| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0558 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Reasonably accommodate the needs and preferences of each resident. Based on observation, and interview the facility staff failed to provide reasonable |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0558 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) each bite, the resident dropped food on his/her lap. 6. During an interview on 3/15/19, at 12:06 P.M., certified nurse assistant (CNA) A said the residents can not get close to the table because of the pedestal under the table if they have leg rests on their wheelchairs. He/She said if there are two residents at the table they are even further away. The CNA said there is only one table with four legs that does not have the center pedestal. During an interview on 3/15/19, at 12:09 P.M., licensed practical nurse (LPN) C said some of the residents are at angle to get as close as they can to the table. He/She said the pedestal keeps residents with foot pedals away from the table. During an interview on 3/15/19, at 2:09 P.M., the director of nursing (DON) said the staff try to get the residents close to the table, but the design of the tables make it difficult. | |
| F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and record review facility staff failed to give appropriate Center for |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) -Last covered day of Part A Service 12/31/18; -The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted; -The resident remained in the facility; -The SNF ABN was not provided; -The NOMNC was given. The resident’s record did not contain a CMS- SNF ABN letter, both the SNF ABN and NOMNC forms are required when the resident remains in the facility. 4. During an interview on 3/13/19 at 3:00 P.M., the social service director (SSD) said he/she gives medicare notices prior to discontinuing Medicare part A services. He/She said he/she knows there is a SNF ABN form but he/she did not know when he/she is supposed to issue the ABN. During an interview on 3/15/19 at 2:13 P.M., the administrator said staff should issue the SNF ABN and the NOMNC to residents who stay in the building. | |
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Assess the resident when there is a significant change in condition **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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) assessment is complete. o A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. o For required Comprehensive assessments, assessment completion is defined as completion of the CAA process in addition to the MDS items, meaning that the registered nurse (RN) assessment coordinator has signed and dated both the MDS (Item Z0500) and CAA(s) (Item V0200B) completion attestations. Since a Comprehensive assessment includes completion of both the MDS and the CAA process, the assessment timing requirements for a comprehensive assessment apply to both the completion of the MDS and the CAA process. 2. Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated assessment, dated 6/3/18, showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive physical assistance of one staff member for locomotion, eating, and hygiene; -Required extensive physical assistance of two or more staff members for bed mobility, transfers, dressing, toilet use, and bathing; -Limited range of motion in both upper and lower extremities; -Always incontinent of bladder; -No weight loss; -126 pounds (lbs.); -No pressure ulcers present; -No medication injections. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Dependent on staff for transfers, bed mobility, dressing, eating, hygiene, toilet use and bathing; -Locomotion on and off the unit did not occur; -Limited range of motion in both lower extremities; -Indwelling urinary catheter; -Significant weight loss; -122 lbs. -Stage 4 pressure ulcer; -Medications that required injections six out of seven days; -Intravenous medications while a resident. Review of the resident’s medical record showed the resident admitted to hospice services on 9/13/18. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Dependent on staff for transfers, bed mobility, dressing, eating, hygiene, toilet use and bathing; -Locomotion on and off the unit did not occur; -Limited range of motion in both lower extremities; |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) -Indwelling urinary catheter; -Fall with injury; -Significant weight loss; -95 lbs. -Stage 3 pressure ulcer; -Medication that required injections every day; -Hospice. Staff did not complete a comprehensive SCSA MDS after the resident had decline in several ADL’s, significant weight loss, new pressure ulcers, and the addition of hospice care. 3. Review of Resident #63’s admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Requires supervision from staff for eating; -No impairment in range of motion; -Occasionally incontinent of bladder, frequently incontinent of bowel; -3 Unstageable pressure ulcers present. Review of the resident’s admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Requires extensive physical assistance of one staff member for eating, and hygiene; -Limited range of motion in one upper extremity; -Always incontinent of bowel and bladder; -4 Stage 3 pressure ulcers. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Requires extensive physical assistance of one staff member for eating, and hygiene; -Limited range of motion in one upper extremity; -Always incontinent of bowel and bladder; -2 Stage 2 pressure ulcers. Staff did not complete a comprehensive SCSA MDS after the resident declined in several ADL’s, continence, new limitations in range of motion, and changes to the number and stages of pressures. 4. During an interview on 3/15/19, on 2:52 P.M., the MDS coordinator said he/she does not know how many or what changes require an SCSA MDS. He/She said it is required to do a SCSA when a resident goes on or off Hospice. He/She said he/she was not the MDS coordinator until November, and is new to the MDS process. He/She said he/she has not been to formal MDS training. During an interview on 3/15/19, at 3:12 P.M., the director of nursing (DON) said the MDS’s should be completed as the RAI manual instructs. | |
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives an accurate assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) resident’s. The facility census was 90, 1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, directs staff as follows: -Ulcer staging should be based on the ulcer’s deepest anatomic soft tissue damage that is visible or palpable. -Review the history of each pressure ulcer in the medical record. If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage. -Pressure ulcers do not heal in a reverse sequence, that is, the body does not replace the types and layers of tissue (e.g., muscle, fat, and dermis) that were lost during pressure ulcer development before they re-[MEDICATION NAME]. Stage 3 and 4 pressure ulcers fill with granulation tissue. This replacement tissue is never as strong as the tissue that was lost and hence is more prone to future breakdown. 4. Clinical standards do not support reverse staging or backstaging as a way to document healing, as it does not accurately characterize what is occurring physiologically as the ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing and contracting such that it is less deep, wide, and long, the tissues that were lost (muscle, fat, dermis) will never be replaced with the same type of tissue. Previous standards using reverse staging or backstaging would have permitted identification of such a pressure ulcer as a Stage 3, then a Stage 2, and so on, when it reached a depth consistent with these stages. Clinical standards now would require that this ulcer continue to be documented as a Stage 4 pressure ulcer until it has completely healed. 2. Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated assessment, dated 6/3/18, showed staff assessed the resident as: -Severe cognitive impairment; -Limited range of motion in both upper and lower extremities; -No pressure ulcers present. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Limited range of motion in both lower extremities; -Stage 4 pressure ulcer. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Limited range of motion in both lower extremities; -Stage 3 pressure ulcer. Observation on 3/13/19, at 4:34 P.M., showed the resident in his/her room. Additional observation showed the resident with contractures of the shoulders, elbows, hands, hips, knees, and feet. Observation on 3/14/19, at 11:42 A.M., showed the resident in his/her room. Additional observation showed the resident with contractures of the shoulders, elbows, hands, hips, knees, and feet. Further observation showed the resident with a wound 3.2 centimeters (cm) in length, 3.6 cm in width, and 0.9 cm in depth, on his/her coccyx. where is the wound? During an interview on 3/14/19, at 11:49 A.M., licensed practical nurse (LPN) C said the resident has contracture hands shoulders, legs, hips, and knees. He/She said the resident’s wound is a healing stage 4 wound. He/She said the resident has had the wound since (MONTH) or August. 3. Review of Resident #63’s admission MDS, dated [DATE], showed staff assessed 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) resident as: -Severe cognitive impairment; -4 Stage 3 pressure ulcers. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -2 Stage 2 pressure ulcer. During an interview on 3/14/19, at 11:49 A.M., LPN C said the resident’s current wounds are Stage 3 wounds the resident had on admission. He/She said the wounds are improved and are healing stage 3 wounds. 4. Review of Resident # 30’s admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Admission weight 212 pounds; -No weight loss of 5 % or more in the last month or loss of 10% or more in the last 6 months. Review of the resident’s admission assessment MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Admission weight 199 pounds; -No weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of the resident’s weight loss documentation shows a 6.13% weight loss in less than one month. 5. During an interview on 3/15/19, on 2:52 P.M., the MDS coordinator said he/she codes the MDS’s according to the staffs’ documentation. He/She said he/she backstaged wounds, but just read wounds should not be back staged. He/She said limited range motion should be coded on the MDS, he/she is learning the resident’s and does not know which resident’s have contractures. He/She said he/she was not the MDS coordinator until November, and is new to the MDS process. He/She said he/she has not been to formal MDS training. During an interview on 3/15/19, at 3:12 P.M., the director of nursing (DON) said the MDS’s should be completed as the RAI manual instructs. | |
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide activities to meet all resident’s needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) documented in the one-on-one activity book that is kept in the activity department. Then these notes will be documented and should coordinate with the quarterly notes that are kept in the residents chart on the wings. It will also be part of their care plan. The activity director will bring a list of residents that are one-on-one to the care plan meeting on Tuesday to adjust the list for any resident that may need to be added to the one-on-one program. The activity director will also add any resident to the list after the stand-up meeting every weekday morning if it is decided a resident needs to be added to the one-on-one program. 2. Review of the (MONTH) activity calendar showed the following: -No activity scheduled after dinner on weekdays and weekends; -One on one activities scheduled two to four times a week at 2:30 P.M. 3. Review of the (MONTH) activity calendar showed the following: -No activity scheduled after dinner on weekdays and weekends; -One on One activities scheduled two to four times with no time noted. 4. Review of the (MONTH) activity calendar showed the following: -No activity scheduled after dinner on weekends or weekdays; -One on one activities scheduled three to four times with no time noted. 5. Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated assessment, dated 6/3/18, showed staff assessed the resident as: -Severe cognitive impairment; -Activity interview was not conducted; -Required extensive physical assistance of one staff member for locomotion, eating, and hygiene; -Required extensive physical assistance of two or more staff members for bed mobility, transfers, dressing, toilet use, and bathing; -Limited range of motion in both upper and lower extremities. -Section V triggered and staff marked addressed in care plan: [MEDICAL CONDITION], cognitive loss/dementia, visual function, communication, psychosocial well-being, and activities. Review of the resident’s care plan, last updated 1/28/19, showed it did not contain direction to the staff regarding activities. Review of the resident’s medical record showed it did not contain a Activity Interest assessment for (YEAR) or 2019. Review of the resident’s Activity Record, dated 1/1/19-3/15/19, showed the resident attended one activity on 1/8/19. The document did not show the resident attended any other activities, or one on one activities. Observation on 3/12/19, at 2:33 P.M., showed the resident with his/her eyes closed in his/her bed, while the activity director conducted an activity. Observation on 3/13/19, at 10:12 A.M., showed the resident with his/her eyes closed in his/her bed, while the activity director conducted an activity Observation on 3/15/19, at 2:14 P.M., showed the resident with his/her eyes closed in his/her bed, while the activity director conducted an activity 6. Review of Resident #33’s quarterly MDS, dated [DATE], showed staff documented the resident as: -Severe cognitive impairment; -Little interest in doing things nearly everyday; -Total dependence for Activities of Daily Living; -No documented goals. Review of the resident’s care plan, dated 8/23/18, showed it did not address activities |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) for the resident. Review of the resident’s Activity Record, dated 1/1/19-3/15/19, showed the resident attended two activities on 2/14/19, and one activity on 1/8/19. Staff did not document they conducted one on one visits. Observation on 3/12/19, at 2:15 P.M., showed the resident asleep in his/her room, while the activity director conducted an activity. Observation on 3/13/19, at 9:30 A.M., showed the resident asleep in his/her room, while the activity director conducted an activity Observation on 3/14/19, at 10:00 A.M., showed the resident asleep in his/her room, while the activity director conducted an activity 7. Review of Resident #137’s entry MDS, dated [DATE], showed the staff documented the resident admitted to the facility on [DATE]. Review of the resident’s nurses notes, dated 2/25/19, showed staff documented the resident: -At most can say hi, yes, or no; -medical history of [REDACTED]. -Impulsive at times and will attempt to stand up and self transfer with impaired judgement; -Visual impairment. Review of the resident’s care plan, dated 2/25/19, showed it did not contain direction to the staff regarding activities. Review of the resident’s medical record showed it did not contain a Activity Interest and Initial assessment. Review of the resident’s Activity Record, dated 2/25/19-3/15/19, showed the staff documented a one on one activity on 2/28/19. The documentation did not show the resident attended any other activities, or one on one activities. Observation on 3/12/19, at 2:10 P.M., showed the resident in his/her wheelchair unattended in the hall, while the activity director conducted an activity. Observation on 3/13/19, at 2:21 P.M., showed the resident with his/her eyes closed in his/her bed, while the activity director conducted an activity. Observation on 3/14/19, at 10:24 A.M., showed the resident in his/her bed, while the activity director conducted an activity. 8. During an interview on 3/15/19, at 12:36 P.M., the activity director (AD) said he/she has been here two months and just got an assistant a month ago. He/She said he/she just started doing a few one on ones, but started with the ones who’s family’s do not visit. He/She said he/she is late and has not completed Resident #137’s Activity assessment yet. During an interview on 3/15/19, at 1:30 P.M., the Activity Director (AD) said he/she has not been able to do any one-on-one time with the residents for a few weeks. During an interview on 3/15/19, at 1:40 P.M., the care plan coordinator (CPC) said that he/she did not know activities triggers on the MDS, his/her software does not pull it to the careplan so residents do not have a plan of care for their activities. During an interview on 3/15/19, at 2:00 P.M., the administrator (ADM) said the activity director is new and they were short an assistant. He/She said they just set up a certified activities director to oversee the new AD. He/She said residents should have activities that meet each resident’s needs. |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) sure if the resident’s with contractures are on a programs, or who documents that the range of motion is completed for those resident’s. During an interview on 3/15/19, at 2:05 P.M., the director of nursing (DON) said restorative therapy performs range of motion. Resident #10 is not on a restorative program to maintain or improve the resident’s range of motion. He/She did not know resident’s with contractures or potential for contractures needed a program to prevent futher decline in range of motion. | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) Review of the resident’s care plan, dated 2/25/19, showed staff are directed as follows: -High risk for falls; -Provide adequate lighting; -Anticipate the resident’s needs and check frequently; -Assist with ADL’s and toileting; -Keep frequently used items within reach. Review of the resident’s nurses notes, dated 3/1/19, showed staff documented they found the resident on his/her back on the floor in front of his/her night stand. The documentation did not include information about physician or family notification. Review of the resident’s nurses notes, dated 3/3/19, showed staff documented they found the resident on the floor in his/her doorway, and he/she did not receive an injury at this time. Review of the resident’s nurses notes, dated 3/5/19, showed staff documented they found the resident face down on his/her left side outside of his/her bathroom. Staff noted the resident with blood on his/her lip and nose, and a large hematoma forming on his/her forehead with bruising started. The resident went via ambulance to the emergency room for evaluation. Review of the resident’s emergency room notes, dated 3/5/19, showed the resident was evaluated for traumatic hematoma of forehead, and abrasion to the left knee. Review of the resident’s nurses notes, dated 3/7/19, showed staff documented the resident fell out of his/her chair and noted blood from his/her back and right side of his/her ear. Staff sent the resident to the emergency room for evaluation. Review of the resident’s emergency room notes, dated 3/7/19, showed the resident was evaluated for a fall, facial contusion, scalp hematoma, and multiple contusions. The resident’s chart did not contain documentation about the fall on 3/8/19. Review of the resident’s nurses notes, dated 3/8/19, showed staff documented a discussion and agreement with the resident’s family for the use of a helmet. The staff documented the family requested the resident have a seat belt. Review of the resident’s emergency room notes, dated 3/8/19, showed the resident was seen for a fall, head injury and laceration on his/her face above the right eye brow. The resident was seen 3 days ago , and yesterday for a fall. Have sutures removed in seven days. Review of the resident’s nurses notes, dated 3/9/19, showed staff documented the resident returned to the facility with a helmet. The emergency room nurse reported the resident received several stitches above the eye. Review of the resident’s care plan, dated 3/15/19, showed staff documented the resident fell six times before staff implemented interventions to address the resident’s falls. 3. Observation on 3/12/19, at 11:50 A.M., showed the resident in the dining room. Additional observation showed the resident with a helmet and a dressing on the right side of his/her forehead and a dark purple discoloration under each eye. Observation on 3/12/19, at 1:33 P.M., showed the resident in his/her wheelchair in the hall. The resident sat on the edge of his/her seat and rocked back and forth as he/she propelled himself/herself down the hall with his/her feet. Observation on 3/13/19, at 9:12 A.M., showed the resident up in his/her wheelchair in his/her room. 4. During an interview on 3/15/19, at 11:36 A.M., CNA A said the resident fell from his/her wheelchair several times, so they got him/her a helmet after he/she received stitches. He/She said they try to check on him/her often. During an interview on 3/15/19, at 12:09 P.M., LPN C said if a resident falls, 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) resident should be examined to check for injury. The physician is notified and gives further instruction if needed, and the family is notified. The care plan should be updated after each fall, and all the information should be documented in the nurses notes. During an interview on 3/15/19, at 4:05 P.M., the director of nursing (DON) said the charge nurse is expected to examine a resident after a fall. If the resident has an injury, they are to call the physician for direction. She said the charge nurse is expected to notify the family and the physician of any fall, and the care plan is updated after the fall is reviewed. The DON said she spoke to the resident’s family about a seat belt. He/She told the DON the resident used one at home and can release it himself/herself. 5. Review of the facility’s Hoyer (mechanical) lift transfers policy, date unknown, directs staff: -Adjust bed height to low position; -Position the chair next to the bed; -By turning the resident side to side, slide the hoyer sling under the resident and position properly; -Wheel the lift into place over the resident with the base beneath the bed; -Attach the sling to the mechanical lift with the hooks in place; -Have the resident fold both arms across their chest, if possible; -Lift the resident until the buttocks are clear of the bed. Make sure the resident is aligned in the sling and is securely suspended in a sitting position with legs dangling over the bottom of the sling; -One staff member should guide the resident’s legs over the edge of the bed; -Move the lift away from the bed, turn the resident so that he/she faces one staff member while the other guides the resident’s body towards the chair; -Open the legs of the lift, then bring the lift into position so the resident is over the seat of the chair; -Release the control knob slowly so that the resident will be gradually lowered into the chair; -Remove the hooks from the frame of the lift. 6. Review of Resident #10’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Dependent on staff for transfers, bed mobility, dressing, eating, hygiene, toilet use and bathing; -Locomotion on and off the unit did not occur; -Limited range of motion in both lower extremities; -Fall with injury. Observation on 3/14/19, at 11:42 A.M., showed LPN C and CNA F transferred the resident with a hoyer lift. Additional observation showed the LPN lifted the resident in the lift and the CNA walked to the other side of the bed while the resident hung in the air. 7. Review of Resident #30’s MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required two person total assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Limited range of motion in one lower extremity. 8. Observation on 3/12/19 at 12:47 P.M., showed CMT/CNA C and CMT/CNA D transfer the resident from the wheelchair to the bed with a hoyer lift. Further observation showed staff positioned the wheelchair approximately one foot from the bed and used the lift to |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) lift the resident into the air. The resident sat suspended in the air for approximately 45 seconds while both of the staff members, each with one hand on the resident, rearranged bed covers. 9. During an interview on 3/15/19 at 3:20 P.M., CNA E said the wheelchair should be right next to the bed while one staff member guides the resident’s legs and the other staff member guides the bottom/back area during a hoyer lift transfer. He/She added staff should always have their hands on the resident during a transfer with a hoyer lift. During an interview on 3/15/19 at 2:55 P.M., LPN B said there should not be space between the bed and the wheelchair during a hoyer lift transfer. He/She said one staff member should keep their hands on the resident at all times during a hoyer lift transfer. During an interview on 3/15/19 at 3:43 P.M., the DON said the wheelchair should be as close as possible to the bed and one staff member should guide the resident with their hands while the other staff member is on the hoyer lift controls during a hoyer lift transfer. He/She further said the resident should not hang freely in the air and the least amount of time in the air the better. | |
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide enough food/fluids to maintain a resident’s health. **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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) said staff fill his/her water pitcher in his/her room, and he/she gets fluids with his/her medications five times a day, and a full glass at every meal. The resident said he/she is not sure if he/she follows his/her 1500 cc fluid restriction because the staff do not tell him/her how much is in each cup but he/she tries to make sure he/she drinks the same amount each day. During an interview on 3/15/19, at 11:34 A.M., certified nurse assistant (CNA) A said there are not any resident’s in the facility that are on a fluid restriction. He/She said the resident on a fluid restriction is in the hospital. He/She said he/she does not know how much fluid the resident is supposed to have, he/she said the staff fill up the water pitcher that has 800 cc and they document how much the resident drinks. He/She said he/she does not know how much fluid dietary or the medication technician gives the resident, he/she said the staff do not coordinate with dietary that he/she knows of. The CNA did not know the resident is on a fluid restriction. During an interview on 3/15/19, at 11:38 A.M., CNA G said he/she always works on the 200 hall. (The resident resides on the 200 hall). He/She said there are not any resident’s on a fluid restriction on the 200 hall. He/She said if a resident is on a fluid restriction, staff track the amount the resident drinks, he/she said there is not a document telling staff how much fluid to serve the resident. During an interview on 3/15/19, at 12:09 P.M., licensed practical nurse (LPN) C said staff are expected to follow physicians orders for a fluid restriction. He/She said the charge nurse notifies dietary if a resident is on a fluid restriction. He/She does not know if the fluids the resident is served is coordinated or monitored. He/She said if residents are on diet and/or fluid restrictions the staff should monitor and ensure the resident is not served what is on the fluid restriction unless it is directly requested by the resident. | |
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 15) – Sixteen [MEDICATION NAME] (medication used to prevent/relieve heartburn) tablets loose in a medication cup; – One bottle of [MEDICATION NAME] (medication used to relieve chest pain) 0.4 milligram (mg) without a resident’s name or prescription label; – 2 unopened sample boxes of myrbetriq (medication used to treat overactive bladder) 50mg (7 day supply) without a resident’s name or prescription label; – three unopened sample boxes of [MEDICATION NAME] (medication used to treat overactive bladder) 8 mg without a name or prescription label; – One loose orange tablet in the middle drawer; – One loose white oblong pill, one loose white round tablet, one 1/2 tablet that is white and oblong, and one container of natural fiber powder with an expiration date of (MONTH) (YEAR) in the bottom middle drawer. 3. During an interview on 3/12/19 at 11:26 P.M., licensed practical nurse (LPN) A said he/she borrowed [MEDICATION NAME] from another medication cart because this medication cart was out of them. During an interview on 3/15/19 at 2:55 P.M., LPN B said all medication should be in it’s original container and not loose in medication cart drawers. All personal medication should be labeled with the resident’s name. During an interview on 3/15/19 at 3:43 P.M., the DON said medication should be stored in it’s original container and have a resident’s name and prescription label on the container. | |
| F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, facility staff failed to serve food in |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 16) Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook Q and the DM served the residents on CCHO diets the following: -a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus); -two oz. of beef gravy (one oz. more than directed by the menus); -one slice of red velvet cake roll (twice as much than directed by the menus). Observation also showed the cook and DM did not serve or offer the half slice of fresh baked bread as directed by the menus. Observation on 03/13/19 at 11:53 A.M., showed Week 3 menus available to staff in the kitchen did not include CCHO menus with portion sizes to be served. During an interview on 03/13/19 at 11:53 A.M., Cook Q said he/she serves the residents with CCHO diets the regular foods and portion sizes all the time. The cook said he/she did not know if the residents with CCHO diets should have anything different than the regular diets because he/she did not have anything that shows what the CCHO diets should get. 3. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal. Observation on 03/13/19 at 12:00 P.M., showed the DM served the residents on pureed diets four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus). Observation also showed the DM did not serve or offer the pureed bread as directed by the menus. 4. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -two oz. of breaded cod scrod (young cod); -a #16 scoop of macaroni and cheese; -a #8 scoop of creamy coleslaw; -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed Dietary Aide (DA) R and the DM served the residents on CCHO diets the following: -four oz. of macaroni and cheese (two oz. more than directed by the menus); -one slice of bread with margarine (twice as much than directed by the menus); -one square of frosted apple spice cake. During an interview on 03/15/19 at 11:42 A.M., DA R said he/she had worked at the facility for a year and, while he/she wished they did, the facility did not have anything that shows what portion sizes to serve. The DA said there is no difference in what is served to residents on CCHO diets unless they have a different texture need. 5. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on mechanical soft diets with four oz. of steamed cabbage at the noon meal. Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R and the DM served the residents on mechanical soft diets four oz. of creamy cole slaw instead of the steamed cabbage as directed by the menus. 6. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on pureed diets with the following: -a #10 (3.2 oz.) scoop of pureed breaded cod scrod; -a #8 scoop of pureed macaroni and cheese; -a #12 scoop of pureed creamy cole slaw; -a #20 scoop of pureed bread with margarine; -a #12 scoop of pureed frosted apple spice cake |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 17) Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the DM served the residents on pureed diets the following: -four oz. of pureed breaded cod scrod (more than directed by the menus); -four oz. of pureed cole slaw (1.4 oz. more than directed by the menus); -four oz. of applesauce. Observation also showed the prepared pureed diets did not include pureed bread with margarine. 7. During an interview on 03/15/19 at 12:36 P.M., the DM said staff should read the menus prior to service and serve foods in accordance with the menus. The DM said he/she did not review the menus before the meal service and he/she had not reviewed the menus with all staff including DA R. The DM said he/she missed that the menus had bread to be served. The DM said the facility had CCHO menus until they switched menu companies in (MONTH) (YEAR) and the registered dietician (RD) noticed the CCHO diet menus missing from the menus during his/her last visit a week ago. The DM said he/she just got the menus for the CCHO diets on 03/11/18 and had not put them in the book yet. The DM said staff served residents with CCHO diets the regular foods and portions while they did not have menus specific for CCHO diets. 8. During an interview on 03/15/19 12:47 P.M., the administrator said he/she would expect staff to prepare and serve food items in accordance with recipes and menus and staff are trained on this requirement. The administrator said he/she would expect the RD to review menus at each visit. The administrator also said the DM should monitor staff for the use of recipes and menus when he/she is at the facility and then it would be the responsibility of the head cook in the absence of the DM. The administrator said he/she tries to visit the kitchen at least once a day at meal time, but he/she did not know there were menus missing prior to 03/11/19 and he/she did not know the menus were not made available to staff once received. | |
| F 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) -four oz. of harvard beets; -one half slice of fresh baked bread; -one half slice of red velvet cake roll. Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook Q served the resident the following: -three oz. of regular beef pot roast; -a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus); -four oz. of beef gravy (three oz. more than directed by the menus); -one slice of red velvet cake roll (twice as much than directed by the menus). Observation also showed the cook did not serve or offer the half slice of fresh baked bread as directed by the menus. During an interview on 03/13/19 at 11:10 A.M., the Cook said the ground meat was by resident request and not a physician’s orders [REDACTED].>Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on mechanical soft, CCHO diets with the following at the noon meal: -two oz. of ground breaded cod scrod (young cod); -a #16 scoop of macaroni and cheese; -four oz. of steamed cabbage; -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed Dietary Aide (DA) R served the resident the following: -a two oz. whole piece of breaded cod scrod; -four oz. of macaroni and cheese (two oz. more than directed by the menus); -one slice of bread with margarine (twice as much than directed by the menus); -one square of frosted apple spice cake. 2. Review of Resident #4’s physician orders [REDACTED]. Further review showed the resident’s diet order as pureed. Review of the resident’s meal tray card showed staff were directed to provide the resident with a pureed diet. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal. Observation on 03/13/19 at 12:00 P.M., showed the Dietary Manager (DM) served the resident four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus). Observation also showed the DM did not serve or offer the pureed bread as directed by the menus. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on pureed diets with the following: -a #10 (3.2 oz.) scoop of pureed breaded cod scrod; -a #8 scoop of pureed macaroni and cheese; -a #12 scoop of pureed creamy cole slaw; -a #20 scoop of pureed bread with margarine; -a #12 scoop of pureed frosted apple spice cake Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the DM served the resident the following: -four oz. of pureed breaded cod scrod (more than directed by the menus); -four oz. of pureed cole slaw (1.4 oz. more than directed by the menus); -four oz. of applesauce. |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) Observation also showed the DM did not include the pureed bread with margarine. 3. Review of Resident #8’S physician orders [REDACTED]. Further review showed the resident’s diet order as pureed. Review of the resident’s meal tray card showed staff were directed to provide the resident with a pureed diet. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal. Observation on 03/13/19 at 12:00 P.M., showed the DM served the resident four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus). Observation also showed the DM did not serve or offer the pureed bread as directed by the menus. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on pureed diets with the following: -a #10 (3.2 oz.) scoop of pureed breaded cod scrod; -a #8 scoop of pureed macaroni and cheese; -a #12 scoop of pureed creamy cole slaw; -a #20 scoop of pureed bread with margarine; -a #12 scoop of pureed frosted apple spice cake Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the DM served the resident the following: -four oz. of pureed breaded cod scrod (more than directed by the menus); -four oz. of pureed cole slaw (1.4 oz. more than directed by the menus); -four oz. of applesauce. Observation also showed the prepared pureed diets did not include pureed bread with margarine. 4. Review of Resident #15’s physician orders [REDACTED]. Further review showed the resident’s diet order as a regular texture, CCHO diet. Review of the resident’s meal tray card showed staff directed to provide the resident with a CCHO diet. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -three ounces (oz.) of beef pot roast; -a #16 (two oz.) scoop of mashed potatoes; -one oz. of beef gravy; -four oz. of harvard beets; -one half slice of fresh baked bread; -one half slice of red velvet cake roll. Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook Q served the resident the following: -a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus); -four oz. of beef gravy (three oz. more than directed by the menus); -one slice of red velvet cake roll (twice as much than directed by the menus). Observation also showed the cook did not serve or offer the half slice of fresh baked bread as directed by the menus. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -two oz. of breaded cod scrod; -a #16 scoop of macaroni and cheese; -a #8 scoop of creamy coleslaw; |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R served the resident the following: -four oz. of macaroni and cheese (two oz. more than directed by the menus); -one slice of bread with margarine (twice as much than directed by the menus); -one square of frosted apple spice cake. 5. Review of Resident #20’s physician orders [REDACTED]. Further review showed the resident’s diet order as a regular texture, CCHO diet with a 1500 milliliter (ml) in 24 hours fluid restriction, no oranges/orange juice, bananas, tomatoes or tomato products, peas and yogurt. Further review showed the resident’s physician directed staff to limit the resident’s milk intake to eight ounces daily and limit potatoes to Mondays, Wednesdays and Fridays. Review of the resident’s meal tray card showed staff were directed to provide the resident with a CCHO diet. During an interview on 3/14/19, at 9:58 A.M., Resident #20 said he/she is on a renal diet and is on [MEDICAL TREATMENT]. He/She said he/she has to look at the menu for each day and instruct the staff on what he/she cannot have. The resident said the staff do not make sure he/she does not get the items on his/her restrictions and if he/she does not tell the staff what to do, the staff serve him/her a regular diet. The resident said his/her phosphorus and potassium levels are often too high or out of range. The resident said he/she also has to keep with his/her fluid restriction. He/She said the staff fill his/her water pitcher in his/her room, gets fluids with his/her medications five times a day, and a full glass at every meal. The resident said he/she is not sure if he/she is following his/her 1500 ml fluid restriction because the staff do not tell him/her how much is in each cup but he/she tries to make sure he/she drinks the same amount each day. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -two oz. of breaded cod scrod; -a #16 scoop of macaroni and cheese; -a #8 scoop of creamy coleslaw; -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R served the resident the following: -four oz. of macaroni and cheese (two oz. more than directed by the menus); -one slice of bread with margarine (twice as much than directed by the menus); -one square of frosted apple spice cake; -an eight ounce glass water. During an interview on 3/15/19, at 12:09 P.M., licensed practical nurse (LPN) C said staff are expected to follow physicians orders for a fluid restriction. The LPN said the charge nurse notifies dietary if a resident is on a fluid restriction and he/she does not know if the fluids the resident is served is coordinated or monitored. The LPN said if residents are on diet and/or fluid restrictions, the staff should monitor and ensure that the resident is not served what is on the fluid restriction unless it is directly requested by the resident. 6. Review of Resident #27’s physician orders [REDACTED]. Further review showed the resident’s diet order as a regular texture, no added sodium, CCHO diet with skim milk and yogurt at meals, half portion of pastry/pie/cake or alternate with fruit and half portion |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) of potatoes/rice/pasta when on the menu. Review of the resident meal tray card showed staff were directed to provide the resident with a CCHO diet with no desserts. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -three ounces (oz.) of beef pot roast; -a #16 (two oz.) scoop of mashed potatoes; -one oz. of beef gravy; -four oz. of harvard beets; -one half slice of fresh baked bread; -one half slice of red velvet cake roll. Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook Q served the resident the following: -a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus); -four oz. of beef gravy (three oz. more than directed by the menus); -one slice of red velvet cake roll (twice as much than directed by the menus). Observation also showed the cook did not serve or offer the half slice of fresh baked bread as directed by the menus. Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R served the resident the following: -four oz. of macaroni and cheese (two oz. more than directed by the menus); -one slice of bread with margarine (twice as much than directed by the menus); -one square of frosted apple spice cake. 7. Review of Resident #28’s physician orders [REDACTED]. Further review showed the resident’s diet order as a regular texture, CCHO diet. Review of the resident’s meal tray card, showed staff were directed to to provide the resident with a CCHO diet. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -two oz. of breaded cod scrod (young cod); -a #16 scoop of macaroni and cheese; -a #8 scoop of creamy coleslaw; -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 at 11:58 A.M., showed the DM served the resident a #8 scoop of macaroni and cheese (two ounces more than directed by the menus) and one square of frosted apple spice cake. Observation also showed the DM did not serve or offer the half slice of bread with margarine as directed by the menus. 8. Review of Resident #45’s physician orders [REDACTED]. Further review showed the resident’s diet order as a regular texture, CCHO diet. Review of the resident’s meal tray card, showed staff were directed to to provide the resident with a CCHO diet. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -two oz. of breaded cod scrod (young cod); -a #16 scoop of macaroni and cheese; -a #8 scoop of creamy coleslaw; -1/2 slice of bread with Margarine; -four oz. of country spiced apples. |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 22) Observation on 03/15/19 at 11:54 A.M., showed the DM served the resident a #8 scoop of macaroni and cheese (two ounces more than directed by the menus) and one square of frosted apple spice cake. Observation also showed the DM did not serve or offer the half slice of bread with margarine as directed by the menus. 9. Review of Resident #46’s physician orders [REDACTED]. Review of the resident’s meal tray card showed staff were directed to provide the resident with a pureed diet. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on pureed diets with the following: -a #8 scoop of pureed roast beef; -a#20 (1.6 oz.) scoop of pureed bread; -a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal. Observation on 03/13/19 at 12:00 P.M., showed the Dietary Manager (DM) served the resident, a #8 scoop of pureed roast beef (4 oz. less than directed by the resident’s physician ordered diet), four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus). Observation also showed the DM did not serve or offer the pureed bread as directed by the menus. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on pureed diets with the following: -a #10 (3.2 oz.) scoop of pureed breaded cod scrod; -a #8 scoop of pureed macaroni and cheese; -a #12 scoop of pureed creamy cole slaw; -a #20 scoop of pureed bread with margarine; -a #12 scoop of pureed frosted apple spice cake Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the DM served the resident the following: -four oz. of pureed breaded cod scrod (2.4 oz. less than directed by the resident’s physician ordered diet); -four oz. of pureed cole slaw (1.4 oz. more than directed by the menus); -four oz. of applesauce. Observation also showed the DM did not include the pureed bread with margarine. 10. Review of Resident #48’s physician orders [REDACTED]. Review of the resident’s meal tray card showed staff directed to provide the resident with a pureed diet. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal. Observation on 03/13/19 at 12:00 P.M., showed the Dietary Manager (DM) served the resident four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus). Observation also showed the DM did not serve or offer the pureed bread as directed by the menus. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on pureed diets with the following: -a #10 (3.2 oz.) scoop of pureed breaded cod scrod; -a #8 scoop of pureed macaroni and cheese; -a #12 scoop of pureed creamy cole slaw; -a #20 scoop of pureed bread with margarine; -a #12 scoop of pureed frosted apple spice cake Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 23) DM served the resident the following: -four oz. of pureed breaded cod scrod (more than directed by the menus); -four oz. of pureed cole slaw (1.4 oz. more than directed by the menus); -four oz. of applesauce. Observation also showed the DM did not include the pureed bread with margarine. 11. Review of Resident #53’s physician orders [REDACTED]. Further review showed the resident’s diet order as pureed. Review of the resident’s tray card showed staff were directed to provide the resident with a pureed diet. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal. Observation on 03/13/19 at 12:00 P.M., showed the Dietary Manager (DM) served the resident four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus). Observation also showed the DM did not serve or offer the pureed bread as directed by the menus. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on pureed diets with the following: -a #10 (3.2 oz.) scoop of pureed breaded cod scrod; -a #8 scoop of pureed macaroni and cheese; -a #12 scoop of pureed creamy cole slaw; -a #20 scoop of pureed bread with margarine; -a #12 scoop of pureed frosted apple spice cake Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the DM served the resident the following: -four oz. of pureed breaded cod scrod (more than directed by the menus); -four oz. of pureed cole slaw (1.4 oz. more than directed by the menus); -four oz. of applesauce. Observation also showed the DM did not include the pureed bread with margarine. 12. Review of Resident #54’s physician orders [REDACTED]. Review of the resident’s meal tray card, showed staff were directed to to provide the resident with a CCHO diet. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -two oz. of breaded cod scrod (young cod); -a #16 scoop of macaroni and cheese; -a #8 scoop of creamy coleslaw; -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 at 12:12 P.M., showed the DM served the resident a #8 scoop of macaroni and cheese (two ounces more than directed by the menus) and one square of frosted apple spice cake. Observation also showed the DM did not serve or offer the half slice of bread with margarine as directed by the menus. 13. Review of Resident #55’s physician orders [REDACTED]. Review of the resident’s meal tray card showed staff directed to provide the resident with a no added sodium with mechanical meat. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on mechanical soft, CCHO diets with the following at the noon meal: |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 24) -three ounces (oz.) of ground beef pot roast; -a #16 (two oz.) scoop of mashed potatoes; -one oz. of beef gravy; -four oz. of harvard beets; -one half slice of fresh baked bread; -one half slice of red velvet cake roll. Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook Q served the resident the following: -three oz. of regular beef pot roast; -a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus); -four oz. of beef gravy (three oz. more than directed by the menus); -one slice of red velvet cake roll (twice as much than directed by the menus). Observation also showed the cook did not serve or offer the half slice of fresh baked bread as directed by the menus. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on mechanical soft, CCHO diets with the following at the noon meal: -two oz. of ground breaded cod scrod; -a #16 scoop of macaroni and cheese; -four oz. of steamed cabbage; -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R served the resident the following: -a two oz. whole piece of breaded cod scrod; -four oz. of macaroni and cheese (two oz. more than directed by the menus); -one slice of bread with margarine (twice as much than directed by the menus); -one square of frosted apple spice cake. 14. Review of Resident #56’s physician orders [REDACTED]. Review of the resident’s meal tray card, showed staff were directed to to provide the resident with a CCHO diet. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -two oz. of breaded cod scrod (young cod); -a #16 scoop of macaroni and cheese; -a #8 scoop of creamy coleslaw; -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 at 11:58 A.M., showed the DM served the resident a #8 scoop of macaroni and cheese (two ounces more than directed by the menus) and one square of frosted apple spice cake. Observation also showed the DM did not serve or offer the half slice of bread with margarine as directed by the menus. 15. Review of Resident #84’s physician orders [REDACTED]. Further review showed the resident’s diet order as a regular texture, no added sodium, CCHO diet with meats served with gravy or sauce due to inability to swallow dry meats. Review of the resident meal tray card showed staff were directed to provide the resident with a no added sodium, CCHO diet; Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 25) -three ounces (oz.) of beef pot roast; -a #16 (two oz.) scoop of mashed potatoes; -one oz. of beef gravy; -four oz. of harvard beets; -one half slice of fresh baked bread; -one half slice of red velvet cake roll. Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook Q served the resident the following: -a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus); -four oz. of beef gravy (three oz. more than directed by the menus); -one slice of red velvet cake roll (twice as much than directed by the menus). Observation also showed the cook did not serve or offer the half slice of fresh baked bread as directed by the menus. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -two oz. of breaded cod scrod; -a #16 scoop of macaroni and cheese; -a #8 scoop of creamy coleslaw; -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R served the resident the following: -four oz. of macaroni and cheese (two oz. more than directed by the menus); -one slice of bread with margarine (twice as much than directed by the menus); -one square of frosted apple spice cake. 16. Review of Resident #92’S physician orders [REDACTED]. Further review showed the resident’s diet order as a regular texture, CCHO diet. Review of the resident’s meal tray card showed staff were directed to provide the resident with a CCHO diet. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -three ounces (oz.) of beef pot roast; -a #16 (two oz.) scoop of mashed potatoes; -one oz. of beef gravy; -four oz. of harvard beets; -one half slice of fresh baked bread; -one half slice of red velvet cake roll. Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook Q served the resident the following: -a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus); -four oz. of beef gravy (three oz. more than directed by the menus); -one slice of red velvet cake roll (twice as much than directed by the menus). Observation also showed the cook did not serve or offer the half slice of fresh baked bread as directed by the menus. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on CCHO diets with the following at the noon meal: -two oz. of breaded cod scrod; -a #16 scoop of macaroni and cheese; -a #8 scoop of creamy coleslaw; |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 26) -1/2 slice of bread with Margarine; -four oz. of country spiced apples. Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R served the resident the following: -four oz. of macaroni and cheese (two oz. more than directed by the menus); -one slice of bread with margarine (twice as much than directed by the menus); -one square of frosted apple spice cake. 17. During an interview on 03/13/19 at 11:53 A.M., Cook Q said he/she serves the residents with CCHO diets the regular foods and portion sizes all the time. The cook said he/she did not know if the residents with CCHO diets should have anything different than the regular diets because he/she did not have anything that shows what the CCHO diets should get. 18. During an interview on 03/15/19 at 11:42 A.M., DA R said he/she had worked at the facility for a year and, while he/she wished they did, the facility did not have anything that shows what portion sizes to serve. The DA said there is no difference in what is served to residents on CCHO diets unless they have a different texture need. 19. During an interview on 03/15/19 at 12:36 P.M., the DM said staff should read the menus prior to service and serve foods in accordance with the menus. The DM said he/she did not review the menus before the meal service and he/she had not reviewed the menus with all staff including DA R. The DM said he/she missed that the menus had bread to be served. The DM said the facility had CCHO menus until they switched menu companies in (MONTH) (YEAR) and the registered dietician (RD) noticed the CCHO diet menus missing from the menus during his/her last visit a week ago. The DM said he/she just got the menus for the CCHO diets on 03/11/18 and had not put them in the book yet. The DM said staff served residents with CCHO diets the regular foods and portions while they did not have menus specific for CCHO diets. The DM said nursing tells dietary how much fluid to serve residents with fluid restrictions at meals. The DM said they only calculate fluids from beverages and do not include any liquids from foods such as soups, ice cream and gelatin. The DM said he/she did not know liquids from foods should be included into the total fluid amounts. The DM said he/she did not know Resident #20 had a fluid restriction. The DM said when dietary gets communication forms from nursing regarding diet changes, dietary staff should change the diet order on the resident’s meal tray card to ensure the proper diet is served. 20. During an interview on 03/15/19 12:47 P.M., the administrator said he/she would expect staff to prepare and serve food items in accordance with recipes and menus and staff are trained on this requirement. The administrator said he/she would expect the RD to review menus at each visit. The administrator also said the DM should monitor staff for the use of recipes and menus when he/she is at the facility and then it would be the responsibility of the head cook in the absence of the DM. The administrator said he/she tries to visit the kitchen at least once a day at meal time, but he/she did not know there were menus missing prior to 03/11/19 and he/she did not know the menus were not made available to staff once received. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, facility staff failed to allow |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 27) sanitized dishes to air dry prior to stacking in storage or use to prevent the growth of food-borne pathogens. Facility staff failed to store dishes inverted or covered to prevent the potential for physical contamination. Facility staff also failed to wash their hands as often as necessary using approved techniques to prevent cross-contamination. The facility census was 90. 1. Review of the Dietary Dish Storage policy dated 05/12/18, showed: -Following cleansing of dishes, dishes are stored upright to air dry for at least eight to 10 minutes, or until completely dried, in the drying area located by the dishwasher/three compartment sink; -Once dishes are completely air dried, the dishes are transferred on a clean cart to the proper clean dish storing area; -Dishes are to be stored inverted until time of usage. 2. Observation on 03/13/19 at 10:28 A.M., showed 10 metal food preparation pans stacked together wet on the metal storage shelves by the dry goods storage area. Further observation showed four plastic dome plate covers stacked together wet and stored upside down under the steamtable. Observation on 03/13/19 at 11:07 A.M., showed Cook Q used the wet stacked plastic dome plate covers to cover plates of food served to residents at the noon meal. 3. Observation on 03/15/19 at 9:25 A.M., showed four metal food preparation pans stacked together wet on the metal storage shelves by the dry goods storage area. Further observation showed Dietary Aide (DA) R brought two metal food preparation pans over from the clean side of the dishwashing station and placed them on the metal rack. Observation showed the pans stacked together wet when the DA placed them on the rack. 4. Observation on 03/15/19 9:30 A.M., showed 13 glass bowls, 27 glass plates, and seven plastic dome plate covers stacked together wet on the steamtable in the upright position uncovered. 5. Observation on 03/15/19 at 9:32 A.M., showed DA S stacked nine plastic dome plate covers together while wet and placed them upside down on the top of a service cart on the clean side of the dishwashing station. 6. During an interview on 03/15/19 at 10:23 A.M., the Dietary Manager (DM) said staff should allow clean dishes to air dry for eight to 10 minutes before they are put in storage or used. The DM said staff should not stack dishes while wet and all staff have been trained on this requirement. 7. Observation on 03/15/19 10:08 A.M., showed DA S removed the food processor from the clean side of the dishwashing station while wet and placed it on the base in the cook’s station. 8. During an interview on 03/15/19 at 10:56 A.M., the administrator said dishes should be air dried before they are put away. The administrator said staff are trained on that requirement upon hire and at least annually. The administrator said the DM is responsible to monitor dish washing and storage daily. 9. Observation on 03/15/19 at 11:55 A.M., showed a stack of plastic dome plate covers stacked together wet on the countertop in the back dining room service station. Further observation showed DM used wet stacked dome plate covers to cover plates of food served to residents who ate in their rooms. 10. Review of the facility’s Handwashing policy dated 06/19/17, showed dietary staff shall clean their hands and exposed portions of their arms after handling soiled equipment or utensils and after engaging in other activities that contaminate the hands. Further review showed the proper handwashing technique included to dry hands thoroughly from the fingers down to the forearms and wrists with a paper towel; if available, use clean paper towel to |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 28) turn off the water. 11. Observation on 03/15/19 from 9:30 A.M. to 9:55 A.M., showed DA S washed soiled dishes at the mechanical dishwashing station. Observation showed, without washing his/her hands, the DA placed clean dishes, which included coffee cups, plates and bowls, onto a service cart. Further observation showed the DA picked up three wet stacked black plastic tubs from the floor and placed them on the bottom shelf of the service cart next to three racks of sanitized coffee cups. During an interview, on 03/15/19 at 9:55 A.M., the DA said he/she had worked at the facility for three years and he/she received training on handwashing upon hire. The DA said staff should wash their hands before washing dishes and then every 15 minutes thereafter. The DA said staff should wash their hands after touching anything dirty and he/she did not have a reason for not washing his/her hands before putting away the clean dishes. 12. During an interview on 03/15/19 at 10:00 AM., the DM said staff should wash their hands when they enter the kitchen, between tasks and after touching anything dirty. The DM said after they wash their hands, staff should turn off the faucet with a paper towel. The DM said all staff are trained on when and how to wash their hands three times a year. 13. Observation on 03/15/19 at 10:05 A.M., showed DA S washed his/her hands at the handing washing sink. Observation showed the DA used his/her wet bare hands to turn off the faucet. Further observation showed the DA washed his/her hands at the handing washing sink a second time. Observation showed the DA used a paper towel to turn off the faucet and then used the same paper towel to dry his/her hands. During an interview on 03/15/19 at 10:06 A.M., the DA said staff should turn the faucet with a paper towel and then dry hands. The DA said the purpose of turning the faucet off with the paper towel is to avoid making hands dirty again. The DA he/she did not think about the towel used to turn off the faucet being dirty and that he/she should not use the same towel to dry his/her hands. 14. During an interview on 03/15/19 10:51 A.M., the administrator said staff should wash their hands before food preparation, after touching their body or anything dirty. The administrator said staff should wash their hands between washing dirty dishes and handling clean dishes. The administrator said staff should dry their hands with a paper towel and then use another paper towel to turn off the faucet. The administrator said it is not acceptable for staff to dry their hands with the same paper towel used to turn off the faucet. The administrator said staff are trained on handwashing upon hire, annually and randomly during competency observations. | |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 29) 1. According to the Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. *Hand washing remains the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and when each resident’s care is completed. 2. Observation on 3/12/19 at 12:47 P.M., showed certified medication technician/certified nurse assistant (CMT/CNA) K wipe Resident #30’s buttocks from back to front while performing bowel movement incontinence care. Observation on 3/12/19 at 12:55 P.M., showed CMT/CNA J wipe resident #30’s buttocks from back to front while performing bowel movement incontinence care. Observation on 3/12/19 at 12:57 P.M., showed CMT/CNA J perform urinary catheter care with the same gloves he/she used to wipe resident’s buttocks when he/she performed bowel movement incontinence care. 3. Observation on 3/12/19, at 12:48 P.M., showed CNA E and CNA F provide care to Resident #46. Additional observation showed the resident soiled with feces. CNA E cleansed the resident’s back perineal area, then cleansed the resident’s front perineal area with the same soiled gloves. The CNA did not provide care in a manner to prevent the spread of infection causing contaminants. 4. Observation on 3/12/19, at 3:55 P.M., showed nurse assistant (NA) D provide care to Resident #63. Additional observation showed the resident soiled with feces. NA D cleansed the resident’s back perineal area, then cleansed the resident’s front perineal area with the same soiled gloves. The NA then touched the resident’s linens, skin, and clean supplies with the same soiled gloves. The NA did not provide care in a manner to prevent the spread of infection causing contaminants. 5. During an interview on 3/15/19 at 2:55 P.M., licensed practical nurse (LPN) I said he/she expects staff to wipe resident’s buttocks from front to back when performing incontinence care and to sanitize hands and change gloves between dirty to clean tasks. During an interview on 3/15/19 at 3:20 P.M., CNA L said he /she should wipe resident’s buttocks from front to back when performing incontinence care and should sanitize hands and change gloves between dirty to clean tasks. During an interview on 3/15/19 at 3:43 P.M., the director of nursing (DON) said he/she expects staff to wipe resident’s buttocks from front to back when performing incontinent care and should sanitize hands and change gloves between dirty to clean tasks. 6. Review of the facility’s Oxygen Therapy policy, undated, showed the following: -Purpose : to provide residents that require oxygen with the safest and most effective care. -Procedure: Tubing, plastic clean storage bag, and humidifier bottle will be replaced weekly and as needed. -Place on TAR to change tubing and humidifier bottle weekly. -Place a clean storage bag on the side of the concentrator to store oxygen tubing (nasal cannula/mask) between use and not in use. Change clean storage bag weekly and as needed. 7. Observation on 3/12/19 at 12:11 P.M., showed Resident #34 in the dining room. Additional observation showed the resident’s oxygen tubing did not contain a label or date. 8. Observation on 3/12/19 at 12:32 P.M., showed Resident #33 in the dining room. Additional observation showed the resident’s oxygen tubing did not contain a label or date. Observation on 3/12/19 at 12:39 P.M., of the resident ‘s room showed the resident’s oxygen |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 30) tubing and nasal cannula lay over the concentrator and not bagged. Observation on 3/14/19 at 10:45 A.M., showed the tubing and cannula in the resident’s room not bagged, lay on the concentrator and without a date on the available plastic bag. Observation on 3/15/19 at 11:30 A.M., showed the resident’s oxygen tubing and cannula lay on the resident’s Geri chair unbagged and undated. 9. During an interview on 3/15/19 at 11:52 A.M., CNA A said when the oxygen tubing is not in use, it is bagged with a date on the tubing. He/She said staff change the tubing every Sunday. During an interview on 3/15/19 at 12:01 P.M., LPN said the oxygen tubing is bagged when not in use and the tubing is dated. 10. Review of the facility’s policy on blood glucometer disinfecting, dated 08/08/17, showed staff are directed as follows: -Glucometers are cleaned before and after use on each resident; -Wash hands for 30 seconds; -Don gloves; -Place a clean paper towel over work area; -Clean glucometer thoroughly using a specified bleach wipe (Product must specify kills[DIAGNOSES REDACTED]) for 1 full minute and discard wipe; -Using a new wipe, wrap the glucometer in the wipe for 3 full minutes; -Place glucometer on designated work area paper towel; -Allow to air dry for 1 full minute; -Remove gloves and wash hands. 11. Observation on 3/13/19 at 10:19 A.M., showed certified medical technician (CMT) M apply hand sanitizer and gloves. Further observation showed he /she picked up the glucometer from the top of the medication cart and wipe it with a micro-kill wipe. Additional observation showed he/she placed the glucometer on top of the medication cart. The CMT did not clean the glucometer as directed by the facility’s policy. Observation on 3/13/19 at 3:28 P.M., showed CMT N apply hand sanitizer and gloves. Further observation showed he/she removed the glucometer from a medication cart drawer. Additional observation showed he/she wiped the glucometer with a micro-kill wipe one time then place it on top of the medication cart. The CMT did not clean the glucometer as directed by the facility’s policy. Observation on 3/14/19 at 4:30 P.M., showed CMT O remove the glucometer from the top of the medication cart then wipe it with a micro-kill wipe one time. Further observation showed he/she then lay the glucometer back on the top of the medication cart. The CMT did not clean the glucometer as directed by the facility’s policy. 12. During an interview on 3/13/19 at 10:19 A.M., CMT M said he/she knew he/she should wipe the glucometer with a micro-kill wipe but did not know how long it needed to sit in a micro-kill wipe or to let it air dry. During an interview on 3/15/19 at 2:55 P.M., LPN I said staff are expected to wipe down the glucometer and wrap it in a wipe for a couple of minutes and allow it to dry before using it on another resident. During an interview on 3/15/19 at 3:43 P.M., the DON said staff are expected to wash the glucometer with a bleach sheet for a minute then wrap it in a new bleach sheet and let it air dry before each use. |
| 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: 265851 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SILVERSTONE PLACE | STREET ADDRESS, CITY, STATE, ZIP 2735 EAGLESON DR | |||||||||
| 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 | ||
