DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0557 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to be treated with respect and dignity and to retain and use personal possessions. Based on observations and interviews the facility failed to respect the dignity of one | |
F 0559 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0559 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) resident as far ahead of time as possible and shall not be permitted where this transfer would result in any avoidable detriment to the resident’s physical, mental, or emotional condition. 2. Review of Resident #35’s annual Minimum Data Set (MDS), dated , 7/29/18, showed: – Cognitive skills intact; – Independent with bed mobility, transfers, dressing and toilet use; – Lower extremities impaired on both sides; – Always continent of bowel and bladder; – [DIAGNOSES REDACTED]. Review of the resident’s social services notes, dated, 9/10/18, at 5:00 P.M., showed: – E-mailed deputy Public Administrator (PA) in regards to planned room move for 9/11; – Requested return call or e-mail if any concerns or questions; – Did not document if the room change was discussed with the resident. Review of the resident’s care plan, dated, 9/24/18, showed: – The resident is up ad lib in wheelchair and is able to transfer him/herself; – The resident is at risk for falls related to medication use and disease process; – One staff to assist the resident with mobility and transfers as needed. During an interview on 10/17/18, at 9:31 A.M., the resident said: – He/she was on the 800 hall and the staff moved him/her to the 900 hall because the younger residents were going to be on the 900 hall; – There are younger people than the resident on the 800 hall; – Staff did not discuss the room change with the resident, just told him/her they were being moved; – In the new room he/she had problems getting into the bathroom with his/her wheelchair, there was not enough room; – The resident talked to the Administrator about it but nothing had changed. During an interview on 10/17/18, at 2:42 P.M., Licensed Practical Nurse (LPN) A said: – The resident was moved to the 900 hall because they were trying to get the younger residents on one hall together; – He/she was not aware of any problems with the bathroom. During an interview on 10/19/18, at 8:54 A.M., the resident said: – It was hard for him/her to get into the bathroom with his/her wheelchair; – He/she had to sit on the toilet sideways; – His/her wheelchair did not fit into the bathroom very well; – He/she had mentioned it to various staff but no one had talked to him/her about it; – When he/she was on the 800 hall, he/she did not have any trouble getting in and out of the bathroom with his/her wheelchair; – He/she would like to move back on the 800 hall. During an interview on 10/19/18, at 5:52 P.M., the Director of Nursing (DON) said: – Room changes are discussed by the Administrator, Social Services, DON or Assistant Director of Nursing (ADON); – It should be documented that we discussed the room change with the guardian and the resident; – The room change should have been discussed with the resident. | |
F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to and the facility must promote and facilitate resident |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) self-determination through support of resident choice. Based on observations, interviews and record reviews, the facility failed to create an |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) During an interview on 10/19/18 at 5:30 P.M., The administrator said: – Staff should not serve residents food that has been left out for an hour. If residents did not come to retrieve their food tray, the trays were to be sent back. It was not okay for staff to let food trays sit out. – Certified Nurse Aides (CNA)’s encourage residents to keep their rooms picked up. If the residents do not pick up after themselves, staff will do it. 3. Observation on 10/19/18 at 12:00 P.M., showed staff served residents pork chops covered in gravy. Staff did not provide a knife utensil with the meal service. Several residents attempted to cut the pork chop with their fork but were not able. Residents attempted to use their fork to lift the pork chop to their mouth in order to eat it but were unsuccessful. Residents then picked up the gravy covered pork chop and ate it by hand. An interview on 10/19/18 at 5:30 P.M. showed: – Licensed Practical Nurse (LPN) A, who was the Rothwell and Rothwell Senior unit manager, said staff does not provide knives to unit residents for meal service. Knives were not allowed on the unit. – The administrator said knives were not sent with meal service unless actually needed. Residents could let staff know if they want a knife. Providing knives for dining service was a safety concern. Butter knives were a safety threat. If residents asked, staff could get them something to cut their meat . | |
F 0575 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observations and interviews, the facility failed to post all required |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0575 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) Protection and Advocacy or Medicaid Investigation Unit and the most recent survey results could not be found. During a Resident Council Meeting with the residents on the Rothwell, Rothwell Senior, Parkwood Senior and Parkwood halls on 10/17/18 at 10:30 A.M. the resident’s said: – -The residents are not aware of any resident rights, there is a survey results signed posted, but do not know where the survey results are at or have access to them. -There are no outside phone numbers available to them, they are unaware of the Ombudsman phone number or how to contact the Ombudsman. They are unaware of who to contact regarding their guardianship and how to restore their rights. 3. Observation on 10/16/18, at 12:25 P.M., on the 800 hall (Parkwood Village), showed: – A laminated sign above the pay phone in the commons area; – The sign was too high for a resident in a wheelchair to read and the phone numbers for State and the Ombudsman were in fine print and difficult to read. 4. During an interview on 10/19/18 at 2:00 P.M. the Customer Service Representative said: -The addresses and phone numbers of the required agencies were not available for the Rothwell and the Rothwell Senior units; -The facility is attempting to find a way to post the required addresses and phone numbers in a way that the is visible to the residents, yet so that the resident’s cannot remove. | |
F 0576 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure residents have reasonable access to and privacy in their use of communication methods. Based on observations, on interviews, and record reviews, the facility failed to provide |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0576 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) 800 unit. During an interview on 10/17/18, at 2:36 P.M., Resident #126 and Resident #9 said: – There’s a white portable phone locked up in the snack room; – You can not call out on the white portable phone; – You have to use the pay phone to make calls; – When your family calls back, you can use the white portable phone. 3. Observation on 10/16/18, 10/17/18, 10/18/18 and 10/19/18 showed a pay phone for resident use on the Rothwell hall. During a group interview on 10/17/18 at 10:30 A.M. with the residents on Rothwell, Rothwell Senior, Parkwood, Parkwood Senior halls the residents said: -The resident’s have to use a pay phone in the hall if they want to make a call and use a calling card. If the resident does not have a calling card, then they have to make a collect call. Not all cell phone will accept collect calls; -The residents on the Rothwell Senior hall had to go to the Rothwell hall to use the pay phone; -The doors are locked between the two halls; -They had to wait for a staff member to be available to take them to the Rothwell hall to use the pay phone. | |
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: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) assessment instrument completed by staff dated [DATE] showed: -Alert and able to make decisions; -Independent with Activities of Daily Living (ADL’s); -[DIAGNOSES REDACTED]. Review of the medical record showed: -The face sheet listed the responsible party on as the resident’s mother and father; -Code Status – Full code – Attachment U (a facility form indicating advanced directives) listed as Full Code. -Physician order [REDACTED]. -physician progress notes [REDACTED]. 2. Review of Resident #153’s MDS, dated [DATE], showed: – Both short and long term memory problems; – Required assistance with activities of daily living; – [DIAGNOSES REDACTED]. Review of the medical record showed: – The face sheet listed the responsible party as the resident’s daughter; – Code Status – Full code; – Attachment U (a facility form indicating advanced directives) listed as DNR (Do Not Resuscitate) signed by the resident’s daughter; – Physician order [REDACTED]. 3. Review of Resident #147’s MDS, dated [DATE], showed: – Both short and long term memory problems; – Required assistance with activities of daily living; – [DIAGNOSES REDACTED]. Review of the medical record showed: -The face sheet listed the resident had been assigned a guardian; -Code Status – Full code – Attachment U (a facility form indicating advanced directives) listed as DNR; -Physician order [REDACTED]. During an interview on [DATE] at 1:36 P.M., Licensed Practical Nurse (LPN) D said: He/she floated and worked in all units of the facility; – There were several places in the resident’s medical chart to find out the resident’s code status. The first page of the record on the face sheet, on admission paper work and on the physician’s orders [REDACTED]. During an interview on [DATE] at 9:30 A.M. the Director of Nursing (DON) said: -She does not know why the physician documented the resident as a DNR; -All documentation in the medical record should match the code status of the resident. | |
F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and record reviews the facility failed to inform two residents |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) – The facility sent a certified letter to the resident’s Public Administrator (PA) on 6/6/18. – The resident’s services ended on 6/7/18. – No other documentation of attempting to contact the resident’s PA by phone or any other means prior to the end of service; – The resident’s Public Administrator signed the notice on 6/18/18. Review of Resident #48’s NMNC showed: – The facility sent a certified letter to the resident’s PA on 7/20/18. – No other documentation of attempting to contact the resident’s PA by phone or any other means prior to the deadline; – The resident’s services ended on 7/23/18. – The resident’s PA signed the notice on 8/1/18. During an interview on 10/19/18 at 3:00 P.M the Social Services Director (SSD) said: – He/she thought the NMNC needed to be sent only one day prior to the end of services. – He/she sent the NMNC to a resident’s guardian but did not fax or call to ensure the form was signed two days prior to the end of service. During an interview on 10/19/18 at 3:00 P.M. the Administrator said: – The SSD was responsible for sending out the NMNC notices to any resident with a PA. – He/she thought that the SSD should notify the resident’s PA one day before the end of services. – He/she did not instruct the SSD to call the resident’s PA 48 hours prior to the end of services,. – He/she thought as long as the SSD mailed the NMNC one day prior to the end of services, no further facility follow up was needed. | |
F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) – Ceiling tile stained in room [ROOM NUMBER]. – Panel wall trim off and/or floor trim off or loose trim in resident rooms and /or restrooms for rooms 401,405,505 and 600. – Resident room restrooms had either a strong odor of urine and/or sticky, pink substances on walls for rooms 400, 401, 402, 408, 411 and 502. – Room doors scuffed and/or dirty and damaged for rooms 405,409, 603 and 702. – Shower room in 400 hall had a scuffed housekeeping closet. – No baseboard or no baseboard paint and/or loose baseboards in rooms and/or restrooms located in room [ROOM NUMBER], 506 and 603. – Near an exit door on the 500 hall the baseboard and the exit door was dirty with trim around windows chipped. – The toilet paper holder was dirty in room [ROOM NUMBER]. – Strong soiled linen smell in room [ROOM NUMBER]. – Drawers with chips in room [ROOM NUMBER]. – Plywood covering the window in room [ROOM NUMBER]. – No Closet curtains or closet curtains coming off the rails in rooms [ROOM NUMBERS]. – Broken tile by the window in room [ROOM NUMBER]. – White wrapping peeling off the pipes by the west 100 hall exit door to the enclosed court yard. – The main dining room had a door to the courtyard that was dented and stained over 75 percent of the surface area with a dirty window. The room trash can lid had food substances and particles on the lid handles and was touched numerous times by residents and staff. The white cabinets in the room were missing knobs and were stained and dirty with food substances. The interior of the white cabinets were dirty and contained a partial container of pop, dead bugs, food particles and drink substances. The exterior of vending machine was 50 percent speckled with gray and white substances. The 16 ceiling light fixtures in the room contained dead bugs. The double doors near the vending machine was dirty and stained over 25 percent of the door area. The ceiling paint in the corner of the room was pealing off and stained over a 13 foot by 9 foot area. – The unit refrigerators of the Rothwell and Rothwell Senior unit had a thick build-up of ice. During observation and interview on 10/17/18 at 1:48 P.M., the Assistant Director of Nursing (ADON) said resident room [ROOM NUMBER] floor was so sticky it caused shoes to stick to the floor. Certified Nurses Aides (CNA) K and CNA L also said the room floor was sticky. During an interview on 10/19/18 at 4:15 P.M., the Environmental Director (ED) said all identified areas shown in environmental observations were areas of concern that needed to be fixed. Floors were sticky, discolored and needed to be refinished. Some rooms had strong urine odors that they were trying to address. Unit staff should clean the refrigerators in their units. He was unaware if it was his responsibility or someone else’s to assure light fixtures were kept clean. The trash can in the main dining room was cleaned every other week. It was not acceptable for residents and staff to touch a dirty trash can with food particles on it. During an interview on 10/19/18 at 4:43 P.M., the Dietary Manager said staff should keep the lid on the dining room trash can clean. It was unsanitary for residents and staff to touch a dirty trash can lid. During an interview on 10/19/18 at 5:30 P.M., Licensed Practical Nurse (LPN) A, who was the Rothwell and Rothwell Senior unit manager, said staff should not let thick ice build-up on the refrigerators. The unit night shift nurse was responsible for defrosting |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) the refrigerators. During an interview on 10/19/18 at 5:30 P.M., the Administrator said: – Certified Nurse Aides (CNA)’s encourage residents to keep their rooms picked up. If the residents do not pick up after themselves, staff will do it. – Residents’ spilt drinks and make messes in their rooms daily. – Window blinds were provided in resident rooms for privacy. – The build-up of dirt was down in the floor tile and would be addressed when the unit remodel was complete. | |
F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) Review of the resident’s MAR, dated, October, (YEAR), showed: – [MEDICATION NAME] ([MEDICATION NAME]) nasal spray, 50 mcg., two sprays in each nostril daily for allergies [REDACTED].M. to 11:00 A.M.; – Vitamin D 3, 2000 units daily with food for nutritional deficiency, scheduled time 7:00 A.M. to 11:00 A.M. Observation on [DATE], at 9:06 A.M., showed: – CMT C placed the Vitamin D 3 in a plastic medication cup and added a heaping teaspoonful of applesauce and administered to the resident; – CMT C handed the resident the [MEDICATION NAME] ([MEDICATION NAME]) nasal spray and instructed the resident to hold one side of his/her nose and spray in the open nostril and repeat on the other side. The resident administered two sprays to each nostril; – The resident did not blow his/her nose before administering the nasal spray and did not lean forward during the administration of the nasal spray. During an interview on [DATE], at 9:30 A.M., the resident said: – He/she did not eat breakfast this morning; – He/she did not eat breakfast because he/she had gastric bypass done and only ate lunch and dinner. During a telephone interview on [DATE], at 7:20 P.M., CMT C said: – He/she should have offered the resident something to eat; – He/she should have followed the guidelines for the nasal spray. During an interview on [DATE], at 5:52 P.M., the Director of Nursing (DON) said: – If the physician ordered to give medication with food, a teaspoonful or tablespoon of applesauce would not be enough, it would need to be a substantial amount; – The staff should follow the guidelines for the nasal spray. 3. Review of Resident #35’s POS, dated, (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR), showed: – an order for [REDACTED].M. to 11:00 A.M. and 6:00 P.M. to 10:00 P.M.; Review of the resident’s MAR, dated, (MONTH) 1, (YEAR) to (MONTH) 31, (YEAR), showed: – [MEDICATION NAME] 20 mg. twice daily, scheduled at 7:00 A.M. to 11:00 A.M. and 6:00 P.M. to 10:00 P.M. During an interview on [DATE], at 5:52 P.M., the DON said: – The staff should get the pain medication times clarified or give at the time stated on the MAR. 4. Review of Resident #80’s face sheet, showed: – Re-admitted [DATE]; – allergies [REDACTED]. Review of the resident’s care plan, dated, [DATE], showed: – The resident was on a regular diet and had food allergies [REDACTED]. – Ensure allergies [REDACTED]. Review of the resident’s POS, dated, (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR), showed: – The resident had an allergy to cinnamon. Observation and interview on [DATE], at 2:00 P.M., showed: – The resident said he/she was served apple pie which had cinnamon in it; – The apple pie smelled like it had cinnamon in it. During observation and interview on [DATE] at 1:59 P.M. Cook A showed a can of the apple pie filling he/she used in the fruit cobbler he/she prepared for lunch. The can showed ingredients included spices. Cook A was not aware of what spices were included in the apple pie filling. A taste sample of the cobbler showed a taste of cinnamon. During an interview on [DATE] at 6:03 A.M., Cook A said they checked with company who |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) provided the apple pie filling and were not able to find out what spices were in the filling. During an interview on [DATE] at 9:40 A.M., Cook A said they had no way to know what the spices were in the apple pie filling served to the resident. He/she thought the spices could include cinnamon. The kitchen staff did not check and should check for resident allergy restrictions prior to meal service to assure residents dietary restrictions were met. During an interview on [DATE] at 12:03 P.M., Dietary Adie (DA) A said since [DATE], when the resident was served apple cobbler, the resident’s dietary card went missing. The card showed the resident was allergic to cinnamon and other food items but he/she cannot find it. During an interview on [DATE] at 4:43 P.M., the Dietary Manager (DM) said she would expect spices in apple pie filling would include cinnamon. Staff should not serve residents foods that were restricted from their diets. During an interview on [DATE], at 5:52 P.M., the DON said: – The CNA’s should check the resident’s dietary card before they serve any food; – The resident’s allergies [REDACTED]. 5. Review of the CPR-D-padz (used to shock a resident in case of [MEDICAL CONDITION]) showed staff should not open the pads until ready to use. Observation on [DATE] at 2:26 P.M. of the emergency crash cart on the Meadowbrook Hall showed: – An opened package of CPR-D-padz. During an interview on [DATE] at 2:26 P.M. the Business Office Manager said: – He/she checked the facility crash carts on a daily basis. – He/she was not aware that the CPR-D-padz should not be opened until ready for use. 6. Review of Resident #105’s care plan, dated [DATE], showed: – The resident was at risk for altered respiratory status due to lung disease. – Staff should administer oxygen to the resident as needed. – Did not address the resident changing the liter flow on his/her oxygen concentrator. Review of the resident’s significant change in condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: – Moderate cognitive impairment; – [DIAGNOSES REDACTED]. – The resident smoked tobacco; – The resident denied shortness of breath; – The resident received oxygen therapy. Review of the resident’s POS, dated (MONTH) (YEAR), showed: – Staff could administer breathing treatments to the resident as needed for shortness of breath; – Did not discuss oxygen therapy. Observation on [DATE] at 11:28 A.M. of the resident in his/her room showed: – The resident was using oxygen from tubing and a humidifier that were not labeled when staff opened them. – The resident moved his/her oxygen tubing from the humidifier directly to the flow meter (bypassing the humidifier) – The resident was adjusting his/her oxygen liter flow while taking to the surveyor. – The resident’s oxygen concentrator filter was dusty. Observation on [DATE] at 10:45 A.M. showed: |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 12) – The resident’s oxygen tubing and humidifier not labeled when opened. – The resident’s oxygen tubing on the floor. During an interview on ,[DATE] /18 at 10:45 A.M. the Director of Nursing (DON) said: – The resident’s oxygen tubing should not be on the floor. – The resident’s oxygen tubing and humidifier should be labeled when opened and changed weekly and as needed. – Staff should clean the resident’s oxygen filter. – Did not specify which staff should clean the oxygen filter. During an interview on [DATE] at 8:15 A.M. Licensed Practical Nurse (LPN) B said: – He/she was the resident’s unit manager. – Staff must label oxygen tubing and humidifiers when opened. – Staff must change resident’s oxygen tubing weekly and as needed. – The night shift must clan oxygen concentrator filters as needed. – Staff must ensure thee resident’s oxygen was attached to a humidifier. | |
F 0660 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Plan the resident’s discharge to meet the resident’s goals and needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0660 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) on 10/19/18 at 4:30 P.M., the resident asked to speak to the surveyors present. The resident stated: – He/she had repeatedly requested to move closer to his/her sisters on the eastern side of the state; – His/her sisters were older than the resident and it was difficult for them to make the long round trip to visit him/her, plus the trip was costly; – He/she had requested to move to a residential care facility; – He/she had caused no problems while at the facility, took his/her medications as ordered, basically took care of him/herself and had no behaviors; – He/she did not feel Social Services at the facility had helped him/her to be able to move closer to his/her family; – He/she asked for information of any agency or resource that could assist him/her; – He/she did not feel the guardian or judge should say the reason he/she could not move was because the guardian did not get paid enough for mileage to go see the resident closer to the eastern side of the state; – He/she felt the judge could appoint him/her a different guardian if he/she still needed one; – The resident went on to discuss finance, insurances and the job he/she held prior to placement at a long term care facility. During an interview on 10/19/18 at 12:22 P.M., the Social Service Director (SSD) and Administrator said: – During scheduled guardian meetings with the resident, the unit coordinator and herself discussion of what the guardian has planned for the resident’s discharge is held; – If what the guardian had planned was not in the best interest of the resident, she tried to speak to the guardian; – The guardian told her the judge that placed the resident with the guardian will only place residents in certain geographical areas to cut down on travel costs; – The guardian told her the resident could not move, it was too far away and would cost too much for the guardian to where the resident wanted to move; – She felt the resident could live in a lesser restrictive environment; – She or the Administrator was unaware of any other resource to use that would help advocate for the resident. 2. Review of Resident #130’s Preadmission Screening and Resident Review (PASRR)/MI (Mental Illness) form (a federally mandatory screening process for individuates with serious mental illness and/or mentally retarded/developmental disability related [DIAGNOSES REDACTED]. -[DIAGNOSES REDACTED]. -History of psychiatric hospitalization s; -Nursing facility short term stay and services recommended to adjust medication and allow to stabilize;- -Does not require secured placement; -Short term recommendations: Nursing facility must initiate discharge planning to evaluate appropriateness of move to less restrictive setting including referrals to community services providers as applicable. Review of the psychosocial history dated 12/5/17 showed: -Services needed/suggested: therapy, dental, audiology, ophthalmology, podiatry, and psychiatric; -Legal guardianship in place; -Anticipated length of stay: until desired level of independence is achieved; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0660 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) -Goals and future desired outcomes: go to school, get a career and work full time. Review of the care plan for discharge date d 12/26/17 showed: -The Public Administrator plans for continued long term placement; -Goal: Maintain current physical and mental health; -Approaches: nursing and social services to meet with guardian via phone and at facility to discuss current placement; hospital evaluation and treatment as needed or ordered. Review of the care plan for the resident will not cause significant harm to self or others dated 3/26/18 showed: -9/30/18: resident reports ingested shampoo, unwitnessed; approaches to send to psychiatric hospital for evaluation; -Undated problem: the resident stated got upset because guardian retired and didn’t pass on information to possibly go to Residential Care Facility (RCF) in the future; approach: offer reassurance, notify guardian of questions or concerns, assist the resident as needed and inform the resident that making false statements or attention seeking behaviors would not him/her move to a less restrictive environment. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 9/11/18 showed: -Alert and oriented and able to make decisions; -No mood or behavior concerns; -Independent with ADL’s; -[DIAGNOSES REDACTED]. -No discharge plan. Review of the social services notes dated 9/13/18 at 9:48 A.M. completed by the Social Services Director (SSD) showed: -The resident has expressed a desire to return to a lesser restrictive environment however his current guardian feels that his/her mental health needs to continue to stabilize before he/she will consider moving him/her. During an interview on at 10/18/18 06:34 AM the Resident stated that he/she was working on a six month program to be discharged to a less restrictive area. His/her Public Administrator (PA) was changed and now all discharge plans have been stopped. He/she would like to be able to work toward discharge planning. No one has worked with him/her on any discharge planning or goals. During an interview on 10/16/18 04:24 P.M. the Social Services Director said: -The resident was recently hospitalized for [REDACTED]. -He/she was aware that the resident wanted to go to a less restrictive environment; -There is no current discharge plan in place nor has he/she talked with the resident about possible discharge plans or goals; -The guardian has not indicated that the resident could be discharged to an RCF; -He/she has not discussed discharge planning with him/her. During an interview on 10/19/18 at 4:00 P.M. the Administrator said: -There are no current psychosocial therapy or discharge planning in place; -He is unaware of any goals the resident had made with the prior or present guardian about being discharged to a less restrictive environment. | |
F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide care and assistance to perform activities of daily living for any resident who is unable. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not remove facial hair as needed for one of 34 sampled residents (Resident #154) and when they failed to provide complete perineal cleansing for three dependent incontinent residents (Resident #37, # 147 and #153), The facility census was 170. 1. Review of the facility policy for Peri-Care, reaffirmed 4/6/17, showed: – To ensure that the male and female genital area is kept clean and proper techniques are used to prevent skin break down, infections or any other impairments that can be caused from not using roper aseptic technique; – Peri-care is very important in maintaining the residents’ comfort; – More frequent care is required for residents who are incontinent; – Always wash front to back to prevent spreading fecal matter from the anal area to the vagina or urethra (opening to the bladder); -Expose peri area, gently wash the inner legs, gently open all skin folds and cleanse from front to back; – Start with the innermost area and proceed cleansing outward. 2. Review of Resident #147’s Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/23/18, showed: – Both short and long term memory loss; – Required extensive assist with bed mobility, toilet use and personal hygiene; – Frequently incontinent of urine and occasionally incontinent of bowel; – [DIAGNOSES REDACTED]. Review of the resident’s care plan, updated 10/8/18, showed – Resident will be clean, dry and odor free; – Provide peri-care after each episode of incontinence and as needed. Observation on 10/16/18 at 4:07 P.M., showed the resident lay in bed on a wet incontinent pad. Certified Nurse Aide (CNA) I and J provided peri care for the resident prior to transferring the resident to his/her wheelchair. CNA I did the following: Poured a bottle of No Rinse peri rinse into a basin of warm water and placed washcloths in the basin; – He/she used different washcloths with each wipe and cleaned once down each groin and wiped twice down the center; – He/she wiped the resident from the rectum to the coccyx and cleaned the right buttock and between the resident’s inner thighs. CNA I did not thoroughly manipulate and cleanse all the perineal folds and clean the left buttock. During an interview on 10/19/18 at 2:40 P.M., CNA I said: – He/she should always wipe in a front to back direction; – He/she should wipe down each groin and then clean the middle, wiping until clean; – He/she should roll the resident to the side and clean one buttock and down the middle front to back. Then roll the resident over and clean the other buttock. 3. Review of Resident #153’s MDS, dated [DATE] showed: – Unable to make daily decisions; – Required extensive assist with bed mobility, toilet use and personal hygiene; – Frequently incontinent of urine and bowel; – [DIAGNOSES REDACTED]. Review of the resident’s care plan, updated 10/4/18, showed: |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) – One to two staff will assist the resident with activities of daily living including personal hygiene. During an observation 10/18/18 at 5:54 A.M., showed the resident lay on an incontinent ad soiled with urine. Urine soaked the incontinent pad up to the top edge of the pad that lay half way up the resident’s back. CNAs F and G provided pericare for the resident. CNA G did the following: – Asked CNA F to retrieve a clean incontinent pad and proceeded to wipe one time down each groin folding the wash cloth once between the wipes; – Rolled the resident to his/her side and wiped once from the rectum to the coccyx, folded the washcloth and wiped once on each buttock from front to back, folding the cloth between each wipe; – CNA G rolled a clean incontinent pad under the resident. CNA G did not manipulate and wash all the perineal folds, between the inner thighs, hips or up the resident’s back that lay on the soiled incontinent pad. During an interview on 10/18/18 at 6:29 A.M., CNA D said: – He/she should wipe own each groin area and then down the middle; – After he/she dried the front side of the resident, he/she should clean the backside, fold the washcloth between each buttock, fold the washcloth again and wipe up the middle of the backside; – He/she should have washed the resident’s hip that lay in urine and up the resident’s back that lay on the wet incontinent pad. 4. Review of Resident #37’s care plan, dated, 4/30/18, showed: – The resident required extensive assistance of two staff for activities of daily living (ADL), grooming and hygiene tasks related to [MEDICAL CONDITION] (impaired muscle coordination caused by damage to the brain before or at birth); – Incontinent of bladder and occasionally incontinent of bowel. Review of the resident’s quarterly MDS, dated , 7/20/18, showed: – Cognitive skills intact; – Required extensive assistance of two staff for bed mobility and transfers; – Required extensive assistance of one staff for toilet use; – Frequently incontinent of urine; – Occasionally incontinent of bowel; – [DIAGNOSES REDACTED]. Observation on 10/18/18, at 9:45 A.M., showed: – CNA A and CNA B used the sit to stand lift (raises the resident to a partial or full standing position) and transferred the resident from his/her wheelchair to the toilet; – CNA A removed the resident’s wet incontinent brief and CNA B lowered the resident onto the toilet; – CNA A raised the resident up from the toilet; – CNA B wiped from front to back five times with fecal material on each wipe; – CNA B wiped from front to back one more time without fecal material on the wipe; – CNA B wiped down one side of the groin, used a new wipe and wiped down the other side of the groin; – CNA B did not separate and thoroughly cleanse the front perineal folds; – CNA B did not clean the buttocks of hips. During an interview on 10/19/18, at 9:30 A.M., CNA B said: – He/she should have separated and cleaned all the perineal folds; – He/she should have cleaned all areas of the skin where urine had touched. 5. Review of Resident #154’s care plan, dated, 4/8/18, showed: |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) – The resident was independent with ADL’s, grooming and hygiene; – Required set up assistance /supervision at times; – The resident will be clean, dry and odor free; – Provide set up assistance /encouragement/ cueing as needed/requested for ADL’s, grooming and hygiene. Review of the resident’s quarterly MDS, dated , 9/22/18, showed: – Cognitive skills intact; – Supervision required for personal hygiene; – [DIAGNOSES REDACTED]. Observation and interview on 10/16/18, at 12:52 P.M., showed: – The resident had several chin whiskers at least a quarter of an inch in length; – The resident said he/she would like to be shaved more often, he/she was lucky if it was done at least once a week; – He/she really wanted it done before he/she had her next dentist appointment; – It bothered him/her to have the chin whiskers and was sure it bothered other people. During an interview on 10/19/18, at 9:04 A.M., CNA A said: – The resident required set up with showers; – The staff assisted the resident when he/she requested to bed shaved. 6. During an interview on 10/19/18 at 5:52 P.M., the Director of Nurses said: – Staff should remove facial hair per the resident’s preferences; – Staff should assist the resident remove facial hair when visible; – Staff should separate and cleanse all perineal folds when they provided incontinent care; – Staff should clean all areas where urine or feces touched the skin. | |
F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 18) – Able to make daily decisions; – Dependent on staff for transfers. Review of the resident’s care plan, updated 9/7/18, showed: – Two staff assist transfer the resident with (Hoyer) mechanical lift. Observation on 10/19/18 at 2:15 P.M., showed the resident sat in his/her wheelchair on a mechanical lift sling. Certified Nurse Aide (CNA) H and CNA I transferred the resident from his/her wheelchair to his/her bed. CNA I opened the legs of the lift and placed the lift around the resident’s wheelchair, CNA I locked the rear casters of the mechanical lift. Staff attached the sling to the mechanical lift. CNA I used the electric control and lifted the resident from the wheelchair, unlocked the brakes and wheeled the resident to his/her bed, positioned the resident over the bed and lowered the resident to the bed. During an interview on 10/19/18 at 2:40 P.M., CNA I said: He/she opened the legs of the lift around the wheelchair and felt most comfortable to leave the legs open under the resident’s bed; He/She locked the rear castors of the lift, hooked the sling up to the lift and lifted the resident; – He/she unlocked the rear castors to move the resident. 3. Review of Resident #37’s quarterly MDS, dated , 7/20/18, showed: – Cognitive skills intact; – Required extensive assistance of two staff for bed mobility and transfers; – Required extensive assistance of one staff for toilet use and personal hygiene; – Frequently incontinent of urine; – Occasionally incontinent of bowel; – [DIAGNOSES REDACTED]. Review of the resident’s care plan, dated, 9/12/18, showed: – The resident used a Hoyer lift with the assistance of two staff for transfers. Observation on 10/18/18 at 9:45 A.M., showed: – CNA A removed the foot pedals from the wheelchair; – CNA A and CNA B locked the wheelchair and placed the lift pad around the resident and fastened it; – CNA B opened the legs of the lift to go around the wheelchair and CNA A and CNA B hooked the resident up to the lift; – CNA B moved from the resident’s wheelchair to the toilet with the legs of the lift open, locked the rear casters on the sit to stand lift, and lowered the resident onto the toilet. During an interview on 10/19/18, at 9:04 A.M., CNA A said: – The brakes are supposed to be locked when we raise the resident up or lower the resident. During an interview on 10/19/18, at 9:15 A.M., CNA B said: – The brakes are locked on the sit to stand lift when we raise or lower the resident. 4. During an interview on 10/19/18 at 5:52 P.M., the Director of Nurses said: – During transfer with the mechanical lifts, staff should lock the rear castors on the mechanical lift before they raised and lowered the resident and unlock the castors when moving the resident. | |
F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for residents who are continent or incontinent of |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 20) NAME](an antibiotic) to treat a UTI. Review of the resident’s medical records showed staff did not monitor the resident’s fluid intake. Observations of the resident in the dining room on 10/16, 10/17, and 10/18 showed the resident had two 8 ounce glasses of fluids that he/she drank at each meal. During an interview on 10/17/18 at 1:50 A.M. the DON said staff should ensure the resident drank enough water. | |
F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) – [DIAGNOSES REDACTED]. – Took antipsychotic and antidepressant medications. Review of the resident’s physician order sheet (POS), dated (MONTH) (YEAR), showed: – An order, dated 4/5/17, for [MEDICATION NAME] 20 milligrams (mg) orally (PO) daily for major [MEDICAL CONDITION]; – An order, dated 4/5/17, for [MEDICATION NAME] 1 mg po twice daily for abnormal movements; – An order,, dated 4/5/17, for [MEDICATION NAME] 20 mg po twice a day for [MEDICAL CONDITION]; – An order, dated 4/5/17, for topirmate 100 mg po twice a day for [MEDICAL CONDITION]; – An order, dated 4/5/17, for [MEDICATION NAME] 500 mg po three times a day for impulse disorder; – An order, dated 4/5/17, for [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 50 mg injections given monthly, no indication given. 3. The facility did not provide an AIMS for Resident #20. Review of the resident’s annual MDS, dated [DATE], showed: – Cognitively impaired; – No behaviors noted; – No mood disorders noted; – [DIAGNOSES REDACTED]. – Received antipsychotic, antidepressant, and antianxiety medications. Review of the resident’s care plan, dated 10/15/18, showed: – The resident was a fall risk due to side effects of medications. – The resident was at risk for adverse side effects due to psychoactive medications, – Staff must perform an AIMS at least quarterly. – PharmD to review medications routinely. – PharmD recommendations to be sent to the nurse (did not specify which nurse) for possible GDRs. Review of the resident’s POS, dated (MONTH) (YEAR), showed: – An order, dated 4/1/16, for trazadone 75 mg po at HS to be given for mood disorder; – An order, dated 3/8/18, for [MEDICATION NAME] 0.5 mg po twice a day for abnormal movements. 4. The facility did not provide Resident #146’s AIMS. Review of the resident’s care plan,dated 4/7/18 showed: – Staff should perform an AIMS quarterly and as needed; – PharmD to routinely monitor the resident’s medications. – A handwritten note, dated 8/17/18 No GDR recommendation this time per the resident’s physician. Review of the resident’s quarterly MDS, dated [DATE], showed: – Mild cognitive impairment; – No abnormal moods noted; – No behaviors noted; – [DIAGNOSES REDACTED].>- Received antipsychotic and antidepressant medications. Review of the resident’s POS, dated (MONTH) (YEAR), showed: – An order, dated 2/7/13, ,for citalopra 40 mg po to be given daily for major [MEDICAL CONDITION]; – An order, dated 12/8/14, for [MEDICATION NAME] 2 mg po to bee given for abnormal movements; – An order, dated 5/29/14, for [MEDICATION NAME] 20 mg po to be taken twice a day for |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 22) [MEDICAL CONDITION]; – An order, dated 11/3017, for [MEDICATION NAME] 100 mg po at HS for [MEDICAL CONDITION]; – An order, dated 3/1/15, for [MEDICATION NAME] 100 mg to be given by injection once a month for paranoid [MEDICAL CONDITION]. Observation on 10/16/18 at 4:11 P.M. showed the resident continually rolling his/her fingers and total body shaking (a possible side effect of psychoactive medications). 5. During an interview and record review on 10/19/18 at 6:00 P.M. the Director of Nursing (DON) said: – The PharmD reviewed each resident medications on a monthly basis. – He/she communicated the PharmD’s recommendations to the residents’ physicians. – The DON did not provide the surveyor PharmD DRR and GDR recommendations for the requested resident. – The DON did not provide any AIMS. 6. Review of Resident #55’s MDS, dated [DATE], showed: – Able to make daily decisions; – No mood disorder noted; – Rejected care at least one to three times during the look back period; – [DIAGNOSES REDACTED]. Took antipsychotic, antianxiety and antidepressant medications. Review of the resident’s care plan, last updated 8/3/18, showed: – Assess for any mood/behavioral changes as needed – Administer medication as ordered; – Observe for adverse side effects, document and report to physician; – Pharm D review/consult on medications routinely and as needed with all recommendations sent to physician for review. Review of the resident’s (MONTH) (YEAR) physician order sheet, showed: – Ordered 2/3/17 aripiprazole (treat [MEDICAL CONDITION])10 mg daily; – Ordered 2/3/17 [MEDICATION NAME] (antidepressant) 30 mg daily; – Ordered 2/3/17 [MEDICATION NAME] (treat major [MEDICAL CONDITION]) 75 mg daily; – Ordered 5/17/18 [MEDICATION NAME] (antidepressant) 100 mg three times daily; – Ordered 8/28/18 [MEDICATION NAME] (antianxiety) 0.25 mg at bedtime. During an interview on 10/19/18 at 9:41 A.M., the assistant Director of Nurses (ADON) said: – Responses from the resident’s physician for the Pharm D recommendatons were kept in a separate notebook; – He/she did not have permission from the administrator to allow surveyors to see the notebook. During and interview on 10/19/18 at 2:51 P.M., the ADON stated the Drug Regimen Review (DRR) and Gradual Dose Reduction (GDR) reviews requested earlier that morning, remained in the DON office, the DON was still working on them. He/she did not provide the requested PharmD DRR/GDR recommendations or physician responses for any requested resident. | |
F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure medication error rates are not 5 percent or greater. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) Based on observations, interviews, and record reviews the facility failed to ensure staff administered medications with a less than 5% medication error rate. Staff made two errors out of 32 opportunities for error which resulted in a 6.25% error rate. This affected three residents (Residents #71, #146). The facility census was 170. 1. Review of the facility policy, dated 4/6/17, on medication administration showed: – Staff must administer medications the right time. – Staff must administer medications the right dose and dosage form. – Staff must schedule medication administration times to best reflect the physician’s orders and drug recommendations. – Medications that are to be given with food, will be given within 30 minutes before or 30 minutes after the meal consumption; – If the medications must be given with food, and it is out of the 30 minute window, then a small snack will be provided to the resident to prevent GI upset, according to their diet. – Staff should give residents a snack for medications that should be administered with food to prevent gastric distress. Review of the undated Prescribing Digital Reference on polyethylene [MEDICATION NAME] showed: – The medication was used to treat constipation. – The medication worked by drawing fluid from the body into the stool for ease of bowel movements. – The medication must be mixed with four to eight ounces of liquid. 2. Review of Resident #146’s physician order sheet (POS), dated (MONTH) (YEAR), showed: – an order for [REDACTED]. – an order for [REDACTED]. Observation on 10/17/18 at 9:03 A.M. of Certified Medication Technician (CMT) A administer medication to the resident showed: – He/she put 17 GM of polyethylene [MEDICATION NAME] in a small glass and added about two ounces of water. – He/she then added 15 ml of [MEDICATION NAME] to the mixture. – He/she gave the medications to the resident. – He/she added water to the empty glass and found the glass held three ounces of water and four ounces when filled to brim of the glass. During an interview on 10/17/18 at 9:03 A.M. CMT A said: – He/she did not know that the glass only comfortably held three ounces of water. – He/she thought it was alright to add the [MEDICATION NAME]. – He/she thought he/she should mix polyethylene [MEDICATION NAME] with at least four ounces of liquid. 3. Review of the undated WebMD website on [MEDICATION NAME] showed: – The medication was used for pain and fever relief. – Normal dosage for the medication was 400 milligrams (mg) to 800 mg; – The medication could cause gastric distress; – To lessen gastric upset, the medication should be administered with food. Review of Resident #71’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED]. Observation on 10/19/18 at 11:45 A.M. of CMT B administering medication to the resident showed: – He/she administered 400 mg [MEDICATION NAME]. – He/she did not give the resident any food. – The resident was waiting for lunch. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) Observation on 10/19/18 at 12:15 P.M. showed facility staff served the resident a glass of milk, During an interview on 10/19/18 at 12:15 P.M. CMT B said: – Did not realize that the resident should have food with [MEDICATION NAME]. – He/she did not realize the resident should have 800 mg of [MEDICATION NAME]. During an interview on 10/19/18 at 12:15 P.M. the DON said: – He/she thought the residents did not need food with [MEDICATION NAME]. – Staff should administer the correct dosage of medication. – Staff should administer polyethylene [MEDICATION NAME] in at least four ounces of water. | |
F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 25) cart showed: – A bottle of saline eye wash with an expiration date of 4/1/14; – Three 100 ml bottles of saline with an expiration date of (YEAR). During an interview on 10/18/18 at 3:00 P.M. the Business Office Manager (BOM) said: – He/she checked the facility crash carts daily for completeness. – He/she did not know he/she should check the crash carts for outdates as well. During an interview on 10/18/18 at 9:00 A.M. the Director of Nursing said: – One of the nursing administration checks the medication rooms and medication carts twice a week. – Staff did not have a check list for checking the medication rooms. – The BOM checks the crash carts daily. – Staff must label all insulins when opened and discard according to manufacture’s instructions. – Staff must discard all expired medications. – Staff must not reuse single dose vials. 3. Observation and interview on 10/17/18, at 3:19 P.M., of the medication room on the 800 hall showed: – Resident #372 had a plastic bag with his/her name on it which contained his/her birth certificate, a piece of paper with a copy of a non driver’s license card on it, seven one dollar bills, and $6.79 in change and CMT C said it looked like the resident’s EBT card. CMT C said the items should not be stored in the medication room; – Resident #63 had a vial of [MEDICATION NAME] (used to treat [MEDICAL CONDITION]), 125 mg./5 ml., IM every 14 days, did not have a date when it was opened; – CMT C said the medication should be dated when it was opened. Observation and interview on 10/18/18, at 6:46 A.M., of the Meadow Brook hall medication room showed: – Resident #48 had a bottle of sterile saline used for injection and did not have a date when it was opened; – Resident #105 had one bottle of sterile saline used for injection and did not have a date when it was opened; – House stock of [MEDICATION NAME] suppositories (laxative), 10 mg. had five plus one that was out of the container and expired 8/2018; – The Assistant Director of Nursing (ADON) said the vials should have a date when they were opened. Staff should not use expired medications. Staff are to take the expired medications to the DON and herself and they destroy them. Observation on 10/18/18, at 3:01 P.M., of the emergency crash cart on the 800 hall, showed: – Two bottles of sterile saline, expired 7/2017; – One container of bleach sanitizer cloth, expired 9/2017. During an interview on 10/19/18, at 5:52 P.M., the DON said: – The CMT or the nurse notify the DON when the medications need to be destroyed; – Staff should not use expired medications; – The nurse or CMT’s should be checking expirations in the carts also. | |
F 0800 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0800 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Based on observations, interviews, and reviews, the facility failed to honor resident |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0800 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | ||
F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review the facility failed to follow menus, or |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 28) – Three of six residents had cornbread and three had a salad. In an interview on 10/18/18 at 7:15 P.M., Cook B said they should have had chili tonight but they had it for lunch with the residents’ choice meals. He/she fixed chicken noodle soup, ran out before all the residents that ate last were served so he/she opened a can of vegetable soup. He/she had about 15 bowls of fruit but that was not enough to give every resident in the group of residents that they served last, so she gave some of the residents cake. The standard alternates for meals was salad, a sandwich or two bowls of cereal. 5. During an interview on 10/19/18 at 4:43 P.M., the Dietary Manager (DM) said: – Menus were not signed off on by a RD. There was no place for the RD to sign. – She discovered her kitchen staff used an alternate choice list that had only three choices listed. She did not know where the list came from or who created it. The three alternate options the staff provided were not satisfactory as they did not provide equal nutritional value when compared with scheduled menu foods. – All residents should be offered a choice of either cold or hot cereal daily per the scheduled menu. It was not satisfactory for kitchen staff to have alternated between the two cereals. – On 10/18/18, kitchen staff should have offered the scheduled menu cinnamon toast. If running low, she would have obtained more cinnamon. – Staff should check before meal preparation to assure they are able to provide what is scheduled on the menu. If scheduled menu items are not available staff were to follow the procedure for substitutions. | |
F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Based on observations, interviews and record review the facility failed to preserve food |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 29) – Cook A said staff were to check food temperatures when food was placed on the steam table and again at mid service. Foods temperatures were not checked today. 3. Observation on 10/18/18 at 7:56 A.M., showed 8 food trays left on cart for residents on the Rothman Senior unit. The dietary aide took the trays to the snack room. The trays were left in the snack room with no warmer or cover on the oatmeal. Observation on 10/18/18 at 8:43 A.M. showed 7 of the 8 food trays still sitting in the snack room. During an interview on 10/19/18 at 5:30 P.M., Licensed Practical Nurse (LPN) A, who was the unit manager, said food trays should not be left in the snack room for residents who slept during meal service. Staff were to get food from the kitchen for residents who wanted to eat when they woke up. During an interview on 10/19/18 at 5:30 P.M., the administrator said staff should not serve food to residents that has been left out in room temperature. If residents did not come to retrieve their food tray, the trays were to be sent back. It was not okay for staff to let food trays sit out. 4. Observation of the Rothwell and Rothwell Senior unit on 10/19/18 at 12:00 P.M., showed: – At 12:00 P.M., staff delivered covered meal trays on a cart to the unit dining room. – At 12:20 P.M., a resident stated the food is going to be cold by the time we get it. It has been sitting there for 20 minutes. – At 12:22 P.M., one staff person began serving the meal trays without checking the food temperature. During an interview on 10/19/18 at 5:30 P.M., LPN A said he/she expected staff to serve residents in the unit dining room within twenty minutes of the time the food was delivered. 5. During an interview on 10/19/18 at 4:43 P.M., the Dietary Manager (DM) said: – Staff should check food temperatures to assure proper temperatures are met for each meal service. – It was not acceptable for the Rothwell and Rothwell Senior unit food to sit out on the tray cart for twenty minutes before staff served residents. In that amount of time the food will lose temperature required for meal service. The unit needed a steam table to assure proper temperatures are maintained. – When residents sleep in, they should be offered breakfast when they wake up. Breakfast foods including cereal, sausage and instant oatmeal should be offered. It was not satisfactory for food trays to sit out while the residents slept. Food sitting out losses proper temperature. Food sitting out for twenty minutes should be discarded. When the resident wakes up nursing staff should come to kitchen and get a new tray for the resident. | |
F 0809 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0809 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 30) staff offered each resident a bedtime snack (HS).This had the potential to affect all facility residents. The facility census was 170. 1. Review of the facility Snacks and House Supplements policy showed: – House snacks provide additional calories and meet a resident’s individualized nutritional and care plan needs. Food is to be handled employing all proper safe food handling practices. – HS snacks should provide a minimum of a starch or bread serving and fruit drink. Review of the facility Snacks policy showed: – Daily snacks are provided in accordance with the prescribed diet and in accordance with state law. Individual and/or bulk snacks are available at the nurses’ station for consumption by residents whose diet orders are not restrictive. – Procedure includes at least one serving or a minimum of two of the following four food components is offered for the bedtime snack: 1. Fruit and/or vegetable or full-strength fruit or vegetable juice. 2. Whole Grain or [MEDICATION NAME] cereals or breads. 3. Milk or other dairy products. 4. Meat, fish, poultry, cheese, eggs, peanut butter. Review of the facility Cycle Menus Policy showed: – Menus are implemented by the Dietary Manager (DM) in conjunction with the Registered Dietitian (RD). – The menus are three-meal plus a snack. 2. During a group interview on 10/17/18 at 10:05 A.M. with residents from the Homestead and Meadowbrook units the residents said: – The units often do not have HS snacks. – Staff never delivered HS snacks. – If a resident did not go to the desk and request a snack, staff did not offer the resident a snack. Observation on 10/18/18 at 7:13 P.M. of the Homestead Unit kitchen showed: – A large bag of crisp rice cereal; – No milk for the cereal; – Six containers of chocolate pudding. During an interview on 10/18/18 Certified Nurse Assistant (CNA) D said: – The unit did not have any HS snacks. – Dietary always sent fresh HS snacks on the evening meal cart. – He/she forgot to remove the snacks from the cart. – He/she would go to the kitchen and get snacks. Observation on 10/18/18 at 8:15 A.M. of the Homestead unit showed: – Several residents coming to the nurses station for a snack. – No staff offering snacks to the residents in their rooms. During an interview on 10/18/18 at 8:15 P.M. Licensed Practical Nurse (LPN) B said: – He/she was the unit manager for the Homestead Unit. – Residents could come to the nurses station and request a snack. 3. In an interview on 10/18/18 at 7:15 P.M., Cook B said he/she sent HS snacks on carts to the facility units. He/she sent oatmeal cookies and some sandwiches for resident with [DIAGNOSES REDACTED]. He/she looked for a list of residents on diabetic diets but was unable to find it. Observation on 10/18/18 at 7:30 P.M., of the snack room on the Meadowbrook unit showed no sandwiches as described by the cook. During an interview on 10/19/18 at 4:05 P.M. CNA N ,who worked on the Meadowbrook unit the |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0809 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 31) evening of 10/18/18, said no HS sandwiches were received from the kitchen to Meadowbrook before 7:30 P.M . During an interview on 10/16/18, at 11:46 A.M., Resident #159 said: – If we want a snack at bedtime, we have to go and see the hall monitor; – The staff do not bring snacks to our room . During an interview on 10/17/18, at 8:12 A.M., Resident #119 said: – The staff do not bring snacks to our rooms; – If we want a snack, we have to go and get it. During resident council on 10/17/18 with 17 residents from the Rothwell, Rothwell Senior, Parkwood and Parkwood Senior unit the residents said the facility does not offer the residents bedtime snacks. During an observation on 10/18/18 at 7:07 PM on the Parkwood and Parkwood Senior hall facility refrigerator had no snacks for the residents and the freezer was empty of any snacks for the residents. During an observation on 10/18/18 at 7:45 PM on the Rothwell and Rothwell Senior halls the facility refrigerator was empty of any snacks for the residents. 4. During an interview on 10/18/19 at 8:15 P.M. the Director of Nursing (DON) said: – Dietary provided HS snacks for the residents. – If a resident wanted a snack, he/she could obtain one at the nurses station. | |
F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview and record review the facility failed to properly store 2. Observation and interview during the initial kitchen tour on 10/16/18 at 10:55 A.M., |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265330 |
| (X3) DATE SURVEY COMPLETED | |||||||
NAME OF PROVIDER OF SUPPLIER NORTH VILLAGE PARK | STREET ADDRESS, CITY, STATE, ZIP 2041 SILVA LANE | |||||||||
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) | |
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F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 32) showed: – Certified Nurse Aide (CNA) M entered the kitchen with no facial net covering his beard and mustache. – DA B prepared and served food with no facial net covering his beard and mustache. – Activity Aide (AA) A in the food preparation area during meal prep and Cook B had hair exposed from underneath hair nets. 4. Observation on 10/18/18 at 7:30 P.M., of the snack room on the Meadowbrook unit showed numerous food items in the snack refrigerator not covered, dated or labeled. 5. During an interview on 10/19/18 at 4:43 P.M., the Dietary Manager (DM) said: – All food stored in refrigerators should be covered, dated and labeled. Staff should discard the food products after three days. – I was not acceptable to have dirty fans in the kitchen. The dirt particles on the fans could blow debris on foods. – All hair should be completely covered with hair and facial nets in the kitchen. | |
F 0923 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Have enough outside ventilation via a window or mechanical ventilation, or both. Based on observation and interview the facility failed to clean and maintain smoke room | |