145403 11/06/2014 name of provider or supplier

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(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

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PRINTED: 12/01/2014FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

145403 11/06/2014STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1545 BARRINGTON ROADALDEN POPLAR CREEK REHAB & HCC

HOFFMAN ESTATES, IL 60194

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

FOSS Survey

Annual Licensure and Certification Survey

Alden Poplar Creek Rehab and Health Care

Center is in compliance with Subpart U,77 Illinois

Administrative Code Section 300.7000.

F 157

SS=D

483.10(b)(11) NOTIFY OF CHANGES

(INJURY/DECLINE/ROOM, ETC)

A facility must immediately inform the resident;

consult with the resident's physician; and if

known, notify the resident's legal representative

or an interested family member when there is an

accident involving the resident which results in

injury and has the potential for requiring physician

intervention; a significant change in the resident's

physical, mental, or psychosocial status (i.e., a

deterioration in health, mental, or psychosocial

status in either life threatening conditions or

clinical complications); a need to alter treatment

significantly (i.e., a need to discontinue an

existing form of treatment due to adverse

consequences, or to commence a new form of

treatment); or a decision to transfer or discharge

the resident from the facility as specified in

§483.12(a).

The facility must also promptly notify the resident

and, if known, the resident's legal representative

or interested family member when there is a

change in room or roommate assignment as

specified in §483.15(e)(2); or a change in

resident rights under Federal or State law or

regulations as specified in paragraph (b)(1) of

this section.

F 157

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete CWEK11Event ID: Facility ID: IL6001366 If continuation sheet of 52

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F 157 Continued From page 1 F 157

The facility must record and periodically update

the address and phone number of the resident's

legal representative or interested family member.

This REQUIREMENT is not met as evidenced

by:

Based on observation, interview and record

review, the facility failed to notify a physician

regarding pressure ulcer pain for one of one

resident (R20) reviewed for notification of

changes in sample of 27.

Findings include:

On 10/23/14 at 9a, R20 was sitting in her

wheelchair. R20 stated that she has pain in her

buttocks whenever she is sitting down. R20

stated she was in pain currently in her bottom.

On 10/23/14 at 12:05pm, R20 stated that her

bottom hurts. On 10/23/14 at 1:30pm, R20 stated

"Be gentle. It is not like peeling wallpaper off the

wall." E9 (treatment nurse) was removing the

foam dressing at the time R20 was complaining

of pain. E20 stated that her buttocks hurt when

you touch it lightly. E20 stated "Ouch" during the

foam dressing removal by E9.

On 10/24/14 at 1p, Z2 (Wound Doctor) stated that

he was not aware that R20 had pressure ulcer

pain. Z2 stated that he had not been notified

regarding R20's pressure ulcer pain. Z2 thanked

the surveyor for letting him know about R20's

pressure ulcer pain.

The facility's Change of Condition policy dated

2/14 reads "The attending physician will be

notified with changes in a resident's condition.

The purpose is to ensure that the resident's


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physician and responsible party are kept informed

regarding the resident's change in condition."

F 246

SS=E

483.15(e)(1) REASONABLE ACCOMMODATION

OF NEEDS/PREFERENCES

A resident has the right to reside and receive

services in the facility with reasonable

accommodations of individual needs and

preferences, except when the health or safety of

the individual or other residents would be

endangered.


by:

F 246


review, the facility failed to have call lights placed

within reach at all times for 4 of 27 residents (R7,

R8, R10 and R17) in the sample and 11 residents

(R32, R33, R34, R35, R36, R38, R39, R40, R41,

R42 and R43) in the supplemental sample.

Findings include:

On 10/21/14 at 9:15am, call lights were not

placed within resident reach for R7, R8, R10,

R17, R32, R33, R34, R35, R36, R38, R39, R40,

R41, R42 and R43. On 10/21/14 at 12 noon,

resident call lights were not within reach for R10,

R17, R32, R33, R35, R38, R42 and R43. On

10/21/14 at 1:30pm, call lights were not in reach

for R7 and R39.

On 10/21/14 at 10:30am, E8 stated that call lights

should be within reach for each resident.

The facility's Use of Call Light policy & procedure


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dated 6/13 reads "Be sure call lights are placed

within resident reach at all times."

F 279

SS=D

483.20(d), 483.20(k)(1) DEVELOP

COMPREHENSIVE CARE PLANS

A facility must use the results of the assessment

to develop, review and revise the resident's

comprehensive plan of care.

The facility must develop a comprehensive care

plan for each resident that includes measurable

objectives and timetables to meet a resident's

medical, nursing, and mental and psychosocial

needs that are identified in the comprehensive

assessment.

The care plan must describe the services that are

to be furnished to attain or maintain the resident's

highest practicable physical, mental, and

psychosocial well-being as required under

§483.25; and any services that would otherwise

be required under §483.25 but are not provided

due to the resident's exercise of rights under

§483.10, including the right to refuse treatment

under §483.10(b)(4).


by:

F 279

Based on observation and record review, the

facility failed to develop a comprehensive plan of

care for nutritional needs, splints and pressure

sores for 2 of 27 residents (R8 and R20)

reviewed for care plans in the sample.

Findings include:

On 10/21/14 at 9a, R8 was eating a bagel without


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any dentures. R8 stated that it was difficult to eat

the bagel. R8 stated that the facility lost his

dentures approximately 2 weeks ago. R8 was

observed to his left sided weakness to the left

hand, left arm and left leg. R8 did not have any

splints on at that time. R8's Physician Order

dated 10/22/14 reads left knee splint and left

hand splint on AM (morning) and off HS (bedtime)

as tolerated.

R8's care plan did not address R8's nutritional

needs regarding eating without any dentures.

R8's care plan did not address R8's splints for his

left knee and left hand.

On 10/23/14 at 8:30am, R20 stated she was in

pain. R20 stated that her bottom hurts because

of the open sores on her buttocks. On 10/23/14

at 12:05pm, 1:30pm and 3:30pm, R20

complained of pain in her pressure sores on her

bottom. R20's care plan for Alteration in comfort

dated 10/14/12 reads "Alteration in comfort

related to diagnosis of DJD and GERD. R20's

Alteration in comfort care plan does not address

R20's pressure ulcer pain. R20's care plan does

not address her nutritional needs related to her

pressure ulcers. R20's care plan does not

address her current serum albumin lab values

and nutritional needs related to the lab values.

R20's care plan for actual alteration in skin

integrity does not include specific treatment

interventions for stage 1 and stage 2 pressure

ulcers.

The facility's Comprehensive Care Plans Policy &

Procedure dated 5/2011 policy statement reads

"An individual Comprehensive Care Plan that

includes measurable objectives and timetables to

meet the resident's medical, nursing, mental and


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psychological needs is developed for each

resident. Each resident's Comprehensive Care

Plan has been designed to: a. Incorporate

identified problem areas; b. Incorporate risk

factors associated with identified problems; c.

Build on resident's strengths; d. Reflect treatment

goals and objectives in measurable outcomes; e.

Identify the professional services that are

responsible for each element of care; f. Aid in

preventing or reducing declines in the resident's

functional status and/or functional levels; and g.

Enhance the optimal functioning of the resident

by focusing on a rehabilitative program."

F 281

SS=D

483.20(k)(3)(i) SERVICES PROVIDED MEET

PROFESSIONAL STANDARDS

The services provided or arranged by the facility

must meet professional standards of quality.


by:

F 281


review, the facility failed to follow their pain

managed policy related to assessing, implement

a comprehensive pain management program and

failed to develop an individualized pain

management program for one of one resident

(R20)with pressure sores reviewed for

professional ' s standards of care in sample of 27.

Findings include:

On 10/23/14 at 8:30am, R20 was sitting in her

wheelchair. R20 stated that she has pain in her

bottom when she sits. R20 stated that she sits in

her wheelchair from morning until after lunch. On

10/23/14 at 12:05pm, R20 complained of pain in


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her bottom. E11 (Nurse) stated that she would

give R20 pain medication.

On 10/23/14 at 1:30pm, R20 complained of pain

in her buttocks. R20 stated that her bottom hurts

even when it is touched lightly. E9 (Wound

Nurse) was removing R20's foam dressing at

1:30pm and R20 stated "Be gentle. It is not like

pulling wallpaper off a wall."

On 10/23/14 at 3:30pm, E9 was performing R20's

left ischium pressure ulcer dressing change. R20

stated "Ouch. The pain medication does not help

the pain I have in my open sore on my bottom."


he was not aware of R20's pressure ulcer pain.

The facility's Pain Management Assessment

Policy dated 3/20/2012 reads "Our mission is to

facilitate resident independence, promote

resident comfort and preserve resident dignity.

Initiate an interdisciplinary plan of care based on

the initial assessment, the choice of pain rating

scale, and the development of pain relieving

strategies. Include both pharmacological and

complementary interventions in the care plan. An

immediate care plan will be initiated upon

admission for any resident with orders for pain

management, with reports of pain/injury or

exhibiting common pain behaviors and reviewed

at each care plan conference."

F 309

SS=D

483.25 PROVIDE CARE/SERVICES FOR

HIGHEST WELL BEING

Each resident must receive and the facility must

provide the necessary care and services to attain

or maintain the highest practicable physical,

F 309


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mental, and psychosocial well-being, in

accordance with the comprehensive assessment

and plan of care.


by:


review, the facility failed to develop

comprehensive pain assessment, care planning,

provided appropriated services and implement

pain management program related to pressure

ulcer pain upon movement for two of three

residents (R5 and R20) reviewed for pressure

ulcer pain in the sample of 27.

Findings include:

1. On 10/23/14 at 8:30am, R20 was sitting in her

wheelchair. R20 stated that her bottom hurts

when she sits on her open sores on her bottom.

R20 stated that she sits all morning until after

lunch each day. On 10/23/14 at 12:05pm, R20

was observed in the bathroom. R20 stated that

her buttocks hurts. E11 stated that she would

give R20 pain medication.

On 10/23/14 at 1pm, E10 stated that R20 kept

complaining of pain in her bottom. E10 stated

when she checked her bottom, she noticed that

she had pressure sores on her buttocks. E10

stated that R20 had been complaining of pain all

the time in her bottom.

On 10/23/14 at 1:30 pm, E9 (Wound Nurse) was

removing R20's foam dressing. R20 stated "Be

gentle. It's not like pulling wallpaper off a wall."

On 10/23/14 at 3:30 pm, E9 turned R20 on her


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side for the dressing change to R20's pressure

ulcer on R20's left ischium. E9 began to apply

Silvadene ointment to R20's left ischium facility

acquired stage 2 pressure ulcer. R20 stated

"Ouch,it hurts, be gentle." R20 stated that the

pain medication she received did not help the

pain for her pressure sore on her bottom. R20

stated that the lightest touch hurts in her pressure

sores. R20 stated that the pain medication does

not help the pain she has in her open sores on

her bottom.

On 10/24/14 at 1pm, Z2 (Wound Doctor) stated

that he was not aware that R20 was experiencing

pain in her pressure sores. Z2 thanked the

surveyor for bringing the pain issue to his

attention.

R20's POS (Physician Order Sheet) dated 9/1/14

- 10/31/14 reads Hydrocodone-Acetaminophen

Tablet 10-325 mg Give 1 tablet by mouth three

times a day for Pain Management and Tramadol

HCL Tablet 50 mg Give 1 tablet by mouth two

times a day for other chronic pain.

R20's care plan for Alteration in comfort is dated

10/14/12. R20's Alteration in comfort care plan

reads "Alteration in comfort related to dx of DJD

and GERD." R20's care plan does not address

R20's pressure ulcer pain.

2. R5 is on contact precautions for ESBL of the

second left toe.

During R5's wound care observation on 10-22-14

at 9:40 AM, R5 was having episodes of facial

grimacing and intensified breathing. E9 (Register

Nurse) did not assess for pain or administer pain

medication during the wound care procedure.

On the Nursing Comprehensive Pain Assessment


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dated 10-13-14, R5's Non- Verbal Patient

Assessment states R5 has non-verbal sounds

(e.g., crying, whining, gasping, moaning, or

groaning), facial expressions (e.g., grimaces,

winces, wrinkled forehead, furrowed brow,

clenched teeth or jaw), and protective body

movements or postures (e.g., bracing, guarding,

rubbing or massaging a body part/area, clutching

or holding a body part during movement). The

Changes in ADL ' s indicate R5 has decreased

physical activity, been on a scheduled pain

medication regimen, received prn pain

medication, received non-medication

interventions for pain.

On R5's pain care plan, facility should monitor for

nonverbal indicators of pain daily with care tasks

and activities.

On Physician's Order Summary Report, R5 has

the following pain medication orders: Morphine

Sulfate (Concentrate) 0.5ml via G-tube every 6

hours for pain management (ordered 10-7-14),

Morphine Sulfate (Concentrate) 0.25ml via

G-tube every 2 hours as needed for moderate

pain (ordered 10-3-14), and Morphine Sulfate

(Concentrate) 0.5ml via G-tube every 2 hours as

needed for severe pain (ordered 10-3-14).

During the interview on 10-23-14 at 1:17 PM, E25

CNA (Certified Nursing Assistant) states that the

R5 was in pain had groaning, facial grimaces,

and breathing changes.


states R5 was not in pain.

The Pain Management Assessment Policy dated

3-20-12 states the facility mission is to facilitate

resident independence, promote resident comfort

and preserve resident dignity. Residents shall be

assessed for pain upon admission, re-admission,

with significant change, post occurrence,

quarterly, annually, and re-assessment as


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necessary.

The facility's Prevention and Treatment of Skin

Breakdown Guidelines dated 6/13 reads

Identification of Residents at risk for skin

breakdown include unrelieved pain. Pain - 1)

Observe and assess for indicators of pain,

itching, and/or discomfort. 2) Manage pain by

controlling source of pain (i.e. adjusting support

surfaces such as lift sheets, splinting, and bed

cradle, elevate legs and repositioning). 3) Initiate

a pain management program with MD/NP. 4)

Offer/administer analgesia, if ordered prior to

dressing changes. 4) Psychological interventions

i.e.; holding hand and offer reassurance,

acknowledge pain, explain interventions.

F 312

SS=E

483.25(a)(3) ADL CARE PROVIDED FOR

DEPENDENT RESIDENTS

A resident who is unable to carry out activities of

daily living receives the necessary services to

maintain good nutrition, grooming, and personal

and oral hygiene.


by:

F 312


review, the facility failed to provide oral care and

grooming for 3 of 6 residents (R8, R15, R24) in

the sample of 27 and failed to provide feeding

assistance for 3 residents (R55, R57, R58) in the

supplemental sample.

Findings include:

On 10/21/14 at 9:30am, R8 was in bed eating

breakfast. R8's hair was not combed. R8 had


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dirty fingernails.

On 10/21/14 at 1:30pm, R15 had dried food on

his shirt and his hair was not combed. On

10/22/14 at 8:30am, R15 was wearing the same

shirt as the day before with dried food on the front

of his shirt. On 10/22/14 at 11:30am, R15's

breakfast tray was still in his room.

On 10/23/14 at 8:30am, R15 had the same shirt

on for the 3rd day of observation. R15's shirt had

dried food on the front of his shirt.

The facility's Morning Care, General Guidelines

dated 6/13 reads "Morning care is provided to the

resident to refresh, provide cleanliness, comfort

and neatness, to prepare the resident for the day

and for meal (breakfast), to assess her/his

condition and needs, to promote psychosocial

wellbeing, and to maintain and improve quality of

life."

On 10/23/2014, at approximately 11:00 am, R 83

was observed sitting in a wheel chair outside the

3rd floor dining room wearing wet pants. The

resident ' s soiled clothing was brought to the

attention of E 27 (activity director) who then

asked E 10 (certified nursing assistant) to take R

83 to her room. Surveyor accompanied E 10 and

R 83 to the residents assigned room to observe

for incontinence. During incontinence care,

surveyor noted that R 83 ' s incontinence brief

was heavily saturated and also held dried stool. E

10 was then asked when was the last time R 83

received incontinence care. E 10 stated that " I '

m not her CNA, I don ' t know when she was last


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was changed " .

On 10/23/2014 at approximately 1:20 pm, during

an interview with E 28 (certified nursing assistant

assigned to R 83), E 28 stated R 83 had not been

changed or assessed for incontinence since 7: 50

am. When E 28 was asked how often residents

should be assessed for incontinence, E 28 stated,

" We are suppose to check them every hour. E 28

further stated " I have not checked her (R 83)

since I got her up " .

On 10/22/2014 at approximately 1:30 pm, during

an interview E 8 stated that the CNA ' s should be

assessing the residents for incontinence

frequently, but the standard is every two hours.

R 83 ' s care plan dated 10/10/2011 and

10/24/2014 denotes, resident is " frequently

incontinent of bowel and bladder related to limited

mobility. The care plan also denotes, R 83 should

be kept clean and dry, and that R 83 ' s voiding

and elimination pattern should be established.

On 10/22/14 at 5:06PM, R55, R57 and R58 was

observed sitting in the dining room waiting to be

fed their dinner meal. At approximately 5:25PM,

R55 received his meal tray from

E17(HouseKeeping Supervisor). E17 did not take

the eating utensils out of the napkin and place

tray within comfortable eating distance for and did

not roll up R55's shirt sleeves. R55 proceeded to

take food from his plate with his fingers and

scooped his soup with his fingers. At this time,

R55 sleeves were wet from the soups, food was

on his shirt and pants. R55 appeared frustrated.

R57 sat waiting for feeding assistance from

5:10PM until 5:45PM. E18(CNA) came to the

table where R55 and R57 were sitting and began

to assist R57 with feeding. At 5:45PM, E18


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commented that R55 usually does not need

assistance with feeding but he will help him too.

At 5:30PM, R58 was dropping food on to her bib

while attempting to feed herself. E17 proceeded

to assist R58 and stated he came in to help assist

residents with feeding.

Feeding Policy dated 5/2010 documents:

Residents who need assistance will be fed a

well-balanced meal by a nurse, CNA or an

individual who has completed a stated approved

feeding course.

On 10/23/14 at approximately 11:05AM, R24

observed with dry mouth and lips. R24 had a

white, pasty-like residue in the corners of her

inner lips and tongue. R24 pants were soiled. At

11:15AM, E22(Nurse) stated that the CNA caring

for R24 went to lunch but she will put chapstick

on R24's lips. On 10/24/14 at 9:30AM, R24

observed to have poor oral hygiene care; her lips

were cracked and her mouth was dry with with a

white pasty-like substance on her tongue and

inner lips. At this time, E13(Nurse) stated that

R24 probably needed better oral care this

morning, she needs more chapstick on her lips.

On 10/24/14 at 11:50AM, E23(CNA) stated she

wiped R24's mouth in the morning but did not

give oral hygiene care due to lack of time. E23

stated today was her first day working the unit

and she was assigned to help out, had to get all

the residents out of bed but did not take time to

provide oral hygiene care for R24. E23 stated she

would usually brush residents teeth and provide

oral rinse.

F 314

SS=D

483.25(c) TREATMENT/SVCS TO

PREVENT/HEAL PRESSURE SORES

F 314


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Based on the comprehensive assessment of a

resident, the facility must ensure that a resident

who enters the facility without pressure sores

does not develop pressure sores unless the

individual's clinical condition demonstrates that

they were unavoidable; and a resident having

pressure sores receives necessary treatment and

services to promote healing, prevent infection and

prevent new sores from developing.


by:


review, the facility failed to identify, assess and

treat a recurrent facility acquired stage II ischium

pressure sore and a new stage I pressure sore,

failed to provide appropriate treatment for R20's

stage II acquired pressure sore from 10/22/14

until 10/23/14 at 3:30pm when the silvadene

arrived from pharmacy and failed to consistently

and accurately assess, monitor and implement

pressure relieving methods to help heal and

prevent development of new and recurring

pressures sore for one of nine (R20) residents

reviewed for pressure sores in sample of 27.

Findings include:

On 10/23/14 at 8:30am, R20 was sitting in her

wheelchair. R20 stated her buttocks hurt when

she is sitting in her wheelchair from the open sore

on her bottom. R20 stated that she kept telling

the nurses that her bottom hurt. R20 stated that

she knew that her pressure sore had opened

again but no one believed her. R20 stated that

E10 (CNA) looked at her bottom and noticed that

her pressure sore was open. R20 stated that she


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developed the pressure sore in the facility.

On 10/23/14 at 12:05pm, R20 was observed in

the bathroom. R20 was noted to have a foam

dressing to her left ischium. E11 (Nurse) stated

that the silvadene that was ordered on 10/22/14

had not arrived from pharmacy. E11 stated that

she covered R20's pressure ulcer on R20's left

ischium with a foam dressing. E11 stated that the

silvadene ointment will be delivered from

pharmacy by 3:30pm. On 10/23/14 at 12:05pm,

R20 stated that her bottom hurts. E11 stated she

would give R20 pain medication. On 10/23/14 at

1:30pm, E9 (Wound Nurse) applied Zinc ointment

to R20's stage II pressure ulcer on R20's left

ischium. R20 stated "Be gentle. It's not like

pulling wallpaper off a wall. When you touch my

sore even lightly, it hurts." On 10/23/14 at 3p,

R20 was in bed with HOB (head of bed) elevated

at a 90 degree angle. R20 had direct pressure on

her buttocks with HOB at 90 degrees.

On 10/23/14 at 3:30pm, E9 turned R20 on her

side for the pressure ulcer dressing change to

R20's pressure ulcer on R20's left ischium. R20

stated "Ouch, it hurts, be gentle." R20 stated that

the pain medication she received did not help the

pain she has in her open sore on her bottom.

R20 stated that the lightest touch hurts her

pressure sore." E9 applied that silvadene

ointment on R20's left ischium pressure ulcer and

then place the foam dressing over the silvadene

ointment. Surveyor asked E9 if she saw the

stage I pressure sore medial to R20's left ischium

pressure sore. E9 stated that the new pressure

sore was not there before and she would

measure it now. R20's new facility acquired

stage I pressure sore measurements were 2 cm

(centimeters) x 1 cm. E9 did not provide any


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treatment for the new facility acquired stage I

pressure ulcer. R20 place the foam dressing

from the left ischium treatment directly over the

new stage I pressure ulcer.

On 10/23/14 at 12 noon, E10 (CNA) stated "I told

the nurse about R20's open sore on her buttocks.

R20 kept complain of pain so I looked at the

buttocks and there was an open sore."


he was not aware that R20 had pain in her

pressure sores. Z2 thanked that surveyor for

bringing this issue to his attention. Z2 stated that

R20's pressure ulcers are avoidable if the

resident is cooperative. Z2 stated R20 has

recurrent stage II pressure ulcers. Z2 stated that

he ordered a dietary recommendation for R20.

R20's Braden score on 9/20/14 was 12 (Mild)

risks. R20's clinical record dated 9/21/14 reads

very limited mobility, unable to make frequent or

significant changes independently. R20's Stage 2

ischium pressure sore measurements dated

9/20/14 were 0.8 cm (centimeters) x 0.7cm x 0.1

cm. R20's right coccyx pressure ulcer

measurement was 0.8cm x 0.7 cm x 0.2 cm.

Bilateral gluteal to perineum dermatitis

documented.

R20's wound measurements are as follows:

9/25/14 - right coccyx pressure sore 0.8 cm x 0.7

cm x 0.2 cm

stage 2 left ischium pressure sore 1.4

cm x 1.0 cm x 0.2 cm

10/2/14 - right coccyx pressure 0.6 cm x 0.7 cm x

0.2 cm

stage 2 left ischium pressure sore closed

10/9/14 - right coccyx 0.6 cm x 0.6 cm x 0.2 cm


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10/16/14 - right coccyx pressure sore closed

10/23/14 - left gluteal fold - stage 2 0.5 cm x 0.7

cm

On 10/23/14 at 12:05pm, R20 did not have

correct dressing for above pressure ulcer.

On 10/23/14, R20's clinical documentation does

not have the new facility acquired stage I

pressure sore measurement 2 cm x 1 cm on

R20's left inner buttocks as observed during the

dressing change on 10/23/14 at 3:30pm.

Surveyor requested daily skin assessments.

R20's shower day worksheet dated 10/18/14

documented R20 as having no open areas

marked on the sheet.

R20's care plan for alteration is skin integrity

dated 10/23/14 does not include the preventive

measures of establishing an individualized turning

and repositioning schedule if the resident is

immobile.

Z2's (Wound Doctor) clinical notes on 10/23/14

reads "Right ischium stage II pressure ulcer 0.9

cm x 0.5 cm x 0.1 cm and coccyx pressure sore

1.2 cm x 1.4 cm x 0. Please refer to dietary and

check serum albumin.

On 10/23/14 at 1:35pm, E11 stated the R20 is not

taking Bene Protein. E11 stated that R20 does

not like the Bene Protein. R20's serum albumin

level on 9/29/14 was 2.8 g/dl (low). The normal

range as identified by the facility is 3.3 - 5.0.

R20's total protein was 5.7 (low). The normal

range is 6.0 - 8.5. On 10/14/14, R20's serum

albumin was 2.4 and total protein was 5.1.


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E11 stated on 10/23/14 at 1p that R20 is not

taking the Ben Protein because she does not like

it. There were no further nutritional assessments

in R20's clinical notes after the 10/14/14 labs

noting R20's albumin and total protein decreased

from the previous levels on 9/29/14.

R20's POS (Physician Order Sheet) dated 9/1/14

- 10/31/14 does not list Bene Protein as noted in

the clinical notes on 9/24/14 "Bene Protein taken

well per staff." R20 is not taking Bene Protein

based on the POS and interview with E11.

The facility's Prevention and Treatment of Skin

Breakdown policy dated 6/13 reads "It is the

policy to properly identify and assess residents

whose clinical conditions increase the risk for

impaired skin integrity, and pressure ulcers; to

implement preventive measures; and to provide

appropriate treatment modalities for ulcers

according to industry standards of care."

The facility's policy on Prevention of Skin

Breakdown reads "Inspect skin every shift with

care for signs and symptoms of breakdown."

There is no documentation that R20's skin was

inspected every shift.

F 328

SS=E

483.25(k) TREATMENT/CARE FOR SPECIAL

NEEDS

The facility must ensure that residents receive

proper treatment and care for the following

special services:

Injections;

Parenteral and enteral fluids;

Colostomy, ureterostomy, or ileostomy care;

Tracheostomy care;

Tracheal suctioning;

F 328


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Respiratory care;

Foot care; and

Prostheses.


by:


review, the facility failed to ensure that nebulized

tubing was dated and cover for 7 residents (R33,

R45, R46, R47, R48 and R56) in the


Findings include:

On 10/21/14 at 10am, R33, R45, R46, R47 and

R48's nebulizer tubing was not dated indicating

when the tubing was changed. E8 (Registered

Nurse) stated tubing should be changed weekly.

When surveyor asked E8 how you would know if

the tubing was changed, E8 stated that she was

not sure based on the fact there is no date on the

tubing.

R33's POS (Physician Order Sheet) dated

10/16/2014 reads DuoNeb Solution 0.5-2.5

mg/3ml (1) vial inhale orally every 6 hours as

needed for Respiratory Symptoms. R33's

admitting diagnosis on 3/20/12 was Chronic

Airway Obstruction.

R45's Physician Order dated 4/19/2014 reads

DuoNeb Solution 0.5-2.5 mg/3 ml (1) vial inhale

orally every 4 hours as needed for Respiratory

Symptoms. R45's admitting diagnosis dated

6/8/13 included Chronic Airway Obstruction.


Xopenex Nebulization Solution 0.63 mg/3ml (1)


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vial inhale orally via nebulizer every 4 hours as


admitting diagnosis dated 3/27/2014 includes

Chronic Airway Obstruction.


Xopenex Nebulization Solution 0.63 mg/3ml (1)

vial inhale orally via nebulizer every 6 hours as


admitting diagnosis dated 9/3/2013 includes

Cough.


DuoNeb Solution 0.5-2.5 mg/ 3 ml (1) vial inhale

orally four times a day for Respiratory Symptoms

and DuoNeb Solution 0.5-2.5 mg/3ml (1) vial

inhale orally every 4 hours as needed for

Respiratory Symptoms. R48's admitting

diagnosis dated 6/28/2014 includes Asthma.

The facility's Equipment Change Schedule Policy

dated 4/14 reads "Equipment will be changed

following established schedules to prevent cross

contamination. Nebulizer set-ups for

bronchodilator therapy changed weekly and prn."

B. On 10/21/14 at approximately 10:00AM with

E21(Nurse), R56's nebulizer face mask was on

resident's night stand uncovered. At this time,

E21 stated that it should be covered.

Demographic Sheet documents on 8/30/14, R56

diagnosed with Acute Respiratory Failure and

Shortness of Breath.

F 329

SS=E

483.25(l) DRUG REGIMEN IS FREE FROM

UNNECESSARY DRUGS

Each resident's drug regimen must be free from

unnecessary drugs. An unnecessary drug is any

F 329


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drug when used in excessive dose (including

duplicate therapy); or for excessive duration; or

without adequate monitoring; or without adequate

indications for its use; or in the presence of

adverse consequences which indicate the dose

should be reduced or discontinued; or any

combinations of the reasons above.

Based on a comprehensive assessment of a

resident, the facility must ensure that residents

who have not used antipsychotic drugs are not

given these drugs unless antipsychotic drug

therapy is necessary to treat a specific condition

as diagnosed and documented in the clinical

record; and residents who use antipsychotic

drugs receive gradual dose reductions, and

behavioral interventions, unless clinically

contraindicated, in an effort to discontinue these

drugs.


by:


review, the facility failed to ensure that

psychotropic medication management program in

place, failed to identify proper indication for use,

failed to document non pharmacological

interventions before use of medication and failed

to attempt gradual dose reductions for four of

eight residents (R9, R15, R16 and R17) review

for psychotropic medication management

program in sample of 27.

Findings include:


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On 10/21/14, 10/22/14 and 10/24/14 at 9a, 12

noon and 2p, R15 was observed in bed. R15's

behavior was calm and quiet. R15 stated that he

felt tired on 10/21/14, 10/22/14 and 10/23/14.

R15 did not exhibit any agitated behavior. R15's

follow-up Psychiatric Evaluation dated 9/5/14

reads "Pleasant, cooperative, engaging. States

depressed because of the war where he lost

many friends. Appears depressed. History of

present illness - Pt with advancing dementia.

Past psychiatric history- anxiety, psychosis and

Alzheimer's." R15's behavior monitoring record

lists refusal to care interventions 4 times in Oct

2014. There are no interventions listed for the

behavior. R15's POS (Physician Order Sheet)

dated Oct.1, 2014 reads Seroquel 25 mg 1 tablet

by mouth in the evening for Agitation. There were

no episodes of agitation documented from 7/14

through 10/14. R15 has not had a gradual dose

reduction documented for Seroquel 25 mg. R15's

Seroquel 25mg order date was 6/12/14.

On 10/21/14 at 12 noon, R16 was sitting quietly in

the dining room holding a stuffed animal. R16's

demeanor was pleasant and calm. On 10/22/14

at 9a and 12:30p, R16 was sitting peacefully and

quiet in the dining room. On 10/23/14 at 11a, R16

was sitting quietly and appeared calm. No

behaviors observed on 10/21/14, 10/22/14 and

10/23/14.

On 10/21/14 at 1pm, E13 (Registered Nurse)

stated that R16 has been really good. On

10/21/14 at 2pm, E12 (CNA) stated that R16 is

confused and sometimes gets frustrated. E12

stated that when R16 gets frustrated, if you talk to

her you can calm her down. R16's behavior

monitoring record does not list any behaviors for

10/14. R16 was admitted to the facility on


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12/26/13 with a diagnosis of Alzheimer's disease

and anxiety. R16's POS (Physician Order Sheet)

dated 10/1/14 reads Xanax 0.25 mg Give 1 tablet

by mouth two times a day regarding to anxiety

state. R16 has been on Xanax 0.25 mg since

admission on 12/26/13 without any attempts of

gradual dose reductions. On 10/24/14 at 1pm,

Z1 (Psychiatric Nurse Practitioner) stated that she

is not going to attempt any gradual dose

reductions for R16. R16's MDS (Minimum Data

Set) dated 9/12/14 under Section E. Behavior

reads "Behaviors (physical, verbal or other

behaviors) not exhibited. R16's MDS dated

6/6/14 reads "No behaviors exhibited (physical,

verbal or other behaviors)."

On 10/24/13 at 11am, E1 (Administrator) stated

that he is not happy with the responses Z1

provides to the nursing staff regarding

psychotropic medications. Z1 stated that he

realizes that the facility does not have a

psychotropic program in place and a program will

be initiated.

The facility's Psychotropic Medication Program

Policy & Procedure dated 5/14 reads "Gradual

dose reductions will be attempted as appropriate,

especially in the dementia population.

Non-pharmacological techniques will be utilized

with residents, including the dementia population,

to prevent mood or behavioral disturbances."

The facility's Quarterly Psychotropic Program

Review dated 9/8/14 reads "Benchmark - no

program in place as of Aug/Sept 2014."


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R17 is a 72 year old admitted to the facility on

10/17/2014 with a diagnosis of Dementia,

Depression, and Anxiety. Record review denotes

R17 is prescribed Aricept 10 mg at bedtime for

Dementia, Depakote 250 milligrams (mg) by

mouth at bed time, Lexapro 10 mg every evening

for depressive disorder, Seroquel 12.5 mg every

evening for dementia with behavioral

disturbances, and Ativan 0.25 mg every four

hours as needed for agitation.

Physician order sheet dated: On 10/24/2014 at

approximately 11:00 am, during a telephone

interview Z6 (medical director) stated R17 was

prescribed Seroquel 25 mg for " Dementia with

agitation " . Z6 also stated that R17 would be

evaluated by a psychiatrist and that the Seroquel

dosage would eventually be decreased.

On 10/24/2014, at 11:15 am, during an interview

Z1 (psychiatric nurse practitioner) stated that R17

was admitted to the facility with Seroquel. Z1

further stated " I know the literature states that

elderly patients should not be prescribed

antipsychotics. I don ' t know why she (R17) is

getting Seroquel for agitation if she is also

prescribed Ativan. I will have to review her

medications, she came in with the medications

and I really don ' t know her " .

In addition, when Z1 was asked if a nurse

happens to contacts her regarding a resident ' s

behavior, what non- pharmacological

interventions are recommended. Z1 stated " I

usually don ' t recommend any

non-pharmacological interventions; however, I am

very conservative with the medication " .

The facilities psychotropic policy dated 5/2014,


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denotes non-pharmacological techniques will be

utilized with residents, including in the dementia

population, to prevent mood or behavioral

disturbances.

R9 is a 75 year old admitted to the facility on

10/24/2012 with a diagnosis of senile Dementia,

Depressive disorder, diabetes, chronic airway

obstruction, unspecified hypertension, and

osteoporosis.

On 10/22/2014, record review denotes that R10

was prescribed Ativan 0.25 milligrams (mg).

Physician order sheet dated 10/1/2014, denotes,

Ativan 0.25 mg is to be administered by mouth,

twice a day for depressive disorder. Physician

order sheet also denotes that R9 is prescribed

Cymbalta 50 mg every day for depression.

On 10/22/2014 at 9:00 am, during an interview E8

(3rd floor nurse manager) stated that R9

sometimes refuses care, but does not display any

other behaviors. E8 further stated that R9 only

refuses care when she does not like the nurse or

certified nursing assistant assigned to her.

On 10/24/2014 at 9:15 am, during an interview

E29 stated that R9 displays behaviors " When

she does not like her nurse or nursing assistant "

. E29 was then asked if R9 displayed any other

behaviors that would warrant administration of

Ativan. E29 stated, no, she get ' s the Ativan for

agitation, they also gave her Ativan for her

depression, she does not want to stay here " .

On 10/24/2014, at 10:30 am, during an interview

Z7 (R9' s medical doctor) was asked the clinical

indication for prescribing Ativan to R9. Z7 stated

that R9 was prescribed Ativan for depression. Z7

was also asked if it was protocol to prescribe

Ativan for depression, Z7 stated no. Z7 was

asked if the facility had expressed that R9 only

displays negative behaviors when she is unhappy

with the assigned nurse or nursing assistant.


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Furthermore, Z7 stated that she had not been

contacted regarding R9 displaying negative

behaviors. Z7 stated that a graduate dose

reduction or discontinuation of the Ativan would

be considered.

A review of R9 ' s psychiatric evaluation dated

9/5/2014 denotes that R9 is mildly depressed.

The psychiatric treatment plan further denotes R9

to participate in cognitive behavioral therapy.

A review of R9 ' s Behavioral Tracking Record

dated 7/22/2014-10/202014 denotes the R9

rejected care during this time period. There were

no additional behavioral disturbances

documented in R9 ' s behavioral tracking record.

The facility failed to provide documentation of a

graduate dose reduction order for R9 's

prescribed Ativan.

The facilities psychotropic policy dated 5/2014,

denotes that graduate dose reductions will be

attempted as appropriate, especially in dementia

population.

F 332

SS=D

483.25(m)(1) FREE OF MEDICATION ERROR

RATES OF 5% OR MORE

The facility must ensure that it is free of

medication error rates of five percent or greater.


by:

F 332

Based on observation and record review, the

facility failed to administer medication as ordered

to maintain a medication error rate of less than

5%. There were 26 opportunities with 4 errors

resulting in a 15.3% medication error rate. This

applies to 3 of 10 residents (R29, R30 and R31)

observed in the medication pass in the


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supplemental sasmple.

Findings include:

1. On 10/21/14 at 4:15pm, E3 (Registered Nurse)

checked R29's blood glucose. R29's blood

glucose was 328. E3 set R29's insulin pen to 6

units. E3 administered R29's 6 unit (u) Humalog

insulin without priming the insulin pen prior to

administration.


10/1/14 reads "Humalog Solution 100 unit/ml

inject per sliding scale 301-350 = 6 units

subcutaneously before meals and at bedtime as

related to Diabetes without complications Type II .

2. On 10/22/14 at 5:15am, E4 (Registered Nurse)

did not shake R30's Dulera inhaler prior to R30

inhaling the medication.


10/1/14 reads "Dulera Aerosol 100-5 mcg/act

Inhalation Chronic Airway Obstruction 2 puffs by

mouth two times daily."

3. On 10/22/14 at 5:35a, E5 (Licensed Practical

Nurse) did not administer the complete dose of

Thera-M MVI (Multivitamin) and Calcium 600 mg

(milligrams)/400u Vitamin D via R31's

Gastrostomy Tube. E5 left medication at the

bottom of the medicine cup for R31's Thera-M

MVI and Calcium 600mg/400u Vitamin D after he

crushed both medications and diluted both

medications. After completion of the medication

administration, there was still medication Thera M

MVI and Calcium 600mg/400units Vitamin D at

the bottom of each medicine cup. E5 threw away

the remaining medicine in each medicine cup for


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Calcium and MVI.


10/1/14 reads "Calcium Carbonate-Vitamin D

Tablet 600-400mg (milligram) unit tablet 1 tab

twice daily. Thera-M (Multiple Vitamins

w/Minerals Tablet 1 Enteral Tube Take 1 tab daily

via g-tube."

The facility's Pharmacy Standard Operating

Policies & Procedures dated 2010-2014 reads,

"Insulin pens - Give a prime air shot before each

injection: Dial 2 units on the insulin pen, point

upward, and press in button to prime the pen.

This ensures the pen is working and that there is

no air in the needle." E3 failed to give a prime air

shot prior to administering R29's 6units Humalog

insulin.

The facility's Clinical Practice Guidelines for

Inhaler Metered Dose (MDI) dated 05/10 reads

"Shake canister several times." The Pharmacy

Standard Operating Policies & Procedures dated

2010-2014 reads "Always shake inhalers prior to

administration."

The Pharmacy Standard Operating Policies &

Procedures for Medication Pass Guidelines dated

6/14 for G tube (gastrostomy tube) medication

reads "Do NOT leaves any residual medication

on the inside on the med cup."

F 333

SS=D

483.25(m)(2) RESIDENTS FREE OF

SIGNIFICANT MED ERRORS

The facility must ensure that residents are free of

any significant medication errors.

F 333


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by:

Based on observation interview and record

review, the facility failed to ensure that one

resident (R29) was free of a significant

medication error based on 26 medication

administration observations in supplemental

sample.

Finding Includes:

On 10/21/14 at 4:15pm, E3 (Registered Nurse)

checked R 29's blood sugar. R29's blood sugar

was 328. R29's POS (Physician Order Sheet)

dated 10/1/14 reads "Humalog insulin 6 units for

blood sugar 301 - 350." E3 dialed R29's insulin

pen to 6 units and administered 6 units Humalog

insulin without priming the insulin pen prior to

administration. E3 stated that this is the correct

amount of insulin.


Policy & Procedure dated 2010-2014 reads

"Insulin pens - Give a prime air shot before each

injection: Dial 2 units on the insulin pen, point

upward, and press in button to prime the pen.

This ensures the pen is working and that there is

no air in the needle." E3 failed to give a prime air

shot before R29's 6 units Humalog insulin

administration.

F 334

SS=E

483.25(n) INFLUENZA AND PNEUMOCOCCAL

IMMUNIZATIONS

The facility must develop policies and procedures

that ensure that --

(i) Before offering the influenza immunization,

each resident, or the resident's legal

representative receives education regarding the

F 334


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benefits and potential side effects of the

immunization;

(ii) Each resident is offered an influenza

immunization October 1 through March 31

annually, unless the immunization is medically

contraindicated or the resident has already been

immunized during this time period;

(iii) The resident or the resident's legal

representative has the opportunity to refuse

immunization; and

(iv) The resident's medical record includes

documentation that indicates, at a minimum, the

following:

(A) That the resident or resident's legal

representative was provided education regarding

the benefits and potential side effects of influenza

immunization; and

(B) That the resident either received the

influenza immunization or did not receive the

influenza immunization due to medical

contraindications or refusal.

The facility must develop policies and procedures

that ensure that --

(i) Before offering the pneumococcal

immunization, each resident, or the resident's

legal representative receives education regarding

the benefits and potential side effects of the

immunization;

(ii) Each resident is offered a pneumococcal

immunization, unless the immunization is

medically contraindicated or the resident has

already been immunized;

(iii) The resident or the resident's legal

representative has the opportunity to refuse

immunization; and

(iv) The resident's medical record includes

documentation that indicated, at a minimum, the


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following:

(A) That the resident or resident's legal

representative was provided education regarding

the benefits and potential side effects of

pneumococcal immunization; and

(B) That the resident either received the

pneumococcal immunization or did not receive

the pneumococcal immunization due to medical

contraindication or refusal.

(v) As an alternative, based on an assessment

and practitioner recommendation, a second

pneumococcal immunization may be given after 5

years following the first pneumococcal

immunization, unless medically contraindicated or

the resident or the resident's legal representative

refuses the second immunization.


by:

Based on interview and record review, facility

failed to follow their Influenza and Pneumococcal

Vaccination policy for one resident (R6) in the

sample of 27 and seven residents

(R32,R44,R59,R60,R61,R62 and R63) in the

supplemental sample reviewed for infection

control. This failure resulted in these residents not

getting their Pneumococcal vaccine

administered/offered.

Findings Include:

Facility's current resident list report for residents

that received/refused pneumococcal

immunization denotes (R6, R32, R44, R59, R60,

R61, R62 and R63) had no explanation of why

pneumococcal immunization was given,


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contraindicated or refused.

R6 face sheet denotes admitted to the facility on

9-30-14. R6 had no documentation in her

nurses/progress note from 9-30-14 thru 10-23-14

that pneumococcal vaccine was given,























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E19 (Assistant Director of Nursing) stated on

10-23-14 at 11:15 am, she is responsible for

tracking the residents that get their flu and

pneumococcal vaccine.

E19 stated there are some residents (R6, R32,

R44, R59, R60, R61, R62 and R63) that were

missed and there was no documentation in those

residents ' records that they were offered the

pneumococcal vaccine. E19 stated they believe

they contacted some of the resident ' s legal

guardians to get consents but they did not follow

up. E19 stated she would start today (10-23-14)

to work on seeing if R6, R32, R44, R59, R60,

R61, R62 and R63 are able to get the

pneumococcal vaccine. E19 stated there was no

reason that R6, R32, R44, R59, R60, R61, R62

andR63 had no documentation in the medical

records the pneumococcal vaccine was given,


Facility's Influenza and Pneumococcal

Vaccination policy denotes in order to minimize

the risk of residents acquiring or experiencing

complications from influenza and pneumococcal

pneumonia it is the policy of this facility to offer

Influenza and pneumococcal vaccinations to all

residents current or newly admitted. Each


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resident shall be offered a pneumococcal

immunization, unless the immunization is

medically contraindicated or the resident has

been immunized. The resident ' s medical record

will include documentation that indicates that

residents received the pneumococcal

immunization; did not receive the pneumococcal

immunization due to medical contraindications; or

refused it.

F 362

SS=E

483.35(b) SUFFICIENT DIETARY SUPPORT

PERSONNEL

The facility must employ sufficient support

personnel competent to carry out the functions of

the dietary service.


by:

F 362

Based on observation and interview, the facility

failed to provide sufficient support staff to assist

residents during mealtimes and to ensure meals

were served in a timely manner in supplemental

sample residents (R71, R77, R79, R80, R81,

R82, R55, R57 and R58). The lack of sufficient

staff to assist with serving and feeding of the

residents has the potential to affect 163 of 177

residents who receive meals from dietary

services.

Findings include:

A. On 10/21/14 at 12:00 PM, on the second floor

dining room there were residents who had been

brought into the dining room at 11:30 AM.

According to the facility dining schedule lunch is

to be served at 12:00 PM. In addition Food


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Temperature Resident Service Policy dated

2/2012 documents food will be served to

residents at a temperature that is palatable and

hot food will be presented to the resident within

30 minutes of leaving the steam table.

Resident council minute meetings dated 2014

documents some residents commented that the

temperature of the food occasionally is not as

they desire.

On 10/21/14 at 12:45 PM, the staff began serving

resident refreshments. At this time R71 said

"Lunch and dinner are frequently late, and there

is normally only two activity staff to serve meals.

They only have all these people helping today

because the state is here." R78 added, " There is

never a Nurse or Activity Director here assisting

with meals, they are only here today because the

state is here." R78 also said "On Sundays there

is only one person serving dinner and on

occasion family members will assist the staff by

applying clothing protectors to residents and

passing out silverware." At this time R77 added "

Staff first serve and assist residents with feeding

in the dining room and then they assist the

residents who eat in their rooms which means

they get served last and late."

B. On 10/22/14 at 11:35AM with E16(Dietary

Supervisor) the residents on unit three were

observed in resident dining room. Ten tables of

residents were observed sitting in the dining room

awaiting the lunch meal to be served. R79, R80,

R81 and R82 were observed sitting at their tables

at 11:35AM until 12:50PM without receiving

feeding assistance. At approximately 12:15PM,

R82 became wrestless and began to move from

the table several times, attempting to walk out of


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dining room.

At 12:50PM E23(CNA) was asked why R82 and

R81, whom sat at the same table, had not been

served their meal tray. E23 stated R82 is

independent and requires table set up with meal

only but her table is served last according to the

schedule and R81 needed assistance with

feeding and is waiting for available feeding

assistant. R81 and R82 were finally served their

tray at approximately 12:55PM.

R79 and R80 were observed sitting at their table

from 11:35 until 1:25PM. R79 and R80 were the

last residents to be served and required feeding

assitance. R79 and R80 were asked simple

questions about their anticipated meal but both

residents did not speak clearly understandable

language. At 1:25PM, R79 and R80 received their

tray however, they did not receive feeding

assistance until 1:45PM.

On 10/22/14 at 1:25PM, E16 was asked about

meal serving times and procedure due to large

number of residents waiting to be served and

provided feeding assistance at this time. E16

stated that they were attempting to stategize how

residents would be served and also provide

feeding assistance to other residents. E16 stated

when servers sit down to assist residents with

feeding then it slows down the process because

there is no one available to serve, this causes

residents to have to wait a long time. E16 stated

there is not enough staff to assist with feeding

residents and to serve residents.

During dinner meal observation on 10/23/14 at

5:06PM, R55, R57 and R58 were observed sitting

in the dining room waiting to be fed their meal


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tray. At 5:25PM, R55 received his meal tray from

E17(Housekeeping Supervisor). E17 did not take

the eating utensils out of the napkin and place

tray within comfortable eating distance for R55

and did not roll up R55's shirt sleeves. R55

proceeded to take food from his plate with his

fingers and scooped his soup with his fingers into

his mouth. At this time, R55 sleeves were wet

from the soup, food was on his shirt and pants.

R55 appeared frustrated. R57 sat waiting for

feeding assistance between 5:10PM until

5:45PM. At approximately 5:45PM, E18(CNA)

came to the table where R55 and R57 were

sitting and began to assist R57. E18 commented

that R55 usually does not need assistance with

feeding but he will help him too.

At approximately 5:30PM, R58 was observed

dropping food on to her bib. At this time, E17

stated he came in to help assist residents.

F 371

SS=E

483.35(i) FOOD PROCURE,

STORE/PREPARE/SERVE - SANITARY

The facility must -

(1) Procure food from sources approved or

considered satisfactory by Federal, State or local

authorities; and

(2) Store, prepare, distribute and serve food

under sanitary conditions


by:

F 371

Based on observations, interviews and record

review, the facility failed to ensure proper storage


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of food under sanitary conditions in the walk in

refrigerator, in the storage room and undated

food items in supplemental resident (R45)

refrigerator. This has the potential to affect 163 of

177 residents whom receive food from the

kitchen.

Findings include:

1. On 10/21/14 at 9:20AM, during dietary tour with

E16 (Dietary Supervisor) there was dried debris

of food build up in the drain of the Steamer

Machine. At this time, E16 said, "I will have the

drained cleaned today."

On 10/21/14 at approximately 9:45AM, in the

walker in cooler, there was a large opened box of

grapes on the shelf below a half shank of beef

that was wrapped in plastic. When asked about

proper storage of vegetables, E16 stated that the

grapes were on the wrong shelf and should not

be stored underneath the beef because it could

drip on the grapes. E16 removed the box of

grapes from the shelf. At this time, an uncovered

head of cabbage was on top of the milk crate cart

with bottles of milk in them. E16 states I will

throw the cabbage away and it should not be on

the milk crate.

On 10/21/14 at approximately 9:50AM, in the dry

storage room, observed a rack with multiple

loaves bread that was outdated (October 9th).

E16 stated that they keep bread for one week.

E16 stated he will discard the loaves of outdated

bread now. Across from the bread cart were two

bunches of bananas, one banana peel was

opened exposed the banana fruit and one

banana was on the floor.


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Food Storage Policy dated 2/2012 documents:

Food storage areas will be maintained in a clean,

safe and sanitary manner. Purpose: To reduce

the risk of food borne illness. Food inventory will

be maintained using first in, first out (FIFO).

2. On 10/21/14 at 10:10a, R45 had undated food

in a tupperware container in her refrigerator,

undated coffeemate and undated french onion

dip.

F 411

SS=D

483.55(a) ROUTINE/EMERGENCY DENTAL

SERVICES IN SNFS

The facility must assist residents in obtaining

routine and 24-hour emergency dental care.

A facility must provide or obtain from an outside

resource, in accordance with §483.75(h) of this

part, routine and emergency dental services to

meet the needs of each resident; may charge a

Medicare resident an additional amount for

routine and emergency dental services; must if

necessary, assist the resident in making

appointments; and by arranging for transportation

to and from the dentist's office; and promptly refer

residents with lost or damaged dentures to a

dentist.


by:

F 411


review, the facility failed to promptly refer one of

one resident with lost dentures to a dentist and

failed to provide emergency dental services for

one resident (R8) in the sample of 27.

Findings include:


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On 10/21/14 at 9am, R8 was eating a bagel. R8

did not have any dentures. R8 stated "It is

difficult to chew without any dentures. They lost

my dentures about 2 weeks ago." On 10/23/14 at

9am, R8 was eating a bagel. R8 stated that he

tries to gum the bagel because he does not have

any dentures.

On 10/24/14 at 1:10pm, Z4 (Dentist) stated that

R8's dentures will take approximately 4 - 6 weeks

to be replaced.

The facility's Dental Services Policy dated 3/11

reads "Dental services are available to all

residents requiring routine and emergency dental

care."

F 425

SS=E

483.60(a),(b) PHARMACEUTICAL SVC -

ACCURATE PROCEDURES, RPH

The facility must provide routine and emergency

drugs and biologicals to its residents, or obtain

them under an agreement described in

§483.75(h) of this part. The facility may permit

unlicensed personnel to administer drugs if State

law permits, but only under the general

supervision of a licensed nurse.

A facility must provide pharmaceutical services

(including procedures that assure the accurate

acquiring, receiving, dispensing, and

administering of all drugs and biologicals) to meet

the needs of each resident.

The facility must employ or obtain the services of

a licensed pharmacist who provides consultation

on all aspects of the provision of pharmacy

services in the facility.

F 425


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by:


review, the facility failed to removed expired

medications on the 1st and the 3rd floor

emergency cart and medicine room and failed to

date tuberculin dose vials upon opening in one of

one refrigerator.

Findings include:

1. On 10/22/14 at 7a, the 1st floor medication

refrigerator had a TB (tuberculin) vial was opened

with no date on the vial. The TB vial lot #

720409. E7 (Licensed Practical Nurse) stated

that the TB vial should be dated when opened.

2. On 10/22/14 at 7:20am, the 1st floor

emergency cart had expired

1) 1000 ml (milliliters) of D5%.45 NS (Normal

Saline) IV (intravenous) solution bag dated Nov.

2013

2) 250 ml 0.9% NS (Normal Saline) IV bag dated

June 2014

3) 250 ml sterile water dated April 2014

4) Irrigation tray with piston syringe dated

06-2014

3. On 10/22/14 at 11:05am, the 3rd floor medicine

room drawer contained Loperamide 2 mg

(milligrams) 2 tabs. The medication was found in

a drawer that contained oxygen tubing. E8 stated

that the medication should not be kept in the

drawer.


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Policy & Procedure Medication Pass Guidelines

dated 6/14 reads "Check expiration dates of all

medications before administration."

F 431

SS=E

483.60(b), (d), (e) DRUG RECORDS,

LABEL/STORE DRUGS & BIOLOGICALS

The facility must employ or obtain the services of

a licensed pharmacist who establishes a system

of records of receipt and disposition of all

controlled drugs in sufficient detail to enable an

accurate reconciliation; and determines that drug

records are in order and that an account of all

controlled drugs is maintained and periodically

reconciled.

Drugs and biologicals used in the facility must be

labeled in accordance with currently accepted

professional principles, and include the

appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

In accordance with State and Federal laws, the

facility must store all drugs and biologicals in

locked compartments under proper temperature

controls, and permit only authorized personnel to

have access to the keys.

The facility must provide separately locked,

permanently affixed compartments for storage of

controlled drugs listed in Schedule II of the

Comprehensive Drug Abuse Prevention and

Control Act of 1976 and other drugs subject to

abuse, except when the facility uses single unit

package drug distribution systems in which the

quantity stored is minimal and a missing dose can

be readily detected.

F 431


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by:


review, the facility failed to label medications in

accordance with labeling requirements, failed to

account for an opened full vial of Lorazepam 30

ml (milliliter) vial and failed to properly store

medication for one resident (R7) in a sample of

27 and 2 residents (R47 and R67) in the


On 10/21/14 at 10am, there were 3 pills noted on

R67's bedside table. R67 stated that he had no

idea what the pills were for because they never

tell him anything. R67 reached over to the

medicine cup on his bedside table and took the

medication. E8 (RN) stated that nurses are not

supposed to leave medication at the bedside.


10/1/2014 reads Flomax Capsule 0.4 mg Give 1

capsule by mouth two times a day, Neurontin 300

mg by mouth 9a pain management, Norco

(Hydrocodone-Acetaminophen) Tablet 7.5-325

mg 9a pain management, Omeprazole capsule

delayed release 20 mg 9a, Oyster Shell

Calcium/Vitamin D tablet 500 mg/200units 9a.

On 10/21/14 at 10:10am, R47 had a cup filled

with MOM (Milk of Magnesia) and water mixed

together by his TV. R47 stated that he was about

to take the medication. E8 stated that medication

is not to be left at the bedside.

On 10/22/14 at 7am, an insulin pen was noted in

the 1st floor medication refrigerator with no lable

on the insulin pen. On 10/22/14 at 7am, E7


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(Licensed Practical Nurse) stated that the insulin

pen should have a label attached to it to identify

the resident.

On 10/22/14 at 11:05am, a full opened 30 ml

(milliliter) vial of Lorazepam 2 mg/ml for R7 was

noted in the 3rd floor medication refrigerator. E8

stated that it is not usual practice to have a full

open bottle of Lorazepam in the medication

refrigerator. R7's narcotic count sheet for

Lorazepam did not have any signatures that the

medication had been given for R7. E8 stated that

a nurse must have opened the vial and realized

there was another vial already open.


Policy & Procedure dated 6/14 reads "Do not

share pens; each resident must have their own

pen."

The facility's Controlled Drug Documentation

Policy dated 8/12 reads "Purpose is to maintain

control and prevent loss and/or diversion of

controlled substances."


Policies & Procedures Medication Pass

Guidelines dated 6/14 reads "Administering

Medications - Watch the resident swallow all

medications. Do NOT leave any meds with the

resident to take later."

B. On 10/21/14 at approximately 10:05AM with

E(21), R4 had one tube of hydrocortisone cream

at bedside. At this time, E21 stated that residents

should not have medications at bedside. On

10/22/14 at approximately 10:30AM,

E2(DON/Director of Nursing) stated that they do

not allow residents to self medicate, residents

should not have medications at bedside and the


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facility does not have a policy on self

administration of medications for residents.

F 441

SS=E

483.65 INFECTION CONTROL, PREVENT

SPREAD, LINENS

The facility must establish and maintain an

Infection Control Program designed to provide a

safe, sanitary and comfortable environment and

to help prevent the development and transmission

of disease and infection.

(a) Infection Control Program

The facility must establish an Infection Control

Program under which it -

(1) Investigates, controls, and prevents infections

in the facility;

(2) Decides what procedures, such as isolation,

should be applied to an individual resident; and

(3) Maintains a record of incidents and corrective

actions related to infections.

(b) Preventing Spread of Infection

(1) When the Infection Control Program

determines that a resident needs isolation to

prevent the spread of infection, the facility must

isolate the resident.

(2) The facility must prohibit employees with a

communicable disease or infected skin lesions

from direct contact with residents or their food, if

direct contact will transmit the disease.

(3) The facility must require staff to wash their

hands after each direct resident contact for which

hand washing is indicated by accepted

professional practice.

(c) Linens

Personnel must handle, store, process and

transport linens so as to prevent the spread of

F 441


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infection.


by:


review, facility failed to follow/adhere to their

infection control program for one resident (R5) in

the sample of 27 and three residents (R64, R65

and R66)in the supplemental sample reviewed

for infection control. This failure resulted in staff

not treating R5's pressure ulcer with proper

infection control standards/practice and

R5,R64,R65,R66 not getting their sensitivity

reports from lab on a regular basis and staff not

washing their hands and grabbing R30 and R69

drinking cups brim after having direct contact with

other residents.

Findings Include:

1. During group interview on 10-22-14 at 10:45

am, R30 and R69 verbalized that they do not like

when staff pass out the trays during meal time

because the aides put their fingers on the brim of

their cups that they have to drink out of.

Observed during dinner on 10-22-14 at 5:10 pm,

CNA make contact with a resident and touch that

resident's shoulder then observed the same CNA

grab a cup by the brim pour lemonade in it and

hand it to R69 to drink.

2. R5 ' s face sheet denotes admitted to the

facility 6-24-14. Facility ' s precaution tracking

form dated 10-14-14 denotes R5 on contact

isolation for ESBL wound on antibiotics. Facility '

s infection control lab report by facility and isolate


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printed 10-23-14 denotes 7-23-14 wound culture

no growth. Facility ' s infection control lab report

by facility and isolate printed 10-23-14 denotes

7-1-14 thru 10-23-14 no report/test of ESBL of the

wound.

R64 ' s face sheet denotes admitted to the facility

9-28-10. Facility ' s precaution tracking form

dated 10-14-14 denotes R64 on contact isolation

for VRE urine on antibiotics. Facility ' s infection

control lab report by facility and isolate printed

10-23-14 denotes 4-3-14 stool culture normal

flora. Facility ' s infection control lab report by

facility and isolate printed 10-23-14 denotes

4-1-14 thru 10-23-14 no report/test of VRE urine.




for C-diff stool on antibiotics. Facility ' s infection


10-23-14 denotes MRSA and wound culture

7-19-14. Facility ' s infection control lab report by


2-1-14 thru 10-23-14 no report/test of C-diff stool.




for c-diff stool on antibiotics. Facility ' s infection


10-23-14 denotes 6-1-14 urine and wound

culture. Facility ' s infection control lab report by


5-1-14 thru 10-23-14 no report/test of C-diff stool

E2 (Director of Nursing) stated on 10-23-14 at

12:15 pm, that she has been overseeing the


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infection control program for the last year. E2

stated the infection control program has not been

running as good as she liked and that she has

been unable to review the micro and sensitivity

reports because the system she had in placed

made it difficult to get those reports that she

needed. E2 stated she would get the micro and

sensitivity reports printed today (10-23-14) and

view them. E2 stated the reports are important to

review. E2 stated she had to be truthful and

inform the surveyor that the facility has not been

getting the micro and sensitivity reports on a

regular basis.

Facility's infection control program denotes the

infection control committee may be composed of

the following members a) Director of Nursing, b)

Medical Director c) Representatives from the

nursing department, d) Others as appointed.

The Director of Nurses or designee is responsible

for directing the infection control program.

Responsibilities review microbiology culture and

sensitivity reports on a regular basis (from labs)

to identify types of organisms causing infections,

monitor antibiotic resistant organisms, and

identify potential transmission of organisms

between residents.

Statistical summaries of infections are compiled

and analyzed by the committee. Committee

members disseminate theses analysis results to

care unit staff as performance feedback.

Recommend aseptic techniques and procedures

to be used in the facility. Enforce policies and

procedures for management of residents with

infectious diseases. The infection control program

is in compliance with relevant federal, state, and

local regulations.

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left second toe.

During R5 ' s wound care observation on

10-22-14 at 9:40 AM, E9 RN (Registered Nurse -

Treatment / Wound Care) performed the ordered

wound care on the infected left toe, cleaned the

scissors with alcohol wipes, set the scissors down

on the end table. E9 washed her hands and

picked up the scissors and proceeded out of R5 '

s room.


stated that she used alcohol wipes on the

scissors, put the scissors on the counter (end

table), washed her hands picked up the scissors

(off the end table) walked out of R5 ' s room with

the scissors and used green wipes outside of the

room to clean the scissors.

The Infection Control Transmission Precautions

from Infection Control Manual dated 2009, states:

after glove removal and hand hygiene, staff

should ensure that hands do not touch potentially

contaminated environmental surfaces or items in

the resident ' s room to avoid transfer of

microorganisms to other residents or

environments. The facility uses contact

precautions to prevent nosocomial spread of

organisms that can be transmitted by direct

resident contact (hand or skin-to-skin contact that

occurs when performing resident care) or by

indirect contact (touching) of environmental

surfaces or contaminated resident care

equipment. Healthcare personnel caring for

resident on Contact Precautions should wear

gown and gloves for all interactions that may

involve contact with the resident or potentially

contaminated areas in the resident ' s

environment. Wear gloves whenever touching the

residents intact skin or surfaces and articles in

close proximity to the resident(e.g., medical

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when handling items potentially contaminated by

antibiotic resistant microorganisms. This may

include items such as bedside tables, over bed

tables, bed rails, television, bed controls, suction,

and oxygen tubing. After glove removal and hand

hygiene, staff should ensure that hands do not

touch potentially contaminated environmental

surfaces or items in the resident ' s room to avoid

transfer of microorganisms to other residents or

environments.

F 465

SS=D

483.70(h)

SAFE/FUNCTIONAL/SANITARY/COMFORTABL

E ENVIRON

The facility must provide a safe, functional,

sanitary, and comfortable environment for

residents, staff and the public.


by:

F 465

Based on observation and interview, the facility

failed to maintain an odor free environment on the

second floor in the large and small second floor

dining room, two resident rooms. This failure has

the potential to affect all 69 residents on the unit.

Findings include:

On 10/21/14 at 9:40 AM, during initial tour

accompanied by E19 (Assistant Director of

Nursing -ADON) there was a pervasive odor of

urine in room 208. E19 stated " I will call

housekeeping and have them clean the room." In

room 210 there was also a strong odor of urine.

E19 stated " R77 has a catheter." R77 was not

in the room at the time of the tour.


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Additionally room 210 had a strong pervasive

odor of urine. R77 was in bed. Foley catheter was

noted to be cloudy yellow. E19 stated she will

notify the physician.

On 10/22/14 at approximately 2:15 PM, there was

a strong odor of urine in room 208. E19 stated "I

don't know why there is an odor because

housekeeping cleaned the room yesterday. I will

speak to the housekeeping supervisor today."

On 10/22/14 at 4:50 PM in the large and small

second floor dining room there was a strong

pervasive odor.

On 10/23/14 at approximately 1:00 PM E19 said,

"I did speak with the physician regarding the

catheter, an order was given to change the

catheter which was done, consult urology,

monitor for signs of infection and encourage

fluids. "


145403 11/06/2014 name of provider or supplier

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