| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) housekeepers should use dust mops to get at the cobwebs and the dust area that are not usually seen in the resident rooms. 4. Observation with the Housekeeping Supervisor on 1/8/19 at 11:31 A.M., showed a 4 inch (in.) rip in the fall mat in resident room [ROOM NUMBER], which rendered it not easily cleanable. During an interview on 1/8/19 at 11:35 A.M., Certified Medication Technician (CMT) A said he/she did not know about that rip in the fall mat in resident room [ROOM NUMBER]. 5. Observation with the Housekeeping Supervisor on 1/8/19 at 11:08 A.M., showed a 3 in. gouge and a 4 in. gouge in the shower tub in the shower room close to the 200 Hall. During an interview on 1/8/19 at 11:33 A.M., Certified Nurse’s Assistant (CNA) B said the chair portion of the lift scraped against the tub which caused the gouges and areas that were not easily cleanable. 6. Record review of the Resident #15’s quarterly Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by facility staff for care planning) dated 10/10/18, showed he/she was able to understand others and make self-understood and had Brief Interview for Mental Status (BIMS) of 14. During an Interview on 1/8/19 at 8:55 A.M., the resident said: – The linens were not change in timely and properly and the bed remained wet even after the sheet were changed; – License Practical Nurses (LPN) D checked the resident after the resident used the call light and CNA E came in to change the sheets, and did not wipe the bed down and – The bed was still wet. During an interview on 1/9/19 at 5:00 A.M., CNA E said: -The LPN D checked on the resident and the resident sheets were changed, and he/she wiped the resident’s mattress; – After about 30 minutes the resident used the call light again and the resident said the bed was soaked again after the CNA E asked the resident what was the matter; – He/she saw that the mattress was damaged with cracks and the liquid had soaked into the mattress and – The resident needed a new mattress, During an interview on 1/9/18 at 6:15 A.M., LPN D said: -The resident’s sheets had sweat stains on them, when he/she was in the room and – He/she was not aware of the juice had been spilled in the resident bed, or there was a wet bed issue. Observations on 1/10/19 at 2:01 showed an 8 inch diameter area of the mattress where the mattress cover was worn away and the presence of a 1 in. tear towards the foot end of the mattress. During interviews on 1/10/19 at 2:02 P.M., LPN A and CNA A said the following after observing the damaged mattress: -CNA A said that mattress has been used by Resident #15 since before Thanksgiving and he/she has noticed the worn area and – LPN A said he/she did not know that Resident #15’s mattress was damaged. During an interview on 1/11/19 at 10:55 A.M., the Maintenance Supervisor said they changed the mattress in room [ROOM NUMBER], and before yesterday (1/10/19) he/she had not heard about the mattress being damaged. Complaint MO 114 |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | ||
| F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) toileting and -Had limited range of motion in both upper and lower extremities. Record review of the resident’s Medical Record showed the following hospitalization s: -From 12/21/18-12/27/18 for chronic urinary tract infection, inflammation of the rectum and elevated blood nitrogen levels; -From 12/3/18 -12/5/18 for nausea, vomiting recurrent urinary tract infection. -On 10/28/18 for abdominal pain and -From 10/10/18 -10/16/18 due to pneumonia and complicated urinary tract infection. Record review of the resident’s Medical Record showed there was no documentation the resident or the resident’s responsible party was informed of the resident’s discharge to the hospital or anticipated return to the facility. 3. Record review of Resident #181’s Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident’s quarterly MDS dated [DATE], showed he/she: -Had memory problems and -Needed extensive assistance with bathing, grooming, dressing, mobility, and toileting. Record review of the resident’s Medical Record showed he/she was hospitalized from [DATE] to 11/10/18 and from 12/27/15 to 1/5/19. There was no documentation showing the facility had notified the resident or his/her responsible party of the reasons for his/her hospitalization or information regarding his/her rights to return to the facility. 4. During an interview on 1/11/19 at 10:34 A.M., the Director of Nursing (DON) said: -He/she did not know the facility was required to give the resident or the resident’s representative a letter with the reasons for the discharge or transfer to a different facility and -He/she knew that a discharge letter had not been given to resident or the resident’s representative. | |
| F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| 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 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) -The resident was cognitively intact; -He/she required supervision only in Activities of Daily Living (ADL’s) and -He/she received [MEDICAL TREATMENT] treatment for [REDACTED]. Record review of the resident’s MDS assessments showed the resident had been discharged with return anticipated on the following dates: -May 1, (YEAR); -June 16, (YEAR); -August 6, (YEAR) and -November 11, (YEAR). During an interview on 1/11/19 at 9:30 A.M., Licensed Practical Nurse (LPN) B said: -He/she did a computer discharge summary for the hospital and -He/she did not give a bed hold letter to a resident or the resident’s representative. During an interview on 1/11/19 at 9:35 A.M. , LPN A said: -He/she did not give a bed hold policy letter to residents at discharge and -He she did not know what a bed hold policy letter was. During an interview on 1/11/19 at 10:00 A.M., the Social Service Designee (SSD) said: -The bed hold policy was reviewed at admissions with the resident and representatives and -He/she did not send out a copy of the bed hold policy when a resident was discharged or transferred. During an interview on 1/11/19 at 10:34 A.M., the Director of Nursing (DON) said: -He/she was not aware the facility needed to give the resident or the resident’s representative a copy of the facility’s bed hold policy at discharge or transfer and -He/she knew a copy of the bed hold policy was not provided to the resident or the resident’s representative(s). | |
| F 0675 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor each resident’s preferences, choices, values and beliefs. **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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| 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 0675 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) Record review of the resident Care Plan dated 1/2/19 showed: -Staff are to assist the resident with all Activity of Daily Living (ADL’s) as needed; -Inadequate nutritional intake-gastric tube for nutritional support; –Head of bed evaluated; –Observe for signs and symptoms of worsening condition and notify the resident’s physician of changes and –Provide opportunity and encourage resident to attend activities and other social events per his/her preference. Record review of the resident’s Entry Tracking Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/1/19 showed: -No documentation related to the resident’s daily preferences and -Was admitted to the facility on [DATE]. Record review of the resident’s progress notes dated from 1/1/19 to 1/9/19 showed no documentation from social services related to the admission and related to preferences of wanting to get dressed in the mornings or wearing a hospital gown all day. Record review of the resident’s medical record showed his/her inventory sheet listed one pair of jeans, one T-shirt and a pair of shoes. During an interview and observation on 1/7/19 at 8:01 A.M., showed: -The resident was in his/her bed with a hospital gown on with no sheets during the interview; -Had not been up in his/her wheel chair as much; -Had not felt like getting out of bed, care staff had been repositioning the resident and -His/her catheter bag was covered hanging off the side of the bed. Observation and interview on 1/7/19 at 11:40 A.M. showed: -The resident lying in bed with the head of the bed elevated; -Had contractures of his/her hands and had a specialized call light system that you blow into for assistance; -Had a Low air lost mattress on his/her bed; -Had a catheter and the catheter drainage bag was covered in low position on the side bed rail; -Had a tracheotomy in place and had a suction machine at the bed side for use as needed; -Had oxygen in place per an oxygen concentrator; -Denied any concerns with staff not providing care as needed; -No odors noted in the resident’s room and -The resident was wearing a hospital gown. Observation on 1/8/19 at 1:25 P.M. showed the resident after his/her shower: -Certified Nurse Assistant (CNA) F had redressed the resident into a clean hospital gown; -The care staff did not offer or ask the resident about getting dressed in regular clothes and -The resident had contractures to both his/her arms and hands. During an interview on 1/8/19 at 2:00 P.M., the Director of Nursing (DON) and CNA F said: -The resident prefer to wear a hospital gown; -He/she does not have any other clothes at the facility, except for the jeans that the resident likes; -The DON said was easier for the resident to have gown on because of all the tubes and appliance the resident had and the resident did not have any other clothes at the facility; -The resident’s spouse had not brought back any other clothes for the resident and -The resident got hot easily and didn’t like to have a blanket on. |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| 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 0675 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) Observation on 1/9/18 at 12:15 P.M., showed the resident: -Had been placed in his/her wheelchair and was sitting in the bistro dining area; -Other residents were eating lunch and the television was on and -Had a hospital a gown on and had a sheet covering his/her legs. During an interview on 1/11/19 at 9:30 A.M., the resident said: -He/she would like to be able to have regular clothes on during the day time, and had not been offered thee choice of what to wear except for the hospital gown; -When the resident lived at home, he/she would get dressed in regular clothes daily and -The jeans in the closet did not fit right, related to his/her ostomy and catheter, had complained of discomfort when he/she had worn them. Observation on 1/11/19 at 9:33 A.M. of the resident’s closet showed one pair of jeans, one T-shirt and one pair of shoes. During an interview on 1/11/19 9:40 A.M., Social Service Designee (SSD) said: -He/she was not aware the resident did not have clothes or that resident wish to get dressed daily; -Upon admission the staff completed the inventory sheet and he/she completed the social service assessment, which include daily routines and preferences; -If a resident is admitted with no clothes he/she would ask the resident’s family first to provide clothing; -Then he/she would reach out to local groups to assist and the facility does have a fund to be able to get clothes for the residents; -The family thought the resident was only going to be at the facility temporarily and but now the facility will be the resident’s home; -He/she will reach out to the resident’s family for clothes and -Nursing staff or the housekeeping staff will let him/her know if a resident’s clothes are worn out, too big or too small, then he/she will follow-up. | |
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide activities to meet all resident’s needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) In planning activities, the staff should consider: -Resident choice and abilities -Plans to encourage residents to attend, or to promote activities -Assistance for residents to get to activities. -Means to record participation and resident response to activities. 1. Record review of Resident #37’s Face Sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident’s quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 11/28/18, showed the resident: -Was alert and oriented with communication deficits; -Needed total assistance of two staff members for bathing, dressing, mobility, and toileting and -Had limited range of motion in both upper and lower extremities. Record review of the resident’s Care Plan dated 12/31/18, showed the resident’s activity care plan identified the resident liked visiting with residents, staff, family and peers, computer access, religious activities, going outside, watching television and musical activities. The care plan did not show any measurable goals for activities for the resident (to include frequency of attendance) and did not show that the facility provided any one to one activities with the resident. Record review of the resident’s Group Activity Participation Record dated (MONTH) 2019, showed: -The resident refused to participate in from two to four activities daily; -Everyday the resident participated in an independent activity; -On 1/7/19 it showed the resident chose not to attend social programs and physical programs; -On 1/8/19 it showed the resident refused intellectual programs, religious programs and social programs; -On 1/9/18 it showed the resident refuse to participate in social programs; -On 1/10/19 it showed the resident refused to participate in diversional programs, social programs and physical programs and -There was no documentation on 1/11/19. Record review of the facility’s Activity Calendar showed: -On 1/7/19 showed activities for the day were 9:30 A.M. Unit Reminiscing; 10:30 A.M. Sittersize; 11:00 A.M. Rob the table and 2:30 P.M. Bingo. There were no scheduled activities after 2:30 P.M; -On 1/8/19 showed the activities for the day were 9:30 A.M. Unit Music; 10:30 A.M. Bible Study; 1:30 P.M. Riddle Me This and 2:30 P.M. Music with a scheduled musician. There were no scheduled activities after 2:30 P.M; -On 1/9/19 showed the activities for the day were 9:30 A.M. Unit Volleyball; 10:30 A.M. Life Stories; 1:30 P.M. Dominoes and 2:30 P.M. Bingo; -On 1/10/18 showed the activities for the day were 9:30 A.M. Unit Reading; 10:30 A.M. Warm Up; 10:45 A.M. Noodle Wars; 1:30 P.M. Crafts and 2:30 P.M. Billy Winds; – On 1/11/18 showed the activities for the day were 9:30 A.M. Unit Crafts, 10:30 A.M. Pass the Pigs; 1:30 P.M., Bistro Board Game and 2:30 P.M. Happy Hour; -Record review of the Activity Calendar showed the latest daily activity for the week began at 2:30 PM. There were no activities scheduled after 2:30 PM from 1/7/19 to 1/11/18. Observations from 1/7/19 to 1/9/19, showed the resident stayed in his/her bed during the day. Nursing staff did not get the resident up out of bed into his/her wheelchair during |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) the day shift (7:00 A.M. to 3:00 P.M.) or the night shift (11:00 P.M. to 7:00 A.M.). There were no observations of the resident participating in scheduled activities. The resident was observed to watch television during the day while in bed. Observation at 1/10/18 at 5:30 P.M., showed the resident was up in his/her specialized wheelchair in the television room watching television with other residents. There was no structured activity at this time. At 6:00 P.M., nursing staff took the resident back to his/her room. During an interview on 1/9/19 at 5:30 A.M., Certified Nursing Assistant (CNA) Q said they normally do not get the resident up on the night shift. The resident usually is in bed for most of the day, but staff will get the resident up in the evening (around 4:00 P.M.-5:00 P.M.), at the resident’s request, and the resident usually stays up late into the evening. He/she did not know if the resident received activities during the day while he/she was in his/her room. During an interview on 1/11/19 at 9:49 A.M., the Activity Director said: -He/she writes the activity care plan and he/she was new to the process and was still learning to write them; -He/she provided one to one activities to the residents who were total care and do not/can not come to group activities; -He/she documents the activity participation sheets to show the activities he/she does individually with residents; -He/she tries to provide one to one activities twice weekly; -He/she will complete the last activity of the day at 2:30 PM and that will last longer than some of the other activities, but he/she leaves at 5:00 P.M. unless he/she is going to do an evening activity then he/she will stay later; -He/she does not schedule an evening activity daily, maybe twice monthly; -He/she does not complete an evening activity schedule for the nursing staff to initiate for the residents; -He/she was the only person who initiates activities; -He/she had not gotten around to providing one to one activities with some of the residents this week; -He/she had not provided activities with the resident this week; – The resident did not get up during the day and usually staff got him/her up in the evening; – The resident watched television during the day and when he/she was up in the evening, he/she liked to get on his/her computer; -He/she provided one to one activities to the resident because he/she needed total assistance and he/she did not usually get up during the day (when scheduled activities are provided); -Normally when he/she goes to provide one to one activities to the resident he/she will talk to him/her; -He/she made a mistake on the resident’s activity documentation and had written that he/she provided one to one activities to him/her this week and that was not correct. 2. Record review of Resident #3’s Admission Face Sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. direct airway through an incision in the trachea), Flaccid neuropathic bladder (caused by neurological damage that can cause incontinence, [MEDICAL CONDITION], frequency and urgency), [MEDICAL CONDITION] (paralysis caused by an injury or illness that results in the partial or total loss of use of all four limbs and torso), [MEDICAL CONDITION] (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) part of the colon); -Came in with an indwelling catheter ( a tube inserted into the bladder to drain the urine) and had contractures (a muscle or tendon that is shortened or tightened to the point that it can’t stretch normally). Record review of the resident Care Plan dated 1/2/19 showed: -Staff are to assist the resident with all Activity of Daily Living (ADL’s) as needed and -Provide opportunity and to encourage the resident to attend activities and other social events per his/her preference Record review of the resident’s Entry Tracking MDS, dated [DATE] showed he/she was admitted to the facility in 1/1/19 and the staff did not document the resident’s preferences. Record review of the resident’s Activity Documentation showed: -October (YEAR) choose not to attend most group activity and under independent activity had social contact; –At the top of the page the staff wrote the resident talks to his/her spouse daily and sits in the bristo, top page hand written talks to wife daily sit in bistro; -November (YEAR) choose not to attend most group activity and under independent activity had social contact and television; –top page hand written talks to wife daily sit in bistro and -Was admitted to hospital from 11/25/18 to 12/31/18. Record review of the resident’s Activity Admission Review dated 1/1/19 showed: -Had a [DIAGNOSES REDACTED]. -Able to make self-understood and understand others clear comprehension; -Had unclear speech, no difficulty seeing; -Preference and customary routine include passive activity sitting outdoors, movies and television; -Other observation details had; talks to wife daily, sits in bistro and watches Television and -No other documentation found related to specialty activity plan or assessment for resident with limitation. During an interview on 1/11/19 at 9:15 A.M., Activity Director said: -The resident’s like to watch Television, talks to wife on the phone daily and goes to Bistro sometime; -Activity staff try to provide one on one with the resident at least 1-2 times a week; -Was not sure if the resident care plan included one-one activity with the resident; -On the facility monthly activity calendar are the days marked for 1-1 visit or room visit; -During those room visit would provide information about the current news, read to them, nail care, lotion and massage of arms and hands provide during one on one; -He/she said at this time does not currently have any special activity for resident that are bed bound or that require special equipment, such as resident with limited use of hands; -Activity staff had not provided or inquired about the resident’s past interest or occupation for possible ideas for initialized type activities for the resident; -Had not reach out to occupation therapy or speech therapy for resources for resident with limitation; -Had been working on putting in place a sensory box for use with the residents and -He/she had online training for his/her position as Activity Director. 3. Record review of Resident #62’s face sheet showed he/she was admitted to the facility |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) on [DATE] with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] (Persistent problems falling and staying asleep); -Parkinson (A disorder of the central nervous system that affects movement, often including tremors) and -Type II Diabetes (A chronic condition that affects the way the body processes blood sugar). Record review of the resident’s annual MDS dated [DATE] showed he/she: -Had a Brief Interview Mental Status (BIMS) score of 12, which describes the resident was cognitive alert and oriented; -Was able to express some ideas and wants to others in a consistent and reasonable manner; -Was a one person assist with Activities of Daily Living (ADL) for eating, bathing, dressing, transferring, personal hygiene and mobility needs and -Was able to eat independently with set up help only. Record review of the resident’s Care Plan dated, 4/21/17 showed he/she: -Was to encourage family visits; -Deliver mail timely; -Resident often enjoys doing exercises in room including standing and stretching along door frame and sitting on floor for stretching and -He/she enjoys music activities. Record review of the resident’s Group Activity Participation Record dated (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) showed resident: -Had participated in the following activities during the morning hours intellectual, spiritual/religious, community based, social programs, physical programs and independent activities; -The above group activity participation recorded dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) did not indicate the resident had participated in evening activities and no timeframes had been indicated for the resident and -Did not have an individual activity participation record on file when the information was requested during annual survey process. Observations showed the resident: -On 1/7/19 at 10:30 A.M. was resting in bed; -On 1/8/19 at 10:25 A.M. was sleeping in bed; -On 1/9/19 at 11:00 A.M. was standing near the nurse’s station alone; -On 1/9/19 at 3:00 P.M. was laying in his/her bed and -On 1/9/19 at 4:30 P.M. was laying in his/her bed and talking to his/her roommate. Record review of the facility monthly calendar dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) showed activities starting between the hours of 10:30 A.M. – 2:30 P.M. Record review of the facility monthly calendars for the month of October, (MONTH) and (MONTH) indicated one evening activity for the above months during the holiday season, (i.e. Halloween, Thanksgiving and Christmas); -The remaining nine months calendar did not show or indicate an evening activities for resident to select or choose from after 2:30 P.M. and -The weekend activities consisted of morning church or devotional activities. Non-religious activities were not found on the 12 month activity calendar for the residents. 4. During an interview on 1/10/19 at 1:30 P.M. the Activity Director said: -He/she provided monthly activities for the residents; -He/she had recorded group activity participation record and had been behind on his/her charting record to show how he/she individualize for the residents at the facility; |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) -He/she was the only Activity Director to provide activities for 70 residents; -He/she said sometime the nursing staff were able to assist him/her with activities for the resident but not on a consistent basis; -He/she tries to come back on the weekend and evenings to assist with activities with the resident but the current monthly calendars of the month only showed evening’s activities during the month of Thanksgiving (YEAR) and (MONTH) (YEAR) and -He/she mainly offers evening activities during the holiday months. During an interview on 1/11/19 at 11:00 A.M., the MDS Coordinator said: -He/she had only worked the facility for a few months and desire to work closely with the Activities Director to promote and enhance the resident’s cognitive and emotional health and development of each resident through structured learning activities; -He/she was interested in documenting positive outcomes for each resident as he/she continues to work with the Activities Director for the resident’s to have self-expression and to meet the interests and needs of the residents and -He/she stressed the importance of creating an individualized and structured learning plan for each resident. During an interview on 1/11/19 at 12 Noon, the Social Services Designee said: -He/she expected activities to be offered during day and evening hours to help promote the resident psycho-social development of each resident within the facility and -He/she expected activities need to go into the community so that the residents can maintain in touch with their community and participate in social events (i.e. gardening, arts, crafts and music). During an interview on 1/11/19 at 12:15 P.M., the Charge Nurse said activities are offered to the residents mainly doing the morning hours; -He/she said the facility currently only had one Activity Director for approximately 70 residents and -He/she said the nursing staff tries to provide assistant to the Activities Director but it depends on what nursing cares are immediate needed to the residents on the varied floors and work shifts. During an interview on 1/11/19 at 12:30 P.M., the Director of Nursing ( DON) said: -Activities are very important to the resident because it provides stimulation, and the activities help to meet the resident emotional health and it allows for self-expression and support and their choices of activities; -He/she tries to assist the Activities Director with getting the residents to the planned activities and -He/she encourages the resident to participate and he/she is responsive to the psych-social needs of each resident. | |
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate treatment and care according to orders, resident’s preferences and goals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident’s Quarterly Minimum Data Set (MDS – a federally mandated assessment instrument completed by facility staff for care planning) dated 10/10/18 showed; -Able to understand others and make self-understood; -Had Brief Interview for Mental Status (BIMS,is used to get a quick snapshot of how well you are functioning cognitively at the moment) of 14 score, not cognitively impaired; -Medication insulin injections were given during look back period and -Had [DIAGNOSES REDACTED]. Record review of the resident’s physician’s orders [REDACTED].>-Had a [DIAGNOSES REDACTED].>-[MEDICATION NAME] (long-acting insulin) administer 45 units subcutaneous ( sub-q-under the skin) every day at bedtime and -Check the resident’s blood Sugar at bedtime and notify the resident’s physician immediately if below 60 and/or above 400. Record review of the resident’s Medication Administration Record [REDACTED] -At 9:00 P.M., check the resident’s blood sugar at bedtime and to notify the resident’s physician immediately if the blood sugar results were below 60 and/or above 400; -The last blood sugar documented was on 1/7/19 at 7:35 P.M. and it was 206; -On 1/7/19 the resident was to receive [MEDICATION NAME] 45 units sub-q daily at bedtime and -The staff did no document the resident’s blood sugar of 87 that was taken on the night shift on 1/7/19. During an interview on 1/8/19 at 8:55 A.M., the resident said: -Had concerns with his/her blood sugar that had dropped on 1/7/19 and felt the staff did not care for him/her as they should had; – Licensed Practical Nurse (LPN) D had checked the resident’s blood sugar and gave him/her a glass of apple juice with no lid or straw; -Was not able to remember what his/her blood sugar was at that time, but felt weak most of the night afterwards; -He/she was weak and ended up spilling the glass of apple juice, Certified Nurse Assistant (CNA) E had assisted the resident with changing his/her sheets and -LPN D did not recheck the resident blood sugar after giving him/her the apple juice, or follow up to see how he/she was feeling. During an interview on 1/9/19 at 5:00 A.M., CNA E said: -LPN D had checked on the resident and his/her blood sugar had dropped and LPN D gave the resident a glass of apple juice; -CNA E and LPN D had went into the resident’s room at separate times; -The resident does have monitoring of his/her blood sugar when they are low or high; -The staff did not stay with the resident after the resident received his/her apple juice; -The resident had a history of [REDACTED]. |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) -Gave the resident’s apple juice in a regular cup and then left the resident’s room; -He/she did not follow-up with the resident after he/she had given the resident the apple juice and did not recheck his/her blood sugar; -The protocol would have been to call the resident’s physician if the resident’s blood sugar was less than 70 or above 400; -LPN D said the resident requested to have his/her blood sugar checked and had behaviors of not receiving his/her juice as requested; -The staff does not tell the resident his/her blood sugar results; -The staff does document the resident’s bloods sugar results in the nurse’s progress notes or on the resident’s MAR; -Did not document or report that the resident was sweaty and clammy; -The LPN D said the resident’s sheets had sweat stains on the sheets; -He/she was not aware the resident had spilled his/her juice and -The resident does not need a specialty cup and was able to transfer himself/herself as needed. During an interview on 1/11/19 at 8:55 A.M., Assistant Director of Nursing (ADON) said; -The resident complains of not feeling well and requests to have his/her blood sugar tested ; -For a blood sugars of 87 the staff would give the resident a snack or juice; -He/she would expect the nursing staff to follow-up with the resident, to see how he/she was feeling and -Would expect the nursing staff to document in the nurse’s progress note or the nursing 24 hour report about the resident’s blood sugar and/or if was having related attention seeking behaviors for liquids and this still needed to be documented in the resident’s medical record. During an interview on 1/11/19 at 9:50 A.M., LPN A said; -If a resident is not feeling well and their blood sugar was 87, he/she would follow-up to see how the resident was feeling and -Should have documented in the resident’s medical record if the resident had a blood sugar check done and any steps that were taken. During an interview on 1/11/19 at 11:58 A.M., Director of Nursing (DON) said: -Would expect the resident’s blood sugar check to be documented in the resident’s medical record, if the resident had his/her blood sugar checked with complaints of not feeling well; -If a resident requesting blood sugar checks was related to a behavior pattern, he/she would still expect the nursing staff to document it in the resident’s behavioral progress note and -When the resident was given apple juice as an intervention for the resident’s blood sugars, he/he would expect the nursing staff to document the follow-up. | |
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| 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 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) maintain accurate documentation of services when services were not provided for two sampled residents (Resident #37 and #53) out of 22 sampled residents. The facility census was 79 residents. 1. Record review of Resident #37’s Face Sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident’s quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 11/28/18, showed he/she: -Was alert and oriented with communication deficits; -Needed total assistance of two staff members for bathing, dressing, mobility, and toileting and -Had limited range of motion in both upper and lower extremities. Record review of the resident’s Physician’s Order Sheet (POS) dated 12/2018 and 1/2019, did not show any physician’s orders for rehabilitative services. Record review of the resident’s Functional Maintenance plan dated 11/6/18, showed Occupational Therapy (OT) recommended the resident to receive active and passive range of motion, if tolerated, to the resident’s bilateral upper extremities, to include shoulder flexion, elbow flexion, forearm and wrist flexion and extension to decrease risk of further contractures and skin breakdown. Complete 10-20 reps to his/her tolerance up to three times weekly. Record review of the resident’s Restorative Nursing Record showed he/she was scheduled to receive restorative services on Tuesday, Wednesday and Thursday. The records instructed the restorative aide to report all the refusals to the charge nurse and to write a note. The resident’s restorative report showed: -From 11/6/18 to 11/30/18, the resident received restorative services on 11/13, 11/15, 11/16, 11/20, 11/23, 11/27 and 11/30/18. There was no documentation showing why restorative services were not provided or if the restorative service was offered and the resident refused services; -From 12/1/18 to 12/31/18, the resident received restorative services on 12/18, 12/19, 12/20, 12/28 and 12/31/18. There was no documentation showing why restorative services were not provided or if the restorative service was offered and the resident refused services and -The resident had documentation showing he/she received restorative services three times from 1/1/19 to 1/9/19. Observation on 1/7/19 at 10:25 A.M., showed the resident was laying in his/her bed on his/her back with the head of his/her bed up at least 30 degrees. The resident was non-verbal, but was able to use a communication board to make his/her needs known. He/she had contractures in both hands and had a rolled up towel in his/her right hand. The resident was able to use his/her call light to call for assistance and to raise and lower his/her bed. 2. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident’s Admission MDS dated [DATE], showed the resident: -Was alert and oriented with some confusion and -Needed extensive assistance with bathing, dressing, grooming, mobility, and toileting. Record review of the resident’s POS dated 12/2018 and 1/2019, showed there were no physician’s orders for restorative services. Record review of the resident’s Physical Therapy Functional Maintenance Plan dated 10/29/18, showed he/she was to receive left lower extremity strengthening and right lower |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| 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 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) extremity passive and active range of motion upon discharge from therapy services. Record review of the resident’s Restorative Nursing Record showed the resident was to receive restorative services on Tuesday, Wednesday and Thursday. Directions also instructed the Restorative Aide to report all that refuse to the charge nurse and to write a note. The resident’s restorative report showed: -From 10/1/18 to 10/19/18, the resident received restorative services on 10/16, 10/17, 10/18, and 10/19. The restorative aide documented the resident was in the hospital from 10/20 to 10/30/18; -From 11/1/18 to 11/30/18, the resident received restorative services on 11/2, 11/5, 11/6, 11/8, 11/13, 11/15, 11/16, 11/20 and 11/21 and -There was no documentation of restorative services recorded from 11/22 to 11/30 and there was no documentation showing why no services were offered or provided to the resident during that time. Record review of the resident’s Physical Therapy Functional Maintenance Plan dated 12/17/18, showed he/she was to receive left lower extremity strengthening and right lower extremity passive and active range of motion upon discharge from therapy services. There was documentation showing the resident was refusing to participate in therapy. Record review of the resident’s Restorative Nursing Record showed he/she was to receive restorative services on Tuesday, Wednesday and Thursday: -From 12/1/18 to 12/31/18 showed the resident received restorative services on 12/20, 12/28 and 12/31 and -There was no documentation showing why restorative services wee not offered or provided up to three times weekly. Observation on 1/7/19 at 10:25 A.M., showed the resident was sitting in his/her wheelchair in his/her room. The resident was leaning to the right side in his/her wheelchair and complained of pain. He/she said that he/she had not yet told the nurse. The call light was turned on and the Restorative Nurse Aide (RNA) came in within two minutes and asked the resident what he/she needed. The resident said that he/she was experiencing some shoulder and back pain. The RNA said that the resident’s pain may be because of his/her positioning in his/her wheelchair and asked if he/she could assist the resident to re-position. The RNA tried to assist the resident to reposition and asked if he/she wanted to go to the exercise group-the resident said no. The RNA told the resident that he/she would tell the nurse that he/she was having pain and assisted to lay the resident down. The resident said he/she did not always go to the exercise group. During an interview on 1/11/19 at 10:53 A.M., The RNA said: -He/she received orders for restorative services from the rehabilitation team (Physical Therapy, Occupational Therapy and Speech Therapy); -Once he/she received the orders for restorative services, he/she will begin providing service once he/she receives the stop date from therapy and will start the following day; -He/she would only wait to start restorative services if he/she was pulled to the floor to work or if the resident went to the hospital before services started; -He/she tried to provide restorative services to everyone on his/her restorative list at least twice weekly, but tried to provide restorative services three times weekly to those residents who were unable to move at all independently, like Resident #37; -Depending on his/her caseload, the frequency that he/she was able to provide restorative services may vary-currently he/she had 13 residents on his/her caseload and was able to see everyone at least twice weekly; -Every time a resident goes to the hospital, he/she cannot resume restorative services until the therapist re-evaluated the resident and wrote a new order for restorative |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| 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 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) services; -If a resident refused restorative services, he/she was able to document that on the RNA record; -He/she documents all of the restorative services he/she provided on the RNA records; -He/she tried to document on the RNA record as he/she provided the service, but sometimes he/she doesn’t get around to it and has to chart later; -He/she has on occasion had to work on the floor and has been unable to complete restorative services on those days, but it has not happened often and -He/she should ensure that when he/she was not able to provide restorative services to the resident, he/she documented why on the resident’s restorative record. During an interview on 1/11/19 at 12:18 P.M., Licensed Practical Nurse (LPN) C said: -The RNA sometimes is pulled to work the floor and is not able to provide restorative service when that occurs. He/she said it does not occur often, but it has occurred and -The RNA should document when he/she provided restorative services and he/she would assume that if the RNA was not able to provide the service, he/she would also document that in the resident’s restorative record . During an interview on 1/11/19 at 1:42 P.M., the Director of Nursing (DON) said: -If the RNA is unable to complete service to the resident for any reason they should document that in their restorative charting; -If there is any additional documentation or reasoning for why services were not provided, it should be documented on the back of the RNA’s charting; -Sometimes the RNA is pulled to the floor but that rarely happens; -The RNA did not seem to be giving himself/herself credit for the services that he/she is providing and the documentation needed to be there and -He/she will work on that with the RNA. | |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) -The resident had a [DIAGNOSES REDACTED]. -Post discharge instructions recommended the staff to follow through on encouragement education with the resident regarding use of provale cup (is specialty cup for a place for your nose so your head does not tilt back to prevent aspiration) to improve carryover of small drinks that would help to reduce the signs and symptoms of aspiration with thin liquids. -Precautions: Staff was to ask the resident questions that he/she can answer with using yes and no; -Required staff supervision at meals and -Resident had been discharged from skilled nursing and the staff had been educated on providing the resident with a provale cup at meals for cold drinks, and the resident may continue with coffee in a regular cup. Record review of the resident’s Quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/28/18 showed he/she: -Weighed 228 pounds and had no swallowing problems; -Required one person assistance during meal time for supervision, cueing, oversight and encouragement; -Usually was able to understand others (difficulty communicating some word or finishing thoughts, but is able if prompted or given time) and was able to be understood by others; – Was cognitively intact and was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 14 (showing he/she was alert and orientated) and -Had no documentation related to his/her dysphasia. Record review of the resident’s Registered Dietician (RD) progress notes dated 10/06/18, showed the resident: -Was on a Consistent Carbohydrate diet; -Required meal set up in the bistro dining room and was able to feed himself/herself; -Had no swallowing problems and -Had no documentation related to his/her dysphasia. Record review of the resident’s discharge MDS dated [DATE] showed he/she: -Had been discharged on [DATE] to the hospital; -Required supervision of one staff member during meal times for oversight, encouragement or cueing; -Had no documentation marked under swallowing disorder or difficultly swallowing and -Weighed 221 pounds (on admission he/she weighed 228 pounds) and the staff did not document that the resident had any weight loss since being admitted on [DATE]. Record review of the resident’s hospital Speech Pathology Oropharyngeal Swallow Function Evaluation Test dated 12/13/18 showed: -The resident has pharyngeal dysphasia (arises from abnormalities of muscles, nerves, pharynx, and upper [MEDICAL CONDITION] sphincter) and possible aspiration; -Recommendation were to have Nothing by mouth (NPO) / due to unsafe feeding and -Speech Pathologist recommends video function swallow study for further assessment of swallow function and risk for aspiration. Record review of the resident’s hospital Video Film Swallow Study record dated 12/14/18 showed: -He/she had a history of [REDACTED]. -Impression: Abnormal swallow, there may be increased risk for aspiration pneumonia. Review of the resident’s Physician order [REDACTED].>-Nectar thickened liquids; -May crush medications and mix with applesauce pudding/yogurt and |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 18) -Pureed Consistent Carbohydrate diet. Record review of resident’s nurses progress notes showed: -On 12/17/18 at 2:16 P.M., The resident arrived to facility at 1:15 P.M., — Had been readmitted with [DIAGNOSES REDACTED]. –The resident was totally dependent on staff for cares; –The resident returns with physician’s orders [REDACTED]. -On 12/19/18 at 9:01 A.M., the resident required staff assistance with meal set up and cueing during the morning meal. Review of the resident’s nutritional care plan was updated on 12/13/18 showed: -He/she was to have a Registered Dietician (RD) consult; -The resident will not have any signs and system of aspiration; -The staff are to observe the resident for signs and symptoms of aspiration; congestion, fever, wet breath sounds; -On 12/21/18, the resident had a new intervention to administer the resident the Thrive dietary supplement at lunch and dinner; -On 12/28/18, the resident had a new intervention to administer Med plus (a dietary supplement 60 cubic centimeter (cc) four times a day and –There was no interventions in place to instruct the staff to offer the nectar thicken liquids or a puree diet. Record review of the resident’s Registered Dietician (RD) Progress noted dated 12/20/18 showed the resident: -Was on a puree Consistent Carbohydrate diet; -Required the staff to assist the resident with setting up his/her meals and the resident eats his/her meals in the bistro dining room; -The resident needed encouragement to eat; -Had a decline in oral intake and it was recommended the resident to be given Med Plus 60 cc three times a day between meals and at bedtime; -Did not have any swallowing problems and -The RD did not document anything related to the resident’s dysphasia. Record review of the resident’s weight review progress notes dated 12/21/18 at 2:17 P.M., showed: -The resident had been readmitted on a Consistent Carbohydrate Diet pureed diet with nectar thickened liquids; -The resident required assistance at times during meals; -Requested a RD consult due to the change in the resident’s weight and diet on readmission and -Continue to monitor the resident’s weight weekly and update the resident’s care plan. Record review of the resident’s Care Plan updated and reviewed on 12/24/18 showed the resident will have speech therapy (ST) evaluate and treat him/her for possible aspiration pneumonia, Record review of the resident’s Progress Notes on 12/24/18 at 1:41 P.M. showed the resident: -The resident has pneumonia and –Upon his/her return ST did evaluate and changed the resident’s diet. Observation on 1/08/19 at 8:07 A.M., of the resident’s room showed the resident had two glasses of thickened liquids on the bedside table that were approximately half full. Observation on 1/8/19 at 8:55 A.M., showed the resident: -Was in the bistro dining room with two other resident’s eating breakfast; -Was sitting in his/her wheelchair at the table; |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) -Had a glass of thickened liquid and coffee and his/her meal was served in a divided plate; -The resident was able to feed himself/herself with his/her left hand; -Observed his/her left hand shaking while trying to feed himself/herself; -The resident’s speech was difficult to understand at times and -There were no staff members in the bistro dining room during this meal observation. Observation on 1/08/19 at 12:16 P.M., showed the resident: -Sitting in the bistro dining room; -Had pureed food on a divided plate and had thickened liquid drinks in regular cups; -The staff assisted the resident with setting up his/her meal and the resident able to feed himself/herself; -No facility staff stayed in the bistro dining area during meal time and -Bistro dining room area had a total of four resident’s eating lunch. Observation on 1/9/19 at 5:46 A.M., showed the resident: -Had a glass of thickened liquids left in his/her room on the bedside table; -Licensed Practical Nurse (LPN) D said the resident was allowed to have thickened liquids in his/her room; The resident has the right to drink and -The resident had a history of [REDACTED]. During an interview on 1/9/19 at 5:00 A.M., Certified Nursing Assistant (CNA) E said: -The resident had not been able to reach the thicken liquid that was left in the room; -He/she requires assistance from staff; -For convince at night for the staff and the resident, they have been leaving thicken liquid drinks in the resident’s room and -The resident requires staff supervision or a mindful eye during meals and with drinks. During an interview 1/9/18 at 6:15 A.M. LPN D said the resident : -Was on nectar thicken liquids, had a special cup for liquids and was to have his/her head of the bed up when taking pills; -Should have some supervision at some level with meals and liquids; -Prefers not to eat in the main dining area; -Does not like crowds and has increase anxiety in crowded areas; -The bistro dining room area was a high traffic area; -Staff are walking by the bistro dining area all the time; -During meals times the resident does have some supervision when the staff are setting-up the meal and for follow-up assistance if needed and -Most of the time there are nursing staff behind the nursing station desk which is located behind the bistro dining area. During an interview on 1/9/19 at 10:00 A.M., the Speech Therapist said: -He/she would expect the staff to frequently monitor the resident during meal times; -The resident was now on nectar thickened liquid; -Hew/she has not provided a re-evaluation of the resident since his/her return from the hospital on [DATE]; -The facility and the rehab department are aware of resident’s swallowing issues; -The resident’s preference was to have meals in the bistro dining room and, -Prior recommendation was for the resident to have a special cup, because of his/her refusal of the nectar thicken liquids. During an interview on 1/11/19 at 8:55 A.M., Assistant Director of Nursing (ADON) said: -During the morning staff meeting the resident is talked about a lot; -If the resident was on thickened liquids then the resident should have supervision during meals and it was not recommended for the resident to eat in his/her bedroom and |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 20) -The staff needed to be within eye sight during meal times. During an interview on 1/11/19 at 11:58 A.M., Director of Nursing (DON) said; -The resident prefers eat in the bistro dining area due to it is a smaller area; –The staff set-up the resident’s meals; -The staff do not stay in that dining area, they leave the area; -He/she said since there were other resident’s in the bistro dining room area, those residents could call for help if anything would had happen to the resident; –The facility nursing staff and CNAs will check on the residents throughout the meal times; –Other staff members and visitors pass by the dining several times during the meal; –Do not have a facility staff member assigned to stay in the bistro dining area during meal times; -The resident does not require ongoing or one on one supervision at this time; -The resident was able to feed himself/herself and had been on a pureed diet with thicken liquids and -Was not planning on placing a time frame on how often the staff are required to make rounds or check on resident’s that require extra supervision during meal time. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) -CNA D then instructed the resident to hold onto the sling or cross his/her arms as he/she lifted the resident; -CNA P positioned the resident’s specialized wheelchair at an angle from the lift; -CNA D transferred the resident into his/her wheelchair while CNA P assisted with positioning the resident; -Once CNA D and CNA P had positioned the resident in his/her wheelchair, CNA P began to groom the resident and CNA D moved the resident’s wheelchair out of the resident’s room; -CNA P without washing his/her hands, then took the resident out of the room to go to the lunch room and -CNA D went back into the resident’s room and washed his/her hands. During an interview on 1/8/19 at 11:30 A.M., CNA P and CNA D, CNA P said: -They were instructed to wash their hands before they begin care on a resident; -During care they usually have one CNA who completes the clean task and one who completes the dirty task; -After care is provided they are supposed to wash their hands and then again before they leave the resident’s room; -Both CNA P and CNA D said that if they are only going in to transfer the resident, they did not need to wash their hands prior to doing so and -They said they had just finished completing incontinence care on the resident and exited the room, but they did not know that they should have washed their hands upon re-entering the resident’s room since they were only going to transfer the resident. 2. Record review of Resident #37’s Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident’s quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with communication deficits; -Needed total assistance of two staff for bathing, dressing, mobility, and toileting and -Had limited range of motion in both upper and lower extremities. Observation on 1/9/19 at 4:36 A.M., showed the resident laying in his/her bed with his/her eyes closed. The resident’s bed was low to the floor and his/her call light was within reach. The resident’s catheter was below his/her bladder but there was nothing on the floor preventing the resident’s catheter bag from resting on the floor. Observation on 1/9/19 at 6:35 A.M.,showed the resident laying in his/her bed awake, with his/her call light within reach. The resident’s bed was low to the floor and his/her catheter bag was still resting on the floor without a barrier between the catheter bag and the floor. 3. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident’s Admission MDS dated [DATE], showed the resident: -Was alert and oriented with some confusion and -Needed extensive assistance with bathing, dressing, grooming, mobility, and toileting. Observation on 1/7/19 at 10:50 A.M., showed: -The resident was sitting in his/her wheelchair in his/her room; -CNA N and CNA O brought the full body lift into the resident’s room and told the resident they were going to lay him/her down; -Without washing their hands, CNA N and CNA O began to attach the sling to the lift; -Once in place, CNA O operated the lift while CNA N assisted with moving the resident to his/her bed; -Once they transferred the resident to his/her bed, CNA O and CNA N washed their hands and assisted the resident to roll to the side to remove the sling from underneath him/her and |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 22) -CNA N and CNA O then washed their hands before leaving the resident’s room. During an interview on 1/7/18 at 11:05 A.M., CNA N said that they are supposed to wash their hands upon entering the resident’s room, during care when they go from a clean to dirty task, after changing their gloves and before leaving the resident’s room. 4. Record review of Resident #3’s Admission Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on 01/08/19 at 1:25 P.M., of the resident when returning from the shower showed: -The resident was transferred from the shower chair to his/her bed; -The staff placed the resident’s catheter drainage bag on top of his/her bed after completing his/her transfer; -Staff proceeded to roll the resident to his/her side to removing the sling from underneath the resident and -After removing the sling the CNA’s finished dressing the resident, while the catheter drainage bag remained on top of his/her bed. Observation 01/10/19 2:22 at P.M., of the resident catheter tubing and bag showed: -Had to have red ting urine and clots flowing through the tube into the bag; -Licensed Practical Nurse (LPN) A said the resident supra pubic catheter was changed last night because was clogged, and was not flowing and -After the catheter had been changed by facility nursing staff it may cause irritation or bleeding afterwards. During an interview on 1/11/19 at 10:07 A.M., CNA G and CNA H said: -The resident’s catheter should be kept below the bladder and not be laid on bed during cares and -Upon enter and exiting the resident’s room they should wash hands and place gloves on for cares During an interview on 1/11/19 at 9:50 A.M., LPN A said: -During resident care the catheter should be kept below the bladder and not lied on the bed and -Should wash hand your hands when enter the resident’s room and before leave the resident room. 5. Observation 1/9/19 at 8:00 A.M., of Resident #62’s accu check (a blood sugar reading obtained by a small sample of blood from the finger) by LPN E showed: -LPN E entered the residents room to check his/her blood sugar; -When finished he/she removed his/her gloves and washed his/her hands; -He/she returned to the nurse’s medication cart and obtained a bleach wipe with no gloves on his/her hands; -He/she proceeded to clean the soiled glucometer with the disinfecting bleach wipes; -He/she then wrapped the glucometer with the bleach wipe let it set; -Sanitized his/her hands with hand sanitizer then proceed to obtain the second glucometer; -LPN E then entered Resident #57’s room proceeded with the resident’s blood sugar testing; -Returned to the nurse’s medication cart and obtained a bleach wipe with no gloves on |
| 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: 265565 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PLEASANT HILL HEALTH AND REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 1300 BROADWAY | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 23) During an interview on 1/9/19 at 8:10 A.M., with LPN C said when cleaning the soiled glucometer gloves should had worn. 6. During an interview on 1/11/19 at 11:58 A.M., the Director of Nursing (DON) said: -The resident catheter drainage bag should kept below level of the bladder; -The bag should not be placed on top of the resident’s bed during care; -All catheter bags should be covered-right now they are using the leaf bags but the also have privacy bags; -The catheter bag should not be on the floor at any time; -Regarding Handwashing-nursing staff was supposed to wash their hands upon entering the resident’s room, before they leave the resident’s room, and when they go from performing a dirty to clean task, that is the standard; -She expected the nursing staff to wash their hands or use hand sanitizer upon entering the resident’s room, prior to providing cares turning off call lights and with transfers; -During care anytime they take off gloves and go from dirty to clean tasks, and before leaving the room they should wash their hands; -The resident’s catheter bag should be kept below the resident’s bladder and should not be on the floor at anytime; -He/she expected nursing staff to wear gloves when cleaning the glucometer with bleach wipes and -When completing a transfer with a Hoyer lift, gloves are not required unless there is possible exposure to bodily fluids, then he/she would expect staff to wear gloves. | |
| F 0925 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Based on observation and interview, the facility failed to ensure the attic areas above | |
