| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 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 review, the facility failed to assure the notices provided | |
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) – Kills 22 different types of viruses, fungi and bacteria including E coli, Salmonella, S. Schottmelleri, Shigella dysenteriae and Staphylococcus which can cause gastroenteritis, food poisoning, diarrhea, nausea, cramps, and vomiting. – Reduces the hazards of cross-contamination from surfaces. – Fast, easy way to kill a wide variety of harmful microorganisms including germs that cause odors. 2. Review of Resident #32’s care plan with a revision date of 11/18/17, showed: – Activities of daily living (ADL) self-care deficit; – Assist of two staff for toileting; – Limited physical mobility; – Bladder incontinence; – Change brief when wet and PRN (as needed), establish voiding patterns, and provide perineal care after each incontinent episode. Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/21/18, showed: – A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made his/her own decisions; – Extensive assist of two or more staff for toileting; – Frequently incontinent of bladder; – Occasionally incontinent of bowel; – Diuretics (rids body of excess fluid which causes swelling and [MEDICAL CONDITION]) in last seven days; – Toileting program for bowel and bladder; – [DIAGNOSES REDACTED]. stroke). Review of the January, 2019 physician’s orders [REDACTED]. – [MEDICATION NAME] (a diuretic) 20 milligrams (mg) BID (twice daily). 3. Review of Resident #44’s quarterly MDS, dated [DATE], showed: – Short- and long-term memory problems; – Severe cognitive impairment, did not make own decisions; – Extensive assist of two or more staff for toileting and transfers; – Limited assist of two or more staff for bed mobility; – Always incontinent of bowel and bladder; – Physical and verbal behaviors directed towards staff daily; – [DIAGNOSES REDACTED]. Observation on all days of the survey, 1/14/19 through 1/17/19, showed: – A lingering, pungent smell of urine on the South hallway of the facility; – The urine smell was noticeable at the beginning of the hallway and increased in intensity toward the two residents’ rooms at the middle and end of the hallway; – The odor permiated from the mattresses of both resident’s beds; – Urine odor was noticeable in both Resident #32’s and Resident #44’s rooms. During an interview on 1/16/19, at 3:03 P.M., Certified Nurse’s Aide (CNA) A said: – He/she cleaned mattresses when he/she changed bed linen. – He/she did not know where the urine smell came from. During an interview on 1/16/19, at 3:10 P.M., CNA B said: – He/she did not know where the urine smell came from. – He/she said it could be from Resident #32’s room. – He/she used bleach wipes to clean the mattresses when he/she changed linen. During an interview on 1/16/19, at 3:15 P.M., Housekeeping Aide (HA) A said: – He/she did not know where the urine smell came from. |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) – He/she thought it might be from Resident #32’s or Resident #44’s rooms. – Resident rooms are deep cleaned only when a resident is discharged . – CNAs are responsible for wiping down the mattresses of the residents when they change the linen. – He/she cleaned mattresses with Pursue Disinfectant Cleaner by Amway during deep cleaning. – CNAs use bleach wipes to clean the mattresses. – He/she thought the urine odor might be coming from the carpet on the South hallway after a toilet overflowed and the carpet was not cleaned well. – He/she removed the mattress cover from Resident #32’s mattress and laundered the cover. During an interview on 1/16/19, at 6:03 P.M., the Director of Nursing said: – The urine smell probably came from Resident #44’s room; the resident was a moderate wetter. – CNAs reported the smell to her and she noticed the urine smell, but not sure where the smell came from. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) associated with identified problems; build on the resident’s strengths; identify the professional services that are responsible for each element of care; aid in preventing or reducing decline in the resident’s functional status and/or functional levels; enhance the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standards of practice for problem areas and conditions. – Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. – Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. – Care plan interventions are chosen only after careful data gathering, proper sequencing of events, and careful consideration of the relationship between the resident’s problem areas and their causes, and relevant clinical decision making. – Assessments of residents are ongoing and care plans are revised as information about the resident and the resident’s conditions change. – The IDT must review and update the care plan when there has been a significant change in the resident’s condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment, a federally mandated assessment instrument completed by facility staff. – The resident has the right to refuse to participate in the development of the care plan and medical treatments and such refusals will be documented in the resident’s clinical record. Review of the facility’s Using the Care Plan policy, dated August, 2006, showed: – The care plan shall be used in developing the resident’s daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. – Certified nurse’s aides (CNAs) are responsible for reporting to the nurse supervisor any change in the resident’s condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved. – Other facility staff noting a change in the resident’s condition must also report those changes to the Nurse Supervisor and/or MDS Coordinator. – Changes in the resident’s condition must be reported to the MDS Coordinator so that a review of the resident’s assessment and care plan can be made. – Documentation must be consistent with the resident’s care plan. 2. Review of Resident# 32’s care plan last revised on 11/18/17, showed: – Limited physical mobility; – Physical and occupational therapy (PT/OT) referrals as ordered, PRN (as needed); – Activities of daily living (ADL) self-care deficit; – Required assist of two staff for toileting; – Did not assess and care plan need for mechanical lift transfers. Review of the annual MDS, dated [DATE], showed: – A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made his/her own decisions; – Extensive assist of two or more staff for bed mobility, transfers, and toileting; – Not steady and only able to stabilize with staff assist for moving from seated to standing position, walking, moving on and off toilet, and surface to surface transfers (transfers between bed and chair or wheelchair); – No falls; – [DIAGNOSES REDACTED]. stroke). |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) Observation on 1/15/19, at 10:00 A.M., showed: – Two staff transferred the resident to his/her recliner with a mechanical lift. 3. Review of Resident #2’s annual MDS, dated [DATE], showed: – A BIMS score of 00 which indicated the resident could not complete the Brief Interview for Mental Status; – No change in mental status; – Inattention- behavior continuously present; – Disorganized thinking- behavior continuously present; – Altered level of consciousness- not present; – Delusions; – Extensive assist of one staff for bed mobility, transfers, and toileting; – Limited assist of one staff for walking in room and in corridor; – Limited assist of one staff for locomotion on and off unit; – Not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfers (transfers between bed and chair or wheelchair); – No impairment of the upper or lower extremities; – Walker; – Urinary catheter (a sterile tube inserted into the urinary bladder to drain urine); – Antipsychotic medications in last seven days; – [DIAGNOSES REDACTED]. Review of the care plan last revised on 1/16/19, showed: – ADL self-care deficit; – Will demonstrate appropriate use of walker to increase stability in ambulation; – (MONTH) use Sit to Stand (a mechanical lift in which the resident stands and holds to handle bars to transfer) lift when resident unable to pivot (turn) transfer; – Use mechanical lift (a lift that uses a body sling to lift and lower residents) PRN when resident refuses to stand; – Required assist by staff to move between surfaces; – The resident uses walker to maximize independence with transferring; – The resident required stand-by assist by staff to walk with walker and as necessary; – PT/OT referrals as ordered, PRN; – Moderate risk for falls related to confusion, gait/balance problems, incontinence, unaware of safety needs; – Will be free of falls and injury; – Impaired visual function; – Remind resident to wear glasses when up; – Did not assess, reassess, or care plan for the use of a gait belt for transfers; – Did not assess or reassess for the most appropriate type of transfer to prevent injury for the resident. Observation on 1/15/19, at 10:32 A.M., showed Certified Nurse Aide (CNA) C and CNA D did and said: – Assisted the resident out of the bathroom with a gait belt; the resident used his/her walker; – CNA C and CNA D held the gait belt with one hand; – The gait belt was loose around the resident’s waist and pulled up towards the resident’s upper back when lifted off the toilet and when standing; – The resident was very confused and attempted to sit in the wheelchair before he/she reached the wheelchair and almost fell ; |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) – The CNAs assisted him/her to sit in the wheelchair; – The resident wanted to go to bed and CNA C stood the resident with the walker; – The gait belt remained loose around the resident’s waist; – CNA D tightened the gait belt; – The resident could not stand up straight or pivot; – CNA C said today was not a good day for the resident; – CNA C said he/she had good days and bad days; – CNA C and CNA D sat the resident in the wheelchair and CNA C left the room to obtain the Sit-to-Stand lift; – Both CNAs applied the sling around the resident’s torso, attached the sling to the lift, locked the back casters (wheels), opened the legs to the widest width, raised the resident out of the wheelchair and placed the resident in bed; – CNA D said the gait belt should be snug around the resident’s waist and it was not until she tightened the belt. During an interview on 1/15/19, at 5:27 P.M., CNA C said: – Resident #2 was getting worse; he/she fights, kicks, and hits at staff; – Today staff were able to use the gait belt when he/she went to the bathroom; – The gait belt should not be tight but loose enough to get two fingers beneath the belt when transferring; – The belt was loose and CNA C’s belt had teeth that were not as sharp as some so the belt did not hold as snug as it should have; – He/she found out today that staff could use the Sit-to-Stand lift to transfer the resident; – The wheels of the Sit-to-Stand and the mechanical lifts should be locked when raising and lowering a resident; – The legs of the lifts should be opened fully during a transfer. 4. Review of Resident #15’s quarterly MDS, dated [DATE], showed: – A BIMS score of 15 which indicated he/she made his/her own decisions; – Extensive assist of two or more staff for transfers; – Resident did not walk in room or corridors; – [DIAGNOSES REDACTED]. Review of the January, 2019 physician’s orders [REDACTED]. – Ace wrap (elastic bandage to help reduce [MEDICAL CONDITION]) to the LLE, apply in the A.M. and remove in P.M. to decrease swelling; – Monitor ankle creases closely and skin folds BID (twice daily) for [MEDICAL CONDITION]; – Fluid restriction every shift for swelling, 2,000 milliliters per 24 hours; – Daily weights in the morning before meal in wheelchair, wheelchair weighs 44.8 pounds; – Heel protector to left foot at bedtime related to paralysis of left leg and foot; – Cleanse right buttock wound with wound cleanser, pat dry, apply skin prep around wound bed edges, apply foam dressing, and change every other day until healed and PRN until healed; – Cleanse open area in perineal area next to the buttocks with wound cleanser, apply foam dressing until healed daily; – Must lie down in bed for at least one hour in the A.M. and P.M. every day to reduce pressure to buttocks; – Weekly skin assessment. Review of the care plan last revised 12/16/18, showed: – No plan of care for 4+ (excessive fluid buildup in the lower extremity) [MEDICAL CONDITION] to the LLE; |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) – No plan of care for monitoring ankle skin creases and skin folds for [MEDICAL CONDITION]; – No plan of care for the potential wound formation in the ankle crease of the LLE related to previous open wound to the area; – No plan of care for elastic ace wrap to LLE to reduce [MEDICAL CONDITION], daily weights, and fluid restriction to prevent [MEDICAL CONDITION] and [MEDICAL CONDITION]; – No plan of care for wound care to open wounds to perineal area and right buttock; – No plan of care for weekly skin assessment or preventing pressure to the buttocks and perineal area. 5. During an interview on 1/16/19, at 3:30 P.M., the MDS/Care Plan Coordinator said: – She was new to the position; – She was going through all care plans now to update and would update the care plans quarterly and as needed; – Significant medication changes, changes in ADLs, falls, skin issues, and transfers should all be care planned; – PRN mechanical lift transfers should not be care planned; CNAs should tell licensed staff about a change in condition to determine type of transfer to be used for the resident; – PRN was used because residents have good days and bad days with transfers; – Wound care, treatments and areas of potential breakdown should be care planned. During an interview on 1/16/19, at 6:03 P.M., the Director of Nursing (DON) said: – Care plans should give a picture of the person; – Changes should be added PRN; – Care plans should be updated quarterly and PRN; – Care plans should include ADLs, wound and wound care, medications, activities, transfers, special diets, behaviors and anything else pertinent to a resident; – The previous MDS/Care Plan Coordinator did not update care plans as they should have been updated; – Care plans should be updated immediately if issues develop. | |
| F 0689 Level of harm – 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 7) (YEAR), showed: – In order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. – Residents safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. – Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents’ needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan and shall include resident preference for assistance, resident’s mobility (degree of dependency), resident’s size, weight bearing ability, cognitive status, whether the resident is usually cooperative with staff and the resident’s goals for rehabilitation, including restoring or maintaining functional abilities. – Staff responsible for direct resident care will be trained in the use of manual (gait belts and lateral boards) and mechanical lifting devices. – Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. – Only staff with documented training on the safe use and care of the machines and equipment used will be allowed to lift or move residents. – Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. – Mechanical lifts shall be made readily available and accessible to staff 24 hours a day; back up battery packs on remote chargers shall be provided as needed so that the lifts can be used 24 hours a day while batteries are being recharged. – Appropriate slings, in sizes required by residents in need will be available at all times. – Maintenance staff shall perform routing checks and maintenance of equipment used for lifting to ensure that it remains in good working order. – All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints. – Safe lifting and movement of residents is part of an overall facility employee health and safety program which involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies; addressed reports of work place injuries; provides training on safety, ergonomics (designing the workplace, keeping in mind the capabilities and limitations of the worker) and proper use of equipment; and continually evaluates the effectiveness of workplace safety and injury prevention strategies. Review of the facility’s Using a Mechanical Lifting Machine policy, dated July, (YEAR), showed: – The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer’s training or instruction. – At least two nursing assistants are needed to safely move a resident with a mechanical lift. – Mechanical lifts may be used for transferring a resident from bed to chair, lateral transfers, toileting/bathing or repositioning. – Types of lifts that may be available are floor-based, full body sling lifts and Sit-to-Stand lifts. |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 8) – Lift design and operation vary across manufacturers; staff must be trained and demonstrate competency using the specific machines or devices utilized by the facility. – Before using a lifting device, assess the resident’s current condition including: Can the resident assist with the transfer; is the resident’s weight and medical condition appropriate for the use of a lift; can the resident understand and follow instructions; does the resident express fear or appear anxious about the use of a lift; is the resident agitated, resistant, or combative? – Use the proper fitting sling for the resident. – Prepare the environment by provide an unobstructed path for the lift machine; ensure there is enough room to pivot; position the lift near the receiving surface and place the lift at the correct height. – Make sure the battery is charged. – Make sure the lift is stable and locked. – Make sure that all necessary equipment (slings, hooks, chains, staps and supports) is on hand and in good condition. – Make sure the sling size is not too large or too small for the resident. – Check the resident’s comfort level by asking or observing for signs of pinching or pulling of skin. – Lift the resident and gently support the resident as he/she is moved, but do not support any weight. – Slowly lower resident into receiving surface when reached. Review of the facility’s Use of a Gait Belt (GB) policy, dated December, (YEAR), showed: – It is the policy of the facility to use a gait belt for all residents in accordance with assessed needs, the care plan and standards of practice to provide optimal safety. – GBs are to be used for all transfers that require staff assistance and when assisting residents to ambulate. – The facility requires that each nursing staff member have a GB. – Staff will be trained in the use of GBs and will be observed for competency in correct use of a GB. – Thread the belt through the teeth side first, pull back through on the opening on the other side, and then secure the GB around the waist. – Give the belt a slight tug to ensure that it will not slip during the process of ambulating or transferring the resident. – Have the resident move to the edge of the bed or chair and place feet flat on the floor. – Support the weaker leg if necessary. – Utilize the safe transfer technique: Move with the resident, with staff knees bent and strong grasp under the GB on each side of the buckle; at no time should staff lift up on the area under the resident’s arms; at no time should the resident have their hands near the staff’s neck during a transfer. – Instruct the resident to place the back of his/her knees against the wheelchair/chair/bed and to use his/her hands or arms to lower him/herself into the seat. – Inform the charge nurse of any changes in the resident’s transfer or ambulation skills. – Nurses will report any changes in ability to ambulate and transfer to the restorative nurse. – Changes in condition will be discussed and changes made to ensure safe transfers. Review of the undated Apex Lift model 650HD battery operated patient lift owner’s manual showed: – Purchased, received date 11/24/08, by the facility, written by facility staff on front of manual. |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 9) – Special care must be taken with users/patients who cannot themselves provide assistance while being lifted. – During lowering or lifting, whenever possible, always keep the base (legs) of the lift in the widest position. – The base of the lift should be closed before moving the lift. – While being lifted in a sling, always keep the user/patient centered over the base and facing the caregiver operating the lift. – Maximum weight that can be safely lifted is 600 pounds. – Select an Apex Lift sling that is both practical and comfortable. The sling selected should be one that serves the needs of the patient, while providing the patient with optimal safety. – Replace any worn parts with only [MEDICATION NAME] Apex Lift parts. – Apex Lift parts are not interchangeable with parts from other patient lift brands. – Using other patient lift parts on Apex Lift products is unsafe and may result in serious injury to user and caregiver. – Service and repair of the Apex Lift equipment should be performed only by Apex Dynamics Healthcare Products [MI]L.C. and is not responsible for any consequences resulting from any unauthorized service or repair. – Keep lifter base widened and brakes locked during lifting. Review of the undated Apex Lift model 450 E battery operated patient lift owner’s manual showed: – Delivered 1/28/09, written on manual by facility staff. – Special care must be taken with users/patients who cannot themselves provide assistance while being lifted. – Should be used solely for transferring a patient and not for transporting a patient from one location to another. – During lifting and lowering, whenever possible, always keep the base of the lift in the widest position. – While being lifted in a sling, always keep the user/patient centered over the base and facing the caregiver operating the lift. – Maximum weight that can be lifted safely is 400 pounds. – Select an Apex Lift sling that is both practical and comfortable. The sling selected should be one that serves the needs of the patient, while providing the patient with optimal safety. – Replace any worn parts with only [MEDICATION NAME] Apex Lift parts. – Apex Lift parts are not interchangeable with parts from other patient lift brands. – Using other patient lift parts on Apex Lift products is unsafe and may result in serious injury to user and caregiver. – Service and repair of the Apex Lift equipment should be performed only by Apex Dynamics Healthcare Products [MI]L.C. or an authorized dealer and is not responsible for any consequences resulting from any unauthorized service or repair. Review of the undated Medline battery operated Sit-to-Stand patient lift owner’s manual showed: – No purchase or delivery date recorded by facility staff. – Replace any worn parts only with [MEDICATION NAME] Medline Lift parts. Medline Lift parts are not interchangeable with parts from other patient lift brands. Using other patient lift parts on Medlin Lift products is unsafe and may result in serious injury to patient and caregiver. – Service or repair of Medline Lift equipment should be performed only by Medline or 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 10) authorized dealer. – Operating instructions: Position the base of the lift around or under the object; widen the base and engage the caster brakes. 2. Review of Resident# 32’s care plan last revised on 11/18/17, showed: – Limited physical mobility; – Physical and occupational therapy (PT/OT) referrals as ordered, PRN (as needed); – Activities of daily living (ADL) self-care deficit; – Required assist of two staff for toileting; – Did not assess and care plan the need for mechanical lift transfers. Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/21/18, showed: – A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made his/her own decisions; – Extensive assist of two or more staff for bed mobility, transfers, and toileting; – Not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off toilet, and for surface to surface transfers, transfer between bed and chair or wheelchair; – Weight: 332 pounds; – No falls; – Pain constantly; – [DIAGNOSES REDACTED]. stroke). Observation on 1/15/19, at 10:00 A.M., showed: – Certified Nurse’s Aide (CNA) A and CNA E transferred the resident to his/her recliner with a mechanical lift; – Used the Apex Lift Model 650 HD; – The Apex Lift had been modified by an unknown staff when they removed the electrical, battery pack equipment from the lift and installed a three ton long ram double piston jack and a handle to manually work the lift; – Attached the sling to the lift; – Did not open the lift to the widest position beneath the resident’s bed and then locked the back caster brakes; – CNA E used the hand crank of the lift with some difficulty and lifted the resident off the bed; – Unlocked the back caster brakes, rolled the lift from beneath the bed, opened the legs of the lift with difficulty; CNA E worked the lift; CNA A stepped away from the resident to move a table; – The resident swung in the air and complained of the sling hurting him/her; – CNA A moved a table, then grabbed the sling to guide the resident over the resident’s chair as CNA E moved the lift around the resident’s chair with legs open; – CNA E lowered the resident into the chair and CNA A guided the resident as he/she was lowered; – The resident said he/she wanted to use the Sit-to-Stand lift for transfers and did not know why staff had to use the mechanical lift; the sling hurt his/her legs every time they transferred him/her. During an interview on 1/16/19, at 3:10 P.M., CNA A said: – The legs of the lift should be open during a transfer; – The back caster brakes should be locked; – The resident should be supported/guided during transfer. 3. Review of Resident #2’s annual MDS, dated [DATE], 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 11) – A BIMS score of 00 which indicated the resident could not complete the Brief Interview for Mental Status; – No change in mental status; – Inattention- behavior continuously present; – Disorganized thinking- behavior continuously present; – Altered level of consciousness- not present; – Delusions; – Extensive assist of one staff for bed mobility, transfers, and toileting; – Limited assist of one staff for walking in room and in corridor; – Limited assist of one staff for locomotion on and off unit; – Not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfers (transfers between bed and chair or wheelchair); – No impairment of the upper or lower extremities; – Walker; – Urinary catheter (a sterile tube inserted into the urinary bladder to drain urine); – Antipsychotic medications in last seven days; – [DIAGNOSES REDACTED]. Review of the care plan last revised on 1/16/19, showed: – ADL self-care deficit; – Will demonstrate appropriate use of walker to increase stability in ambulation – (MONTH) use Sit to Stand (a mechanical lift in which the resident stands and holds to handle bars to transfer) lift when resident unable to pivot (turn) transfer; – Use mechanical lift (a lift that uses a body sling to lift and lower residents) PRN when resident refuses to stand; – Required assist by staff to move between surfaces; – The resident uses walker to maximize independence with transferring; – The resident required stand-by assist by staff to walk with walker and as necessary; – PT/OT referrals as ordered, PRN; – Moderate risk for falls related to confusion, gait/balance problems, incontinence, unaware of safety needs; – Will be free of falls and injury; – Impaired visual function; – Remind resident to wear glasses when up; – Did not assess, reassess, or care plan for the use of a gait belt for transfers; – Did not assess or reassess for the most appropriate type of transfer to prevent injury for the resident. Observation on 1/15/19, at 10:32 A.M., showed Certified Nurse’s Aide (CNA) C and CNA D did and said: – Assisted the resident out of the bathroom with a gait belt and the resident used his/her walker; – CNA C and CNA D held the gait belt with one hand on each side of the belt; – The gait belt was loose around the resident’s waist and pulled up towards the resident’s upper back when lifted off the toilet and when standing; – The resident was very confused and attempted to sit in the wheelchair before he/she reached the wheelchair and almost fell ; – The CNAs assisted him/her to sit in the wheelchair; – The resident wanted to go to bed and CNA C stood the resident with the walker; – The gait belt remained loose around the resident’s waist; |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 12) – CNA D tightened the gait belt; – The resident could not stand up straight or pivot; – CNA C said today was not a good day for the resident; – CNA C said he/she had good days and bad days; – CNA C and CNA D sat the resident in the wheelchair and CNA C left the room to obtain the Sit-to-Stand lift; – The battery operated Medline Sit-to-Stand Lift had been modified by unknown staff when when someone removed the electrical, battery pack equipment from the lift and installed a three ton long ram double piston jack and a handle to manually work the lift; – Both CNAs applied the sling around the resident’s torso, attached the sling to the lift, locked the back casters (wheels), opened the legs to the widest width, raised the resident out of the wheelchair and placed the resident in bed; – CNA D said the gait belt should be snug around the resident’s waist and it was not until she tightened the belt; – Both CNAs said they notified nursing staff when the resident did not transfer well with a GB. During an interview on 1/15/19, at 5:27 P.M., CNA C said: – Resident #2 was getting worse; he/she fights, kicks, and hits at staff. – Today, staff were able to use the gait belt when he/she went to the bathroom. – The gait belt should not be tight but loose enough to get two fingers beneath the belt when transferring. – The belt was loose and CNA C’s belt had teeth that were not as sharp as some so the belt did not hold as snug as it should have. – He/she found out today that staff could use the Sit-to-Stand lift to transfer the resident. – The wheels of the Sit-to-Stand and the mechanical lifts should be locked when raising and lowering a resident. – The legs of the lifts should be opened fully during a transfer. 4. During an interview on 1/16/19, at 4:18 P.M., the Director of Nursing (DON) said: – Only Resident #32 used the mechanical lift and Resident #2 used the Sit-to-Stand lift. – The modified lifts could be unsafe to use. – She knew the lifts were modified from battery powered to manual lifts, but did not know when or who modified them. – The legs of the mechanical lifts do not work properly, the legs will not engage and lock in place when staff open them. – Legs of the lift should be opened fully when under the bed. – Staff should not lock the back caster brakes. During an interview on 1/16/19, at 4:18 P.M., Certified Occupational Therapy Assistant (COTA) A said: – Resident #32 cannot use the Sit-to-Stand lift because he/she was unsafe to stand and hold on to the lift properly. – The resident would only use two fingers to hold onto the handle bar when staff stood him/her with the lift. – COTA A did not know facility staff had modified the Sit-to-Stand lift or the mechanical lifts. – COTA A said they could be unsafe to use. During an interview on 1/16/19, at 4:30 P.M., the Assistant Administrator (AA) said: – The lifts were modified about [AGE] years ago because the batteries kept dying and staff did not plug in the lifts to recharge the batteries. |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 13) Observation on 1/16/19, at 6:00 P.M., showed: – Staff brought up a second battery operated Apex Lift, model 450 E, kept in the basement of the facility. – Staff had previously modified the Apex Lift when they removed the electrical, battery pack equipment from the lift and installed a three ton long ram double piston jack and a handle to manually work the lift. – The AA removed the two Apex Lifts from the building but the Medline Sit-to-Stand Lift remained in the facility. During an interview on 1/16/19, at 6:03 P.M., the DON said: – Staff told her today Resident #2 did not transfer well with the gait belt. – Gait belts should always be snug around the resident’s waist during a gait belt transfer. – CNAs should report changes in condition of any resident and the nurse should evaluate to determine the type transfer to perform. – Care plans should not indicate to use a lift PRN. Observation on 1/16/19 at 6:10 P.M. showed: – The maintenance supervisor brought in with the new mechanical lift from a local pharmacy. – The MS did not obtain a new Sit-to Stand lift. | |
| F 0865 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Have a plan that describes the process for conducting QAPI and QAA activities. **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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0865 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 14) QAPI Program. – The Administrator is responsible for assuring that the facility’s QAPI Program complies with Federal, State, and local regulatory agency requirements. – The QAPI Committee shall oversee implementation of the QAPI plan. A QAPI Coordinator shall coordinate QAPI Committee activities, including documentation. – The committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. – The QAPI Committee shall oversee and authorize QAPI activities, including data collection tools, monitoring tools, and the basis for and appropriateness and effectiveness of QAPI activities. – The committee shall approve any corrective actions, including changes in policies and/or procedures, employment practices, standards of care, etc., and shall also monitor all corrective activities for appropriateness and/or the need for alternative measures. – The committee may recommend ways to reinforce and expand identified positive approaches and outcomes to various departments of service. – Individual departments or services shall develop quality indicators for programs and services in which they are involved and which affect their function. – Information regarding QAPI activities is confidential and may be disclosed only in accordance with applicable laws and regulations. – Departments, services, and committees shall submit their reports to the QAPI Committee as directed by the committee. – The facility shall evaluate the effectiveness of its QAPI Program at least annually and shall present their conclusions to the owner/governing board for review. – The QAPI Committee, Administrator, and the governing board shall review and approve a summary of problems and corrective measures. – The QAPI Coordinator shall attend and/or review minutes of meetings of other committees or departments as needed. – The QAPI Coordinator will help other committees, individuals, departments, and/or services develop quality indicators, monitoring tools, criteria, and assessment methodologies, and help them identify and evaluate concerns impacting resident care and safety. – The QAPI Coordinator will act as a liaison among committees, individuals, services, and/or departments regarding QAPI activities. Review of the Quality Assurance and Performance Improvement (QAPI) Program, dated April, 2014, showed: – The facility shall develop, implement, and maintain an ongoing, facility-wide QAPI program that builds on QAA Program to actively pursue quality of care and quality of life goals. – The primary purpose of the QAPI Program is to establish data driven, facility wide processes that improve the quality of care, quality of life and clinical outcomes of the residents. – The QAPI Program has been developed with five strategic elements. – Design and scope: The program is ongoing and comprehensive; it involves the full range of services and departments in the facility; it covers all systems of care and management practices, with priority given to quality care, quality of life and resident choice; goals, targets and benchmarks are established and measured based on the best available evidence. – Governance and leadership: Input is sought from facility staff, residents, family members and individuals who are involved in the care of residents; resources are allocated |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0865 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 15) to conduct QAPI efforts; members of the facility leadership are accountable for QAPI efforts; staff are trained in QAPI systems and culture; staff are encouraged to identify and report quality concerns as well as opportunities for improvement. – Feedback, data systems, and monitoring: Systems are in place to monitor care and services; systems are designed to incorporate feedback from caregivers, residents, family and staff as appropriate. – Care processes and outcomes are monitored using performance indicators, these performance indicators are measured against quality benchmarks and targets that the facility has established; adverse events are tracked, monitored, and investigated as they occur; action plans are implemented to prevent recurrence of adverse events. – Performance improvement projects: Performance improvement projects (PIPs) are initiated when problems are identified; PIPs involve systematically gathering information to clarify issues and to intervene for improvements. – Systematic analysis and systematic action: Root Cause Analysis (RCA) is used to determine whether identified issues are exacerbated by the way care and services are organized or delivered, and if so, how; RCA serves as a highly structured approach to fully understanding the nature of an identified problem, its cause and the implications of making changes to improve the problem. -The following steps are employed or will be employed to support and enhance the facility QAPI Program. – Establishing a QAPI Committee/sub-committee that works in [MEDICATION NAME] with the facility leadership and the QA&A Committee. – Allocating resources for QAPI initiatives. – Providing staff, family members, and residents with information about the QAPI Program and inviting them to meet with the QAPI leadership. – Providing concrete channels of communication between staff, residents, family members, and leadership. – Establishing a zero tolerance policy for retaliation against individuals who appropriately report or communicate quality concerns. – Creating task oriented or goal oriented teams for QAPI; establishing a clear purpose for each team; defining specific roles for each team member. – Utilizing established QAPI self-assessment tools to initiate and then periodically re-evaluate the QAPI program. – Identifying this facility’s Guiding Principles and the using them to guide decision making and set priorities. – Establishing a QAPI Pan that guides quality efforts and serves as the main document that supports the QAPI implementation. – Communicating the QAPI Plan and principles to all caregivers, including consultants, contractors, and business associates. – Communicating the QAPI Plan and principles to residents and families, and encouraging their participation in the systems. – Providing frequent leadership and staff training on the QAPI Plan and its underlying principles, including the concept that systems of care and business practices must support quality care or be changed. – Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include: Clinical outcomes of pressure ulcers, infections, medication use, pain, falls, etc.; complaints from residents and families; re-hospitalization s; staff turnover and assignments; staff satisfaction; care plans; state surveys and deficiencies; and Minimum Data Set (MDS, a federally mandated assessment |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0865 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 16) instrument completed by facility staff) assessment data. – Setting measurable goals for improvement that may include percentage of reductions or increases from the measured baseline of a particular goal. – Identifying benchmarks of performance and comparing facility data with national and state performance benchmarks. – Recognizing patterns in systems of care that can be associated with quality problems. – Prioritizing identified quality issues based on risk of harm and frequency of occurrence, and determining which will become the focus of PIPs. – Planning, conducting, and documenting PIPs. – Conducting Root Cause Analysis to identify the underlying issues that contribute to recognized problems. – Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing. Review of the facility’s last survey process for the (YEAR)-2018 fiscal year showed a survey with an exit date of 4/20/18. The revisit for the annual survey was conducted on 6/12/18, and the facility was found in substantial compliance for a deficiency regarding their QAPI Plan at that time. During an interview on 1/15/19, at 4:18 P.M., the Owner/Administrator did and said: – She was cleared as having a QAPI Plan in August, (YEAR), after a citation was issued for not having the QAPI Plan in place during the annual survey dated 4/20/18. – She said a QAPI meeting was not held in June, (YEAR), but planned a meeting in August, (YEAR). – The meeting in (MONTH) was not held. – She held a meeting in early October, (YEAR) and late December, (YEAR) but only three people attended. – The Medical Director could not attend as she was too busy. – The Medical Director has too much to do to attend and therefore she does not set a meeting time. – Staff are too busy to attend a meeting as they have had problems retaining staff. – She did not have any documentation of what issues were discussed in the (MONTH) and December, (YEAR) meetings. – She did not have any documentation to show who attended the meetings in (MONTH) and December, (YEAR). – She knew the QAPI meeting needed to be held and discuss issues but there just was not enough time or staff to have the meeting. – She knew there should be at least five attendees at the meetings to include the Administrator (herself), the Medical Director, the DON, and two other staff. – She did not say residents or families would be invited as noted in the QAPI Plan. During an interview on 1/16/19, at 6:03 P.M., the Director of Nursing (DON) said: – She was aware a QAPI meeting needed to be held quarterly. – Problems and objections should be discussed at the meeting and a follow up meeting should take place to discuss outcomes of the issues. – There should be a list of attendees of each meeting. – She had spoken with the Medical Director about some issues, but had not documentation of the issues, monitoring, or conclusions related to the issues. – No meetings were scheduled so the Medical Director could attend. – She thought the Medical Director would attend if given prior notice. |
| 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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0865 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | ||
| F 0881 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Implement a program that monitors antibiotic use. **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: 265796 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEARL’S II EDEN FOR ELDERS | STREET ADDRESS, CITY, STATE, ZIP 611 NORTH COLLEGE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0881 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 18) continuation or change in antibiotics. – The physician/provider will evaluate for the duration of antibiotics, discontinuance of the antibiotic, and identify and address possible complications resulting from the antibiotic treatment. During antibiotic stewardship record review and interview with the Director of Nurses (DON) on 1/16/19, at 6:03 P.M., the DON said: – The facility had an Antibiotic Stewardship policy and program, but they did not have a monitoring system in place. – She provided Daily Administrative Report sheets, dated 12/31/18 through 1/16/19, that showed residents who have infections, urinary tract infections (UTIs) and new antibiotics. – The sheets showed five residents who had infections and were prescribed antibiotics. – When asked how many residents were on antibiotics, she did not know without counting the residents written on each report sheet. – The sheet only showed the resident name, type infection, and name of medication the resident took. – She did not follow up, monitor, or record any information related to the infection, progression, or outcome after treatment and resolving of the infection. | |
| F 0921 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
