| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) resident. During an interview on 2/06/19 at 10:22 A.M., the administrator said staff should wipe down soiled wheel chair and G/C seats with soap or a disinfecting wipe and allow to dry before placing a resident back into the chair. Staff should provide oral care at least every two hours to resident’s that need assistance. 2. Review of Resident #65’s quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required extensive assistance from staff with dressing, tilting and personal hygiene. Required supervision with eating; -[DIAGNOSES REDACTED]. Observations of the resident on 2/5/19 at 1:15 P.M., showed staff placed the residents lunch tray on a three tiered wheeled cart by the nurses’ station. Staff sat with the resident and assisted him/her with eating, taking bites of food to give the resident off the plate, which sat on the cart. Further observations of the resident on 2/3/19 at 10:34 A.M., 2/4/19 at 1:15 P.M., 2/5/19 at 8:48 A.M., 2/6/19 at 7:59 A.M., and 2/7/19 at 8:45 A.M., showed the following: -The resident’s name written in black marker in capital letters across the front of his/her shirt; -The resident’s name written in black marker in capital letters on the front of one leg of his/her pants; -The resident’s name written in black marker in capital letters on the collars of his/her shoes. During an interview on 2/7/19 at 10:05 A.M., the administrator said it is a dignity issue to have the resident’s name written on the front of his/her clothes and visible on his/her shoes. 3. Review of Resident #64’s quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Supervision required for all care; -[DIAGNOSES REDACTED]. Observations on 2/5/19 at 8:12 A.M., 12:55 P.M. and 2/6/19 at 8:03 A.M., showed the resident sat on the bed and ate from the tray of food that sat on his/her bed. During an interview on 2/5/19 at 12:55 P.M., the resident said it would be nice to have a table to eat off of but there was no table available. 4. Review of Resident #54’s annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Supervision to limited assistance with all care; -[DIAGNOSES REDACTED]. Observations on 2/5/19 at 8:12 A.M., 12:55 P.M. and 2/6/19 at 8:03 A.M., showed he/she sat on the side of the bed, staff removed the plates from the food tray and placed them on the top shelf of a three tiered hard plastic mobile cart where he/she ate his/her meal. 5. Review of Resident #63’s quarterly MDS, dated [DATE], showed the following:-No cognitive impairment; -Supervision required for all care; -[DIAGNOSES REDACTED]. Observations on 2/5 at 8:11 A.M., 12:55 P.M. and 2/6/19 at 7:52 A.M., showed he/she sat on the side of the bed and ate his/her food from the tray that sat on the bedside table. 6. Review of Resident #59’s quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Independent with all 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) -[DIAGNOSES REDACTED]. Observations on 2/5/19 at 8:12 A.M., 12:55 P.M. and 2/6/19 at 8:03 A.M., showed the resident stood next to a side table and ate his/her meal. During an interview on 2/6/19 at 12:57 P.M., he/she said it would be nice to be able to sit but there was no room. 7. Review of Resident #52’s annual MDS, dated [DATE], showed the following: -No cognitive impairment; -Supervision required with all care; -[DIAGNOSES REDACTED]. Observations on 2/5/19 at 8:11 A.M., 12:55 P.M. and 2/6/19 at 8:03 A.M., showed the resident sat on the bed and ate from the food tray that sat on his/her bed. During an interview on 2/6/19 at 1:00 P.M., he/she said it would be so nice to have a chair to sit in and a table to hold his/her food. 8. Review of Resident #13’s quarterly MDS, dated [DATE], showed the following: -Resided in room [ROOM NUMBER]; -Severe cognitive impairment; -Supervision required for all ADL’s; -[DIAGNOSES REDACTED]. Observation on 2/6/19 at 8:00 A.M., showed the resident stood at the third floor nurses station across from room [ROOM NUMBER], held a breakfast tray and said Where am I going to go? The resident took the tray and entered room [ROOM NUMBER], placed the meal tray on the bedside table and ate his/her breakfast standing up. At 8:05 A.M., the resident came out of the room with the meal tray, placed it on the cart and stood at the elevator. 9. During an interview on 2/7/19 at 10:05 A.M., the administrator said the facility does not have enough tables for residents to use on the second and third floors. It is not dignified to use over the bed tables and carts and no one should have to eat with their tray on the bed. | |
| F 0568 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Properly hold, secure, and manage each resident’s personal money which is deposited with the nursing home. Based on interview and record review, the facility failed to ensure acceptable general |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0568 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) Resident #11. The order, showed an amount of $308.92 and that it would be charged to the resident’s trust account. Review of the resident’s fund management agreement, did not show that the resident gave authorization for the facility to spend his/her money. Review of the receipt, showed only one staff’s initials indicating the clothing was received. Review of the resident’s record, showed no personal inventory sheet. 3. Review of the resident trust account reconciliation for (MONTH) (YEAR), showed a discrepancy of $5,066.76. There was no explanation for the difference on the form. 4. Review of the resident trust account reconciliation for (MONTH) (YEAR), showed a discrepancy of $50.00. There was no explanation for the difference on the form. 5. During an interview on 2/7/18 at 9:30 A.M., the business office manager said they have a shopping program where the nurse initials and she is suppose to initial when they receive the inventory. They do not have approval from the residents because they are buying the clothing for residents who can’t speak for themselves. She asks the aides what the resident needs and then she orders it. She gives the form to social services and they are suppose to put the items on the inventory sheets. They do not have a written policy or procedure on the shopping program. The residents do not sign that they receive the items. The difference in the accounts was before she was in charge of the trust account. She did not know why there was a descrepancy. | |
| F 0569 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Based on interview and record review, the facility failed to notify the resident or |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0569 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) payee for most of the residents so she was told she did not have to send a letter. She has not notified Medicaid if over the $3,000 amount. | |
| F 0574 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | The resident has the right to receive notices in a format and a language he or she understands. Based on observation and interview, the facility failed to provide accessible information | |
| F 0577 Level of harm – Potential for minimal harm Residents Affected – Many | Allow residents to easily view the nursing home’s survey results and communicate with advocate agencies. Based on observation and interview the facility failed to notify residents of the current |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0577 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 5) said they would like to know what the results were. During an interview on 2/7/19 at 10:05 A.M., the administrator said the survey binder is kept at the front desk, which has someone at it 24 hours a day, 7 days a week. He said it is kept there because residents have used it to throw at other residents or staff. He agreed it was not easily accessible to all residents without having to ask. | |
| F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) competent enough to sign a code status form. If a resident has a guardian, the guardian should always be the one to sign and not the resident. They added that the code status should always be on the POS and a facility code status form signed for every resident. | |
| 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** Based on observations and interviews, the facility failed to provide a clean, safe, 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 7) NUMBERS]. The tiles around the signs were removed and wires hung down out of the ceiling approximately 6 inches. During an interview on 2/07/19 at 8:52 A.M., Employee L said the exit sign tiles on 300 hall have been missing for at least a month. 5. Oservations on 2/05/19 at 1:08 P.M., of 100 unit resident rooms, showed: -room [ROOM NUMBER]: Wall damaged above base board, paint chipped off and an approximate area of 1 foot by 4 inch area gouged out of the wall; -room [ROOM NUMBER]: Gouged and chipped drywall at edge of window ledge; -room [ROOM NUMBER]: Night stand bottom ledge broken and laying on floor. The window ledge chipping paint and gouges out of drywall, area measured approximately 1 1/2 feet by 2 1/2 feet. 6. Observations of the 200 unit for all days of the survey 2/3/19 through 2/7/19, showed the following: -room [ROOM NUMBER]: -No head board on bed one and two of three drawers on the bedside table off their tracks; -Three water spots on the wall over the closet that measured approximately 1 inch round. A second area measured 1 by 2 inches in round and a third area meaured approximately 5 by 2.5 inches in circumference; -Shared bathroom that joined rooms [ROOM NUMBERS], showed no working light. -room [ROOM NUMBER]: -Wall at the head of the bed, showed an area approximately 1 foot long by 8 feet wide not painted; -Broken face plate on electric outlet; -room [ROOM NUMBER]: -Missing handle on the third drawer of a three drawer table; -Wall across from the beds, showed 26 areas of missing paint that measured aprroximately 1 to 1 and 1/2 inches wide by 6 inches long; -The vertical blinds that covered the window had three slats missing; -Bathroom that joined rooms [ROOM NUMBERS], showed: -Left side of the vanity the wall had not been painted; -Dirty, rusty caulk where the sink joined the wall; -Vent that measured approximately 10 inches long by 8 inches wide covered in rust; -room [ROOM NUMBER]: -No mattress on bed one; -Second bed foot board chipped in two different places; -Multiple areas of chipped paint along the wall outside of the bathroom, along the wall of bed three and around the bathroom door frame. -room [ROOM NUMBER]: -Entry wall of the room showed an unpainted area approximately 3 feet by 3 feet; -Multiple areas of chipped paint; -Bathroom door nailed shut. -room [ROOM NUMBER]: -7 slats missing from the blinds for the window over bed one and no blinds over the window for bed one; -No headboard or foot board on bed three; -Lower 6 inches of the bathroom door chipped. -room [ROOM NUMBER]: -Slats on vertical blinds that covered the window all missing except for four blind slats; |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 8) -room [ROOM NUMBER]: -Ceiling tiles gray and cracked with a large bulge in the tiles over the bed; -Missing chipped paint on all four walls; -No curtains or blinds covered the window; -Vent under the window covered in dust and rust. -room [ROOM NUMBER]: -Three blinds missing over the window for bed one and no blinds over the window for bed two. -Vertical blinds that covered the window were missing four slats; -Vent under the window covered in dust and rust. -room [ROOM NUMBER]: -Vertical blinds that covered the window missing five blind slats; -Approximately 20 areas of chipped paint over bed two; -Ceiling tiles faded in to three different colors and nine tiles, each measured approximately 2 feet by 18 inches, bulged over bed two; -Vertical blinds that covered the window were missing five slats. -room [ROOM NUMBER]: -Two drawers off the track on the bedside table; -Tile ceiling bulged in three different areas; -Multiple areas of chipped paint around the door frame; -Vertical blinds missing more than half of the slats; -Missing ceiling tile outside of rooms [ROOM NUMBERS]. A flex metal pipe and an electrical cord hung from the missing tile outside of room [ROOM NUMBER]. 7. During an interview on 2/7/19 at 8:26 A.M., the Maintenance Director said he was made aware of the black mold when it was shown to the administrator on 2/5/19. He completes rounds on each resident floor every day. He expects staff to let him know if repairs need to be made. There are lists on each floor for staff to fill out. He is aware of the environmental issues and said they repair things, but the residents are very destructive. He is aware of the missing tiles, but has not replaced them because they have not arrived yet. He expects they should arrive today. He is aware the tiles by the exit signs are missing because construction company did work and didn’t replace them. He did not notice the wires hanging down and agreed it could be a safety issue. 8. During an interview on 2/7/19 at 10:05 A.M., the administrator said he expected maintenance staff to complete rounds on the resident floors at least weekly. Staff should also submit work orders for items they noticed needed repaired. The maintenance department identifies issues and then prioritize what will be addressed. Every window should have blinds and all slats. | |
| F 0604 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. **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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0604 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) Review of the facility’s physical restraint management policy, revised on 9/2017, showed: -Guidelines: -An order has been obtained that includes type of restraint, when to use the restraint and periodic release of the restraint; -When the resident’s condition necessitates consideration for a restraint, alternative interventions should be attempted and fully documented in the nurse notes and the care plan; -The resident and/or family member or legal representative will be included in the decision process and will be informed of how use of the restraint will treat the resident’s medical condition and promote highest practicable physical and psychosocial well-being, the benefits and possible negative outcomes of the restraint use and any alternatives to the restraint; -During the time the restraint is in place, the restraint is periodically removed and the resident is assisted with change in position, range of motion and/or stretching; -Restraints will be assessed on a quarterly basis for appropriateness and attempts for reductions of the restraint. Review of Resident #4’s physical restraint assessment, completed on 9/28/18, showed: -Reason for use of the physical restraint: unsteady gait, agitated behavior, interference with specific medical treatments, frequent falls, sliding out of wheelchair, attempts to self transfer and climbs out of bed, one on one certified nurse aide (CNA) observation uses helmet. The resident had an extremely unsteady gait, and lacked the ability to maintain proper posture and positioning, he/she is a risk to himself/herself and unable to be redirected in unsafe situations; -History: no entry to address what had worked in the past to control/limit behaviors/issue to prompt the need for the restraint; -Alternatives used to reduce the risk of harm prior to the use of the restraint: recliner, family companion, one on one activities, directed ambulation, mattress on the floor, alternate seating, regular toileting, anticipate hunger, pain, heat and cold, acceptance of risk, normal schedule/routine, medication review, one to one CNA supervision, helmet use. The resident lacked the ability to understand and follow simple commands. He/she continues to be a risk for himself/herself despite alternate interventions; -Decision to restrain: The resident poses a risk to him/herself if additional interventions are not put into place to ensure safety. A geri-chair (G/C, reclining, padded chair) with a lap table (hard plastic table that locks into place in the arms of a chair) had been encouraged by the family. The family is aware of the benefits and risks of a G/C with a lap table. The decision to use the geri-chair and lap table had been determined by the interdisciplinary team with the resident’s physician to ensure the continued safety of the resident; -Family notified by phone of decision on 9/18/18; -Order received from the resident’s physician to clarify restraint parameters and timeframe’s of appropriate ambulation on 9/28/18; -No family signed consent for restraint use to include potential risks and benefits. Review of the resident’s (MONTH) (YEAR) treatment administration record (TAR), dated 11/1/18 through 11/30/18, showed: -An order dated, 10/24/18 to reposition the resident every two hours and may use a G/C with a lap tray at all times. Staff initialed every 7:00 A.M. to 3:00 P.M., 3:00 to 11:00 P.M. and 11:00 P.M. to 7:00 A.M., shift daily as completed; -An order dated, 10/31/18 to release tray table every two hours and place helmet on his/her head. All dates and every two hour times initialed as completed. |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0604 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) Review of the resident’s (MONTH) (YEAR) TAR, dated 12/1/18 through 12/31/18, showed: -An order dated, 10/24/18 to reposition the resident every two hours and may use a G/C with a lap tray at all times. Staff initialed every 7:00 A.M. to 3:00 P.M., 3:00 to 11:00 P.M. and 11:00 P.M. to 7:00 A.M., shift daily as completed; -An undated order to release the lap tray every two hours at 12:00 A.M., 2:00 A.M., 4:00 A.M., 6:00 A.M., 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M., 10:00 P.M. Staff initialed every two hours time slot and daily as completed. Further review of the medical record, showed no further restraint assessment completed after 9/28/18. Review of the resident’s (MONTH) 2019 TAR, dated 1/1/19 through 1/31/19, showed: -An order dated, 10/24/18 to reposition the resident every two hours and may use a G/C with a lap tray at all times. Staff initialed 7:00 A.M. to 3:00 P.M., on 1/1/19 through 1/5/19, on the 3:00 P.M. to 11:00 P.M. shift staff initialed on 1/2/19 and 1/3/19 and on the 11:00 P.M. to 7:00 A.M., shift on 1/1/19 through 1/5/19 as completed; -No order, tracking or assessment of the table tray released every two hours. Review of the annual Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 1/5/19, showed: -Severe cognitive impairment; -Total dependence on staff for all care and mobility; -[DIAGNOSES REDACTED]. -Does not use a trunk or limb restraint; -Used a chair that prevents rising daily. -Not involved in a turning and/or repositioning program. Review of the resident’s care plan updated on 1/20/19, showed: -Focus: The resident may use a G/C with a tray table for positioning and safety related to abnormal posture and safety related to stroke and [MEDICAL CONDITION]; -Goal: The resident will remain free of injury, skin break down and other complications related to use of G/C with tray table; -Interventions: Education provided to family of risk and benefits of use of G/C such as skin breakdown and injury, ensure family is in agreement of use of geri chair with the tray, least restrictive devices used prior to the use of gerichair with tray table was PT/OT therapy evaluations & 1:1 location monitoring, Fall mats, staff encouraged him/her to lay down, helmet used during ambulation, staff to monitor and document report to the physician changes regarding effectiveness of restraint of less restrictive device, if appropriate; any negative or adverse effects noted including a decline in mood, change in behavior, decrease in self performance, decline in mood, change in behavior, decline in cognitive ability or communication, contracture formation, skin breakdown, and falls or accidents; -Staff will evaluate the resident quarterly and as needed for the use of G/C with tray table; -Staff will release tray table every two hours and as needed; -Therapy evaluation for seating positioning as needed. Review of the resident’s (MONTH) 2019 physician order [REDACTED]. Observations of the resident during the survey, showed: -On 2/3/19 at 8:31 A.M., 9:42 A.M., 10:55 A.M., and 11:24 A.M., he/she sat in his/her room in his/her G/C and no table tray in place. The resident wore a blue plastic helmet. The table tray lay against the bedroom wall. Further observation of the resident, showed: -On 2/4/19 at 7:21 A.M., 8: 45 A.M., 10:15 A.M., and 1:22 P.M., he/she sat in his/her G/C |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0604 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) in his/her room. The bedroom door opened to the hallway. The table tray attached to the G/C. He/she yelled out go school loudly at times, no staff entered the room. The resident did not have his/her helmet on; -On 2/5/19 at 6:48 A.M., 9:27 A.M., 12:33 P.M., and 1:16 P.M., showed he/she sat in his/her G/C in his/her room and occasionally yelled out loudly go school. No staff entered his/her room when he/she yelled out. The table tray in place and secured into the arms of the G/C. He/she wore the blue plastic helmet. During an interview on 2/5/19 at 10:03 A.M., CNA E said the night shift staff get the resident up daily around 5:00 A.M., and put the table tray into place on the G/C. The resident had a fall history and liked to try to get up out of his/her G/C without assistance and would try to walk. The tray kept him/her in the G/C. He/she thinks the tray is to be removed every couple hours but is not sure, the resident can not reposition him/herself. The aides do not document when the table tray is removed. Observation on 2/6/19 at 6:41 A.M. through 8:58 A.M., showed the resident sat in his/her G/C in his/her bedroom with the blue plastic helmet on and the table tray in place and occasionally yelled out go school or banged on the top of the tray. Staff did not enter the room and check on the resident as he/she yelled out or banged on the tray. Staff did not remove the tray and did not provide repositioning. During an interview on 2/05/19 at 12:56 P.M., nurse K said the table tray is used because the resident is a fall risk and had fallen a few times. Staff are supposed to release the tray every two hours and then he/she should have his/her helmet on when the tray is off. The helmet should not be worn if the table tray is used. The two should not be used at the same time. The restorative aide will ambulate the resident at times, but the restorative aide is not able to walk the resident daily. He/she did not know of any restraint assessment that needed to be completed or if one had been completed. The resident’s POS had orders for the table tray and the G/C. The nurses document in the residents TAR the removal of the table tray every two hours. He/she verified the resident’s (MONTH) TAR did not have an order to release the table tray and provide repositioning. During an interview on 2/06/19 at 7:42 A.M., nurses K and G said they had not completed a restraint assessment for the lap tray and do not know where to locate the restraint assessment to complete it. They said the nursing management probably completed the assessment but they do not know where it is or what the assessment showed. Staff are to release the tray every two hours and document the table tray release on the resident’s TAR. Both nurses verified no entry or orders for the release of the tray on the (MONTH) TAR. During an interview on 2/6/19 at 7:58 A.M., the administrator said the resident’s charge nurses complete restraint assessments on him/her quarterly and the assessments should be in the hard chart and then scanned into the electronic record. Staff should document in the monthly TAR the removal of the tray every two hours. Further review of the resident’s medical record on 2/6/19 at 8:29 A.M., showed no restraint assessment completed after 9/28/18. No orders or documentation to release the table tray every two hours. During an interview 2/6/19 at 8:51 A.M., the Director of Nursing said the nurses should have completed a restraint assessment for December. The restraint form is in the electronic system and is done quarterly. The staff also should be removing the tray every two hours and documenting on the TAR that it is being done, provide repositioning and also offer to walk the resident. The resident could be brought into the hallway for socialization and monitoring. |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0604 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | PASARR screening for Mental disorders or Intellectual Disabilities **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 13) 6. Review of Resident #34’s quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Experienced delusions; -Limited staff assistance needed with mobility, toileting, meal set up and transfers; -[DIAGNOSES REDACTED]. Review of the resident’s medical record, showed: -No DA-124 completed; -No PASARR level II screening completed. 7. Review of Resident #44’s quarterly MDS, dated [DATE], showed: -Cognitively intact; -Experienced delusions; -Limited staff assistance needed with toileting, mobility and transfers; -[DIAGNOSES REDACTED]. Review of the resident’s medical record, showed: -No DA-124 completed; -No PASARR level II screening completed. 8. Review of Resident #40’s quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Inattention and disorganized thinking comes and goes, and changes in severity; -Independent with most activities of daily living; -[DIAGNOSES REDACTED]. Review of the resident’s medical record, showed: -No DA-124 level I screen found; -No PASARR level II screen found. 9. Review of Resident #84’s quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Behaviors exhibited included hallucinations and delusions; -Alarms: wander/elopement used daily; -Required extensive assistance from staff for dressing, tilting and personal hygiene; -Required no assistance for ambulation; -[DIAGNOSES REDACTED]. Review of the resident’s medical record, showed: -No DA-124 level I screen found; -No PASARR level II screen found. On 2/6/19 at 7:30 A.M., the administrator was requested to provide PASARR documentation for the above residents. During an interview on 2/07/19 at 7:37 A.M., the administrator said he is waiting for PASARRs from a third party. He does not currently have them for any resident in his possession, but he should. They are aware of the issue and have put processes in place and its taking time to get documentation back. The forms have to go through their corporate office before they can get a hard copy. He said he knew they should have them on hand. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) Based on observation, interview and record review, the facility failed to ensure staff provided timely updates and revisions to individual resident care plans used to guide staff to provide resident care to include a resident to resident altercation, a resident with sexually inappropriate behaviors, a resident with a wanderguard bracelet (a device worn to alert staff of an attempted elopement) and revise a resident’s continence status. This practice affected three (Residents #40, #84 and #10) out of 19 sampled residents. The facility census was 94. 1. Review of Resident #40’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/30/19, showed the following: -Moderate cognitive impairment; -Inattention and disorganized thinking comes and goes, and changes in severity; -Independent with most activities of daily living (ADL’s); -[DIAGNOSES REDACTED]. Review of the resident’s nurses notes, showed the following: -1/10/19 at 6:04 A.M., The resident approached staff and residents on floor offering sexual favors. A resident reported this resident came into his/her room two times during the night offering sexual favors. This nurse redirected the resident and asked resident to stay out of other residents room and explained that offering sexual favors is inappropriate, unwelcomed and requested that the resident stop. Resident verbalized an understanding of expectations. Staff asked to monitor resident closely and redirect resident if needed. Staff verbalized an understanding of plan to monitor residents for safety; -1/10/19 at 1:37 P.M., Social Services Note, this writer met with resident to see how he/she was doing and to discuss recent behaviors. Resident stated he/she did not mean to be disrespectful towards another peer. This writer informed resident that if he/she has any thoughts or concerns to speak to this writer. Resident was very apologetic and stated that he/she will not do that again. Resident did not have any other issues or concerns at this time. Resident will continued to be monitored accordingly; -1/11/2019 at 8:03 A.M., The resident remains on 15 minute checks for inappropriate behavior but has not had any episodes thus far and states none will occur. Will continue to monitor; -1/11/19 at 11:40 A.M., This writer met with resident to see how he/she was doing and to discuss recent behaviors. Resident stated that he/she was tired of dealing with dumb ass people here at the facility. This writer asked resident what was wrong. Resident stated that he/she did not want to go into details. This writer informed resident that if he/she needs to talk about anything to find this writer. Resident stated ok just not today. Resident did not display any fearfulness or have any concerns at this time. Resident will continued to be monitored accordingly; -1/13/19 at 11:37 A.M., no behaviors observed, continued close monitoring; -1/14/19 at 11:46 A.M., no behaviors noted or observed; -1/14/19 at 1:52 P.M., This writer met with resident to see how he/she was doing and to discuss recent behaviors. Resident stated that he/she was doing good and was awaiting on his/her next smoke break. Resident stated that he/she is done trying to get residents to like him/her, and that he/she will just stick to him/heself for now. This writer informed resident that it is ok to have friends, and the problem only comes when the issues are pushed. Resident did not voice any other issues or concerns at this time. Resident will continued to be monitored accordingly; -1/29/19 3:00 P.M., This nurse was notified by the Director of Nursing (DON) that the resident was kicked by another resident in the leg because he/she was upset about how 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) resident talked to a staff member. Spoke to resident, he/she had no comment and stated it was stupid and he/she ok and had pain of one out of 10. Resident remains alert and oriented times 3, able to make needs known. Administrator notified and guardian called. Review of the resident’s care plan, updated 1/21/19, showed the following: -On 12/5/18, the resident was involved in a physical altercation with another resident, unprovoked; -On 1/21/19, the resident was verbally abusive to staff and unable to redirect; -Goal, the resident will be kept safe in the facility; -Interventions, 1/21/19 resident sent to hospital for evaluation, keep resident separate from other resident involved, monitor for 72 hours for signs of fearfulness, obtain x-ray, provide skin and pain assessments; -No mention of sexually inappropriate behaviors; -No mention of the incident of 1/29/19. During an interview on 2/7/19 at approximately 10:00 A.M., the DON said she expected care plans to reflect the current needs of the residents. The resident’s sexually inappropriate behavior should be included on the care plan, as well as the incident of being kicked by another resident, along with appropriate interventions. 2. Review of Resident #84’s quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Behaviors exhibited included hallucinations and delusions; -Alarms: wander/elopement used daily; -Required extensive assistance from staff for dressing, tilting and personal hygiene; -Required no assistance for ambulation; -[DIAGNOSES REDACTED]. Review of the resident’s medical record, showed the following: -A (MONTH) 2019 physician order [REDACTED]. -A care plan, last revised on 8/17/18, and in use during the survey, showed the following: -Focus: Resident wanders on his/her unit. Will roam in other residents’ room due to cognitive loss. Resident is at risk for elopement related to limited cognition; -Goal: Resident’s safety will be maintained through the review date (no date listed); -Interventions: Staff did not include the use of the wanderguard bracelet or how to know if it was in place or worked. Observations of the resident on 2/4/19 at 8:21 A.M., 2/5/19 at 7:25 A.M., and 2/6/19 at 7:21 A.M., showed the resident wore a wanderguard bracelet on his/her right wrist. During an interview on 2/6/19 at 7:37 A.M., nurse G said the resident wanders, but not as much as he/she used to. The resident wore a wanderguard and it will go off if he/she tries to go outside. He/she can get on the elevator without it going off. Nurse G was not sure who checked the placement or function of the wanderguard. He/she thought maybe someone from social services took the resident to the main entrance to test the function of the wanderguard. 3. Review of Resident #10’s quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent for activities of daily living; -Continent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, last revised on 6/24/18 and in use during the survey, showed the following: -Focus: Resident is incontinent at night related to cognitive loss; -Goal: Resident will decrease frequency of urinary incontinence through the next review |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) date (no date given); -Interventions included: ask resident if he/she would like staff to wake him/her up at night for toileting needs and ensure resident has unobstructed path to the bathroom. During an interview on 2/05/19 at 8:13 A.M., the resident said he/she no longer is incontinent at night. He/She does that at a new place because he/she feels insecure, but he/she now feels very comfortable at the facility. During an interview on 2/7/19 at 8:51 A.M., certified nurse aide (CNA) J said the resident is no longer incontinent at night. It has been a long time since the resident was incontinent. Staff failed to update the care plan to reflect the resident’s current continence status. During an interview on 2/7/19 at 10:05 A.M., the DON said staff should obtain an order for [REDACTED]. The MDS coordinator is responsible for updating the care plan. The interdisciplinary team can also update the care plan. The care plan should reflect the resident’s current status. | |
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide activities to meet all resident’s needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 17) -On 1/7/19: Talked about going to school; -On 1/14/19: Resident asleep; -On 1/16/19 and 1/21/19: Talked about going to school; -On 1/29/19: Music therapy; -On 2/4/19: Talked about going to school; -No further documentation of one to one visits. Observations of the resident during the survey, showed: -On 2/03/19 at 8:43 A.M., and 10:23 A.M., he/she in his/her bedroom facing his/her TV. The TV was on and the image flickered on the screen and was not clear. He/she yelled out randomly Go school. Bedroom door opened to hallway; -On 2/04/19 6:53 A.M., 10:52 A.M., 11:35 A.M., and 2:05 P.M., the resident sat up in his/her room, the door opened to the hallway, and the TV off. He/she yelled out occasionally go school. Multiple staff walked past his/her room; -On 2/06/19 at 7:40 A.M., the resident sat in his/her geri-chair (padded, reclining chair) in his/her room, the TV on and the image flickered. He/she yelled out multiple times go school. The bedroom door opened to the hallway. Multiple staff looked into the resident’s room as they walked past the resident’s room. No staff entered the resident’s room; -at 8:44 A.M., the resident yelled out in his/her room and banged on the top of his/her table tray. Nursing staff pushed his/her G/C into the hallway along the wall. He/she stopped yelling, no staff spoke to him/her or engaged with him/her. 2. Review of Resident #3’s quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Supervision required with ambulation; -Extensive assistance to total dependence on staff for all personal care; -[DIAGNOSES REDACTED]. Review of the care plan, last updated on 8/6/18, showed the following: -Problem: Resident is dependent on staff for activities, cognitive stimulation, He/she likes to roam the halls on the unit and required one to one activities related to short attention span and cognitive loss; -Goal: Resident will maintain involvement in cognitive stimulation and social activities as desired through the review date; -Approaches: one to one bedside-in room visits and activities if unable to attend out of room events and all staff to converse with resident when providing care. Review of the activity interview for daily and activity preferences, dated 12/20/18, showed the following: -Should interview be conducted? No; -Activities that are important but resident can not do consistant religious activities, fresh air, music, books, magazines, keeping up with the news, participating in activities with groups of people and using the phone in private; -The resident served as primary respondent to the questionnaire. Review of the one to one activity visit log, dated 11/1 through 11/30/18, showed the following: -11/12 from 10:40 A.M. to 10:45 A.M., small talk and listed to music; -11/14 from 9:55 A.M. to 10:00 A.M., listen to the radio; -11/19 from 8:00 A.M. to 8:00 A.M., small talk; -11/21 from 8:00 A.M. to 8:05 A.M., small talk; -11/28 from 12:30 P.M. to 12:35 P.M., played with checkers. Review of the one to one activity log, dated 12/1 through 12/31/18, showed the following: -12/3 from 12:30 P.M. to 12:35 P.M., small talk; |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) -12/12 from 8:40 P.M. to 8:50 A.M., combed his/her hair and washed his/her face. Review of the one to one activity log, dated 1/1 through 1/31/19, showed the following; -1/7 resident refused; -1/21 from 11:30 to 11:35 A.M., small talk; -1/29 from 11:00 to 11:05 A.M., music therapy; –No other documenttion of activity participation. Observations on 2/4/19 at 10:00 A.M. and 1:44 P.M., 2/5/19 at 10:36 A.M. and 12:07 P.M., 2/6/19 at 10:54 A.M., showed he/she sat at the nurse’s desk, alone, no one communicated with him/her. 3. Review of Resident #65’s quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Unable to ambulate; -Extensive assistance to total dependence on staff for all personal hygiene; -[DIAGNOSES REDACTED]. Review of the care plan, last updated on 8/15/18, showed the following: -Problem: Resident has little or no activity involvement related to unspecified intellectual disabilities and inappropriate social behavior (i.e continuous crying and yelling out); -Goal: Resident will participate in activities one to two times by the review date; -Approach: Allow him/her to have control over activity if possible during one on one time; -Preferred activities are one on one activities -Offer verbal praise to reinforce positive social behavior in group activities Review of the activity interview for daily and activity preferences, dated 12/8/18, 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) 2/6/19 at 10:54 A.M., showed he/she sat at the nurse’s desk, quiet, no one spoke to him/her. 4. Review of Resident #25’s quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Unable to ambulate; -Extensive assistance to total dependence on staff for all personal care; -[DIAGNOSES REDACTED]. Review of the care plan, last updated on 1/30/19, showed the following: -Problem: Resident has memory loss and impaired thought process; -Will maintain current level of cognitive function through the review date; -Engage resident in simple, structured activities that avoid overly demanding tasks. Review of the activity interview for daily and activity preferences, dated 1/26/19, showed | |
| F 0684 Level of harm – Minimal harm or potential for 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 20) Based on observation, interview and record review, the facility failed to prevent the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 21) -Total dependence on staff for toileting, transfers, hygiene and mobility; -No skin issues; -At risk to develop skin ulcers (wounds or damage to skin); -Always incontinent of bowel and bladder; -Use pressure reducing device for the bed; -No pressure reducing device used in the chair; -Not involved in a turning and/or repositioning program; -Received no ointments or dressings to areas other than the feet. Review of the resident’s care plan, updated on 1/20/19, showed: -Focus: The resident has a pressure ulcer to buttocks refer to the TAR for treatment; -Goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review date; -Interventions: Staff administer treatments as ordered and monitor for effectiveness. Assess, record and monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the resident’s physician. Monitor nutritional status; -Focus: The resident is incontinent of bowel and bladder and he/she wears briefs; -Goal: He/she will remain free of skin breakdown related to incontinence and brief use; -Interventions: Staff check the resident every two hours and as required for incontinence, change clothing PRN. He/she to wear briefs while up for incontinence. Review of the resident’s (MONTH) 2019 TAR and the physician order [REDACTED]. No additional skin care orders noted. Observations on 2/3/19 at 8:31 A.M., 9:42 A.M., 10:55 A.M., and 11:24 A.M., showed the resident was awake in his/her room and sat in his/her geri-chair (G/C, padded reclining chair). No staff provided or offered perineal (perineal care, cleansing the front of the hips, between the legs and buttocks and back of the hips) care. Further observation of the resident, showed: -On 2/4/19 at 7:21 A.M., 8:45 A.M., 10:15 A.M., and 1:22 P.M., he/she sat in his/her G/C in his/her room. The bedroom door opened to the hallway. The table tray (locking tray secured into the arms of a chair) attached to the G/C. He/she yelled out go school loudly at times, no staff entered the room or provided care; -On 2/5/19 at 6:48 A.M., through 9:50 A.M., showed he/she sat in his/her G/C in his/her room and occasionally yelled out loudly go school. No staff entered his/her room when he/she yelled out or offered or provided incontinence care. The table tray in place and secured into the arms of the G/C. Observation and interview on 2/5/19 at 9:53 A.M., showed certified nurse aide (CNA’s) E and N entered the resident’s room and prepared to provide peri-care. Staff assisted the resident to stand. The blanket in the seat of the resident’s G/C was urine saturated. The back of the resident’s pants urine saturated from the top of the waist band to the back of both knees. Staff placed the resident into bed and unfastened his/her brief. The brief contained a second thick brief inside and appeared urine saturated and contained a large amount of bowel movement which oozed from the top front of the brief. CNA’s E and N cleaned the front of the groin and assisted the resident on to his/her side and exposed the buttocks. CNA’s E and N cleaned the resident’s hips and buttocks. An open area noted to the right gluteal fold. The wound appeared red and approximately measured 1.0 centimeters (cm) x 1.5 cm and no depth. CNA E said he/she had not seen the wound before. The night shift aide did not report anything to him/her about the open area. Night shift gets the resident up around 4:30 A.M. to 5:00 A.M. CNA N applied vitamin A&D ointment to the buttocks and the wound. CNA E applied a second thick liner inside 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 22) clean brief and said they always put an extra thick liner in his/her brief, all of the shifts do, he/she is a heavy wetter. CNA E said he/she had not changed the resident until this time. He/she will need to tell the nurse about the open area to the buttock. The CNA’s do not document open areas, aides tell the nurses and the nurses handle the rest of it; -Neither CNA’s notified the resident’s nurse to observe the open area prior to completing care and applying and securing the double brief on to the resident. During an interview on 2/5/19 at 1:15 P.M., nurse K said that the the resident does not have any open areas. He/she had not been notified of any skin issues. The resident had a history of [REDACTED]. When the aides discovered an open area they are to notify the resident’s nurse immediately so the wound can be assessed and measured. Aides should not apply ointments or apply briefs until the nurse can assess the wound site. The nurse would apply the standing wound order to the wound and document in the resident’s record. Observation on 2/5/19 at 1:23 P.M. through 2:39 P.M., showed the resident up in his/her room in the G/C. No staff entered the resident’s room to provide or offer care. The charge nurse did not provide the skin assessment. Further review of the resident’s care plan and medical record on 2/6/19 at 6:15 A.M., showed: -No care plan updates regarding skin changes or skin care interventions discovered on 2/5/19; -No nurse notes, wound assessments, no new wound care orders or documentation following the wound discovered on 2/5/19. Observation on 2/6/19 from 6:34 A.M. through 7:25 A.M., showed the resident remained in the G/C in his/her room. The bedroom door opened to the hallway. The lap tray in place attached to the G/C. The resident yelled out occasionally go school. Multiple staff walked past his/her room. At 7:31 A.M., the surveyor notified CNA E that he/she wanted to observe the resident’s skin. CNA E said the resident had been up in his/her G/C since 5:00 A.M., and he/she had started his/her shift at 7:00 A.M., that morning. He/she would provide incontinence care to the resident after breakfast had been served to the other unit residents around 9:30 A.M. to 10:00 A.M. During an observation and interview on 2/6/19 at 8:35 A.M., the resident remained in his/her room in the G/C. The bedroom door opened to the main hallway. He/she yelled loudly and banged on the lap tray. Staff entered the resident’s room and pushed him/her into the hallway and placed him/her along the wall. The resident laughed, smiled and sat straighter in his/her G/C. Nurse G said the night shift gets the resident up daily around 4:30 A.M. to 5:00 A.M. The resident is always incontinent of bowel and bladder and should be changed and repositioned every two hours. If aides notice a change in skin they should immediately tell the charge nurse. He/she had not be notified of any changes in the resident’s skin. He/she started his/her shift on 2/5/19 at 10:30 P.M. and worked the night shift. None of the night shift CNA’s had notified him/her of skin issues. Observation and interview on 2/6/19 at 8:58 A.M., showed CNA E and C applied a gait belt, removed the lap tray and transferred the resident into his/her bed. The blanket in the G/C seat was urine saturated and the back of the resident’s pants was urine saturated the entire area of the buttocks. CNA E pulled down the resident’s pants and removed the double saturated brief and assisted the resident onto his/her side and exposed the resident’s buttocks. Two open were wounds observed to the right buttock fold. Both of the wounds actively bled and blood ran down toward the right buttock toward the groin. The upper right open wound observed on 2/5/19 bled and a second new wound observed that measured approximately 0.5 cm x 0.5 cm and no depth. Neither wound had a treatment or dressing in |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) place. CNA E said he/she had notified nurse K on 2/5/19 in the afternoon of the discovered open area after the resident’s care had been completed. He/she did not provide incontinence care again before he/she left work on 2/5/19. He/she agreed that on 2/5/19 the resident had one open area and the wound had not been bleeding at that time, a new second wound had developed and both of the wounds were actively bleeding at the time of the observation. CNA C exited the room and notified nurse K of the bleeding wounds. CNA E cleaned the blood off of both wounds and applied pressure to the wounds. Nurse K entered the resident’s room and measured the two open and bleeding wounds. The upper right wound measured 1.5 cm x 1.0 cm x 1.0 cm and second wound measured 0.5 cm x 0.5 cm. Nurse K told the CNAs to leave the areas uncovered and he/she would gather supplies and apply a treatment to both of the open, bleeding wounds. During an interview on 2/06/19 at 9:15 A.M., nurse K said CNA E had told him/her on 2/5/19 in the late afternoon that CNA E had discovered the single open area to the resident’s right upper buttock fold. Nurse K did not document or assess the wound at the time the aides had already applied the resident’s brief and gotten him/her dressed and placed back into his/her G/C. He/she called the resident’s physician and received an order to apply [MEDICATION NAME] (skin barrier) to the area. He/she did not put the [MEDICATION NAME] order on to the current (MONTH) POS or the resident’s current (MONTH) TAR. He/she could not recall if he/she notified the change in the resident’s skin condition to the oncoming shift on 2/5/19. It appeared the resident had developed a secondary open wound below the first wound discovered on 2/5/19. Both of the wounds had been actively bleeding when he/she assessed them on 2/6/19. The wounds would need a treatment since the areas are bleeding and two wounds are now present. The nurses use a standing wound care order and he/she will put that in place until the resident’s physician can be reached and the order verified. The resident had a history of [REDACTED]. The resident is always incontinent of bowel and bladder and should be toileted at least every two hours, double briefing should not be used. Night shift gets the resident up daily between 4:30 A.M. and 5:00 A.M. He/she would have to make a late entry note regarding the wound discovered on 2/5/19 and write the [MEDICATION NAME] order on to the (MONTH) POS and TAR. During an interview on 2/6/19 at 9:21 A.M., the administrator said that when the CNAs notice a change in skin, they should immediately get the charge nurse so he/she could perform a skin assessment and place a treatment on the wound if needed, get physician orders [REDACTED]. Aides should be checking and changing incontinent residents every two hours. Residents that have frequent incontinence episodes and a history of skin wounds should be checked on more frequently than every two hours. Residents should not be double briefed. Further review of the resident’s progress notes on 2/6/19 at 10:30 A.M., showed: -Late entry: on 2/5/19 at 2:57 P.M., The CNA reported skin breakdown after providing care. Physician notified and order obtained from [MEDICATION NAME]. During an interview 2/6/19 at 11:24 A.M., nurse K said he/she followed the facility’s standing wound care order for stage II pressure ulcer (partial-thickness skin loss) and placed the standing order of medi-honey and to covered the areas with a dry dressing onto both of the open wounds. He/she had not documented the assessment, measurements or notified the resident’s physician to confirm standing order treatment or let the physician know of the original wound from 2/5/19 or that the resident had developed a secondary open wound within 24 hours. During an interview on 02/06/19 on 12:30 P.M., the resident’s attending nurse practitioner (NP) said that the resident is totally dependent on staff to meet all of his/her needs. He/she is not able to make he/she needs or wants clearly known and care or needs are |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) anticipated by the staff. He/she is incontinent of bowel and urine and had a history of [REDACTED]. Neither he/she or the resident’s physician had been notified of any changes in the residents skin since 2/5/19 until present. The facility had standing orders for wounds and skin issues that maybe applied until the physician or himself/herself can be reached to verify the standing wound orders. He/she and the physician expected the nurse to verify the standing wound care orders for wound treatments once an issue with the resident’s skin is determined. The staff should have called him/her or the physician when the original wound had been discovered on 2/5/19 and then called on 2/6/19 with the discovery of the second open area and notified of the bleeding. Staff should be providing peri-care and cleansing every two hours for incontinent residents and more frequently if the skin is impaired, the resident should probably be lied down in between meals until the wound heals. Double briefing is not acceptable, the practice exposes the skin to large amounts of fluid and applies more pressure with the larger amount of brief padding. Further review of the resident’s medical record and care plan on 2/6/19 at 1:15 P.M., showed no contact to the resident’s physician or NP, no wound care orders, no wound treatments entered onto the resident’s POS or TAR and no nurse note regarding measurements or wound assessment from 2/6/19 at 8:58 A.M. No updates noted to the resident’s care plan regarding development of buttock wounds. During an interview on 2/06/19 on 1:33 P.M., the Assistant Director of Nursing said if the charge nurse was notified on 2/5/19 of the first wound, then he/she should have called the physician and obtained an order, documented his/her assessment and updated the care plan. The resident has a history of pressure ulcers and MASD. The most recent documented buttock wound had been healed in 12/2018. There were no new orders on the POS or the TAR for skin treatments as of the time of the interview. The ADON had called the resident’s physician the afternoon of 2/6/19 after nurse K measured the areas and the resident’s physician gave an order to administer [MEDICATION NAME]. The facility requested the NP to provide a skin assessment on 2/6/19. Staff should change incontinent residents at least every two hours especially if there is history of skin issues and double briefing should not occur. There should have been a note from the skin measurements from the morning of 2/6/19, however the ADON requested nurse K not enter the measurements since each nurse preformed wound measurements differently and the ADON would enter his/her wound findings instead of nurse K after the resident is seen by the NP later in the day. Further review of the resident’s progress notes on 2/6/19 at 1:38 P.M., showed: -On 2/6/19 at 11:00 A.M., two areas of breakdown to right back upper thigh. The upper wound measured 1.5 cm x 1.0 cm x 0.1 cm. The second lower wound measured 0.5 cm x 0.5 cm x 0.0. The measurements reported to the supervisor. Will continue to monitor; -On 2/6/19 at 1:04 P.M., the nurse notified the resident’s legal guardian of the wounds; -On 2/6/19 at 2:50 P.M., the resident’s NP evaluated skin and diagnoses of MASD given. NP ordered [MEDICATION NAME] and a G/C seat cushion. Treatment administered this shift, and the resident turned and repositioned every hour. Further review of the resident’s (MONTH) 2019 POS, dated 2/1/19 through 2/28/19, showed: -Late entry: 2/5/19 to apply [MEDICATION NAME] to area of skin breakdown on the right upper thigh. Apply every shift and PRN after each incontinence episode; -An order dated 2/6/19 to clean areas to the right buttock with wound cleanser, apply medi-honey, cover with foam dressing, change daily and PRN. The order stuck out and noted as discontinued on 2/6/19; -An order dated 2/6/19 to apply [MEDICATION NAME] to wound #2 on the right buttocks for MASD. Apply each shift and PRN. Record review of the resident’ medical record, showed a progress note, dated 2/6/19 |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 25) completed by the resident’s NP. The resident had been seen today related to skin breakdown to right lower buttocks. The area is shallow and superficial. The resident is incontinent, noncompliant and resistive to care and this placed him/her at high risk for skin breakdown and further injury. The wounds are reoccurring due to moisture and incontinent MASD and fragile skin. Continue with current treatment of [REDACTED]. Staff to apply seat cushion to prevent further breakdown. Therapy evaluation requested for assessment. Further review of the resident’s care plan, showed an undated entry: -Focus: The resident has a diagnoses of MASD and has an actual impairment related to incontinence and impaired mobility. On 2/5/19 he/she had an open area to the right buttock and right upper thigh; -Goal: He/she will have no complications due to the open areas to the right buttock; -Interventions: Avoid scratching and keep the resident’s hands clean, keep excessive moisture away from the area, educate the family and caregivers of the factors and measures to prevent skin injury, encourage good nutrition, follow facility policy and protocols for the treatment of [REDACTED]. The resident has been given a pressure relief cushion in his/her G/C to facilitate prevention of alteration in skin integrity. 2. Review of Resident #79’s admission MDS, dated [DATE], showed the following: -Short and long term memory problems; -Inattention, disorganized thinking and altered level of consciousness always present; -Supervision required for most activities of daily living (ADL’s, ability to complete daily self care tasks); -Occasionally incontinent of bladder; -No diagnoses listed. Review of the resident’s progress notes, showed the following: -12/11/2018, 2:30 P.M., Admission note, the resident arrived at 10:45 A.M., per stretcher and paramedics. History of dementia, [MEDICAL CONDITION] (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), [MEDICAL CONDITION], and chronic [MEDICAL CONDITION] (abnormally low sodium level in the blood, with normal blood sodium level between 135 and 145 milliequivalents per liter (mEq/L )), fluid restriction (FR) of 1500 milliliters (ml) per day; Review of the resident’s initial nutrition assessment, dated 12/19/2018, showed a history of low sodium, level typically between 130-133mEq/L. On a 1500 ml FR per the hospital and appears the resident is on FR per the nursing notes. Recommend to add 1500 ml FR to physician’s orders [REDACTED]. Review of the resident’s care plan, updated on 1/7/19, showed the fluid restriction had not been included as a problem, with no goals or interventions noted. Review of the resident’s POS, dated 2/1 through 2/28/19, showed the following: -1500 ml per day FR, shown on the right hand side of the POS; -An order, dated 1/17/19 for a comprehensive metabolic panel (CMP-measurement of substances in the blood, including sodium). Review of the facility’s staff assignment sheet per shift, kept at the nurse’s station on the third floor showed the following: -Resident #79, alert and oriented times three, regular diet mechanical soft texture, served hall meal trays, takes his/her medications whole. **FLUID RESTRICTION-1500 MG/24 HR** Review of the resident’s diet slip, showed no mention of the ordered fluid restriction. Review of the resident’s MAR and TAR, showed no order for a fluid restriction and no documentation that fluid intake had been monitored by the staff. During an interview on 2/6/19 at 10:45 A.M., nurse M said there were no residents on 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 26) third floor with a fluid restriction. Observation of the resident, showed the following: -On 2/4/19 at 12:43 P.M., the resident sat at a tray table across from the elevator, ate lunch and consumed an 8 ounce (oz.) carton of milk, an 8 oz. glass of red liquid and an 8 oz. cup of coffee; -On 2/5/19 at 10:01 A.M., resident carried an 8 oz. styrofoam cup with a lid onto elevator, he/she said the cup contained water; -On 2/6/19 at 12:50 P.M., the resident sat at a table tray across from the elevator, ate his/her lunch and consumed an 8 oz. carton of milk, 8 oz. glass of clear liquid and an 8 oz. carton of milk. During an interview on 2/7/19 at 9:36 A.M., the Director of Nursing (DON) said three residents had fluid restrictions, provided the three resident names, but did not include Resident #79. She expected staff to document fluid intakes for any residents ordered a FR. Some residents are noncompliant. She had asked the physician’s to discontinue the fluid restriction orders but the physicians declined. She expected that staff monitor intake to not exceed 1500 ml and document in the nurses notes. Noncompliance should also be documented. All physician’s orders [REDACTED]. During an interview on 2/7/19 at approximately 11:30 A.M., nurse M called the facility’s laboratory company and asked for results of the ordered CMP, ordered on [DATE]. The laboratory representative said the only results of laboratory tests for the resident showed a date of 12/28/18. The laboratory did not have results or a sample received from the order dated 1/17/19. 3. Review of the facility’s Routine Infection Control Surveillance in Long Term Care policy, undated, showed the following: -The primary purpose of infection control surveillance is the collection of information for action. It is more than just evaluation of laboratory reports, including cultures. Infection control includes routine surveillance of residents, surveillance of staff, and surveillance of the environment. This may be accomplished using the following guidelines; -A facility’s surveillance system should include monitoring for appropriate antibiotic use. A positive culture in a person without clinical symptoms rarely requires treatment with antibiotics. Review of Resident #85’s quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance from staff for dressing, toileting and personal hygiene; -Frequent bladder incontinence; -Diagnoses included heart failure, diabetes, stroke, overactive bladder and [MEDICAL CONDITION]; -No urinary tract infections (UTI’s) in the last 30 days. During an interview on 2/3/19 at 10:12 A.M., the resident said he/she gets frequent UTI’s and they are very painful. Review of the resident’s medical record, showed the following: -A physician’s orders [REDACTED]. -No results of the UA; -No documentation indicating the resident had any signs or symptoms of a UTI; -A physician’s orders [REDACTED]. During an interview on 2/7/19 at 10:05 A.M., the administrator said to treat a UTI, they must follow three criteria, which are to document signs and symptoms of an infection, notify the resident’s physician and obtain an UA. They did not follow their process to treat the resident and should have obtained a UA prior to starting antibiotic 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0730 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Observe each nurse aide’s job performance and give regular training. Based on interview and record review, the facility failed to ensure certified nurse aides | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to maintain the low temperature |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 28) sanitizer buckets. Normally, the representative changes it when he/she comes every couple of weeks. Her staff should know how to prime a new bucket of sanitizer when it is placed in use. During an interview on 2/15/19 at 10:25 A.M., the facility’s service representative said he does not change the sanitizer bucket because he only comes out once a month. If you do not prime the machine by pressing a button on it’s side after replacing the sanitizer, ten to fifteen loads will not be sanitized properly due to air in the lines. | |
| F 0914 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide bedrooms that don’t allow residents to see each other when privacy is needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0917 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident’s needs; or 5) adequate closet space. |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0917 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide each resident with functional furniture suitable for the comfort of the resident and visitors by not providing chairs for residents in his/her room. This deficient practice had the potential to affect all residents residing in the facility. The sample was 19 and the census was 94. 1. Review of the facility’s Admission Agreement, undated, showed the following: -Covered items and services: Payment by the Medicaid/Medicare Program covers room and board. This includes nursing care, regular meals and snacks, certain equipment, activities and routine personal hygiene items. Certain items and services are not covered in the Medicaid/Medicare Program daily rate. There are extra charges for those non-covered items and services; -Extra charges for items and services which are not included in the basic daily rate, and which are not covered by the Medicaid/Medicare program included private room, private nurse or aide, hair dresser and therapy; -The Admission Agreement did not state over the bed tables and chairs in residents’ rooms were considered items not covered by the Medicaid/Medicare Program or residents would need to purchase these items separately. 2. Review of the Facility Assessment, dated 8/18/17, and provided to the survey team on 2/4/19, showed the facility would provide physical equipment for residents, and included bed frames, mattresses, room and common space furniture. 3. Observation of the 200 unit on all days of the survey, 2/3 through 2/7/19, showed the following: -A total of 16 resident rooms with a capacity of 37 residents; -30 of 37 beds occupied; -No room had a chair for a resident or visitor to sit. 4. Observation of the 300 unit on all days of the survey, 2/3/19 through 2/7/19, showed the following: -room [ROOM NUMBER] equipped with two beds and no chairs; -room [ROOM NUMBER] equipped with four beds, no chairs; -room [ROOM NUMBER] equipped with three beds and no chairs; -room [ROOM NUMBER] equipped with three beds, no chairs; -room [ROOM NUMBER] equpped with four beds, no chairs; -room [ROOM NUMBER] equipped with three beds and no chairs; -room [ROOM NUMBER] equipped with two beds and no chairs. 5. During the Resident Council interview on 2/5/19 at 10:45 A.M., two of the 8 residents in attendance said they had chairs in their room. The residents would like to have chairs in their rooms. They all agreed this would allow them to have a place to sit beside the bed. | |
| F 0919 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Make sure that a working call system is available in each resident’s bathroom and bathing area. **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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0919 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 30) This deficient practice had the potential to affect all residents, staff, and visitors who might need to use the toilets and would need staff assistance. The facility had a census of 94. 1. Observation on 2/6/19 at 11:15 A.M., showed two resident bathrooms located in the hallway of the third floor. Call light boxes were located on the wall of each bathroom. Neither call light box had a string to activate the call light system. 2. Observation on 2/6/19 at 11:20 A.M., showed resident room [ROOM NUMBER] with four occupied beds. Call light boxes were located on the wall above the beds. None of the call light boxes had strings to activated the call light system. 3. Observation on 2/6/19 at 11:20 A.M., showed resident room [ROOM NUMBER] with four occupied beds. Four call light boxes were located on the wall above the beds. None of the call light boxes had strings to activate the call light system. Further observation of the call light outside room [ROOM NUMBER], showed the light detached from the ceiling tile and hung diagonally from wires. During an interview on 2/7/19 at 8:26 A.M., the Maintenance Director said he completes rounds on each floor daily. He was not aware of the malfunctioning call lights. During an interview on 2/7/19 at 10:05 A.M., the administrator said all call lights should function. | |
| F 0920 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Based on observation, interview and record review, the facility failed to adequately |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0920 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 31) stay on their floor for meals. He said they do not have enough tables and chairs on those floors for residents to use during meal times. | |
| F 0921 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to ensure equipment in the kitchen |
| 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: 265578 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER NORMANDY NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 7301 ST CHARLES ROCK RD | |||||||||
| 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 0921 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | ||
