| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to provide a comfortable and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) smelled of urine and he/she did not like it. Observations on 6/12/19 at 8:56 A.M. and throughout the day showed a strong odor of urine noted upon entrance to the facility and on the 100 Hall. Observation on 6/12/19 at 10:56 A.M. showed a strong odor of urine present upon entrance to the facility and on the 200 Hall. During an interview on 6/13/19 at 2:10 P.M., the housekeeping manager said the following: -There were cans of Lysol or springtime air freshener located in the janitor’s closet for staff to use for increased odors when needed after housekeeping hours; -Staff were aware the charge nurse had access to the closet. During an interview on 6/13/19 3:55 P.M. the Director of Nursing (DON) and the care plan/Minimum Data Set (MDS), coordinator said the following: -They would expect the staff to use disinfectants to clean the residents’ beds and use periwash or soap to clean the residents; -Unclean resident beds, rooms, and residents could cause the facility to smell. | |
| F 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure residents do not lose the ability to perform activities of daily living unless there is 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: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) -The resident is limited in ability to transfer self, related-to visual impairment and weakness: -Restorative program three times weekly for PROM to upper body and ambulation; -Instruct the resident in proper transfer techniques; -Provide assistance for transferring. Review of the resident’s undated Certified Nurse Aide (CNA) Care Card showed restorative and nursing interventions for walk to dine, multi podus boots (used for those at risk for plantar flexion contracture, foot drop, hip rotation and decubitus heel ulcers) on as tolerated and AFO (ankle and foot orthoses brace) on while in wheelchair. Review of the resident’s physician orders [REDACTED]. Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed staff documented the resident received restorative therapy one day out of two days for active range of motion (AROM – exercises the resident is able to perform independently) and walking. Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed the following: -Staff documented the resident received restorative therapy zero days out of 34 for PROM; -Staff documented the resident received restorative therapy eight days out of 34 for walking. 3. Review of Resident #30’s annual MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -The resident’s cognition was severely impaired; -The resident did not reject care; -The resident was dependent on two or more staff for transfers, dressing and toilet use; -The resident was dependent on one staff with bed mobility, eating, locomotion on the unit, personal hygiene and bathing; -The resident did not walk in his/her room or in the corridor; -The resident used a wheelchair for assistance with mobility; -Staff performed passive range of motion one time for 15 minutes in the last week. Review of the resident’s physician order [REDACTED]. -[DIAGNOSES REDACTED]. -Restorative aide three times a week for range of motion for upper extremities and lower extremities. Review of resident’s care plan last reviewed 4/4/19 showed the following: -The resident’s ability to perform activities of daily living (ADLs) was at risk for deterioration due to weakness and [DIAGNOSES REDACTED]. -The resident required assistance of one staff with ADLs; -The resident was to receive restorative therapy three times a week for neck support and range of motion (ROM). Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed staff documented the resident received restorative therapy six days out of 12. Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed staff documented the resident received restorative therapy three days out of 12. During an interview on 6/11/19 at 4:00 P.M., Restorative Aide/CNA (RA/CNA) A said the following: -The resident was supposed to receive restorative therapy three times a week; -He/She was unable to provide therapy because he/she was pulled to work other areas and tasks due to staff shortage; -Not receiving restorative care could cause a decline. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) 4. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following: -The resident had [DIAGNOSES REDACTED]. -The resident’s cognition was severely impaired; -The resident required extensive assistance of one staff with transfers and toilet use; -The resident was dependent on one staff with personal hygiene and bathing; -The resident did not walk in his/her room or in the corridor; -The resident required limited assistance of one staff with locomotion on and off of the unit (on 12/29/18 quarterly MDS the resident did not require assistance with locomotion on and off from the unit); -The resident used a wheelchair for assistance with mobility. Review of resident’s care plan last reviewed 4/4/19 showed the following: -The resident’s ability to perform activities of daily living (ADLs) was at risk for deterioration due to weakness and [DIAGNOSES REDACTED]. -The resident required assistance of one staff with ADLs; -The resident was to receive restorative therapy three times a week for neck support and range of motion (ROM). Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed the facility’s staff documented the resident received restorative therapy four days out of 12. Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed staff documented the resident received restorative therapy two days out of 12. During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following: -The resident was supposed to receive restorative therapy three times a week; -He/She was unable to provide therapy because he/she was pulled to work other areas and tasks due to staff shortage; -The resident had declined within the last couple of weeks; -The resident had orders to walk to dine, but it was not being done because he/she was unable to walk with him/her. 5. Review of Resident #40’s quarterly MDS dated [DATE] showed the following: -The resident’s [DIAGNOSES REDACTED]. -The resident’s cognition was moderately impaired; -The resident was dependent on two staff with transfers and dressing; -The resident received restorative therapy one day out of the last seven days. Review of the resident’s care plan last reviewed on 4/29/19 showed the following: -The resident was totally dependent on staff for all ADLs due to [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke) with left sided [MEDICAL CONDITION] (paralysis of one side of the body), weakness, impaired mobility, and unsteady balance; -The resident was to receive restorative therapy three times a week with staff performing PROM to all of the resident’s joints to improve and maintain the resident’s left upper extremity range of motion; -The resident was supposed to wear a resting hand splint (on his/her left hand). Review of the resident’s undated CNA Care Card showed no documentation the resident received restorative nursing services or that he/she was supposed to wear a hand splint. Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed the following: -Staff documented the resident received restorative therapy six days out of 12; -There was no documentation to show the resident refused to wear the left hand splint. Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed the following: -Staff documented the resident received restorative therapy one day out of 12; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) -There was no documentation to show the resident refused to wear the left hand splint. Observation on 6/09/19 at 4:00 P.M. showed the following: -The resident sat in his/her wheelchair outside of his/her room. His/her head leaned to the right side; -The resident’s left hand was contracted; -There was no splint on his/her left hand. Observation on 6/10/19 at 8:59 A.M. showed the following: -The resident sat in his/her wheelchair; -The resident’s left hand and left foot were contracted; – There was no splint on his/her left hand. During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following: -The resident was supposed to have restorative therapy three times a week, but he/she had been pulled from his/her restorative nursing duties to perform care; -He/She was also unable to complete restorative nursing duties because he/she took residents to appointments, completed residents’ weights and vital signs, attended care plan meetings, and updated CNA Care Cards; -There was a second CNA trained to assist with restorative therapy, but he/she worked as a CNA on the day shift and was unable to assist with restorative therapy; -The resident was supposed to wear a brace to his/her left hand and he/she had tried, but the resident refused to wear the brace. 6. Review of Resident 54’s annual MDS dated [DATE] showed the following: -The resident’s cognition was intact; -The resident’s [DIAGNOSES REDACTED]. -The resident was dependent on two staff with bed mobility; -The resident required extensive assistance of two staff with transfers; -The resident required extensive assistance of one staff with dressing and toileting; -The resident did not walk in his/her room or in the corridor; -The resident’s range of motion was impaired on one side of upper and lower extremities; -The resident required the use of a wheelchair for mobility; -The resident received restorative therapy three out of the previous seven days. Review of the resident’s care plan last updated on 6/9/19 showed the following: -The resident required extensive assistance with ADLs related to [DIAGNOSES REDACTED]. -The resident was to wear a splint to his/her left hand to assist with contraction; -The resident was to have restorative therapy three times a week for left upper extremity range of motion and right upper extremity strength. Review of the resident’s undated care card showed the following: -The resident had left sided weakness; -He/She was to have a splint applied in the morning and removed at night (no documentation to show the type of splint the resident was to wear). Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed the following: -Staff documented the resident received restorative therapy six days out of 12; -There was no documentation to show the resident refused wearing the left hand splint. Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed the following: -Staff documented the resident received restorative therapy two days out of 12; -There was no documentation to show the resident refused wearing the left hand splint. Observation on 6/10/19 at 1:47 P.M. showed the following: -The resident’s left hand was contracted; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) -No splint on his/her left hand. During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following: -The resident was supposed to have restorative therapy three times a week; -The resident was supposed to have a brace on his/her left hand, but he/she refused to wear the brace; -He/She was unable to complete the resident’s restorative therapy the last couple of weeks because he/she was pulled from his/her restorative nursing duties to provide resident care; -He/She was pulled from his/her restorative nursing duties to provide resident care at least once or twice a week due to lack of staff. 7. During interview on 6/11/19 at 10:30 A.M., RA/CNA A said the following: -He/She was working as a CNA today. There is a backup RA when he/she was not here but the backup RA was off today; -He/She was to do RA today but got pulled to the floor due to short staffed for CNAs; -He/She has been pulled from RA to CNA a lot lately, like twice a week. He/She was hired to be a RA and he/she feels like he/she is letting the residents down as they are not getting what they are supposed to get for restorative; -He/She felt like residents were declining as he/she was unable to do the restorative when he/she gets pulled to the floor. During an interview on 6/13/19 at 3:55 P.M., the MDS/Care Plan Coordinator said the following: -He/She would not expect the RA to be pulled from restorative duties to provide resident care; -The RA had been pulled from his/her restorative nursing duties to provide resident care within the last month or two due to lack of staff. | |
| 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** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 6) -The purpose was to cleanse the perineum and prevent infection and odor; -Prepare supplies including warm water and perineal solution; -Wash hands and apply gloves; -Wash all frontal perineal skin folds front to back with wet wash cloth and soap and water or perineal wash, rinse and pat dry; -Wash buttocks with clean wash cloth and soap and water or perineal wash, rinse and pat dry; -Remove gloves and wash hands. 3. Review of the 2001 revision of the Nurse Assistant In A Long Term Care Facility manual, showed the purpose of peri-care (perineal) is to clean the peri area for the resident who is unable to or has difficulty with adequately cleaning self, prevents itching, burning, and odor, and prevents infections. The manual also showed the resident who is continent should have peri-care daily with morning care, the resident who is incontinent, after each voiding or stool, and perineal care is very important in maintaining the resident’s comfort. More frequent care is required for residents who are incontinent. Review of the 2001 revision of the Nurse Assistant In A Long Term Care Facility manual, also showed the procedures staff were to follow when they provided peri-care for a male (steps 7 through 13) included the following: -Cover the resident; -Expose the perineal areas included, wash the penis from the tip downward, rinse, and dry (specific instructions for uncircumcised); -Wash and rinse the scrotum; -Wash and rinse other skin areas between the legs; -Wash and rinse the anal area; -Pat the area dry. For the female resident (steps 7 through 14) included the following: -Cover the resident; -Expose the peri area, wash the inner legs and outer peri area along the outside of the labia (Labia Majora); -Use a clean area of the washcloth for each wipe of the peri area; -Wash the outer skin folds from front to back; -Wash the inner labia (Labia Minora) from front to back; -Gently open all the skin folds and wash the inner area (urinary meatus and vaginal area) from front to back; -Rinse the area well, start from the innermost area and proceed outward; -Wash and rinse the anal area; -Pat the peri area dry. 4. Review of the Nurse Assistant in a Long Term Care Facility manual, Revision (MONTH) 2001, showed the following: -Purposes of oral hygiene (mouth care): A clean mouth and properly functioning teeth are essential for physical and mental well-being of the resident, prevent infections in mouth, remove food particles and plaque, stimulate circulation of gums, eliminate bad taste in mouth, thus food is more appetizing. 5. Review of Resident #40’s quarterly MDS dated [DATE] showed the following: -The resident’s cognition was moderately impaired; -The resident was dependent on two staff with transfers and dressing; -The resident was dependent on one staff with personal hygiene and bathing; -The resident was always incontinent of bowel and bladder; -There was no documentation to show the resident’s dental/oral status. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 7) Review of the resident’s care plan last reviewed on 4/29/19 showed the following: -The resident was totally dependent on staff for all ADLs due to [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke) with left sided [MEDICAL CONDITION] (paralysis of one side of the body), weakness, impaired mobility, and unsteady balance; -Staff were to provide reminders and supervision as needed for all ADLs; -Staff were to assist the resident with bathing body parts that the resident could not do her/himself; -The resident was at risk for skin breakdown related to episodes of incontinence; -Staff were to keep the resident’s skin clean and dry -Staff were to wash the resident’s skin with soap, rinse, and dry all areas. Review of the resident’s undated CNA Care Card showed the following: -The resident required assistance of one staff with brushing his/her gums (no teeth), providing peri-care, and shaving; -The resident required assistance of one staff with dressing; -The resident required assistance of one staff with showers which were scheduled on Tuesdays and Fridays; -The resident was incontinent of bowel and bladder, and wore an adult brief. Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 4/1/19 to 4/30/19 showed the resident’s showers were scheduled Tuesdays and Fridays. There was no documentation to show the resident received showers on 4/9/19, 4/12/19, 4/16/19, 4/19/19, 4/22/19, 4/26/19, and 4/30/19. Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 5/1/19 to 5/30/19 showed the resident’s showers were scheduled Tuesdays and Fridays. There was no documentation to show the resident received showers on 5/3/19, 5/7/19, 5/10/19, and 5/21/19. The resident received showers on 5/13/19, 5/19/19 and 5/24/19. Observation on 6/9/19 1:30 P.M., showed the following: -The resident sat in his/her wheelchair and had a strong urine odor; -The resident appeared unkempt with greasy uncombed hair, and dried white substance around his/her mouth. Observation on 6/10/19 at 8:53 A.M. showed the following: -The resident had a strong urine odor; -The resident’s mouth had a dried white substance around his/her mouth. Observation on 6/11/19 at 6:41 A.M. showed the resident laid in bed with a strong urine odor noted. Observation on 6/11/19 at 6:45 A.M. showed the following: -CNA G entered the resident’s room to provide perineal/post-incontinence care; -The Director of Nurses (DON) entered the resident’s room to assist CNA G with providing care; -There was a strong odor of urine noted in the room; -The resident’s bed linens were saturated with urine; -The resident was incontinent of a large amount of feces; -CNA G used wash cloths to remove feces from the resident by smearing stool around the resident’s buttocks in a circular motion,; -The DON instructed CNA G to clean the resident up as best as he/she could because the resident was going to go to shower after he/she ate breakfast; -CNA G sprayed peri spray on a towel and used the towel to finish removing feces by wiping several times without changing the surface of the towel; -Staff assisted the resident to his/her right side; there was feces on his/her buttocks and coccyx (tailbone); |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 8) -CNA G and the DON applied an adult brief without removing feces from the resident’s right buttock and without washing the resident’s front perineal area; -CNA G told the DON that feces remained on the resident and it appeared that he/she was not done with having a bowel movement; -The DON obtained a wash cloth and cleansed the right buttock, but did not wash the resident’s front perineal or coccyx areas; -CNA G and the DON finished dressing the resident; -Staff continued prepping the resident for transfer even though bowel and bladder incontinence continued; -Staff transferred the resident to his/her wheelchair and then assisted him/her into the dining room for breakfast. During an interview on 6/11/19 at 7:30 A.M. CNA G said the following: -He/She should have allowed the resident to finish voiding before they placed him/her in the wheelchair; -They were just trying to get him/her down to eat breakfast; -It was difficult to get all tasks done due to shortage of staff. During an interview on 6/13/19 at 3:55 P.M., the DON said the following: -He/She was not used to the process regarding performance of peri-care and knew they were not performing it properly; -They should have stopped and let the resident finish voiding before they took him/her to the dining room to eat; -The resident should have been clean before going to breakfast. Observation on 6/11/19 10:54 A.M. showed the following: -The resident had a strong odor of urine; -The resident had a dried white substance around his/her mouth; -The resident’s hair appeared greasy. During an interview on 6/11/19 at 10:48 A.M., CNA D said the following: -He/She had not given the resident a shower yet this morning or had not started any of the scheduled showers; -It was hard to get everything done that needed to be done because of short staffing. Observation on 6/11/19 showed the following: -At 2:49 P.M., the resident lay in bed with a fecal odor noted; he/she dug at his/her peri area with his/her fingers -At 2:58 P.M., staff prepared the resident for transfer from the bed to his/her wheelchair; -The resident had smeared feces noted on his/her bed pad; -CNA E removed feces from the resident’s rectal and inner buttock areas by wiping multiple times without changing the surface of the cloth; -Staff did not provide peri-care to the resident’s front perineal area. Observation on 6/12/19 at 9:45 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room with urine odor noted; -The resident had a dried white substance around his/her mouth. 6. Review of Resident #24’s 30 day prospective payment system (PPS) MDS dated [DATE] showed the following: -The resident’s cognition was moderately impaired; -The resident was dependent on two staff with transfers and dressing; -The resident was dependent on one staff with personal hygiene and bathing; -The resident was always incontinent of bowel and bladder. Review of the resident’s care plan last reviewed on 4/29/19 showed the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 9) -The resident was required staff assistance with ADL’s related to intellectual disability; -Required staff assistance with pericare after each incontinence episode; -The resident was at risk for skin breakdown related to episodes of incontinence. Review of the resident’s undated CNA Care Card located in the resident’s room showed the following: -The resident required assistance of one staff for peri-care and incontinency care; -The resident wore incontinency briefs; -The resident was incontinent of bowel and bladder and required assistance of one staff with post-incontinence care. Observation on 6/11/19 at 3:58 P.M. showed the following: -CNA L entered the resident’s room; -The resident lay in bed on his/her left side; -The resident was incontinent of urine, his/her room had a strong urine odor and his/her bedding was saturated with urine; -The resident was incontinent of a moderate amount of feces; -CNA L removed feces with a wet wash cloth; -CNA L used a wet wash cloth without soap or peri wash to clean the resident’s perineal area and rectum; -CNA L used a wet wash cloth without soap or perineal wash to clean the resident’s inner and outer thighs, left side of the resident’s back and the resident’s buttocks that were in contact with urine. During an interview on 6/12/19 at 5:10 P.M. CNA L said the following: -The resident was incontinent of bowel and bladder; -The facility was short staffed which made staff rush with resident cares so they can get to the next resident; -He/She normally used soap or perineal wash to clean the incontinent residents; -The resident was saturated in urine from the middle of his/her back to his/her knees; -He/She was in a hurry when caring for the resident and failed to use soap or peri wash to clean the resident and failed to clean all areas of the resident that were in contact with urine and/or feces; -Not using soap or peri wash to clean the resident could cause the resident to get urinary tract infections and smell bad. 7. Record review of Resident #4’s annual MDS dated [DATE], showed the following: -Short term and long term memory problems; -Bathing somewhat important; -Frequently incontinent of bowel and bladder. Record review of the resident’s quarterly MDS, dated [DATE], showed the following: -Short term and long term memory problems; -No rejection of care; -Required extensive assistance of one staff for dressing and bathing; -Required total assistance of one staff for personal hygiene; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, revised 5/24/19, showed the following: -Assist as needed with oral care; -Assist with activities of daily living (ADLs); -Requires extensive assist with dressing, bathing, hygiene and bathing related to impaired cognition and visual function; -Shower two times per week. Check finger and toenails. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 10) Review of the resident’s CNA care card located in the resident’s closet, undated, showed the following: -Personal hygiene – brush teeth, comb hair, shave with assist of one staff; -Dressing – assist of one staff; -Bathing – shower with assist of one staff. Record review of the facility’s shower assignment sheet showed the resident was to have a shower on Tuesday and Friday evening shift. Review of the resident’s comprehensive CNA shower review documentation provided by the facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following: -The resident’s last documented shower was on 5/30/19; -No documentation to show the resident had been shaved or that cares had been provided or refused on 3/8/19, 3/12/19, 3/19/19, 4/2/19, 4/12/19, 4/19/19, 4/26/19, 4/30/19, 5/3/19, 5/7/19, 5/10/19, 5/14/19, 5/17/19, 5/24/19, 5/28/19 and 6/4/19. Observation on 06/10/19 at 5:10 P.M. showed the following: -The resident sat in a chair in the dining room; -The resident had unshaven facial hair resembling stubble; -The resident had a white film-like substance on his/her teeth. Observation on 06/11/19 at 11:30 A.M. showed the following: -The resident sat in a chair the dining room; -The resident had unshaven facial hair resembling stubble. Observation on 06/12/19 at 10:45 A.M. showed the following: -The resident sat on his bed in his/her room; -The resident had unshaven facial hair resembling stubble; -The resident had a white film-like substance on his/her teeth. During interview on 6/13/19 at 1:39, the resident’s guardian/family member said the following: -Oral care was not completed; -The resident had $5800 worth of dental work completed in (MONTH) 2019 due to the staff not completing oral care and the resident would not initiate oral care; -The resident had to take Tylenol ([MEDICATION NAME]) before every meal to be able to eat due to build up of residue on his/her teeth. He/she couldn’t eat; -The resident does not shave him/herself and he/she would want to be shaved daily. 8. Review of Resident #11’s care plan last reviewed on 3/19/19 showed the following: -The resident required staff reminders and supervision with bathing, and hygiene related to impaired thought process; -The resident was incontinent of urine and required staff to toilet at times; -Staff were to provide appropriate equipment for resident to groom self. Review of the resident’s quarterly MDS dated [DATE] showed the following: -The resident was cognitively intact; -The resident was independent with personal hygiene and bathing; -The resident was occasionally incontinent of bowel and bladder; -The resident refused care 4-6 times a week but not daily. Observation on 6/9/19 at 1:00 P.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled; -The resident had an approximately one inch long gray hair on his/her chin. Observation on 6/10/19 at 2:00 P.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 11) -The resident had an approximately one inch long gray hair on his/her chin. Observation on 6/11/19 at 5:29 A.M. and 2:05 P.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled; -The resident had an approximately one inch long gray hair on his/her chin. Observation on 6/12/19 at 10:54 A.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled; -The resident had an approximately one inch long gray hair on his/her chin. Observation on 6/13/19 at 10:15 A.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled. During interview on 6/13/19 at 10:15 A.M. the resident said the following: -His/Her family member came yesterday evening and shaved him/her; -He/She liked to be shaved and did not like facial hair; -He/She had asked the staff to shave him/her but they never had time. During an interview on 6/13/19 at 10:42 A.M. CNA K said the following: -He/She was on light duty and was responsible for shaving the residents; -He/She had not shaved the resident because he/she ran out of time; -The resident liked to be shaved; -The resident required staff to shave him/her. During an interview on 6/13/19 at 10:28 A.M. Registered Nurse (RN) M said the following: -The staff had to shave the resident; -The resident preferred his/her facial hair waxed but the facility didn’t wax the resident’s facial hair any longer; -The resident required staff assistance to be shaved. 9. Record review of Resident #16’s significant change MDS, dated [DATE], showed the following: -Cognition intact; -Bathing very important; -Always incontinent of bowel and bladder. Record review of the resident’s quarterly MDS, dated [DATE], showed the following: -Cognition intact; -No rejection of care; -Required total assistance of two or more staff for dressing; -Required total assistance of one staff for personal hygiene and bathing; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, revised 6/6/19, showed the following: -Requires assist with ADLs; -Assist with bathing; -Assist with dressing; -Shower or bath two times per week; -Supervise and assist the resident as needed while bathing/showering. Review of the resident’s CNA care card located in the resident’s closet, undated, showed the following: -Personal hygiene – brush teeth, comb hair, peri care and shave with assist of one staff; -Dressing – assist of one staff; -Bathing – shower with assist of one staff. Record review of the facility’s shower assignment sheet showed the resident was to have a |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 12) shower on Wednesday and Saturday evening shift. Review of the resident’s comprehensive CNA shower review documentation provided by the facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following: -The resident’s last documented shower was on 5/31/19; -No documentation to show the resident had been shaved or that cares had been provided or refused on 3/7/19, 4/6/19, 4/10/19, 4/17/19, 5/4/19, 5/8/19, 5/25/19, 6/1/19, 6/5/19, 6/8/19 and 6/11/19; -Resident refused a shower on 4/24/19 due to it was too late; -Resident refused a shower on 5/1/19 due to he/she was already in bed. Observation on 06/12/19 at 9:43 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident had unshaven facial hair resembling stubble. Observation on 06/13/19 at 1:00 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident had unshaven facial hair resembling stubble. During interview on 6/12/19 at 9:43 A.M., the resident said the following: -Staff help him/her shave on shower days; -Shower days are Wednesday and Saturday with the make-up day on Sunday, but if the facility is short staffed showers do not get done on Sundays; -It has been two weeks since he/she had a shower (review of the shower sheets show his last shower was 5/31/19); -He/She does not like the stubble of facial hair on his/her face. 10. Record review of Resident #25’s annual MDS, dated [DATE], showed the following: -Cognition intact; -Bathing somewhat important; -Frequently incontinent of bowel and bladder. Review of the resident’s quarterly MDS dated [DATE] showed the following: -The resident’s cognition was moderately impaired; -No rejection of care; -Required extensive assist of one staff with transfers, dressing, personal hygiene and bathing; -[DIAGNOSES REDACTED]. Review of the resident’s care plan last reviewed on 4/2/19 showed the following: -The resident is limited in ability to transfer self, related-to visual impairment and weakness: -Instruct the resident in proper transfer techniques; -Provide assistance for transferring; -The resident experiences bladder incontinence related to visual impairment and need of assistance for transfers. Review of the resident’s CNA care card located in the resident’s closet, undated, showed the following: -Personal hygiene – brush teeth, comb hair, peri care and shave with assist of one staff; -Dressing – assist of one staff; -Bathing – shower with assist of one staff. Record review of the facility’s shower assignment sheet showed the resident was to have a shower on Monday and Thursday evening shift. Review of the resident’s comprehensive CNA shower review documentation provided by the facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following: -The resident’s last documented shower was on 6/2/19; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 13) -No documentation to show the resident had been shaved or that cares had been provided or refused on 3/7/19, 3/14/19, 3/18/19, 3/21/19, 4/1/19, 4/4/19, 4/15/19, 4/22/19, 4/25/19, 4/29/19, 5/2/19, 5/6/19, 5/13/19, 5/16/19, 5/20/19, 5/30/19, 6/3/19, 6/6/19 and 6/10/19; -Resident refused his/her shower on 3/28/19, 4/8/19, 4/23/19 due to it was too late. 11. Record review of Resident #29’s significant change MDS, dated [DATE], showed the following: -Cognition severely impaired; -No rejection of care; -Prefers showers; -Requires total assist of one staff with dressing, personal hygiene and bathing; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan last reviewed on 6/9/19 showed the following: -When the resident wakes for the day, assist with morning cares; -Assist as needed with oral care; -Requires extensive with activities of daily living (ADLs) related-to [MEDICAL CONDITION] and cognitive impairment; -Shower two times per week. Check finger and toenails; -Provide pericare after toileting and after episodes of incontinence. Review of the resident’s CNA care card located in the resident’s closet, undated, showed the following: -Personal hygiene – brush teeth, comb hair, peri care and shave with assist of one staff; -Dressing – assist of one staff; -Bathing – shower with assist of one staff on Wednesday and Saturday. Record review of the facility’s shower assignment sheet showed the resident was to have a shower on Monday and Thursday day shift. Review of the resident’s comprehensive CNA shower review documentation provided by the facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following: -The resident’s last documented shower was on 6/4/19; -No documentation to show the resident had been shaved or that cares had been provided or refused on 4/1/19, 4/4/19, 4/8/19, 4/15/19, 4/22/19, 4/25/19, 4/29/19, 5/2/19, 5/6/19, 5/9/19, 5/13/19, 5/23/19, 6/6/19 and 6/10/19. Observation on 06/10/19 at 4:30 P.M. showed the following: -The resident sat in his/her wheelchair in the dining room; -The resident had unshaven facial hair resembling stubble. Observation on 06/12/19 at 10:00 A.M. showed the following: -The resident sat in a chair in the day room; -The resident had unshaven facial hair resembling stubble. 12. Review of Resident #37’s quarterly MDS dated [DATE] showed the following: -The resident’s cognition was severely impaired; -The resident was dependent on two staff for transfers; -The resident was dependent on one staff with dressing, toilet use, personal hygiene, and bathing; -The resident was always incontinent of bowel and bladder; -There was no documentation provided regarding the resident’s dental/oral status. Review of the resident’s care plan last reviewed on 4/17/19 showed the following: -The resident was totally dependent on staff for all ADLs; -The resident was incontinent of urine and wore an adult brief; -There was no documentation to show the resident’s bathing schedule and/or his/her |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 14) preferences. Review of the resident’s undated CNA Care Card located in the resident’s room showed the following: -The resident required assistance of one staff with brushing his/her teeth, combing his/her hair, peri-care, and shaving; -The resident was to receive a shower with assistance of one staff on Mondays and Thursdays; -The resident was incontinent of bowel and bladder and required assistance of one staff with post-incontinence care. Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 4/1/19 to 4/30/19 showed the resident’s showers scheduled on Mondays and Thursdays. There was no documentation to show the resident received showers on 4/2/19, 4/8/19, 4/11/19, 4/18/19, 4/22/19, 4/25/19, and 4/29/19. Staff documented that the resident received showers on 4/3/19 and 4/14/19 during this time frame. Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 5/19/19 to 5/31/19 showed the resident’s showers scheduled on Mondays and Thursdays. There was no documentation to show the resident received showers on 5/2/19, 5/6/19, 5/9/19, 5/16/19, 5/27/19, and 5/30/19. Staff documented that the resident received showers on 5/13/19, 5/19/19, 5/22/19, and 5/25/19 during this time frame. Review of resident’s Physician order [REDACTED]. Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 6/1/19 to 6/13/19 showed the resident’s showers scheduled on Mondays and Thursdays. There was no documentation to show the resident received showers on 6/6/19, 6/10/19, and 6/13/19. Staff documented that the resident received a shower on 6/2/19 during this time frame. Observation of the resident on 6/9/19 at 1:45 P.M. showed the following: -The resident sat in front of the nurse’s station with an orange colored substance on his/her shirt, pants, and wheelchair; -The resident had visible facial hair noted on his/her chin; -The resident had a strong urine odor. Observation on 6/11/19 at 5:30 A.M. showed the resident lay in bed with his/her eyes closed. A strong urine odor was noted in his/her room. Observation on 6/11/19 at 7:40 AM showed the following: -CNA D was assisting the resident up for the day; -The resident’s teeth had a white film on them; -The resident had visible facial hair on his/her chin; -CNA D failed to offer/provide oral care before assisting the resident to the dining room for breakfast. During an interview on 6/11/19 at 7:45 A.M., CNA D said it was difficult to complete resident’s showers due to the facility’s staffing shortage. Observation of the resident on 6/12/19 at 10:26 A.M. showed the following: -The resident sat in his/her wheelchair in the day area; -His/Her teeth had a white film on them; -The resident had visible facial hair noted on his/her chin; -The resident’s hair appeared greasy and unkempt. 13. Record review of Resident #41’s significant change MDS, dated [DATE], showed the following: -Cognition intact; -Bathing very important; -Frequently incontinent of bowel and bladder. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 15) Review of the resident’s quarterly MDS dated [DATE] showed the following: -Cognition intact; -No rejection of care; -Required supervision and setup help for bathing; -[DIAGNOSES REDACTED]. Review of the resident’s care plan last reviewed on 6/9/19 showed the following: -The resident is mostly independent with ADLs. Needs assist with showering and shaving; -Assist the resident with ADLs. Review of the resident’s CNA care card located in the resident’s closet, dated 6/26/18, showed the following: -Personal hygiene – brush teeth and comb hair independently; -Personal hygiene – shave with assist; -Dressing – independent; -Bathing – shower independently with assist on Monday and Thursday. Record review of the facility’s shower assignment sheet showed the resident was to have a shower on Wednesday and Saturday evening shift. Review of the resident’s comprehensive CNA shower review documentation provided by the facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following: -The resident’s last documented shower was on 6/1/19; -No documentation to show the resident had been shaved or that cares had been provided or refused on 3/2/19, 3/9/19, 4/6/19, 4/10/19, 4/13/19, 4/17/19, 4/24/19, 4/27/19, 5/4/19, 5/8/19, 5/18/19, 5/25/19, 5/29/19, 6/5/19 and 6/8/19. Observation on 06/9/19 at 2:22 P.M. showed the following: -The resident sat on his/her bed in his/her room; -The resident had unshaven facial hair resembling stubble. Observation on 6/11/19 at 1:30 P.M. showed the resident walked in the hallway with unshaven facial hair resembling stubble. During interview on 6/9/19 at 2:22 P.M., the resident said he/she did a lot of care for him/herself but required staff help with bathing and shaving. 14. During an interview on 6/11/19 at 7:45 A.M., CNA D said it was difficult to complete residents’ showers due to the facility’s staffing shortage. During an interview on 6/11/19 at 4:00 P.M., restorative aide (RA) RA/CNA A said the following: -Residents should be assisted with oral care twice a day; -Morning ADL cares should include oral hygiene, brushing resident’s teeth, shaving residents if needed, washing their faces, and combing hair; -Women should be shaved as well as men if they want facial hair removed. During an interview on 6/13/19 at 3:55 P.M., the MDS/Care Plan Coordinator said the following: -Oral hygiene should be offered/provided every morning, before residents go to bed, and as needed if staff noted a film on the resident’s teeth; -He/She would expect CNAs to follow the CNA Manual; -He/She would expect CNAs to follow the CNA guidelines when providing perineal care for both male and female residents; -He/She expected all areas of the perineum to b | |
| F 0678 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide basic life support, including CPR, prior to the arrival of emergency medical |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0678 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 16) personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 – Some | (continued… from page 17) showed the following: -Each community would appoint a fall champion to assist in the oversight and monitoring of the community’s fall prevention program; -Anyone who scored a ten or more on the fall risk assessment would be considered at risk for falls; -Admissions who scored a ten or more would be placed on the falling star program for two weeks and would be removed from the program if the resident did not fall within those two weeks; -The Fall Champion was responsible for ensuring a falling star was on the resident’s name plate and any equipment such as wheelchairs or walkers; -Every event report would be taken to a morning stand up meeting along with the resident’s chart for review by the interdisciplinary (IDT) team after the primary portion of the stand-up meeting was done; -Review of the resident’s events included review of nurse’s notes, neurological checks, interventions that were put into place, and surrounding circumstances that occurred prior to the resident’s fall; -Staff was to document the IDT note in the nurse’s note as to what happened, what was in place, and what was being done as well as any other information pertinent to prevention of future falls; -The resident’s care plans and care cards would be updated with writing FALL RISK in capital letters on the top of the care card and highlight in yellow to bring attention to the risk; -Weekly, the fall champion would monitor the falling star program to ensure that starts were placed on doors and equipment; -The IDT team would meet weekly and discuss the facility’s falls and the interventions put into place along with the effectiveness; -The fall champions would collaborate with the MDS Coordinator to ensure the resident’s care plan was updated as necessary. 2. Review of the facility’s undated policy for the Falling Star Program showed the following: -If a star was next to the resident’s name located on the door, this indicated the resident as at high risk for falling; -When walking down the hall, peek in on those residents to make sure they are not in a position to fall, they have their call light within reach, etc.; -Encourage the residents to keep their doors open unless the resident preferred otherwise. 3. Review of Resident #32’s [NAME]s Hopkins Fall Risk Assessment Tool, dated 3/27/19, |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 – Some | (continued… from page 18) -Interventions implemented to prevent further falls included to not leave the resident in his/her room alone; -Staff documented the interventions were effective; -Staff documented the care plan was reviewed. Review of the resident’s care plan showed no documentation regardings the resident’s fall on 4/16/19, including interventions to prevent further falls. Review of the resident’s event report, dated 4/20/19, showed the following: -The resident experienced an unwitnessed fall in his/her room on 4/19/19 at 10:30 P.M.; -The resident was lying in his/her bed just prior to the fall; -There were no preventative interventions implemented; -Staff documented interventions were effective. Review of the resident’s care plan showed no evidence staff re-evaluated current fall interventions or implemented new interventions after the resident fell on [DATE]. Review of the resident’s event report, recorded on 4/20/19, showed the following: -The resident experienced an unwitnessed fall in his/her room on 4/20/19 at 4:15 A.M.; -The resident was lying in bed prior to the fall; -The resident complained of mild pain to his/her left cheek and left shoulder; -Preventative interventions implemented included placement of a fall mat; -Staff documented interventions were effective; -Staff documented the care plan was not reviewed. Review of the resident’s care plan showed no documentation regarding the resident’s fall on 4/20/19. Review of the resident’s care plan, last reviewed on 4/24/19, showed the following: -The resident was at risk for falls related to use of [MEDICAL CONDITION] medications; -The resident liked to lay on the floor at times; -The resident was instructed to seek assistance with getting up; -The resident’s bed was to remain in the lowest position when the resident was unattended. Review of the resident’s event report, dated 4/25/19, showed the following: -The resident experienced an unwitnessed fall in his/her room; -There was no documentation to show what the resident was doing just prior to the fall; -There were no preventative interventions implemented. Review of the resident’s care plan showed no evidence staff re-evaluated current fall interventions or implemented new interventions to prevent further falls after the resident fell on [DATE]. Review of the resident’s event report, dated 5/16/19, showed the following: -The resident experienced an unwitnessed fall in his/her room on 5/16/19 at 1:30 A.M.; -The resident was lying in bed prior to the fall; -The resident suffered a 2 centimeter (cm) by 2 cm laceration to the left hip area; -Preventative interventions implemented included to ensure the resident’s necessary items were in reach; -Staff documented the care plan was not reviewed. Review of the resident’s care plan showed no documentation regarding the resident’s fall on 5/16/19. Review of the resident’s care plan, revised on 6/4/19, showed the following: -The resident fell on [DATE], 4/19/19, 4/20/19, 4/22/19, and 4/24/19; -The resident was found on the floor next to the bed during the falls; -Falls occurred early morning or on the evening shift; -On 5/16/19, the resident was found on the fall mat next to his/her bed; -The resident was placed on the falling star program on 5/8/19. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 – Some | (continued… from page 19) Observation on 6/11/19 at 5:30 A.M. showed the resident lay in bed in his/her room unattended. During an interview on 6/12/19 at 4:54 P.M., Certified Nurse Assistant (CNA) E said the following: -There was not enough staff to have someone stay with the resident when he/she was in his/her room; -The resident was in a high low bed but it did not go completely to the floor; -He/she checked on the resident every chance he/she got; -Staff has tried everything, but the resident continued to put himself/herself on the floor and would not stay in bed. During an interview on 6/13/19 at 10:30 A.M., Licensed Practical Nurse (LPN) I said the following: -The resident slid himself/herself on the floor because he/she liked to be on the floor; -It was difficult to have staff with the resident while he/she was in his/her room, especially due to the staffing the facility had at that time; -Charge nurses were responsible for updating the resident’s care plans after falls. 4. Review of Resident #53’s significant change MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment; -Independent with transfers; -Not stable during surface to surface transfers; -[DIAGNOSES REDACTED]. -Had one fall without injury since admission and prior assessment. Review of the resident’s care plan, approach date 3/14/19, showed the following: -The resident was at risk for falls; -The resident has limited range of motion to his/her left arm; -The resident’s fall mat was removed due to increased independence. Review of the resident’s event report, recorded on 4/22/19, showed the following: -The resident was coming out of the bathroom and was seen trying to push the door with his/her shoulder. The resident lost his/her balance and slid down the wall onto his/her buttocks; -Staff documented the interventions were effective; -Staff did not document any interventions to be put in place following the fall; -Staff documented the care plan was not reviewed. Review of the resident’s care plan showed the following: -The resident fell coming out of the bathroom on 4/22/19; -No evidence staff re-evaluated current fall interventions or implemented new interventions after the resident fell on [DATE]. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment; -Independent with transfers; -Used a cane or crutch; -Independent with locomotion on and off the unit; -Was not stable from surface to surface transfers; -Had one fall without injury since admission and prior assessment on 1/24/19. Review of the resident’s event report, recorded on 5/4/19, showed the following: -Witnessed fall at 9:15 A.M.; -The resident attempted to sit down in a chair in the sun room, misjudged, and fell to the floor; -Staff assisted the resident into the chair; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 – Some | (continued… from page 20) -Staff will continue to monitor; -Staff did not document if interventions were effective or interventions put in place to prevent further falls. Review of the resident’s care plan showed the following: -The resident fell coming out of the bathroom on 5/4/19; -Staff documented on 5/4/19 the resident had poor safety awareness and is easily agitated during care; -No evidence staff re-evaluated current fall interventions or implemented new interventions after the resident fell on [DATE]. 5. Review of Resident #4’s care plan, dated 8/13/16, showed the following: -Resident at risk for falls related to poor safety awareness, use of [MEDICAL CONDITION] medication, visual impairment, and gait/balance is unsteady at times; -Keep pathways clear for him/her to ambulate; -Attempt to identify reason for him/her wanting to get up, offer assistance as appropriate; -Continue to monitor for safety and provide assistance with ambulation; -Encourage him/her to wear tennis shoes or non-skid socks when up. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -The resident had short and long-term memory problems; -The resident required extensive assistance from one staff for bed mobility, transfers, walking in room or corridor, locomotion on and off of the unit, dressing and toileting; -The resident was not steady but was able to stabilize without staff assistance when moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfers; -There were no falls documented since the previous comprehensive assessment (2/9/19). Review of the resident’s [NAME]s Hopkins Fall Risk Assessment Tool, dated 5/17/19, showed a score of 22, which indicated the resident was at high risk for falling. Observation on 6/9/19 at 4:26 P.M., showed the staff assisted the resident to walk from his/her room to the dining room. The resident wore regular socks without non-skid grippers. Observation on 6/9/19 at 4:33 P.M., showed the resident got up from his/her chair in the dining room and walked to the exit door in his/her socked feet. Staff instructed the resident to get away from the door. The DON assisted him/her to sit back down. Observation on 6/9/19 at 4:52 P.M., showed the resident stood up and went to the exit door again in his/her socked feet. The DON assisted him/her to sit down. Observation on 6/9/19 at 4:55 P.M., showed the resident then stood again at the door. Staff told the resident to get away from the door. The DON assisted the resident to walk back into his/her room. The resident was not wearing shoes and did not wear non-skid socks. Observation on 6/13/19 at 2:10 P.M. showed the resident walked in the hall with socked feet without non-skid grippers. During interview on 6/13/19 at 2:35 P.M., CNA L said the following: -Staff put non-skid socks and shoes on the resident to prevent falls; -The resident does what he/she wants; -The resident should wear non-skid socks all the time; -The CNA assigned to getting the resident up for the day is responsible for putting non-skid socks on the resident; -The resident should have non-skid socks on and he/she doesn’t know why the resident doesn’t. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 – Some | (continued… from page 21) During interview on 6/13/19 at 2:38 P.M., LPN I said the CNAs should make sure the resident wears the non-skid socks and they are on him/her when he/she gets up in the morning. During interview on 6/13/19 at 4:55 P.M., the Director of Nursing (DON) and MDS/care plan coordinator said the following: -Residents should wear non-skid socks when it is care planned; -The nurse or CNA is responsible for making sure the residents wear no-skid socks. 6. During an interview on 6/12/19 at 4:44 P.M. and 6/13/19 at 4:55 P.M., the MDS/Care Plan Coordinator said it was the charge nurses were responsible to review and update the residents’ care plans after falls.The charge nurses had a difficult time coming up with interventions. She and the administrator tried to review falls and make sure interventions were put in to place. The interdisciplinary team (IDT) had not been meeting about falls as they should due to being short staffed and not having a DON. During an interview on 6/20/19 at 1:41 P.M., the MDS/Care Plan Coordinator said the following: -The charge nurse should put fall interventions in place and update the care plan at the time a resident falls; -The fall champion is normally the DON but the facility had been without a DON; -The Administrator and Care plan/MDS Coordinator were trying to fill in as the fall champion; -The fall champion was in charge of making sure the fall interventions were appropriate and put on the care plan along with making sure fall events were completed; -After reviewing Resident #53’s interventions, he/she was not sure why there weren’t interventions for each fall. | |
| F 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Past noncompliance – remedy proposed **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 22) -Site should be monitored for signs of infection; -Nursing staff should check and document the thrill (important sound and indicator of how well the [MEDICAL TREATMENT] fistula is functioning) daily; -Staff should contact the physician if no thrill sensation is felt. 2. Review of the Resident #14’s physician’s orders [REDACTED]. Review of the resident’s significant change Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 5/19/19 showed the following: -The resident’s cognition was intact; -The resident received [MEDICAL TREATMENT]. Review of the resident’s care plan last reviewed on 6/4/19 showed no documentation the resident had a [MEDICAL TREATMENT] shunt/fistula. Review of the resident’s undated certified nursing assistant (CNA) care card showed no documentation regarding the resident’s [MEDICAL TREATMENT] shunt/fistula. Observation on 6/10/19 at 4:43 P.M. showed the following: -The resident returned from [MEDICAL TREATMENT] at approximately 3:00 P.M.; -His/Her right arm was wrapped with a gauze dressing; During interview on 6/10/19 at 11:12 AM. and 4:45 P.M., the resident said the following: -He/She had a [MEDICAL TREATMENT] shunt/fistula located in his/her upper right arm; -He/She received [MEDICAL TREATMENT] treatments every Monday, Wednesday, and Friday; -Staff did not monitor his/her [MEDICAL TREATMENT] shunt daily or when he/she returned from [MEDICAL TREATMENT] treatments; -He/She had to leave a dressing on the [MEDICAL TREATMENT] shunt/fistula area after his/her treatment to make sure that it did not bleed; -Facility staff did not come down and assess his/her [MEDICAL TREATMENT] shunt /fistula area when he/she returned from [MEDICAL TREATMENT]. Review of the resident’s medical record showed the following: -There were no documented daily assessments of the resident’s [MEDICAL TREATMENT] shunt/fistula; -There was no documented assessment of the resident’s [MEDICAL TREATMENT] shunt/fistula when he/she returned from [MEDICAL TREATMENT] on 6/10/19. During an interview on 6/11/19 at 2:40 P.M., Licensed Practical Nurse (LPN) C said the following: -He/She was unaware of any specific documented assessments to monitor the resident’s [MEDICAL TREATMENT] shunt/fistula; -He/She never cared for a resident with a [MEDICAL TREATMENT] shunt/fistula and did not know how to check for bruit (sound generated by turbulent blood flow in an artery due to either an area of partial obstruction or high rate of blood flow through an unobstructed artery); -He/She had worked at the facility for two years and this resident was the first he/she had cared for that required [MEDICAL TREATMENT]. During an interview on 6/13/19 at 10:30 A.M., LPN I said the following: -He/She did not know what to assess for with a resident who had a [MEDICAL TREATMENT] shunt/fistula; -There was no specific assessment that was required; -The facility and/or the [MEDICAL TREATMENT] center did not provide any education on how to care for a resident with a [MEDICAL TREATMENT] shunt/fistula; -The resident had the shunt/fistula for approximately two months and started [MEDICAL TREATMENT] approximately one month ago. During an interview on 6/3/19 at 11:54 A.M., LPN H said the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) -He/She just found out that there was a policy for [MEDICAL TREATMENT] residents; -Staff had not been assessing the resident’s [MEDICAL TREATMENT] shunt/fistula; -If the facility had a Director of Nursing (DON) to provide education maybe they would have been doing them like they should have. During an interview on 6/11/19 at 2:30 P.M., Registered Nurse (RN) B said the following: -There were no specific assessments of the resident’s [MEDICAL TREATMENT] shunt/fistula completed daily or when the resident returned from [MEDICAL TREATMENT]; -There should be a documented assessment, but that has been overlooked. During an interview on 6/13/19 at 3:55 P.M., the MDS/Care Plan coordinator said the following: -Residents who have [MEDICAL TREATMENT] shunts/fistulas should be assessed every day by the charge nurse; -Resident’s care plan and CNA care cards should include care of the resident’s [MEDICAL TREATMENT] shunt/fistula; -There had been no education provided to the staff regarding care/assessment of the [MEDICAL TREATMENT] shunt/fistula. | |
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 24) the following: -Required extensive assistance of one staff for bathing; -Required total assistance of one staff for personal hygiene. Review of the resident’s care plan, revised 5/24/19, showed the following: -Assist as needed with oral care; -Requires extensive assist with dressing, bathing, hygiene and bathing related to impaired cognition and visual function; -Shower two times per week. Review of the resident’s undated certified nurse assistant (CNA) care card, located in the resident’s closet, showed the following: -Personal hygiene – brush teeth, comb hair, shave with assist of one staff; -Bathing – shower with assist of one staff. Record review of the facility’s shower assignment sheet showed the resident was to have a shower on Tuesday and Friday evening shift. Review of the resident’s comprehensive CNA shower review documentation, provided by the facility for (MONTH) 2019 through 6/11/19, showed the following: -The resident’s last documented shower was on 5/30/19; -No documentation to show the resident had been shaved or care had been provided or refused on 3/8/19, 3/12/19, 3/19/19, 4/2/19, 4/12/19, 4/19/19, 4/26/19, 4/30/19, 5/3/19, 5/7/19, 5/10/19, 5/14/19, 5/17/19, 5/24/19, 5/28/19 and 6/4/19. Observation on 06/10/19 at 5:10 P.M. showed the following: -The resident sat in a chair in the dining room; -The resident had unshaven facial hair resembling stubble; -The resident had a white film substance on his/her teeth. Observation on 06/11/19 at 11:30 A.M. showed the following: -The resident sat in a chair the dining room; -The resident had unshaven facial hair resembling stubble. Observation on 06/12/19 at 10:45 A.M. showed the following: -The resident sat on his bed in his/her room; -The resident had unshaven facial hair resembling stubble; -The resident had a white film substance on his/her teeth. 4. Review of Resident #11’s care plan, last reviewed on 3/19/19, showed the following: -The resident required staff reminders and supervision with bathing, and hygiene related to impaired thought process; -Staff was to provide appropriate equipment for resident to groom self. Review of the resident’s quarterly MDS dated [DATE] showed the following: -The resident was cognitively intact; -The resident was independent with personal hygiene and bathing. Observation on 6/9/19 at 1:00 P.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled; -The resident had approximately 1 inch long gray hairs on his/her chin. Observation on 6/10/19 at 2:00 P.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled; -The resident had approximately 1 inch long gray hairs on his/her chin. Observation on 6/11/19 at 5:29 A.M. and 2:05 P.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 25) -The resident had approximately 1 inch long gray hairs on his/her chin. Observation on 6/12/19 at 10:54 A.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled; -The resident had approximately 1 inch long gray hairs on his/her chin. Observation on 6/13/19 at 10:15 A.M. showed the following: -The resident sat in his/her chair; -The resident’s hair was oily and disheveled. During interview on 6/13/19 at 10:15 A.M., the resident said the following: -His/Her family member came yesterday evening and shaved him/her; -He/She liked to be shaved and did not like facial hair; -He/She had asked the staff to shave him/her but they never had time. During an interview on 6/13/19 at 10:42 A.M., CNA K said the following: -He/She was on light duty and was responsible for shaving the residents; -He/She had not shaved the resident because he/she ran out of time; -The resident liked to be shaved; -The resident required staff to shave him/her. During an interview on 6/13/19 at 10:28 A.M., Registered Nurse (RN) M said the following: -The staff had to shave the resident; -The resident preferred his/her facial hair waxed but the facility didn’t wax the resident’s facial hair any longer; -The resident required staff assistance to be shaved. 5. Record review of Resident #16’s quarterly MDS, dated [DATE], showed the following: -Cognition intact; -Required total assistance of one staff for personal hygiene and bathing. Review of the resident’s care plan, revised 6/6/19, showed the following: -Requires assist with ADLs; -Assist with bathing; -Assist with dressing; -Shower or bath two times per week; -Supervise and assist the resident as needed while bathing/showering. Review of the resident’s CNA care card, located in the resident’s closet, undated, showed the following: -Personal hygiene- brush teeth, comb hair, peri care and shave with assist of one staff; -Assist of one staff for dressing and showers. Record review of the facility’s shower assignment sheet showed the resident was to have a shower on Wednesday and Saturday evening shift. Review of the resident’s comprehensive CNA shower review documentation, provided by the facility for (MONTH) 2019 through 6/11/19, showed the following: -The resident’s last documented shower was on 5/31/19; -No documentation to show the resident had been shaved or that cares had been provided or refused on 3/7/19, 4/6/19, 4/10/19, 4/17/19, 5/4/19, 5/8/19, 5/25/19, 6/1/19, 6/5/19, 6/8/19 and 6/11/19; -Resident refused a shower on 4/24/19 due to it was too late; -Resident refused a shower on 5/1/19 due to he/she was already in bed. Observation on 06/12/19 at 9:43 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident had unshaven facial hair resembling stubble. Observation on 06/13/19 at 1:00 P.M. showed the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 26) -The resident sat in his/her wheelchair in his/her room; -The resident had unshaven facial hair resembling stubble. During interview on 6/12/19 at 9:43 A.M., the resident said the following: -Staff help him/her shave on shower days; -Shower days are Wednesday and Saturday with the make-up day on Sunday, but if the facility is short staffed showers do not get done on Sundays; -It has been two weeks since he/she had a shower (review of the shower sheets show his last shower was 5/31/19); -He/She does not like the stubble of facial hair on his/her face. During interview on 6/9/19 at 1:38 P.M, the resident said he/she needed help toileting this morning but he/she was told he/she needed to wait because they were short staffed and only had one aide for the day. He/she likes to get up at 4:00 A.M., but staff told him/her he/she had to stay in bed until 6:00 A.M. when the day shift arrived due to he/she was passing medications and the other staff member was busy (only had two staff on the schedule for the night shift). 6. Review of Resident #25’s quarterly MDS, dated [DATE], showed the following: -The resident received restorative therapy for passive range of motion (PROM – involves assistance in moving a joint) two days out of the last seven; -The resident received restorative therapy for walking four days out of the last seven. Review of the resident’s care plan, last reviewed on 4/2/19, showed the following: -The resident is limited in ability to transfer self related to visual impairment and weakness: -Restorative program three times weekly for PROM to upper body and ambulation; -Instruct the resident in proper transfer techniques; -Provide assistance for transferring. -The resident experiences bladder incontinence related to visual impairment and need of assistance for transfers. Review of the resident’s undated Certified Nurse Aide (CNA) Care Card showed the following: -Restorative and nursing interventions for walk to dine, multi podus boots (used for those at risk for plantar flexion contracture, foot drop, hip rotation and decubitus heel ulcers) on as tolerated and AFO (ankle and foot orthoses brace) on while in wheelchair; -Personal hygiene – brush teeth, comb hair, peri care and shave with assist of one staff; -Dressing – assist of one staff; -Bathing – shower with assist of one staff. Record review of the facility’s shower assignment sheet showed the resident was to have a shower on Monday and Thursday evening shift. Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed staff documented the resident received restorative therapy one out of two days for active range of motion (AROM – exercises the resident is able to perform independently) and walking. Review of the resident’s physician orders [REDACTED]. Review of the resident’s Restorative Nursing Report, dated 5/12/19 to 6/11/19, showed the following: -Staff documented the resident received restorative therapy zero days out of 34 for PROM; -Staff documented the resident received restorative therapy eight days out of 34 for walking. Review of the resident’s comprehensive CNA shower review documentation, provided by the facility for (MONTH) 2019 through 6/11/19, showed the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 27) -The resident’s last documented shower was on 6/2/19; -No documentation to show the resident had been shaved or that cares had been provided or refused on 3/7/19, 3/14/19, 3/18/19, 3/21/19, 4/1/19, 4/4/19, 4/15/19, 4/22/19, 4/25/19, 4/29/19, 5/2/19, 5/6/19, 5/13/19, 5/16/19, 5/20/19, 5/30/19, 6/3/19, 6/6/19 and 6/10/19; -Resident refused shower on 3/28/19, 4/8/19, 4/23/19 due to it was too late. 7. Review of Resident #30’s physician order, dated 3/27/19, showed the following: -[DIAGNOSES REDACTED]. -Restorative aide three times a week for range of motion for upper extremities and lower extremities. Review of resident’s care plan, last reviewed 4/4/19, showed the following: -The resident’s ability to perform activities of daily living (ADLs) was at risk for deterioration due to weakness and [DIAGNOSES REDACTED]. -The resident required assistance of one staff with ADLs; -The resident was to receive restorative therapy three times a week for neck support and range of motion (ROM). Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed staff documented the resident received restorative therapy six days out of 12. Review of the resident’s Restorative Nursing Report, dated 5/12/19 to 6/11/19, showed staff documented the resident received restorative therapy three days out of 12. During an interview on 6/11/19 at 4:00 P.M., Restorative Aide (RA)/CNA A said the following: -The resident was supposed to receive restorative therapy three times a week; -He/She was unable to provide therapy because he/she was pulled to work other areas and tasks due to staff shortage; -Not receiving restorative care could cause a decline. 8. Review of Resident #31’s care plan, last reviewed 4/4/19, showed the following: -The resident’s ability to perform ADLs was at risk for deterioration due to weakness and [DIAGNOSES REDACTED]. -The resident required assistance of one staff with ADLs; -The resident was to receive restorative therapy three times a week for neck support and range of motion (ROM). Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed the facility’s staff documented the resident received restorative therapy four days out of 12. Review of the resident’s Restorative Nursing Report, dated 5/12/19 to 6/11/19, showed staff documented the resident received restorative therapy two days out of 12. During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following: -The resident was supposed to receive restorative therapy three times a week; -He/She was unable to provide therapy because he/she was pulled to work other areas and tasks due to staff shortage; -The resident had declined within the last couple of weeks; -The resident had orders to walk to dine, but it was not being done because he/she was unable to walk with him/her. 9. Review of Resident #40’s care plan, last reviewed on 4/29/19, showed the following: -The resident was totally dependent on staff for all ADLs due to [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke) with left sided [MEDICAL CONDITION] (paralysis of one side of the body), weakness, impaired mobility, and unsteady balance; -The resident was to receive restorative therapy three times a week with staff performing PROM to all of the resident’s joints to improve and maintain the resident’s left upper extremity range of motion; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 28) -The resident was supposed to wear a resting hand splint (on his/her left hand). Review of the resident’s undated CNA Care Card showed no documentation the resident received restorative nursing services or that he/she was supposed to wear a hand splint. Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed the following: -Staff documented the resident received restorative therapy six days out of 12; -There was no documentation to show the resident refused to wear the left hand splint. Review of the resident’s Restorative Nursing Report, dated 5/12/19 to 6/11/19, showed the following: -Staff documented the resident received restorative therapy one day out of 12; -There was no documentation to show the resident refused to wear the left hand splint. Observation on 6/09/19 at 4:00 P.M. showed the following: -The resident sat in his/her wheelchair outside of his/her room. His/her head leaned to the right side; -The resident’s left hand was contracted; -There was no splint on his/her left hand. Observation on 6/10/19 at 8:59 A.M. showed the following: -The resident sat in his/her wheelchair; -The resident’s left hand and left foot were contracted; – There was no splint on his/her left hand. During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following: -The resident was supposed to have restorative therapy three times a week, but he/she had been pulled from his/her restorative nursing duties to perform care; -He/She was also unable to complete restorative nursing duties because he/she took residents to appointments, completed residents’ weights and vital signs, attended care plan meetings, and updated CNA Care Cards; -There was a second CNA trained to assist with restorative therapy, but he/she worked as a CNA on the day shift and was unable to assist with restorative therapy; -The resident was supposed to wear a brace to his/her left hand and he/she had tried, but the resident refused to wear the brace. 10. Review of Resident #54’s annual MDS, dated [DATE], showed the following: -The resident’s range of motion was impaired on one side of upper and lower extremities; -The resident received restorative therapy three out of the previous seven days. Review of the resident’s care plan, last updated on 6/9/19, showed the following: -The resident required extensive assistance with ADLs related to [DIAGNOSES REDACTED]. -The resident was to wear a splint to his/her left hand to assist with contraction; -The resident was to have restorative therapy three times a week for left upper extremity range of motion and right upper extremity strength. Review of the resident’s undated care card showed the following: -The resident had left sided weakness; -He/She was to have a splint applied in the morning and removed at night (no documentation to show the type of splint the resident was to wear). Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed the following: -Staff documented the resident received restorative therapy six days out of 12; -There was no documentation to show the resident refused wearing the left hand splint. Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed the following: -Staff documented the resident received restorative therapy two days out of 12; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 29) -There was no documentation to show the resident refused wearing the left hand splint. Observation on 6/10/19 at 1:47 P.M. showed the following: -The resident’s left hand was contracted; -No splint on his/her left hand. 11. Record review of Resident #29’s significant change MDS, dated [DATE], showed the resident requires total assist of one staff with personal hygiene and bathing. Review of the resident’s care plan, last reviewed on 6/9/19, showed the following: -When the resident wakes for the day, assist with morning cares; -Assist as needed with oral care; -Requires extensive with activities of daily living (ADLs) related-to [MEDICAL CONDITION] and cognitive impairment; -Shower two times per week. Review of the resident’s CNA care card, located in the resident’s closet, undated, showed the following: -Personal hygiene – shave with assist of one staff; -Bathing – shower with assist of one staff on Wednesday and Saturday. Record review of the facility’s shower assignment sheet showed the resident was to have a shower on Monday and Thursday day shift. Review of the resident’s comprehensive CNA shower review documentation provided by the facility for (MONTH) 2019 through 6/11/19, showed the following: -The resident’s last documented shower was on 6/4/19; -No documentation to show the resident had been shaved or that cares had been provided or refused on 4/1/19, 4/4/19, 4/8/19, 4/15/19, 4/22/19, 4/25/19, 4/29/19, 5/2/19, 5/6/19, 5/9/19, 5/13/19, 5/23/19, 6/6/19 and 6/10/19. Observation on 06/10/19 at 4:30 P.M. showed the following: -The resident sat in his/her wheelchair in the dining room; -The resident had unshaven facial hair resembling stubble. Observation on 06/12/19 at 10:00 A.M. showed the following: -The resident sat in a chair in the day room; -The resident had unshaven facial hair resembling stubble. 12. Review of Resident #37’s quarterly MDS, dated [DATE], showed the following: -The resident’s cognition was severely impaired; -The resident was dependent on one staff with dressing, toilet use, personal hygiene, and bathing; -The resident was always incontinent of bowel and bladder. Review of the resident’s undated CNA Care Card, located in the resident’s room, showed the following: -The resident required assistance of one staff with brushing his/her teeth, combing his/her hair, peri-care, and shaving; -The resident was to receive a shower with assistance of one staff on Mondays and Thursdays; -The resident was incontinent of bowel and bladder and required assistance of one staff with post-incontinence care. Review of the resident’s skin monitoring/comprehensive CNA shower reviews, dated 4/1/19 to 4/30/19, showed the resident’s showers were scheduled on Mondays and Thursdays. There was no documentation to show the resident received showers on 4/2/19, 4/8/19, 4/11/19, 4/18/19, 4/22/19, 4/25/19, and 4/29/19. Staff documented the resident received showers on 4/3/19 and 4/14/19 during this time frame. Review of the resident’s skin monitoring/comprehensive CNA shower reviews, dated 5/19/19 |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 30) to 5/31/19, showed the resident’s showers were scheduled on Mondays and Thursdays. There was no documentation to show the resident received showers on 5/2/19, 5/6/19, 5/9/19, 5/16/19, 5/27/19, and 5/30/19. Staff documented the resident received showers on 5/13/19, 5/19/19, 5/22/19, and 5/25/19 during this time frame. Review of the resident’s skin monitoring/comprehensive CNA shower reviews, dated 6/1/19 to 6/13/19, showed the resident’s showers were scheduled on Mondays and Thursdays. There was no documentation to show the resident received showers on 6/6/19, 6/10/19, and 6/13/19. Staff documented the resident received a shower on 6/2/19 during this time frame. Observation on 6/9/19 at 1:45 P.M. showed the following: -The resident sat in front of the nurse’s station with an orange colored substance on his/her shirt, pants, and wheelchair; -The resident had visible facial hair noted on his/her chin; -The resident had a strong urine odor. Observation on 6/11/19 at 5:30 A.M. showed the resident lay in bed with his/her eyes closed. A strong urine odor was noted in his/her room. Observation on 6/11/19 at 7:40 AM showed the following: -CNA D was assisting the resident up for the day; -The resident’s teeth had a white film on them; -The resident had visible facial hair on his/her chin; -CNA D did not offer or provide oral care before assisting the resident to the dining room for breakfast. During an interview on 6/11/19 at 7:45 A.M., CNA D said it was difficult to complete resident’s showers due to the facility’s staffing shortage. Observation resident on 6/12/19 at 10:26 A.M. showed the following: -The resident sat in his/her wheelchair in the day area; -His/Her teeth had a white film on them; -The resident had visible facial hair noted on his/her chin; -The resident’s hair appeared greasy and unkempt. 13. Review of Resident #41’s quarterly MDS, dated [DATE], showed the following: -Cognition intact; -Required supervision and setup help for bathing. Review of the resident’s care plan, last reviewed on 6/9/19, showed the resident is mostly independent with ADLs. The resident needs assist with showering and shaving. Review of the resident’s CNA care card, located in the resident’s closet, dated 6/26/18, showed the following: -Personal hygiene-shave with assist; -Bathing-shower independently with assist on Monday and Thursday. Record review of the facility’s shower assignment sheet showed the resident was to have a shower on Wednesday and Saturday evening shift. Review of the resident’s comprehensive CNA shower review documentation provided by the facility for (MONTH) 2019 through 6/11/19, showed the following: -The resident’s last documented shower was on 6/1/19; -No documentation to show the resident had been shaved or that cares had been provided or refused on 3/2/19, 3/9/19, 4/6/19, 4/10/19, 4/13/19, 4/17/19, 4/24/19, 4/27/19, 5/4/19, 5/8/19, 5/18/19, 5/25/19, 5/29/19, 6/5/19 and 6/8/19. Observation on 06/9/19 at 2:22 P.M. showed the following: -The resident sat on his/her bed in his/her room; -The resident had unshaven facial hair resembling stubble. Observation on 6/11/19 at 1:30 P.M. showed the resident walked in the hallway with |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 31) unshaven facial hair resembling stubble. During interview on 6/9/19 at 2:22 P.M., the resident said he/she did a lot of care for him/herself but required staff help with bathing and shaving. 14. During interview on 6/13/19 at 4:55 P.M, the DON and MDS/care plan coordinator said the facility is short staffed and when there are only two CNAs the department heads help out to complete resident’s needs and cares. Review of the daily staffing from 5/1/19 to 6/7/19 showed the following: -The administrator worked the floor as a CMT/CNA 12 out 38 days; -The night shift only had two staff for 24 days out of 38 days. During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following: -He/She was unable to complete the resident’s restorative therapy the last couple of weeks because he/she was pulled from his/her restorative nursing duties to provide resident care; -He/She was pulled from his/her restorative nursing duties to provide resident care at least once or twice a week due to lack of staff. During interview on 6/11/19 at 10:30 A.M., RA/CNA A said the following: -He/She was working as a CNA today. There is a backup RA when he/she was not here but the backup RA was off today; -He/She was to do RA today but got pulled to the floor due to short staffed for CNAs; -He/She has been pulled from RA to CNA a lot lately, like twice a week. He/She was hired to be a RA and he/she feels like he/she is letting the residents down as they are not getting what they are supposed to get for restorative; -He/She felt like residents were declining as he/she was unable to do the restorative when he/she gets pulled to the floor. During an interview on 6/13/19 at 3:55 P.M., the MDS/Care Plan Coordinator said the following: -He/She would not expect the RA to be pulled from restorative duties to provide resident care; -The RA had been pulled from his/her restorative nursing duties to provide resident care within the last month or two due to lack of staff. During interview on 6/13/19 at 11:18 A.M., the Administrator said the following: -The facility has had staffing issues since May; -They have tried recruiting and have hired several staff but none stay; -They use PPD (per patient day which is census times eight times seven divided by 40) to get the total number of staff needed per shift; -They do not use the facility assessment or acuity to staff the facility; -She would prefer and according to the PPD they should have two to four licensed staff and four to five CNAs on the day shift, and two licensed staff and four to five CNAs on the evening shift, and one licensed staff and two to three CNAs on night shift; -The facility had several night shifts that only had two staff members on the shift which included one licensed nurse and one CNA/Nurse Aide (NA)/CMT; -Staff was not able to get the residents shaved, clean under the finger nails, and showers completed since the facility had been short staffed; -She has worked the floor as a CMT and CNA to provide resident care. | |
| F 0727 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0727 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 32) director of nurses on a full time basis. Based on interview and record review, the facility failed to provide the services of a | |
| F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Based on observation and interview, the facility failed to serve food that was palatable |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 – Some | (continued… from page 33) degrees Fahrenheit. During interview on 06/10/19 at 02:49 P.M., the dietary manager said staff only take the temperatures of the food when they put the food on the steam table. She expected the food to be served at 120 degrees Fahrenheit or above. She was not aware the serving temperatures did not meet the 120 degree temperature. During interview on 06/11/19 at 11:10 A.M., the administrator said she expected the food temperatures to be at least 120 degrees Fahrenheit at the time of service. | |
| 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: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 34) -Do not shake or place linen directly on the floor; -Staff was to place soiled linens saturated with moisture in a plastic bag and tie the end in a knot; -Place the bag in an approved laundry bag. 4. Review of Resident #24’s significant change MDS dated [DATE], showed the following: -The resident’s cognition was moderately impaired; -The resident was dependent on one staff for personal hygiene; -The resident was always incontinent of bowel and bladder. Review of the resident’s care plan, last reviewed on 4/29/19, showed the following: -The resident required staff assistance with activities of daily living (ADLs); -Required staff assistance with pericare after each incontinence episode. Observation on 6/11/19 at 3:58 P.M. showed the following: -The resident lay in bed; -The resident was incontinent of bowel and bladder; -The resident’s bedding was saturated in urine and had a yellow ring from the middle of the resident’s back to his/her knees; -Certified Nurse Assistant (CNA) L washed his/her hands and applied gloves; -CNA L provided perineal care and removed the urine saturated sheets; -With the same soiled gloves, CNA L put clean sheets on the urine saturated mattress. CNA L did not clean the urine soiled mattress prior to placing clean sheets on the resident’s bed. CNA L applied a clean incontinence brief on the resident, touched the resident’s clean pants, socks, and dressed the resident. CNA L put the mechanical lift sling under the resident turning the resident from side to side touching the resident’s clean clothes, bare arm and neck. During an interview on 6/12/19 at 5:10 P.M., CNA L said the following: -The facility was short staffed which made staff rush with cares of the residents so they can get to the next resident; -He/she was in a hurry when caring for the resident and failed to clean the resident’s urine saturated mattress before putting clean sheets on it. 5. Review of Resident #37’s quarterly MDS, dated [DATE], showed the following: -The resident’s cognition was severely impaired; -The resident was dependent on one staff for toilet use and personal hygiene; -The resident was always incontinent of bowel and bladder. Review of the resident’s undated CNA Care Card, located in the resident’s room, showed the resident was incontinent of bowel and bladder, and required assistance from one staff with post-incontinence care. Observation on 6/11/19 at 7:40 A.M. showed the following: -The resident was incontinent of bladder; -CNA D wore gloves and removed the resident’s urine soiled pants and incontinence brief; -CNA D grabbed the perineal wash off the bedside table with his/her contaminated gloves and cleansed the resident’s perineal area; -Without removing his/her gloves, CNA D placed a clean incontinence brief, pants, and a Hoyer lift (mechanical full body lift) pad under the resident; -CNA D removed his/her soiled gloves, and without washing his/her hands, exited the room to obtain the Hoyer lift; -CNA D returned to the room with the Hoyer lift. During an interview on 6/13/19 at 2:08 P.M., CNA D said the following: -He/she was supposed to wash his/her hands and change gloves when they became contaminated; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 35) -He/she should never touch clean items with contaminated gloves; -He/she should wash his/her hands when he/she entered a resident’s room, before putting on gloves, and after removing contaminated gloves; -He/she did not know why he/she touched clean items with contaminated gloves/hands. 6. Review of Resident #40’s quarterly MDS, dated [DATE], showed the following: -The resident’s cognition was moderately impaired; -The resident was dependent on one staff with personal hygiene; -The resident was always incontinent of bowel and bladder. Review of the resident’s care plan, last reviewed on 4/29/19, showed the following: -The resident was totally dependent on staff for all ADLs due to [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke) with left sided [MEDICAL CONDITION] (paralysis of one side of the body), weakness, impaired mobility, and unsteady balance; -Staff was to provide reminders and supervision as needed for all ADLs. Review of the resident’s undated CNA Care Card showed the following the resident was incontinent of bowel and bladder, and wore an incontinence brief. Observation on 6/11/19 at 6:45 A.M. showed the following: -CNA G entered the resident’s room and applied gloves without washing his/her hands; -The Director of Nursing (DON) entered the resident’s room and applied gloves; -The resident’s bed linens were saturated with urine; -The resident was incontinent of large amount of feces; -With gloved hands, CNA G removed feces from the resident’s rectal area; -Without removing his/her gloves, CNA G obtained peri-wash spray from the resident’s bedside table and sprayed it onto a towel to finish removing feces from the resident’s buttocks. CNA G removed his/her gloves, and without washing his/her hands, he/she put on new gloves and placed clean socks on the resident; -The DON assisted with repositioning the resident and touched the soiled sheets with his/her gloves; -The DON removed his/her gloves, did not wash his/her hands, and exited the room (by touching the resident’s door knob to open the door). He/she re-entered the resident’s room, and without washing hands, put on new gloves; -The DON assisted the resident with putting on his/her clean shirt and pants; -The DON and CNA G tucked the resident’s incontinence brief under him/her and pulled it through to fasten it; -Feces was noted on the resident’s buttock; -The DON obtained a wash cloth, cleansed the resident’s right buttock, and placed the soiled linens directly on the floor beside the bed; -The DON removed his/her gloves, and without washing his hands, he touched the door knob and exited the room; -The DON returned to the resident’s room with a clean Hoyer lift pad and put on gloves without washing his hands; -The DON and CNA G placed the Hoyer lift pad under the resident; -Once the pad was under the resident, the DON removed his gloves and exited the room (by opening the door with door knob) without washing hands; -The DON returned to the room with the Hoyer lift and without washing hands, he connected the Hoyer pad to the machine; -CNA G operated the Hoyer lift by pushing the controls; -CNA G and the DON transferred the resident to his/her wheelchair; -The DON exited the room without washing his hands; -CNA G removed his/her gloves and exited the resident’s room without washing his/her |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 36) hands. During an interview on 6/11/19 at 6:30 A.M., CNA G said the following: -He/she was supposed to wash his/her hands before and after resident care, and before exiting a resident’s room; -He/she would remove gloves when cleaning up urine and feces, but he/she did not always wash his/her hands between because there was too much going on and it was easier if he/she just kept working when he/she provided post incontinence care; -Soiled linens should not be placed on the floor and should be contained in a plastic bag; -He/she should never touch clean surfaces with contaminated gloves and hands. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 37) him inspections only needed to be done annually. He implemented the Legionella program in (MONTH) 2019. There was a 12-inch section of dead-end pipe attached to the whirlpool tub drain and this area could be an issue. If water was run to the tub, the water should go down the floor drain, but some water could possibly remain in the dead-end section. The tub was only used every four or five months. The ice machine had an air gap and had an open drainage and dual filtration system that emptied into the floor drain. Maintenance staff cleaned and sanitized the unit annually. The Dietary Manager also cleaned the unit monthly. He said the city came to the facility and pulled a water sample from the handwashing sink in the kitchen once a year. The facility identified two areas of concern, however, no water samples or testing had been conducted for these two areas nor had there been testing of any other areas in the facility. During an interview on 6/11/19 at 2:40 P.M., the Administrator said no water samples had been tested and she was ultimately responsible for implementation and maintenance of the program. | |
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement policies and procedures for flu and pneumonia vaccinations. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 38) resident’s stay at this facility. However, if there is a change in the decision to consent for this immunization they may do so, but must notify the facility of this decision; -General consent or refusal column; -Consent or refusal column for Pneumococcal PPSV23 and Pneumococcal PCV13 vaccines; -Last received date and location column; -Signature of resident and/or responsible party column; -Signature of witness column. 3. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Time for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR 13), a pneumococcal vaccine that is used to protect adults against disease caused by the bacterium streptococcus pneumonia (pneumococcus) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23), an injection that protects against 23 types of pneumococcal causing bacteria: -One dose of PCV13 was recommended for adults [AGE] years or older who had not previously received PCV13; -One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered; -For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history, administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions; -For those age [AGE] years or older who previously received one dose of PPSV23 and no doses of PCV13, administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions. 4. During an interview on 6/7/19 at 2:39 P.M. the administrator said the Minimum Data Set (MDS), /Care Plan Coordinator was responsible for monitoring and overseeing the residents’ flu and pneumonia vaccines. 5. Review of Resident #24’s thirty day prospective payment system (PPS) Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 3/29/19, showed the following: -The resident’s cognition was moderately impaired for making daily decisions; -The resident did not receive the pneumococcal vaccine; -Staff did not offer the resident pneumococcal vaccine; -Resident was over age 65. Review of the resident’s physician orders dated 5/11/19 to 6/11/19 showed the following: -[DIAGNOSES REDACTED]. -admitted [DATE]. Review of the resident’s immunization consent or refusal showed the following: -The resident’s responsible party signed for the resident to have PPSV23 and PCV13 on 9/28/18; -The resident had received PPSV23 on 11/27/07 in the physician’s office; -The resident had not received PCV13. Review of the resident’s medical record showed the following: -The resident had a guardian; -No documented consent to show the resident and/or the resident’s representative refused the vaccination; -No documentation the facility provided education regarding the benefits of the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 39) vaccination. Review of the facility’s Preventative Health Care Report for pneumonia vaccinations dated 5/22/19 to 6/13/19 showed the resident was not included in the report and did not receive the vaccine. 6. Review of Resident #54’s Preventative Medicine documentation showed the resident received Prevnar 13 or PCV 13 on 2/7/17. Review of the resident’s quarterly MDS, dated [DATE] showed the following: -The resident’s cognition was moderately impaired for making daily decisions; -The resident’s [DIAGNOSES REDACTED]. -The resident was up to date with pneumonia vaccine. -The resident was over age 65. Review of the resident’s physician orders dated 3/31/18 showed the resident’s [DIAGNOSES REDACTED]. Review of the resident’s nursing progress notes dated 7/5/18 at 2:38 A.M. showed the resident refused PPSV 23 vaccination. Review of the resident’s medical record showed the following: -No documented consent to show the resident and/or the resident’s representative refused the vaccination; -No documentation the facility provided education to explain the benefits of the vaccination. Review of the resident’s progress notes dated 4/30/2019 at 1:20 P.M. showed the resident was started on [MEDICATION NAME] (oral antibiotic) 250 mg twice a day (BID) for [DIAGNOSES REDACTED]. Review of the facility’s infection antibiotic control log date (MONTH) 2019 showed the following: -The resident was started on [MEDICATION NAME] on 4/6/19 for pneumonia; -His/her symptom of shortness of breath started on 4/5/19; -Antibiotic was completed on 4/18/19. 7. During an interview on 6/13/19 at 10:35 A.M., Licensed Practical Nurse (LPN) I said the following: -He/She did not know who was supposed to be monitoring the residents’ vaccinations; -Education on vaccinations was provided to residents verbally; -There was no written documentation provided to the residents regarding the vaccinations; -The MDS/Care Plan Coordinator asked him/her a couple of weeks ago to make a list of residents who needed to have the pneumonia vaccinations per the CDC guidelines. Residents who were 65 and older, residents with certain [DIAGNOSES REDACTED]. -Resident #54 recently had pneumonia. During an interview on 6/13/19 at 11:54 A.M., LPN H said the following: -Nursing administration were supposed to provide education regarding the vaccinations when consents were signed; -Education was supposed to be reviewed prior to administration of the vaccinations; -Usually the Director of Nursing (DON) monitors the immunizations, but since the current DON was new to the facility, he/she thought the MDS/Care Plan Coordinator was overseeing the immunizations. During an interview on 6/13/19 at 2:21 P.M. the social service designee said the following: -She was not a nurse therefore she gave the resident’s/ resident’s responsible party the pneumococcal CDC vaccine information statement at the time of admission but he/she did not educate the residents; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265611 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILEX COMMUNITY CARE | STREET ADDRESS, CITY, STATE, ZIP 111 DUNCAN MANSION ROAD | |||||||||
| 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 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 40) -She also made sure the resident or responsible party signed a consent/refusal for the pneumococcal vaccine at the time of admission. During an interview on 6/13/19 at 3:00 P.M. and 3:55 P.M. the MDS/Care Plan Coordinator said the following: -He/She was not responsible for monitoring residents’ vaccinations, including pneumonia; -He/She only monitored vaccinations for MDS purposes; -There was no specific staff designated to ensure residents received vaccinations; -He/She would expect staff to supply the CDC immunization information for education whether the resident/resident party consents or refuses the immunization; -He/She expected staff to offer the pneumococcal vaccine on admission and as needed. During an interview on 6/13/19 at 3:15 P.M., the DON said that he/she was unsure of the facility’s policy regarding pneumonia vaccinations. During an interview on 6/12/19 at 11:48 A.M. and 5:30 P.M. and 6/13/19 at 11:18 A.M. the administrator said the following: -She could not find any documentation that Resident #24 was offered or educated about the pneumococcal vaccines. The resident/resident’s responsible parties had signed consents but she was not sure why they were not given; -She could not find any documentation that Resident #54 was educated about the pneumococcal vaccines; -The facility provided education information regarding the vaccinations upon admission and she was not sure if the information was provided again at the time of the consent; -She expected staff to get immunization consents upon admission and annually; -She doesn’t have a medical background and therefore does not do any teaching for immunizations; -She would expect the staff to provide teaching to the residents and residents’ responsible parties; -The DON is normally responsible for monitoring the flu and immunization vaccines but because the facility did not have a DON for a period of time the care plan/MDS coordinator was responsible; -The MDS/Careplan coordinator was responsible for tracking and administration of immunizations for the residents. During an interview on 6/25/19 at 10:27 A.M. the medical director said the following: -He/she expected staff to follow the CDC guidelines; -He/she would expect staff to get a history, educated and offer the vaccine to the resident/responsible party; -Anyone with pneumonia or history of immunocompromised may need the PCV13 or PPSV23; -He/She would expect staff to follow policy and guidelines they have discussed. | |
