound treatment, frequent repositioning, offloading and proper nutrition to support effective wound healing. Observation on 8/8/18 at 9:50 A.M. showed the following: -Licensed Practical Nurse (LPN) C prepared dressing change supplies on the resident’s bedside table; -The resident lay on his/her left side with buttocks exposed. A tan colored thick substance covered the resident’s left ischial wound area with no dressing in place; -The resident said he/she took a shower last night and the CNA removed the wound dressings prior to the shower; -LPN C opened the resident’s skin folds and exposed an open left inner buttock wound with no dressing. The wound was approximately half dollar size with a dark red base; -LPN C cleansed the resident’s left ischial wound of the tan colored thick substance revealing an approximate pea size open area with undetermined depth. LPN C cleansed the left inner buttock wound with wound cleanser; -LPN C applied collagen and hydrogel wound treatment to both wounds, covered with non-adhesive dressings and secured with tape. During interview on 8/8/18 at 3:00 P.M. LPN C said the evening staff removed the resident’s wound dressings on 8/7/18. Staff should cover the resident’s wounds prior to showers or leave the dressing in place. Following the shower, the charge nurse should provide the resident’s wound treatments and cleanse the wounds. During interview on 8/9/18 at 4:20 P.M. CNA V said the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 21) -He/she gave the resident’s shower on 8/7/18 at approximately 9:00 P.M.; -He/she removed the resident’s wound dressings before the shower while the resident was in bed; -He/she wore gloves while removing the dressings but did not wash his/her hands prior to applying gloves; -He/she and another staff member transferred the resident to a reclining shower chair with the mechanical lift, provided the shower and transferred the resident back to bed with the mechanical lift; -He/she told the charge nurse following the shower the resident’s wound needed a dressing. During telephone interview on 8/9/18 at 7:15 P.M. LPN Y said he/she was the charge nurse during the 8/7/18 night shift. He/she was aware the resident had showered that evening and the resident’s wound dressings were removed before the shower. He/she attempted to provide the resident’s wound care at approximately 3:00 A.M. on 8/8/18. The resident did not want to wake up and allow the wound care provided. He/she passed the wound care on to the day shift and was unable to provide the wound care on his/her shift. During interview on 8/10/18 the MDS Coordinator said the following: -CNA staff should cover residents’ pressure ulcers and wounds before showers and tell the charge nurse following the shower. The charge nurse should change the resident’s wound dressing and cleanse the wound following the shower; -Staff should not leave a resident’s wound soiled after a shower for hours and pass the information on to the next shift. This could cause the wound not to improve or heal. 5. Review of Resident #110’s Admission MDS, dated [DATE] showed the following: -Severely impaired cognition; -Extensive assist of two for bed mobility; -Extensive assist of one for personal hygiene; -Always incontinent of bladder and bowel; -At risk for pressure ulcers. Review of the resident’s care plan, dated 7/11/18, showed the pressure ulcer was not addressed. Review of the resident’s wound report, dated 8/2/16, showed the following: -Stage/ type: pressure ulcer; -Location: Right ischium; -Measurements: 2 centimeter (cm) x 1.8 cm x 0.1 cm; -Date of onset: 7/11/18; -Acquired: in house; -Status: deteriorating; -Treatment: Santyl (presription medicine that removes dead tissue from wounds)/hydrogel (gel composed of one or more polymers suspended in water) with border gauze. Review of the resident’s POS, dated 8/1/18, showed the following: -Left buttock: cleanse, apply Sure Prep, apply Santyl to the wound bed, cover with border gauze. Change daily and as needed for soiling/dislodgement (original order dated 7/19/18); -Barrier cream to affected areas as needed for preventative (original order dated 6/21/18). Review of the resident’s Treatment Administration Record (TAR), dated 8/1/18, showed the following: -Right ischium wound: Cleanse with cleanser, apply sure prep to surrounding tissue, Santyl to wound bed, hydrogel on top, cover with border gauze. Change daily and as needed for soiling/dislodgement (original order dated 7/26/18); -The TAR showed a handwritten notation which read Healed on 8/4/18, although the treatment |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 22) was recorded as completed on 8/5/18; -The order was re-written under the original directions without a date; -The treatment was not documented as completed on 8/6/18, 8/7/18, 8/8/18 or 8/9/18. Review of the resident’s POS, dated (MONTH) (YEAR), showed no evidence the order to treat the pressure ulcer on the resident’s ischium was discontinued. During interview on 8/27/18 at 10:42 A.M., the administrator said the following: -The treatment order, dated 7/19/18, for the left buttock should have read right buttock as that is the only skin issue the resident has had; -The wound documentation sheet should be dated 8/2/18 instead of 8/2/16; -A new wound team saw the resident on 8/6/18 and marked on the TAR that the resident’s pressure ulcer as healed but must have looked at the resident’s wrong buttock as the administrator had interviewed nursing staff and the area was not healed. Observation on 8/9/18 at 5:50 A.M., showed the following: -The resident lay in his/her bed; -CNA M and CNA K entered the room and performed perineal care after removing the urine soiled incontinent brief; -CNA M applied barrier cream over the right ischium (hip, buttock area) pressure ulcer which did not have a dressing; -CNA K said the wound did require a dressing at all times, however it may have become soiled in the night and had to be removed; -CNA M said he/she did not see a dressing that night. Review of the resident’s wound documentation sheet for the right ischium, dated 8/9/18, showed the following: -Measurements : 1 centimeter (cm) x 1 cm x 0; -Treatment: Sure Prep as needed; -Status: Healed. During interview on 8/10/18 at 9:05 A.M., LPN A said the following: -He/she worked the night of 8/8/18 and was responsible for the resident’s treatment; -The resident was supposed to have a dressing on his/her pressure ulcer at all times; -Staff had not reported the dressing was off; -He/she usually checked dressings to ensure they were intact and did not know why he/she had not checked the dressing that night; -He/she did not know who marked it as healed on 8/4/18, as it was not healed. During interview on 8/14/18 at 6:30 P.M., the DON said the following: -Staff should administer residents’ treatments as ordered by the physician; -She expected wound dressings to be applied as ordered and nursing should monitor for the placement of the dressing every shift; -The charge nurse should remove a resident’s wound dressing prior to showers and following the shower the charge nurse should cleanse the resident’s wound and provide the prescribed wound treatment; -Staff should not leave the resident’s wound dirty and uncovered following the shower until the next day before cleansing the wound and applying the wound treatment; -CNA staff should tell the charge nurse if a resident’s wound dressing became soiled or dislodged and the charge nurse should change the dressing. | |
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 23) infections. **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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 24) urinary catheter bag on the top bar of the mechanical lift, approximately two feet above the level of the resident’s bladder. Cloudy yellow urine flowed down the catheter tubing to the resident’s bladder; -CNA U applied the resident’s shoes; -CNA V maneuvered the mechanical lift towards the resident’s wheelchair. The resident’s urinary catheter bag remained hanging on the top bar of the mechanical lift, approximately two feet above the level of the resident’s bladder. No urine remained in the catheter tubing; -CNA V lowered the resident into the wheelchair, removed the resident’s urinary catheter drainage bag from the top bar of the mechanical lift and handed CNA U the resident’s catheter bag; -CNA U placed the catheter bag in a privacy bag under the resident’s wheelchair; -Cloudy yellow urine flowed from the resident’s bladder down the catheter tubing into the drainage bag. Observation on 8/8/18 at 3:00 P.M. showed NA S wiped feces from the resident’s buttocks with wet wipes, obtained a clean wet wipe and wiped the resident’s anal area, reached between the resident’s legs from the back and wiped the perineal area and skin folds with the same wet wipe, turned the resident and wiped the resident’s frontal pubic area and thighs. NA S did not wash the resident’s perineal inner skin folds or provide catheter care. Observation on 8/9/18 at 6:50 A.M. showed the following: -The resident lay in bed; -CNA I washed the resident’s pubic area and one wipe down each side of the outer perineum; -CNA I did not wash the resident’s inner skin folds or the resident’s urinary catheter; -CNA I and NA R turned the resident side to side, wiped the resident’s buttocks and applied a clean incontinence brief. Review of the resident’s nurses’ notes dated 8/9/18 showed at 8:00 P.M. on 8/8/18 the resident’s temperature was 100.1 degrees Fahrenheit (normal 98.6 degrees Fahrenheit). The physician was notified and order received for urinalysis with culture and sensitivity. Review of the resident’s urinalysis dated 8/9/18 showed the following: -Color was amber (normal: clear/yellow/straw); -Clarity was cloudy; -Blood- small (normal: negative); -[MEDICATION NAME]-positive; -Leukocyte (a white blood cell in the urine indicating UTI)-large (normal: negative); -White blood cells-too numerous to count; -Red blood cells-5-15 (normal: 0-4); -Bacteria-few. During interview on 8/9/18 at 2:25 P.M. CNA U said the following: -He/she should place a resident’s catheter bag under the resident’s wheelchair and not on the floor; -He/she should not hold the resident’s catheter bag above the level of the resident’s bladder; -He/she should provide catheter care down the tubing from the insertion site and provide perineal care from front to back; -He/she did not have anywhere else to hang the catheter bag during a mechanical lift transfer except on the top bar of the lift; -If the resident was incontinent of bowel, then he/she would do complete catheter care and perineal care. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 25) During interview on 8/9/18 at 4:20 P.M. CNA V said the following: -He/she washed the resident’s catheter tubing with wet wipes and washed up and down the catheter tubing from the insertion site; -He/she washed the resident’s perineal area from back to front; -He/she should place the resident’s urinary catheter bag below the level of the bladder. Urine running back into the bladder could cause infection. 4. Review of Resident #18’s care plan dated 5/2/18 and last revised 8/2/18, showed the following: -Problem: Indwelling urinary catheter, at risk for UTIs; -Goal: I will have no complications or UTIs related to my use of urinary catheter; -Approaches: Monitor placement of my catheter during care and transfers, place in a catheter bag to keep off the floor. Provide catheter care every shift and PRN. Review of the resident’s UA dated 6/4/18 showed the following: -Bacteria: Few (none); -Leukocytes: large (negative). Review of the resident’s urine culture report dated 6/6/18 showed greater than 100,000 CFU/ML E Coli (ESBL+) Currently on [MEDICATION NAME] 250 mg by mouth two times daily. Review of the resident’s urine culture report dated 7/7/18 showed the organism was E Coli. Review of the resident’s urine culture report dated 7/20/18 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 26) -CNA K assisted the resident to the wheelchair and the resident wheeled him/herself out of the room and down the hall as the catheter tubing drug the floor. During interview on 8/9/18 at 11:35 A.M and 8/21/18 at 2:32 P.M. CNA K said the following: -CNAs are responsible for catheter care and he/she did not perform it on the resident this morning; -No part of the urinary drainage system should touch the floor as would be an infection control issue; -Catheter care should be done during perineal care in the morning; -Catheter care should include cleaning the catheter from the insertion site outward with a clean wash cloth. 5. Review of Resident #16’s quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Total dependence of two staff for bed mobility and transfers; -Supra-pubic catheter (thin sterile tube inserted through the abdominal wall directly into the bladder to drain urine from the body); -No history of UTI. Review of the resident’s UA, dated 6/11/18 showed the following: -Leukocytes: Large (negative); -WBCs: Too numerous to count (0-4); -Red blood cells (RBCs): 16-25 (0-4); -Bacteria: Rare (none); -Amorphous crystal: few (none). Review of the resident’s Physician order [REDACTED]. Review of the resident’s care plan, dated 6/25/18, showed the following: -Problem: Bilateral lower extremity paralysis and need for extensive assist with all Activities of Daily Living (ADLs) and transfers; -Approaches: Assist of two staff and Hoyer lift (mechanical lift used for non- weight bearing residents) for transfers, notify my physician of changes or decline in condition, monitor skin for redness or breakdown and notify charge nurse; -Problem; Supra-pubic catheter, Increased risk for UTI’s due to indwelling catheter; -Approaches: Monitor placement of my catheter during care and transfers, keep below the level of the bladder, place in a catheter bag and keep up off of floor. Review of the resident’s POS dated 8/1/18 to 8/31/18 showed the following: -[DIAGNOSES REDACTED]. Symptoms can include retention); -Supra-pubic catheter (6/1/18); -Up with assist of two staff and Hoyer lift. Observation on 8/08/18 at 8:28 AM showed the resident lay in bed and the urinary catheter tubing lay hooked around wheel (caster) and leg of the over the bed table. Observation on 8/8/18 at 3:19 P.M., showed the following: -The resident sat in his/her electric scooter (on the Hoyer pad sling) in his/her room. The catheter bag hung from the chair and the tubing lay on the scooter’s foot rest; -The Assistant Director Of Nursing (ADON) and CNA D entered the room with the Hoyer lift and attached the resident’s sling to the mechanical lift; -CNA D hung the urinary drainage bag from the same hook as the sling. As the resident was lifted, the drainage bag rose above the level of the resident’s bladder and urine flowed backward in the tubing toward the insertion site. During interview on 8/9/18 at 5:05 P.M. CNA D said a urinary drainage bag should not be raised above the level of the bladder because it would flow back. 6. Review of Resident #11’s care plan dated 8/14/17 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 27) -Problem: Incontinent of bladder and bowel; -Approach: Provide me with perineal care after each incontinent episode and monitor for signs and symptoms of urinary tract infection [MEDICAL CONDITION]. Review of the resident’s urinalysis (UA) (a diagnostic lab procedure used to determine urinary changes and infection), dated 1/17/18, showed the following: -Appearance: slightly cloudy (normal: clear); -Epilthelial cells (cells which line the surfaces of the body): 0-5/high power field (hpf) (normal 0-4); -[MEDICATION NAME]: positive (presence indicates urinary tract infection)(normal: negative); -Mucous: present (normal: negative); -White blood cells (WBC’s) (cells that fight infection when present in the urine indicate UTI): 0-5/hpf (normal: 0-4); -Bacteria: greater than 100/hpf (normal: none). Review of the nurse’s notes, dated 1/18/18, showed the resident was admitted to the hospital with [REDACTED]. Review of the urine culture and sensitivity report (diagnostic lab procedure used to identify the type of bacteria causing an infection and identify the antibiotic medication appropriate to treat the bacterial infection) dated 1/21/18 showed the following: -Growth of a gram negative organism; -Greater than 100,000 organisms per milliliter; -Heavy growth of Escherichia Coli (E. Coli). Please note; this E. Coli has a sensitivity with a positive extended-spectrum Beta-Lactamase (ESBL+). Review of the resident’s discharge summary from the hospital dated 1/23/18 showed the following: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (antibiotic) 500 milligrams (mg) by mouth daily. Review of the resident’s discharge summary from the hospital dated 4/19/18 showed the following: -[DIAGNOSES REDACTED].>-[MEDICATION NAME] Sod-Tazobactam So (broad-spectrum antibiotic)- 3.375 gram intravenous piggyback every eight hours. Review of the resident’s quarterly MDS, a federally mandated assessment instrument to be completed by the facility and dated 5/7/18 showed the following: -Severely impaired cognition; -Total dependence of two staff for toilet use and total dependence of one staff for personal hygiene; -Always incontinent of bladder and bowel; -No rejection of care. Observation on 8/10/18 at 3:47 P.M. showed the following: -CNA N and CNA O entered the resident’s room to perform perineal care, un-taped the resident’s urine soiled incontinent brief and rolled the resident to his/her left side; -CNA N picked up a moistened wash cloth, reached through the resident’s legs to the front and then pulled it back through. The CNA then repeated the same with a second cloth; -Staff failed to perform proper perineal care and did not cleanse all soiled areas including the frontal perineal area, the inner thighs or bilateral groin. During interview on 8/10/18 at 4:10 P.M., CNA N and CNA O said front perineal care should be attempted. During interview on 8/14/18 at 3:45 P.M., CNA X said that when performing perineal care on the resident, he/she cleaned by turning the resident from side to side and reaching |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 28) through (between the legs), wiping front to back. 7. During interview on 8/14/18 at 6:30 P.M. the DON said the following: -He/she would expect front perineal care to be attempted on residents; -He/she would expect one staff to hold the resident’s legs and the other to perform the care; -If staff cleaned by reaching from behind to the front there would be potential for bacteria to be pushed forward; -Staff should provide urinary catheter care every shift and as needed; -Staff should provide incontinence care and clean the perineal area from front to back, then clean the urinary catheter tube from insertion site outward. Staff should not wipe the urinary catheter tube back and forth with one washcloth or wet wipe; -Staff should keep urinary drainage bags fastened on the resident’s bed frame, off the floor and below the level of the bladder; -Staff should not hang the resident’s urinary drainage bag on the top bar of the mechanical lift and should not allow urine to flow from the urinary catheter tubing back into the resident’s bladder; -Staff should not step on the resident’s urinary catheter tubing; -Staff should not hang the resident’s urinary catheter bag over the bedside table base or the resident’s wheelchair footrests; -Staff should provide complete perineal care, incontinence care and catheter care for residents with contractures or had difficulty spreading legs. Staff should provide frontal care; -Ineffective or improper cleansing could lead to urinary tract infections as seen in the facility. | |
| F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident’s well being. **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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 29) catheter drainage bag in a privacy bag, removed the gloves and without washing hands checked Resident #19’s mouth; -NA R without washing hands, applied gloves and turned Resident #10 (in the same room) to his/her side. NA R with the same soiled gloves and without washing hands, obtained wet wipes and removed small soft feces from the resident’s anal area, obtained a clean wet wipe and wiped the resident’s buttock areas and did not wash the resident’s urine soiled hips, thighs, frontal skin folds or perineal area; -NA R without washing hands and with the same soiled gloves turned the resident side to side and removed the resident’s urine soiled incontinence brief and dressed the resident; -NA R without washing hands and with the same soiled gloves transferred the resident to a wheelchair and combed his/her hair and did not provide the resident oral care or wash his/her face; -NA R removed the soiled gloves and without washing hands answered a call light in room [ROOM NUMBER], obtained clean gloves from the clean linen cart and without washing hands, applied the gloves and entered room [ROOM NUMBER]. 2. Observation of CNA U on 8/7/18 at 3:45 P.M. showed the following: -CNA U completed Resident #10’s transfer to the wheelchair and without washing hands or applying gloves attached the mechanical lift sling under resident #19 (Resident #10’s roommate) to the mechanical lift, removed the resident’s urinary catheter bag from the side of the bed and hung the urinary catheter bag on the top bar of the mechanical lift, approximately two feet above the level of the resident’s bladder. Cloudy yellow urine flowed down the catheter tubing to the resident’s bladder; -CNA U without washing hands or applying gloves assisted CNA V with Resident #19’s mechanical lift transfer. The resident’s urinary catheter bag remained hanging on the top bar of the mechanical lift, approximately two feet above the level of the resident’s bladder. No urine remained in the catheter tubing. CNA U moved the resident’s urinary drainage bag containing urine from the top of the mechanical lift bar to the privacy cloth bag under the resident’s wheelchair, lifted and repositioned the resident in the wheelchair with the mechanical lift sling under the resident, adjusted the resident’s shirt and touched the resident’s hair; -CNA U without washing hands washed Resident #19’s face and hands and without washing hands adjusted Resident #10’s hair and pushed the mechanical lift into the hallway. 3. Observation of CNA V on 8/7/18 at 3:45 P.M. showed the following: -CNA V completed Resident #10’s transfer to the wheelchair and without washing hands or applying gloves attached the mechanical lift sling under Resident #19 (Resident #10’s roommate) to the mechanical lift, and assisted CNA U with the resident’s mechanical lift transfer. He/she lifted and repositioned the resident in the wheelchair with the mechanical lift sling under the resident, obtained washcloths from the clean linen cart in the hallway and wet the washcloths at the resident’s room sink; -CNA V without washing hands or applying gloves washed Resident #10’s face, opened the room door and rolled Resident #19 in his/her wheelchair into the hallway. During interview on 8/9/18 at 2:35 P.M. NA R said the following: -He/she changed the resident’s soiled briefs, removed the brief, wiped them down a little and put on a clean brief; -He/she did not know the proper way to provide incontinence care. He/she wiped them down, put on a clean brief and got the resident up in the wheelchair. -He/she did not know when or how often he/she should wash hands and change gloves; -He/she should not use the same gloves from one room to the next room; -He/she should not wear gloves in the hallway; |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 30) -He/she should not wear soiled gloves and touch other things or touch clean linens; -He/she thought washing hands when gloves were changed made sense; -He/she was told to throw soiled linens on the floor and pick up after cares were provided. He/she now thought linens did not belong the floor. -The facility provided him/her two days of orientation and then he/she observed a CNA work with residents for two days. After that he/she was assigned a hall independently. During interview on 8/9/18 at 4:20 P.M. CNA V said the following: -He/she washed the resident’s catheter tubing with wet wipes and washed up and down the catheter tubing from the insertion site; -He/she washed resident’s perineal area from back to front; -He/she should place the resident’s urinary catheter bag below the level of the bladder. Urine running back into the bladder could cause infection. 4. Observation on 8/8/18 at 3:19 P.M. showed the following: – CNA D and the ADON entered the room, and without washing hands or applying gloves prepared to transfer Resident #16 to bed. CNA D and the ADON connected the Hoyer sling to the lift and CNA D picked up and moved the urinary drainage bag (without gloves) from the chair to the lift arm (raising it above the level of the bladder and allowing it to backflow into the resident’s bladder); -CNA D operated the remote as the resident was raised into the air. The ADON walked to the other side of the bed. The resident hung freely as he/she was lifted and his/her left foot hit the emergency stop button on the lift bar. CNA D then grabbed the resident’s lower legs and attempted to move the resident’s feet to the other side of the center hydraulic bar, scraping the resident’s bilateral feet on the bar. The resident yelled ouch. CNA D lowered the resident into bed and backed the lift away from the bed; -The resident was transferred to bed and CNA D and the ADON rolled the resident to remove the sling; -The ADON, without washing his/her hands exited the room; -CNA D washed his/her hands, gloved, retrieved a gown, removed the resident’s soiled top, applied the gown, rolled the resident, pulled the ressident’s pants down and removed the dry incontinent brief. He/she picked up the catheter bag, threaded it through the resident’s pant leg, removed the pants and tossed them along with other linens on the floor.; -CNA D degloved and without washing hands exited the room; -CNA D re-entered the room with a clean sheet, covered the resident, picked up the linens from the floor and exited without washing his/her hands. During interview on 8/9/18 at 5:05 P.M., CNA D said the following: -He/she did know that he/she scraped the resident’s feet against the lift bar, he/she did not know the resident’s foot had hit the emergency button; -He/she should have guided the resident’s feet around the bar instead of forcing them or had a second staff pull the resident back away from the bar. 5. Observation on 8/10/18 at 3:47 P.M. showed the following: -CNA N and CNA O entered Resident #11’s room to perform perineal care, un-taped the resident’s urine, soiled incontinent brief and rolled the resident to his/her left side; -CNA N picked up a moistened wash cloth, reached through the resident’s legs to the front and then pulled it back through. The CNA then repeated the same with a second cloth; -Staff failed to perform proper perineal care and did not cleanse all soiled areas including the frontal perineal area, the inner thighs and groin. During interview on 8/10/18 at 4:10 P.M., CNA N and CNA O said frontal perineal care should be attempted. |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 31) During interview on 8/14/18 at 6:30 P.M. the Director of Nursing said the following: -New NA staff receive six days of orientation and work with another CNA. No other training was provided for the NA staff and no skills check offs were completed prior to NAs providing resident care independently; -All NA and CNA staff currently needed skills check offs to ensure appropriate care was provided; -Untrained staff and inappropriate care resulted in poor quality of care. During interview on 8/14/18 at 5:30 P.M., the administrator said the following: -There is no one following CNAs to ensure they are transferring correctly and washing hands; -He/she was aware of the 16 hours required for the CNA program; -The faciility does not have a policy for CNA competency. | |
| F 0758 Level of harm – Actual harm Residents Affected – Few | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 32) medication; -PRN orders for [MEDICAL CONDITION] medications were only used when the medication was necessary and PRN use was limited. 2. Review of the facility policy Antipsychotic Medication Use, dated(NAME)(YEAR), showed the following: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The attending physician and other staff will gather and document information to clarify a resident’s behavior, mood, function, medical condition, symptoms and risks; -The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions; -Nursing staff will document in detail an individual’s target symptoms; -The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; -Staff will observe, document, and report to the physician information regarding the effectiveness of any interventions, including antipsychotic medications; -Based on assessing the resident’s symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medications; -Antipsychotic medications shall only be used for the following conditions/diagnoses as documented in the record: Schizo-affective disorder, mood disorders, depression with psychotic features, [MEDICAL CONDITION], brief [MEDICAL CONDITIONS], delusional disorder, schizophreniform disorder, atypical [MEDICAL CONDITION], dementing illnesses with associated behavioral symptoms, and medical illnesses or [MEDICAL CONDITION] with manic or psychotic symptoms; -For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: -Not due to a medical condition that can be expected to improve or resolve as the underlying condition is treated; and -Persistent of likely to reoccur without continued treatment; and -Not sufficiently relieved by non-pharmacological interventions; and -Not due to environmental stressors that can be addressed; -Not due to psychological stressors that can be expected to improve or resolve as the situation is addressed. -Antipsychotic medications will not be used if the only symptoms are one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, [MEDICAL CONDITION], unsociability, inattention, fidgeting, nervousness, uncooperativeness, verbal expressions or behavior that are not due to conditions listed under indications and do not represent a danger to the resident or others. 3. Review of drugs.com showed the following for [MEDICATION NAME]: -[MEDICATION NAME] is an antipsychotic medicine; -[MEDICATION NAME] is indicated for use in the treatment of [REDACTED]. -[MEDICATION NAME] is not approved for use in psychotic conditions related to dementia. This medicine may increase the risk of death in older adults with dementia-related conditions. Review of drugs.com showed the following for [MEDICATION NAME]: -[MEDICATION NAME] is an antipsychotic medicine; -[MEDICATION NAME] is used to treat [MEDICAL CONDITION] and is also used to treat symptoms of [MEDICAL CONDITION] disorder; |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 33) -[MEDICATION NAME] is not approved for use in psychotic conditions related to dementia. It may increase the risk of death in older adults with dementia-related conditions. 4. Review of Resident #4’s physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety; -[MEDICATION NAME] (an antipsychotic medication) 0.25 milligrams (mg) every morning for delusional disorder (original order dated 7/18/17); -[MEDICATION NAME] 1 mg at bedtime (original order dated 9/15/17); -[MEDICATION NAME] (an antianxiety medication) 15 mg twice daily (original order dated 9/11/17); -[MEDICATION NAME] (an antianxiety medication) 1 mg every six hours as needed (PRN) for anxiety and aggressiveness (original order dated 7/7/17). Review of the resident’s physician progress notes [REDACTED]. -Family wants the resident off of [MEDICATION NAME]. Discontinue [MEDICATION NAME] and change to [MEDICATION NAME] for self-protection and agitation. Decrease [MEDICATION NAME]; -The resident is confused and easily agitated; -[DIAGNOSES REDACTED]. Review of the resident’s physician orders, dated (MONTH) (YEAR), showed new orders were received on 10/12/17 for the following: -Discontinue [MEDICATION NAME]; -Decrease [MEDICATION NAME] at bedtime to 0.75 mg; -Add [MEDICATION NAME] 2 mg every six hours PRN for agitation. Review of the resident’s [MEDICAL CONDITION] monitoring record showed the resident had paranoia on the 3:00 P.M. to 11:00 P.M. shift on 10/13/17. (This was the only day staff documented the resident had paranoia in (MONTH) (YEAR). There was no documentation to show the resident had delusions.) Review of the resident’s Medication Administration Record (MAR), dated (MONTH) (YEAR), showed on 10/13/17 at 4:35 P.M., staff administered PRN [MEDICATION NAME] for increased anxiety and agitation. Review of the resident’s nurses notes, dated 10/13/17, showed no evidence the resident received PRN [MEDICATION NAME] as documented in the MAR, and no documentation of non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION NAME] on this day. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/14/17, showed the following: -Usually understood others; -Usually able to make himself/herself understood; -Severe cognitive impairment; -Inattention present, but fluctuates; -No behaviors, no delusions, and no hallucinations; -Diagnoses included dementia and anxiety; -No [DIAGNOSES REDACTED]. -Received antipsychotic and antianxiety medications on all days in the seven-day look back period; -Antipsychotic medications received on a routine basis. Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 10/14/18 at 9:30 A.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident’s nurses notes, dated 10/14/17 at 11:54 P.M., 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 34) had periods of restlessness earlier this shift; he/she was difficult to redirect. Will continue to monitor. (Review showed no evidence the resident received PRN [MEDICATION NAME] as documented in the MAR, and no documentation of non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION NAME] on this day.) Review of the resident’s care plan, dated 10/17/17, showed the following: -[DIAGNOSES REDACTED]. -[MEDICAL CONDITION] medication use: Give [MEDICATION NAME] (an antipsychotic medication) scheduled and [MEDICATION NAME] (an antipsychotic medication) as needed for increased anxiety. The resident is at risk for side effects from his/her medications. -The resident will be free from adverse affects or worsening symptoms related to the use of [MEDICAL CONDITION] medications; -Assess the resident for any changes in his/her behaviors or moods; -Notify the physician of status changes; -The pharmacist and physician are to review record and assess the effectiveness of medication, and routinely assess for possible decreased dose or discontinuation of medication. -The resident is forgetful and confused and does not always understand what is going on around him/her or where he/she is at. He/she has made threats and gestures to hit at staff and can be resistive to care. The resident has a [DIAGNOSES REDACTED].>-Provide the resident with frequent reorientation; -Allow resident time to comprehend what is said; -Do not confront or argue with the resident. Attempt to interest the resident in a diversional activity with decreased stimuli; -If the resident becomes aggressive during care, stop and explain what you are doing and why, allow the resident time to calm down. -If unable to calm the resident and he/she remains resistive, assure him/her he/she is in a safe environment and leave the room to let him/her calm down and reapproach later. If he/she still resists, have someone else try to assist him/her; -Encourage socialization and activities. Offer toileting and activities; -Notify charge nurse of the resident’s unresolved behaviors and the resident’s family member who may come to help decrease the resident’s agitation; -Administer [MEDICATION NAME] (an antipsychotic medication) scheduled and [MEDICATION NAME] as ordered; -Notify the physician of changes in mood or behaviors that are unresolved. Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 10/22/17 at 2:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident’s nurses notes, dated 10/22/17 at 4:43 P.M., showed the resident was displaying increased agitation and was difficult to redirect. Staff gave the resident PRN [MEDICATION NAME] per physician orders with no further negative behaviors. (Review showed no documentation of non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION NAME].) Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 10/30/17 at 3:30 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident’s nurses notes dated 10/30/17 showed no evidence the resident received PRN [MEDICATION NAME] as documented on the MAR, and no documentation of non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION NAME] on this day. |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 35) Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety; -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 11/6/17 at 6:00 P.M., staff administered PRN [MEDICATION NAME] for agitation. Review of the resident’s nurses notes, dated 11/6/17, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 11/20/18 at 11:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident’s PRN Anti-anxiety, Anti-Psychotic, and Hypnotic Documentation, dated 11/20/17, showed the following: -Non-pharmacological interventions attempted: Calm resident, offer bathroom, and offer food; -PRN [MEDICATION NAME] given at 11:00 P.M. for agitation. Review of the resident’s nurses notes, dated 11/20/17, showed no documentation for the resident on this day. Review of the resident’s MAR, dated (MONTH) (YEAR), showed the following: -On 11/21/18 at 11:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given; -On 11/22/18 at 5:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident’s nurses notes for 11/21/18 and 11/22/18, showed no documentation for the resident on these days. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed on 11/22/17, the resident had on delusions the 3:00 P.M. to 11:00 P.M. shift. (There was no documentation to show the resident presented with delusions on other days during (MONTH) (YEAR).) Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician’s orders did not indicate the duration of this PRN order.) Review of the resident’s MAR, dated (MONTH) (YEAR), showed the following: -On 12/11/17 at 4:30 A.M., staff administered PRN [MEDICATION NAME] for agitation; -On 12/14/17 at 8:00 A.M., staff administered PRN [MEDICATION NAME] for anxiety and agitation. Review of the resident’s nurses notes, dated 12/11/17 and 12/14/17, showed no documentation for the resident on these days. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident’s physician’s progress notes, dated 12/14/17, showed the following: -The physician saw 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 36) -The resident has increased confusion; -The resident’s medical record and medications were reviewed; -Diagnoses of confusion and multi infarct dementia; -Continue current therapy. (Review showed no evidence the resident’s physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME].) Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 12/29/17 at 5:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident’s nurses notes, dated 12/29/17, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety; -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician’s orders did not indicate the duration of this PRN order.) Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 1/8/18 at 7:00 A.M., staff administered PRN [MEDICATION NAME] for combative behavior, uncooperative, and unable to redirect. Review of the resident’s nurses notes, dated 1/8/18, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident’s physician’s progress notes, dated 1/11/18, showed the following: -The physician saw the resident and reviewed his/her medical record and medications; -Staff reported no new changes; -Diagnoses of confusion and multi infarct dementia; -Continue current treatment. (Review showed no evidence the resident’s physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME].) Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 1/13/18 at 1:05 P.M., staff administered PRN [MEDICATION NAME] for agitation. Review of the resident’s nurses notes, dated 1/13/18, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the pharmacist consultation report, dated (MONTH) (YEAR), showed the following: -Recommendation to discontinue the PRN [MEDICATION NAME]. The physician declined the recommendation and wrote, the resident has post head trauma with episodic outbreaks requiring medication. The physician signed and dated the consultation report on 2/13/18; -The resident received [MEDICATION NAME] 0.25 mg A.M. and 0.75 mg P.M. since 10/12/17, when it was reduced. This reduction seems successful. Please consider gradual dose reduction to 0.25 mg A.M. and 0.5 mg P.M. while monitoring for emergence of target and/or withdrawal symptoms. The physician declined the recommendation because a reduction was |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 37) clinically contraindicated. Continued use of the medication was in accordance with current standards of practice and an reduction attempt is likely to impair the individual’s function or cause psychiatric instability by exacerbating an underlying medical condition of psychiatric disorder as documented below (space below was left blank). Review of the resident’s quarterly MDS, dated [DATE], showed the following: -Usually understood others; -Usually able to make himself/herself understood; -Severe cognitive impairment; -Inattention present, but fluctuates; -Disorganized thinking continuously present, does not fluctuate; -No behaviors, no delusions, and no hallucinations; -Diagnoses included dementia and anxiety; -No [DIAGNOSES REDACTED]. -Received antipsychotic and antianxiety medications on all days in the seven-day look back period; -Antipsychotic medications received on a routine basis. Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician’s orders did not indicate the duration of this PRN order.) Review of the resident’s physician’s progress note, dated 2/8/18, showed the following: -The physician saw the resident and reviewed his/her medical record and medications; -The resident was confused; -Diagnoses of confusion and multi infarct dementia; -Continue current therapy. (Review showed no evidence the resident’s physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME].) Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 2/23/18 at 4:00 P.M., the resident received PRN [MEDICATION NAME] for agitation. Review of the resident’s nurses notes, dated 2/23/18, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder and anxiety; -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician’s orders did not indicate the duration of this PRN order.) Review of the resident’s PRN Antianxiety, Antipsychotic, and Hypnotic Documentation, dated 3/4/18 at 6:15 A.M., the resident was hitting other residents and staff. He/she was |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 38) restless, loud, hollering, rude, making verbal threats, scaring and upsetting other residents, taunting and aggravating other residents, and kicking chairs. Staff attempted to calm the resident; reorient the resident; offer water, bathroom, and food; reposition the resident; offer pain medication; and waited a few minutes and tried again. PRN [MEDICATION NAME] was given at 7:00 A.M. Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 3/4/18 at 7:00 A.M., staff administered PRN [MEDICATION NAME]. Review of the resident’s physician’s progress notes, dated 3/8/18, showed the following: -The physician saw the resident and reviewed his/her medical record and medications; -The resident was very confused; -Diagnoses of confusion and multi infarct dementia; -Continue with current therapy. (Review showed no evidence the resident’s physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME].) Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 3/30/18 at 7:15 A.M., staff administered PRN [MEDICATION NAME] for agitation. Review of the resident’s nurses notes, dated 3/30/18, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the pharmacist consultation report, dated for (MONTH) (YEAR), showed the following: -The resident has a PRN order for an antipsychotic, which has been in place for greater than 14 days without a stop date. [MEDICATION NAME] 2 mg every six hours as needed for agitation. -Recommendation- Please review and discontinue PRN [MEDICATION NAME]. If this PRN antipsychotic cannot be discontinued at this time, current regulations require that the prescriber directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated prior to issuing a new PRN order. -Rationale for recommendation: CMS requires that PRN orders for antipsychotic medications be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the resident’s condition and progress to determine if the PRN antipsychotic is still needed. Report of the resident’s condition from facility staff to the prescriber does not meet the criteria for an evaluation. -The physician marked he/she declined the recommendation above and did not wish to implement any changes due to the reasons below. The physician wrote to continue the PRN for severe change in mood with self-harm environment (illegible). Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder and anxiety; -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. Handwritten note, dated 4/2/18, showed to continue PRN for severe change in mood with self-harm. (The physician’s orders did not indicate the duration of this PRN order.) Review of the resident’s quarterly MDS, dated [DATE], showed the following: -Usually understood 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 39) -Usually able to make himself/herself understood; -Severe cognitive impairment; -Inattention present, but fluctuates; -Disorganized thinking continuously present, does not fluctuate; -No behaviors, no delusions, and no hallucinations; -Diagnoses included dementia and anxiety; -No [DIAGNOSES REDACTED]. -Received antipsychotic and antianxiety medications on all days in the seven-day look back period; -Antipsychotic medications received on a routine basis. Review of the resident’s nurses notes showed the following: -On 4/17/18 at 7:20 A.M., the resident sat in his/her chair, leaning forward to the point of almost falling out of his/her chair. The resident was jerking all over upper and lower extremities and torso. Did not answer to verbal stimuli, moaned at intervals. -On 4/17/18 at 7:54 A.M., the resident was transported to the hospital. -On 4/19/18 at 1:04 P.M., the resident returned to the facility. Review of the resident’s hospital discharge summary, dated 4/19/18, showed the resident was admitted from a nursing home secondary to changes in behavior. The resident has advanced dementia with behavioral issues. The resident’s [MEDICATION NAME] was stopped secondary to tardive dyskinesia (a condition affecting the nervous system, often caused by long-term use of psychiatric medications). Review of the patient transfer form from the hospital, dated 4/19/18, showed to discontinue [MEDICATION NAME] secondary to tardive dyskinesia Review of the resident’s physician’s orders, dated 4/19/18, showed the following: -Discontinue [MEDICATION NAME] and [MEDICATION NAME]; -Handwritten note added on 4/19/18 to restart [MEDICATION NAME] 0.25 mg, three tablets at bedtime. Review of the resident’s physician progress notes [REDACTED]. There was no further documentation in the note. (Review showed no evidence the resident’s physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME]. The medical record did not include documentation to support adding [MEDICATION NAME] 0.25, three tablets at bedtime.) Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident’s physician orders, dated (MONTH) (YEAR), showed an order for [REDACTED]. Further review showed no physician order for [REDACTED]. Review of the resident’s History and Physical, dated 5/10/18, showed the following: -Medical diagnoses included Alzheimer’s dementia and recurrent UTIs; -Resident is confused; -Resident’s behavior is appropriate. (Review showed no documented evidence to address the resident’s medication regimen.) Review of the resident’s MAR, dated (MONTH) (YEAR), showed the following: -[MEDICATION NAME] 2 mg every six hours PRN for extreme behaviors. (Review of the resident’s physician’s orders showed no evidence the resident had an order for [REDACTED]. -On 5/22/18 at 9:40 A.M., staff administered PRN [MEDICATION NAME]. The resident was yelling, hitting, and fighting with staff and family; -On 5/25/18 at 1:00 P.M., staff administered PRN [MEDICATION NAME]. The resident was hitting and trying to stand; |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 40) -On 5/25/18 at 9:00 P.M., staff administered PRN [MEDICATION NAME]. The resident was yelling and hitting; very agitated; -On 5/27/18 at 8:30 P.M., staff administered PRN [MEDICATION NAME]. The resident had increase agitation, and was yelling and hitting; -On 5/28/18 (time illegible), staff administered PRN [MEDICATION NAME]. The resident was agitated and hitting. The medication helped the resident stay busy; -On 5/28/18 at 2:00 P.M., staff administered PRN [MEDICATION NAME]. The resident was agitated and had aggression. (Review showed no evidence staff documented the effectiveness of the medication, except for on 5/28/18.) Review of the resident’s nurses notes for (MONTH) (YEAR) showed no evidence the resident had delusions, aggression, agitation, or any physical or verbal behaviors directed towards others during the month. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME] during (MONTH) (YEAR). Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety; -[MEDICATION NAME] 0.25 mg, take three tablets (0.75 mg) at bedtime; -[MEDICATION NAME] 2 mg every six hours as needed for agitation. (The physician’s orders did not indicate the duration of this PRN order.) Review of the resident’s MAR, dated (MONTH) (YEAR), showed the following: -[MEDICATION NAME] 2 mg every six hours PRN for extreme behaviors; -On 6/4/18 at 6:30 A.M., staff administered [MEDICATION NAME] for agitation; -On 6/5/18 at 3:25 A.M., staff administered [MEDICATION NAME] for agitation and yelling; -On 6/5/18 at 11:30 P.M., staff administered [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident’s nurses notes for (MONTH) (YEAR) showed no documentation for the resident on 6/4/18 and 6/5/18(when staff administered PRN [MEDICATION NAME]). There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 6/8/18 at 2:00 A.M., showed staff administered [MEDICATION NAME] for yelling. Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed on 6/8/18 on the 7:00 A.M. to 3:00 P.M. shift, showed the resident presented with delusions. Review of the resident’s nurses notes for (MONTH) (YEAR) showed no documentation for the resident on 6/8/18 (when staff administered PRN [MEDICATION NAME]). There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 6/10/18 at 10:45 A.M., staff administered [MEDICATION NAME] for agitation and yelling. Review of the resident’s nurses notes for (MONTH) (YEAR) showed no documentation for the resident on 6/10/18 (when staff administered PRN [MEDICATION NAME]). There was no evidence non-pharmacological inter | |
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure medication error rates are not 5 percent or greater. **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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 41) medication error rate was less than five percent. Thirty five opportunities were observed with two medication errors, resulting in a medication error rate of 5.7 percent. The facility census was 57. 1. Review of the facility policy Medication, Administration Guidelines from Nursing Guidelines Manual, (MONTH) (YEAR), showed the following: -The purpose was that residents received their mediations on a timely basis and in accordancew the established policies; -Medications were given to benefit a resident’s health as ordered by the physician; -For administration of tablets or capsules offer resident water before/after administering medication to aid in swallowing, do not crush any medication if a liquid form was available. Certain medications should never be crushed, refer to pharmacy manual if unsure if a medication could be crushed. 2. Review of www.drugs.com showed the following: -[MEDICATION NAME], an anti-epileptic drug used to treat partial onset [MEDICAL CONDITION], swallow the tablet whole and do not crush, chew or break it; -Potassium chloride, a mineral found in many foods and was needed for several functions of your body especially the beating of the heart, swallow the pill whole, do not crush, chew, break or suck on an extended-release tablet or capsule. Breaking or crushing the pill may cause too much of the drug to be released at one time. 3. Review of Resident #21’s Physician Order Sheet dated (MONTH) (YEAR) showed the following: -[MEDICATION NAME] (blood pressure medication) 25 milligrams (mg) one tablet two times daily at 8:00 A.M. and 5:00 P.M.; -[MEDICATION NAME] ([MEDICATION NAME] medication used to improve blood flow in the legs) 100mg one tablet two times daily at 8:00 A.M. and 5:00 P.M.; -[MEDICATION NAME] 750 mg one tablet two times daily at 8:00 A.M. and 5:00 P.M.; -[MEDICATION NAME] (diabetic medication) 500 mg one tablet two times daily at 8:00 A.M. and 4:00 P.M.; -KCL (potassium chloride) 20 milliEquivalent (mEq) extended release one tablet two times daily at 8:00 A.M. and 5:00 P.M. Observation on 8/8/18 at 3:30 P.M. showed the following: -Certified Medication Technician (CMT) O obtained [MEDICATION NAME] 25 mg one tablet, [MEDICATION NAME] 100mg one tablet, [MEDICATION NAME] 750mg one tablet, [MEDICATION NAME] 500mg one tablet and KCL 20 mEq one tablet from the medication cart drawer, placed all the medications in a plastic sleeve and crushed the medications; -CMT O poured the crushed medication powder into a medication cup, added applesauce and administered the medications; -CMT O did not administer [MEDICATION NAME] and KCL whole. During interview on 8/10/18 at 2:35 P.M. and 8/14/18 at 2:20 P.M. CMT O said the following: -He/she learned yesterday not to crush potassium chloride. He/she did not know that before. Currently he/she crushed all potassium chloride medications if the resident was unable to swallow the medication whole; -He/she was not aware [MEDICATION NAME] medication should not be crushed. He/she always crushed [MEDICATION NAME] if the resident was unable to swallow the medication whole. During interview on 8/14/18 at 6:30 P.M. the Director of Nursing said staff should not crush potassium chloride tablets or [MEDICATION NAME] medications. If the resident was unable to swallow the medications whole, staff should contact the physician for a different form of the medication to administer. |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| 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. **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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 43) expired Resident #208 (expired on 6/8/18); -Pantoprazole (medication used to treat gastric reflux) 40 mg, 20 tablets dispensed 5/21/18 and discontinued on 6/5/18, [MEDICATION NAME] (antacid medication) 150mg approximately 100 tablets, medication expired on 6/21/18, belonging to Resident #7; -[MEDICATION NAME] (medication used to treat dementia) 10 mg, 28 tablets dispensed 6/12/18 belonging to expired Resident #206 (expired on 6/25/18); -[MEDICATION NAME] (antipsychotic medication) 5mg/milliliter (ml) 2 vials dispensed 6/27/14 and expired in (MONTH) (YEAR) belonging to expired Resident #204 (expired on 1/4/15); -[MEDICATION NAME] 5mg/ml 3 vials dispensed 8/19/16 and expired in (MONTH) (YEAR) belonging to expired Resident #203 (expired on 1/13/17); -[MEDICATION NAME] Lock Flush (blood thinning medication) 16-5ml syringes dispensed 2/20/18 belonging to expired Resident #202 (expired on 5/20/18); -[MEDICATION NAME] 2mg/ml, 15ml liquid bottle dispensed 5/18/18 and [MEDICATION NAME] (anti -nausea medication) 10 mg, 3 tablets dispensed on 5/18/18 belonging to expired resident #201, (expired on 5/30/18); -[MEDICATION NAME] (neurological pain medication) 100 mg, 270 capsules dispensed on 6/11/18 belonging to discharged Resident #200 (discharged on [DATE]); -[MEDICATION NAME] suspension (liquid medication used for oral yeast infection) 100,000 units/ml, approximately 60 ml bottle dispensed 6/26/18 and [MEDICATION NAME] (liquid breathing medication) 0.5mg/3mg/3ml, 30 vials dispensed 6/26/18 belonging to expired Resident #205 (expired on 7/2/18); -[MEDICATION NAME] 2mg/ml, 20 ml bottle dispensed 5/25/18, Senna (laxative medication) 8.6 mg, 14 tablets dispensed 5/10/18, [MEDICATION NAME] (anti-depressant medication) 50mg, 24 tablets dispensed 4/2/18, [MEDICATION NAME] (muscle relaxant medication) 10mg, 22 tablets dispensed on 4/2/18 belonging to expired Resident #207 (expired on 6/10/18); -Influenza Vaccine 2.5 vials expired 6/30/18. During interview on 8/9/18 at 1:00 P.M. Certified Medication Technician (CMT) X said staff should destroy or return to pharmacy all discontinued medications and expired medications within a few days. Staff should destroy or return to pharmacy all medications belonging to discharged or expired residents immediately after discharge or death. During interview on 8/14/18 at 6:30 P.M. the Director of Nursing said the following: -Staff should destroy residents’ medications at the time the resident was discharged or expired. Currently staff placed medications for destruction under the sink in a box in the medication room until destroyed; -Staff should not keep medications no longer needed past 30 days; -There was no designated person to destroy medications. | |
| F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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, the facility failed to ensure meals |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 – Some | (continued… from page 44) 1. Review of the facility spread sheet for the lunch meal service on 8/7/18 showed two #10 scoops of mashed potatoes were to be served to residents on a pureed diet. Observations on 08/07/18 between 11:42 A.M. and 12:18 P.M. during the lunch time meal service showed the following: -A #10 (3.25 oz) scoop was used to serve mashed potatoes; -One scoop of mashed potatoes was served to Resident #7; -One scoop of mashed potatoes was served to Resident #11; -One scoop of mashed potatoes was served to Resident #19; -One scoop of mashed potatoes was served to Resident #25; -One scoop of mashed potatoes was served to Resident #28; -One scoop of mashed potatoes was served to Resident #213; -One scoop of mashed potatoes was served to Resident #214; -One scoop of mashed potatoes was served to Resident #215; During interview on 08/07/18 at 1:59 P.M., the dietary supervisor said the spread sheet calls for two #10 scoops of mashed potatoes, and two scoops should have been given to each resident on a pureed diet. During interview on 8/8/18 at 9:06 A.M., the registered dietician said the correct serving size for mashed potatoes for the lunch meal on 8/7/18 should have been two #10 scoops. This portion was carefully calculated in order to ensure proper nutrition was met for each resident. | |
| 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** 1. Review of the facility policy Blood Glucometer disinfecting dated (MONTH) (YEAR) 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 45) -Gloves were not a cure-all. They should reduce the likelihood of contaminating the hands but gloves could not prevent penetrating injuries due to needles or sharp objects. Dirty gloves were worse than dirty hands because microorganisms adhere to the surface of the glove easier than to the skin on your hands. Handling medical equipment and devices with contaminated gloves was not acceptable. 3. Review of the facility policy Handwashing dated (MONTH) 2012 showed handwashing remained the single most effective means of preventing disease transmission. Wash hands often and well, paying particular attention to areas around and under the fingernails and between fingers. Wash hands whenever they were soiled with body substances, before food preparation, before eating, after using the toilet, before performing invasive procedures and when each resident’s care was competed. 4. Review of the Infection Control Guidelines for Long Term Care Facilities, (MONTH) 2005 edition, Section 3.0, Body Substance Precautions, Subsection 3.2 Implementing the Body Substance Precautions System, showed the following regarding gloves and handwashing: -Instructions should be followed by ALL personnel at all times regardless of the resident’s diagnosis; -Gloves: Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash; gloves must be changed between residents and between contacts with different body sites of the same resident. Section 3.0: Body Substance Precautions Subsection 3.2 Implementing the Body Substance Precautions System INFECTION CONTROL GUIDELINES FOR LONG TERM CARE FACILITIES Guidelines for appropriate management of soiled linen include: ? Place all soiled linens in laundry bags provided at the point of use. ? Avoid contact with your uniform/clothing and surrounding patient care equipment. ? Do not shake or place linen directly on the floor. ? For linens lightly to moderately moist, fold and/or roll in such a way as to contain the moist area in the center of the soiled linen. ? For soiled linens that are saturated with moisture, place them in a plastic bag followed by tying or knotting the open end. The plastic bag containing wet linens should then be placed in an approved laundry bag and closed before transporting to the proper designated area. ? DO NOT OVERFILL BAGS more than 2/3 of capacity as overfilled bags tend to rupture if they are dropped. 5. Review of the CDC and Centers for Medicare and Medicaid (CMS) recommendations, August, 2010, showed the following: -Blood contamination is often evident on glucometers even if one cannot see it; -Facilities must use an EPA-registered disinfectant to clean glucometers; -Rubbing alcohol is not an effective disinfectant against [MEDICAL CONDITION] and should not be used; -It is important to use a glucose monitoring device designed for institutional use that can be disinfected frequently; -The manufacturer’s instructions should say which cleaning solution a device can withstand; -If the manufacturer’s instructions do not specify steps for cleaning and disinfecting between uses of glucose monitoring devices, the devices generally should not be shared among residents according the CMS. 6. Review of Resident #11’s care plan dated 8/14/17 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 46) -Problem: Incontinent of bladder and bowel; -Approach: Provide me with perineal care after each incontinent episode. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility and dated 5/7/18 showed the following: -Severely impaired cognition; -Total dependence of two staff for toilet use and total dependence of one staff for personal hygiene; -Always incontinent of bladder and bowel. Observation on 8/10/18 at 3:47 P.M. showed the following: -The resident lay in his/her bed; -Certified Nurse Assistant (CNA) N and CNA O entered the resident’s room to perform perineal care, un-taped the resident’s urine soiled incontinent brief and rolled the resident to his/her left side; -CNA N picked up a moistened wash cloth and reaching from behind, reached through the resident’s legs (with surfaces of the cloth touching the inner thighs) to the front and then pulled it back through. The CNA then repeated the same with a second cloth. -CNA N tucked the soiled brief and then without washing hands or changing gloves tucked the clean brief; -CNA N without changing gloves or washing hands and CNA O rolled the resident to his/her right side; -CNA O pulled the urine soiled brief out from under the resident, and then pulled the clean brief out, assisted the resident to his/her back and both CNAs fastened the brief and covered the resident; -CNA N without changing glove or washing hands exited the room carrying the bag of soiled items, walked down the hall to the soiled utility, disposed of the bags and degloved; -CNA N then walked to the shower room where he/she washed his/her hands. During interview on 8/10/18 at 4:10 P.M., CNA N said hands should be washed after they become soiled and gloves changed after perineal care. CNA O said hands should be washed and gloves changed after perineal care and before touching clean items and before exiting the room. 7. Review of Resident #19’s quarterly MDS dated [DATE] showed the following: -Short and long term memory problem -Required total assistance of two staff members with transfers; -Required extensive assistance of two staff members with bed mobility and toileting; -Required extensive assistance of one staff member with dressing and personal hygiene; -Required an indwelling urinary catheter (a sterile tube place in the bladder to drain urine) and was always incontinent of bowel. Review of the resident’s care plan revised 5/31/18 showed the following: -[DIAGNOSES REDACTED]. -The resident was incontinent of urine, required a urinary catheter and was at increased risk of urinary tract infections and complications. Staff should provide catheter care every shift and maintain a closed urinary catheter system using aseptic (clean) technique when accessing the catheter; -The resident was confused and required one or two staff members assistance with Activities of Daily Living, transfers and incontinence care. Staff should provide total assistance with ADLs; provide urinary catheter care every shift, and bowel incontinence care as needed. Assist with ADLS and be clean, dry and well-groomed at all times. Observation on 8/7/18 at 3:45 P.M. showed the following -CNA U and CNA V completed Resident #10’s mechanical lift transfer to the wheelchair 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 47) CNA V combed the resident’s hair; -CNA U and CNA V without washing hands or applying gloves attached the mechanical lift sling under Resident #19 to the mechanical lift. CNA U picked up the resident’s urinary drainage bag containing urine and placed it on the mechanical lift bar while CNA V applied the resident’s shoes; -CNA U and CNA V without washing hands or applying gloves transferred the resident to the wheelchair; -CNA V without washing hands or applying gloves picked up the resident’s urinary catheter bag containing urine and handed CNA U the bag; -CNA U without washing hands or applying gloves placed the resident’s urinary drainage bag containing urine in the privacy cloth bag under the resident’s wheelchair; -CNA U and CNA V without washing hands or applying gloves lifted the resident with the mechanical lift sling under the resident and repositioned the resident in the wheelchair; -CNA U without washing hands adjusted the resident’s shirt and touched the resident’s hair; -CNA V without washing hands obtained washcloths from the clean linen cart in the hallway and wet the washcloths at the resident’s room sink; -CNA V without washing hands handed CNA U a wet washcloth; -CNA U without washing hands washed the resident’s face and hands while CNA V without washing hands washed Resident #10’s face; -CNA V without washing hands opened the room door and pushed Resident #19’s wheelchair into the hallway; -CNA U without washing hands adjusted Resident #10’s hair, pushed the mechanical lift into the hallway and pushed the soiled linen cart down the hallway. Observation on 8/9/18 at 6:20 A.M. showed the following: -Nursing Assistant (NA) R wore gloves and wiped feces from the resident’s buttocks; -NA R without washing hands or changing gloves removed the resident’s gown and placed the gown on the floor; -NA R without washing hands or changing gloves dressed the resident and assisted with a mechanical lift transfer to the wheelchair; -NA R without washing hands, changed gloves and applied Resident #10’s (Resident #19’s roommate) clean socks and pants, removed the gloves and without washing hands, obtained an oxygen portable tank from the closet down the hall, opened a package of oxygen tubing and attached the oxygen tubing to Resident #19’s oxygen concentrator. During interview on 8/9/18 at 2:25 P.M. CNA U said the following: -He/she should wash hands and change gloves every time he/she provided the residents cares; -He/she should change gloves and wash hands anytime the gloves were soiled and in between the resident’s cares; -He/she did not wash hands and change gloves while providing the residents cares and went from one resident to another without washing hands. During interview on 8/9/18 at 4:20 P.M. CNA V said he/she should wash hands and change gloves after caring for every resident and when the gloves were soiled. 8. Review of Resident #10’s quarterly MDS dated [DATE] showed the following: -Short and long term memory problem; -Severely impaired daily decision making ability; -Required extensive assistance of two staff members with bed mobility, dressing and toileting; -Required extensive assistance of one staff member with personal hygiene; |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 48) -Always incontinent of bowel and bladder. Review of the resident’s Care Plan revised 8/2/18 showed the following: -[DIAGNOSES REDACTED]. -The resident was incontinent of bowel and bladder. Staff should check the resident every two hours and as needed for incontinent episodes, provide perineal care after each incontinent episode and apply incontinence briefs while up in the wheelchair. The goal was to keep the resident clean, dry and odor free at all times; -The resident had right sided weakness due to a stroke and was dependent on staff for ADLs. Staff should provide assistance with all ADLs and shower the resident twice weekly. Goal was the resident clean, dry and well-groomed at all times with staff performing ADLs. Observation on 8/9/18 at 7:00 A.M. showed the following: -NA R without washing hands applied gloves, obtained supplies from the clean linen cart in the hallway, returned to the resident’s room and placed Resident #19’s urinary catheter drainage bag in a privacy bag, removed the gloves and without washing hands checked Resident #19’s mouth; -NA R without washing hands, applied gloves and turned Resident #10 to his/her side. The resident said I am wet; -NA R without washing hands or changing gloves obtained wet wipes and removed small amount of soft feces from the resident’s anal area; -NA R with the same soiled gloves obtained a clean wet wipe and wiped the resident’s buttock areas; -NA R without washing hands and with the same soiled gloves, turned the resident side to side, removed the resident’s urine soiled incontinence brief, dressed the resident, transferred the resident to a wheelchair and combed his/her hair; -NA R removed the soiled gloves and without washing hands answered a call light in room [ROOM NUMBER], obtained clean gloves from the clean linen cart and without washing hands, applied the gloves and entered room [ROOM NUMBER]. During interview on 8/9/18 at 2:35 P.M. NA R said the following: -He/she did not know when or how often he/she should wash hands and change gloves; -He/she should not use the same gloves from one room to the next room; -He/she should not wear gloves in the hallway; -He/she should not wear soiled gloves and touch other things or touch clean linens; -He/she thought washing hands when gloves were changed made sense; -He/she was told to throw soiled linens on the floor and pick up after cares were provided. He/she now thought linens did not belong the floor. 9. Review of Resident #16’s quarterly MDS, dated [DATE], showed the following: .-Cognitively intact; -Total dependence of two staff for bed mobility and transfers; -Supra-pubic catheter (thin, sterile tube inserted directly into bladder to drain urine from the body). Review of the resident’s Care plan, dated 6/25/18, showed the following: -Problem: Bilateral lower extremity paralysis and need for extensive assist with all Activities of Daily Living and transfers; -Approaches: Assist of two staff and Hoyer lift (mechanical lift used for non-weight bearing residents) for transfers. Review of the resident’s Physician Order Sheet dated 8/1/18 to 8/31/18 showed the following: -[DIAGNOSES REDACTED]. -Up with assist of two staff and Hoyer lift. |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 49) Observation on 8/8/18 at 3:19 PM showed the following: -The resident sat on a Hoyer sling in his/her chair; -CNA D and the ADON entered the room and without washing hands or applying gloves prepared to transfer the resident to bed. CNA D and the ADON connected the Hoyer sling to the lift and CNA D picked up and moved the urinary drainage bag (without gloves) from the chair to the lift; -The resident was transferred to bed and CNA D and the ADON rolled the resident to remove the sling; -The ADON without washing his/her hands exited the room; -CNA D washed his/her hands, gloved, retrieved a gown, removed the resident’s soiled top, applied the gown, rolled the resident, pulled the resident’s pants down and removed the dry incontinent brief. He/she picked up the catheter bag, threaded it through the resident’s pant leg, removed the pants and tossed the pants along with other linens on the floor; -CNA D degloved and without washing hands exited the room; -CNA D re-entered the room with a clean sheet, covered the resident, picked up the linens from the floor and exited without washing his/her hands. 7. Review of Resident #18’s care plan dated 5/2/18 and last revised 8/2/18, showed the following: -Problem: I am weak and unsteady and need assist of one for ADL’s and transfers; -Goal: I will be assisted with my ADL’s by staff and be clean; -Approaches: Urinary catheter and occasionally incontinent of bowel, provide me with perineal care. Review of the resident’s quarterly MDS dated [DATE] showed the following: -Indwelling catheter; -Occasionally incontinent of bowel; -Limited assist of one staff for bed mobility, personal hygiene, dressing and transfers. Review of the resident’s POS dated 8/1/18 through 8/31/18 showed the following: -[DIAGNOSES REDACTED]. -Up as desired to a wheelchair. Observation on 8/9/18 at 6:50 AM showed the following: -The resident lay on his/her back in his/her bed; -CNA K applied gown, gloves and mask, entered the room, prepared washcloths in the sink and sat them on the over the bed table without a barrier; -He/she untaped the dry incontinent brief, removed it while the resident lay on his/her right side, picked up a wash cloth from the table and performed perineal care, degloved and without washing his/her hands applied clean gloves; -He/she applied the resident’s pajama pants, picked up the catheter bag, threaded it through the pant leg and without washing hands or changing gloves,applied the resident’s shoes, moved the wheelchair close to the bed, moved the catheter bag to the wheelchair and assisted the resident to sit on the side of the bed; -Without removing his/her gloves and washing hands he/she applied the resident’s deoderant and shirt; -He/she degloved and without washing his/her hands transferred the resident to his/her wheelchair. During interview on 8/9/18 at 11:35 A.M. and 8/21/18 at 2:32 P.M. CNA K said the following: -Hands should be washed before gloving, when soiled and when finished with cares; -Gloves should be changed after perineal care and hands should be washed; |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 50) -A barrier should be placed on a surface prior to placing clean cloths on them; -Clean items touched with soiled hands would be contaminated. 8. Review of Resident #110’s Admission MDS, dated [DATE] showed the following: -Severely impaired cognition; -Extensive assist of two for bed mobility; -Extensive assist of one for personal hygiene; -Always incontinent of bladder and bowel. Review of the resident’s POS, dated 8/1/18 showed barrier cream to affected areas as needed for preventative (6/21/18). Review of the Resident’s Treatment Administration Record, dated 8/1/18 showed right ischium wound: Cleanse with cleanser, apply sure prep (creates barrier film on peri-wound skin) to surrounding tissue, Santyl (a sterile enzymatic [MEDICATION NAME] ointment) to wound bed, Hydrogel (a gel in which the liquid component is water) on top, cover with border gauze. Change daily and as needed for soiling/dislodgement (7/26/18). Observation on 8/9/18 at 5:50 A.M., showed the following: -The resident lay in his/her bed; -CNA M entered the room and washed his/her hands and donned gloves. CNA K entered the room with gloved hands; -CNA K unfastened the resident’s urine soiled incontinent brief; -CNA M picked up a moistened washcloth and cleansed the resident’s front perineal area; -CNA K rolled the resident to his/her right side and CNA M tucked the soiled brief, picked up a clean cloth, wiped the hip, buttock area, degloved and washed his/her hands and applied clean gloves; -CNA M picked up a clean cloth and wiped the resident’s anal area and without changing gloves or washing hands picked up and placed a clean incontinent brief; -CNA M rolled the resident to his/her left side and CNA K pulled out the soiled brief and placed it in a bag; -CNA M applied barrier cream with the same soiled gloves to the resident’s soiled right hip, wiping over the right ischium wound which did not have a dressing; -CNA M and CNA K without washing hands and changing gloves rolled the resident to his/her backside and fastened the resident’s clean brief; -CNA K bagged the linens and without washing hands exited the room. During interview on 8/9/18 at 6:25 P.M., CNA M said the following: -Hands should be washed and gloves changed after perineal care and before applying barrier cream; -All soiled areas of the incontinent resident’s skin should be cleansed prior to applying cream; -Clean items/surfaces would be considered contaminated if touched with soiled hands. During interview on 8/21/18 at 2:32 P.M., CNA K said clean items touched with soiled hands would be contaminated. 9. Review of Resident #12’s quarterly MDS, dated [DATE], showed the following: -Required extensive assistance from one staff for toileting and dressing; -Required limited assistance from one staff for hygiene; -Occasionally incontinent of bowel and bladder. Review of the resident’s care plan, dated 7/5/18, showed the following: -The resident is incontinent of bowel and bladder; -Staff should provide the resident with pericare after each incontinent episode; Review of the resident’s hospital discharge summary, dated 8/1/18, showed he/she was admitted to the hospital with [REDACTED]. His/her urine culture grew escherichia coli (E. |
| 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: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 51) coli). Observation on 8/08/18 at 9:45 A.M. showed the following: -CNA G and CNA F entered the resident’s room, did not wash hands and applied gloves; -CNA G assisted the resident to turn to his/her left side; -CNA F removed the resident’s urine soiled incontinence brief, removed his/her gloves, and applied clean gloves without washing his/her hands. CNA F cleaned the resident’s peri area, buttock and thighs. CNA F rolled the resident to his/her right side; -CNA G cleaned the left side of the resident’s buttock and thighs, removed the soiled gloves and applied clean gloves without washing his/her hands. CNA G applied a clean incontinence brief and pulled up the resident’s pants; -CNA G and CNA F removed gloves and without washing hands, assisted the resident into his/her wheelchair and left the room. Observation on 8/09/18 at 7:11 A.M. showed the following: -CNA G entered the resident’s room and without washing his/her hands applied gloves; -CNA G placed his/her gloved hand under the resident and felt the incontinence pad under the resident. The resident was wet with urine. The resident did not want to be cleaned up at this time. CNA G removed his/her gloves and without washing his/her hands left the room; -Licensed Practical Nurse (LPN) B entered the resident’s room. Without washing his/her hands, LPN B applied gloves and attempted to remove the wet incontinence pad. The resident said he/she did not want to get up or be changed. LPN B removed his/her gloves and without washing his/her hands left the room. 10. Review of Resident #111’s POS dated 8/1/18 showed an order for [REDACTED].>Observation on 8/8/18 at 8:07 P.M., showed Certified Medication Technician (CMT) H entered the room, performed a blood glucose test on the resident and exited the room. CMT H cleaned the glucometer with an alcohol prep pad. During interview on 8/8/18 at 8:15 A.M. CMT H said: -He/she cleaned the glucometer with an alcohol pad; -The resident was on precautions for [MEDICAL CONDITION] (bacterium that can cause symptoms ranging from diarrhea to life threatening inflammation of the colon.) Review of the manufacturer user’s guide showed the following: -The glucometer was EVENCARE G3; -It recommended EPA disinfecting wipes to clean the machine; -It did not list alcohol wipes as an acceptable disinfectant. 11. Observations on 8/8/18 showed the following: -At 8:35 A.M. the clean linen cart sat uncovered at the end of the B hall with the front cover flipped open over the back of the cart. The cart contained stacks of clean linens and faced toward a resident’s room with a sign indicating the resident was on transmission based precautions. The resident’s door was open with staff entering and exiting the resident’s room; -At 9:50 A.M. the same clean linen cart remained uncovered in the center of the B hall. Observations on 8/8/18 at 1:30 P.M. showed a clean linen cart sat uncovered in B hall with the front cover flipped over the back of the cart. The linen cart contained stacks of clean linens and was open to the hall with staff walking past, in and out of resident rooms, obtaining supplies from the cart and not recovering the clean linen cart. Observation on 8/10/18 at 3:45 P.M. showed a clean linen cart sat uncovered on B hall. The front cover was flipped over the top exposing clean linens. Staff removed items from the cart and did not recover the cart. 12. During interview on 8/14/18 at 6:50 P.M., the DON said the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265407 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER MOBERLY NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 700 EAST URBANDALE DRIVE | |||||||||
| 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 52) -He/she expected staff to wash hands upon entering a resident’s room, between moving from dirty to clean, with every glove change and upon completion of resident care; -He/she expected staff to wear gloves when providing residents’ cares, and while touching body fluids; -He/she would expect staff to deglove, place the soiled gloves in the trash bag, tie it, wash hands and reglove before exiting the resident room with soiled linen/trash bags; -Staff should not apply gloves without hand washing; -Staff should not wear soiled gloves and provide cares to multiple residents or go in and out of residents’ rooms wearing soiled gloves; -Clean items touched with soiled hands became contaminated; -Staff should place soiled linens on the end of the resident’s bed, not on the floor. It was not necessary to bag soiled linens in the resident’s room if using a dirty linen cart in the hallway; -Clean linen carts in the hallway should remain covered at all times. Staff should not obtain supplies from the clean linen carts with soiled hands or while wearing soiled gloves and should cover the linen cart after use; -Staff should follow the manufacturer’s guidelines for cleaning glucometers. Micro-wipes should be used. Some glucometers are approved to be cleaned with alcohol. He/she was not sure of the policy of the facility. | |
