| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 0570 Level of harm – Potential for minimal harm Residents Affected – Many | Assure the security of all personal funds of residents deposited with the facility. reviewed CW | |
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) -No behaviors; -No wandering; -Extensive assistance of one staff for ambulating in the corridor and locomotion on and off the unit and dressing; -Limited assistance of one staff for transfers, toileting, and personal hygiene. Review of the resident’s care plan, last updated 01/19/18, showed staff did not update the care plan to include sexually inappropriate behaviors after the incident occurred on 02/24/18. Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally required resident assessment, dated 02/10/18, showed staff assessed the resident as: -Brief Interview of Mental Status (BIMS-a cognitive assessment) of 4 (severely impaired); -No behaviors; -No wandering; -Supervision of one staff member for bed mobility, transfers, eating, and personal hygiene; -Independent for ambulating in his/her room, ambulating in the corridor, and locomotion on and off the unit. Review of nurse’s notes, dated 02/24/18, showed Licensed Practical Nurse (LPN) D saw Resident #16 lean forward in his/her wheelchair and touch Resident #26 on the left upper chest. LPN D documented he/she moved Resident #16 to the nurse’s station. He/She documented the residents had no injuries, were monitored, and the family and guardian were notified. Review of the State Survey Agency database, showed facility staff did not report the resident-to-resident inappropriate sexual contact. Review of the facility’s records showed facility staff did not complete an investigation for the allegation, and did not report the allegation to the state survey agency as directed by the policy. During an interview on 03/28/18 at 5:16 P.M., the DON said they did not contact the state or the authorities about the incident on 02/24/18 because neither resident was injured or even remembered what happened. During an interview on 03/28/18 at 8:17 A.M., the Social Worker said he/she was made aware of the incident between the residents after the fact and was told it was handled. He/She said the incident happened over the weekend and he/she wasn’t made aware until the next week. He/She said the families were notified but he/she was not sure if there was an investigation done. He/She said the residents were supposed to be separated after the incident and staff moved Resident #26 to a new hall a few weeks later but for another reason. He/She said staff did not discuss the incident in any of the interdisciplinary team meetings. During an interview on 03/29/18 at 6:24 P.M., the Administrator and DON said they do have a policy in place to protect their residents from abuse, neglect, and exploitation. They said when abuse, neglect, or exploitation is reported, the accused staff member is immediately suspended pending the outcome of the investigation. He/She said any reports of abuse and neglect should be reported to the State Elder Abuse and Neglect Hotline within two hours but it has not been done that way recently. The Administrator does not know why staff did not report the resident-to-resident sexual contact to the hotline. The DON said they did not interview other residents or complete a full investigation after the incident but they did document the incident in the charts and contact the physician and representatives. The DON said he/she would expect a monitoring protocol to be put in a resident’s care plan after they have sexual behaviors. He/She said they tried to ensure |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) the safety of other residents by telling staff to keep Resident #16 in sight at all times. The DON said the charge nurse should report allegations of abuse and neglect to the hotline but he/she, the Administrator, or the Social Worker can report as well. 3. Review of Resident #37’s annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident’s care plan, last updated 3/5/18, showed staff are directed the resident prefers to have his/her door locked at all times, and the key to the door is on a hook so staff can gain entry in case of an emergency. Review of the State Survey Agency database showed facility staff did not report the resident’s allegation of the missing items. Review of the facility’s records showed facility staff did not complete an investigation for the allegation, and did not report the allegation to the state survey agency as directed by the policy. During an interview on 3/27/18 at 2:57 P.M., the resident said some items, including music cd’s and hair items were taken from his/her room, but he/she thinks they got rid of the person who did it. The resident said he/she tries to keep his/her door locked (knob turned). During an interview on 3/28/18 at 6:01 P.M., the administrator said an investigation was not done. The administrator said normally an investigation would have been completed and reported to Department of Health and Senior Services (DHSS), but he/she said we didn’t. During an interview on 3/29/18 at 6:29 P.M., the DON said he/she or the administrator should have reported the allegation to the state survey agency, but did not. | |
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Respond appropriately to all alleged violations. **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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) -Facility will investigate all types of abuse (physical, mental, sexual, financial, involuntary seclusion) and report; -Investigative documentation will include: -Specific description of the incident; -Names, addresses, home telephone numbers, date of birth, social security numbers, and positions for staff involved in the incident; -Written statements of all persons with knowledge of the incident. Statements must be signed and dated with specific details; – Documentation of any interviews conducted with other residents who might have been affected, or that the involved staff person worked with to determine if there are additional concerns; – Documentation of any interviews conducted with persons who might have some knowledge of the incident; -Copy of disciplinary action taken including the date, if any action was taken; -Summary of investigation, including corrective actions/monitoring the facility implemented to prevent the incident from reoccurring. 2. Review of the facility’s Grievance/Complaints Policy, updated 12/2016, showed the following: – The resident or resident representative may file a verbal or written grievance referral at any time. It is recommended that a written referral is completed to ensure all the facts are investigated including the date of the referral and summary of facts regarding the grievance or complaint; – The date of the referral will be clearly noted and the investigation will be completed in most cases within 5 working days of the referral date; – The referring party will be notified of the results of the investigation and any necessary corrective actions in writing. If the party is not satisfied with the findings and conclusion of the investigation, the party filing the grievance will be informed that the referral will be given to the administrator for a review of the investigation; – The date of the referral to the administrator will be clearly noted. The investigation will be completed within 5 working days of the referral date; – The party filing the grievance may file a complaint with Department of Health and Senior Services (DHSS) or the Ombudsman at any time. However, it is strongly recommended that the facility be provided the opportunity to investigate and correct any grievance. 3. Review of Resident #16’s admission MDS, dated [DATE], showed staff assessed the resident as follows: – Brief Interview of Mental Status (BIMS-a cognitive assessment) of 7 (severely impaired) -Did not display behaviors; -Did not wander; -Extensive assistance of one staff for ambulating in the corridor and locomotion on and off the unit and dressing; -Limited assistance of one staff for transfers, toileting, and personal hygiene. Review of the resident’s care plan, last updated 01/19/18, showed staff did not update the care plan to include sexually inappropriate behaviors after the incident occurred on 02/24/18. Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally required assessment, dated 02/10/18, showed staff assessed the resident as: – Brief Interview of Mental Status (BIMS-a cognitive assessment) of 4 (severely impaired); -No behaviors; |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) -No wandering; -Supervision of one staff member for bed mobility, transfers, eating, and personal hygiene; -Independent for ambulating in his/her room, ambulating in the corridor, and locomotion on and off the unit. Review of nurse’s notes, dated 02/24/18, showed LPN D saw Resident #16 lean forward in his/her wheelchair and touch Resident #26 on the left upper chest. LPN D said he/she moved Resident #16 to the nurse’s station. He/She documented the residents had no injuries, staff monitored the residents, and notified the families and guardians. Observation on 03/29/18 at 1:29 P.M., showed Resident #16 in his/her wheelchair in the television lounge with several other residents outside the view of the nurse’s station. During an interview on 03/28/18 at 5:16 P.M., the DON said they did not contact the state or the authorities about the incident on 02/24/18 because neither resident was injured or even remembered what happened. He/She said staff updated the residents’ charts and notified the doctor, family, and guardian. During an interview on 03/28/18 at 8:17 A.M., the Social Worker said he/she was made aware of the incident between the residents after the fact and was told it was handled. He/She said the incident happened over the weekend and he/she wasn’t made aware until the next week. He/She said staff notified the families but he/she was not sure if staff completed an investigation. He/She said the residents were supposed to be separated after the incident and staff moved Resident #26 to a new hall a few weeks later but for another reason. He/She said staff did not discuss the incident in any of the team quality improvement meetings. During an interview on 03/29/18 at 1:16 P.M., CNA E said the resident will say inappropriate things sometimes like sexual comments towards the aides. He/She said the resident’s care plan does not state the resident has sexual behaviors but the staff know about it because they talk about it during report. He/She believes Resident #16 has made physical advances towards one other resident but no staff members. During an interview on 03/29/18 at 1:24 P.M., CMT F said Resident #16 has no behaviors and is quiet. He/She said the only thing he/she has heard the resident say is wow when females walk by. He/She believes the resident has a limited vocabulary. He/She has not witnessed the resident doing or saying anything sexual to the other residents or staff and does not know of any time that has happened. During an interview on 03/29/18 at 6:24 P.M., the Administrator and DON said they do have a policy in place to protect their residents from abuse, neglect, and exploitation. They said when abuse, neglect, or exploitation is reported, the accused staff member is immediately suspended pending the outcome of the investigation. They said any reports of abuse and neglect should be reported to the State Elder Abuse and Neglect Hotline within two hours but it has not been done that way recently. The Administrator said he/she does not know why the resident-to-resident sexual contact was not reported to the hotline. The DON said they did not interview other residents or complete a full investigation after the incident but they did document the incident in the charts and contact the physician and representatives. He/She said he/she would expect a monitoring protocol to be put in a resident’s care plan after they have sexual behaviors. He/She said they tried to ensure the safety of other residents by telling staff to keep Resident #16 in sight at all times. The DON said the charge nurse should report allegations of abuse and neglect to the hotline but he/she, the Administrator, or the Social Worker can report as well. 4. Review of Resident #37’s annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/2/18, showed staff assessed the resident as cognitively intact. |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) Review of the resident’s care plan, last updated 3/5/18, showed staff are directed the resident prefers to have his/her door locked at all times, and the key to the door is on a hook so staff can gain entry in case of an emergency. Review of a grievance report, completed by the housekeeping supervisor on 3/8/18, showed he/she documented the resident reported he/she was missing some personal items, and felt that the housekeeper (HK A) who cleaned his/her room was responsible. The housekeeping supervisor questioned the alleged employee, who became very belligerent and quit. Further review showed the administrator signed the report on 3/12/18. Review of the facility’s records showed staff did not complete an investigation for the allegation. During an interview on 3/27/18 at 2:57 P.M., the resident said some items including music cd’s and hair items were taken from his/her room, but he/she thinks they got rid of the person who did it. The resident said he/she tries to keep his/her door locked (knob turned). During an interview on 3/28/18 at 3:36 P.M., the DON said the resident alleged HK A took some items (a cd, some Halloween thing, and maybe two other things) from his/her room, and the DON referred the situation to the housekeeping supervisor, since it was not his/her direct employee. The DON said when the housekeeping supervisor contacted HK A, he/she walked out the door. The DON said the resident always locks his/her door from the inside, but a key hangs outside the door for staff to enter if needed. During an interview on 3/28/18 at 3:54 P.M., the administrator said HK A had already turned in his/her notice of resignation and just left the day he/she was approached by the housekeeping supervisor. During an interview on 3/28/18 at 3:57 P.M., the Social Services Designee (SSD) said he/she usually takes all grievance/complaints and forwards to the administrator, but was told that this particular situation was already taken care of by the housekeeping supervisor and the administrator. The SSD said normally, if a resident reports missing/stolen items, staff considers the items missing/stolen unless proven otherwise by an investigation. The SSD said, the resident has a lot of items and knows where everything is in his/her room, so there might be some truth to his/her claim. He/She said regardless of the situation, there should have been an investigation completed, and to his/her knowledge, the administrator completed one. During an interview on 3/28/18 at 6:01 P.M., the administrator said an investigation was not done, and it was our fault. The administrator said normally an investigation would have been completed, and reported to Department of Health and Senior Services (DHSS), but we didn’t. Additionally, he/she said the facility could have tried to replace the missing items, but staff just never investigated the situation. During an interview on 3/29/18 at 12:52 P.M., the resident said there were 2 Boxcar(NAME) yodel CDs (taken from the drawer), 2 clips for his/her hair, and a bottle of lotion/perfume (taken from the top of the boxes near the window), that he/she got at the Halloween party. He/She thinks HK A took the items when he/she cleaned the room. During an interview on 3/29/18 at 6:29 P.M., the DON said we tried to investigate but the alleged staff member walked out. He/She said they did not interview any additional staff or residents about the allegation. An attempt to contact HK A via telephone on 3/29/18 at 1:35 P.M., was unsuccessful. A recording was received that the person is not accepting calls at this time. |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives an accurate assessment. **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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) 4. During an interview on 03/29/18 at 5:35 P.M., the MDS Coordinator said he/she completes the MDS assessments per RAI guidelines. He/She said the MDS should accurately reflect the resident’s condition. He/She said restraints, catheters, and tracheostomies should be correctly coded on the MDS. He/She said he/she or the DON is responsible for updating the MDSs. He/She said the MDS is updated every three months or when there is a significant change. He/She said he/she reviews the charts and interviews staff prior to completing the MDS. He/She said the DON reviews the MDS for accuracy and signs off on them before they are submitted. 6. During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said the MDS coordinator completes the MDS’s. The RN said he/she was not sure if Resident #25 currently had a catheter, but the MDS assessment should reflect that information accurately. He/she was not sure if Resident #34 had/used grab bars, but they would not be considered a restraint for him/her. Resident #52 does have a trach, which should be documented on the MDS. 7. During an interview on 3/29/18 at 6:29 P.M., the Director of Nurses (DON) said he/she expects each resident’s MDS assessment to be completed by the RAI guidelines. The DON said Resident #25 did not have a catheter, and once the catheter was removed, staff should update the MDS. Resident #34 does not have/use bed rails/alarms, or any other restraint device, so a restraint should not be documented on his/her MDS. Resident #52 has a [MEDICAL CONDITION], which should be documented on the MDS. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -No behaviors; |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) -Independent for ambulating in his/her room, ambulating in the corridor, and locomotion on and off the unit. Review of the resident’s physician’s orders [REDACTED]. Review of the resident’s care plan dated 02/08/18, showed it did not address the use of grab bars. Observation on 03/27/18 at 2:56 P.M., showed the resident in bed with grab bars on each side. Observation on 03/29/18 at 9:46 A.M., showed the resident in bed with grab bars on each side. 3. Review of Resident #52’s MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Used a feeding tube; -No [MEDICAL CONDITION] care. Review of the resident’s POS, dated 3/16/18 through 4/9/18, showed the physician ordered: -[MEDICAL CONDITION] care daily; -Gastrostomy tube ([DEVICE]), a tube inserted through the abdomen that delivers nutrition directly to the stomach) care daily with cleaning warm soapy water, rinse dry and split gauze. Observation on 3/29/18 at 1:22 P.M., showed Licensed Practical Nurse (LPN) C entered the resident’s room. Observation showed the resident with a [MEDICAL CONDITION] and a feeding tube. Observation showed LPN C provided [MEDICAL CONDITION] care and feeding tube care to the resident. Review of the resident’s care plan, dated 3/28/18, showed staff did not document direction to the staff for care of the resident’s [MEDICAL CONDITION] or [DEVICE]. 4. During an interview on 03/29/18 at 5:35 P.M., the MDS Coordinator said he/she is responsible for updating care plans. He/She said care plans should be updated with any changes. He/She said nurses can update care plans too. He/She said if a nurse removes a catheter, they should update the care plan. He/She said any falls should be documented on the care plan. He/She said the care plan should accurately reflect the resident’s condition. He/She said feeding tubes, [MEDICAL CONDITION] care, transfers, dentures, and catheters should be addressed in the care plan. He/She said the care plan should be specific about how to transfer residents and staff should follow the care plan to know how to transfer residents. He/She said if the care plan says use a hoyer lift PRN (as needed), it means if a resident can not bear weight staff should use a hoyer lift and the care plan should say it in detail. During an interview on 3/29/18 at 5:44 P.M., Certified Medication Technician (CMT)/Certified Nurse Assistant (CNA) L said resident’s care plans should be accurate, and he/she hopes they are. The CMT said residents have care cards (care plans) inside their closets that directs staff on how much assistance and level of care is required. During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said the MDS coordinator updates the care plans, but the charge nurse can update with any changes as well. The RN said the care plan should accurately reflect the resident. The RN said interventions for Resident #26’s grab bars, and interventions for Resident #52’s [DEVICE] [MEDICAL CONDITION] be on his/her care plan. During an interview on 3/29/18 at 6:22 P.M., the Director of Nursing (DON) said the MDS Coordinator is responsible to create the care plan for residents. The DON said Resident 26’s grab bars and Resident #52’s [DEVICE] and [MEDICAL CONDITION] should be included on their care plans. |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) wheelchair. Further observation showed the resident did not bear full weight, and the CNAs pulled his/her pants to help transfer the resident to the chair. The resident sat with his/her pants twisted to the left. CNA I said staff usually use two aides to transfer the resident. The CNA said the resident was a little stiff, and did not bear much weight. He/She has never used a mechanical lift to transfer the resident. The CNA said the care cards inside the closet directs staff on how to care for each resident (transfers, hygiene, feeding, etc.). Review of the resident’s Condensed Care Plan/care card (inside the closet), last updated 1/31/18 showed staff are directed the resident feeds self with set-up help, provide extensive assist with care, and transfer using a mechanical lift. Staff did not update the care card after the comprehensive care plan was updated on 2/5/18. During an interview on 3/28/18 at 5:10 P.M., CNA I said, I guess I should have looked at the care card before. During an interview on 3/29/18 at 8:57 A.M., CNA D, said the resident has only had his/her upper denture since November, that he/she can recall, and they have always been loose. The CNA said the denture adhesive does not work well to secure the resident’s teeth in his/her mouth. The resident’s denture flops around in his/her mouth when eating, and could be a choking hazard. The CNA said the resident is transferred by two staff members with a gaitbelt, and sometimes with a hoyer lift, but staff has not used the hoyer since about November, and some days the resident is dead weight. 3. Review of Resident #25’s quarterly MDS, dated [DATE] showed staff assessed the resident as cognitively intact, has an indwelling catheter (tube inserted into the bladder to drain urine), and always continent of urine. Review of the resident’s care plan, last updated 2/8/18, showed staff are directed the resident has an indwelling catheter, and to: -Change the catheter monthly and as needed (PRN); -Change foley bag monthly and PRN; -Monitor and document intake per policy; -Monitor for signs and symptoms of discomfort due to catheter. Observation and interview on 3/27/18 at 10:59 A.M., showed the resident in bed, and did not have a catheter in place. The resident said he/she did not have a foley catheter. During an interview on 3/27/18 11:54 A.M., Licensed Practical Nurse (LPN) G, said the resident did not have a catheter for probably the past few months. During an interview on 3/28/18 at 5:14 P.M., CNA I said the resident used to have a catheter, but it has been removed for a while now. The CNA said the resident did not currently have a catheter. During an interview on 3/28/18 6:20 P.M., LPN H said the resident’s catheter was removed a while ago and should be documented in the nurses’ notes in his/her chart. During an interview on 3/29/18 at 9:52 A.M., LPN E/charge nurse said based on the nurses’ notes, the resident’s catheter was removed prior to 12/2717 (at least 3 months ago). Staff did not update the care plan after the resident’s catheter was removed. 4. During an interview on 3/29/18 at 5:44 P.M., CNA L said residents’ care plans should be accurate, and he/she hopes they are. The CNA said residents have care cards (care plans) inside their closets that directs staff on how much assistance and level of care is required. The CNA said the care plan should direct staff on how many people to transfer, and how to transfer (hoyer lift, gaitbelt, etc.), interventions for oral care, but he/she was not sure if catheter interventions should be on the care plan. During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said the MDS coordinator updates the care plans, but the charge nurse can update with any changes as |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) well. The RN said the care plan should accurately reflect the resident, and staff should be able to walk in a room, open the closet door, and get a pretty good picture of what to do to care for the resident. The RN said Resident #23’s oral care, assistance with feeding, and how to transfer should be accurate on his/her care plan. Additionally, the resident’s loose-fitting dentures could be a choking hazard if not monitored properly. Staff should have updated Resident #25’s care plan when they removed the catheter. During an interview on 3/29/18 at 6:29 P.M., the Director of Nurses (DON) said the MDS Coordinator updates care plans at least quarterly, but any nurse can update the resident’s care plan with changes, and the care plans should match the information on the MDS. The DON said he/she expects staff to transfer Resident #23 with a mechanical lift and that specific instruction should be on the care plan. He/She also expects staff to assist the resident with feeding and/or provide close oversight during meals, because his/her loose-fitting dentures creates a possible choking hazard for him/her. Resident #25 does not have a catheter, therefore, interventions for a catheter should not be documented on his/her current care plan. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide care and assistance to perform activities of daily living for any resident who is unable. **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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 – Few | (continued… from page 12) Review of the shower sheets for (MONTH) (YEAR), and review of the monthly shower tracker, showed staff documented the resident was offered a shower/bed bath: -3/1/18 (six days after the last shower): only one shower that week; -3/6/18 (five days after the last shower): only one shower that week; -3/13/18 (seven days after the last shower): only one shower that week; -Staff did not document a shower/bath for the week of 3/18/18 to 3/25/18; -3/27/18 (14 days after the last shower). The resident only received four showers/bath in one month. Staff did not ensure the resident received a minimum of two baths each week as directed by facility policy. During an interview on 3/27/18 11:04 A.M., the resident said the facility needs more aides, because he/she does not get a shower sometimes for two weeks. He/She feels like when staff gets to his/her name on the list, they just skip over it. He/She does not know what days he/she is scheduled to get a shower, and told staff several times he/she needs a shower, since the last one he/she had was about two weeks prior. The resident said he/she really likes to feel the hot water, and it would have been nice the other night because it got cold. During an interview on 3/29/18 at 3:22 P.M., the resident said he/she did not really refuse on 2/13/18, but signed the refusal sheet because staff asked him/her to. The resident said he/she had a scheduled surgery on 2/14/18 and needed an antibacterial cleanse prior, which staff provided the morning of 2/14/18. 3. Review of Resident #23’s MDS, dated [DATE], showed staff assessed the resident as: -Brief Interview of Mental Status (BIMS-a cognitive assessment): not assessed; -Physical behaviors, but no rejection of care; -Extensive assist of one person physical assist with personal hygiene and dressing; -Extensive assist of two or more staff with transfer; -Total dependence of one staff for bathing and toileting. Review of the resident’s care plan, last updated 2/5/18, showed staff are directed: -Provide one staff participation with personal hygiene and oral care; -Provide two staff participation with bed mobility, dressing, and transfers; -Mechanical aid sling for transfers as needed (PRN); -Care level: extensive assist. The care plan did not indicate how often to offer the resident a shower. Review of the shower sheets for (MONTH) (YEAR), and review of the monthly shower tracker, showed staff documented the resident was offered a shower: -3/12/18 (12 days after the last shower); -Staff did not document a shower was offered from 3/16/18 to 3/28/18; -3/29/18 (14 days after the last shower on 3/15/18): only one shower that week. The resident only received three showers in one month. Staff did not ensure the resident received a minimum of two baths each week as directed by facility policy. Observation on 3/27/18 at 3:15 P.M., showed the resident propelled in the hallways, with overgrown facial hair. Observation on 3/27/18 at 10:20 A.M., showed the resident propelled in the hallways, with overgrown facial hair. During an interview on 3/29/18 at 8:57 A.M., Certified Nurses Assistant (CNA) D said staff usually shave residents when they provide their shower. 4. Review of Resident #29’s MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and required: -Extensive assist of two or more staff with bed mobility and toilet use; -Total dependence of two or more staff with transfer; |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 – Few | (continued… from page 13) -Physical help with bathing. Review of the resident’s care plan, updated 2/17/18, showed staff are directed: -One staff assist with personal hygiene; -Hoyer as needed for transfers, require two staff with transfers; -Resident refuses to got to the shower room and continues to have a bed bath, encourage to go to the shower room; -Provide with a sponge bath when a full bath or shower cannot be tolerated; -Require one person total care assist with bathing. The care plan did not indicate how often to offer the resident a shower/bed bath. Review of the shower sheets for (MONTH) (YEAR), and review of the monthly shower tracker, showed staff documented the resident received a shower/bed bath: -2/4/18: only one shower that week; -2/21/18 (six days after the last shower on 2/15/18): only one shower that week; -Staff did not document a shower/bath was offered from 2/21/18 to 2/28/18. The resident received a total of five showers/bath in one month. Staff did not ensure the resident received a minimum of two baths each week as directed by facility policy. Review of the shower sheets for (MONTH) (YEAR), and review of the monthly shower tracker, showed staff documented the resident was offered a shower/bed bath: -3/6/18 (13 days after the last shower on 2/21/18): only one shower that week; -3/12/18 (six days after the last shower): only one shower that week; -3/23/18 (10 days after the last shower): only one shower that week; -Staff did not document a shower/bath was offered between 3/23/18 and 3/29/18, and did not document the resident refused any showers/bath for the month. The resident only received three showers/bath in one month. Staff did not ensure the resident received a minimum of two baths each week as directed by facility policy. Observation and interview on 3/28/18 at 11:00 A.M., showed the resident in bed, with his/hair greasy. The resident said he/she does not usually go to the shower room because they need two people to transfer him/her with a hoyer (mechanical lift), and sometimes they don’t have enough staff to do it. The resident said there are no set days for his/her shower or bed bath, it varies. The resident said the last bath he/she received was on Friday, and today is Wednesday. The resident said he/she would love to have a warm shower with running water sometimes, and get his/her hair washed. Observation on 3/29/18 at 9:25 A.M., showed the resident in bed, with his/her hair greasy. 5. During an interview on 3/27/18 at 2:49 P.M., Resident #37 said he/she usually receives |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 – Few | (continued… from page 14) said ideally if there are four to five aides (including a shower aide), the CNA’s can get the showers done, but they are not always successful due to staffing issues. The CNA said Resident #14 does not have specific days to get a shower, and sometimes the resident thinks staff forgets him/her, but the CNA said that is not the case. Resident #29 does not have specific days to get a shower/bed bath, and sometimes refuses, but usually signs the refusal sheet. During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said the CNA’s give residents showers, but mostly on the day shift. The RN said if staffing permits, some residents are offered a shower in the evenings, but that is a rarity. Resident #14 occasionally refuses his/her showers, but staff give him/her a bed bath to supplement. Resident #29 sometimes refuses, but staff gives him/her a bed bath instead. The RN said a female resident complained to the DON about not getting showers a couple months prior, and said he/she thought the DON addressed it. During an interview on 3/29/18 at 6:29 P.M., the DON said he/she expects the CNA’s to offer residents showers from the list they receive daily. The DON said showers are offered at least once a week, sometimes twice, and sometimes three to four times. The DON said showers are not necessarily scheduled, but are offered on a rotating basis (day, evening, Saturday, and Sunday), and varies based on staffing levels and resident refusals. The CNA’s are expected to document the showers they provided on shower sheets, which are reviewed by the charge nurse, the DON, and filed monthly. | |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 15) -Sunday, 2/18/18: 2 P.M. local church group; -Saturday, 2/24/18: family time, 2 P.M. games; -Sunday, 2/25/18: 2 P.M. Anutt Community Church. Staff did not plan weekend activities other than church and unspecified games. 3. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the following: -Saturday, 3/3/18: family time, 2 P.M. Karaoke; -Sunday, 3/4/18: First Baptist Church; -Saturday, 3/10/18: family time, 2 P.M. games; -Sunday, 3/11/18: 2 P.M. New Home Church; -Saturday, 3/17/18: family time; 2 P.M. WII; -Sunday, 3/18/18: 2 P.M. local church group; -Saturday, 3/24/18: family time, 2 P.M. games; -Sunday, 3/25/18: P.M. Anutt Community Church; -Saturday, 3/31/18: family time, 2 P.M. WII. Staff did not plan weekend activities other than church and unspecified games. 4. Review of Resident #1’s Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/9/17, showed staff assessed the resident as follows: -Cognitively intact; -Somewhat important to participate in music, group, and outdoor activities; -Independent with bed mobility, transfers, and toileting. Review of the resident’s care plan dated 12/9/17 showed staff are directed to do the following: -Encourage to attend activities; -Receive new monthly calendar every month; -Explain importance of social interaction; -Encourage participation by inviting to each activity; -Preferred activities are watching television (TV) in room like horror movies in room, remind him/her that he/she can leave activities at any time and is not required to stay for an entire activity. Review of the resident’s activity note, dated 12/9/17, showed staff documented the resident is awake mostly at night. He/She likes to watch TV, talk on the phone, and visit with staff. Family do not visit the resident. Review of the resident’s activity note, dated 3/7/18, showed staff documented the resident is awake mostly at night. The resident likes to watch TV, talk on the phone, and visit with staff. The resident’s family never visits. Review of the resident’s medical record showed staff did not complete an Activity log for the resident for (MONTH) (YEAR), (MONTH) (YEAR), or (MONTH) (YEAR). Observation on 3/28/18 at 12:17 P.M., showed the resident in bed. Staff did not engage the resident in an activity. Observation on 3/29/18 at 8:41 A.M., showed the resident in bed. Staff did not engage the resident in an activity. Observation on 3/29/18 at 9:48 A.M., showed the resident in bed. Staff did not engage the resident in an activity. 5. Review of Resident #22’s activities assessment, dated 6/23/15, showed the resident likes the following: -Cards and games; -Music; -Sports; |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 16) -Reading; -Going outdoors; -Going on trips; -Watching TV; -Pets; -Gardening; -Talking; -Cooking. Staff are directed the resident would like to participate in bowling, music, church, outdoor socials, watching TV, and visiting. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Physical and verbal behaviors; -Total dependence on two or more staff for bed mobility, transfers, and dressing. Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended only one activity during the month. Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended only one activity during the month. Observation on 03/27/18 at 11:22 A.M., showed the resident sat up in his/her bed. Staff did not engage the resident in an activity. Observation on 03/28/18 at 2:40 P.M., showed the resident in bed. Staff did not engage the resident in an activity. 6. Review of Resident #27’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -No behaviors; -Supervision for transfers, walking, and eating; -Limited assistance of one or more staff for dressing. Review of the resident’s care plan dated 02/14/18, showed staff are directed to: -Provide one on one activities; -Escort resident to activities; -Converse with resident during activities; -Invite resident to activities; -Provide resident with an activities calendar; -Thank the resident for attending activities. Review of the resident’s undated activity evaluation showed the resident likes the following: -Games; -Crafts; -Music; -Religious activities; -Going outdoors; -Gardening; -Social events. Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended only one activity during the month. Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended only one activity during the month. |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 17) Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended only one activity during the month. Observation on 03/28/18 at 2:42 P.M., showed the resident lay in bed. Staff did not engage the resident in an activity. Observation on 03/29/18 at 9:49 A.M., showed the resident lay in bed. Staff did not engage the resident in an activity. 7. Review of Resident #28’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Unable to complete the cognitive assessment; -No behaviors; -Supervision for walking and eating; -Extensive assistance of one or more staff for dressing and toileting. Review of the resident’s care plan, dated 02/17/18, showed staff are directed to: -Engage the resident in simple structured activities; -Provide resident with an activities calendar. Review of the resident’s activity evaluation, dated 11/11/17, showed the resident likes the following: -Games; -Crafts; -Exercise; -Music; -Baking/cooking; -Religious activities; -Watching TV; -Watching movies; -Talking; -Social events. Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended only one activity during the month. Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended only two activities during the month. Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended only one activity during the month. Observation on 03/27/18 at 11:37 A.M., showed the resident lay in bed. Staff did not engage the resident in an activity. Observation on 03/28/18 at 2:45 P.M., showed the resident lay in bed. Staff did not engage the resident in an activity. Observation on 03/28/18 at 3:54 P.M., showed the resident lay in bed. Staff did not engage the resident in an activity. Observation on 03/29/18 at 9:48 A.M., showed the resident lay in bed. Staff did not engage the resident in an activity. 8. Review of Resident #34’s activity evaluation, dated 06/18/13, showed the resident likes the following: -Crafts; -Exercise; -Music; -Watching movies; -Talking; -Staff are directed the resident would like to participate in music, movies, parties, |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) manicures, outdoor socials, and cooking club. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Unable to complete the cognitive assessment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, and locomotion; -Total dependence on one or more staff for eating. Review of the resident’s care plan, dated 02/27/18, showed staff are directed to: -Encourage the resident to attend activities; -Provide the resident with an activities calendar in his/her room. Review of the resident’s medical record showed staff did not document the resident attended any activities during (MONTH) (YEAR), (MONTH) (YEAR), or (MONTH) (YEAR). Observation on 03/27/18 at 11:14 A.M., showed the resident in his/her recliner. Staff did not engage the resident in an activity. Observation on 03/28/18 at 1:21 P.M., showed the resident in his/her recliner. Staff did not engage the resident in an activity. 9. Review of Resident #38’s MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; -Very important to the resident to participated in music, and outside activities; -Somewhat important to the resident to participate in animal, favorite, and outside activities; -Required limited assistance of one staff for transfers, dressing, toileting, and personal hygiene. Review of the resident’s activity note, dated 11/30/17, showed staff documented family visits monthly, staff does one on one activities and visits with him/her three times weekly. Staff are directed to give reminders and assist the resident to activities of his/her choice. Review of the resident’s activity note, dated 2/28/18, showed staff documented family visits monthly, staff does one on one activities and visits with him/her three time weekly. Staff are directed to give reminders and assist the resident to activities of his/her choice. Review of the resident’s care plan, dated 3/2/18, showed staff are directed to do the following; -Encourage the resident to join activities; -Give updated activity calendar monthly. Review of the resident’s activity interest survey, dated 3/2/18, showed the facility staff assessed the resident as follows: -Current interests are playing cards, games, crafts/arts, music/singing/dancing, reading/talking books, spiritual/religious activity, walking/wheeling outdoors, TV/radio/movies, gardening/plants, talking, parties, pet visits. -Religious preference Baptist but does not want to attend religious services, does attend Bible study and church that comes to the facility; -Likes to visit with staff, watch TV in room, music, bowling, cards, coloring, social hour, and outdoor socials. Review of the resident’s medical record showed an Activity log not completed for the resident for (MONTH) (YEAR), (MONTH) (YEAR), or (MONTH) (YEAR). Observation on 3/29/18 at 8:42 A.M., showed the resident in bed. Staff did not engage the resident in an activity. |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) Observation on 3/29/18 at 9:47 A.M., showed the resident in bed. Staff did not engage the resident in an activity. 10. Review of Resident #52’s MDS, dated [DATE], showed facility staff assessed the resident as follows: -Cognitively intact; -Somewhat important to the resident to do music, favorite, and outdoors activities; -Totally dependent on two or more staff for bed mobility, transfers, dressing, toileting, and bathing. Review of the resident’s Activity Evaluation, dated 3/15/18, facility staff assessed the resident’s current interests include music, reading/audio books, baking/cooking, computer, trips/shopping, spending time outdoors, walking/wheeling outdoors, watching TV/radio, watching movies, talking/conversing, helping others/volunteer work, parties/social events, and keeping up with the news. Review of the resident’s medical record showed an Activity log not completed for the resident for (MONTH) (YEAR). Observation on 3/29/18 at 1:22 P.M., showed the resident in bed. Staff did not engage the resident in an activity. 11. During an interview on 03/28/18 at 3:45 P.M., Certified Nurse Assistant (CNA) P said staff usually do not provide activities to residents on the unit. He/She said the other residents did Easter crafts and hung some back there but the residents who live on the special care unit did not get to participate. He/She said the Activities Director does not come get the residents who live on the special care unit and take them to activities in the main part of the facility and rarely does any activities with them in the unit. He/She said they do have books and puzzles back there but not stuff the residents can really do. He/She thinks the residents would like crafts. During an interview on 3/29/18 at 3:19 P.M., Resident #14 said the Activities Director (AD) only helps Resident #17 with activities. The resident said the AD does not do much for the dependent residents, and often times just throws the dominoes on the table, without helping. The resident said staff does not provide anything for activities on the weekends, and he/she felt sorry for the residents who really need the help. The resident said at least I can move around and find something for myself to keep busy. During an interview on 03/29/18 at 3:20 P.M., CNA Q said, Honestly, there are no activities going on over there (the special care unit). He/She said one on one activities would be the best because some of the residents are not able to do much. During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said weekend activities consist of church, music, card games, and bingo. The RN said the AD comes in on the weekends for special occasions, but normally the nurse and the aides assist residents to music. The RN said he/she thinks there is only one calendar for the entire building, and did not think there was a specific activity calendar for the residents on the special care unit. During an interview on 3/29/18 at 6:22 P.M., the Administrator and Director of Nursing said activities are scheduled and put on by the activity director and if the activity director can not be there someone will fill for him/her. The Administrator said the special care unit has some activities that the CNA can do with the residents but they are expected to be invited to the activities. The Administrator said staff should document activities on the activity log for each resident and if activities are not documented on the activity log, they were not done. The Administrator said he/she is not sure why the activities were not documented on the activity logs for each resident, and it was his/her oversight. The Administrator said the weekend activities are church services on Sundays |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 20) and family time where family comes and visits the residents and the activity director is supposed to set out activity materials for the weekend staff to initiate activities. The administrator said if residents do not have family or if they do not want to attend religious services the activity director is expected to provide activities for residents to do such as WII or games/cards. The Administrator said special care unit staff should assist those residents to attend activities outside the special care unit. | |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 21) the cabinet in the shower room should be locked when the room is unattended by staff. The RN said a spray bottle of bleach is unsafe to residents if left in the hallway unattended. During an interview on 3/29/18 at 6:22 P.M., the Director of Nursing (DON) said sharps and | |
| F 0732 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Post nurse staffing information every day. Based on observation, interview, and record review, facility staff failed to post required |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 – Some | ||
| F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Based on observation and interview, facility staff failed to properly maintain the During an interview on 3/27/18 at 2:12 P.M., Resident #21 said the food does not taste 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 23) #46 said the food is worse since they switched companies about a year ago. The residents said the potatoes are hard, the broccoli is hard, the meat is tough, and the room trays are cold. During an interview on 3/29/18 at 5:44 P.M., Certified Nurses Assistant (CNA) L said the CNA’s are responsible to deliver resident’s room trays, but anyone can. The CNA said staff ensure the temperature is okay by keeping the plate covered, and delivering the meal as soon as it leaves the kitchen. If a resident complains of his/her food being cold, staff are expected to return the meal to the kitchen and inform the dietary staff, but microwaves are also available if needed. During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said CNA’s deliver room trays to residents, but anyone can deliver them. RN B said staff ensure the food temperature is maintained by keeping the plate covered, and deliver it immediately. If a resident complains of his/her meal being cold, staff are expected to use the microwave (on each hall) to reheat the meal. During an interview on 03/28/18 at 12:19 P.M., the Dietary Supervisor (DS) said the kitchen has around 26 hall trays not counting the special care unit, for the lunch time meal, and said it is often more than 26 hall trays for the evening meal. The DS said the number of hall trays has increased over the past year. The DS said the kitchen does not have anything to keep the hall trays warm once the food leaves the steam table. The DS said if there are not enough staff to transport the hall trays, then sometimes the carts that carry the hall trays are not delivered right away to the residents. During an interview on 3/29/18 at 6:22 P.M., the Director of Nursing (DON) and administrator said they expect the kitchen to fill hall trays and tell the nursing aid. The nursing aid is expected to deliver the meal to the residents immediately, which would keep the food at the appropriate temperatures. They said the CNA passing trays is usually assigned by the charge nurse. The DON and administrator expect staff to take the resident’s meal back to the kitchen and request a new tray if the food is cold. The administrator and DON said they were not aware of complaints of cold food or food that tasted bad. | |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 24) -Maintain a back-up glucose monitor to be used in the event of equipment malfunction. There should be two monitors per sides of the building for use at all times; -Finger stick device is used on one resident and then cleaned with bleach wipe, placed in the plastic container where it remains until dry (approximately three minutes). DO NOT leave device wrapped in the bleach wipe when placed in the container. 2. Observation on 3/27/18 at 11:01 A.M., showed Licensed Practical Nurse (LPN) G wore gloves, entered Resident #14’s room and checked his/her blood glucose level. The LPN exited the room, placed the unsanitized multi-use glucometer on top of the cart (without a barrier), and walked away from the cart. Observation at 11:05 A.M., showed the LPN returned to the cart, applied gloves, prepared and administered the required insulin (medication to treat high blood glucose levels), to the resident. The LPN exited the room, removed gloves, disposed of the needle, and pushed the cart down the hall. The LPN did not sanitize the multi-use glucometer after use, and did not wash/sanitize his/her hands before and after he/she administered the insulin. Observation on 3/27/18 at 11:09 A.M., showed LPN G wore gloves, entered Resident #29’s room, and used the unsanitized multi-use glucometer to check the resident’s blood glucose level. The LPN exited the room, placed the unsanitized glucometer on top of the cart (without a barrier), and went down the hall to the med room. Observation showed the LPN returned to the cart at 11:14 A.M., gloved, prepared the insulin, entered the room, and administered the insulin to the resident. The LPN exited the room, removed gloves, disposed of the needle, and pushed the cart down the hall. The LPN did not sanitize the multi-use glucometer before and after use, and did not wash/sanitize his/her hands before and after he/she administered the insulin. Observation on 3/27/18 at 11:17 A.M., showed LPN G wore gloves, entered Resident #25’s room, and used the unsanitized multi-use glucometer to check the resident’s blood glucose level. The LPN exited the room and placed the unsanitized glucometer on top of the cart (without a barrier). The LPN gloved, prepared the insulin, entered the room, administered the insulin to the resident, returned to the cart and proceeded down the hall. The LPN did not sanitize the multi-use glucometer before and after use, and did not wash/sanitize his/her hands before and after he/she administered the medication. Observation on 3/28/18 at 11:37 A.M., showed LPN O wore gloves, entered Resident #14’s room, placed the multi-use glucometer on the resident’s thigh (without a barrier), checked his/her blood glucose level, and exited the room. The LPN placed the unsanitized glucometer on top of the cart (without a barrier), sanitized hands, prepared and administered the insulin to the resident, and sanitized hands. He/She sanitized the glucometer with a bleach wipe and placed the glucometer back on top of the cart (without a barrier). The LPN did not place the sanitized glucometer in a plastic container to dry, as directed by the policy. Observation on 3/28/18 at 4:44 P.M., showed LPN H wore gloves, entered Resident #43’s room, placed the multi-use glucometer on the resident’s bed pad (without a barrier), checked his/her blood glucose level, and exited the room. The LPN returned to the cart and placed the contaminated glucometer on top of the cart (without a barrier). The LPN sanitized hands, prepared and administered the insulin to the resident, and sanitized hands. The LPN did not sanitize the multi-use glucometer after use. Observation on 3/28/18 at 4:52 P.M., showed LPN O wore gloves, entered Resident #19’s room and used the unsanitized multi-use glucometer from the cart, to check the resident’s blood glucose level. He/She exited the room, placed the unsanitized glucometer directly on top of cart (without a barrier), sanitized hands, and proceeded down the hall. The LPN did not sanitize the multi-use glucometer after 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 25) During an interview on 3/29/18 at 5:58 P.M., RN B said staff are expected to clean the multi-use glucometer between each resident use, and again at the end of the shift. The glucometer should be placed on a barrier to prevent contamination, and not directly on the resident or a bed. 3. According to the Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. *Hand washing remains the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and when each resident’s care is completed. Observation and interview on 3/29/18 at 8:17 A.M., showed Certified Medication Technician (CMT) N prepared medications for Resident #208. Observation showed the CMT opened two unidentified capsules with his/her bare hands, poured them into a plastic medication cup, added applesauce and administered to the resident. The CMT said the capsules were [MEDICATION NAME] and [MEDICATION NAME]. The CMT did not wear gloves to handle the medications, and did not wash/sanitize his/her hands after handling the medications. Further observation showed the CMT pushed the cart down the hall, pulled his/her hair back several times while he/she prepared Resident #27’s medications, and did not wash/sanitize his her hands. Additional observation and interview at 8:28 A.M., showed the CMT entered the room, administered the medications to the resident, then sanitized his/her hands. The CMT said staff are expected to wash hands when contaminated, before they enter/leave a room, before clean tasks, and sanitize/wash hands after a few patients when they administer medications. The CMT said he/she was not trained to wear gloves when handling capsules directly, but now that he/she thought about it, he/she probably should. The CMT said he/she never really thought about sanitizing his/her hands after pulling his/her hair back, but probably should. During an interview on 3/29/18 at 5:58 P.M., RN B said staff are expected to wash hands between each resident when they administer medications. Staff should wear gloves to open capsules and wash hands after to prevent contamination, and it is not okay to pull your hair when preparing meds without cleaning hands in between. 4. Review of the facility’s policy on Hand-Washing, undated, showed staff are directed to wash hands: -Before and after providing residents with personal care (dressing/undressing, and perineal care); -Before and after serving/assisting/feeding resident’s meal tray. 5. Observation on 3/27/18 at 11:19 A.M., showed Certified Nurse Assistant (CNA) K and CNA P entered Resident #13’s room, did not wash hands, and applied gloves. to their hands. Observation showed the resident incontinent of urine. Observation showed CNA P cleansed the resident’s bottom and CNA K provided frontal perineal care to the resident. Observation showed CNA P applied barrier cream, to the resident’s bottom with the same soiled gloves. Observation showed CNA P changed gloves and did not wash his/her hands. CNA K and CNA P touched the resident’s clean clothes and skin with the same contaminated gloves. Observation showed the CNAs did not wash their hands and change gloves in a manner to prevent the spread of bacteria. 6. Observation on 3/27/18 at 12:24 P.M., showed CNA Q served lunch trays and drinks to multiple residents. The CNA did not wash his/her hands between residents or wear gloves during the meal service. 7. Observation on 3/27/18 at 12:32 P.M., showed the Speech Therapy Assistant touched |
| 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: 265521 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SEVILLE CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 35625 HIGHWAY 72, PO BOX 746 | |||||||||
| 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 26) Resident #208’s bread with his/her bare hands. He/She did not wash his/her hands or wear gloves. 8. Observation on 3/28/18 at 12:29 P.M., showed CNA R touched Resident #38’s bread with his/her bare hands. He/She did not wash his/her hands or wear gloves to handle resident food. 9. Observation on 3/28/18 at 12:35 P.M., showed LPN O buttered Resident #41’s bread with his/her bare hands. The LPN did not wear gloves to handle resident food. 10. Observation on 3/28/18 at 4:56 P.M., showed CNA I washed hands, placed gloves, applied socks to Resident #23’s feet, placed pants on his/her legs, and placed a gaitbelt around the resident’s waist. Further observation showed CNA I and CNA J held the gaitbelt and transferred the resident from the bed to the chair. CNA I went to the sink, cleaned the resident’s dentures, and placed the dentures in the resident’s mouth. The CNA did not change gloves and wash/sanitize his/her hands after he/she dressed the resident and before he/she provided oral care to the resident. 11. During an interview on 3/29/18 at 5:44 P.M., CNA L said staff are expected to wash hands before they enter/exit a room, when soiled, between clean and dirty tasks, and during perineal care. Staff are also expected to change gloves and wash hands after they dress a resident, before they clean/insert dentures, and again after they provide oral care. 13. During an interview on 3/29/18 at 6:22 P.M., the DON staff should wash their hand or use hands sanitizer when they enter/exit a residents room, between glove changes, between dirty/clean tasks, every their mediation during medication pass, before eye drops, oral medications, after touching their face/hair and before passing medications. The DON said he/she expects staff to wear gloves when staff handle medication capsules. Staff are expected to not touch residents’ food with their hands, and are expected to wear clean gloves if they have to touch resident food. The DON said the glucometers should be cleansed with the bleach wipes and staff should wait three minutes after each use and should use the extra glucometer to perform the next blood sugar check while they wait for the sanitizer to take effect. | |