| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement policies and procedures to prevent abuse, neglect, and theft. **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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) complete a Report of Incident/Accident form and submit the original to the Director of Nursing (DON) within 24 hours of the incident/accident. – The DON shall ensure the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. 2. Review of the Incident/Accident Report for Resident #25, dated 2/13/18, showed: – Staff getting the resident up for lunch, unhooking mechanical lift sling and bumped the resident’s head. Review of a nurse’s progress note, dated 2/9/18, and written by Licensed Practical Nurse (LPN) B showed: – History of previous head injury from mechanical lift; – Staff getting the resident up for lunch, had the resident in wheelchair, unhooking lift seat from the mechanical lift, lift accidentally hit the resident above the right eyebrow; – No redness, bruising or scratch noted to skin; pupils, grips, movement of extremities normal, pain response appropriate, notified physician, and family member. Review of Resident #25’s quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/2/18, showed: – A Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident made his/her own decisions; – Extensive assist of two or more staff for bed mobility, toileting and hygiene; – Total dependence of two or more staff for transfers; – Only able to stabilize with staff assistance for surface to surface transfers between bed and chair or wheelchair; – Impairment of the lower extremities; – Wheelchair; – [DIAGNOSES REDACTED]. Review of the care plan, updated 10/4/18, showed: – Transfer with the assist of two staff and the mechanical lift; – The hooks of the lift should be covered during transfer and staff should hold on to the arm to keep it from swinging and hitting the resident. Review of the Resident Care Guidelines/Messages used by certified nurse aides (CNA) to determine type of care for residents, dated 10/26/18, showed: – Extensive assist of two staff with mechanical lift for all transfers. Review of a nurse’s progress note, dated 10/27/18, at 11:36 A.M., and written by LPN D showed: – Noted resident with bruise over left eyebrow; – CNAs reported that the mechanical lift hit the resident; – Primary Care Physician (PCP) notified via fax, family notified via phone; – Will continue to monitor. – LPN D did not record he/she notified the DON and did not complete an incident report. Review of a nurse’s progress note, dated 10/27/18, at 10:38 P.M., and written by Registered Nurse (RN) A showed: – Resident denied pain/discomfort related to bruise over left eye; – Neurological checks (pupil size, grips, movement of extremities, cognition) within normal limits for the resident. Review of a nurse’s progress note, dated 10/28/18, at 7:55 A.M., and written by LPN E showed: – At 7:05 A.M., aides reported the resident hit on head with mechanical lift related to aide lowering lift quickly; – Upon entering room, the resident in wheelchair with purple, golf-ball size knot located |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) on right side of forehead; – Bruise located on left side of forehead related to mechanical lift lowering too quickly yesterday morning as well; – Resident reported pain to forehead; neuro checks started; – Instructed aide to apply ice; – Vital signs: Blood pressure (B/P) 173/85, Pulse (P) 61, Respirations (R) 20, Temperature (T) 98.2, Oxygen saturation 97%; – Resident alert, pupils equal and reactive to light, grips equal, moves all extremities well; – Called and left message for on-call physician at 7:15 A.M – Called family member to notify; – PCP returned call to facility. – LPN E did not record that he/she contacted the DON or the Administrator of the incident. Review of a nurse’s progress note, dated 10/28/18, at 7:26 P.M., written by RN A showed: – Neurochecks and vital signs within normal limits; – Oriented to person, place and time; – Denies pain; – Area above right eye swollen and purple in color; – Area above left eye purple in color and color spreading around eye orbit. Review of a nurse’s progress note, dated 10/29/18, at 11:05 P.M., and written by LPN C showed: – At 3:00 P.M., noted fax from PCP related to head injury; no new orders, and DON notified; – Bruising continues to left orbital area and forehead. During an interview on 11/1/18, at 10:07 A.M., NA E said: – He/she had not attended CNA class at this time and the next class was scheduled four months from now. – He/she assisted CNA I to transfer the resident from his/her bed to his/her wheelchair on 10/27/18. – They used an old crank-style mechanical lift. – Both CNA I and NA E hooked the mechanical lift sling to the arm of the lift. – CNA I raised the resident off the bed and NA E pulled the resident back into the chair with the handles on the sling. – The wheelchair was in the upright position, not leaned back and CNA I lowered the resident to the wheelchair. – CNA I did not pull back the lift fast enough and the arm of the lift hit the resident in the left temple area of the face; it happened fast. – If CNA I had pulled the lift back and away from the wheelchair a little bit, it would not have hit the resident. – The resident started screaming and CNA I and NA E quickly unhooked the sling loops from the arm of the lift. – Both tried to talk with the resident to calm him/her. – NA E reported the incident to RN A, the night charge nurse who gave report to the oncoming charge nurse. – CNA I finished dressing the resident and about five minutes after the incident, the resident wheeled him/herself to the nurses’ station to tell the charge nurse of the incident. – Neither charge nurse went to the resident’s room to assess the resident after the incident. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) – There was a raised bruise the size of a golf ball on the resident’s forehead near the temple area. – He/she wrote a statement about the incident today (11/1/18). – He/she was in-serviced on the use of lift when he/she started to work at the facility in September, (YEAR). During an interview on 11/1/18, at 10:37 A.M., and 11:26 A.M., the DON said: – The incident form was completed on 2/13/18, for the 2/9/18 incident and no statements were written by the staff involved in the incident. – In-services had not been given since the incident. – The investigation of the 10/27/18 and 10/28/18 incidents were not completed because the facility’s annual survey had started and she did not have time to do it. – She was notified on 10/28/18, of the incident that happened on 10/28/18 by LPN E. – She was not notified of the 10/27/18 incident until Monday morning 10/29/18. – Staffing this past week end was a mess so NAs were used to staff the facility but there should have been a CNA assigned to work with the NAs. – Interviews from staff involved in both incidents were taken on 11/1/18. During an interview on 11/1/18, at 11:26 A.M., NA B said: – He/she only worked in the facility two days, had not been to class, and had not been instructed in the use of the mechanical lift use and operation. – LPN E demonstrated the use of the lift to him/her on 11/28/18, but he/she did not return demonstrate the use and operation of the lift. – NA B and NA C performed the transfer of the resident with the mechanical lift on 10/28/18, the second time the resident was hit in the head. – NA C operated the lift to raise the resident off the bed but he/she had NA B lower the resident into the wheelchair. – When he/she lowered the resident to the wheelchair, he/she lowered the lift too fast and the lift hit the resident in the center of the forehead. – There was a golf ball size raised area of bruising to the center of the resident’s forehead; there was no bleeding and the resident did not lose consciousness. – NA C informed LPN E of the incident and LPN E came immediately to assess the resident and notified the physician. – LPN E asked the NAs to put ice to the area. – NA B did not know the lift could be lowered slower when the lift was used correctly. – No CNA was in the resident’s room with NA B and NA C during the transfer. – LPN E told NA B to be hands off the lift and only watch transfers until he/she could be trained to use the lift. – NA B said he/she had no instruction since on the use of the lift and was not told when he/she would receive training. – He/she wrote statement on 11/1/18 that matched the interview above. During an interview on 11/1/18, at 11:45 A.M., RN A said: – He/she worked from 5:00 P.M. on 10/26/18, until 6:00 A.M. on 10/27/18. – He/she was in report with LPN A, the oncoming day shift charge nurse, when CNA I and NA B came to the desk to report the mechanical lift hit the resident above the left eye. – LPN A and RN A discussed neuro checks. – RN A did not go to the room to assess because the resident came to the desk after the incident. – The resident was mad and a bruise began to form. – LPN A did a neuro check on the resident. – All checks were normal. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) – LPN A was charge nurse on days and LPN D was a new nurse and on orientation. – RN A discussed neuro checks with LPN A and thought all would be taken care of on the day shift. – RN A would have expected LPN A to notify the physician, continue neuro checks, notify family, but protocol did not say to call the Administrator or DON. – If the injury was serious, we should call. – RN A said he/she would not notify DON or Administrator for a simple bump to the head. – RN A saw a written statement by NA D and said that his/her statement was from the February, (YEAR), incident when the resident was hit in the head with the mechanical lift, not the incident that happened on 10/27/18. – He/she thought that the incidents happened because of the technique used by the staff. – LPN A should have assessed the resident immediately as RN A was leaving the facility. – RN A thought LPN A contacted the physician and family but did not contact the DON or Administrator. – No written statement provided from RN A on 11/1/18. During an interview on 11/1/18, at 2:17 P.M., LPN A said: – He/she was charge nurse on 10/27/18. – A NA (did not know who) told him/her the resident bumped his/her head when they transferred the resident with the mechanical lift. – The resident came to the desk and there was a dime size red area, not raised on his/her forehead. – LPN A did not chart any information but assigned the charting to LPN D, the new nurse and on orientation. – The bump was not that bad so neuro checks were not done. – The resident did not complain of pain and was not upset or mad. – The resident went to breakfast and they checked on him/her later that day, – LPN A contacted the physician and family but did not contact the Administrator or the DON. – LPN A did not feel the need to contact the Administrator or DON about the red area above the left brow. – LPN A said he/she only checked neuros if the area was bulging or if the resident acted differently. – No written statement provided from RN A on 11/1/18. During an interview on 11/1/18, at 2:35 P.M., CNA I said: – He/she worked the night of 10/26/18, and the early morning of 10/27/18. – He/she assisted NA E to transfer the resident with the mechanical lift. – The resident leaned forward in the wheelchair and he/she tried to pull the lift back to keep it from hitting the resident. – CNA I worked the lift and NA E guided the resident, but the lift hit the resident in the forehead. – There was a small goose egg on the resident’s forehead and the next day there was bruising around the resident’s eyes. – CNA I informed RN A and LPN A, but neither went down immediately to assess the resident. – CNA I and NA E dressed the resident, which took about 10 minutes, then the resident wheeled him/herself to the nurses’ desk. – The resident yelled out after he/she was hit. – CNA I also worked with NA D two to three months ago when the resident was hit in the forehead with the lift. – The lift hit the resident in his/her right temple area during that incident. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) – The cause was due to the old mechanical lift; staff needed to turn the knob slowly to not let the resident down too fast and because the resident leaned forward during the transfers. – Three staff were needed to safely transfer the resident. – Wrote statement on 11/1/18 that matched the interview above. During a telephone interview on 11/6/18, at 3:48 P.M., LPN E said: – He/she worked the 10/28/18. – Around 7:00 A.M., NA C came to the desk and told him/her the mechanical lift hit the resident again in the forehead. – LPN E immediately went to assess the resident. – There was a golf ball size purple area to the resident’s right temple area. – LPN E started neuro checks immediately on the resident which were normal. – The resident did not lose consciousness, had no bleeding, complained of head pain, but refused pain medication. – NA B worked the lift and lowered the resident too fast and hit the resident. – NA B was new to facility and had not had any instruction on how to work the lift. – LPN E said he/she did not show or work with NA B on how to use the lift prior to NA B operating the lift for the resident. – LPN E told NA B to be hands off the lift until instruction could be provided to him/here on how to operate the lift. – LPN E notified the physician and could not reach a family member. – LPN E informed the family member when they came to the facility later in the day. – LPN E notified the DON later in the morning of the incident. – LPN E spoke to DON about need for in-servicing the NAs in use of lift. During an interview on 11/1/18, at 6:26 P.M., the DON said: – Staff should notify the Administrator or the DON within 24 hours of an incident. – Neuro checks should be performed with head injuries. – If just a bump and no injury to the head, they do not have to notify the Administrator or DON. – LPN A should have started neuro checks on the resident on 10/27/18, because of the head injury from the mechanical lift and should have notified the DON or Administrator immediately of the injury. – The nurse on duty starts the investigation and the DON completes an investigation. – Statements should be taken from all parties involved in the incident. – NAs should always have a CNA working with them. – The facility had NAs working that were not attending CNA class because class size consists of 15 seats and it was difficult to get the NAs into the class. – NAs have to complete the class within four months of hire or they are fired and then re-hired and the four months starts over again. – Some NAs have worked here a long time without attending CNA classes and without certification. – The facility had a full time NA Trainer in the facility that worked with the NAs that are hired. – The NAs should go through 16 hours of training with the NA Trainer. – The DON doubted if the NAs went through another 16 hours of training each time they were rehired. – After 16 hours of training, the NAs could work with a CNA. – A CNA should always work with a NA. During a telephone interview on 11/8/18, at 12:39 P.M., NA C 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) – He/she started to work at the facility five months ago. – He/she worked at the facility previously but was terminated and then rehired. – He/she did not remember the dates of hire. – He/she worked with NA B on 10/28/18, and they transferred the resident with the mechanical lift. – There was a problem with the lift knob that raised and lowered the residents. – Other staff had problems with the lift too. – The knob got stuck and would lower the residents really fast. – On 10/28/18, he/she had to get another staff to help him/her with the stuck knob before the resident was raised off the bed. – The other staff left; he/she raised the resident off the bed and NA B guided the resident to the wheelchair. – NA B had trouble pulling the resident back far enough into the seat of the wheelchair so they switched and NA B was to lower the resident. – As NA B turned the knob, the resident lowered really fast into the wheelchair and the lift hit the resident in the forehead. – He/she immediately informed the charge nurse, LPN E, that the lift hit the resident. – LPN E immediately went to the room and assessed the resident, and called to notify the physician and family. – He/she did not know if LPN E contacted the DON or Administrator. – There were other CNAs working, but none were available to assist NA C and NA B. – LPN B told him/her previously that two NAs could work the lift without a CNA to help them, so they performed the transfer without a CNA. – He/she said he/she was uncomfortable working with NA B because NA B had no training on how to use the lift. – He/she said he/she also worked with another NA that had no training and had been uncomfortable doing so. – He/she told LPN E that he/she was uncomfortable working with NAs that had not had training using the lift and LPN E said he/she did not have to work with them. – He/she said three staff were needed to work the lift and keep the lift from hitting the resident when the resident was transferred. – He/she said he/she was given training on the use of the lift the first day of the first time he/she was hired but received no training when hired five months ago. – He/she said he/she did not know there was a NA Trainer at the facility. 3. Review of the Resident #27’s quarterly MDS, dated [DATE], showed: – No cognitive impairment; – Assistance of one staff for activities of daily living (ADLs); – Used a wheelchair and walker for mobility; – [DIAGNOSES REDACTED]. Review of the resident’s care plan updated on 10/30/18, showed: – Recent fall which resulted in a laceration and fractured ankle. Review of the nurses’ notes, dated 10/23/18, at 10:50 A.M., showed: – The resident slipped in the shower room and fell , laceration to right ankle from hitting the bottom of the shower chair; – Applied pressure to laceration, but it would not stop bleeding; – The resident was sent by ambulance to the emergency room . – Family and physician notified. Review of the resident’s hospital discharge instructions, dated 10/23/18, showed: – Displaced [MEDICAL CONDITION] fibular diametaphysis (ankle fracture, or broken bone, 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) the end of the fibula bone. The fibula is one of two bones that support the ankle joint); – Medial laceration (tearing of the skin that results in an irregular wound); – External casting material applied to the right ankle fracture; – Soft tissue swelling noted and wound dressing present. Review of the nurses’ notes, dated 10/23/18, at 2:27 P.M., showed: – The resident returned from the emergency room with a fractured right ankle with orders for two oral antibiotics (medications to prevent infection) and a narcotic pain medication. – Resident to be non-weight bearing on his/her right foot; – Podiatry appointment needed, will call tomorrow for appointment. During an interview on 11/1/18, at 5:30 P.M., LPN A said: – He/she was the charge nurse on 10/23/18; – Resident #27 had an incident in the shower room that caused a right ankle fracture. – The resident also obtained a very deep laceration to his/her right ankle with exposed bone. – He/she applied pressure to the area, but the bleeding could not be controlled; – The resident was transported via ambulance to the emergency room . – He/she inspected the shower chair for sharp edges and none were identified; – He/she does not know how the resident received the laceration. – The aide providing the shower reported the resident started to go down and the aide lowered the resident to the floor. – The resident returned from the emergency room later the same day with a soft cast; – The cast did not contain a window to visualize the sutures to the laceration. – However, now the soft cast does have a window to observe the laceration. – The resident has an upcoming appointment on 11/4/18, for suture removal. – He/she did not start an investigation of the incident or obtain a written statement from all involved. During an interview on 11/1/18, at 7:00 P.M., the Director of Nursing (DON) said: – The charge nurse should have obtained statements from staff to attempt to determine the cause of the injury for Resident #27 and the resident should have been interviewed; – She is responsible to ensure investigations are initiated and completed. – A thorough investigation for Resident #27 was not done. | |
| F 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Encode each resident’s assessment data and transmit these data to the State within 7 days of 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) transmissions) showed: – Resident #1 discharged to the residential care facility on 1/26/18; staff partially completed the discharge MDS, did not transmit it; the resident readmitted on [DATE]; – Resident #2 admitted on [DATE]; discharged to home on 6/30/18; staff did not complete any or transmit a discharge MDS for the resident. During an interview on 11/1/18, at 6:00 P.M., Registered Nurse (RN) A said: – He/she is responsible for completing and submitting the MDS. – Resident #2 was admitted on [DATE], and discharged to home on 6/30/18, which was a Saturday and he/she believes this is why the assessment was not done. – Resident #1 returned to the facility on [DATE], and discharged to the facility’s apartments on 1/26/18. He/she was unaware that the assessment was only partially completed and had not been submitted. – An MDS should have a transmission date of 14 calendar days after the completion of the assessment. During an interview on 11/1/18, at 7:00 P.M., the Director of Nursing (DON) said: – The facility should complete and submit resident assessments in accordance with current federal and state submission timeframes. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) – The resident was readmitted to the facility from the hospital and the resident had decided to receive hospice services; – On 5/30/18, at 3:00 P.M., the physician initialed the fax which indicated the order was approved. Review of the resident’s care plan updated on 9/10/18, showed: – No hospice care plan. Review of the physician’s orders [REDACTED]. – No order for hospice. 2. Review of Resident #1’s admission MDS, dated [DATE], showed: – No cognitive impairment; – Extensive assistance of one staff for ADLs; – No scheduled pain medications and received as needed pain medication (PRN); – No non-medication interventions for pain and no indication that pain effects sleep; – Non-injury fall. Review of the resident’s POS, dated (MONTH) (YEAR), showed: – [MEDICATION NAME] (narcotic pain medication) [MEDICATION NAME] (application of a medicine or drug through the skin) patch change every 72 hours, 12 micrograms (MCG)/HR (hour); start date 10/17/18, no diagnosis listed; – [MEDICATION NAME] (narcotic pain medication) oral tablet 5/325 milligrams (mg), give one tablet orally every four hours as needed; start date 10/17/18, no diagnosis listed. Review of the Resident Care Guidelines/Messages, updated on 10/31/18, a tool used to determine care needs for the resident, showed: – No interventions for pain control. Review of the resident’s hospital discharge instructions, dated 10/17/18, showed the resident had a nondisplaced fracture (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) of left clavicle (collarbone is a long bone that serves as a strut between the shoulder blade and the sternum or breastbone), and nondisplaced fracture of proximal phalanx of left middle finger from a fall. Review of the resident’s current care plan updated on 10/26/18, showed: – Recent clavicle fracture with interventions that included to ensure the resident wears the sling (most clavicle fractures can be treated by wearing a sling to keep the arm and shoulder from moving while the bone heals). – The care plan did not identify a problem of pain with interventions for pain control. During an interview on 10/31/18, at 11:10 A.M., the resident said: – He/she lived in the facility’s apartments prior to the recent fall; – He/she has a history of falls and the recent fall resulted in a clavicle and finger fracture; – He/she is receiving pain medication and the pain to his/her left shoulder has not yet improved since the injury; – The pain to his/her shoulder has affected his/her sleep and appetite; – He/she rated the shoulder pain a 4 thru 7 on a pain scale (a tool that doctors use to help assess a person’s pain) of 1 to 10 most days. During an interview on 10/31/18, at 11:16 A.M., Nurse Aide (NA) A said: – Resident #1 frequently reports shoulder discomfort. 3. Review of Resident #53’s quarterly MDS dated [DATE], showed: – A Brief Interview for Mental Status (BIMS) score of three, which indicated the resident did not make his/her own decisions; – Limited assist of one staff for bed mobility, transfers, and toileting; |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) – Extensive assist of one staff for hygiene and bathing; – Not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, surface to surface transfers between bed and chair or wheelchair; – Diagnoses included: [MEDICAL CONDITION], high blood pressure, dementia, pain and weight loss. Review of the hospice initial care plan, dated 10/22/18, showed: – Admit to hospice; – Start of care 10/22/18. Review of the care plan last updated on 10/30/18, showed: – No care plan for hospice. Review of the October, (YEAR) physician’s orders [REDACTED]. – No order for hospice. During an interview on 11/1/18, at 6:26 P.M., the Director of Nursing (DON) said: – She expected hospice to be care planned when the resident was admitted to hospice. 4. Review of Resident #25’s quarterly MDS, dated [DATE], showed: – A BIMS score of 15 which indicated the resident made his/her own decisions; – Extensive assist of two or more staff for bed mobility, toileting, and hygiene; – Total dependence of two or more staff for transfers; – Only able to stabilize with staff assistance for surface to surface transfers between bed and chair or wheelchair; – Impairment of the lower extremities; – Wheelchair; – Diagnoses included: [MEDICAL CONDITION] (a debilitating disease that affected the brain, spine, and central nervous system). Review of the care plan last updated on 10/30/18, showed: – Staff did not update the plan or develop a care plan with in depth approaches related to three injuries to the face/forehead from staff hitting the resident with the mechanical lift during transfers. During an interview on 11/1/18, at 6:26 P.M., the DON said: – She expected staff to care plan in depth approaches related to the three head injuries the resident experienced from being hit in the face/forehead by staff when they transferred the resident with the mechanical lift. 5. During an interview on 10/31/18, at 11:45 A.M., LPN A said: – He/she recently administered narcotic pain medication to Resident #1 as he/she had complaints of left shoulder pain; – Resident #36 receives hospice services and it was unclear why his/her POS did not include this order; – A resident receiving hospice should have hospice a care plan; – A resident receiving scheduled and PRN narcotic pain medication should have a care plan to address his/her needs; – The aides are to use the care guides located on the kiosk. During an interview on 11/01/18, at 11:41 A.M., Certified Nurse Aide (CNA) A said: – A resident’s care needs can be found in the kiosk. During an interview on 11/1/18, at 11:45 A.M., NA B said: – He/she is unaware of any tool that directs care needs for residents; – He/she is aware of the care needs for each resident as other aides have verbally informed him/her of the care needs for residents. During an interview on 11/1/18, at 6:00 P.M., Registered Nurse (RN) A 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) – He/she is responsible for completing and submitting the MDS; – He/she implements appropriate interventions on the care plan for residents and responsibilities include writing these care plans and updating as needed; – Resident #1 recently fractured his/her clavicle and finger and should have a care plan related to pain control; – Resident #36 is on hospice and he/she should have a care plan with interventions that direct staff with care; – The resident care guidelines are a tool for staff and should reflect the care plan; – He/she was aware that several of the care guidelines require updating. During an interview on 11/1/18, at 7:00 P.M., the Director of Nursing (DON) said: – A care plan should be individualized and provide a picture of the resident, one should be able to identify the resident from the care plan; – The nurse is responsible for implementing immediate interventions when new problems are identified; – The MDS Coordinator is responsible for ensuring the care plans are individualized and specific to the needs of the resident and are updated when changes occur and at least quarterly; – The resident care guidelines located in the kiosk are one of the tools that staff use to direct cares, she was unaware that some of them have not been updated for over two years; – A resident receiving hospice care should have a care plan for these services. | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure services provided by the nursing facility meet professional standards of quality. **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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) changes in the resident’s medical condition or status. – If a significant change in the resident’s physical or mental condition occurs, a comprehensive assessment of the resident’s condition will be conducted by the care plan coordinator. 2. Review of Resident #24’s October, (YEAR) physician’s order sheet (POS) showed: – [MEDICATION NAME] (used to treat allergies [REDACTED]. Review of a faxed physician’s order, dated [DATE], and written by Licensed Practical Nurse (LPN) B showed: – Has an order for [REDACTED].>- Due to Centers for Medicare Services (CMS) rules, would you consider a dose reduction of this medication? – The attending physician responded with no changes. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: – Long- and short-term memory problems; – Extensive assist of two or more staff for bed mobility, transfers, locomotion on and off the unit, dressing and toileting; – Total dependence of one staff for bathing; – Limited assist of one staff for eating; – Not steady, only able to stabilize with staff assistance for surface to surface transfers between bed and chair or wheelchair; – Always incontinent of bladder and bowel; – Mechanically altered, therapeutic diet; – Weight- 138 pounds; – [DIAGNOSES REDACTED]. Review of the care plan, updated [DATE], showed: – Assisted to eat meals by spouse or staff; – Advanced dementia, severe cognitive impairment, will not verbally respond to conversation; – At risk for dehydration. Review of a nurse’s progress note, dated [DATE], at 5:32 P.M., showed: – Spouse verbalized the resident had nasal drainage while assisted with noon meal; – Day shift nurse notified physician for orders; awaiting orders. Review of a fax to the Nurse Practitioner dated [DATE] showed: – Resident noted to have clear nasal drainage, no cough, lung sounds diminished. – Blood pressure (BP) ,[DATE], Pulse (P) 77, Respirations (R) 16, Temperature (T) 97.7, and Oxygen saturation (level of oxygen in blood, O2 sat) 93% low normal. Review of an updated fax to the Nurse Practitioner, dated [DATE], showed: – BP ,[DATE], P 70, O2 sat 94% (normal), T 96.9, R 18 (normal) and unlabored; – Spouse complained of nasal drainage and decreased appetite, green drainage from eyes but no redness; Review of a nurse’s progress note, dated [DATE], at 9:06 A.M., showed: – Fax sent to Nurse Practitioner A per spouse request related to clear nasal drainage. Review of the [DATE], fax to the Nurse Practitioner showed: – The NP ordered to start [MEDICATION NAME] (used to treat allergic rhinitis, allergies [REDACTED]. Review of a nurse’s progress note, dated [DATE], at 10:26 A.M., showed: – New order: [MEDICATION NAME] 10 mg daily for 30 days then stop. Observation and interview on [DATE], at 9:40 A.M., showed: – The resident sat at nurses’ station in hall way asleep in wheelchair; |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) – Spouse A sat with the resident and said the resident was very sleepy since adding allergy medication. – Said he/she was not eating now and normally ate well. Observation and interview on [DATE], at 12:12 P.M., showed: – The resident slept in wheelchair at dining room table; – Spouse A attempted to assist the resident to eat lunch; – The resident would not eat; – Spouse A attempted to give the resident liquids but the liquid ran from the resident’s mouth, and he/she was not able to drink; – Spouse A said staff do not offer to assist the resident to eat when he/she was in the facility and assisted the resident to eat. – LPN B approached the resident but did not offer to assist the resident to eat. Review of a nurse’s progress note, dated [DATE], at 2:11 A.M., showed: – Primary Care Physician (PCP) faxed back stating [MEDICATION NAME] could be causing the resident’s changes of not eating and sleeping all the time. – The PCP asked that staff fax to him/her the physician’s order sheet (POS) so that the [MEDICATION NAME] can be stopped. – POS faxed and awaiting new order to discontinue these two medications. Observation and interview on [DATE], at 11:28 A.M., showed: – The resident’s spouse informed LPN B he/she was concerned about the resident; he/she was sleepy and not eating again today. – LPN B said resident’s spouse contacted the attending physician on [DATE], to get medications changed. – LPN B said he/she faxed the physician this morning ([DATE]) to get an order to discontinue Novlog insulin. – LPN B and the restorative aide told the spouse an order was needed to assist the resident to eat. – LPN B said an order was needed for speech therapy to evaluate the resident. – LPN B said staff faxed the physician on [DATE], for orders because the spouse reported a runny nose and they did not hear back from the physician. – LPN B said staff faxed the physician again but the physician never responded with orders until [DATE], seven days after the spouse reported the resident had a runny nose and no staff followed up on the previous faxes. – LPN B said, on [DATE], the physician ordered [MEDICATION NAME] (an over the counter allergy medication). – The resident had an order from [DATE] for [MEDICATION NAME] 10 mg daily, not a new order. – LPN B said he/she did not fax the physician on [DATE], about the resident’s increased lethargy, inability to rouse the resident, and not eating or drinking that he/she observed. – He/she did notify the physician on [DATE], after learning that the spouse called the physician on [DATE], about the resident’s lethargy and the resident not eating. – The physician made monthly rounds already this month and had not seen the resident since the increased lethargy began. – Staff should have notified the physician of the resident’s change of condition but did not until this morning ([DATE]). – Spouse A would not allow staff to assist the resident to eat when he/she was assisting the resident with a meal. During an interview on [DATE], at 11:45 A.M., Spouse A 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) – The resident was not doing well. – After he/she contacted the physician on [DATE], medication changes were made but he/she did not know what medications were changed. – The resident had a temperature this morning of 98.8 which was high for the resident; his/her normal temperature was 97.6 and he/she was worried about the increased temperature. – Spouse A appeared teary eyed as he/she said he/she contacted the resident’s family member to come to the facility. – He/she said he/she did not know what else to do. Observation showed on [DATE], at 12:30 P.M., showed: – The resident’s room door was closed and family said they did not want to be bothered by anyone. Review of a fax to Nurse Practitioner (NP) A, dated [DATE], at 12:55 P.M., showed: – Resident continued to decline; – Not eating well for staff or spouse; – Difficult to get medication administered; – Blood Pressure-,[DATE], Pulse-95, Respirations-18, Temperature-97, oxygen saturation- 95%, lungs clear but diminished, no nasal drainage, no strong urine odor, no cough or behaviors or falls; – Consumed less than 5% of breakfast, blood sugar check 89 mg/dl (low); – NP A ordered urine by straight catheter if needed, blood work- CMP (chemistry levels), CBC (complete blood count to determine infection, [MEDICAL CONDITION]), TSH ([MEDICAL CONDITION] levels), and Hgb A1C (blood sugar level) this week, STAT (immediately); – Stop [MEDICATION NAME] if not already off of medication. Observation and interview on [DATE], at 1:30 P.M., LPN B did and said: – He/she drew blood work for labs and collected a urine specimen via a straight catheter (sterile tube inserted into the bladder to drain urine for a specimen and then removed) as ordered by the physician. – Blood and urine sent to the lab at the hospital for evaluation. Record review of a nurse’s progress note written by LPN B and dated [DATE], at 4:11 P.M., showed: – Resident continued to eat poorly for staff and spouse, continued to sleep more than usual, resident is not lethargic, blood sugar level this morning was 79 mg/dl, consumed less than 5% of breakfast, blood sugar level after breakfast was 87 mg/dl, Blood Pressure-,[DATE], Pulse-95, Respirations-18, T-97, oxygen saturation-95%, lungs clear but diminished, no nasal drainage, no strong urine odor, no cough or behaviors or falls; – Spoke with Spouse A and informed him/her that the physician was notified of the resident’s status; – Spoke with family member and informed family member that at family’s request the resident could be sent to the hospital for evaluation; – Family member did not want resident poked and prodded; – Hospice discussed and ordered by PCP; – Orders received for stat lab work. Review of a nurse’s progress note written by LPN C and dated [DATE], at 5:35 P.M., showed: – NP A called and gave verbal orders to send the resident to the emergency room for evaluation and treatment of [REDACTED]. – Spouse A and family member notified; – Transported to the hospital by non-emergent ambulance. Review of a telephone order, dated [DATE], at 5:20 P.M., showed: |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) – Sent to hospital for evaluation and treatment. Review of critical lab values, dated [DATE], at 6:14 P.M., showed: – Sodium level 168 (critical), normal range ,[DATE] MEQ/L (milliequivilents/liter); – Chloride level 132 (high), normal range ,[DATE] MEQ/L. During an interview on [DATE], at 10.37 A.M., the Director of Nursing (DON) said: – The PCP should be notified of any change of condition. During an interview on [DATE], at 5:43 P.M., the MDS Coordinator said: – Staff usually told her if there was a change in condition of a resident and she would assess and add to the care plan. – Changes should be care planned immediately. – Changes in condition are discussed every morning in the morning meetings. 3. The facility did not provide a policy related to following physicians’ orders. 4. Review of Resident #53’s quarterly MDS, dated [DATE], showed: – A Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident did not make daily decisions; – [DIAGNOSES REDACTED]. Review of October, (YEAR), POS showed: – No order for admit to hospice for end of life care. Review of the care plan, updated [DATE], showed: – Hospice not care planned. Review of the Hospice Interdisciplinary Initial Care Plan/Physicians’ Orders, dated [DATE], showed: – Start of care date [DATE]. During an interview on [DATE], at 2:52 P.M., LPN B said: – The resident expired the evening of [DATE]. 5. Review of Resident #37’s admission MDS, dated [DATE], showed: – A BIMS score of 13 which indicated supervision needed in daily decision making; – Oxygen, indwelling catheter; – [DIAGNOSES REDACTED]. Review of the care plan, dated [DATE], showed: – Hospice. Review of the October, (YEAR), POS showed: – No order for admit to hospice. During an interview on [DATE], at 6:26 P.M., the DON said: – An order should be written when a resident was placed on hospice. | |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 16) skin irritation, and to observe the resident’s skin condition; – Wash hands and apply gloves; – Wipe perineal area front to back; – Separate the large skin folds and wash front to back; if the resident had an indwelling catheter, gently wash the juncture of the tubing from the urinary opening down the catheter three inches; gently rinse and dry area; – Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]; – Rinse perineum thoroughly and dry skin; – Turn the resident and wash the rectal area thoroughly, wiping from base of large skin folds and extending over the buttocks; – Rinse thoroughly and dry skin; – Remove gloves and wash hands. 2. Review of Resident #37’s admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/7/18, showed: – A Brief Interview for Mental Status (BIMS) score of 13 which indicated supervision needed for daily decision making; – Extensive assist of two or more staff for bed mobility and hygiene; – Total dependence on two or more staff for toileting; – Indwelling urinary catheter; – Frequently incontinent of bowel; – [DIAGNOSES REDACTED]. Review of the care plan, dated 9/17/18, showed: – Provide perineal care after each incontinent episode. Review of the Resident Care Guidelines/Messages (used by direct care staff to determine type of care needed), dated 10/12/18, showed: – Catheter; – Used bedpan; – Assist of one staff for hygiene; – Extensive assist of two staff for bed mobility. Observation and interview on 10/31/18, at 12:52 P.M., Certified Nurse Aide (CNA) G and CNA H did and said: – Provided perineal and catheter care to the resident; – Both CNAs washed their hands and applied gloves; – Front perineal care and catheter care provided in the correct manner; – Neither CNA turned the resident nor washed the resident’s rectal area, thighs, or buttocks; – CNA G and CNA H said they should wash all areas of the skin and perineal area during perineal and catheter care, but they did not. 3. Review of the quarterly MDS, dated [DATE], for Resident #60 showed: – A BIMS score of three which indicated severe cognitive impairment, did not make own daily decisions; – Extensive assist of two or more staff for bed mobility, toileting, and hygiene; – Frequently incontinent of bladder and bowel. Review of the care plan, dated updated 10/11/18, showed: – Alteration in urinary continence related to increasing incontinence of bladder without potential for improvement; – Provide prompt incontinence care; – Assist with toileting upon rising, before meals, prior to laying resident down, and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 17) check regularly during the night. Observation and interview on 10/31/18, at 10:01 A.M., CNA G and CNA H did and said: – CNA H used 14 wipes to wipe front to back the rectal area and fecal material was noted to each wipe; – CNA H changed gloves and washed his/her hands; – CNA G rolled the resident to the other side; – CNA H used one wipe and wiped front to back the rectal area and fecal material was noted to the wipe; – CNA H asked the resident, Do you feel clean? – The resident did not answer the CNA’s question. – CNA G told CNA H to stop cleaning the resident even though there was fecal material on the last wipe used; – CNA H did not wash the resident’s right buttock; – CNA H said he/she should have washed all area of the perineum soiled with urine or fecal material; – Said he/she should have cleansed the rectal area until it was without fecal material but he/she did not. 4. Review of Resident #72’s quarterly MDS, showed staff assessed the resident as follows: – Severe cognitive impairment; – Occasional incontinence of bladder and required assistance of one staff for personal hygiene and dressing. Review of the resident’s care plan, updated 10/2/18, showed: – [DIAGNOSES REDACTED]. – Problem: Resident has dementia and is in facility for generalized weakness and cognitive impairment; – Approach: Incontinent of bladder at times, wears adult briefs, and assist resident as needed. Observation on 10/31/18, at 10:10 A.M., showed CNA C and CNA D did the following: – Assisted the resident onto the toilet, and removed clothing soaked with urine and loose stool; – Staff assisted the resident to stand and CNA C stood behind the resident, wiping large amounts of loose stool from the rectal area; – CNA C moved to the front of the resident, did not change soiled gloves, wiped down each groin area once, wiped down in the inner perineal fold once, and did not open and clean between the perineal folds; – CNA C did not clean between thighs, sides of thighs and hips, supra perineal area and all areas wet with urine or soiled. During an interview on 10/31/18, at 11:05 A.M., CNA C said: – He/she should have cleaned all areas and opened and cleaned between the perineal folds. – Should have changed gloves and washed hands, when going from the back soiled area to the frontal area. During an interview on 10/31/18, at 11:10 A.M., CNA D said staff should clean all perineal areas and clean between the perineal folds. 2. Review of Resident #70’s quarterly MDS, dated [DATE], showed: – [DIAGNOSES REDACTED]. – Required extensive assistance of staff for personal hygiene. Review of the resident’s care plan, updated 10/12/18, showed: – [DIAGNOSES REDACTED]. – Recent hospitalization for UTI and confusion; |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 18) – Staff to assist personal hygiene and perineal care as needed. Review of the urinalysis (UA, lab to detect UTIs) and fax cover sheet, dated 10/3/18, showed: – UTI, [MEDICATION NAME](an antibiotic used for UTIs) 500 milligram (mg) twice a day (BID) for five days. Observation on 10/31/18, at 4:00 P.M., showed CNA E and CNA F washed and gloved to provide perineal care in the following manner: – As the resident lay on his/her back, CNA F wiped from back to front over the inner perineal folds with three separate wipes; – CNA E rolled the resident onto his/her right side, and CNA F wiped over the lower half of each buttock once, wiped the rectal area twice, did not clean all areas wet with urine. During an interview on 10/31/18, at 4:10 P.M., CNA E said staff should wipe from front to | |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) – Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. – All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the uses of restraints. – Safe lifting and movement of residents is part of an overall facility employee health and safety program which involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies; provides training on safety and proper use of equipment; and continually evaluates the effectiveness of workplace safety and injury prevention strategies. Review of the facility’s Use of the Portable Lifting Machine, dated October, 2010, showed: – Purpose: To help lift residents using a manual lifting device; – The portable lift can be used by one staff if the resident can participate in the lifting procedures, if not, two staff are required to perform the procedure; – Attach hooks/loops to the lift. Be sure the hook/loops are placed so that they are facing away from the resident; – The policy did not address the condition of the slings. 2. Review of Resident #53’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/28/18, showed: – A Brief Interview for Mental Status (BIMS) score of three which indicated the resident did not make daily decisions; – Limited assist of one staff for transfers and bed mobility; – Not steady, only able to stabilize with staff assistance for surface to surface transfers (transfer between bed and chair or wheelchair); – Wheelchair; – [DIAGNOSES REDACTED]. Review of the care plan updated on 10/30/18, showed: – Potential for falls related to unsteadiness, cognitive impairment, and [MEDICAL CONDITION] drug use. – Will not suffer further injury from a fall or other source. – Provide one staff assist for transfers. Review of the Resident Care Guidelines/Messages, dated 10/31/18, and used by the certified nursing assistants (CNA) and nurse assistants (NA) to determine care for the resident showed: – Transfers: Assist of one staff. – The Resident Care Guidelines/Messages did not address the type of transfer to be performed for the resident. During an interview on 10/31/18, at 9:57 A.M., Licensed Practical Nurse (LPN) B said: – Staff moved the resident to a private room because he/she was actively dying and on hospice. Observation and interview on 10/31/18, at 12:32 P.M., CNA G and CNA H did and said: – CNA G said staff usually used a gait belt and one staff to transfer the resident because there was no order for a mechanical lift. – Two staff were needed for a mechanical lift transfer. – Someone was at the facility to put a low air loss mattress on the resident’s bed and staff needed to transfer the resident to the wheelchair while the mattress was changed. – CNA G spoke with LPN B (also the charge nurse) about using the mechanical lift on the resident. – LPN B said the lift could be used as needed (PRN) one time. – CNA G obtained a lime green sling and said one strap was broken, the strap was not |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) stitched to make a loop to place on the lift; the strap was completely open, made one big loop, and was not stitched to form different lengths of the sling to attach to the lift. – CNA G said this was the only sling he/she could find so they needed to use the sling to transfer the resident. – CNA G and CNA H attached the sling to the lift; the strap on the right side of the sling was stitched to make a small loop; the strap on the left side of the sling was not stitched to make a small loop. – CNA G operated the lift, raised the resident off the bed, rolled the lift from beneath the bed and turned the lift. – The resident swung in the air. – CNA H walked over to the Broda chair (a wheeled chair) and moved the chair towards the lift then guided the resident to sit in the chair. – CNA G said they should not use a broken sling but this sling was all they had to use. – Both CNAs said one should support the resident during a transfer and the resident should not swing in the air. 3. Review of Resident #72’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: – Severe cognitive impairment; – Required assistance of one staff for ambulation in room or corridor. Review of the resident’s care plan, updated on 10/2/18, showed: – [DIAGNOSES REDACTED]. – Problem: Resident has dementia and is in facility for generalized weakness and cognitive impairment; – Approach: At risk for falling related to weakness and shortness of air. Review of the resident’s medical records, dated 5/18/18, showed resident had a fall in the shower room when staff did not lock the shower chair. Review of resident’s fall assessment, dated 7/15/18, showed: – History of one to two falls in the last three months and fall score of 18 (greater than 10 is high risk for falls). Review of the resident’s medical records, dated 9/28/18, showed resident fall with no injuries. Observation on 10/31/18, at 10:10 A.M., CNA C and CNA D did the following: – Assisted the resident to the toilet, did not place a gait belt around the resident’s waist, and removed soiled clothing; – Staff assisted the resident to stand, did not place a gait belt on the resident, and let the resident lean on his/her walker, while CNA C performed perineal care; – Staff ran out of wipes; CNA D left the room to get wipes while CNA C let the resident stand and lean on his/her walker; – CNA D returned with wipes; CNA C completed perineal care on the resident, assisted the resident to dress, and CNA C left to wash his/her hands, and remove trash; – CNA D ambulated the resident, without a gait belt, to his/her bed, assisted the resident to sit, and raised the resident’s legs into bed. During an interview on 10/31/18, at 11:10 A.M., CNA D said they should have put a gait belt on the resident because he/she believes they should give safe care. 4. Review of Resident #1’s admission MDS, dated [DATE], showed: – No cognitive impairment ; – Extensive assistance of one staff for activities of daily living (ADLs); – Non-injury fall. Review of the resident’s hospital discharge instructions, dated 10/17/18, showed: |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) – Nondisplaced fracture (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) of left clavicle (collarbone is a long bone that serves as a strut between the shoulder blade and the sternum or breastbone) – Nondisplaced [MEDICAL CONDITION] middle finger from a fall. Review of the resident’s care plan updated on 10/26/18, showed: – At risk for falls with interventions to ensure the resident wears the sling (most clavicle fractures can be treated by wearing a sling to keep the arm and shoulder from moving while the bone heals) as instructed due to a recent clavicle fracture from a fall. – One staff to assist with transfers; – The care plan did not instruct staff on how to transfer the resident with the sling in place. Observation on 10/31/18, at 11:02 A.M., showed NA A assisted the resident in the following manner: – NA A loosely applied the gait belt around the resident’s waist and instructed him/her to stand; – As the resident stood up, NA A put his/her arm under the resident’s left arm pulling upwards and assisted the resident to stand; – The resident’s left shoulder raised upwards and the gait belt slid up the resident’s back towards the clavicle sling approximately 2 inches; – NA A held the gait belt with one hand and had the other hand under the resident’s left arm as the resident walked to the bathroom; – NA A assisted the resident to sit on the commode; – Without retightening the gait belt around the resident’s waist, NA A assisted the resident to stand; – Putting his/her arm under the resident’s left arm, NA A pulled upwards and assisted the resident to stand; – The resident’s left shoulder raised upwards as he/she stood up from the commode; – NA A held the gait belt with one hand and had the other hand under the resident’s left arm as the resident walked back to his/her recliner; – NA A removed his/her arm from under the resident’s left arm as he/she sat down – NA A removed the gait belt from around the resident’s waist. During an interview on 10/31/18, at 11:10 A.M., the resident said: – He/she lived in the facility’s apartments prior to the recent fall; – He/she has a history of falls and the recent fall resulted in a clavicle and finger fracture; – He/she is receiving pain medication and the pain to his/her left shoulder has not yet improved since the injury; – When staff move his/her shoulder in any way, it caused increased pain; – When NA A assisted him/her up from the recliner, he/she experienced increased pain and rated the pain a 5 on a pain scale (a tool that doctors use to help assess a person’s pain) of 1 to 10. During an interview on 10/31/18, at 11:16 A.M., NA A said: – He/she recently informed the charge nurse of the technique used to transfer Resident #1 and the nurse plans to assist him/her the next time the resident needs to use the bathroom; – He/she should not have put his/her arm under the resident’s left arm to assist the resident to stand; – Staff should apply a gait belt snug with just enough room to get your fingers under it; – He/she was unsure how to transfer a resident with a fractured clavicle. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 22) During an interview on 10/13/18, at 11:45 A.M., LPN A said: – Staff should use the gait belt to assist with transferring and staff should never put their arm under a resident’s arm; – Moving Resident’s # 1’s shoulder could effect the healing process and cause discomfort. 5. During an interview on 11/1/18, at 6:30 P.M., the DON said: – Residents at risk for falls should have gait belts on; – Nurses should assess what kind of transfer the resident should be. – A gait belt is to be used to safely assist with a transfer and ambulation; – Staff should always use a gait belt when transferring a resident and the gait belt should be applied snug around the resident’s waist; – Staff should never put their arms under a resident’s arm especially when the resident has a fractured clavicle. – Broken slings should not be used. – She did not know why there was not another sling available for use with the mechanical lift. | |
| F 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident’s well being. Based on observation, interview and record review, the facility failed to ensure they had |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) the lift. – He/she and NA C performed the transfer of Resident #25 with the mechanical lift. – NA C operated the lift to raise the resident off the bed but then had him/her lower the resident into the wheelchair. – When he/she lowered the resident to the wheelchair, he/she lowered the lift too fast and the lift hit the resident in the center of the forehead. – He/she did not know the lift could be lowered slower when the lift was used correctly. – No CNA was in the resident’s room with him/her and NA C during the transfer. – LPN E told him/her to be hands off the lift and only watch transfers until he/she could be trained to use the lift. – He/she said he/she had no instruction since on the use of the lift and was not told when he/she would receive training. 3. Review of the Employee Record for NA D showed: – Hire date: 2/13/18. – Rehire date: 10/12/18. Review of the facility’s Staff List, dated 10/30/18, showed: – NA D listed as a NA in training; – Worked 120 days; – Terminated on 10/11/18; – Re-hired full time on 10/12/18. Review of the Attendance Time Card Detail for October, (YEAR) showed: – NA D worked Friday through Monday and Wednesdays on the evening shift and as needed shifts from 10/1/18 through 10/31/18. 4. Review of the facility’s Staff List, dated 10/30/18, showed: – NA A listed as a NA in training; – Worked 120 days; – Termination date: 10/17/18; – Rehire date: 10/18/18. Review of the Attendance Time Card Detail sheet showed: – NA A worked the day shift on Monday through Thursday and as needed form 10/1/18 through 10/31/18. During an interview on 10/31/18, at 11:16 A.M., NA A said: – He/she was hired four months ago. – He/she was not sure when the facility planned to enroll him/her in CNA class. – He/she thought there might be a class on line. 5. Review of the Facility’s Staff List, dated 10/30/18, showed: – NA F hired 5/8/18 full time. Review of the Attendance Time Card Detail Sheet showed: – NA F worked the evening shift Monday through Thursday from 10/9/18 through 10/31/18 as a NA in training. 6. Review of the Facility’s Staff List, dated 10/30/18, showed: – NA G terminated 9/27/18; – Rehired: 9/28/18; – Worked 120 days. Review of the Attendance Time Card Detail Sheet showed: – NA G worked the day shift Monday through Thursday and as needed as a NA in training from 10/1/18 through 10/31/18. 7. During an interview on 11/1/18, at 3:30 P.M., the Nurse Aide Trainer said: – The Administrator wanted newly hired NAs to work six months before being enrolled 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0726 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) CNA class because most would quit prior to class, quit while attending class or would leave after certification and the classes cost $500.00 per NA. – NAs can only work four months before they become certified as CNAs. – The facility hires NAs, terminates the NAs, then rehires them so they have another four months to get into class. – It is very hard for this area to get anyone into a CNA class. – There were only 10-15 seats available at any time and you cannot reserve seats. – The facility had quite a few NAs that work, terminate, and then rehired and have been doing this for a long time. – Each NA should have a CNA working with them at all times. – She did not know why the NAs were not working with a CNA when the accident happened with Resident #25. 8. During an interview on 11/1/18, at 6:26 P.M., the DON said: – NAs should always have a CNA working with them. – The facility had NAs working that were not attending CNA class because class size consists of 15 seats and it was difficult to get the NAs into the class. – The facility looked into become a certified training center but it was very costly and they did not do that. – NAs have to complete the class within four months of hire or they are fired and then re-hired and the four months started over again. – Some NAs have worked here a long time without attending CNA class and without certification. – The facility had a full time NA Trainer in the facility who worked with the NAs that are hired. | |
| F 0728 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on observation, interview and record review, the facility failed to not use any |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0728 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 25) Review of the facility’s Staff List dated 10/30/18 showed: – NA B listed as a NA in training. – Hired full time on 10/19/18. During an interview on 11/1/18 at 11:26 A.M., NA B said: – He/she only worked in the facility two days, had not been to class, did not know when he/she would attend certified nurse aide (CNA) classes and had not been instructed in the use of the mechanical lift and operation. – Licensed Practical Nurse (LPN) E demonstrated the use of the lift to him/her on 10/28/18 but he/she did not return demonstrate the use and operation of the lift. – He/she and NA C performed the transfer of Resident #24 with the mechanical lift. – NA C operated the lift to raise the resident off the bed but had him/her lower the resident into the wheelchair. – When he/she lowered the resident to the wheelchair, he/she lowered the lift too fast and the lift hit the resident in the center of the forehead. – NA B did not know the lift could be lowered slower when the lift was used correctly. – No CNA was in the resident’s room with them during the transfer. – LPN E told him/her to be hands off the lift and only watch transfers until he/she could be trained to use the lift. – He/she had no instruction since on the use of the lift and was not told when he/she would receive training. 3. Review of the facility’s Staff List, dated 10/30/18, showed: – NA E listed as a CNA. – Hired: Full time on 9/12/18. During an interview on 11/1/18, at 10:07 A.M., NA E said: – He/she did not attend CNA class at this time and the next class was scheduled four months from now. – He/she was in-serviced on the use of lift when he/she started to work at the facility in September, (YEAR). 4. Review of the Employee Record for NA C showed: – Hire date: 7/17/18. Review of the facility’s Staff List, dated 10/30/18, showed: – NA C listed as a NA in training. – Hired part-time on 7/17/18. Review of the Attendance Time Card Detail for October, (YEAR), showed: – NA C worked Friday through Monday day time shift- 6:00 A.M. to 6:00 P.M. from 10/5/18 through 10/29/18. During an interview on 11/8/18 at 12:39 P.M., NA C said: – He/she started to work at the facility five months ago. – He/she worked at the facility previously but was terminated and then rehired. – He/she did not remember the dates of hire. – He/she worked with NA B on 10/28/18, and they transferred the Resident #24 with the mechanical lift. – There were other CNAs working but none were available to assist them. – LPN B told him/her previously that two NAs could work the lift without a CNA to help them, so he/she and NA B performed the transfer without a CNA. – He/she was uncomfortable working with NA B because NA B had no training on how to use the lift. – He/she also worked with another NA that had no training and had been uncomfortable doing so. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0728 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 26) – He/she told LPN E that he/she was uncomfortable working with NAs that had not had training using the lift and LPN E said he/she did not have to work with them. – He/she was given training on the use of the lift the first day of the first time he/she was hired but received no training when hired five months ago. – He/she did not know there was a NA Trainer at the facility. 5. Review of the Employee Record for NA D showed: – Hire date: 2/13/18. – Rehire date: 10/12/18. Review of the facility’s Staff List, dated 10/30/18, showed: – NA D listed as a NA in training. – Worked 120 days. – Terminated on 10/11/18. – Re-hired full time on 10/12/18. Review of the Attendance Time Card Detail for October, (YEAR) showed: – NA D worked Friday through Monday and Wednesdays on the evening shift and as needed shifts from 10/1/18 through 10/31/18. 6. Review of the facility’s Staff List, dated 10/30/18, showed: – NA A listed as a NA in training. – Worked 120 days. – Termination date: 10/17/18. – Rehire date: 10/18/18. Review of the Attendance Time Card Detail sheet showed: – NA A worked the day shift on Monday through Thursday and as needed form 10/1/18 through 10/31/18. During an interview on 10/31/18, at 11:16 A.M., NA A said: – He/she was hired four months ago. – He/she was not sure when the facility planned to enroll him/her in CNA class. – He/she thought there might be a class on line. 7. Review of the Facility’s Staff List, dated 10/30/18, showed: – NA F hired 5/8/18 full time. Review of the Attendance Time Card Detail Sheet showed: – NA F worked the evening shift Monday through Thursday from 10/9/18 through 10/31/18 as a NA in training. 8. Review of the Facility’s Staff List, dated 10/30/18 showed: – NA G terminated 9/27/18. – Rehired: 9/28/18. – Worked 120 days. Review of the Attendance Time Card Detail Sheet showed: – NA G worked the day shift Monday through Thursday and as needed as a NA in training from 10/1/18 through 10/31/18. 9. During an interview on 11/1/18, at 3:30 P.M., the Nurse Aide Trainer said: – The Administrator wanted newly hired NAs to work six months before being enrolled in a CNA class because most would quit prior to class, quit while attending class or would leave after certification and the classes cost $500.00 per NA. – NAs can only work four months before they become certified and CNAs. – The facility hires NAs then terminates NAs and then rehires them so they have another four months to get into class. – It is very hard for our area to get anyone into a CNA class. – There were only 10-15 seats available at any time and you cannot reserve seats. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0728 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 27) – The facility had quite a few NAs that work, terminate, and then are rehired and have been doing this for a long time. – Each NA should have a CNA working with them at all times. – She did not know why the NAs were not working with a CNA when the accident happened with Resident #25. During an interview on 11/1/18, at 6:26 P.M., the Director of Nursing (DON) said: – NAs should always have a CNA working with them. – The facility had NAs working that were not attending CNA class because class size consists of 15 seats and it was difficult to get the NAs into the class. – The facility looked into become a certified training center but it was very costly and they did not do that. – NAs have to complete the class within four months of hire or they are fired and then re-hired and the four months started over again. – Some NAs have worked here a long time without attending CNA class and without certification. – The facility had a full time NA Trainer in the facility that worked with the NAs that are hired. | |
| F 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. **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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 28) approach. – Assess for environmental or physical triggers, reduce if possible. – Encourage me to express feelings appropriately as I am able and let staff know when I’m getting upset. – Divert my behavior by talking about my family. – Assess my interests and invite me to become involved in activities. – Explain all procedures when giving me care, engage my cooperation and allow me time to adjust to changes. – Did not include staff instructions for interventions related to the resident’s refusal of assistance with ADL cares. Review of the resident’s current physician order [REDACTED]. – [DIAGNOSES REDACTED]. Observation on 10/29/18, starting at 9:00 A.M., showed: – The door to Resident #21’s room was closed. – Someone repeatedly yelling stop, get your hands off me! and leave me alone! could be heard from outside the closed door. – Two other voices could be heard repeatedly yelling the resident’s name and saying that’s not nice! and stop that! – Upon entering the room, the resident was standing in the bathroom doorway with his/her back facing the room. – Certified Nursing Aide (CNA) A was standing on the left side of the resident and Certified Medical Technician (CMT) A was standing in the bathroom on the right side of the resident, with a wheelchair positioned behind the resident. – The resident’s right arm was extended at a forty-five degree angle and bent at the elbow; CMT A was holding the resident’s arm near the elbow. – The resident attempted to jerk his/her arm away and continued to yell at staff to leave him/her alone and let go. – CNA A and CMT A used a loud tone of voice to tell the resident they needed to help him/her finish using the restroom and the resident continued to resist. – CNA A and CMT A said to one another that the resident was not going to cooperate and stopped what they were doing and allowed the resident to return to his/her wheelchair. – CMT A offered to help the resident go to the restroom and the resident refused. – CMT A said he/she was going to take the resident to the dining room. CNA A stepped away from the resident and started to empty the trash. – CNA J entered the room, spoke with CMT A as CMT A was leaving the room with the resident. – The resident was holding his/her chair alarm in his/her hands and had a soiled disposable pad sticking out approximately six inches above his/her waistband at the back of his/her pants and brown fecal material on the back of his/her brief as CMT A wheeled the resident out of the room. – CMT A wheeled the resident into the hall and returned to the resident’s room. – The resident’s eyes were open wide, nostrils flared, and jaw clenched. The resident said, pointing his/her finger in the air, he/she used to be the boss of this place and did not like people pushing him/her around and continued to speaking incoherently. – CMT A returned and said the resident had behaviors and sometimes they got bad like today and wheeled the resident down the hall. – CNA A and J stepped into the hall. During an interview on 10/29/18 at 9:30 AM, CNA A and CNA J said: – The resident had behaviors and sometimes the behaviors escalated to what happened today. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 29) – When the behaviors escalate, they notified the charge nurse, who administered [MEDICATION NAME] (an antipsychotic used to treat certain types of mental disorders) to the resident. – They would ask for additional staff when the resident’s behaviors escalated. – They did not think there was anything on the care sheets on the nursing kiosks to tell them how to provide care for the resident when he/she had behaviors. During a telephone interview on 11/1/18, at 9:40 A.M., Family Member A said: – It seems like they let the resident stay in bed a lot because it is easier than getting him/her up and dealing with the resident’s behaviors. – He/she would like to see the resident up and doing something but thought staff get busy and do not have time to deal with him/her because it takes a long time to get him/her going. – He/she had told the facility he/she would like for the resident to be up and active but staff told them there is not much for him/her to do because of the resident’s behaviors and he/she could be destructive so they just let the resident stay in bed. – The resident gets frustrated with staff; his/her behaviors escalate, and the resident would become combative or runs from staff. – The resident’s spouse was physically and emotionally abusive; the old staff knew that and knew how to approach him/her but he/she did not think the new staff know that and are not patient with the resident. – Negative tones of voice and snotty attitudes are triggers for the resident and if the resident feels like staff are going to be aggressive with him/her then he/she wants to run/escape the situations. – Feels the resident would do better if staff approached him/her in a calm manner with a calm voice and when behaviors begin, try different staff or leave the resident alone. – (MONTH) perceive their tone as aggression. – There is a current staff member in the facility that worked at the facility when the resident did and can usually calm him/her down and he/she did not understand why they did not have that staff member work with the resident when behaviors escalate. During an interview on 11/1/18, at 6:00 P.M., Registered Nurse (RN) A said: – He/she is responsible for completing and submitting the MDS. – He/she implements appropriate interventions on the care plan for residents and responsibilities include writing these care plans and updating as needed. – The resident care guideline is a tool for staff and should reflect the care plan. – He/she was aware that several of the care guidelines required updating. During an interview on 11/1/18, at 7:00 P.M., the Director of Nursing (DON) said: – A care plan should be individualized and provide a picture of the resident; one should be able to identify the resident from the care plan. – The nurse is responsible for implementing immediate interventions when new problems are identified. – The MDS Coordinator is responsible for ensuring the care plans are individualized and specific to the needs of the resident and are updated when changes occur and at least quarterly. – The resident care guidelines located in the kiosk are one of the tools that staff use to direct care. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure medication error rates are not 5 percent or greater. **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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 31) bottle of sucralfatate 1g read to not administer with other medications for at least two hours; – He/she was not aware that sucralfatate should be administered at least one hour prior to a meal; – Staff are encouraged to use the online Clinical Drug Information for residents’ medications and can be accessed for the residents electronic Medication Administration Record [REDACTED] 2. Review of [MEDICATION NAME]’s (medication used long term to improve [MEDICAL CONDITIONS], by decreasing inflammation and opening airways) official Astra Zenica website showed: – Shake inhaler well for at least five seconds right before each use; – Exhale fully, place mouthpiece fully in the mouth, and close lips around it; – Inhale deeply and slowly through mouth and press down on inhaler to release the medication; – Continue to breathe in and hold breath for ten seconds or for as long as comfortable before exhaling; – Before exhaling, release your finger from the top of the inhaler, keep the inhaler upright, and remove from your mouth. – Shake the inhaler again for at least five seconds and repeat steps for second puff. Review of Resident #61’s quarterly MDS, dated [DATE], showed: – Severe cognitive impairment and anxiety. Review of the resident’s (MONTH) (YEAR) POS, showed: – [DIAGNOSES REDACTED]. – [MEDICATION NAME] 160-4.5 micrograms (mcg.), 2 puffs twice a day (BID), administer morning and evening. Observation on 10/30/18, at 10:05 A.M., showed Certified Medication Technician (CMT) B did the following: – Entered the resident’s room to administer the [MEDICATION NAME] inhaler, and washed his/her hands; – Shook the inhaler for five seconds, placed the inhaler in the resident’s mouth, counted to three, and the resident inhaled deeply while CMT B administered the inhaler; – Did not allow the resident to hold the medication in his/her lung for at least 10 seconds or for as long as was comfortable; – Did not remove the inhaler from the resident’s mouth, and shake again for at least five seconds, before he/she administered the second dose; – Left the inhaler in the resident’s mouth, did not allow the resident to exhale fully, and quickly gave another dose, on the count of three, in about ten to 15 seconds. During an interview on 10/31/18, at 3:10 P.M., CMT C said: – If you need to give a second puff, you should wait at last two minutes before you give it; – Staff should not give a [MEDICATION NAME] inhaler dose ad then give another one right away. During an interview on 11/1/18, at 12:00 P.M., CMT B said he/she should have waited a minute before giving a second dose of the inhaler. 3. During an interview on 11/1/18, at 7:00 P.M., the Director of Nursing (DON) said: – Staff must always follow physician’s orders [REDACTED]. – Staff are directed to read the label three times before administering medications; – Staff should use the five rights for medication administration the right patient, the right drug, the right dose, the right route, and the right time; |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 32) – Staff should follow the manufacturer’s guidelines for medications; – [MEDICATION NAME] should be given at least one minute between puffs. | |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 33) – One bottle of OTC Tylenol 500 milligrams (mg) for a discharged resident with no date of opening and an expiration date of 10/18. – One expired bottle of [MEDICATION NAME]with no date of opening and an expiration date of August, (YEAR). – One open bottle of [MEDICATION NAME] with no opening or discard date and an expiration date of 3/1/21. – One expired bottle of Vitamin E (a supplement) with date of opening of 10/22/18 but with an expiration date of February, (YEAR). – One expired bottle of ASA (aspirin, to treat fever and pain) 325 mg with an expiration date with no date of opening and with an expiration date of February, (YEAR). During an interview on 10/31/18, at 10:45 A.M., CMT B said: – All staff who administered medications were responsible for checking expiration dates for medications. – All medications that were expired should be discarded. – All medications should be labeled with an opening date. – All medications should be labeled with the name of a resident. – All insulin pens or bottles should be labeled with an opening and discard date. – Insulins should be discarded 28 days after opening. – He/she did not know why the single vial of [MEDICATION NAME] lay in the drawer with no name or opening date. – He/she did not know why insulins did not have opening and discard dates recorded. – He/she did not know why the bottle of Vitamin E was opened on 10/22/18, but it had expired in February, (YEAR). The bottle should not have been used and should have been discarded. – He/she did not know why outdated medications were not discarded from the cart. 3. Observation on 10/30/18, at 2:48 P.M., of Station One Medication Room, with LPN C present, showed: -2 bottles used [MEDICATION NAME] HCI 1 %, on the medication room counter top, with no resident names; – One bottle [MEDICATION NAME] 0.4 mg. sublingual, (SL), expired September, (YEAR); – Three bottles Klor Con (potassium) M 20 ER (extended release) tab., 20 milliequivilents (meq), expired 10/6/18, expired October, (YEAR), and expired (MONTH) (YEAR); – Four gastrointestinal (GI) panel collection kits for bacteria, parasites, [MEDICAL CONDITION], expired 11/6/17 ( 2 kits), one expired 3/6/18, and one expired 5/21/18; – Medications, for a resident no longer in the facility, multiple boxes of [MEDICATION NAME] inhalation solution, multiple boxes [MEDICATION NAME] sulfate inhalation solution, and one bottle of [MEDICATION NAME]; – Medications, for a resident no longer in the facility, one box of [MEDICATION NAME] inhalation solution; – One bottle of [MEDICATION NAME]100 milliliters (ml), exp. August, (YEAR); – Multiple green, blue, and red expired blood draw vials. During an interview, immediately following the medication room observation, LPN C said: – Medications for residents no longer in the facility should have been discarded; – All expired medications should have been discarded; – Any opened vials or bottles, should have a name and date opened on them. Observation on 11/1/18, at 11:49 A.M., of Station Two medication cart checked with LPN A, charge nurse, showed: – One bottle of saline nasal spray, expired 9/31/18; – [MEDICATION NAME] 70/30 insulin, no open date on bottle or box. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 34) During an interview immediately following the medication cart observation, LPN A said: – The expired bottle of saline nasal spray should have been discarded; – The [MEDICATION NAME]should have had a date on it when opened. 4. During an interview on 11/1/18, at 6:26 P.M., the Director of Nursing said: – She expected all expired medications to be removed from the cart, not used, and discarded. – She expected all insulin pens and bottles to be labeled with and opening and discard date and should be discarded 28 days after opening. – She expected all OTC medications to be discarded one year after the opening date or on the expiration date, which ever came first. | |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 35) OSHA Bloodborne Pathogens Standard; – Policy interpretation and implementation: Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident; – Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer’s instructions. Review of Resident #72’s quarterly Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 10/1/18, showed staff assessed the resident as follows: – Severe cognitive impairment; – Occasional incontinence of bladder and required assistance of one staff for personal hygiene and dressing. Review of the resident’s care plan, updated 10/2/18, showed: – [DIAGNOSES REDACTED]. Observation on 10/31/18, at 10:10 A.M., Certified Nurse Aide (CNA) C and CNA D did the following: – Assisted the resident to stand up from the toilet to assist with perineal care; – CNA C removed a large amount of loose fecal material from the resident’s rectal area, and did not change his/her soiled gloves; – CNA D left the room for a package of perineal wipes, while CNA C stood with the resident, and touched the resident, the walker, the door frame, and the toilet; – CNA C did not change his/her gloves and wash his/her hands, but completed perineal care on the resident’s frontal perineal area; – Staff dressed the resident and assisted him/her out of the bathroom; – A large amount of loose fecal material remained on the toilet seat; – CNA C wiped it off with a perineal wipe, did not use a disinfectant, then removed his/her gloves and washed his/her hands; – Within a few minutes, the resident from the adjoining room, entered the bathroom and sat on the soiled toilet seat. During an interview on 10/31/18, at 11:05 A.M., CNA C said: – Should have changed his/her gloves and washed his/her hands, when going from the back soiled area to the frontal area; – He/she did not know to clean the toilet seat with a disinfectant instead of a perineal wipe. During an interview on 10/31/18, at 11:10 A.M., CNA D said staff should remove dirty gloves and wash their hands after soiled care; – Did not know to use a disinfectant on a soiled toilet seat. During an interview on 11/1/18, at 4:23 P.M., the housekeeping supervisor said staff should use a disinfectant to clean the toilet seats or call the housekeeping aides to clean them appropriately. 3. Review of the facility’s Infection Control policy revised on (MONTH) 2010, showed employees must wash their hands for ten to fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: – Before and after direct care with residents; – When hands are visibly dirty or soiled with blood or other body fluids; – After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; – After removing gloves; – After handling items potentially contaminated with blood, body fluids, or secretions; – Before eating and after using the restroom and when there is likely exposure to spores; – Before handling clean linen; – Before moving from a contaminated body site to a clean body site during resident care; |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 36) – After handling used dressings, contaminated equipment, etc.; – After contact with objects in the immediate vicinity of the resident; and – After removing gloves. Review of the facility’s Handwashing/Hand Hygiene policy, revised in (MONTH) 2012, showed: – The facility considers hand hygiene the primary means to prevent the spread of infections. – The use of gloves does not replace handwashing/hand hygiene. – Staff should wash their hands before and after glove removal and before moving from a contaminated body site to a clean body site during resident care. Review of the facility’s Perineal Care policy dated October, 2010, showed: – Purpose: To provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident’s skin condition; – Wash hands and apply gloves; – Wipe perineal area front to back; – Separate the skin folds and wash front to back; if the resident had an indwelling catheter, gently wash the juncture of the tubing from the urinary opening down the catheter three inches; gently rinse and dry area; – Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]; – Rinse perineum thoroughly and dry skin; – Turn the resident and wash the rectal area thoroughly, wiping from base of the skin folds and extending over the buttocks; – Rinse thoroughly and dry skin; – Remove gloves and wash hands. Review of Resident #64’s quarterly MDS, dated [DATE], showed: – Severe cognitive impairment; – Extensive assist of two staff for activities of daily living (ADLs); – Always incontinent of bowel and bladder. Review of the resident’s care plan, updated on 7/12/18, showed: – Staff assistance with daily care including complete pericare related to bowel and bladder incontinence. Observation on 10/31/18, at 10:15 A.M., showed CNA A and CNA B provided incontinent care as the resident lay in bed and did the following: – Washed their hands and put on clean gloves before starting incontinent care; – CNA B removed the blanket from the resident and the resident had liquid fecal material covering his/her frontal peri area and the incontinent pad that was under the resident; – CNA A used multiple disposable wipes and cleansed the resident’s front perineal skin folds removing liquid fecal material; – CNA A did not remove his/her gloves and wash his/her hands when his/her gloves became soiled with fecal material; – CNA A continued to reach into the package of disposable wipes with dirty gloves that had come in contact with fecal material; – CNA A did not remove his/her gloves and wash his/her hands before he/she assisted CNA B to roll the resident onto his/her side; – CNA A continued to reach into the package of disposable wipes with the soiled gloves and used multiple disposable wipes as he/she wiped the resident’s buttock and rectal area to remove the fecal material; – CNA A folded the fecal material covered linens under the resident and with the same dirty gloves obtained a clean incontinent pad; |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 37) – Both staff rolled the resident onto his/her back then CNA B removed the soiled linens and placed them in a plastic bag; – Neither staff removed their gloves and washed their hands before continuing to provide care; – CNA A reached into the package of disposable wipes and started to cleanse the resident’s front perineal skin folds again removing fecal material and CNA B obtained a clean gown while still wearing dirty gloves; – CNA A did not remove his/her gloves and wash his/her hands before assisting CNA B with putting a clean gown on the resident, lowering the bed, covering the resident up, and picking up the package of disposable wipes from the foot of the bed; – Both staff removed their gloves and washed their hands and exited the room. During an interview on 10/31/18, at 10:45 A.M., CNA A and CNA B said: – After providing peri care, staff should remove gloves and wash their hands and should not touch clean items with dirty hands; – One staff should have done the clean task and one staff should have done the dirty tasks; – Staff should remove their gloves and wash their hands when their gloves contain fecal material. 4. During an interview on 11/1/18, at 6:30 P.M., the DON said: – Staff should wash before and after glove removal, if there is fecal material on their gloves, after perineal care, and should not go from the back and provide perineal care in the front. – Staff should wipe a soiled toilet seat with a disinfectant, not a perineal wipe, and not allow another resident to sit on a soiled toilet seat. – Staff should wash their hands and change gloves between dirty and clean tasks. – Staff should not touch clean items with dirty hands. 5. Review of the facility’s undated policy for ice machine cleaning showed: – All items of equipment are cleaned and sanitized in accordance with the guidelines established by the U.S. Department of health and Human Services as stated in the Food Service Code Manual, 1997. – Ice machine to be cleaned and sanitized inside once a month. – All ice to be removed from ice machine one day of monthly cleaning and put in cooler and placed in freezer. – Wipe exterior of machine daily with warm sanitizing solution. Wipe dry with clean, soft cloth. Observations on 10/30/18, starting 9:30 A.M., showed: – The break room ice machine had streaks of green, white and rust colored substances going down the sides of the machine. – The main kitchen ice machine internal white, plastic ice shield had orange/brown grime on the cover and along the edge of the shield touching the ice. – Staff scooped ice from the ice machine and placed it in the residents insulated room mugs, that were sitting on a cart, and the mugs were delivered to the residents. During an interview on 10/30/18, at 11:05 A.M., the Maintenance Supervisor said he was unsure who was responsible to clean the facility’s ice machines. During an interview on 11/1/18, at 2:00 P.M., the dietary manager said she was unsure who was responsible for cleaning the ice machines. |
| 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: 265715 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNNYVIEW NURSING HOME & APARTMENTS | STREET ADDRESS, CITY, STATE, ZIP 1311 E 28TH STREET | |||||||||
| 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 | ||
