| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| 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 – Potential for minimal harm Residents Affected – Some | 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 | |
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, facility staff failed to maintain sound levels at a |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) Observation on 1/29/19 at 11:17 P.M. through 12:25 A.M., showed multiple call lights sounded loudly throughout the building. Observation on 1/30/19, at 12:10 A.M., showed three residents up in the hall way in the memory care unit. Further observation showed loud audible beeping related to the call light. Observation on 01/30/19 at 3:25 P.M., showed the call light system beeped loudly throughout the Special Care Unit (SCU). Additional observation showed none of the resident room call lights were on. Observation on 1/30/19 at 6:25 P.M. showed call lights sounded loudly throughout the building. Observation on 1/31/19 at 9:52 A.M. through 10:01 A.M., showed call lights sounded loudly on the 400 and 500 hall. Observation on 01/31/19 at 12:34 P.M., showed the call light system beeped loudly throughout the SCU. Additional observation showed none of the resident room call lights were on. Observation on 1/31/19 at 1:59 P.M., showed call lights sounded loudly throughout the building. Observation on 1/31/19 at 2:19 P.M., at 3:30 P.M., and at 4:13 P.M., showed call lights sounded loudly throughout the building. Observation on 2/1/19 from 1:33 P.M. to 1:45 P.M., showed call lights sounded loudly on the 500 hall. Observation on 2/5/19 at 10:40 A.M., showed call lights sounded loudly down the 500 Hall. Further observation showed no lights visibly on down the hall. Observation on 02/05/19 at 10:39 A.M., showed the call light system beeped loudly throughout the SCU. Additional observation showed none of the resident room call lights were on. Observation on 2/5/19 from 10:42 A.M. to 11:04 A.M., showed call lights sounded loudly at the nurses’ station. The activity director announced an activity over the intercom at the nurses’ station but it was difficult to hear the name of the activity or the location over the sound of the call lights. Observation on 02/05/19 at 12:07 P.M., showed the call light system beeped loudly throughout the SCU. Additional observation showed none of the resident room call lights were on. Observation on 02/05/19 at 1:44 P.M., showed the call light system beeped loudly throughout the facility and the SCU. Additional observation showed none of the resident room call lights were on. Observation on 2/5/19 at 4:38 P.M. and 5:19 P.M., showed call lights sounded loudly throughout the building. Observation on 2/6/19 at 2:29 P.M., showed call lights sounded loudly at the nurses’ station. 2. During an interview on 1/29/19 at 3:49 P.M., Resident # 57 said There is not enough staff, the call lights go on all night long. It is bothersome. During an interview on 1/29/19 at 4:42 P.M., Resident # 29 said I close my door at night because the call lights go on all night long, they’re loud, and I can’t sleep. During an interview on 1/29/19 at 11:41 P.M., Resident # 37 said the call lights are loud, sometimes they startle me. During an interview on 1/30/19 at 11:18 A.M., Resident # 74 said the call lights buzzed all night and they seem even louder today, and said we never get any sleep around here. During an interview on 1/30/19, at 12:16 A.M., CNA R said, One person back here (in 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) memory care unit) is not enough staff. You can hear every call light that goes off on every hall, and it keeps the residents that wander up and going all night. During an interview on 2/5/19 at 10:50 A.M., Resident # 73 said the call lights are loud and never seem to shut off, if they do it isn’t long before they are on again. I just don’t get any peace from them. During an interview on 02/05/19 at 10:52 A.M., certified nursing aid (CNA) L said Resident #17 can be bothered by the call light sounding if it goes off too long, and said Resident #40 will also get agitated at times from the call lights sounding. The CNA said sometimes the residents will say, I wish that thing will shut up, and said he/she feels like the call light system is too loud for the residents in the unit. During an interview on 02/05/19 at 11:14 A.M., Resident #2 said he/she thinks the call light system is noisy and said it wakes him/her up at night when he/she is trying to sleep. The resident said he/she is uncertain why the call light system cannot be turned down. During an interview on 02/06/19 at 2:27 P.M., licensed practical nurse (LPN) C said the facility installed a new call light system a few years ago and said he/she thinks it is louder than the previous call light system. LPN C said he/she has heard residents complain that the call lights are too loud and interrupts their sleep. During an interview on 2/6/19 at 5:20 P.M., CNA F said he/she thinks the call light system is a little noisy and has heard residents complain about the noise. During an interview on 02/06/19 at 4:13 P.M., the administrator said the facility had a new call light system installed a few years ago and said the new system is louder than the previous system. The administrator said residents have complained about the call lights being loud and said staff in the SCU has mentioned they believe some of the residents get agitated from the call lights beeping. The administrator said the call light system does go off in the SCU even if there are not any call lights in the SCU on. The administrator said maintenance called the call light company to see about turning it down, but the system is as low as it will go. 3. Observation on 01/30/19 during the Life Safety Code tour, showed resident rooms 101, 104, 204, 302, 303, 304, 305, 310, 401, 402, 404 through 408 and 501 through 509 without window screens. During an interview on 01/30/19 at 2:05 P.M., the Maintenance Director said he/she did not know about the missing window screens and he/she does not conduct any routine inspections of the windows. During an interview on 01/30/19 at 2:45 P.M., the administrator said he/she did not know about the missing window screens and he/she would expect the maintenance director to monitor the resident rooms regularly for needed repairs. The administrator said staff should also notify maintenance if they find something missing or broken. | |
| F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to notify the ombudsman (a |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) resident advocate who provides support and assistance with problems and/or complaints regarding the facility) related to a transfer or discharge to a hospital, including the reasons for the transfer, for three sampled residents (Resident #1, #15, and Resident #37) out of 24 sampled residents. The facility census was 71 residents. 1. Review of Resident #1’s Discharge Return Anticipated Minimum Data Set (MDS), a federally mandated tool completed by the facility to assess resident, dated 11/08/18, showed staff documented they discharged the resident to the hospital. Review of the resident’s nurse’s note, dated 11/08/18, showed staff documented they discharged the resident to the hospital on [DATE]. Review of the resident’s medical record showed staff did not document the staff informed the ombudsman of a transfer and/or the reasons for the transfer. 2. Review of Resident #15’s Discharge Return Anticipated MDS, dated [DATE], showed staff documented they discharged the resident to the hospital. Review of the resident’s nurse’s notes, dated 1/18/19, showed staff documented they discharged the resident from the facility to the hospital on [DATE]. Review of the resident’s medical record showed staff did not document they informed the ombudsman of the resident’s transfer and/or reason for the transfer. 3. Review of Resident #37’s Discharge Return Anticipated MDS, dated [DATE], showed staff documented they discharged the resident to the hospital. Review of the resident’s nurse’s note, dated 10/02/18, showed staff documented they discharged the resident to the hospital on [DATE]. Review of the resident’s medical record showed staff did not document they informed the ombudsman of the resident’s transfer and/or reason for the transfer. During an interview on 02/05/19 05:22 PM, the Social Service director said he/she lets the ombudsmen know of emergent discharges but not of any other transfers or discharges. He/She said, Yes I know I am supposed to be notifying them, but I just haven’t been. During an interview on 02/06/19 at 4:09 P.M., the administrator said staff are expected to issue discharge notices to residents and the ombudsman’s office for all facility initiated transfers and discharges. | |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| 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 4) Review of the RAI manual, dated 10/1/18, showed the definition of a deep tissue injury as a purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Review showed the definition of an unstageable pressure ulcer is a pressure ulcer with the wound bed obscured by slough (Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like.). 2. Review of Resident #2’s medical records showed staff documented a [DIAGNOSES REDACTED]. Further review of the current physician’s orders [REDACTED]. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -At risk for pressure ulcers; -[DIAGNOSES REDACTED].>-Did not have a Stage I or greater; -Did not have a clinical assessment of skin; -Has one Stage 2 Pressure ulcer. Review of the resident’s care plan, last updated 7/12/18, showed staff are directed to perform skin assessments weekly and observations of skin condition daily with cares, and assist the resident with turning and repositioning while in bed. Observation and interview on 01/31/19 at 2:07 P.M., showed Licensed Practical Nurse (LPN) M provided wound care to the resident. Observation showed the resident’s coccyx (tailbone) and left buttock area with a large area of dark pink and purple skin that blanched very slowly, and a wound covered with light brown eschar . The LPN said he/she did not know the wound stage, and said the Director of Nursing (DON) assesses and stages wounds. During an interview on 2/6/19 at 1:45 P.M., the resident said he/she has a pressure ulcer on his/her buttocks, and that he/she has had ongoing issues where they heal and come back. Staff did not accurately complete section M0100 or M0300 of the MDS. Staff did not accurately code the deep tissue injury or Unstageable pressure ulcer, and did not accurately code the resident with two pressure ulcers. 3. Review of Resident #2’s medical records showed staff documented a [DIAGNOSES REDACTED]. Further review of the medical record showed a PASARR, level I (10/07/15) and II (10/22/15) screen completed. Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident as follows: -Resident is not currently considered by the State level II PASARR process to have a serious mental illness and/or Intellectual Disability; -No [DIAGNOSES REDACTED]. -Resident did not have a serious mental illness or Intellectual Disability. Staff did not accurately complete section A1500 or A1510 of the MDS. 4. Review of Resident #66’s medical records showed staff documented a [DIAGNOSES REDACTED]. Further review of the medical record showed a PASARR, level I (1/21/14) and II (1/30/14) screen completed. Review of the resident’s significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Resident is not currently considered by the State level II PASARR process to have a serious mental illness and/or Intellectual Disability; -No [DIAGNOSES REDACTED]. -Resident did not have a serious mental illness or Intellectual Disability. Staff did not accurately complete section A1500 or A1510 of the MDS. |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| 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) 5. During an interview on 2/6/19 at 4:05 P.M., the MDS Coordinator said he/she completes residents’ MDS assessments per the RAI guidelines and each MDS should accurately reflect the resident. He/She completes the MDS on admission, quarterly, with significant changes, per Medicare part A requirements, and upon discharge. He/She uses information from observation, the nurses’ notes, and communication with residents and CNAs to complete the MDS. He/She said pressure ulcers and diagnoses that require a PASARR should be coded on the MDS assessment. During an interview on 2/6/19 at 6:04 P.M., the DON said he/she expects the MDS Coordinator to complete residents’ MDS assessments per the RAI guidelines, and the MDS should accurately reflect each resident. He/She said if a resident has a pressure wound or a [DIAGNOSES REDACTED]. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) Observation on 1/31/19, at 12:15 P.M., showed the resident in the dining room. Further observation showed the resident with messy greasy hair, and unkempt facial hair. Observation and interview on 2/1/19, at 8:57 A.M., showed the resident in his/her room. CNA G and CNA Q raised the resident in a mechanical lift. Further observation showed the resident’s wheel chair cushion saturated with urine. CNA G told CNA Q the resident was up when I came in at 6:00 A.M., they know we can’t get to him/her until after breakfast, he/she is so wet. Additional observation showed the resident’s clothing and the sling for the lift saturated with urine. The resident had deep impressions of wrinkles on his/her buttocks, and a quarter sized red area on the resident’s coccyx (tailbone), and a deep purple area, CNA Q said is hard in the center. Observation showed CNA Q applied finger tip pressure to the purple area, and the area was non-blanchable. Additional observation showed the resident’s hair was greasy, and the resident’s fingernails long, jagged with brown substance under them. CNA Q said, I ask night shift not to get him/her up and let us get him/her up when we come in, because he/she is such a heavy wetter, and then his/her skin breaks down. They get him/her up anyway, and then he/she has skin issues. Observation and interview on 02/05/19 at 11:15 A.M., showed CNA G and CNA H transferred the resident to his/her bed with a mechanical lift to provide incontinence care. The CNAs removed the resident’s urine saturated brief and provided perineal care. Observation showed small open areas to the resident’s coccyx (tailbone) with bleeding noted in the wound beds, and a reddened area to the resident’s right hip which blanched slowly. CNA G said the areas on the resident’s coccyx were red but not open when the CNAs last provided pericare at about 6:30 A.M. 2. Review of Resident #19’s MDS dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -[DIAGNOSES REDACTED]. -Dependent on two staff for bed mobility, transfers, toileting, and personal hygiene; -Dependent on one staff for bathing; -Did not have behaviors; -Did not reject care. Review of the resident’s care plan, updated 11/21/18, showed staff are directed: -Behaviors may include refusal of care; -Document refusal of care; -Dressing and grooming assistance as indicated; -Toileting assistance as indicated; -Transfer assistance as indicated with mechanical lift and two assistance. Observation and interview on 02/05/19 at 1:39 P.M. showed CNA G and CNA I transferred the resident to his/her bed with a mechanical lift to provide incontinence care. Observation showed the resident with dirty hair, dirty fingernails, sweatpants with a torn pocket, and a brief saturated with urine. CNA G said staff last changed the resident and provided incontinence care between 9:00 and 9:30 A.M. The CNA said it is sometimes hard to provide incontinence care every two hours because this hall is very demanding and they rely on a float staff or staff from another hall to assist with care. 3. Review of the facility’s policies showed the policies did not provide guidance related to showers or bathing. 4. Review or Resident #2’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: – Cognition intact; – Required extensive assistance of one person with personal hygiene; |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) – Required total assistance of one person with bathing; – Impairment on both sides of lower extremities; – Uses wheelchair. Review of the resident’s plan of care, revised on 02/15/19, showed staff are directed to document if the resident refuses to participate with care or activities of daily living (ADL), and to see plan of care addressing health conditions which affect the resident’s ability to perform ADLs as needed. Observation on 02/05/19 at 11:14 A.M., showed the resident with long stubble on his/her face and neck and unshaven. During an interview on 02/15/19 at 11:14 A.M., the resident said staff do not help him/her shave when he/she asks for assistance. The resident said he/she thinks it has been around two weeks since he/she received assistance to shave. 5. Review of Resident #8’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Mild depression; -[DIAGNOSES REDACTED]. -Required extensive assistance of two staff for transfers and bed mobility; -Dependent on two staff for toileting; -Dependent on one staff for personal hygiene and bathing; -Physical behaviors one to three days during the lookback period; -Rejected care four to six days during the lookback period. Review of the resident’s care plan, updated 1/31/19, showed staff are directed: -Document refusals of care, if refuses care, offer choices for an agreed time to return to perform cares; -Assist with dressing and grooming as indicated; -Perform toileting assistance as indicated; -Transfer assistance as indicated with mechanical lift and two assistance Review of the resident’s shower sheets showed staff only documented they assisted the resident to shower on three days during the month of January. Observation and interview on 01/31/19 at 3:30 P.M., showed Certified Nurse Aide (CNA) F and CNA J transferred the resident to his/her bed with the mechanical lift. Additional observation showed the resident with matted, greasy hair. CNA F said he/she is not sure how often staff wash the resident’s hair. CNA J said staff are expected to provide two showers a week to residents and should wash their hair with each shower but he/she is not sure when staff last bathed the resident. 6. Review of Resident #21’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -[DIAGNOSES REDACTED].>-Dependent on two staff for personal hygiene and bathing; -Did not display behaviors; -Did not reject care. Review of the resident’s plan of care, updated 11/22/18, showed staff are directed: -Document refusals of care. Observation on 01/31/19 at 9:34 A.M. through 9:55 A.M., showed the resident in his/her wheelchair at the nurses’ station with visible facial hair. Observation on 02/05/19 at 3:47 P.M. showed the resident in his/her wheelchair at the nurses’ station with visible facial hair. 7. Review of Resident #23’s quarterly 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) resident as follows: – Cognition intact; – Requires extensive assistance of one person with personal hygiene; – Requires total assistance of one person with bathing; – Uses a wheelchair. Review of the resident’s plan of care, revised 11/22/18, showed staff are directed to document refusals of care and to encourage choices with care. Review of the resident’s shower sheets showed staff documented they assisted the resident to shower on the following dates: – 12/08/18; – 12/16/18; – 12/20/18; – 12/27/18; – 01/03/19; – 01/13/19; – 01/22/19; – 01/28/19; – 02/04/19. During an interview on 02/05/19 at 2:02 P.M., the resident said he/she usually receives only one shower each week and would like to have at least two showers each week. 8. Review of Resident #26’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: – Cognition intact; – Vision highly impaired; – Requires extensive assistance of one person with personal hygiene; – Requires partial physical help of one person with bathing; – Uses a walker and wheelchair. Review of the resident’s plan of care, dated 05/02/18, showed the following: – Personal hygiene assistance of one as needed; – Encourage choices with cares; – Document refusals of care. Review of the resident’s shower sheets showed the resident received showers on the following dates: – 12/04/18; – 12/09/18; – 12/14/18; – 12/20/18; – 12/27/18; – 12/31/18; – 01/03/19; – 01/09/19; – 01/16/19; – 01/23/19; – 01/31/19. During an interview on 01/31/19 at 9:23 A.M., the resident said he/she cannot choose what time or day he/she receives a shower. The resident said he/she used to receive two showers weekly, but is now only receiving one shower each week. The resident said if he/she asks staff about receiving a shower, the staff tells him/her they do not have a shower aid for the day. |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) 9. During an interview on 02/05/19 at 5:13 P.M., CNA B said some of the nurses pull shower aids to work the floor, which results in showers not getting completed on their shift. During an interview on 2/6/19 at 1:31 P.M., Licensed Practical Nurse (LPN) K said the residents should have at least two showers per week and the Director of Nursing (DON) tracks whether they are given at least twice per week. During an interview on 02/06/19 at 2:27 P.M., LPN C said the DON makes a list of residents who are supposed to receive showers for the day. He/She said if a resident refuses a shower, staff are expected to document the resident refused. LPN C said sometimes the resident showers are not getting completed and said sometimes the shower aids get pulled from completing showers to work the floor. During an interview on 02/06/19 at 4:13 P.M., the DON said he/she keeps track of resident showers and said he/she does think there has been problems with residents receiving showers at least two times weekly. The DON said if a resident refuses a shower, staff are expected to document the residents refusal, and said if a residents cognition is impaired, he/she would expect for the resident to receive at least two showers weekly. The DON said the shower aids do get pulled from showers to work the floor at times. | |
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide activities to meet all resident’s needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) (MONTH) 2019, showed the records did not contain any documentation of the residents’ participation in activities or 1:1s. 4. Review of Resident #21’s Minimum Data Set (MDS), a federally required resident assessment, dated 8/11/18, showed staff assessed the resident as follows: -Severely impaired cognition; -Did not display behaviors or reject care; -Required extensive assistance of one staff for transfers; -Required limited assistance of one staff for locomotion on and off the unit; -Staff did not conduct the interview for daily and activity preferences; -Staff assessment of daily and activity preferences showed staff selected None of the above activities. Review of the resident’s plan of care, updated 11/22/18, showed staff are directed: -Help resident attend activities he/she may enjoy. Observation on 01/30/19 at 11:15 A.M., showed the resident in his/her room in bed. Staff did not interact with the resident or engage him/her in an activity. Observation on 01/31/19 at 9:34 A.M., showed the resident in his/her wheelchair at the nurses’ station with staff present. Staff did not interact with the resident or engage him/her in an activity. Observation on 01/31/19 at 9:55 A.M., showed the resident in his/her wheelchair at the nurses’ station with staff present. Staff did not interact with the resident or engage him/her in an activity. Observation on 02/05/19 at 3:47 P.M., showed showed the resident in his/her wheelchair at the nurses’ station with staff present. Staff did not interact with the resident or engage him/her in an activity. 5. Review of Resident #32’s significant change MDS, showed staff assessed the resident as follows: -Severely impaired cognition; -Did not display any behaviors or reject care; -Required extensive assistance of two staff for bed mobility and transfers; -Dependent on two staff for toileting, personal hygiene, and bathing; -Did not conduct the interview for daily and activity preferences; -Staff assessment of daily and activity preferences showed staff selected None of the above activities. Review of the resident’s care plan, last updated 12/4/18, showed staff are directed the resident enjoys restorative exercise class, please make sure the resident attends three times a week. Invite the resident to his/her favorite activities. Review of the resident’s activity assessment, dated 1/4/19, showed staff documented the resident likes music and watching TV, prefers one on one activities or small groups, and has no participation barriers or strengths. Staff documented the resident spends less than 1/3 of his/her time involved in activities. Observation on 01/31/19 at 9:50 A.M., showed the resident in bed in his/her room. Staff did not engage the resident in an activity or interaction. Observation on 02/05/19 at 10:42 A.M., showed the resident in his/her broda chair (specialized wheelchair) at the nurses’ station with staff present. Staff did not interact with the resident or engage him/her in an activity. Observation on 02/05/19 10:53 A.M., showed the resident in his/her broda chair at the nurses’ station with staff present. Staff did not interact with the resident or engage him/her in an activity. Observation on 02/05/19 at 11:01 A.M. through 11:36 A.M., showed the resident in his/her |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) broda chair at the nurses’ station. Country music played at the desk, but it could not be heard when call lights sounded. Staff did not interact with the resident or engage him/her in an activity. 6. Review of Resident #61’s care plan, last updated 1/04/19, showed staff are directed under nutritional status to do the following related to activities: -Invite me to activities which include food & drinks. Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -No staff assessment for daily and activity preferences; -Dependent with bed mobility, transfers, and toileting. Observation on 2/5/19 from 10:42 A.M. to 11:04 A.M., showed call lights sounded loudly at the nurses’ station. The activity director announced an activity over the intercom at the nurses’ station but it was difficult to hear the name of the activity or the location over the sound of the call lights. Observation showed no activity was offered or participated in by the resident during the survey process. During an interview on 2/6/19 at 5:20 P.M., CNA F said dependent residents on the SCU toss around a beach ball and other games sometimes. He/she said as for other dependent residents outside the unit, I don’t know for sure because activities are done on day shift. 7. During an interview on 02/01/19 at 2:36 P.M., the activity director (AD) said he/she hangs an activity calendar on the wall in the unit and said he/she will go to the SCU to ask if the aids need help completing activities for the residents. The AD says this week has been crazy and he/she has not been back in the SCU this week. The AD said he/she is also responsible to transport and accompany residents to appointments and outings outside the facility in addition to completing activities with residents. The AD said he/she usually goes to the SCU at least two times daily on a regular week to check on residents and activities. The AD said he/she will go to the resident’s room if he/she does not see a lot of participation and will encourage them to participate in activities. The AD said he/she has tried to complete 1:1s with some of the SCU residents, but said they do not respond and he/she is uncertain what else to do with those residents. The AD said the SCU residents family members do not come in to visit so he/she cannot ask them for ideas. The AD said he/she has been in the position since (MONTH) (YEAR) and said a staff member recently showed him/her how to document 1:1s with residents, but said he/she has not documented any individual resident activity participation since beginning the position as AD. During an interview on 02/05/19 at 10:52 A.M., certified nursing assistant (CNA) L said the aids who work in the SCU are the only staff completing activities or 1:1s with the residents and said no other staff comes to the SCU to help complete any of the activities with the residents. During an interview on 02/06/19 at 9:57 A.M., CNA D said no other staff are helping the aids complete activities and 1:1s with the residents in the SCU. The CNA said they have a closet with some activity items like flash cards, magazines, puzzles, etc , but said the aids cannot complete activities in the SCU because they have to monitor the residents and do not have the time. During an interview on 02/06/19 at 2:27 P.M., licensed practical nurse (LPN) C said no other staff are helping the aids in the SCU with activities. The LPN said the residents on the SCU do not get to participate in the birthday parties listed on the calendar, and said |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 12) staff have paid out of pocket to buy the SCU residents cupcakes and desserts related to their birthdays. LPN C said the activities in the SCU are not getting completed related to the activity calendar and staff are not completing 1:1s. During an interview on 02/06/19 at 4:13 P.M., the director of nursing (DON) said the aids are responsible for completing the activities with residents in the SCU, but said the AD helps set the activities up. The DON said none of the aids has mentioned to him/her there were problems with not getting the activities in the SCU completed. The DON said he/she expects the AD to have more oversight to ensure activities are provided in the SCU. | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 13) Observation and interview on 01/31/19 at 3:30 P.M., showed CNA F and CNA J transferred Resident #8 to his/her bed with a mechanical lift to provide incontinence care. CNA F said the resident is terrified of the lift. Staff connected the lift sling to the lift and raised the resident with the sling high on the resident’s upper body, shoulders, and neck. Observation showed the resident’s eyes open very wide during the transfer to his/her bed, and he/she looked back and forth between the two CNAs several times during the transfer. The CNAs did not transfer the resident in a manner to prevent accidents. Observation on 02/15/19 at 12:10 P.M., showed CNA Q and CNA I transferred Resident #8 to his/her bed with a mechanical lift to provide incontinence care. CNA I raised the resident in the mechanical lift as CNA Q adjusted the resident’s bed and bed linens. CNA Q did not maintain contact with or proximity to the resident in the sling as CNA I moved the resident in the sling from his/her geri-chair to bed. CNA I did not adjust the legs of the mechanical lift to provide the widest base of support as he/she moved the resident from the geri-chair to bed. 4. Review of Resident #67’s admission Minimum Data Set (MDS), a federally mandated tool, dated 1/9/19, showed staff assessed the resident as follows: -Cognitively intact; -Requires extensive physical assistance of two or more staff members for bed mobility, transfers, dressing, and toilet use. Observation on 1/30/19, at 12:07 P.M. showed the resident in bed. Certified nurse assistant (CNA) G and CNA P came to get the resident out of bed. The CNAs raised the resident with the mechanical lift, the resident yelled out in pain and pushed against the hoyer lift straps with his/her hand. The resident said, The sling feels like its cutting my legs in half. The resident swung in the air when the staff ran over a cord with the mechanical lift. CNA P did not maintain contact with or proximity to the resident in the sling as CNA G attempted to position the lift. The resident yelled out. The staff lowered the resident down into his/her chair. CNA P told CNA G he/she thinks the sling is way too small. The resident told the staff, I feel so tight and smooshed in it. 5. During an interview on 2/6/19 at 2:17 P.M., LPN K said when staff use a mechanical lift for transfers there should always be two staff present and attentive to the transfer. He/She said that all equipment should be moved like safety mats etc. prior to the transfer and anytime staff transfer a resident into a wheelchair the legs of the mechanical lift should be opened. During an interview on 2/6/19 at 5:22 P.M., CNA F said when assisting a resident with a mechanical lift transfer there should always be two staff members. One staff member is moving and directing the lift and the other is at the side of the resident helping them to transfer. The stability bar should always open when the resident is in the mechanical lift. 6. Review of the facility’s policies, showed the policies did not include guidance on how to propel residents in wheelchairs. 7. Review of Resident #4’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: – Cognition intact; – Required limited assistance of one staff with transfers; – Is totally dependent on one staff for locomotion off the unit; – Uses a wheelchair. Review of the resident’s plan of care, revised 01/29/19, showed staff identified the resident required assistance of one with locomotion via wheelchair and required transfer assistance of one to two staff as indicated. |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 14) Observation on 01/30/19 at 4:17 P.M., showed CNA E propelled the resident in his/her wheelchair without foot rests. Additional observation showed both of the resident’s feet slid across the floor while the CNA propelled the resident in his/her wheelchair. Observation on 01/31/19 at 8:47 A.M., showed CNA D propelled the resident in his/her wheelchair without foot rests. Additional observation showed both of the resident’s feet slid across the floor while the CNA propelled the resident in his/her wheelchair. 8. Review of Resident #48’s annual MDS, dated [DATE], showed staff assessed the resident as follows: – Cognition moderately impaired; – Required extensive assistance of two staff with transfers; – Required extensive assistance of one staff with locomotion off the unit; – Uses a wheelchair. Review of the resident’s plan of care, dated 09/20/17, showed staff identified the resident required transfer assistance of one staff during periods of weakness. Observation on 01/30/19 at 12:27 P.M., showed CNA D propelled the resident in his/her wheelchair without foot rests. Additional observation showed both of the resident’s feet slid across the floor while the CNA propelled the resident in his/her wheelchair. 9. Review of Resident #58’s significant change MDS, dated [DATE], showed staff assessed the resident as follows: – Cognition impaired; – Required extensive assistance of two staff with transfers; – Required extensive assistance of one staff with locomotion off the unit; – Uses a wheelchair. Review of the resident’s plan of care, dated 02/15/19, showed staff identified the resident achieves locomotion via some ambulation and some wheelchair with assistance as needed, and showed the resident required transfer assistance of two staff members. Observation on 01/30/19 at 12:37 P.M., showed CNA D propelled the resident in his/her wheelchair without foot rests. Additional observation showed both of the resident’s feet slid across the floor while the CNA propelled the resident in his/her wheelchair. 10. During an interview on 02/01/19 at 2:06 P.M., CNA E said most of the residents have foot pedals in a bag behind their wheelchairs. The CNA said staff are supposed to place the resident’s feet on the foot rests while propelling the resident and are to make sure the resident’s feet are not touching the ground. CNA E said he/she does not recall propelling the resident without using the foot rests. During an interview on 02/06/19 at 9:57 A.M., CNA D said staff are expected to use foot rests when propelling residents in their wheelchairs and said the residents have foot rests on the back of their wheelchairs. The CNA said he/she probably just got busy and forgot to place the foot pedals on the resident’s wheelchair prior to propelling the resident. During an interview on 02/01/19 at 4:02 P.M., licensed practical nurse (LPN) C said staff should be using foot rest when propelling residents in their wheelchairs and said the foot rests are in a bag on the back of the resident’s wheelchair. LPN C said the resident’s feet should not be sliding on the ground when staff are propelling residents in their wheelchair. 11. During an interview on 02/06/19 at 4:09 P.M., the Director of Nursing and Administrator said if staff propel a resident in his/her wheelchair, they are expected to place the residents’ feet on foot pedals, then remove the pedals again if the resident is able to self propel. Staff are expected to ensure the legs of a mechanical lift should be opened to the widest base of support during transfers. If staff have to close the legs of |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 15) the lift for placement under a wheelchair, they should open the legs after they move the lift away from the wheelchair to ensure safety. Someone should have physical contact with the resident in the sling at all times to ensure the resident will not bump into the lift or other objects and to ensure the sling does not sway back and forth. | |
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide safe, appropriate pain management for a resident who requires such services. **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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| 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 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) uncomfortable I get up anyway. Observation and interview on 1/30/19, at 12:07 P.M. showed the resident in bed. Certified nurse assistant (CNA) G and CNA P came to get the resident out of bed. CNA G removed the resident’s protective boot from his/her right foot and the resident moaned and grimaced. CNA G put on a sock on the residents right foot, the resident moaned and grimaced. The resident said, you are supposed to use the big ones, my ankle is bent and it hurts so bad. The resident started crying when the CNA put on the larger sock. Observation showed the resident’s leg is internally rotated at he knee and ankle. The CNAs rolled the resident from side to side and the resident yelled out and said he/she is in pain. The resident said his/her foot was not inverted before, he/she thinks the boots weigh his/her foot down and that is why it is turned inward. The CNAs put the hoyer sling under the resident. The CNAs placed the resident in a hoyer sling, when they raised the resident legs he/she yelled out and observation showed a facial grimace. The CNAs raised the resident with the mechanical lift, the resident yelled out in pain and pushed against the hoyer lift straps with his/her hand. The resident said, The sling feels like its cutting my legs in half. The resident swung in the air when the staff ran over a cord with the mechanical lift, the staff did not guide the resident when the resident is suspended in the air. The resident yelled out. The staff lowered the resident down into his/her chair. CNA P told CNA G he/she thinks the sling is way too small. The resident told the staff, I feel so tight and smooshed in it. During an interview on 1/30/19, at 12:26 P.M., CNA G said he/she has reported the resident’s pain several times but he/she is going to report it again today. During an interview on 1/30/19, at 12:47 P.M., the director of nursing (DON) said the resident has not had any issues with pain. The DON said he/she never moans or screams with transfers or care that he/she knows of. He/She said the staff got an order for [REDACTED]. Observation on 1/30/19, at 1:12 P.M., showed the resident is in his/her wheelchair in the hallway speaking to the DON. The resident said to the DON, I hate that bed, you know I hate that bed, it makes me hurts so bad as we have talked about many times. It sucks me in one spot, and I can’t move. Observation and interview on 01/30/19 at 1:55 P.M., showed the resident in his/her wheelchair as staff attempted to transfer the resident to his/her bed with a mechanical lift. The resident grimaced, gripped the armrests of the wheelchair and said Watch below my knees! Are you sure this won’t hurt? The DON asked the resident did the pain pill help? and the resident shrugged his/her shoulders. CNA G, Licensed Physical Therapy Assistant (LTPA) T and the DON continued to attempt the transfer. Staff adjusted the lift sling straps, and the resident said they both hurt, it’s digging in, at the last place they used sheepskin to pad the lift sling. The resident said, oh my goodness, moaning, and told the staff to stop. The staff lowered the hoyer sling. The resident said staff could try it again after they adjusted the sling. The resident grimaced and moaned when they raised it again, staff stopped and lowered the resident. The resident said it hurts on both sides and rubbed his/her thighs. Observation and interview at 2:14 P.M., showed the DON returned with sheepskin to place under the resident in the lift sling. The DON and LPTA T adjusted the sheepskin and lift sling, and LTPA T said Try hard, just grit your teeth, and take the pain until you get in bed. It might help if you got dressed each day and wore pants over your legs. Observation on 01/30/19 at 2:19 P.M., showed LTPA returned to the room and said in front of the other staff and DHSS staff, the resident never had any clothes at any of the other buildings either. Staff transferred the resident into his/her bed after they placed and adjusted the sheepskin. LPTA T raised the resident’s leg to position him/her and he/she |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| 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 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) yelled out in pain. Additional observation showed a large red mark on the resident’s skin behind his/her knee that was tender to staff’s touch. During an interview on 1/30/19, at 11:25 A.M., the resident said, I want to know why the hoyer hurts me so bad, I just scream in pain, I don’t know if its not big enough or what the problem is. He/She said, no one has tried to fix it but this bed is so uncomfortable I get up anyway. During an interview on 1/30/19, at 2:14 P.M., CNA G said the resident has had this pain with transfers since he/she got here, sometimes he/she yells even louder. He/She said the resident is in a lot of pain when they transfer him/her. During an interview on 01/30/19 at 2:48 P.M. the DON and LPN M said there is no definite setting to monitor on the resident’s low air loss mattress, the nurses just spot check it to ensure the mattress is at the appropriate setting for pressure relief and comfort. During an interview on 02/06/19 at 2:32 P.M., the DON said he/she did not know of the resident’s complaint of pain during transfers with the lift before last week, and therapy staff did not report any complaints of pain, but said the resident did refuse therapy 2/4/19 and 2/5/19. He/She said the sheepskin helps when the resident will get up. The DON said the resident declined stronger pain medication, denied pain at various times, and expressed a concern about developing an addiction to pain medication. The DON said he/she expects staff to report a resident’s complaint of pain during transfers. He/She said the mattress company replaced the resident’s mattress the day of 1/30/19. During an interview on 02/06/19 at 2:40 P.M., the resident’s physician said he/she feels the resident’s complaints of pain during transfers and discomfort with his/her bed is related to extremely dry skin and pruritis (severe itching) which have caused the resident to scratch excessively, and the resident’s history of [MEDICAL CONDITION] (damage to peripheral nerves, which causes weakness, numbness and pain, usually in the hands and feet) . The physician also said he/she ordered blood tests today to determine if the resident suffers from a vitamin deficiency which could worsen the dry itchy skin. | |
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) -Moderately impaired cognition; -[DIAGNOSES REDACTED]. -Required extensive assistance of two staff for transfers and bed mobility; -Required extensive assistance of one staff for personal hygiene; -Dependent on two staff for toileting; -Dependent on one staff for bathing; -Always incontinent of bowel and bladder; -Did not have behaviors; -Did not reject care. Review of the resident’s shower sheets showed staff documented they assisted the resident to shower on the following dates: – 1/2/19; – 1/14/19; – 1/23/19; – 1/26/19. Review of the resident’s care plan, updated 1/28/19, showed staff are directed: -Dressing and grooming assistance as indicated; -Personal hygiene assistance of one; -Toileting assistance as indicated; -Transfer assistance as indicated with two staff and mechanical lift; -Turning and repositioning schedule per assessment. Rest periods in bed after meals unless attending an activity of choice. Observation on 1/29/19, at 12:10 P.M., showed the resident in the dining room. Further observation showed the resident with greasy hair, and unkempt facial hair. Observation on 1/31/19, at 12:15 P.M., showed the resident in the dining room. Further observation showed the resident with messy greasy hair, and unkempt facial hair. Observation and interview on 2/1/19, at 8:57 A.M., showed the resident in his/her room. CNA G and CNA Q raised the resident in a mechanical lift. Further observation showed the resident’s wheel chair cushion saturated with urine. CNA G told CNA Q the resident was up when I came in at 6:00 A.M., they know we can’t get to him/her until after breakfast, he/she is so wet. Additional observation showed the resident’s clothing and the sling for the lift saturated with urine. The resident had deep impressions of wrinkles on his/her buttocks, and a quarter sized red area on the resident’s coccyx (tailbone), and a deep purple area, CNA Q said is hard in the center. Observation showed CNA Q applied finger tip pressure to the purple area, and the area was non-blanchable. Additional observation showed the resident’s hair is greasy, and the resident’s fingernails long, jagged with brown substance under them. CNA Q said, I ask night shift not to get him/her up and let us get him/her up when we come in, because he/she is such a heavy wetter, and then his/her skin breaks down. They get him/her up anyway, and then he/she has skin issues. Observation and interview on 02/05/19 at 11:15 A.M., showed CNA G and CNA H transferred the resident to his/her bed with a mechanical lift to provide incontinence care. The CNAs removed the resident’s urine saturated brief and provided pericare. Observation showed small open areas to the resident’s coccyx (tailbone) with bleeding noted in the wound beds, and a reddened area to the resident’s right hip which blanched slowly. CNA G said the areas on the resident’s coccyx were red but not open when the CNAs last provided pericare at about 6:30 A.M. Staff did not provide incontinence care and repositioning every two hours or as needed. 3. Review of Resident #8’s MDS, dated [DATE], showed staff assessed the resident as follows: |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) -Severely impaired cognition; -Mild depression; -[DIAGNOSES REDACTED]. -Required extensive assistance of two staff for transfers and bed mobility; -Dependent on two staff for toileting; -Dependent on one staff for personal hygiene and bathing; -Physical behaviors one to three days during the lookback period; -Rejected care four to six days during the lookback period. Review of the resident’s care plan, updated 1/31/19, showed staff are directed: -Document refusals of care, if refuses care, offer choices for an agreed time to return to perform cares; -Assist with dressing and grooming as indicated; -Perform toileting assistance as indicated; -Transfer assistance as indicated with mechanical lift and two assistance. Review of the resident’s shower sheets showed staff documented they assisted the resident to shower on the following dates in January: -1/2/19; -1/13/19; -1/28/19. Observation and interview on 01/31/19 at 3:30 P.M., showed CNA F and CNA J transferred the resident to his/her bed with the mechanical lift. Observation showed the resident with matted, greasy hair. CNA F said he/she is not sure how often staff wash the resident’s hair. CNA J said staff are expected to provide two showers a week to residents and should wash their hair with each shower but he/she is not sure when staff last bathed the resident. 4. Observation and interview on 02/05/19 at 1:39 P.M. showed CNA G and CNA I transferred Resident #19 to his/her bed with a mechanical lift to provide incontinence care. Observation showed the resident with dirty hair, sweat pants with a torn pocket, and a brief saturated with urine. CNA G said staff last changed the resident and provided incontinence care between 9:00 and 9:30 A.M., four hours prior. The CNA said it is sometimes hard to provide incontinence care every two hours because this hall is very demanding and they rely on a float staff or staff from another hall to assist with care. 5. During an interview on 1/29/19 at 3:49 P.M., Resident # 57 said There is not enough staff, the call lights go on all night long. It is bothersome. During an interview on 1/29/19 at 4:42 P.M., Resident #29 said I close my door at night because the call lights go on all night long, they’re loud, and I can’t sleep. During an interview on 1/30/19 at 11:18 A.M., Resident #74 said the call lights buzzed all night and they seem even louder today. Observation on 1/30/19, at 12:10 A.M., showed three residents up in the hall way in the memory care unit. Further observation showed loud audible beeping related to the call light. During an interview on 1/30/19, at 12:16 A.M., CNA R said, One person back here (in the memory care unit) is not enough staff. You can here every call light that goes off on every hall, and it keeps the residents that wander up and going all night. During the resident group council interview on 1/31/19, one group member said he/she recently had to wait one and a half hours to be transferred out of his/her bed. Additional interviews during the group council interview showed five of six residents said they believe staffing has gotten worse over the past year and said they think the facility needs more staff to meet the 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) During an interview on 2/05/19 at 2:02 P.M., Resident #23 said he/she laid in his/her feces last night for nearly four hours. The resident said he/she pressed his/her call light around 6 P.M. and staff did not answer it until about 10 P.M. The resident said it usually takes staff a long time to answer call lights and to receive staff assistance, and said he/she thinks this is because the facility does not have enough help. The resident also said he/she has only been receiving one shower every week and said he/she would like at least have two showers each week. During an interview on 2/01/19 at 11:28 A.M., CNA I said he/she thinks there are not enough staff to meet the resident’s needs. The CNA said staff are not checking the residents every two hours for incontinence and said he/she have seen issues with call lights getting answered timely. CNA I said he/she has heard residents complain that their call lights are not answered for an hour and a half. During an interview on 02/01/19 at 2:06 P.M., CNA E said he/she thinks the facility does not have enough staff and said the facility has had a lot of call ins lately and staff quitting. The CNA said because of the low staffing residents are not getting checked every two hours for incontinence. CNA E said he/she has frequently seen issues with call lights not getting answered timely and said, with the exception of a couple nurses, no other staff will answer call lights. During an interview on 02/05/19 at 5:13 P.M., CNA J said he/she primarily works evenings and weekends and staff he/she believes the staffing is low in the evening. The CNA said the low staffing is affecting staffs ability to get residents up, answering call lights timely, and getting residents to the dining room. The CNA said certain nurses are pulling the shower aids from showers to work the floor. CNA J said no other staff are helping to answer call lights, but is solely the aids responsibility. During an interview on 2/6/19 at 5:20 P.M., CNA F said staff are instructed to answer call lights as soon as you see or hear one. CNA F said he/she thinks the call light system is a little noisy and has heard residents complain about the noise. During an interview on 02/06/19 at 2:27 P.M., licensed practical nurse (LPN) C staff call ins has gotten a lot worse in the past three to four months and said he/she feels like the facility has half the staff they had from a couple of years ago. The LPN said call lights being answered timely has been an issue, said some staff will walk past the call light going off and not answer it, and said some of the aids do not answer call lights very well. The LPN said he/she believes facility staffing is low which has affected residents getting checked every two hours and staff providing timely incontinent care. The LPN said residents are not receiving assistance with grooming and personal hygiene as they should, such as brushing hair and shaving. During an interview on 02/06/19 at 4:09 P.M., the Director of Nursing (DON) and Administrator said they feel there is adequate staffing. The DON said they have discussed some different staff utilization options including a float position. The DON said all staff are expected to answer call lights, including charge nurses. 6. During an interview on 02/01/19 at 2:36 P.M., the activity director (AD) said he/she hangs an activity calendar on the wall in the unit and said he/she will go to the SCU to ask if the aids need help completing activities for the residents. The AD says this week has been crazy and he/she has not been back in the SCU this week. The AD said he/she also transports residents in addition to completing activities. The AD said he/she usually goes to the SCU at least two times daily on a regular week to check on residents and activities. The AD said he/she will go to the residents rooms if he/she does not see a lot of participation and will encourage them to participate in activities. The AD said he/she has tried to complete 1:1s with some of the SCU residents, but said they do not respond |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0725 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) and is uncertain what else to do with those residents. The AD said the SCU residents family members do not come in to visit so he/she cannot ask them for ideas. The AD said he/she has been in the position since (MONTH) (YEAR) and said a staff member recently showed him/her how to document 1:1s with residents, but said he/she has not documented any individual resident activity participation since beginning the position as AD. During an interview on 02/05/19 at 10:52 A.M., certified nursing assistant (CNA) L said the aids who work in the SCU are the only staff completing activities or 1:1s with the residents and said no other staff comes to the SCU to help complete any of the activities with the residents. During an interview on 02/06/19 at 9:57 A.M., CNA D said no other staff are helping the aids complete activities and 1:1s with the residents in the SCU. The CNA said they have a closet with some activity items like flash cards, magazines, puzzles, etc ., but said the aids cannot complete activities in the SCU because they have to monitor the residents and do not have the time. During an interview on 02/06/19 at 2:27 P.M., licensed practical nurse (LPN) C said no other staff are helping the aids in the SCU with activities. The LPN said the residents on the SCU do not get to participate in the birthday parties listed on the calendar, and said staff have paid out of pocket to buy the SCU residents cupcakes and desserts related to their birthdays. LPN C said the activities in the SCU are not getting completed related to the activity calendar and staff are not completing 1:1s. During an interview on 02/06/19 at 4:13 P.M., the director of nursing (DON) said the aids are responsible for completing the activities with residents in the SCU, but said the AD helps set the activities up. The DON said none of the aids has mentioned to him/her there were problems with not getting the activities in the SCU completed. The DON said he/she would expect for the AD to have more oversight to ensure activities were getting completed in the SCU. | |
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 22) -Not due to a medical condition or problem; -Persistent or likely to reoccur without continued treatment; -Not sufficiently relieved to reoccur without continued treatment; -Not due to environmental stressors; and -Not due to a psychological stressor. 3. Review of Resident #15’s MDS, dated [DATE], showed staff documented the resident’s [DIAGNOSES REDACTED].>-Dementia, unspecified without behavior disturbances; -Anxiety; -No irregularities in mood or behavior. Review of the resident’s physician’s orders [REDACTED]. 4. Review of Resident #28’s MDS, dated [DATE], showed staff documented the resident’s [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]; -Anxiety; -No irregularities in mood or behavior. Review of the resident’s physician’s orders [REDACTED]. 5. Review of Resident #63’s MDS, dated [DATE], showed staff documented the resident’s [DIAGNOSES REDACTED].>-Dementia, unspecified with behavior disturbances; -Anxiety; -Depression; and -No irregularities in mood or behavior. Review of the resident’s physician’s orders [REDACTED]. 6. During an interview on 2/06/19 at 2:17 P.M., Licensed Practical Nurse (LPN) K said the pharmacist comes in once per month to review the medications for unnecessary medications. He/She said the Director of Nursing (DON) is responsible for tracking unnecessary medications, but he/she would not expect to see a resident with a [DIAGNOSES REDACTED]. During an interview on 2/6/19 at 4:13 P.M., the DON said some residents come from the hospital without an appropriate diagnosis, and staff try to catch them. The DON said she and the charge nurses try to look at those, and the medical director and pharmacy consultant also review those [DIAGNOSES REDACTED]. The DON said the facility has had recent changes in the pharmacy consultant services. | |
| F 0801 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview, and record review, the facility staff failed to employ a qualified |
| 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: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| 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 0801 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 23) During an interview on 01/29/19 at 1:00 P.M., the DM said he/she had worked at the facility for about a year and he/she did not have a degree or certification in food service management. The DM said he/she was not currently attending or enrolled in any courses for certification. The DM said the registered dietician comes to the facility on ce a month to provide consultation. During an interview on 01/30/19 at 12:42 PM, the administrator said the DM did not have a degree, accreditation, or certification in food service management. The administrator said the facility had enrolled the DM in a course arranged by the corporation, but they did not have another class that started within the year and the DM would have to wait until (MONTH) 2019. The administrator said he/she did not seek out any other programs for the DM to attend for certification and the facility did not have any other person on staff that is certified in food service management that works full time. The administrator said the facility’s registered dietician works as a consultant on a part-time basis. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. Based on observation, interview, and record review, staff failed to provide care in a |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265225 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER ST JAMES LIVING CENTER | STREET ADDRESS, CITY, STATE, ZIP 415 SIDNEY STREET, PO BOX 69 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 24) to remove his/her gloves and wash hands before leaving the resident’s room. 3. Observation on 01/31/19 at 3:59 P.M., showed CNA F and CNA J provided incontinence care to Resident #8. CNA J used the same area of the cloth for multiple wipes as he/she cleansed the resident’s perineal area. During an interview on 2/6/19 at 5:24 P.M., CNA F said hands should be washed when entering and exiting the resident’s room. When providing care for a resident use the cloth for one swipe, then toss it and get another wipe. CNA F said during care you always wipe front to back and change gloves if they get soiled. 4. Observation on 02/05/19 at 1:39 P.M., showed CNA G and CNA I provided incontinence care to Resident #19. CNA G used the same area of the cloth for multiple wipes and used a back and forth motion as he/she cleansed the resident’s perineal area. 5. Review of the facility’s Medication Administration Guidelines, dated (MONTH) (YEAR), showed the guidelines did not provide guidance for staff to sanitize their hands between administering medications to residents. 6. Observation on 02/05/19 at 11:03 P.M., showed Licensed Practical Nurse (LPN) K did not wash his/her hands in between residents during medication administration. LPN K did not wash/sanitize hands at appropriate times during medication administration, and between each resident to prevent the spread of infection. 7. During an interview on 2/05/19 at 12:05 P.M., Licensed Practical Nurse (LPN) K said staff should sanitize their hands before and after meds and they should stop and wash their hands after about 5 passes. He/She said, I don’t know why I didn’t do that, I knew I was supposed to. During an interview on 02/06/19 at 4:09 P.M., the Director of Nursing (DON) said staff are expected to cleanse residents from front to back, and use a new area of the wipe or cloth for each swipe as they provide perineal care. Staff are expected to cleanse the front perineal area first but if they cleanse the back first, staff should wash hands and change gloves in between, then repeat the frontal perineal care. Staff are expected to wash hands and apply gloves when they enter a resident’s room, after they touch a resident’s soiled brief, between clean and dirty tasks, and before they leave a resident’s room. Staff are also expected to wash or sanitize their hands between each resident during medication pass. If staff drop a pill or tablet on top of the medication cart, they are expected to dispose of that medication and obtain a new one. | |
