| 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: 265854 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER REST HAVEN CONVALESCENT AND RETIREMENT HOME | STREET ADDRESS, CITY, STATE, ZIP 1800 SOUTH INGRAM | |||||||||
| 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 | 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: 265854 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER REST HAVEN CONVALESCENT AND RETIREMENT HOME | STREET ADDRESS, CITY, STATE, ZIP 1800 SOUTH INGRAM | |||||||||
| 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) fill out a repair request form and turn it in to the administrator, who then classifies the job by priority 1, 2, or 3 and then gives it back to him/her. After looking through his/her forms, he/she did not have a request to repair Resident #33’s wheelchair. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident # 11’s quarterly MDS, dated [DATE], showed the facility assessed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265854 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER REST HAVEN CONVALESCENT AND RETIREMENT HOME | STREET ADDRESS, CITY, STATE, ZIP 1800 SOUTH INGRAM | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) During an interview on 1/10/19 at 3:30 P.M., the DON said he/she expects staff to check all residents for cleanliness every couple hours. Staff should comb residents’ hair and wash their faces upon getting them up in the morning and anytime during the day as needed. The DON said residents should have clean clothes on at all times, if staff notice a resident needs changed they are expected to do it. | |
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 265854 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER REST HAVEN CONVALESCENT AND RETIREMENT HOME | STREET ADDRESS, CITY, STATE, ZIP 1800 SOUTH INGRAM | |||||||||
| 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 – Some | (continued… from page 3) Review of the resident’s POSs dated 1/1/19-1/31/19, did not show an order for [REDACTED].>Review of the resident’s plan of care, dated 11/29/18, showed staff are directed to ask for therapy orders to address discomfort through exercise and non-medication interventions. During an interview on 1/08/19 at 4:11 P.M., the resident said restorative aides used to come in but they quit. 3. Review of Resident #58’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Utilizes a wheelchair for mobility; -Received no minutes of PT seven of the seven days in the look back period; -Received no minutes of OT seven of the seven days in the look back period; -And Received no minutes of RNP seven of the seven days in the look back period. Review of the resident’s POSs dated 11/1/18-11/30/18, showed the following Order wrote on 11/21/18: PT Clarification: Patient is discharged from Skilled PT. Set up RNP for three times per week for twelve weeks. Review of the resident’s plan of care, dated 12/20/18, showed staff are directed to ask for therapy and Restorative Nursing Program orders as needed and encourage my participation. Observation on 1/8/19 at 11:22 A.M. showed the resident in his/her wheelchair. Further observation showed the resident to have contractures to both lower extremities. Additional observation showed the resident did not have any assistive devices in place. Observation on 1/10/19 at 8:45 A.M., showed the resident in his/her wheelchair. Further observation showed the resident to have contractures to both lower extremities. Additional observation showed the resident did not have any assistive devices in place. During an interview on 1/10/19 at 10:00 A.M., the resident said he/she does not receive therapy at this time, and he/she does not have any devices for his/her legs. 4. During an interview on 1/10/19 at 11:24 A.M., Certified Nurse Aid (CNA) C said he/she thought that Resident #26 was working with therapy. He/She said there is no one assigned right now to do range of motion and /or restorative care with the residents. He/She said that if they get time they do some, but they don’t have it documented anywhere. During an interview on 1/10/19 at 3:15 P.M., Licensed Practical Nurse (LPN) T said the facility does not have a Restorative Nursing Aid (RNA) at this time. He/she said there is no place available for the staff to document when they provide ROM or restorative services, or which residents received the services. During an interview on 1/10/19 at 3:27 P.M., the Director of Nursing (DON) said the facility does not currently have an RNA to perform the RNP program at the facility. | |
| F 0732 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Post nurse staffing information every day. Based on observation, interview, and record review, facility staff failed to complete or |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265854 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER REST HAVEN CONVALESCENT AND RETIREMENT HOME | STREET ADDRESS, CITY, STATE, ZIP 1800 SOUTH INGRAM | |||||||||
| 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 0732 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 4) posting sheet in an area readily accessible to residents and visitors. 2. Observation on 1/08/19 1:54 P.M., showed facility staff did not display the nurse staff posting sheet in an area readily accessible to residents and visitors. 3. Observation on 1/09/19 3:05 A.M., showed facility staff did not display the nurse staff posting sheet in an area readily accessible to residents and visitors. 4. Observation on 1/10/19 1:01 P.M., showed facility staff did not display the nurse staff posting sheet in an area readily accessible to residents and visitors. 5. During an interview on 1/10/19 at 1:38 P.M., the Director of Nursing (DON) said other than the schedule they do not post nurse staffing hours. He/She did not know they were expected to complete and post a nurse staffing sheet. During an interview on 1/10/19 at 1:54 P.M., the Administrator said he/she expects staff to post the nurse staffing sheet at the 100 hall nurses station. He/She said it is usually posted and he/she does not know where it is. During an interview on 1/10/19 at 3:10 P.M., Licensed Practical Nurse (LPN) C said he/she doesn’t know of a nurse staffing sheet that is posted, but the facility does have a form titled daily assignment report. | |
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265854 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER REST HAVEN CONVALESCENT AND RETIREMENT HOME | STREET ADDRESS, CITY, STATE, ZIP 1800 SOUTH INGRAM | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) medication. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 11/15/18, showed staff assessed the resident as follows: -Physical behavior coded as 1 (occurred 1-3 days); -Verbal behavior coded as 2 (occurred 4-6 days); -Mood Severity score of 2 (minimal depression); and -[DIAGNOSES REDACTED].>Review of the resident’s Physician order [REDACTED]. Review of the resident’s Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. 3. Review of Resident #42’s care plan, dated 5/11/18, showed it directed staff: -Monitor for adverse reactions; -[DIAGNOSES REDACTED].>-No behaviors. Review of the resident’s quarterly MDS, dated [DATE], showed staff documented the resident’s diagnoses as follows: -Dementia; -Diabetes; -Recurrent [MEDICAL CONDITION]; -[MEDICAL CONDITION]; and -No irregularities in mood or behavior. Review of Resident #42’s medical record showed it did not contain a Medical Evaluation of the medication [MEDICATION NAME] (antipsychotic). Review of the resident’s POS, dated 1/1/19 through 1/31/19, showed an order for [REDACTED]. Review of the resident’s MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. 4. Review of Resident #51’s MDS, dated [DATE], showed staff documented the resident’s diagnoses as follows: -Alzheimer’s; -Depression; -No [DIAGNOSES REDACTED]. Review of the resident’s physician’s orders [REDACTED]. Review of the resident’s POS showed an order for [REDACTED]. 5. During an interview on 1/10/19 at 3:10 P.M., Licensed Practical Nurse (LPN) C said he/she believes the Minimum Data Set (MDS) coordinator is responsible to track the gradual dosage reductions and unnecessary medications. During an interview on 1/10/19 at 3:17 P.M., the MDS coordinator said he/she expects that gradual dosage reductions and unnecessary medication tracking would be part of his/her job, but he/she has not yet been told that. He/She said it had been discussed with the Director of Nursing (DON) but neither of them were doing it yet. During an interview on 1/10/19 at 3:22 P.M., the DON said he/she expects unnecessary medications and gradual dosage reductions to be reviewed, tracked, and attempted as recommended according to regulations. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. |
| 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: 265854 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER REST HAVEN CONVALESCENT AND RETIREMENT HOME | STREET ADDRESS, CITY, STATE, ZIP 1800 SOUTH INGRAM | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Based on observation, interview and record review, facility staff failed to allow sanitized kitchenware to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. The facility census was 57. 1. Review of the facility’s General Dishroom Sanitation policy, dated (MONTH) 2006, showed All items are to be air dried. No moisture can be found on any stacked item. 2. Observation on 01/09/19 at 9:40 A.M., showed Dietary Aide (DA) A removed five plastic insulated dome lids from dishwasher, stacked the lids while wet and placed the stack on the shelf above the steamtable. 3. Observation on 01/09/19 at 9:46 A.M., showed 12 plastic insulated plate holders, four divided plates and six plastic insulated dome lids stacked wet on the shelf above the steamtable. 4. Observation on 01/09/19 at 9:55 A.M., showed 12 metal food preparation and service pans stacked wet on the storage shelf in the baker’s area. 5. Observation on 01/09/19 at 9:58 A.M., showed 13 plastic food service trays stacked wet on the countertop ion front of the service window. 6. Observation on 01/09/19 at 3:32 P.M., showed 12 metal food preparation and service pans stacked wet on the storage shelf in the baker’s area. 7. During an interview on 01/09/19 at 9:48 A.M., the Dietary Manager said dishes should be air dried before they are put away and all staff are trained on this requirement. 8. During an interview on 01/10/19 at 12:45 P.M., the administrator said all dishes should be air dried before they are put away and all staff are trained on this requirement. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | 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: 265854 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER REST HAVEN CONVALESCENT AND RETIREMENT HOME | STREET ADDRESS, CITY, STATE, ZIP 1800 SOUTH INGRAM | |||||||||
| 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 – Many | (continued… from page 7) -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In (YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. 2. Review of the facility’s Oxygen Administration Policy, dated (MONTH) 2010, showed it did not give direction to staff in regards to oxygen tubing cleanliness. Review of the facility’s Oxygen Tubing In-Service form, dated 3/29/18, showed facility staff are directed to change oxygen tubing every Saturday on the evening shift. Additionally, staff are directed to date the oxygen tubing and bag to hold the tubing when it is changed. 3. Review of Resident #1’s significant change Minimum Data Set (MDS), dated [DATE], showed the resident receives oxygen therapy. Review of the physician’s orders [REDACTED]. Review of the resident’s care plan, dated 5/07/18, showed it did not contain direction to the staff on how to care for the resident related to the oxygen and its use. Observation on 01/07/19 at 2:43 P.M., showed the resident’s nasal cannula tubing was undated and was not in the storage bag. Further observation showed the nasal cannula draped across the floor while in use. Observation on 01/08/19 at 11:03 A.M., showed the resident’s nasal cannula tubing was undated and was not in the storage bag. Further observation showed the nasal cannula draped across the floor while in use. |
| 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: 265854 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER REST HAVEN CONVALESCENT AND RETIREMENT HOME | STREET ADDRESS, CITY, STATE, ZIP 1800 SOUTH INGRAM | |||||||||
| 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 – Many | (continued… from page 8) 4. Review of Resident #18’s Significant Change MDS, dated [DATE], showed the facility assessed the resident as not receiving oxygen therapy. Review of the resident’s POS’s dated 1/01/19 to 1/31/19 showed the following orders: -Oxygen at two liters per minutes per nasal cannula (N/C) at bedtime (HS); -And Change oxygen tubing and humidifier every Saturday. Observation on 1/8/19 at 2:20 P.M., showed an oxygen concentrator in the resident’s room. Further observation showed the oxygen tubing on the concentrator was undated. Observation on 1/9/19 at 1:46 P.M., showed an oxygen concentrator in the resident’s room. Further observation showed the oxygen tubing on the concentrator undated. 5. Review of Resident #39’s quarterly MDS, dated [DATE], showed staff assessed the resident receives oxygen therapy. Review of the resident’s POS, dated 1/1/19 to 1/31/19, showed the resident has an order for [REDACTED]. Review of the resident’s care plan, dated 5/07/18, showed it did not contain direction to the staff on how to care for the resident related to the oxygen and its use. Observation on 01/08/19 at 12:01 P.M., showed the resident with portable oxygen in use. Further observation showed the nasal cannula tubing was undated and was not in the storage bag. Observation on 01/09/19 at 11:51 A.M., showed the resident with portable oxygen in use. Further observation showed the nasal cannula tubing was undated and was not in the storage bag. 6. During an interview on 1/10/19 at 11:25 A.M., CNA C said the staff are expected to change oxygen tubing every week on Saturdays and that it should have a dated piece of tape to show it has been changed. During an interview on 1/10/19 at 2:50 P.M., Licensed Practical Nurse (LPN) C said the nurse in charge for night shift is responsible for either changing oxygen tubing or making sure it is changed weekly per treatment sheet. During an interview on 1/10/19 at 3:10 P.M., CNA E said the CNA’s are in charge of changing the resident’s oxygen tubing, however he/she is unaware how often it is done. CNA E said staff is to date the tubing when it is changed. 7. Review of the facility’s Administering Medications Policy, dated (MONTH) 2012, showed facility staff are directed to follow the established infection control procedures for administration of medications, as applicable. Observation on 01/08/19 at 12:00 P.M., showed Licensed Practical Nurse (LPN) F did not wash his/her hands in between residents during medication administration. LPN F did not wash/sanitize hands at appropriate times during medication administration, and between each resident to prevent the spread of infection. During an interview on 1/10/19 at 3:40 P.M., the DON said he/she would expect the staff passing out medication to sanitize hands between each pass and wash his/her hands after every five passes. During an interview on 1/10/19 at 3:00 P.M., LPN D said the staff who pass medications are to wash before starting, then sanitize between each pass but wash his/her hands if they touch anything. After you sanitize about 8 times, staff are expected to wash hands with soap and water. | |
