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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard ▼ | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6238 | 6238 | KINDRED NURSING & REHAB - NAMPA | 135019 | 404 NORTH HORTON STREET | NAMPA | ID | 83651 | 2010-12-03 | 323 | G | CUQM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint from the general public, record review, observation, and staff and resident interview, it was determined the facility failed to ensure each resident received adequate supervision and care planned interventions to prevent falls. The facility did not consistently identify hazards; evaluate, analyze, and monitor interventions for effectiveness; or revise interventions as necessary to prevent further falls or injury. This was true for 6 of 10 (#s 4, 6, 9, 11, 12, and 13) sampled residents. Resident #4 sustained a humerus fracture, Resident #6 sustained a hip fracture, and Resident #9 sustained a thoracic spine fracture due to their falls, and all required surgery after their injuries. These injuries constituted harm for Residents #s 4, 6 and 9. Findings included: The facility's Falling Stars policy documented, "Falling Stars are used for residents identified at high risk for falls and/or with a history of falls (past or current). It establishes a common method of communication to remind staff to monitor these residents for fall prevention. It alerts staff to residents at risk for falls and who have approaches or interventions on their care plans to reduce and/or prevent repeat falls." Procedures included, in part: "1. Identify residents that are newly admitted or readmitted with a high-risk falls or have a potential for repeat falls: 2. Assess resident quarterly, annually, and with significant change to identify residents' change in risk status: * Falls Risk Assessment, * Medications Associated with Falls 3. Update and/or implement Falling Stars interventions if the resident is identified at high risk or has a history of falls (past or current).... 5. Communicate to caregivers the initiation of Falling Stars interventions.... 6. Monitor daily for falls and/or lack of falls to determine effectiveness of Falling Stars interventions as identified by no falls. 7. Notify and educate the Resident and/or Family member/responsible pa… | 2014-04-01 | ||
| 6239 | 6239 | KINDRED NURSING & REHAB - NAMPA | 135019 | 404 NORTH HORTON STREET | NAMPA | ID | 83651 | 2010-12-03 | 441 | E | CUQM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review it was determined the facility did not ensure handwashing between resident contacts for 2 of 10 sampled residents. This occurred after personal care for resident (#7) who was identified with an infection and during assistance with dining for resident (#8). In addition, handwashing did not occur in the dining room for 4 random residents assisted with meals and for random resident #18 when blood glucose testing was performed. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], documented the resident was moderately cognitively impaired with short and long term memory deficits. He required total assistance of two staff for transfers. During the tour on 11/29/10 at 10:15 am, it was noted the resident had a sign posted next to his door directing visitors to contact the nurses station before entering the room. LN-10 answered surveyor questions related to residents on the tour, and stated the resident was only on contact isolation. Resident #7's physician's orders [REDACTED]. On 11/29/10 at 3:00 pm, Resident #7 was seated in his wheelchair next to the door in his room. He asked the surveyor if he could lay down. The surveyor alerted CNA-8 the resident wanted to lay down. CNA-8 said he would get help and a mechanical lift. CNA-8 was gone momentarily and quickly returned with a mechanical lift and indicated he had to wait for a another staff to help assist the resident. In approximately 2 minutes, CNA-9 came to Resident #7's room. The two CNAs used the mechanical lift and transferred the resident to his bed. While preparing for the transfer CNA-8 removed the resident's catheter bag, with gloved hands, from the modesty bag under the wheel chair. CNA-8 then touched the mechanical lift and sling. After the transfer was complete CNA-9 left the room while CNA-8 stayed to provide further care for Resident #7. CNA… | 2014-04-01 | ||
| 6240 | 6240 | KINDRED NURSING & REHAB - NAMPA | 135019 | 404 NORTH HORTON STREET | NAMPA | ID | 83651 | 2010-12-03 | 281 | D | CUQM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint from the general public, observation, record review, staff interview, and review of the facility's Blood Sugar Monitoring procedure, it was determined the facility failed to ensure that accepted standards of practice were followed. This was true for 2 random residents (#s 18 and 20) observed during medication pass observations. Specifically, Resident #18's blood glucose (synonym for sugar) check was incorrectly performed; and, Resident #20's medications were signed as given before they were actually given. Findings included: The complainant alleged nurses wait until the end of the day to sign for medications and narcotics that they gave that day. 1. Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 11/10 recapitulation of physician's orders [REDACTED]...150-200 4 units(,) 201-300 6 units(,) 301-400 14 units(,) above 400 call MD (physician)(,) Please notify MD if BG (less than) 70 or (greater than) 400..." On 11/30/10 at 11:40 a.m., LN #1 was observed as she performed a blood glucose (BG) check for Resident #18. LN #1 had parked the medication (med) cart, with a glucometer on top of the cart, 4 1/2 rooms away from Resident #18's room. LN #1 cleansed the resident's left 4th finger with an alcohol swab, waited 2 to 3 seconds, then punctured the center of the resident's finger with a lancet. LN #1 did not wipe away the first droplet of blood; instead, she applied the first droplet of blood onto the test strip. LN #1 then walked approximately 50 feet to the med cart and turned on the glucometer. After a few more seconds, she inserted the test strip into the machine. The BG was 469. LN #1 was immediately interviewed regarding the BG check and BG results. LN #1 said she "usually" left the med cart down the hall and she "frequently" used the center of the finger "because it's not as sore." LN #1 also said she "always" used an alcohol pad and she "always" used the first drop … | 2014-04-01 | ||
| 6241 | 6241 | KINDRED NURSING & REHAB - NAMPA | 135019 | 404 NORTH HORTON STREET | NAMPA | ID | 83651 | 2010-12-03 | 332 | D | CUQM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a public complaint, observation, record review, and staff interview, it was determined the facility failed to ensure that it was free of medication error rates of 5 percent or greater. This was true for 2 of 40 medications (5 percent) observed during medication passes; and, affected Residents #6 and #18. Findings included: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/30/10 at 8:50 a.m., during a medication pass observation, LN #3 poured the following 6 medications to Resident #6: [MEDICATION NAME]-Apap 5-500 - 1 tablet, [MEDICATION NAME] 10 mg (milligrams) - 1 tablet, [MEDICATION NAME] 5 mg - 1 tablet, [MEDICATION NAME] 100 mg - 1 tablet, [MEDICATION NAME] 50-200 - 1 tablet, and multivitamin - 1 tablet. LN #3 attempted to administer the medications to the resident. However, after taking the [MEDICATION NAME], multivitamin, and [MEDICATION NAME], the resident spit out the [MEDICATION NAME] and refused the remaining medications. LN #3 wasted the [MEDICATION NAME], and [MEDICATION NAME] and said she would attempt to administer those medications again after the resident ate breakfast. Review of Resident #6's 11/10 Physician order [REDACTED]. Resident #6's Physician order [REDACTED]." The order was dated 11/9/10. The MAR indicated [REDACTED]. This indicated that Vitamin E was to be administered in the morning. In addition, adjacent to the Vitamin E medication, staff initials were circled in the spaces for 11/10 through 11/25 and 11/27 through 11/30. This indicated the medication had not been given on those dates; and, for 11/26, the space was blank other than a pinpoint dot. LN #3 was immediately interviewed regarding the Vitamin E medication. LN #3 stated, "We haven't been giving it. It's not available in that dose." On 12/1/10 at approximately 4:15 p.m., the Administrator, DON, and Regional Consultant were informed of the medication error. No further information was received from the facility. 2… | 2014-04-01 | ||
| 6242 | 6242 | KINDRED NURSING & REHAB - NAMPA | 135019 | 404 NORTH HORTON STREET | NAMPA | ID | 83651 | 2010-12-03 | 333 | D | CUQM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on public complaint, observation, record review, and staff interview, it was determined the facility failed to ensure residents are free of significant medication errors. This was true for 1 of 6 residents (#18) during medication pass observations. Specifically, LN #1 intended to administer insulin to Resident #18 that was: a) outside of the physician ordered sliding scale (SS) parameters; and b) based on a potentially erroneous blood glucose (BG) test result. Findings included: Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 11/10 recapitulation of physician's orders [REDACTED]...150-200 4 units(,) 201-300 6 units(,) 301-400 14 units(,) above 400 call MD (physician)(,) Please notify MD if BG (less than) 70 or (greater than) 400..." On 11/30/10 at 11:40 a.m., LN #1 was observed as she incorrectly performed a blood glucose (BG) check (refer to F281, Professional Standards of Quality) for Resident #18. This BG check resulted in a high reading at 469. However, the LN did not retest to validate the results. Instead, LN #1 checked the resident's MAR for the SS insulin orders and said she would give 14 units of [MEDICATION NAME] R insulin then call the physician. LN #1 then drew up [MEDICATION NAME] R insulin 14 units and headed to Resident #18's room with the insulin syringe in hand. Before entering the resident's room, LN #1 again said to the surveyor that she would call the physician after she gave the insulin. LN #1 was stopped just before she entered the resident's room. She was informed the BG of 469 was possibly erroneous because of improper technique and a retest was needed to validate the BG results. LN #1 stated, "I can do that if you want me to." Note: The SS instructions directed LNs to notify the physician for BGs above 400. However, even though the BG was 469, LN #1 drew up and intended to administer [MEDICATION NAME] R insulin 14 units, the dosage for a BG between 301 … | 2014-04-01 | ||
| 6243 | 6243 | KINDRED TRANSITIONAL CARE & REHAB - LEWISTON | 135021 | 3315 8TH STREET | LEWISTON | ID | 83501 | 2010-08-27 | 309 | D | N5Z211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure each resident received the necessary care and services to attain and maintain the highest practicable physical well-being. This related to the facility's failure to ensure the Comprehensive Care Plan (CCP)included information on how to manage emergencies related to [MEDICAL TREATMENT] treatments. This was true for 1 of 2 sampled residents who received [MEDICAL TREATMENT] services (#12). In addition, the facility failed to ensure Physician's Orders were followed for the administration of antibiotics. This was true for 1 of 6 (#1) residents sampled for antibiotic therapy. Findings included: 1. Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's Significant Change MDS assessment, dated 8/3/10, documented the following: * Modified independence for daily decision making * Special treatment [MEDICAL TREATMENT] * Monitoring acute medical condition The CCP, dated 12/10/09, stated in the problem section, "Fluid Imbalance: Risk for R/T (related to) [MEDICAL TREATMENT]". The "Approach" section stated Resident #12 had [MEDICAL TREATMENT] on Monday and Friday. Included in this section it documented staff were to monitor the shunt site for symptoms of infection and were not to take blood pressures on the shunt site arm. The instructions did not include any information on possible emergencies or complications related to [MEDICAL TREATMENT]. On 8/26/10 at 3:05 p.m., the DNS was informed that the care plan did not include any information on how to manage emergencies related to the shunt site such as bleeding. No further information was provided. 2. Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's History and Physical, dated 1/21/10 and signed by the resident's physician, documented under the Impression section: "Diarrhea,… | 2014-04-01 | ||
| 6244 | 6244 | KINDRED TRANSITIONAL CARE & REHAB - LEWISTON | 135021 | 3315 8TH STREET | LEWISTON | ID | 83501 | 2010-08-27 | 280 | E | N5Z211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure that resident care plans were updated or revised to reflect the residents' current status and needs. This was true for 4 of 5 sampled residents reviewed (#s 1, 2, 3, & 5). Findings include: 1. Resident #5 was initially admitted the facility on 10/20/09. The resident was readmitted on [DATE], following a fall which resulted in injury and required an ORIF (Open Reduction and Internal Fixation) surgical repair of the left hip. The resident was also readmitted on [DATE] following a hospitalization for pneumonia [MEDICAL CONDITION]. The resident's current [DIAGNOSES REDACTED]. The resident's 10/20/09 admission MDS assessment coded the resident had dementia, short term and long term memory loss, moderately impaired cognition for daily decision making, required extensive assistance of at least one person for transfering, and had an unsteady gait. A Fall Risk Assessment, dated 10/21/09, documented the resident was disoriented daily and ambulated/transferred safely when accompanied by staff. The box for "Knows how to transfer safely (on own)" was not marked. The total fall risk score was 23, which the form documented as high risk for falls. The resident's 11/18/09 CCP for Falls documented the resident was at risk for falls due to dementia, weakness, medication regime, and a high risk assessment score. The CCP listed the following interventions: * "Bed/wheelchair alarm at all times... respond to alarm promptly" * "Blue fall mat at bedside at all times..." * "Do not leave alone in bathroom." * "Keep adjustable bed in low position for safe transfers." * "Lock bed brakes." A significant change MDS assessment, dated 12/7/09, coded the resident had a decline in her ability to perform ADLs, was not able to stand without assistance, and had a fall within the past 30 days. On 4/14/10, at 1:00 pm, an IPN documented- "... Noted slight increase in agitation (related to) de… | 2014-04-01 | ||
| 6245 | 6245 | KINDRED TRANSITIONAL CARE & REHAB - LEWISTON | 135021 | 3315 8TH STREET | LEWISTON | ID | 83501 | 2010-08-27 | 441 | D | N5Z211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility's Infection Control Procedures, it was determined the facility failed to ensure the infection control program was implemented to prevent the possible spread of infection. This related specifically to: 1) The procedures used by staff for a resident identified by the facility as under infection control precautions, (#1). 2) A resident's catheter tubing was observed laying on the carpet, (#8). This affected 2 of 10 (#s 1 & 8) residents sampled for infection control. Findings included: 1. Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 8/13/10, coded moderately impaired cognitive skills for daily decision-making, short-term memory problems, [DIAGNOSES REDACTED].e. monitoring acute medical condition. On 8/24/10 at 7:25 a.m., the surveyor observed a personal protection equipment storage container that was attached to the resident's door by two loops at the top of the container. Staff informed the surveyor that the container identified the resident in the room as under isolation procedures. On 8/24/10 at 9:20 a.m., the Infection Control RN stated, "Resident #1 has[DIAGNOSES REDACTED] so we (the facility) are very careful (not to spread[DIAGNOSES REDACTED]). Anyone who goes into the resident's room and touches any surfaces is required, after leaving the room, to wash their hands in the utility room sink." The surveyor observed that the utility room was located on the same hall, within 15 feet of the resident's room. On 8/25/10 at 12:12 p.m., Housekeeper #1 was observed emptying the trash in the resident's room. The housekeeping cart was located outside of the room approximately three feet away from the door to the room. The Housekeeper placed the bag of potentially contaminated trash in the housekeeping cart trash container. The Housekeeper was no… | 2014-04-01 | ||
| 6246 | 6246 | KINDRED TRANSITIONAL CARE & REHAB - LEWISTON | 135021 | 3315 8TH STREET | LEWISTON | ID | 83501 | 2010-08-27 | 323 | G | N5Z211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of accident and incident reports (Post-Event Assessments), review of clinical records, and staff interview, it was determined the facility failed to develop and implement interventions to prevent falls. This was true for 1 of 4 residents (#5) reviewed for falls. This failure resulted in harm to Resident #5, who fell and sustained a left hip fracture which required surgical repair. Findings include: Resident #5 was initially admitted to the facility on [DATE]. The resident was readmitted on [DATE], following a facility fall which resulted in injury and required an ORIF (Open Reduction and Internal Fixation) surgical repair of the left hip. The resident was also readmitted on [DATE] following a hospitalization for pneumonia and sepsis. The resident's current [DIAGNOSES REDACTED]. The resident's 10/20/09 admission MDS assessment documented the resident had dementia with both short term and long term memory loss, as well as moderately impaired cognition for daily decision making. The MDS documented the resident required extensive assistance of at least one person for transferring, and had an unsteady gait. A Fall Risk Assessment, dated 10/21/09, documented the resident was disoriented daily and ambulated/transferred safely when accompanied by staff. The box for "Knows how to transfer safely (on own)" was not marked. The total fall risk score was 23, which, according to the Assessment, indicated the resident was at high risk for falls. The resident's 11/18/09 CCP for Falls documented the resident was at risk for falls due to dementia, weakness, medication regime, and a high risk assessment score. The CCP listed the following interventions: * "Bed/wheelchair alarm at all times... respond to alarm promptly" * "Blue fall mat at bedside at all times..." * "Do not leave alone in bathroom." * "Keep adjustable bed in low position for safe transfers." * "Lock bed brakes." A significant change MDS assessment, dated 12/7/09, documented the r… | 2014-04-01 | ||
| 6247 | 6247 | COEUR D'ALENE HEALTH CARE & REHABILITATION CENTER | 135052 | 2514 NORTH SEVENTH STREET | COEUR D'ALENE | ID | 83814 | 2010-12-15 | 157 | D | Q7S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint from the general public, staff interview and record review, it was determined the facility failed to notify a resident's physician and legal representative when the resident developed new skin breakdown. This was true for 1 of 4 residents (#1) sampled for skin breakdown. The findings include: Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The resident's current [DIAGNOSES REDACTED]. The resident's 11/09/10 quarterly MDS assessment documented the resident was at risk for pressure ulcers, had a Stage II pressure ulcer from 11/1/10 (Note: Pressure Ulcer Skin Grids documented the pressure ulcer was resolved on 11/8/10), and had 4 venous and arterial ulcers, with other open [MEDICAL CONDITION] of the foot. The December 2010 Physician Recapitulation Orders (Recaps) instructed staff to, "Monitor buttocks/sacral area for any open areas Q (every) shift. Apply barrier cream and [MEDICATION NAME] to open areas buttock and hip Q brief change until resolved. Then apply barrier ointment/cream to buttocks/sacral area to protect." The order was dated 9/30/10. The December Recaps also documented, "May use house protocols for skin tears and pressure sores after physician notification." The order was dated 7/3/09. On 12/15/10 at 11:00 am, Resident #1's skin condition was observed by the two surveyors, the DON, LN #1 and CNA #2. The resident had multiple stasis ulcers on her bilateral lower extremities. The resident's skin on her entire body was thin and frail. The resident's buttocks were observed to have old scar tissue bilaterally. There was a current dark pink denuded area with defined edges and granulation. The area was approximately 2 cm (centimeters) long and .75 cm wide and was located on the the fleshy part of the resident's inner left cheek. When the upper cheek was allowed to come back into a normal position it rested directly against the denuded area. Resident #1 had a Foley catheter which as… | 2014-04-01 | ||
| 6248 | 6248 | COEUR D'ALENE HEALTH CARE & REHABILITATION CENTER | 135052 | 2514 NORTH SEVENTH STREET | COEUR D'ALENE | ID | 83814 | 2010-12-15 | 309 | D | Q7S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint from the general public, observation, staff interview and record review, it was determined the facility failed to ensure that a denuded area between the cheeks of a resident's buttocks was assessed and monitored, and that interventions were initiated to prevent further breakdown. This was true for 1 of 4 residents (#1) sampled for skin breakdown. The findings include: Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The resident's current [DIAGNOSES REDACTED]. The resident's 11/09/10 quarterly MDS assessment documented the resident was at risk for pressure ulcers, had a Stage II pressure ulcer from 11/1/10 (Note: Pressure Ulcer Skin Grids documented the pressure ulcer was resolved on 11/8/10), and had 4 venous and arterial ulcers, with other open [MEDICAL CONDITION] of the foot. The December 2010 Physician Recapitulation Orders (Recaps) instructed staff to, "Monitor buttocks/sacral area for any open areas Q (every) shift. Apply barrier cream and [MEDICATION NAME] to open areas buttock and hip Q brief change until resolved. Then apply barrier ointment/cream to buttocks/sacral area to protect." The order was dated 9/30/10. The December Recaps also documented, "May use house protocols for skin tears and pressure sores after physician notification." The order was dated 7/3/09. A Weekly Skin Sweep (WSS) sheet, dated 11/2/10, documented the resident had a "New skin impairment this week... see TAR." The November 2010 TAR documented the application of barrier cream as order on the December 2010 Recaps. Prevention of Skin Impairment and Wounds Section of the Care Management Summaries for 11/2/10 through 12/2/10 documented: * 11/2 - "New (treatment) orders... to open areas. Self inflicted scratching." * 11/9 - "Areas to buttocks closed as of 11/3, initially followed as 2 Stage II, resolved quickly, resident scratched self." * 11/18 - "Areas to buttocks remain resolved (for) 2 weeks, continue plan… | 2014-04-01 | ||
| 6249 | 6249 | SAFE HAVEN CARE CENTER OF POCATELLO | 135071 | 1200 HOSPITAL WAY | POCATELLO | ID | 83201 | 2011-01-04 | 225 | E | ZSO711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on two facility reported incidents, record review, staff interview, and review of Incident/Accident Occurrence reports it was determined the facility failed to thoroughly investigate accidents to rule out abuse or neglect by staff. This involved 4 of 7 residents reviewed (Resident #s 1, 4, 7 and 9.) Specifically, a) The investigation for Resident #4 involved a food choking death. The facility failed to: * Include interviews/statements from all staff and local emergency responders involved in the incident; * Investigate why the facility's telephone/intercom system failed as one staff attempted to call "911" and an in-house "code blue" (emergency staff alert response); * Investigate the inconsistent staff statements regarding the amount of meat served and the content/size of food extracted from the resident's airway; * Investigate whether the resident consumed the entire sandwich or if any food, such as the bread, was left on the plate; * Obtain the Medical Director's death investigation report prior to determining and submitting its conclusions to the BFS; b) The investigation for Resident #1 involved a fall with injury. The facility failed to interview and obtain statements from all staff assigned to the residents on the hall prior to determining that neglect had not occurred, and failed to address inappropriate actions by licensed nurses that contributed to the lack of supervision; c) The investigations for Resident #7 involved a burn injury, and Resident #9 involved a fall. In both of these cases the facility failed to interview staff responsible for the resident's supervision during the shift, identify exactly what happened and take appropriate corrective action. Please refer to F323, cited at the level of immediate jeopardy, specific to Resident #s 1, 4 and 9. Findings include: 1. On [DATE] at 3:29 pm, the Administrator notified the BFS by telephone that Resident #4, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The … | 2014-04-01 | ||
| 6250 | 6250 | SAFE HAVEN CARE CENTER OF POCATELLO | 135071 | 1200 HOSPITAL WAY | POCATELLO | ID | 83201 | 2011-01-04 | 323 | K | ZSO711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on two facility reported incidents, staff interview, observation, policy review and record review, it was determined the facility failed to provide the necessary supervision for residents, identified by the facility as requiring one-to-one (1:1) staff observation, to ensure their safety. This involved 5 of 11 residents (Resident #s 1, 4, 5, 6 and 9.) a) This failed practice resulted in serious harm, constituting immediate jeopardy to Resident #4, who choked on his food while unobserved by the 1:1 staff member who left the resident's room and was out of view of the resident. The resident died a short time later after staff and EMTs were unable to resuscitate him. b) The identified failed practice resulted in an injury, constituting immediate jeopardy to Resident #1, who had a history of [REDACTED].#1 and her roommate were also asked by a LN to provide supervision to a third resident. One staff left the room to request and go on break, leaving one staff to supervise all three residents. The resident, while unobserved by a 1:1 staff, stood from her wheelchair and fell . She required emergent care and treatment after sustaining extensive facial bruising. c) The facility's practice of allowing assigned 1:1 staff to provide supervision to more than one resident at a time also had the high potential for harm, injury, impairment, or death, "to occur in the very near future," (as identified in Appendix Q - Guidelines for Determining Immediate Jeopardy) involving Resident #s 5, 6 and 9, who fell when identified 1:1 supervision was not provided. This also constituted immediate jeopardy. In addition, 2 of 2 residents reviewed for smoking, (Residents #s 7 and 8) were harmed when they were not properly supervised while smoking. Both residents sustained burns due to smoking while oxygen was in use. There was the potential for greater harm to any residents or staff present during these incidents where flammable gases were present while smoking. The fai… | 2014-04-01 | ||
| 6251 | 6251 | SAFE HAVEN CARE CENTER OF POCATELLO | 135071 | 1200 HOSPITAL WAY | POCATELLO | ID | 83201 | 2011-01-04 | 280 | D | ZSO711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility reported incidents, record review and staff interview it was determined the facility failed to ensure care plans were updated to include necessary goals and interventions related to 1:1 staff supervision for 1 of 11 sample residents reviewed who required 1:1 supervision (Residents #4.) Findings include: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His admission MDS assessment, dated [DATE], identified the resident: * required one person physical assist for dressing and eating, two plus physical assist for toilet use, personal hygiene and bathing * was severely impaired in cognition and was easily distracted * had periods of altered perception or awareness of surroundings * had periods of restlessness and repetitive physical movements, wandering * had mental functioning which varied over the course of the day, with socially inappropriate/disruptive behavioral symptoms, and resisted care * was rarely/never understood/understands and had no speech. The admission physician's orders [REDACTED]. * "1:1 24 (hours per day)..." The Physician order [REDACTED]. * "Mechanical soft diet. Double portions. Thin liquids. Offer finger foods as much as possible * May have regular diet on special occasions * 1:1 staffing 24 hr (hours) a day R/T (related to) elopement risk/profound MR with autism/lack of safety awareness. May staff 2 on 1 PRN (as needed) if resident behaviors escalate..." The resident's [DATE] care plan, updated on [DATE], contained no documentation that the resident was to have 1:1 staff coverage on a 24 hour basis, and contained no direction to staff regarding their responsibilities for the 1:1 assignment, such as their proximity to the resident, line of sight, etc. The care plan, under the section, Nutritional Risk, contained handwritten entries which appeared to be in three different staff's handwriting. Intervention #17 stated, "resident frequently eat (sic) his food in a very … | 2014-04-01 | ||
| 6252 | 6252 | SAFE HAVEN CARE CENTER OF POCATELLO | 135071 | 1200 HOSPITAL WAY | POCATELLO | ID | 83201 | 2011-01-04 | 490 | F | ZSO711 | Based on two facility reported incidents, observation, staff interview, review of incident and accident reports, and review of clinical records it was determined the Administrator failed to monitor implementation of policies and procedures related to prevention of accidents and investigation of accidents. These failures resulted in findings of immediate jeopardy at F323 for resident #s 1, 4, 5, 6 and 9. Additionally, deficiencies were identified in: Resident Behavior and Facility Practice at F225 for lack of thorough investigation affecting Resident #s 1, 4, 7 and 9; Resident Assessment for care plan revision for Resident #4; and Administration regulations at F498 and F520 related to CNA competencies and Quality Assurance oversight respectively. This affected 16 of 16 sample residents (#1- 16) and had the potential to effect 100% of the residents of the facility. Findings include: 1. The facility did not ensure that 1:1 supervision was provided related to a food choking emergency for Resident #4 and a fall with injury for Resident #1. Additionally, Resident #s 7 and 8 were not provided with safety measures while smoking, resulting in injury. Refer to the findings of immediate jeopardy at F323 for additional details. 2. The facility did not ensure thorough investigations into accidents were conducted to rule out neglect by staff. This impacted Resident #4's food choking emergency, and Resident #1's fall with injury. Further, when investigations did reveal problems with staff performance, there was often no evidence of corrective action taken. Refer to the findings at F225 for additional details. 3. The facility did not ensure that care plans were updated to reflect assessed supervision need for Resident #4. Refer to the findings at F280 for additional details. 4. The facility did not ensure adequate CNA training in regard to safety interventions for Resident #4 and all other residents in the facility. Refer to F498 for additional details. 5. An interview was conducted on 12/28/10 at 4:30 p.m. with the Staff Develo… | 2014-04-01 | ||
| 6253 | 6253 | SAFE HAVEN CARE CENTER OF POCATELLO | 135071 | 1200 HOSPITAL WAY | POCATELLO | ID | 83201 | 2011-01-04 | 520 | F | ZSO711 | Based on staff interview and review of the Quality Assurance Program, it was determined the Quality Assurance Committee failed to identify significant issues involving resident care and well being as quality problems and failed to act on them. This failure resulted in the lack of development and implementation of plans of action and system monitoring for these issues. This had the potential to affect all residents of the facility. Findings include: The Quality Assurance (QA) coordinator, the facility Administrator, was interviewed on 12/29/10 at 11:15 a.m. When asked how the QA committee identified current and on-going issues for committee action, he stated daily reports, nursing 24 hour reports, Incident/Accident reports, periodic audits of resident counsel meetings and communication with resident and families were all used. Resident safety concerns with falls/accidents while residents were on 1:1 staff supervision had been found by the survey team in Incident/Accident reports, facility reports to BFS, and internal investigations, and had been reported to and investigated by the Administrator and DON. Refer to F323 for details of resident falls, choking and smoking injuries to residents while on 1:1 supervision. When asked if the QA committee knew or should have known of issues related to 1:1 supervision and accidents, the Administrator stated the committee met at the end of November 2010, but did not address the issues. He further stated the QA committee met on 12/28/10 in response to the survey team identifying a potential immediate jeopardy at F323, and had taken steps to implement an action plan to address those issues. | 2014-04-01 | ||
| 6254 | 6254 | SAFE HAVEN CARE CENTER OF POCATELLO | 135071 | 1200 HOSPITAL WAY | POCATELLO | ID | 83201 | 2011-01-04 | 498 | F | ZSO711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility reported incidents, record review and staff interview it was determined the facility failed to ensure CNA competency to carry out safety procedures. This was demonstrated when CNAs were unable to activate the emergency paging system to summon assistance during a food choking emergency which resulted in the death of Resident #4 and during a subsequent mock cod blue drill initiated by surveyors during the investigation. This affected Resident #4 and had the potential to impact the safety of all residents in the facility. Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 3:29 p.m., the Administrator notified the BFS by telephone that Resident #4 had died following a food choking incident. The Abuse Hotline report from the facility documented in part: "[DATE], approx(imately) 6:50 p.m....Res(ident) passed away d/t (due to) blockage in airway despite staff involvement and EMT intervention." The completed investigation report, faxed to the BFS on [DATE] at approximately 2:30 p.m. included the following documents and recorded in part: *The Occurrence Investigation form, signed/dated by the DON on [DATE], documented in part: -Staff was able to answer questions regarding the residents (sic) care plan? 'Yes' was marked. -According to the statements from staff on shift and the resident, is there reason to believe that either abuse or neglect occurred? 'No' was marked. -Further details if needed for clarification: 'Appropriate & immediate intervention provided at time of incident.'" This statement was written by the DON. * An Incident/Accident Committee Review report, dated [DATE], documented in part: "Res has (no) prior Hx (history) of choking or poor swallowing, has Hx of eating food fast...Res plan of care followed, staff assisted appropriately...DNS to schedule monthly mock code blue (type of emergency drill announced over the intercom system) for ongo… | 2014-04-01 | ||
| 6255 | 6255 | TRINITY MISSION HEALTH & REHAB OF MIDLAND | 135076 | 46 NORTH MIDLAND BOULEVARD | NAMPA | ID | 83651 | 2010-12-03 | 280 | E | KR9C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility did not ensure residents' care plans were updated and revised. This was true for 4 of 11 sampled residents (#s 1, 4, 5, & 10). Specifically, the care plans did not include revisions for problems and/or interventions as follows: *Resident #1 - The care plan was not updated to include a pureed diet; the resident no longer had dentures; and, the resident's behaviors, interventions, and type of hallucinations were not identified. *Resident #4 - The resident was readmitted with pressure ulcers and the care plan was not revised to include interventions to address the pressure ulcers. *Resident #5 - The care plan was not revised to include interventions for mood state and behaviors as identified on his annual MDS assessment. *Resident #s 10- The care plan was not revised to reflect approval to self administer medications. Findings included: 1. Resident #4 was admitted to the facility on [DATE], readmitted on [DATE] and 11/12/10, with [DIAGNOSES REDACTED]. The resident's most recent significant MDS assessment, dated 8/26/10, coded: * Moderately impaired cognitive skills for daily decision-making * Extensive assistance for bed mobility and transfers * Pressure ulcers or stasis ulcers were not coded The resident's Skin Condition Assessment for 11/1/10 documented, "Res. (resident) admitted with (L)(left) buttocks .3 x. 4 cm pink, 0 drainage, 0 infection." The intervention section stated, "Pressure relieving cushions placed and eval. (evaluated) by Rehab. (rehabilitation)." Resident #4's medical record contained "Wound Care Orders" from the wound center, dated 11/1/10, that documented a wound to the left buttocks, wound cleanser was to be used with a "cream" cover dressing. The dressing was to be changed daily. The "Restrictions" section documented "Offload buttocks - Keep dsgs (dressing) dry with bathing." Resident #4's care plan, dated 11/1/10, included in the problem ons… | 2014-04-01 | ||
| 6256 | 6256 | TRINITY MISSION HEALTH & REHAB OF MIDLAND | 135076 | 46 NORTH MIDLAND BOULEVARD | NAMPA | ID | 83651 | 2010-12-03 | 312 | D | KR9C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a public complaint, observation, record review and staff interview, it was determined the facility failed to ensure personal grooming was provided for a resident unable to carry out activities of daily living. This related specifically to Resident #1's fingernails. This affected 1 of 11 (#1) sampled residents. Findings included: The complainant stated that an identified resident's fingernails were long because staff neither clipped the resident's nails or took the resident to the activity titled Manicure Tuesday. Resident #1 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 10/1/10 quarterly MDS assessment coded severely impaired cognitive skills for daily decision-making, required physical assistance of one person for dressing, and totally dependent on staff for hygiene and bathing. On 11/29/10 at 2:37 p.m., the surveyor observed CNA #13 returning the resident to his room after a shower. CNA #13 told CNA #14 that the resident would not allow a razor shave while in the shower room. Note: The surveyor did not observe CNA #13 tell CNA #14 that the resident would not allow grooming for the resident's fingernails. - At 2:46 p.m., after the resident was transferred to bed, both CNAs left the resident's room. - At 2:50 p.m., the resident appeared to be quietly resting in bed with his eyes closed. A visible dark brown line was observed on the underside of the resident's fingernails, right and left hands. The fingernail of the 4th digit on the right hand was jagged in appearance. - At 3:12 p.m., two surveyors observed that the resident's fingernails were in the same condition as indicated above. During observations on 11/30/10 at 7:50 a.m., at 8:30 a.m., at 9:15 a.m., at 10:35 a.m., at 12:20 a.m., and again at 2:05 p.m., the resident's fingernails appeared in the same condition as indicated in the above paragraphs. On 11/30/10 at 2:15 p.m., the resident was obs… | 2014-04-01 | ||
| 6257 | 6257 | AVAMERE TRANSITIONAL CARE & REHAB - BOISE | 135077 | 1001 SOUTH HILTON STREET | BOISE | ID | 83705 | 2011-01-24 | 157 | D | 2DZC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint from the public, staff interviews and record review, it was determined the facility failed to notify the resident's family member and/or the resident's physician when there was a significant change in the resident's physical status. This applied specifically to 2 of 15 sampled residents (#s 1 & 7): 1) Resident #1 sustained an injury fall which was not reported to the resident's physician or the resident's family until the following day. The fall resulted in bilateral femur fractures which required hospitalization . 2) Resident #7 complained of abdominal pain and difficulty with his bowels, which led to dehydration and fecal impaction, which required hospitalization . Findings included: A complaint from the public included an allegation that the facility failed to immediately notify the legal representative of a fall with injury which resulted in the resident's hospitalization . 1. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A facility reported incident, submitted to the BFS on [DATE], documented details of an investigation into an unwitnessed fall sustained by Resident #1 on [DATE] between 12:30 p.m. and 1:00 p.m., when she was found on the floor of her room with her legs bent under her after a fall from her wheelchair. CNA #1 reportedly called for the assistance of LN #2 and the resident was assisted to bed. The LN reported she then assessed the resident and noted no abnormalities. According to the investigation report, LN #2 failed to notify the physician or the legal representative of the event. An incident report was not filled out for the fall on [DATE], and information that the fall occurred was not communicated to on-coming staff at the end of LN#2's shift. The full, completed investigation report, provided by the facility on [DATE], included a statement by CNA #1 stating the resident complained of pain in her legs at the time she was put to bed after the f… | 2014-04-01 | ||
| 6258 | 6258 | AVAMERE TRANSITIONAL CARE & REHAB - BOISE | 135077 | 1001 SOUTH HILTON STREET | BOISE | ID | 83705 | 2011-01-24 | 309 | G | 2DZC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint from the public, observation, record review and staff interview it was determined the facility failed to ensure the highest level of functioning and well being for 5 of 15 residents, (#1, # 2, #5, #7 & #14). *Resident #1 was harmed due to sustaining bilateral femur fractures as the result of being found on the floor after an unwitnessed fall. The responsible LN did not complete an incident report, document an initial or ongoing assessment of the resident's condition after the fall or report the fall to the next shift of oncoming nursing staff. This resulted in a delay of treatment of [REDACTED]. *Resident #7 was harmed when he was not adequately assessed for constipation and subsequently was hospitalized for [REDACTED]. *Resident #5 did not receive an ordered evaluation by a hand specialist. *Resident #2 had a fecal impaction which required digital disimpaction, in addition to not receiving care-planned vital signs related to receiving a beta blocker medication. *Resident #14 had ongoing issues with constipation without appropriate intervention to address bowel care. Findings included: A complaint from the public included an allegation that the facility failed to immediately notify the legal representative of a fall with injury which resulted in the resident's hospitalization and subsequent death. 1. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A facility reported incident, submitted to the BFS on [DATE], documented details of an investigation into an unwitnessed fall sustained by Resident #1 on [DATE] between 12:30 p.m. and 1:00 p.m., when she was found on the floor of her room with her legs bent under her after a fall from her wheelchair. CNA #1 reportedly called for the assistance of LN #2 and the resident was assisted to bed. According to the CNA, LN #2 then assessed the resident and noted no abnormalities. According to the investigation report, LN #2 failed t… | 2014-04-01 | ||
| 6259 | 6259 | AVAMERE TRANSITIONAL CARE & REHAB - BOISE | 135077 | 1001 SOUTH HILTON STREET | BOISE | ID | 83705 | 2011-01-24 | 325 | G | 2DZC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined the facility failed to ensure acceptable parameters of nutritional status for 2 of 15 (#7 and #13) sampled residents. Residents #7 and #13 both sustained severe weight loss, Resident #7 in a one month period, and Resident #13, in a three month period, resulting in harm to the residents. The facility documented the residents had histories of nutritional deficiency but failed to monitor and evaluate the residents' responses to the care-planned nutrition interventions. Findings included: 1. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE] and again on 1/17/11, with [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated 12/6/10, documented the following: * Bowel sounds present, abdomen distended * Experiencing pain, pain management prescriptions * Extensive assist requiring one person for assistance for toilet use * Supervision for eating * Disoriented occasionally * Regular diet type with regular consistency * Independent fluid and eating intake * No weight loss * No risk factors for dehydration, refusing fluids * Dehydration Risk Assessment Score of 3 -10 indicates high risk potential for dehydration On readmission after hospitalization , on 1/8/11, the resident was assessed as having a history of dehydration, with a Dehydration Risk Assessment Score of 10, which represented the resident was assessed as a high risk potential for dehydration. This was after the resident had been diagnosed with [REDACTED]. In addition, it documented three pounds weight loss in one month and limited physical assistance required for eating. NOTE: The resident had already sustained a greater than three pound weight loss and should have been scored higher due to this fact. On 1/17/11, after his second readmission following a hospitalization for amputation of his left lower leg, the resident was assessed with [REDACTED]. The resident's admission MDS assessmen… | 2014-04-01 | ||
| 6260 | 6260 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 164 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to ensure residents received privacy during personal cares and during medication administration for 3 of 14 sampled residents (#s 3, 5 & 7). Resident #3 & 5 were not provided privacy during personal cares and Resident #7's door was open during treatment with insulin injections. Findings include: 1.a) Resident #7 was observed on 9/9/10 at 9:40 am. The door to his room was open and LN-7 was observed in the room with Resident #7. LN-7 lifted up the resident's gown and gave him two injections in the stomach. A housekeeper was in the room mopping the floor. The treatment could be clearly observed from the hallway. The resident was interviewed after LN-7 and the housekeeper left. He stated he had to get poked two times with medication for his diabetes. The resident was not provided privacy during treatment with injections. b) In addition, nurse progress notes for 9/2/10 (2:45 pm), documented: "Res called nsg (nursing) station and stated was on floor. Upon entrance into room res was noted to be leaning against air mattress and bottom to be on floor. Right side of bed was tilted to the side....This nurse and CNA got res arm unstuck and layed res on a sheet (with) pillows on floor. Res also pulled out s/p (suprapubic) cath(eter) while falling. This nurse replaced cath while maintenance examined bed...." The reinsertion of the catheter should not have been completed while the maintenance staff was in the room. 2. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 8/9/10 quarterly MDS assessment coded: * Short and long term memory problems * Modified independence in daily decision making * Extensive one person physical assistance needed with bed mobility and transfers. During an observation of cares on 9/8/10 at 8:25 am, Resident #5 was lying on her back in bed. CNA #8 entered the resident's room and asked t… | 2014-04-01 | ||
| 6261 | 6261 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 221 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review it was determined that the facility failed to identify the use of a recliner as a restraint when it prevented a resident from independently rising. This was true for 1 of 9 resident's reviewed (#3). The findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 8/10/10 admission MDS coded: * Short and long term memory problems with severely impaired cognitive skills for daily decision making * Periods of restlessness and mental function varies over the course of the day * Extensive assistance of at least one person with bed mobility, transfers, and walking in corridors * Limited range of motion of leg and foot with partial loss of voluntary movement * No use of devices or restraints The resident's "At Risk for Falls" plan of care, dated 8/30/10, documented, "During (change) of shift and other times when there is (increases) in activity (stimulation) assist resident to sit in recliner in day room with feet up." During observations on 9/7/10 between 1:35 pm and 2:30 p.m., Resident #3 sat in an electric recliner in his room with the feet in an elevated position. Initially the resident was restless and leaned his torso forward in an attempt to get up but was unable to. The facility's Payroll Clerk/CNA (PC) sat with the resident and began reading a memory book with him. The PC stated that she was asked at times to help sit with the resident when he was real active or anxious. Resident #3 eventually relaxed, looked at the book for a short while and then fell asleep. During the observation, the PC was asked if the resident was able to get out of the reclining chair on his own. The PC indicated no, that the resident would have difficulty using the electric controls to lower the legs to the chair. On 9/8/10 at 1:45 pm, CNA #2 assisted Resident #3 to lay down. CNA #2 stated he was familiar with the resident and frequently worked with him. CNA #2… | 2014-04-01 | ||
| 6262 | 6262 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 242 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, and staff interview, it was determined the facility failed to consider the importance and significance of the use of an electric wheel chair in the resident's life in the facility towards exercising choice and self-determination. The facility evaluated the resident as unsafe to independently operate his electric wheelchair, required the resident to forfeit the use of his electric wheel chair in lieu of a manual wheelchair which the resident was not able to independently move, and then failed to develop a plan to assist the resident in becoming safe to independently operate his electric wheel chair. This was true for 1 of 9 sampled residents (#4). Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 10/13/09 admission MDS assessment coded: * Short and long term memory OK * Independent cognitive skills for daily decision making * Responsible for self * Moves independently indoors ( in prior living environment) * Supervision with locomotion on/off unit * Total assistance of 2 people with bed mobility and transfers * Extensive assistance with eating During the initial tour of the facility on 9/7/10 at 8:15 am, Resident #4 expressed frustration that he had lost a great deal of his independence since moving to the facility. The resident stated he was no longer allowed to use his electric wheel chair. The resident stated that he brought the chair with him and used it in and out of the facility "for a few months," before he was told that he was not safe to use the chair. Resident #4 stated the facility had provided a manual chair for him but he was totally dependent on staff when he was up in it. The resident stated that this bothered him because he wanted to move independently about the facility and also the electric wheel chair was set up so he could independently off load his weight and also go into a tilt position when needed for his dysreflexia. Reside… | 2014-04-01 | ||
| 6263 | 6263 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 272 | E | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and review of facility incident/accident reports (I&A) it was determined that the facility failed to do safety assessments for residents who were observed to use side rails. This was true for 4 of 4 (#s 3, 4, 7 and 9) sampled residents with side rails. Findings include: 1. Resident #7 was originally admitted to the facility on [DATE] with [MEDICAL CONDITION] (MS) and diabetes. He was discharged to a hospital for pressure ulcer care on 3/17/10, and returned to the facility on [DATE]. The resident's most current quarterly MDS was dated 7/18/10. The MDS coded the resident as bedfast most of the time and used bed rails for bed mobility. The resident was observed 9/7/10 at approximately 8:10 am, in bed and with half side rails up, on both sides of the bed. The resident had an air mattress on his bed. This was the case for all observations throughout survey observation days of 9/7 through 9/10, and on 9/13/10. The resident's care plan, revision date 5/17/10, documented, "Resident uses 2 1/2 rails for mattress stability and for bed mobility..." The resident's "Restrictive Device Evaluation" was for the use of two 1/2 side rails. It was completed on 4/29/10 after his readmission to the facility. The form had a sticker placed on the back that documented, "This device has been assessed safe for this resident." The sticker was initialed but not dated. There was no documentation on the form pertaining to how the facility arrived at the "safe for this resident" conclusion. The form had a date of 8/12/10 for the quarterly review. This portion indicated nothing had changed and the device was to remain on the care plan. A facility I&A form, dated 9/2/10, was provided with the following documentation: "Res(ident) called nurses station, stated that he was on floor. Upon entrance to room this nurse noted res bed to be tilted to left. Res was on his bottom with back against the air mattress sitting up. He was … | 2014-04-01 | ||
| 6264 | 6264 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 309 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview, it was determined that the facility failed to provide necessary care and services for three residents. Specifically the facility staff failed to follow: - Resident #9's physician's orders for supervision at meals, - Resident #4's care plan for getting up in a wheelchair, and - The facility's bowel protocol to meet the bowel care needs of Random Resident #17. This was true for 2 of 14 sampled residents (#s 4 and 9) and 1 random resident (RR #17). Findings include: 1. Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent annual MDS assessment, dated 6/20/10, documented the resident: * Had a problem with short term memory, * Had modified independence with daily decision making, * Required extensive assistance of one to two staff for ADL care, * Was incontinent of bowel and bladder, and * Required the use of side rails for bed mobility. The resident's care plan, dated 9/9/09, for the problem: "Potential for altered skin integrity related to prior history of skin issues and current physical status" had an intervention of, "(name) is able to eat small meals and he requires direct supervision ith (sic) meals." The resident's physician wrote an order on 5/3/10 that read, "resident to be sitting in wheelchair for meals. If he is in bed, he must be sitting up at 90 degrees and have supervision while he eats. (spouse name) can supervise or CNA can supervise." The dietitian notes, dated 7/19/10, documented, "...also has order for house ground diet via p.o. (oral) intake, when up in chair or bed with supervision, wife may supervise." The facility failed to follow the medical professional recommendations for supervision. The resident was observed, on 9/7/10 at 9:15 a.m., in his room, lying in bed, eating a breakfast of cheese strata and drinking a brown fluid. The bed was positioned at about 75 degrees and the resident was … | 2014-04-01 | ||
| 6265 | 6265 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 328 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents received adequate respiratory care in accordance with physician's orders [REDACTED].#s 5 and 14) sampled for respiratory therapy. Findings included: 1. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The "All Active Orders for September 2010" for Resident #14 documented, "O2 (oxygen) via n/c (nasal cannula) at 2L/NC (2 liter per nasal cannula). Order Date 4/10/2010, Start Date 4/10/2010." In addition, the physician orders [REDACTED]. However, it did not state to keep saturations levels above a certain percentage. On 9/13/10 at 11:35 am, Resident #14 was observed sitting in her wheelchair in the day room of the East Wing after an activity. The surveyor observed the resident was wearing a nasal cannula with a portable liquid oxygen tank hanging on the back of her wheelchair. The surveyor picked up the tank and after repositioning several times, observed the oxygen tank to be empty, the indicator at the far left of the red area on the gauge. The surveyor alerted CNA #3 that the oxygen tank was empty and CNA #3 took the tank to be refilled. The surveyor followed CNA #3 to the oxygen storage room and informed the CNA that an oxygen saturation level needed to be obtained on the resident when she was finished. When the surveyor returned to the day room, it was observed Resident #14 was absent. Staff was queried and they stated they had taken Resident #14 to the dining room. The surveyor informed staff the resident had no oxygen and needed to be brought back to the East Wing nurse's station for evaluation of her oxygen saturation and application of oxygen. The staff immediately retrieved the resident from the dining room. CNA #3 was observed as she applied the refilled oxygen tank to the back of Resident #14's wheelchair, attached the nasal cannula and turned it on to 2 liters per… | 2014-04-01 | ||
| 6266 | 6266 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 329 | E | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff and resident interview, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs. The facility specifically failed to: - monitor medications used for behavior, - monitor medications used for sleep, - monitor residents who were were receiving duplicate therapy, - document rationale why a gradual dose reduction (GDR) was not done, and - document a clear indication for using a medication. This was true for 6 of 16 (#s 2, 4, 6, 9, 12 and 13) sampled residents. Findings include: 1. Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 8/15/10, documented the resident; * Had short term memory problems, * Had independent decision making skills, * Required limited to extensive assistance of one to two staff for ADL care, * Was continent of bladder, and * Was receiving psychoactive medications seven days a week. The resident's admission and readmission orders [REDACTED]. On 5/26/10, the pharmacist wrote a comment to the physician that stated, "...was admitted with an order for [REDACTED]. It cannot be used to treat sleeplessness or [MEDICAL CONDITION]" The pharmacist made the recommendation, "Please consider clarifying the [MEDICATION NAME] order to: [MEDICATION NAME] 25 mg po qhs for OBS ([MEDICAL CONDITION]) with agitated features." The nurse practitioner (NP) checked the box that stated: "I accept the recommendation(s) above, please implement as written." The physician never documented that he concurred with the NP's decision. The medical record was reviewed for agitated behaviors that the resident exhibited to justify the use of an antipsychotic medication. There was no behavior documentation for the resident until June 2010. The June, July and August 2010 "Psychoactive Drug Monthly Flow Record", used to document behaviors, showed that the resident did not have any e… | 2014-04-01 | ||
| 6267 | 6267 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 428 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the pharmacist failed to address duplicate use of atypical antipsychotic medications for a resident between April 2010 and July 2010. This was true for 1 of 13 residents reviewed (#13). Findings include: Resident #13 was admitted to the facility on [DATE]. The resident's current [DIAGNOSES REDACTED]. Resident #13's 8/1/10 annual MDS assessment coded: * Short and long term memory problems * Moderately impaired daily decision making skills * Wondering * Depression * Use of antipsychotic medication and antidepressant 7 days per week The resident's Physician Recapitulation Orders for August 2010 listed the following antipsychotic medications. Both of these antipsychotic medications contain black box warnings in regards to use with the elderly population: *"Seroquel 25 mg (milligram) by mouth daily," start date 6/15/10 *"Zyprexa 2.5 mg may give 2 tablets at first and 1 tablet every 4 hours after PRN (as needed)," start date 4/24/10 * "Zyprexa 2.5 mg by mouth at bedtime," start date 5/19/10 NOTE: Review of Physician's Recapitulation Orders for April through August 2010 revealed that Resident #5 continually received Seroquel, with a variety of dose adjustments between 9/23/09 and 8/31/10. The Zyprexa was not started until 4/24/10. The manufacturere's black box warning for both of these medications documented, "Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death ... (Neither Seroquel or Zyprexa) are approved for the treatment of [REDACTED]." A Medication Follow-up Evaluation, dated 8/16/10, signed by the resident's contracted Behavioral Specialist, documented, "Apparently her (Resident #13's) PCP (Primary Care Provider) prescribed Zyprexa but I was unaware that she was on both Seroquel and Zyprexa.... Plan ... Discontinue Zyprexa... Increase Seroquel 25 mg 1 bid (twice per day). She does not need to be on two atypical antipsychotic medications. … | 2014-04-01 | ||
| 6268 | 6268 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 498 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined the facility failed to ensure that a CNA used safe transfer techniques when assisting a resident to go from a laying position to a sitting position. This was true for 1 of 10 sampled residents observed (#5) Findings include Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 8/9/10 quarterly MDS assessment coded: * Short and long term memory problems * Modified independence in daily decision making * Extensive one person physical assistance needed with bed mobility and transfers. During an observation of cares on 9/8/10 at 8:25 am, Resident #5 was laying on her back in bed. The bed was in the flat position. CNA #8 entered the resident's room and asked the resident if she needed to go to the bathroom. Resident #5 stated she did need to use the bathroom. CNA #8 then put her left hand directly behind Resident #5's neck and pulled the resident to a sitting position. After coming to a sitting position, Resident #5 stood at her bedside with moderate physical assistance, and pivot transferred to her wheelchair. The resident was able to bear weight and was also able to use her hands to grab the handrests on the wheelchair and the transfer bars in the bathroom. Immediately following the observation on 9/8/10 at 8:25 am, CNA #8 was asked if the transfer observed was a typical transfer for Resident #5. CNA #8 stated "Yes." The CNA was then asked if pulling the resident to a sitting position, by using the neck, was an acceptable practice. CNA #8 stated she thought it was and added the resident had not complained about it. On 9/13/10 at 11:55 am, the facility's Staff Development Coordinator (SDC) was interviewed about the transfer techniques CNA staff were taught to use, specifically when assisting a resident from a laying to a sitting position. The SDC stated the transfer technique that CNA staff were expected to follow were the s… | 2014-04-01 | ||
| 6269 | 6269 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 241 | E | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's "Feeding/Assisted Diners" policy, and resident and staff interview, it was determined the facility failed to ensure residents' dignity was respected. This applied specifically to: 1) Resident #11 was observed walking in the hallway with nothing but a shirt on. 2) A CNA stood while assisting Random Resident #s 18 & 19 to eat. 3) Two unidentified residents felt disrespected by nursing staff when asking questions about their medications. This affected 1 of 14 (#11) sampled residents, 2 of 6 (#s 18 & 19) random residents, and 2 of 12 unidentified residents who attended the Group Interview. Findings included: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS assessment, dated 8/29/10, documented that the resident: - Had short and long term memory problems, - Had moderately impaired decision making skills, - Required assistance of one to two staff for ADL care, - Was incontinent of bowel and bladder. - Resisted care from staff 1 to 3 days a week and the behavior was not easily altered. On 9/7/10 at 8:15 a.m., the resident was observed walking the 400 hallway with a blanket wrapped around him. The resident was saying something unintelligible, then removed the blanket and attempted to give it to the surveyor. The resident had a shirt on but was naked from the waist down. The resident then started to walk away with nothing covering the lower body. There were no CNA staff in the area. A housekeeper came out of a room at 8:17 a.m. The housekeeper said to the resident, "(name) look at you." The housekeeper then took the resident into his room. The housekeeper came out of the room and stated, "I don't know where the girls are, I'm not supposed to assist them, but I do when they are in danger." On 9/14/10 at 3:30 p.m., the Administrator, the DON, and the RN Consultant were informed of the observation. No further information was provided.… | 2014-04-01 | ||
| 6270 | 6270 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 318 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview, it was determined the facility failed to consistently provide the restorative program for 2 of 10 (#s 7 & 10) sampled residents. This applied specifically to range of motion exercises for Resident #10 and training for bed mobility with gentle stretching exercises for Resident #7. Findings included: 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Care Plan, with a print date of 3/16/10, identified the "Focus" area of Self Care Deficit, weakness, unstable health condition, and decreased balance. One of the Focus area "Interventions" was, "...RNA as ordered." The resident's quarterly MDS assessment, dated 6/13/10, coded independent cognitive skills for daily decision-making, no short- or long-term memory problems, limited assistance of one person for dressing, set up help for eating, and independent with toilet use and personal hygiene. The resident's "All Active Orders for September 2010" (recapitulation) contained an order, dated 5/19/10, for "RNA program provided." The resident's undated "Restorative Nursing Program Flow Sheet" forms contained a handwritten entry at the top left of each form, "Start 7/12/2010 6x wk/60 days (starting 7/12/2010, provide restorative nursing program 6 times per week for 60 days)." - The forms contained handwritten entries for: Goal: "Maintain ROM (range of motion) Bilateral hands over next 60 days" Plan: "Ball squeezes 10x2 (10 repetitions x 2 sets), Towel slides 10x2, Finger ROM Bilat(eral) hands, Thera putty (with hands)." - The forms documented the time frame as 7/12/10 through 9/19/10. The Restorative Nursing Program was documented as provided 5 times per week not "6 times per week" on the following weeks. *7/19/10 through 7/25/10 *7/26/10 through 8/1/10 *8/9/10 through 8/15/10 *8/16/10 through 8/22/10 On 9/7/10 at 11:30 a.m., Resident #10 stated, "An aide helps me do squeezes with a tennis ball for my ha… | 2014-04-01 | ||
| 6271 | 6271 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 367 | E | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's diet manual, and staff interview, it was determined the facility failed to ensure the residents received food in the texture ordered by the physician. This related specifically to: 1) Four residents with a ground texture diet received raw fruits (#s 9, 18, 20, & 21). 2) Resident #7's physician ordered a mechanical soft diet, however, the resident received a regular texture diet. This affected 2 of 10 (#s 7 & 9) sampled residents and 3 of 6 (#s 18, 20, & 21) random residents. Findings included: 1. a) Random Resident #18 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 6/27/10, coded moderately impaired cognitive skills for daily decision-making, short- and long-term memory problems, chewing problem, and required extensive one person assistance for eating. The resident's "All Active Orders for September 2010" (recapitulation orders) contained a 3/18/10 diet order for, "Type: House Texture: Ground." The resident's Nutrition Care Plan, with a print date of 8/13/2010, identified a "Focus" area of , "State of Nourishment," with an "Intervention" of, "Diet: house, ground..." b) Random Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's annual MDS assessment, dated 6/27/10, coded moderately impaired cognitive skills for daily decision-making, short-term memory problems, set up help for meals, and swallowing problem. The resident's "All Active Orders for September 2010" (recapitulation orders) contained a 4/6/09 diet order for, "Type: House Texture: Ground." The resident's Nutrition Care Plan, with a print date of 8/7/2010, identified a "Focus" area of, "State of Nourishment...related to; Difficulty in chewing/swallowing..." with an "Intervention" of, "...Resident eats in dining room. Encourage him to eat through proper set-up and frequent cueing..."… | 2014-04-01 | ||
| 6272 | 6272 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 371 | E | U2X811 | Based on observation and staff interview, it was determined the facility failed to prepare and serve food under sanitary conditions. This applied specifically to: 1) The unsanitary condition of the shelf beneath the food preparation area where cleaned and sanitized metal containers were stored; and 2) A food service employee coughing while preparing fried eggs. This affected residents in the East wing dining room who requested fried eggs for breakfast on 9/8/10 and had the potential to affect all other residents who dined in the facility. Findings included: 1. On 9/7/10 at 8:15 a.m. during the initial tour of the facility's kitchen, the metal shelf beneath the food preparation area was observed with an accumulation of what appeared to be dried food debris and dried liquid splatter. Cleaned, sanitized, and inverted metal containers were stored on this shelf. - At 8:22 a.m., the NSD was informed of the condition of the metal shelf. The NSD indicated that the shelf appeared to be in need of cleaning. On 9/8/10 at 12:45 p.m., the surveyor observed that the metal containers were relocated and stored on a multi-shelf metal cart. The metal shelf, beneath the food preparation area, appeared clean and no food containers were observed on the shelf. The 2009 FDA Food Code, Chapter 4, Subsection 601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicates, "...(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris." Subsection 602.13, Nonfood-Contact Surfaces indicates, "Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues." 2. On 9/8/10 at 8:25 a.m. during the breakfast meal service, the NSD was observed coughing while preparing fried eggs. The NSD did not turn her head away from the grill when coughing. The NSD was not wearing any protective equipment to cover her mouth while cooking the fried eggs. While coughing, the NSD was not observed to step away fro… | 2014-04-01 | ||
| 6273 | 6273 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 278 | B | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined the facility failed to ensure that the MDS assessments accurately reflected the status of sampled residents. This was true for 6 of 16 (#s 2, 6, 7, 8, 9 and 11) sampled residents. Findings include: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS assessment, dated 8/29/10, documented that the resident: - Had short and long term memory problems, - Had moderately impaired decision making skills, - Required assistance of one to two staff for ADL care, - Was incontinent of bowel and bladder, - Resisted care from staff 1 to 3 days a week and not easily altered, and - Had a stage II pressure sore. The resident's medical record was reviewed and the resident had unstageable eschar on the left heel. The MDS 2.0 manual, page 3-160, documented; "Coding: Record the number of skin ulcers at each stage on the resident's body, in the last 7 days. If necrotic eschar is present, prohibiting accurate staging, code the skin ulcer as Stage '4' until the eschar has been debrided (surgically or mechanically) to allow staging." The facility failed to accurately code the resident's pressure sore as a stage 4. The MDS coordinator was interviewed on 9/13/10 at 2:15 p.m. and stated she would submit a correction. 2. Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The most recent annual MDS assessment, dated 6/20/10, documented the resident: * Had a problem with short term memory, * Had modified independence with daily decision making, * Required extensive assistance of one to two staff for ADL care, * Was incontinent of bowel and bladder, and * Required the use of side rails for bed mobility. The resident's annual MDS, dated [DATE], documented at H3a "Appliances and Programs" that the resident had "Any scheduled toileting program." Review of the resident's medical record and care p… | 2014-04-01 | ||
| 6274 | 6274 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 314 | G | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff/resident interview and record review it was determined the facility did not ensure 2 of 4 residents (#s 7 & 11) reviewed for pressure ulcers did not develop pressure ulcers unless clinically unavoidable. Resident #7 was harmed when he developed pressure ulcers that included a pressure ulcer on the left tuberosity that progressed to a Stage IV, a pressure ulcer to the coccyx that progressed to a Stage IV, and a pressure ulcer to the right hip that developed to a Stage IV. The resident developed subsequent infections to the wounds and experienced pain, and during the survey, was bedfast related to wound healing. Resident #11 developed a Stage II pressure ulcer to his left heel that was not monitored frequently and progressed to an unstageable pressure ulcer with eschar. In addition, 1 of 4 residents (#1) was readmitted to the facility with two Stage II pressure ulcers that were identified and no further care was documented. Findings include: 1. Resident #7 was originally admitted to the facility on [DATE] with [MEDICAL CONDITION] (MS) and diabetes. He was discharged to a hospital for pressure ulcer care on 3/17/10 and returned to the facility on [DATE]. A physician progress notes [REDACTED]. "The patient is seen in followup for multiple pressure ulcers, including bilateral hips, as well as gluteal region. The patient had extensive bedside debridement performed last visit last week, and now we have been utilizing VAC therapy on the sacral ulceration. He continues with nutritional support, and his [MEDICATION NAME] is within normal limits. We have him on a Clinitron off-loading mattress surface..." "Diagnoses: [REDACTED]. 2. Right hip, stage III, now appears to be clinically showing itself as a stage IV pressure ulcer. 3. Left ischial tuberosity ulceration, improved. PLAN: 1. We will suspend the VAC and switch to Santyl to the sacral ulceration to help enzymatically clean up the tissue. We will also use this to the rig… | 2014-04-01 | ||
| 6275 | 6275 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 441 | D | U2X811 | Based on observation, staff interview and the facility's Policy and Procedure for Glucometer Cleaning and Storage, it was determined that the facility failed to ensure that the 200 hall glucometer was cleaned according to policy between residents. Residents receiving glucose monitoring would be affected by the failed practice. This was true for 1 of 1 (#9) sampled residents and 1 of 1 (#23) random residents on 200 hall receiving glucose monitoring. Findings include: On 9/10/10 at 11:10 a.m., LN #1 was observed returning from Resident #9 's room after using a glucometer to check his blood sugar level. LN#1 was starting to clean the glucometer with an alcohol swab. The surveyor stopped LN#1 and questioned her as to the facility policy for cleaning the machines between residents. LN#1 was unsure and left the area and went to the nurses station to speak with another LN there. At 11:11 a.m., LN#1 returned to the medication cart. She had a container of "Dispatch" with her. Dispatch is a hospital cleaner that had pop-up wipes. LN#1 removed a wipe from the container and wiped the glucometer with it. She then proceeded to immediately wipe it dry with a tissue. The surveyor questioned the LN if she had read the instructions. The LN gave the surveyor a puzzled look and proceeded to read the instructions. The cleaning instructions read, "Wipe surface with towel until completely wet. Allow to remain wet for one minute at room temperature (68 - 77 degrees Farenheit)... Gloves should be worn." The LN then proceeded to clean the glucometer and left it wrapped in the towelette. At 11:20 a.m., LN#1 went to Resident #23's room to do glucose testing. The LN placed a paper towel on the resident's bedside table and placed the glucometer still wrapped in the towelette on the paper towel. The LN performed the finger stick with a disposable lancet and obtained the blood. The LN noted the reading and wrapped the glucometer with the paper towel from the over bed table and returned to the medication cart. The LN removed her gloves and sanit… | 2014-04-01 | ||
| 6276 | 6276 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 253 | D | U2X811 | Based on observation, resident interview and staff interview, it was determined the facility failed to ensure that a resident's room was clean and sanitary. This was true for Random Resident (RR) #17. In addition, the facility failed to ensure that the doors to rooms 203 and 206 were functional. Findings included: 1. On 9/7/10 at 9:40 am, the IV (intravenous) pole in RR #17's room was observed to have multiple areas where a brownish substance was dried on the bottom of the IV pole. A bottle of Jevity solution was observed hanging on the pole at the time. The Physician (recapitulation) Orders for RR #17, dated August 2010, documented, "Clean/wipe down feeding pump and pole. Ensure pump is functioning properly. - QS (every shift) Everyday...Order Date 8/20/2010, Start Date 8/20/2010." The MAR for RR #17 documented his last infusion of Jevity would have ended at 6:30 am on 9/7/10. In addition, RR #17 informed the surveyor of an incident approximately six weeks prior where a LN attempted to run his Jevity into his PEG (percutaneous endoscopic gastrostomy) tube while it was clamped. RR #17 stated the Jevity blew out of the side port since the tube was clamped and sprayed all over him, the ceiling, wall and window blinds. RR #17 pointed out to the surveyor multiple visible brownish-beige stains on the ceiling above his bed, on the wall to the right of his window and on the lower right slats in the window blinds. He stated staff was aware of the stains but no attempt to clean them had been done. The Administrator and DON were informed of these issues on 9/9/10 at 2:50 pm. No further information was received. 2. On 9/9/10 at 1:15 p.m., the surveyor attempted to close the door to room 203. The door would not close. The upper edge of the door was outside the frame and there was about a 1 inch gap at the top corner. The facility maintenance man was informed at 1:45 p.m. The maintenance man stated that the hinge was loose and would repair it. On 9/10/10 at 11:45 a.m., the surveyor closed the door to room 206. The door closed… | 2014-04-01 | ||
| 6277 | 6277 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 274 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined the facility did not ensure a significant change assessment was completed within 14 days for 1 of 10 sampled residents (#1) who had newly coded declines in ADLs. Findings include: Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's annual MDS assessment, dated 2/14/10, coded: - independent with bed mobility - required supervision and set up with transfers - walked independently in room - required supervision and set up when walking in corridor - independent with dressing and hygiene - required set up help only with bathing According to a local hospital Transfer Summary, on 5/6/10 the resident was transferred to the emergency room of the hospital due to an elevated temperature and returned to the facility from the hospital on [DATE]. The resident's quarterly MDS assessment, dated 5/21/10, coded: - required extensive one person physical assistance with bed mobility - required extensive one person assistance for transfers - walking in room did not occur - required limited assistance of one person when walking in corridor - required extensive one person assistance with dressing and hygiene - required extensive assistance with bathing Federal guidance at ?483.20(b)(2)(ii) Guidelines The following are the criteria for significant changes: A significant change reassessment is generally indicated if decline...is consistently noted in 2 or more areas of decline...Decline: Any decline in activities of daily living (ADL) physical functioning where a resident is newly coded as 3, 4, or 8 Extensive Assistance, Total Dependency, activity did not occur (note that even if coding in both columns A and B of an ADL category changes, this is considered 1 ADL change)..." On 9/10/10 at 2:40 p.m., the Administrator, DON, and RN Consultant were informed of the finding. No further information was provided. | 2014-04-01 | ||
| 6278 | 6278 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 312 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, it was determined the facility did not ensure services to maintain grooming and personal hygiene related to nail care. This was the case for 1 of 13 sampled residents (#7) observed during the survey. Findings include: Resident #7 was originally admitted to the facility on [DATE] with [MEDICAL CONDITION] (MS) and diabetes. He was discharged to a hospital for pressure ulcer care on 3/17/10, and returned to the facility on [DATE]. The resident's most current quarterly MDS was dated 7/18/10. He was coded as extensive assistance to total dependence for all ADL care except eating. In addition, his MS had caused [MEDICAL CONDITION], and he was unable to ambulate. His range of motion was limited on both sides of his neck, arms (including shoulders and elbows), hands (including wrists and fingers), legs (including hip or knee), and feet (including ankles and toes). All of these identified areas had either partial or total loss of voluntary movement. The resident was observed on 9/8/10 at 8:00 am, with dirty and long fingernails. His fingernails were approximately 1/4 to 3/8 inches long and grew in a curved manner over the tips of his fingers. During lunch his nails were observed in the same condition. The resident used his hands frequently to pick celery out of his fresh vegetable bowl. On 9/9/10 at 9:50 am, the surveyor interviewed the resident in his room. His fingernails were in the same condition as the day before. He had just finished eating breakfast. The facility administrator and DON were told about the condition of the resident's fingernails on 9/10/10 at 2:40 pm. They agreed he was not able to cut them himself, and stated it would be taken care of. The administrator advised the surveyor later that day that Resident #7 had his nails cut, by the unit manager LN. | 2014-04-01 | ||
| 6279 | 6279 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 167 | C | U2X811 | Based on observation and staff interview, it was determined the facility did not post the most recent Life Fire Safety survey results in a conspicuous place where residents or interested family/personal representatives could see it and locate the survey results. This had the potential to affect all residents or families who wished to review the survey results. Findings included: On 9/7/10 at 10:10 am, a surveyor observed that neither facility survey books for the East or West wings contained the most recent Life Fire Safety survey results. The Administrator was informed of this issue and she stated the books had recently been updated and the Life Fire Safety surveys had inadvertently been removed. No further information was received. | 2014-04-01 | ||
| 6280 | 6280 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 246 | D | U2X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interview, it was determined the facility failed to accommodate the needs of residents by not having the call bell accessible at all times. This was true for Random Resident (RR) #17. Findings included: RR #17 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RR #17's most recent admission MDS assessment, dated 7/8/10, documented the following: * Short term and long term memory okay * Independent cognitive skills for daily decision-making * Extensive assistance requiring two persons for physical assistance for bed mobility and toilet use * Total dependence requiring two persons for physical assistance for transfers and bathing * One sided limitation in range of motion with partial loss of voluntary movement * Full loss of voluntary movement in neck, arms, legs, and feet * Lifted mechanically * Moderate pain daily * [MEDICAL CONDITION] * Feeding tube The Care Plan for RR #17, documented the problem, "Risk for falls related to: unstable health condition, weakness r/t (related to) ALS," with an intervention, "Place call light within easy reach of resident." NOTE: An additional handwritten entry, not present at the time of the incident, dated 9/13/10 with no time documented, "Resident does have a noise maker/shaker that family wants him to use which is within reach on night stand or overbed table in place of call light depending on resident preference." On 9/8/10 at 11:55 am, RR #17 and his spouse were interviewed regarding possible problems with staff answering the resident's call light in a timely manner. They both reported long delays in staff answering call lights and one instance of the resident being left unattended on the toilet while staff answered another call light. RR #17 showed the surveyor a noise maker/rattle that his wife had brought to him. His wife stated that if staff didn't answer the call light, they might respond to the loud noise made by… | 2014-04-01 | ||
| 6281 | 6281 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 468 | E | U2X811 | Based on observation and staff interview, it was determined the facility failed to ensure that handrails were firmly affixed to the wall in 1 of 6 resident hallways (600 Hallway) and 1 of 2 dining hallways, both in the West Wing. This had the potential to affect all ambulatory residents, residents utilizing wheelchairs for locomotion, and visitors in the facility. Findings included: On 9/7/10 at 11:30 am, during an initial tour of the facility, the following issues were found: * In the 600 Hallway, by the right of the door marked, "Staff Only," the handrail completely detached from the wall when pulled. The Administrator was immediately made aware of the hazard. * In the West Wing Dining Hallway, by the Fire Alarm, the handrail was loose and slid 1/2 inch vertically and 1/2 inch away from the wall when pulled, creating a pinch hazard. The Administrator and DON were made aware of these issues on 9/9/10 at 2:45 pm. The Administrator informed the surveyors that the handrails had been repaired. | 2014-04-01 | ||
| 6282 | 6282 | APEX CENTER | 135079 | 8211 USTICK ROAD | BOISE | ID | 83704 | 2010-09-14 | 518 | D | U2X811 | Based on staff interview and facility policy review, it was determined the facility failed to ensure all employees were adequately trained and prepared to respond to emergency situations, including power outages. This was true for 1 of 3 staff members interviewed and had the potential to affect all residents throughout the facility. Findings included: On 9/8/10 at 2:45 pm, a certified nursing assistant (CNA) was interviewed about training he had received in emergency and disaster preparedness. When asked how staff should respond to power outages for residents who required electrically powered medical equipment, such as an oxygen concentrator, CNA #4 stated he didn't know what to do. CNA #4 stated he would hand the plug to a nurse who knew what to do. He was unaware of the facility's emergency power procedures. On 9/9/10 at approximately 2:00 pm, the Maintenance Director furnished a copy of the facility's Electrical Outage policy which stated, "General Information: The following areas in your facility are on the alternate power supply system: All emergency lighting, and all red emergency outlets as will (sic) as fire alarm system." On 9/9/10 at 2:45 pm, the Administrator and DON were informed of the results of the interviews. No further information was received. | 2014-04-01 | ||
| 6283 | 6283 | DESERT VIEW CARE CENTER OF BUHL | 135089 | 820 SPRAGUE AVENUE | BUHL | ID | 83316 | 2010-11-08 | 272 | E | EFUF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's were comprehensibly assessed for safety when physical restraints were in use. This affected 4 of 4 sampled residents (#s 4, 7, 8, and 9) with restraints and applied specifically to: a) a lap buddy and 1/4 side rail (SR) for Resident #7; b) a self releasing seat belt for Resident #8; c) a full bed rail with pad for Resident #4 and #9. Findings include: 1. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #7's annual MDS assessment, dated 8/22/10, documented: * Short and long-term memory problems * Moderately impaired cognitive skills for decision making * Usually understood others and understood by others * Required assistance of 2 plus persons for bed mobility, transfers, dressing, toileting, and bathing; * Occasional bowel incontinence; * Bladder incontinence; * Other types of side rails used, such as half rail or one side, used daily; * Trunk restraint used daily. Resident #7's November 2010 Physician order [REDACTED]. Lap Buddy when up in chair for patient safety..." Both orders were dated 11/16/09. Resident #7's care plan, dated 10/12/10, identified the problem, "Restraints-Restraint Used Resident uses lap buddy while up in w/c (wheelchair) (and) 1/4 rail on bed r/t (related to) [MEDICAL CONDITION] secondary to encephilitis (sic)." Approaches to the problem included, "1) Resident uses lap buddy while up in w/c for positioning (and) to keep him from falling when he is having a [MEDICAL CONDITION], buddy to be released every 2 hours for positioning. 2) Resident request 1/4 on one side of bed... 3) Restraint assessments to be reviewed quarterly (and) as needed..." Resident #7 was observed in a w/c with a lap buddy in place on the following dates/time: * 11/1/10 at 4:45 p.m.; * 11/2/10 at 8:00 a.m., 8:54 a.m., 10:50 a.m., 12 noon, 12:58 p.m., and 3:15 p.m.; * 11/3/10… | 2014-04-01 | ||
| 6284 | 6284 | DESERT VIEW CARE CENTER OF BUHL | 135089 | 820 SPRAGUE AVENUE | BUHL | ID | 83316 | 2010-11-08 | 281 | D | EFUF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to follow physician orders [REDACTED].#9) sampled residents. This applied specifically to: a) [MEDICATION NAME] administered IM (intramuscular) to Resident #7 for [MEDICAL CONDITION] activity that did not meet the parameters in the physician's orders [REDACTED]. b) [MEDICATION NAME] administered to Resident #9 after it was discontinued. Findings included: 1. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #7's November 2010 Physician order [REDACTED]. (G)ive if 3 consecutive [MEDICAL CONDITION] in 12 hr (hour) period [MEDICATION NAME] more than 5 min(utes)- [MEDICAL CONDITION]." The date of the order was 11/16/09. The September and October 2010 MARs, and their accompanying Nurse's Notes, documented [MEDICATION NAME] 1 mg IM was administered to Resident #7 on the following dates/times and the reason the medication was given: * 9/14 at 9:15 a.m. "[MEDICATION NAME] 1 mg IM [MEDICAL CONDITION] over 5 min. * 9/28 at 9:10 a.m. "[MEDICATION NAME] 1 mg [MEDICAL CONDITION] 06 (6:00 a.m.) 1M (minute), 09 (9:00 a.m.) multiple for 5 min." * 10/26 at 5:45 p.m."[MEDICATION NAME] 1 mg IM r/t (related to) (illegible) multiple [MEDICAL CONDITION] activity." Review of Nurse's Notes (NN), dated 7/29/10 at 12:30 p.m. through 10/29/10 at 5:15 a.m., revealed the following, in part: * 9/13 at 1:00 p.m. through 9/14 at 1:30 a.m., no [MEDICAL CONDITION] activity documented. * 9/14 at 9:15 a.m., "...had [MEDICAL CONDITION] activity-stiffened body-clenched fists, snorting resp(irations) 6 min(utes). Res(ident) assisted to room...IM [MEDICATION NAME] given..." Note: One [MEDICAL CONDITION] in twenty hours did not meet the criteria to administer IM [MEDICATION NAME]. * 9/27 at 5:30 p.m. through 9/28 at 5:30 a.m., no [MEDICAL CONDITION] activity documented. * 9/28 at 6:00 a.m., "(One) on 1 staff reported to this nurse that res h… | 2014-04-01 | ||
| 6285 | 6285 | DESERT VIEW CARE CENTER OF BUHL | 135089 | 820 SPRAGUE AVENUE | BUHL | ID | 83316 | 2010-11-08 | 328 | D | EFUF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure oxygen (O2) saturation levels were monitored every shift as ordered for 1 of 2 (#3) sampled residents with O2 therapy. Findings included. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS assessment, dated 9/28/10, documented the following: * Short and long-term memory problems; * Moderately impaired decision making skills requiring cues/supervision; * Limited ability to make concrete requests * Responds adequately to simple, direct communication; * Oxygen therapy. Physician Telephone Orders, dated 10/27/10 at 8:30 a.m., documented, "O2 2L NC for SOB prn (O2 at 2 liters per minute per nasal cannula for shortness of breath). Notify MD (physician) of increased SOB or O2 (less than) 90% (percent). Monitor O2 sats Q shift (Monitor O2 saturation levels every shift)." A November 2010 Vital Sign and Weight Flow Sheet (VS/WFS) documented, * "(N)oc 11-1-10 90% RA (Night shift 11/1/10, O2 saturation level 90 percent on room air); * (N)oc 11-2-10 94% 2L/NC; * 11/3/10 (no shift or time)...94% 2L/NC." There were no other entries on the VS/WFS. In addition, there were no nursing note entries for November found in the resident's clinical record by the afternoon of 11/2/10. On 11/3/10 at 3:00 p.m., LN #3 was interviewed regarding monitoring of Resident #3's O2 saturation. LN #3 stated, "I haven't been doing them on days. No." LN #3 said she thought the order was for the noc shift only. LN#3 reviewed the MAR and stated, "It's not on there. It's only on here (the LN was looking at the VS/WFS). Noc's checks it." The facility did not document O2 saturation levels for every shift as ordered. On 11/4/10 at 3:35 p.m., the Administrator, DNS, Corporate Director of Clinical Services, and Corporate Director of Accounts Receivable Resources were informed of concern regarding monitoring of O2 saturation levels. No further information was… | 2014-04-01 | ||
| 6286 | 6286 | DESERT VIEW CARE CENTER OF BUHL | 135089 | 820 SPRAGUE AVENUE | BUHL | ID | 83316 | 2010-11-08 | 431 | D | EFUF11 | Based on observation and staff interview, it was determined the facility failed to ensure medications were labeled with the accurate expiration date and that expired medications were discarded and not available for resident use. This was true for one of one medication refrigerators. Findings included: On 11/3/10 at 11:15 a.m., the DNS assisted the surveyor to inspect the refrigerator in the medication room. During the inspection, four vials of 2 mg/ml (milligram per milliliter) injectable Lorazepam (Ativan) and one box of 12 Phenodoz suppositories were found expired in the refrigerator. The expiration date for each of the vials of Ativan was 5/2010. A pharmacy label on the box of Phenodoz suppositories said the expiration date was 11/11/2010. However, the actual expiration date on the Phenodoz box was 2/2010. The DNS took the medications and said she would, "throw them away." On 11/5/10 at approximately 3:30 p.m., the Administrator, DNS, Corporate Director of Clinical Services, and the Corporate Director of Accounts Receivable Resources were informed of the issues. No further information was received from the facility. | 2014-04-01 | ||
| 6287 | 6287 | DESERT VIEW CARE CENTER OF BUHL | 135089 | 820 SPRAGUE AVENUE | BUHL | ID | 83316 | 2010-11-08 | 458 | B | EFUF11 | Based on observation and staff interview, the facility did not ensure that 4 of 4 multi-resident rooms (#2 South (S), 4 S, 13 North (N), and 15 N) provided at least 80 square feet (sq. ft.) of usable space per resident. Each of these three rooms were licensed and certified for three beds. Findings included: On 11/1/10 from 11:15 a.m. to 1:00 p.m., during the initial tour of the facility, and daily through 11/4/10, observations of rooms 2 S, 4 S, 13 N, and 15 N revealed that the rooms were equipped for three resident beds. There were two residents in each of the rooms and only two beds in each of the rooms. The room measurements were: * 13 N - 235.91 sq. ft.; * 15 N - 237.00 sq. ft. * 2 S - 239.59 sq. ft.; * 4 S - 238.23 sq. ft. The total measurement of each of the rooms equipped for occupation by three residents did not meet the required minimum of 240 square feet, or 80 square feet per resident. None of the rooms were overcrowded; and, equipment, such as mechanical lifts, wheelchairs, or oxygen concentrators would have ample room if required. During interview with the Administrator and DNS on 11/4/10 at 5:55 p.m., the Administrator indicated the rooms would remain with two beds only and that she intended to request a waiver for the rooms. | 2014-04-01 | ||
| 6288 | 6288 | DESERT VIEW CARE CENTER OF BUHL | 135089 | 820 SPRAGUE AVENUE | BUHL | ID | 83316 | 2010-11-08 | 463 | E | EFUF11 | Based on observation and staff interview, it was determined the facility failed to ensure all restrooms available to residents had a call light system to the nurse's station. Two of two public/employee restrooms were found unlocked and did not have a call light system to the nurse's station. This had the potential to affect all independently mobile residents in the facility. Findings included: On multiple occasions from 11/1 to 11/4/10, the survey team observed that the public/employee restrooms on the West Unit and the South Unit were unlocked and did not have a call light system to the nurse's station. The West Unit public/employee restroom was located between the DNS' office and the pantry. It was across the hall and approximately 20 feet from the west dining room. The South Unit public/employee restroom was directly across the hall from the nurses station. It was located on the main hallway between the West and East Units and the intersection between the North and South Units. On 11/4/10 at 9:05 a.m., the Maintenance Manager (MM) was interviewed. He acknowledged both public/employee restrooms were unlocked and did not have a call light system to the nurses' station. The MM said residents "never" use the public restrooms. When asked how he knew residents do not use the public/employee restrooms, the MM did not respond. When asked if the nurses' station was continuously staffed, the MM said, "No." On 11/4/10 at 11:05 a.m., a male resident was observed independently operating an electric wheelchair in the hallway near the South Unit public/employee restroom. The resident was alone. A LN was observed going in and out of resident rooms on the North Unit, but no other staff were present in the hallways or at the nurses' station. The resident lingered in the hallway momentarily then continued down the hallway toward the West Unit. On 11/4/10 at 3:05 p.m., a female resident was observed independently ambulating with a front wheeled walker from the North Unit hallway into the intersection with the South Unit hallway. … | 2014-04-01 | ||
| 6289 | 6289 | DESERT VIEW CARE CENTER OF BUHL | 135089 | 820 SPRAGUE AVENUE | BUHL | ID | 83316 | 2010-11-08 | 514 | D | EFUF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review it was determined the facility failed to ensure that residents' physician's orders were transcribed as written by the physician, and that lab results were placed in the residents' charts in a timely manner. This was true for 1 of 12 sampled residents (#3), and 1 random resident (#13): 1) During a medication pass, Resident #13 received [MEDICATION NAME] according to the physician's most current order written in August 2010. However, the order was not transcribed on the resident's November MAR indicated [REDACTED]. 2) Resident #3's [MEDICATION NAME] Acid level was drawn in May 2010. The facility did not obtain a copy of the lab results, or the physician's response to the results, until October 2010. 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 9/28/10 quarterly MDS assessment documented the resident had short term memory problems and moderately impaired cognitive skills for daily decision making. During a medication pass observation on 11/1/10 at 4:35 pm, Random Resident # 13 received [MEDICATION NAME] 4 mg (milligrams) by mouth. During the reconciliation of the medication pass, the resident's current (October 2010) Physician Recapitulation orders read: * "[MEDICATION NAME] ([MEDICATION NAME]) 4 mg PO (by mouth) every 5 days. Blood Thinner." The start date for the order was 7/23/10. * "[MEDICATION NAME] ([MEDICATION NAME]) 5 mg PO (by mouth) two times a week. Blood Thinner." The start date for the order was 7/23/10. The same [MEDICATION NAME] orders were also written on the September 2010 Recapitulation orders. The orders did not specify which days the [MEDICATION NAME] were to be given. The description section on the November, October, and September 2010 MARs also documented, "[MEDICATION NAME] ([MEDICATION NAME]) 4 mg PO by mouth) every 5 days." and "[MEDICATION NAME] ([MEDICATION NAME]) 5 mg (PO by mouth) two times a week." However, t… | 2014-04-01 | ||
| 6290 | 6290 | DESERT VIEW CARE CENTER OF BUHL | 135089 | 820 SPRAGUE AVENUE | BUHL | ID | 83316 | 2010-11-08 | 371 | F | EFUF11 | Based on observation and staff interview, it was determined the facility failed to store, prepare, and serve food under sanitary conditions, following proper food handling practices. This applied specifically to: 1) A 1/2 head of lettuce and a partially used package of sandwich meat, located in the walk in refrigerator, were not properly covered and stored. 2) The plastic drip tray and the stainless steel base of the ice machine were crusted with brown and yellow debris. The drip tray also contained a kernel of corn. 3) A food service worker used a potentially contaminated plastic glass to scoop Thicket from a storage bin. 4) Milk, pudding, and juice that were ready to be placed on resident trays and served during a lunch meal, registered 48 degrees Farenheit (*F), 52 *F, and 50 *F consecutively. The walk-in refrigerator, from which the cold foods were removed, was open during food preparation. The inside temperature of the refrigerator registered 50 degrees *F. This affected sampled Residents #s 1 through 11 and had the potential to affect all residents dining in the facility. Findings include: 1. On 11/1/10 at 11:10 a.m. during the initial tour of the facility's kitchen: a. A 1/2 head of lettuce was sitting in a plastic bin on top of other produce in the walk-in refrigerator. The head of lettuce was not covered to protect the cut end from exposure. b. A plastic ziplock bag contained 4 slices of bologna in the original package that was cut open. The ziplock bag was not zipped closed which left the bologna exposed to air. At 11:05 am, the DM (Dietary Manager) covered the lettuce and sealed the ziplock bag. 2. On 11/3/10 at 9:15 am, the drip tray of the ice machine located in the west dining room, was crusted with brown and yellow debris. The yellow debris partially wiped free with a glove. The brown debris required scraping to come off. The stainless steel base of the ice machine contained a 1 inch strip of the same type of debris along the left side. There was also a kernel of corn laying in the drip tray. The D… | 2014-04-01 | ||
| 6291 | 6291 | DESERT VIEW CARE CENTER OF BUHL | 135089 | 820 SPRAGUE AVENUE | BUHL | ID | 83316 | 2010-11-08 | 518 | E | EFUF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to ensure all employees were adequately trained and prepared to respond to emergency situations including the use of battery powered suction machines during power outages. This was true for 1 of 3 staff members interviewed (LN #8) for emergency preparedness, and a second LN (#3) observed attempting to assist LN #8 to access a battery powered suction machine in the East Hall dining room. This had the potential to affect Resident #4, who required suctioning on an intermittent basis, and any resident requiring suctioning during a power outage. Findings include: Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's current [DIAGNOSES REDACTED]. The resident's 10/14/10 quarterly MDS assessment documented the resident had a [MEDICAL CONDITION] and required suctioning. The resident's 10/11/10 Care Plan documented the resident was at risk for aspiration related to a [MEDICAL CONDITION] secondary to a persistive vegetative state. The approaches included, "Licensed nurse to 1:1 (one to one) suction PRN (as needed)." Nursing Progress Notes and Treatment Administration Records for September and October 2010 documented the resident [MEDICAL CONDITION] on 10 occassions in September (9/1, 9/5, 9/9, 9/12, 9/11 (x 2)9/13 (x 2), and 9/30 (x 2)), for "excess mucous." The residents record documented he required suctioning 12 times in October (10/5, 10/7, 10/8, 10/9 (x 2), 10/12 (x 3), 10/14, 10/15, 10/17, and 10/20). On 11/4/10 at 9:15 am, LN # 8 was interviewed about emergency preparedness. LN #8 stated the facility did not have a back up generator and in the case of a power outage, the facility had two battery powered suction machines. When asked where the suction machines were located, LN #8 stated she knew that one was in the East dining room. LN #8 was asked to show the surveyor the suction machine. LN #8 went to a closet in the East Dining … | 2014-04-01 | ||
| 6292 | 6292 | LIFE CARE CENTER OF VALLEY VIEW | 135098 | 1130 NORTH ALLUMBAUGH STREET | BOISE | ID | 83704 | 2010-12-10 | 314 | D | 08UN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint from the general public, record review, and staff interview, it was determined the facility failed to ensure residents at risk for pressure ulcers did not develop unavoidable decubitus. This was true for 2 of 2 residents sampled for pressure ulcer prevention and treatment (Resident #s 1 and 3). Resident #1 developed an "unstageable" pressure ulcer when the facility failed to implement individualized and adequate interventions to prevent the wound from deterioration after its initial discovery as a Stage I ulcer. The characteristics of this wound, as described in the resident's medical records and by staff caring for the resident, indicated this decubitus more closely resembled a Stage II wound than one that was "unstageable." Resident #3 developed a pressure ulcer when the facility failed to modify interventions as the wound deteriorated. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to a nearby hospital on [DATE], and readmitted to the facility on [DATE]. The resident expired at the facility on [DATE]. The resident's admission MDS assessment, dated [DATE], documented the following: * Moderately impaired cognitive skills for daily decision making * Short- and long-term memory impairment * Extensive assistance of one staff member required for bed mobility * Extensive assistance of at least two staff members required for transfers * No pressure ulcers Braden Scale for Predicting Pressure Sore Risk assessments were conducted on [DATE], [DATE], [DATE], [DATE], and [DATE]. A score of 17 was documented for each assessment, placing the resident "at risk" for pressure ulcers. The Braden Scale classifies scores of less than 9 as "very high risk," scores of ,[DATE] as "high risk," scores of ,[DATE] as "moderate risk," and scores of ,[DATE] as "at risk." Resident #1's Braden score was documented as 15 on [DATE] and 13 on [DATE]. Resident #1's Pressure Ulc… | 2014-04-01 | ||
| 6293 | 6293 | LIFE CARE CENTER OF VALLEY VIEW | 135098 | 1130 NORTH ALLUMBAUGH STREET | BOISE | ID | 83704 | 2010-12-10 | 153 | C | 08UN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Admission Packet, review of facility policies and procedures for release of information, and interview with staff, it was determined the facility did not ensure that residents', or their legal representatives, can receive a copy of their medical records within 2 working days of the request and without a signed/written request. This had the potential to affect all residents residing at the facility. Findings include: On [DATE], the facility's Admission Packet was reviewed. The packet included a list of the Resident Bill of Rights and Attachment B- Notice of Privacy Practices. The Resident Rights documented, "The Resident or Legal Representative has the right, upon oral or written request, to access all records pertaining to himself or herself, including clinical records, within twenty-four hours. After receipt of his or her records, the Resident or Legal Representative has the right to purchase (at a cost not to exceed the community standard) photocopies of the records or any portions of them upon request and with two day's advanced notice to the Facility." The top of the Resident Rights list documented, "By signing the Resident Admission Agreement Acknowledgment, the Resident/Representative acknowledged that he/she has received a copy of these Resident Rights." Attachment B contained a section, titled Your Health Information Rights, which stated, "To inspect and copy medical information that may be used to make decisions about you, you must submit your request to the facility's Health Information Management Director... " On [DATE] at 10:30 am, the facility's Health Information Management Director (HIMD) was interviewed regarding the facility's practice for facilitating residents' review of their medical records and obtaining copies of their medical records. The HIMD stated resident's could review their medical records upon request. The HIDM stated this usually occurred immediately upon request (oral or writte… | 2014-04-01 | ||
| 6294 | 6294 | LIFE CARE CENTER OF VALLEY VIEW | 135098 | 1130 NORTH ALLUMBAUGH STREET | BOISE | ID | 83704 | 2011-01-21 | 371 | F | 446511 | Based on a complaint from the public, observation, review of maintenance and kitchen records, and staff interviews, it was determine the facility failed to keep the floors of the kitchen free from dropped food and miscellaneous debris. The observed debris created an unsanitary environment which had the potential to attract pests and rodents. This had the potential to affect sampled Residents #s 1 - 18, as well as all other residents who received food from the kitchen. The findings include: A complaint received from the public stated the facility had a problem with mice/mice droppings in the kitchen, that traps were put down to catch the mice, but the problem had never resolved. The complainant also stated the kitchen was not kept clean. During the entrance tour of the facility on 1/18/11 at 8:20 am, five mouse traps were observed under metal storage racks in the entrance area, clean dish drying room, and dry food storage room. The metal storage racks were on wheels which made them movable. The racks were pushed up against the walls in these areas. The storage racks in the entrance area were filled with packaged loaves of bread and styrofoam plates. The storage racks in the dish drying room were filled with drying steam pans, metal utensils, soup bowls, coffee cups, and plastic drink pitchers. The metals racks in the dry storage area contained foods such as crackers and canned goods. During the tour, 1/2 to 2 inch wide clusters of dried food, such as raisins and bread crumbs, and miscellaneous debris were observed on the floor under the moveable storage racks. The dropped food and miscellaneous debris lined the walls under the racks and also encircled each of the mouse traps. On 1/19/11 at 8:30 am, a second visit was made to the kitchen. The CDM and the Consulting RD accompanied the surveyors on the visit. The food and miscellaneous debris had not been cleaned from the areas observed the previous day. In addition, dried food debris and miscellaneous debris was observed on the floor in the open area between the sto… | 2014-04-01 | ||
| 6295 | 6295 | PRESTIGE CARE & REHABILITATION - THE ORCHARDS | 135103 | 1014 BURRELL AVENUE | LEWISTON | ID | 83501 | 2010-10-22 | 280 | D | KBBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to review and accurately revise care plans in relation to oxygen therapy and toileting cares. This was true for 1 of 3 residents sampled for oxygen therapy (#3) and 1 of 9 residents (#4) whose rooms were sampled for homelike environment. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's admission MDS assessment, dated 7/6/10, documented the resident received oxygen therapy. The resident's most recent quarterly MDS assessment, dated 9/29/10, documented that oxygen therapy was no longer in use. The resident's recapitulated physician orders [REDACTED]." The start date for the order was 6/26/10. Resident #3's Care Plan in effect for October 2010 documented the following: * "Problem: Resident has impaired gas exchange r/t hx (related to history) of pneumonia and [MEDICAL CONDITION]. Problem Start Date: 07/07/2010." * "Goal: Resident will have an effective gas exchange as evidenced by: clear breath sounds, mental status within normal limits, pulse oximetry ranging (greater than) 90%. Goal Target Date: 12/27/2010." * "Approach: Monitor oxygen saturation via pulse oximetry every shift. Approach Start Date: 07/07/2010." No documentation of Resident #3's pulse oximetry monitoring was found during a review of the resident's medical records. On 10/20/10, at 11:10 a.m., the facility's Administrator and DON were interviewed. When asked to produce documentation of the resident's pulse oximetry monitoring, the Administrator stated, "That (monitoring) should have been changed to PRN." The DON stated the order should have been "D/C'd (discontinued) from the Care Plan." 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 9/16/10, documented the following: * Extensive assistance of one staff member required for transfer… | 2014-04-01 | ||
| 6296 | 6296 | PRESTIGE CARE & REHABILITATION - THE ORCHARDS | 135103 | 1014 BURRELL AVENUE | LEWISTON | ID | 83501 | 2010-10-22 | 322 | D | KBBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined the facility did not ensure that staff were documenting hang times of formula per manufacturer recommendations to prevent potential microbial growth. This was the case for 1 of 1 sampled resident (#5) who received nutrition via a feeding tube. Findings include: Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 8/15/10, documented Resident #5 was totally dependent on staff for all ADLs (activities of daily living) and received his nutrition via a feeding tube. The resident's current physician order [REDACTED]. *Elevate HOB (head of bed) 30 degrees, continuous *[MEDICATION NAME] 2.0 FS 80 CC/HR (hour) x 14 hours *Check total cc's formula administered per shift *Check residual every shift *Check feeding tube placement every shift *Flush feeding tube with 50 CC every shift *Flush tube with 400 CC three times a day Resident #5 was observed on 10/19/10 at 8:40 am, in his bed. The tube feeding pump in his room was not running, however a bag of formula hung from a pole. There was no name, date or time on the bag of formula. The one to one staff for Resident #5 was asked about the bag of formula. He stated Resident #1 had vomited and the tube feeding had been disconnected. At that time LN #1 was asked about the bag of formula not being labeled. She stated the formula should have the resident's name, date, time and the rate of flow written on the bag. During subsequent observations on 10/19/10 at 11:25 am and 1:30 pm the resident's name, the date, hang time or rate of flow had not been written on the bag of formula. The administrator and DON were advised of the above findings on 10/20/10 at 5:00 p.m.. The DON stated the bag should have been dated and timed. She also stated the resident's medical record did not include any documentation of the date or time when the bag of tube feed… | 2014-04-01 | ||
| 6297 | 6297 | PRESTIGE CARE & REHABILITATION - THE ORCHARDS | 135103 | 1014 BURRELL AVENUE | LEWISTON | ID | 83501 | 2010-10-22 | 309 | E | KBBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to provide adequate bowel care for residents. This was true for 7 of 13 residents sampled for bowel care (Resident #s 1, 3, 5, 7, 8, 11, and 13), and had the potential to cause harm. Findings include: 1. Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's annual MDS assessment, dated 9/21/10, coded that the resident was usually continent of bowel, and experienced constipation. The resident's care plan included the 7/19/10 problem, "Resident has history of fecal impaction r/t (related to) abdominal hernia with penetration by intestines." The goal was, "Resident will be free of fecal impaction," by 12/23/10. Approaches to meet this goal included, "Administer cathartic medications per MD order. Monitor effectiveness and side effects. Place resident in facility protocol bowel management program. Monitor for signs of constipation (decreased bowel sounds / abdominal pain / distention / decreased appetite / fever, etc). Check resident for fecal impaction if s/s (signs or symptoms of) constipation noted." The resident's 9/29/10 Care Conference Report documented, "No blockages or issues with the hernia.... Resident reports that sometimes she wakes up r/t bowel problems and then can't get back to sleep.... Resident is having regular bowel movements...." The resident's October 2010 Physician order [REDACTED]. * MOM (Milk of Magnesia) 30 cc (cubic centimeters, or milliliters) orally as needed for no bowel movement (BM) in 2 days. * [MEDICATION NAME] tabs 10 mg (milligrams) orally as needed for no BM in 3 days. * [MEDICATION NAME] suppository 10 mg rectally daily as needed for constipation. * Fleets enema rectally as needed for no BM in 5 days. Documentation of the resident's BMs and bowel care medications for 5/1/10 through 9/30/10 was reviewed. Bowel care medications should have been provided as ordered b… | 2014-04-01 | ||
| 6298 | 6298 | PRESTIGE CARE & REHABILITATION - THE ORCHARDS | 135103 | 1014 BURRELL AVENUE | LEWISTON | ID | 83501 | 2010-10-22 | 312 | D | KBBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and record review it was determined the facility did not provide consistent bathing services for 1 of 13 sampled residents reviewed for bathing (#9) to ensure good personal hygiene. Findings include: Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 7/26/10, documented the resident required setup help for dressing, eating, toileting use and personal hygiene. Resident #9 required physical help "in part of bathing." Resident #9's Care Plan, undated, stated in the "Problem" section he required limited assistance with ADLs (Activities of Daily Living). The target date was 10/22/10 and the "Approach" was to "Provide resident with the opportunity to bathe at least weekly." Baths, showers, and refusals were to be documented. The "ADL (Activities of daily living) Flowsheet" for 7/10 documented the resident did not have a shower for 10 days (7/11/10 -7/22/10). The flowsheet did not document any refusals. The DON was interviewed on 10/21/10 at 9:45 a.m. regarding Resident #9 not being bathed for a period of 10 days. She stated she would check for further documentation on bathing for Resident #9. Later that day the DON provided a "Shower List" for 7/10/10 which included Resident #9. However, no other documentation was provided by the facility. | 2014-04-01 | ||
| 6299 | 6299 | PRESTIGE CARE & REHABILITATION - THE ORCHARDS | 135103 | 1014 BURRELL AVENUE | LEWISTON | ID | 83501 | 2010-10-22 | 323 | G | KBBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, accident report review and record review, it was determined the facility failed to ensure assistive devices were utilized as care planned for for 1 of 13 sampled residents (#6). This resulted in harm to Resident #6 when she sustained a fracture to the left femur. Findings included: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 4/13/10, coded: * Severely impaired cognitive skills for daily decision-making * Total assistance of two plus persons for transfer, bed mobility, dressing and toilet use * No limitation of ROM on the neck * No limitation on the foot - including ankle or toes * No recent fractures were documented The resident's most recent quarterly MDS assessment, dated 7/14/10, coded: * Severely impaired cognitive skills for daily decision-making * Total assistance of two plus persons for transfer, bed mobility, dressing and toilet use * Sustained a fracture in the past 180 days * Limitation of ROM on both sides of the neck * Limitation to ROM of one foot- including ankle or toes Note: ROM had decreased after the fracture, on the foot and neck. Resident #6's Plan of Care, not dated, documented in the problem section the resident required total assistance with ADL's, the goal was for Resident #6 to "...remain free from injury requiring out of facility medical intervention." The "Approach" section, dated 10/14/07, stated "Provide 2 person assist with all bed mobility, incontinence care, and transfers." Progress Notes for Resident #6, dated 4/30/10, documented a CNA reported Resident #6 displayed signs and symptoms of pain "with movement of left leg. Assessment of left leg reveals no obvious deformity, no areas of localized redness, with PROM (passive range of motion) resident grimaces and clasps hands together on her stomach. Resident has a HX (history) of FX (fracture) to lower legs." The physician was faxed … | 2014-04-01 | ||
| 6300 | 6300 | PRESTIGE CARE & REHABILITATION - THE ORCHARDS | 135103 | 1014 BURRELL AVENUE | LEWISTON | ID | 83501 | 2010-10-22 | 311 | D | KBBS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide restorative nursing services as physician ordered and care planned. This was true for 2 of 6 residents sampled for ADL decline (#s 2 and 3). Findings include: 1. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 8/17/10, documented the following: * Bilateral range-of-motion limitations of the legs * Extensive assistance of at least two staff members required for bed mobility and toileting * Total dependence on at least two staff members for transfers * Total dependence on one staff member for locomotion on the unit Resident #2's recapitulated physician orders [REDACTED]. * "(RNA) (Restorative Nursing Aides) Heel slides 5-10 reps each side 5 times per week. Once a day on Sun(day), Mon(day), Tue(sday), Wed(nesday), Sat(urday); Shift 1." Start date: 4/2/10. * "(RNA) Manually assist hip and knee extinsion (sic) 5-10 reps each leg 5 times per week. Once a day on Sun, Mon, Tue, Wed, Sat; Shift 1." Start date: 4/2/10. * "(RNA) Quad sets 5-10 reps 5 times per week. Once a day on Sun, Mon, Tue, Wed, Sat; Shift 1." Start date 4/2/10. The resident's Care Plan in effect for October 2010 documented the following: * "Problem: Resident has a history of conflict with staff, as she has routinely been non-compliant with cares and treatment modalities (weights, prescribed diet, fluid restriction, therapy, etc.)." Problem Start Date: 8/17/10. * "Goal: Resident will maintain compliance with cares and treatment modalities, as evidenced by interviews with resident and direct care staff." Goal Target Date: 11/17/10. * "Approach: Resident will be compliant with CNA and Nursing cares. Resident will comply with ordered therapies." Approach Start Date: 8/17/10. Restorative Flowsheets for July 2010 through October 2010, and related Progress Notes (PN), were revie… | 2014-04-01 | ||
| 6301 | 6301 | TWIN FALLS CENTER | 135104 | 674 EASTLAND DRIVE | TWIN FALLS | ID | 83301 | 2010-12-08 | 157 | G | BXPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: ID 849 Intakes: ID 849 Based on a complaint from the community, medical record review and staff interview, it was determined the facility failed to notify a resident's physician when the resident developed symptoms of a cough, elevated temperature, rapid respirations, and low oxygen level (SaO2) within the previous 20 days of treatment for [REDACTED]. The resident was diagnosed with [REDACTED]. The lack of physician notification was true for 1 of 4 sampled residents (#1) reviewed for respiratory infections and condition changes. Findings include: A complaint from the community documented that an identified resident (Resident #1)developed a cough in [DATE]. The resident later developed bilateral crackling in her lungs. The resident received breathing treatments and cough syrup at the time, but her lungs were not checked by the nurses and the resident's primary care physician was not notified of the condition change. Resident #1 was admitted to the facility on [DATE]. The resident's current [DIAGNOSES REDACTED]. The resident's [DATE] annual MDS assessment coded: * Short term and long term memory problems with moderately impaired daily decision making skills. * Usually understood others - may miss some part/intent of message. * Dependent on extensive assistance of at least one person for bed mobility, transfers, dressing, toileting, and personal hygiene. * Required no special treatments such as oxygen therapy or monitoring of an acute medical condition. The nursing note sections (NNs) of the Interdisciplinary (IDT) Progress Notes, dated [DATE] through [DATE], documented the resident was diagnosed and treated for [REDACTED]. [DATE] - "Resident with increased confusion (and) behaviors." Note: The resident's primary care physician's office was notified and the facility was instructed to do a urinalysis. The urninalysis was negative for infection. [DATE] - "Received... order from (physician) (for) [MEDICATION NAME] 100 mg (by mouth) BID (tw… | 2014-04-01 | ||
| 6302 | 6302 | TWIN FALLS CENTER | 135104 | 674 EASTLAND DRIVE | TWIN FALLS | ID | 83301 | 2010-12-08 | 309 | G | BXPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint from the community, medical record review and staff interview, it was determined the facility failed to ensure a resident, who was treated for [REDACTED]. This resulted in harm to the resident when, within 12.5 hours of developing an elevated temperature and rapid respirations, developed severe [MEDICAL CONDITION] and required transportation to the hospital for emergency treatment. The resident was diagnosed with [REDACTED]. The lack of adequate monitoring of a decline in medical condition was true for 1 of 4 sampled residents (#1). Findings include: A complaint from the community documented that an identified resident (Resident #1)developed a cough in September. The resident later developed bilateral crackling in her lungs. The resident received breathing treatments and cough syrup at the time but her lungs were not checked by the nurses. The complainant stated that the resident's primary care physician was not notified of the condition change. Resident #1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's [DATE] annual MDS assessment coded: * Short term and long term memory problems with moderately impaired daily decision making skills. * Usually understood others - may miss some part/intent of message. * Dependent on extensive assistance of at least one person for bed mobility, transfers, dressing, toileting, and personal hygiene. * Required no special treatments such as oxygen therapy or monitoring of an acute medical condition. Interdisciplinary (IDT) Progress Notes for [DATE] through [DATE] documented the resident was diagnosed and treated for [REDACTED]. [DATE] - "Resident with increased confusion (and) behaviors." Note: The resident's primary care physician's office was notifed and the facility was instructed to do a urinalysis. The urninalysis was negative for infection. [DATE] - "Received... order from (physician) (for) [MEDICATION NAME] 100 mg (by mouth) BID (twice per d… | 2014-04-01 | ||
| 6303 | 6303 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 156 | D | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review it was determined the facility did not ensure an advance directive was accurately reflected for 1 of 14 sampled residents (#1). Resident #1 executed a Do Not Resuscitate (DNR) advance directive; however, the physician's recapitulation orders documented cardiopulmonary resuscitation (CPR). Depending on which document was reviewed in the event of emergency, the resident's wishes may not have been honored. In addition, the facility did not ensure advocacy group information was posted to inform sampled residents (#1 - #14) or family/personal representatives how to contact advocacy agencies. This had the potential to affect all residents of the facility. Findings include: 1. Resident #1 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent [DATE] admission MDS assessment coded under Section A, do not resuscitate. The resident's "Do Not Initiate Cardiopulmonary Resuscitation (DNR) Informed Consent" form was signed by the resident on [DATE]. The resident's physician signed the form on [DATE]. The resident's ,[DATE] "All Active & Discontinued Orders" (recapitulation orders, recap orders) documented under the Advance Directive section, "CPR" with a date of [DATE]. The resident's physician signed the recap orders on [DATE]. On [DATE] at 12:45 p.m., the surveyor informed LN #1 of the discrepancy between the resident's DNR status and the recap orders for CPR. On [DATE] at 1:00 p.m., LN #1 provided the surveyor with an updated DNR order, dated [DATE]. On [DATE] at 11:15 a.m., the Administrator, the DON, and the RN Consultant were informed of the finding. No further information was provided. 2. On [DATE] at approximately 9:45 am, and [DATE] at approximately 9:30 am, the facility was observed for the location of postings for advocacy groups. There were no postings in the lobby area of the main entrance or the sepa… | 2014-04-01 | ||
| 6304 | 6304 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 164 | D | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation it was determined the facility did not provide privacy in treatment for one of one sampled resident (#9) observed from the corridor, while she received podiatry care. Findings include: Resident #9 was admitted to the facility on [DATE] for after care related to a [MEDICAL CONDITION] sustained from a fall at home. Resident #9 was observed on 10/21/10 at 11:15 am, from the corridor. While the surveyor walked past the room of Resident #9, she was observed receiving podiatry care. The resident was seated in her wheel chair, which was facing the open door to her room. The Podiatrist was seated on the floor in front of the resident. There was a box which contained podiatry instruments to his right. The Podiatrist was wearing latex gloves and clipping the resident's toenails. The resident was not provided privacy during treatment. | 2014-04-01 | ||
| 6305 | 6305 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 167 | C | 84X411 | Based on observation and staff interview it was determined the facility did not post, in a conspicuous place, notice for the location of the most recent survey results where residents or interested family/personal representatives could see it, and locate survey results. This had the potential to affect 14 of 14 sampled residents (#1 - #14) and all residents or family/personal representatives who wished to review the survey results. Findings include: During environmental observations of the facility, on 10/20/10 at approximately 9:15 am, the surveyor could not locate the most recent survey results. At 9:45 am, the surveyor asked the receptionist in the lobby, where the survey was located. The receptionist escorted the surveyor to the location of the survey. The survey results were in a black plastic container mounted on the wall, around the corner from the lobby, at the beginning of the 100 hall. The survey was in a black binder with a small white label that had the words, "Most Recent Survey Results", printed across the label. The print was small, and when the binder was in the black container, the only words slightly visible were, "Most Recent." The receptionist was asked where the sign was that directed residents or other interested persons to locate the survey. The receptionist said, "We don't have a sign directing where it is." As individuals walked through the front door of the facility, through the lobby there was no sign posted to direct them to the survey, located at the corridor at the beginning of the 100 hall. The printed label on the survey binder was obscured by the container, and not large enough for residents or other individuals to notice. In addition, the facility had a separate entrance for the Solona unit (locked unit). There was no sign or survey in a conspicuous location to direct interested individuals to the most recent survey information located on the other side of the facility, at the beginning of the 100 hall. The regulation at F167 directs: "The facility must make the results available… | 2014-04-01 | ||
| 6306 | 6306 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 241 | D | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview and record review, it was determined the facility failed to promote the dignity of residents by speaking respectfully to residents (#8), failed to ensure resident's visual privacy was maintained when the resident was wheeled backwards down the hall from the shower (#18) and failed to ensure a resident was assisted to bed when the resident desired (#2). This was true for 2 of 10 sampled residents (#s 2 & 8) and 1 random resident (#18). Findings included: 1. Resident #8 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's annual MDS assessment, dated 8/8/10, coded: * Short and long term memory problems * Severely impaired cognitive skills for daily decision-making * Rarely/never understood * Rarely/never understands Resident #8's Care Plan identified the problem, dated 10/16/09, "Altered cognitive status and communication deficit AEB (as evidenced by): short and long term memory problem, impaired decision making, confusion, and disorientation to person, place and time." Interventions for this problem included: * "Use pleasant interaction to reassure him when confused... * Gently attempt to calm and redirect focus when anxious or frustrated. * Attempt to make him secure and safe. * Reassure (Resident #8) he is secure and safe." The Care Plan, additionally, identified the problem, dated 10/16/09, "Potential for mood impairment related to dementia..." Interventions for this problem included: * "Offer praise and support and positive comments when indicated. * Encourage staff to assist him as needed, being kind and non threatening..." On 10/19/10, between 8:25 am and 9:20 am, Resident #8 was observed in the Solana dining room. The resident was set-up with the breakfast meal at 8:25 am. No staff assistance was provided during the entire meal. At 8:45 am, the resident had finished the eggs on the plate and poured some of hi… | 2014-04-01 | ||
| 6307 | 6307 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 246 | D | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident interview, it was determined the facility did not accommodate the physical environmental needs for one of one sampled resident (#2) by ensuring that her over bed light was functional and met her needs. Findings include: Resident #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS, documented she was cognitively independent (decisions were consistent and reasonable). During an interview on 10/20/10 at 10:50 am, the surveyor observed the resident's over bed light in her room. It was noted that the light had a small silver bead chain for pulling the light on or off. The chain was about 5 inches long and had a piece of cord tied to it. The cord was frayed and hung down approximately 3-4 inches from the chain. There was not enough legnth to drape the cord over the head of the bed so the resident would be able to reach it. The resident was asked how she was able to turn her light off and on. She said she could not, but if staff wanted to see, they turned it on. She said, "You tell them you can't reach it and they say they will fix it, and they don't." She stated that if she did get to bed early enough she may want to read, but would not be able to without the light. | 2014-04-01 | ||
| 6308 | 6308 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 251 | C | 84X411 | Based on staff interview and review of the facility personnel list, it was determined the facility did not have a qualified social worker on a full-time basis, for the facility with a total of 158 certified beds. This had the potential to affect residents of the facility who may have required social services. Findings include: During the entrance conference on 10/18/10 at approximately 10:45 am, the administrator was provided with a form requesting staff names and employee designators. It was noted that two staff were documented as social workers. Directly under this documentation was a request for names of support services designees. This space had ditto marks under the names of the two staff identified as social workers. The administrator was asked on 10/20/10 at approximately 5:15 pm, if one or both of the designated social services staff was a licensed social worker or had a bachelor's degree in social work or a related field. The administrator said they did not. The DON was present, and stated she thought it was based on census and not bed size. The surveyor shared the documentation in the regulations as follows: "A facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is an individual with a bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology; and one year of supervised social work experience in a health care setting working directly with individuals." The facility failed to employ a qualified social worker. | 2014-04-01 | ||
| 6309 | 6309 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 252 | B | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident and staff interview, it was determined the facility did not ensure a homelike environment for 1 of 14 sampled residents (#9) and one random resident (#19). Resident #19's room lacked personalization and unnecessary medical equipment was stored in the room for Resident #9. In addition, areas that could be frequented by residents lacked order and a comfortable clean environment. One area was used for storage and another area had a chair that was very stained and soiled. This had the potential to affect all 14 sample residents. Findings include: 1. Random Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/18/10 at 10:30 am during the initial tour, and on 10/19/10 at 11:25 am, Resident #19's room was observed to be devoid of any decoration or pictures. On 10/19/10 at 11:25 am, the resident was interviewed regarding the room but did not respond to the surveyor's questions. On 10/19/10 at 3:10 pm, the Administrator, DON and Nurse Consultant were informed of the issue. On 10/20/10 at 2:00 pm, Resident #19's room was observed with a picture hanging on the wall and flowers in a vase. The Administrator stated the family had been called and encouraged to bring in items to personalize Resident #19's room. No further information was received from the facility. 2. Resident #9 was admitted to the facility on [DATE] for after care related to a hip fracture sustained from a fall at home. The resident's quarterly MDS, dated [DATE], documented her cognitive status as independent (decisions consistent and reasonable). On 10/18/10 at 3:05 pm, the resident was in her room sitting on the side of her bed. She told the surveyor that she had just come back from a visit with the chiropractor and was feeling good but ready for a nap. The surveyor commented that she had an oxygen concentrator in her room and she was not using oxygen. She stated she had used it, a while back, for about seven days. She sai… | 2014-04-01 | ||
| 6310 | 6310 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 253 | B | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined the facility did not provide maintenance services to ensure floors in 12 of 72 resident rooms (118, 120, 122, 124, 126, 127, 129, 131, 202, 501, 503 and 506) were maintained for ease in cleaning and a comfortable interior. In addition, resident #8 had a torn mat in his room and the patio designated for Solona unit resident smoking had a chair in disrepair. Findings include: 1. During environmental observations of the facility it was noted that several resident room had floor tiles that were in poor condition. The tiles were separating were they joined and many of the tiles had a crackled appearance over the top of the tile with the black/brown undercoating of the tile showing through. The rough texture and cracks that were developing made this surface a potential trap for soil and bacteria when cleaned. This was the case for the following 12 resident rooms: 118, 120, 122, 124, 126, 127, 129, 131, 202, 501, 503 and 506. Not all rooms were observed related to residents wanting doors kept closed and related to privacy issues. The maintenance supervisor and surveyor observed some of the floors on 10/20/10 at 9:30 am. He agreed that several of the floors were in poor condition and needed to be replaced. He said the facility had been gradually remodeling rooms and that he had a list of floors scheduled for replacement in the next year. The list was requested and provided. It documented the following rooms were scheduled for floor replacement: 112, 114, 118, 120, 122, 124, 127, 501, 507 and 510. (Eight rooms on the 400 hall were not in use during the survey. Some of the rooms were locked and some used for storage). The administrator was advised of environmental concerns with the floors on 10/20/10 at 5:00 pm. She also indicated at least one resident room a month was remodeled and this included new floors. She was advised that some of the floors identified in poor condition by the surveyor, w… | 2014-04-01 | ||
| 6311 | 6311 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 258 | E | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation it was determined that comfortable sound levels were not maintained when a loud call bell system rang incessantly through meal time in the Medicare dining/activity room. The call system was also loud in the 100, 200 and 300 halls. This had the potential to affect all residents with normal hearing ability on these halls. Findings include: On 10/20/10 at 11:25 am, the surveyor was seated in a small area next to an entrance door by the Medicare nurses' station. The area had a table with a puzzle on it, and a chair on one side with a foot stool on the other side. The Medicare dining room was also next to this area. A metal box/panel that identified room numbers and sounded the call light bell, was directly across from the surveyor and nurses' station. It was attached to the wall at the corner of the 300 hall. The 100, 200, 300 halls all converged in this area with the nurses' station and exit door. At 11:25 am, the call bell began to ring. The surveyor observed the box/panel and the light for room [ROOM NUMBER] was indicated. The bell continued to ring loudly for 10 minutes when the light went off for room [ROOM NUMBER]. It continued to ring as the light then went on for another room. This loud ringing continued until 11:38 am. This was a total of 13 minutes of constant loud ringing, while at least 6 residents were seated in the adjacent Medicare dining room for lunch. The bell only ceased for 2 minutes, and then began to ring again at 11:40 am. The bell continued to ring, almost without interruption; the surveyor left the area at 12:20 pm. Six residents were in the dining room eating. As the surveyor walked up the 100 hall, the bell could be heard loudly ringing over half way up the 100 hall. The 100 hall was the longest of the three halls, and had a small lounge with a TV at about the half way point of the hall. The bell could still be heard loudly at that point in the 100 hall. The 200 and 300 halls were about half the siz… | 2014-04-01 | ||
| 6312 | 6312 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 272 | E | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure that Resident Assessment Instruments (RAIs), completed prior to 10/1/10, were accurate and comprehensive to ensure care plans were reflective of residents' assessed needs and that appropriate care would be provided based on those assessed needs. Specifically: 1) Resident #6's medical record did not contain a RAP Profile or a Trigger Listing & RAP Information form for the 9 triggered areas on the RAP Summary form and 2) The triggered areas on the RAP Summary form were not consistently assessed. This affected 8 of 10 (#s 2, 4-10) sampled residents. Findings included: The facility utilized two different types of forms to document the RAP triggered areas, one form titled, RAP Profile, and/or another form titled, Trigger Listing & RAP Information. Both of these forms contained a section titled "Additional Notes" that provided an area for the facility's clinical decision making summary to be documented. The federal guidance at ?483.20(b)(1)(xvii) indicates, "Documentation of summary information (xvii) regarding the additional assessment performed through the resident assessment protocols (RAPs)...refers to documentation...of assessment information in support of clinical decision making relevant to the RAP, documentation regarding where, in the clinical record, information related to the RAP can be found, and for each triggered RAP, whether the identified problem was included in the care plan." 1. Resident #6 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent admission MDS assessment, dated 4/30/10, contained a RAP Summary that triggered 9 RAP Problem areas: [MEDICAL CONDITION], cognitive loss, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, mood state, nutritional status, dehydration/fluid maintenance, a… | 2014-04-01 | ||
| 6313 | 6313 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 280 | E | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure care plans were updated as indicated: 1) Resident #3's care plan after a fall on 4/3/10, for the use of alarms and bed side mats, for physician ordered weekly weights, and goal dates for nutrition, activities, and chronic progressive decline, 2) Resident #1's care plan for oxygen therapy, 3) Resident #6's care plan for ace wraps intervention, 4) Resident #9's care plan for restraints, 5) Resident #8's care plan for weekly weights. This affected 4 of 10 (#s 1, 3, 6, 8 and 9) sampled residents. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's quarterly MDS assessment, dated 4/25/10, coded severely impaired cognitive skills for daily decision-making, short- and long-term memory problems, rarely/never understood, rarely/never understands, and no falls in the preceding 30 days. a. Resident #3 sustained a fall on 4/3/10 at 10:00 pm. The facility's Risk Management Summary (Incidents and Accidents, I&As), documented in the "Describe the circumstances of the event and what actions, if any, have been taken lately" section, "He was on his bedside grey mat...The alarm box was on 'immediate' and 'loud'. The battery was replaced and checked for functionality...Inservice to staff left for signature regarding alarm box and functionality prior to leaving residents room." The section titled "care plan updated" documented, "yes." The form indicated the nurse who initiated the I&A was a registered nurse (RN). Note: Please refer to F278 for accuracy of MDS assessment for falls. On 10/18/10 at 3:10 p.m., the surveyor observed the resident laying in bed with bed side mats on the floor at both the left and right sides of the bed. Review of the resident's care plan, printed on 9/8/10, revealed no updated information after the 4/3/10 fall. The resident's care plan identified the focus area of potenti… | 2014-04-01 | ||
| 6314 | 6314 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 312 | D | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, it was determined the facility failed to ensure residents who needed assistance with eating, grooming and personal hygiene received assistance from facility staff. This was true for 3 of 10 sampled residents (#s 7, 8 & 9). Resident #9 did not receive nail care services. Resident #s 7 & 8 did not receive bathing services as scheduled. In addition, Resident #8 did not receive assistance with dining and dressing. Findings included: 1. Resident #8 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's annual MDS assessment, dated 8/8/10, coded: * Short and long term memory problems * Severely impaired cognitive skills for daily decision-making * Rarely/never understood * Rarely/never understands * Requires physical help of one person in part of bathing activity * Requires extensive assistance of 2 persons for dressing * Requires extensive assistance of 1 person for personal hygiene and eating * Chewing and swallowing problem * Mechanically altered diet * Plate guard, stabilized built-up utensil, etc. a. Resident #8's Dysphagia Evaluation form, dated 1/7/10, documented, "Poor oral control and/or copious residue orally, which increases risk with consecutive bites." The speech therapist's short term goals documented, "Caregiver education to ensure pts (patients) safety & that hydration/nutrition needs are met." Resident #8's Medical Nutrition Therapy Assessment, dated 8/12/10, documented: * "Diet Order: House puree... * Adaptive equipment: nosey cup * Dining Ability: Extensive Assistance * Oral Problems: chewing and swallowing * Swallowing ability: some difficulty * Assessment: ...MDS criteria is met d/t (due to) use of mechanically altered diet r/t (related to) chewing and swallowing difficulty. Extensive assistance is given in DR (dining room) as well as nosey cups to improve oral intake. Dementia has … | 2014-04-01 | ||
| 6315 | 6315 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 356 | C | 84X411 | Based on observation and staff interview it was determined the facility did not post, in a clear and readable format, and at the beginning of each shift on a daily basis, staffing information regarding categories of licensed staff and unlicensed staff responsible for resident care. This had the potential to affect 14 of 14 sampled residents (#1 - #14) and all residents or family/personal representatives who wished to review the survey results. Findings include: During environmental observations of the facility on 10/20/10 at 9:45 am, the posting for staffing in the facility was located. The surveyor had not noticed the location. The lobby had an end table with an 8 x 10 inch, plastic picture frame on it. The surveyor picked the frame up and could then see a piece of paper with staffing for three shifts was documented with pen. The writing was not bold and this was the only location for the staffing information even though there was another entrance by a nurses' station on the Medicare hall and by the Solona unit (locked unit). The administrator and DON were advised on 10/20/10 at 5:00 pm that the posting for staffing did not meet regulatory requirements. They did not comment. | 2014-04-01 | ||
| 6316 | 6316 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 514 | D | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review it was determined the facility did not ensure that 1 of 17 sampled resident's (#13) records reviewed was complete related to documentation of a resident fall. Findings include: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's initial MDS, dated [DATE], documented he was cognitively independent, and had fallen in the last 30 days. Facility "Event Reports" (incident and accident reports) were reviewed. An Event Report, dated 8/7/10 (12:01 am), documented the following: "Was found after calling out for help, he was lying on the floor of his room, with his head near the bathroom door, and his feet pointed toward the bed. He is normally a Hoyer lift for all transfers. He stated had gotten up out of bed and started to walk towards his electric wheelchair when he fell down. Denied any pain/discomfort. A pressure alarm was placed in his bed." No injury was documented. The nurse progress notes were reviewed. A note was written on 8/5/10 and the next note was documented on 8/9/10 (11:50 am). There was no nurse progress note documented on 8/7/10 when the resident fell . The 8/9/10 note was an "IDT review" note and documented the resident did fall (no reference date included). The note indicated the resident was assessed and no injury was observed. The note was not signed by the same nurse who documented the Event Report. The note indicated that the MD and family would be notified. This was two days after the fall. The nurses' notes had not documented when the resident fell . There was no documentation of how an assessment was completed, i.e., before resident was lifted from floor, assessed for head injury or neurological checks needed, was the resident put back to bed or in a wheel chair. The note indicated the resident was "normally non-ambulatory and uses a mechanical lift for transfers." There was no documentation of how the resident was lifted from the floor. There were no notes of … | 2014-04-01 | ||
| 6317 | 6317 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 281 | D | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and medical record review, it was determined the facility failed to ensure services provided met professional standards of quality for safe administration of medicines and treatments. This was true for 1 of 3 LNs observed initialing medications before they were administered to residents and 1 of 10 sampled residents (#6) who had leg wraps applied without a physician's orders [REDACTED]. The liquid medicine appeared to have leaked from the medicine container to the inside of the plastic bag and covered the bottle of medication. Findings included: 1. The Bureau of Facility Standards Information Letter #97-3, dated 4/16/97 states, "...long term care facility staff were signing medications as given at the time of the medication preparation, not after the resident actually had taken the medication. ...the Board's (of Nursing) expectation, and the accepted standard of practice, is that licensed nurses document those things they have done, not what they intend to do." On 10/21/10 at 9:05 am, LN #3 was observed passing medication to Resident #6. LN #3 prepared 14 oral medications (tablets/capsules) for administration. The LN signed each medication with her initials on the MAR indicated [REDACTED]. LN #3 stated, "I sign (my initials) as I am checking the medications (before administering to the resident). If I don't mark it (MAR) somehow, I may miss it (pouring the medication). That's my was of making sure I don't duplicate any (medications poured). So often we get interrupted (during the medication pass)." At 9:25 am, the DON was informed of the medication pass observation. At 11:00 am, the DON handed the surveyor an Inservice form. The form was signed by LN #3 and documented the following: * "Attention: (LN #3) * Regarding: Med(ication) Pass * Date: 10/21/10 * Med pass procedure: Compare med card to order, punch med, dot box, continue until all meds are poured. Administer meds to resident. Go back to MARS and s… | 2014-04-01 | ||
| 6318 | 6318 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 309 | D | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined the facility did not ensure residents received the necessary care and services according to the comprehensive plan of care and the physician's orders [REDACTED].#s 7 & 8). Resident #s 7 & 8 were not provided as needed (prn) bowel care and went from 4 to 7 days without a bowel movement. In addition, Resident #8 was not weighed weekly as ordered by the physician. Findings included: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 8/22/10, coded: * Moderately impaired cognitive skills for daily decision-making * Short and long term memory problems * Usually understood and usually understands * Requires extensive assistance of 1 person for toileting * Continent of bowel Resident #7's physician Active Orders for October 2010 (recapitulation) included the following PRN medication for constipation: * "Milk of Magnesia (Magnesium [MEDICATION NAME]) 400 mg/5ml (400 milligrams/5 milliliters) Suspension by mouth (oral) - PRN: Give 30 cc's (cubic centimeters) for PRN constipation." The resident also routinely received the medications calcium, [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] all of which could cause constipation. Resident #7's Care Plan included the problem, dated 4/5/10, "Potential for decline in mood..." Interventions included, "Monitor the resident's bowel elimination pattern and follow bowel regime for establishing elim(ination) routine." Another problem, dated 10/23/09, was, "Self Care Deficit..." Interventions included, "(Resident #7) wears incontinent briefs for incontinent episodes d/t (due to) not reaching the bathroom in time. 1 person limited assist with toileting..." Resident #7's Resident Functional Performance Record documented the resident had no bowel movement on the following dates and the resident's corresponding MAR indicated [REDACTED] * 8/13/10 to 8/16/10 - … | 2014-04-01 | ||
| 6319 | 6319 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 431 | E | 84X411 | Based on observation and interview, it was determined the facility failed to ensure expired medications were discarded and not available for resident use. This was true for 2 of 5 medication carts with a total of 4 expired medications and 1 of 2 medication rooms with 2 expired medications. This had the potential to affect residents receiving those medications. Findings included: On 10/20/10 at 9:45 am, the Solana Unit medication room was observed to contain the following expired medications: * Albuterol Sulfate 0.083% 2.5 mg/3 ml (2.5 milligrams per 3 milliliters) for inhalation with expiration date 6/22/10. * Ipratropium Bromide 0.5 mg and Albuterol Sulfate 2.5 mg for inhalation with expiration date 3/18/10. On 10/20/10 at 10:20 am, a Center Unit medication cart was observed to contain the following expired medications: * Hydramine Liquid - diphenhydramine 12.5 mg with expiration date 2/2009. * Ibuprofen 200 mg with expiration date 7/2010 * Ipratropium Bromide 0.5 mg and Albuterol Sulfate 3.0 mg for inhalation with expiration date 6/5/10. On 10/20/10 at 10:55 am, a Medicare Unit medication cart was observed to contain Citrate of Magnesia oral solution with an expiration date of 6/2010. LN #12 stated the nurses are responsible for checking the medication carts and medication rooms for expired medications. All expired medications were removed from the medication room and medication carts by the licensed nursing staff. On 10/20/10 at 5:00 pm, the Administrator, DON and Nurse Consultant were informed of the issue. No further information was received from the facility. | 2014-04-01 | ||
| 6320 | 6320 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 441 | D | 84X411 | Based on observation and staff interview, it was determined the facility failed to ensure infection control practices were followed to prevent infections in the facility. This was true for 1 of 10 sampled residents (#6) and 1 random resident (#20). Specifically: 1) A glucometer contained in a plastic bag was laid on a resident's bed without a protective barrier (Resident #20). 2) Oral medication (tablets/capsules) was handled with bare hands and then administered to a resident (Resident #6). Findings included: 1. On 10/19/10 at 11:20 am, LN #5 was observed performing a blood sugar check using a glucometer on Random Resident #20. The LN gathered the supplies needed, including a glucometer in a plastic bag. The LN entered the resident's room and laid all of the supplies on the resident's bed in direct contact with the linens on the bed. The LN removed the glucometer from the bag, performed the blood sugar check, disinfected the glucometer and then placed the glucometer back into the plastic bag. The plastic bag containing the glucometer was then removed from the resident's room and stored in the medication cart. LN #5 was asked about placing the plastic bag with the glucometer on the resident's bed. She replied, "I shouldn't have put it there. I should have used some kind of drape." On 10/20/10 at 4:10 pm, the Infection Control Nurse was asked about placing the plastic bag with the glucometer on the resident's bed. He stated the expectation was that the nurse would "use a barrier" and not place the plastic bag "directly on the resident's bed." 2. On 10/21/10 at 9:05 am, LN #3 was observed passing 14 oral medications (tablets/capsules) to Resident #6. The LN positioned the medicine cup on the medication cart and popped the medication from the blister pack. Seven of the medications landed in her bare hand instead of in the medicine cup. She then transferred the medication from her bare hand into the medicine cup and administered the medication to the resident. LN #3 was asked about bare hand contact with medications.… | 2014-04-01 | ||
| 6321 | 6321 | RIVER RIDGE CENTER | 135106 | 640 FILER AVENUE WEST | TWIN FALLS | ID | 83301 | 2010-10-22 | 314 | D | 84X411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure Resident #3 received services to prevent the development of pressure ulcers. This related specifically to: 1) Physician ordered heel protectors were not in use for the resident on 10/18/10 & 10/19/10 and 2) Resident #3's 10/10 treatment sheet documented the heel protectors were applied to the resident on 10/18/10. This affected 1 of 10 (#3) sampled residents. Findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 9/26/10 quarterly MDS assessment coded severely impaired cognitive skills for daily decision-making, short- and long-term memory problems, rarely/never understood, rarely/never understands, received preventative or protective foot care, and no pressure ulcers. The resident's care plan, printed 9/7/10, identified the 5/28/10 focus area of potential for alteration in skin integrity. One of the focus area interventions was, "heel protectors at all times." The resident's "Active Orders from 10/1/2010 to 10/31/2010" (recapitulation orders, recap orders) contained an 4/8/10 order for, "Assure heel protectors are in place thruout {sic} shift. Assess thruout {sic} shift for max. (maximum) offloading of pressure. - ns, ds (night shift and day shift) Everyday..." On 10/18/10 at 3:10 p.m., the resident was observed laying in bed. The surveyor requested to observe the resident's heels. CNA #4 removed the resident's socks, discussed the resident's skin condition with the surveyor, reapplied the socks to both feet, and then covered the resident's feet with a blanket. The resident was not observed wearing heel protectors. The foot board of the resident's wheelchair (wc) was observed with padding across the entire surface where the resident's feet would be placed when the resident was in the wc. On 10/19/10 at 7:10, 8:15, 9:15, 10:15, and 11:15 a.m., and at 1:15 p.m., the resident was obse… | 2014-04-01 | ||
| 6322 | 6322 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 151 | E | X6TY11 | Based on observation and staff and resident interview, it was determined the facility failed to ensure residents were afforded their rights as citizens of the United States. The building was maintained in a locked state, preventing resident egress. This had the potential to affect all mobile residents in the facility not court mandated or at risk for elopement, including 5 sample residents (#1,2,6,8 & 10) and 2 random residents (12 & 15). Findings include: The facility was located on the grounds of a psychiatric hospital. Upon arrival at the facility on 8/23/10 at 2:45 p.m. the survey team entered through an unlocked front door to a small foyer area on the first floor of the building, and waited for staff to unlock the internal door and allow entry. Initial tour of the facility confirmed keys were required to take the elevator from the front ground floor entrance, the only handicapped accessible entrance, to the first and second floors where residents lived. Keys were also required for entry to a second elevator and all stairwell doors. The basement rear door was unlocked, but led to a locked, fenced area designated for smoking. On 8/25/10 at 8:25 a.m. the DON was asked about the locked status of the building. He said, "It's an open campus (for the hospital patients). We're getting the folks with behaviors (referring to the patients in the psychiatric hospital) and I don't know if they'd (referring to the residents) be safe out there without someone with them." He further that stated 13 of the 27 residents in the facility were court ordered to live there, and some of those residents were at risk for elopement. A Group Interview was conducted on 8/25/10 at 11:00 a.m., which was attended by 12 of the 27 residents in the facility. When asked about their ability to leave the building, only one resident stated they had a key and could come and go on the campus at will. Other residents stated they could only leave the building when taken out to the canteen on campus, or other destinations off campus, by the Activity Di… | 2014-04-01 | ||
| 6323 | 6323 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 159 | F | X6TY11 | Based on record review, resident interview, and staff interview, it was determined the facility failed to notify Medicaid and Medicare residents of their right to access up to $50 and $100 respectively from the petty cash fund. This had the potential to affect all Medicaid and Medicare residents in the facility, including Random Resident #13. Findings include: Federal Guidelines 483.10(c)(1) through (3) state, "The law and regulations are intended to assure that residents have access to $50.00 ($100.00 for Medicare residents) in cash within a reasonable period of time, when requested. Requests for less than $50.00 ($100.00 for Medicare residents) should be honored within the same day. Although the facility need not maintain $50.00 ($100.00 for Medicare residents) per resident on its premises, it is expected to maintain amounts of petty cash on hand that may be required by residents." The facility's admission agreement with residents was reviewed on 8/25/10 at 8:15 a.m. The admission agreement documented the following: * "Cash disbursements for funds are limited to $15.00 per day." * "Due to the Financial Services Office limited petty cash fund, cash withdrawals are limited to $15.00 cash per day. Fifteen-dollar cash limit may be waived ... The Financial Officer or designee may waive the $15.00 cash limitation." At the time the admission agreement was provided to surveyors, the facility's administrative assistant stated the Financial Services Policy was being revised and included a handwritten note that read, "Still Under Review - NOT Final Draft." On 8/25/10, at 11:00 a.m., a group meeting of 6 male and 6 female residents was conducted. When asked about their access to petty cash, one resident who wished to remain anonymous stated he could not "get money out of my account," while a majority of residents stated they were allotted $2 per day in petty cash and that petty cash was not available on weekends. On 8/25/10, at approximately 8:00 a.m., Random Resident #13 was observed asking the Social Services Director fo… | 2014-04-01 | ||
| 6324 | 6324 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 225 | D | X6TY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and review of facility Significant Event Review (SER) report forms, it was determined the facility did not ensure investigations to rule out abuse or neglect were thorough for 1 of 9 sample residents (#6). Between 3/1/10 and 8/23/10 Resident #6 sustained at least 41 bruises and/or other injuries of unknown origin. Twelve of the incidents did not include a thorough investigation to rule out abuse. Findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/11/10 quarterly MDS assessment documented the resident experienced wandering, persistent anger and resisted cares. The resident was on a 1-to-1 staff ratio at all times when awake and visual checks every 15 minutes when asleep. Resident #6's Care Plan contained the following: a) Behavior Care Plan, dated 2/10/10, which included instructions for staff to document behavior, including if the resident wandered or paced, struck out at staff, walls or objects, pinched, climbed on furniture, dropped her weight or sat on the floor. b) Potential for injury: falls, dated 6/30/08 and updated at varied dates through 2/11/10, which included the 1 to 1 staffing, use of gait belt when ambulating, and use of tab alarm when in bed. c) In addition, 11 temporary care plans had been put in place to address minor injuries, such as bruises and skin tears, between 6/21/10 and 8/4/10. On 8/24/10 at 7:00 a.m. Resident #6 was observed in bed asleep. A staff was present in the room. The staff stated the facility had 1-to-1 staff "floating" over from the psychiatric hospital in 2 hour shifts all that day. SER reports for Resident #6 were reviewed for the period of 3/1/10 through 8/23/10. Of the 41 reports reviewed, 23 were initially selected for further review as uninvestigated injury of unknown origin. Of those 23 reports initially selected, 24-hour reports were not provided until after the survey had been completed. (NOTE: Facility staf… | 2014-04-01 | ||
| 6325 | 6325 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 241 | E | X6TY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility did not ensure that residents were appropriately clothed and groomed. This was evident for 3 of 9 sampled residents (#1, 4 & 6) and 2 random residents (#11 & 12) observed. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on a 1 to 1 staff ratio at all times when awake. On 8/24/10 at 6:35 a.m. Resident #6 was observed walking in the hallway with staff in attendance with in arm's reach. Resident #6 had sweat pants on which contained 2 tears below the waist band in the back, exposing her underwear. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/24/10 at 7:00 a.m., 8/25/10 at 10:25 a.m. and at additional random times between 8/24/10 and 8/27/10 Resident #4 was observed wearing black leather slip on shoes which were too large, leaving a gap at the back. The shoes were visibly torn, with portions of the leather hanging off the shoes. 3. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS assessment, dated 6/27/10, documented the resident was severely impaired for daily decision making, exhibited periods of lethargy, behaviors, was not able to move independently, and was totally dependent on staff for all ADLs. During the breakfast meal on 8/24/10 at 7:30 a.m. staff was observed attempting to feed Resident #1. Throughout the meal a piece of tape protruded from the nasal cannula above the resident's upper lip. The tape was soiled with an unknown brown substance and was unsightly. 4. Resident #12 was observed on 8/24/10 at 7:30 a.m. in the dining room. He had on a T-shirt and sport pants. The T-shirt was torn and frayed around the entire neckline and the ends of the sleeves. The pants were too long, dragged on the floor and were frayed at the cuffs. The resident was observed on 8/25/10 … | 2014-04-01 | ||
| 6326 | 6326 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 250 | D | X6TY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to provide residents with appropriate and timely social services related to their advance directive, living situation, and/or behavioral challenges. This was true for 2 of 9 residents sampled (#s 1 & 4). Findings included: 1.a. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's [DATE] annual MDS assessment documented a legal guardian was in place and under advance directives "none of the above" was checked, indicating the resident did not have a Do Not Resuscitate (DNR) order in place. A Significant Event Report (SER) for [DATE] described an incident at 12:50 p.m. when Resident #1 was noted to be gasping for air and turning blue. Staff assessment at the time revealed an absence of pulse and respirations, pale skin and circumoral cyanosis (blue appearance to skin around the mouth and lips). The report stated "Code status verified and code called..." Cardiopulmonary resuscitation (CPR) was initiated, emergency personnel were called and the resident was subsequently transported via ambulance to the emergency room at the local hospital. The record included a Resident Face Sheet dated [DATE]. Under the Advance Directives section, "None of Above" was checked, indicating the resident was a full code and CPR would be initiated if needed. Further record review showed a Durable Power of Attorney document from another state, dated [DATE], was in place. The document stated, "If I am found to be without a pulse or not breathing, I do not want CPR to be given to me." The DON was interviewed on [DATE] at 8:00 a.m. and was asked about the code status. He stated all court mandated residents were considered to be "Full Code" status, according to the facility legal council. Resident #1 was, however, a voluntary admission to the facility with a legal representative and advance directives in place prior to the admiss… | 2014-04-01 | ||
| 6327 | 6327 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 272 | D | X6TY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview it was determined the facility failed to ensure a safety assessment was in place for the use of a self releasing seat belt for 1 of 9 sample residents (#4). Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/24/10 at 9:45 a.m. Resident #4 was observed in the hallway on the second floor dozing in her wheelchair. A seat belt was observed to be in place. No safety assessment was present in Resident #4's record. On 8/26/10 at 1:20 p.m. the DON was interviewed and when asked about the safety assessment for the self releasing seat belt he stated no safety assessment had been completed since the resident's admission to the facility on [DATE]. No further information was provided. | 2014-04-01 | ||
| 6328 | 6328 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 280 | D | X6TY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to revise care plans to reflect current resident status with regard to the use of eye glasses, cognitive loss, and falls. This affected 1 of 9 sampled residents (#1). Findings included: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS assessment, dated 6/27/10, documented the resident was severely impaired for daily decision making, exhibited periods of lethargy, exhibited no behaviors, was not able to move independently, and was totally dependent on staff for all ADLs. The Care Plan, dated 11/25/09 and updated 1/14/10, included under ADL self care deficit, "(Resident #1) wears glasses. Ensure they are clean and used daily." Resident #1 was observed on 8/23/10 - 8/26/10 at varied times both in bed and in the dining room without her glasses. Under Potential for Falls, the Care Plan instructed, "Keep bed in lowest position and locked mode...." Resident #1 was observed on 8/24/10 at 6:45 a.m. and on 8/25/10 at 10:35 a.m. in bed with the bed in a raised position. The Care Plan for Cognitive Loss stated a goal of, "(Resident #1) will not show a decline in her level of cognition during the next quarter." The resident's cognitive level at the time of the last MDS was assessed at the most severe level, and cognitive loss could not reasonably been prevented due to her medical diagnoses. The DON and clinical RN consultant were interviewed on 8/26/10 at 11:00 a.m. They confirmed the care plan did not reflect the resident's current status. No other information was provided. | 2014-04-01 | ||
| 6329 | 6329 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 329 | D | X6TY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview it was determined the facility failed to ensure antipsychotic drugs were not used without adequate indication for use and were evaluated after a change in condition/status. This was true for 1 of 9 sample residents reviewed (#1.) Findings include: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS assessment, dated 6/27/10, documented the resident was severely impaired for daily decision making, exhibited periods of lethargy, exhibited no behaviors, was not able to move independently and was totally dependant on staff for all ADLs. The Doctor's Orders, recapitulated, for 8/10 included renewal orders for [MEDICATION NAME] 50 mg (milligrams) by mouth twice daily for aggressive behaviors. An additional [MEDICATION NAME] order was renewed for the month of 8/10 for 100 mg by mouth PRN (as needed) at bedtime for [MEDICAL CONDITION]/agitation at night. A Psychiatric Gradual Dose Reduction form, dated 5/5/10, recommended discontinuing the PRN dose of [MEDICATION NAME] due to non use for more than 30 days. Resident #1 was observed on 8/24/10 at 6:45 a.m. in bed, asleep. At 7:30 a.m. she was observed in the dining room in a reclining wheelchair asleep. Staff was observed to have a difficult time rousing the resident to feed her breakfast throughout the meal. At 9:45 a.m. the resident was observed in bed asleep. Resident #1 was again observed in the dining room at 12:40 p.m., asleep. Staff sat next to her, roused her, and began to feed her lunch. She was able to keep her eyes open through most of the meal. On 8/25/10 at 10:35 a.m. the resident was observed in bed, asleep. Summarized Behavior data was requested from the DON on 8/25/10 at 5:25 p.m. Clinical Progress Notes provided on 8/26/10 documented the following: 7/16/09 - "...It was also noted that (Resident #1) no longer is striking out at those providin… | 2014-04-01 | ||
| 6330 | 6330 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 371 | E | X6TY11 | Based on observation and staff interview it was determined the facility failed to maintain sanitary conditions for food preparation. The microwave oven was heavily soiled. This had the potential to affect all sample residents (#1 - 9) and all other residents in the facility. Findings include: During initial tour of the kitchen on 8/23/10 at 3:35 p.m. the microwave oven was found to have a heavily soiled top inner surface, with food debris and a wide pattern of spatters. The plastic ceiling surface was cracked the width of the oven. The Dietitian was present and informed of the observation. | 2014-04-01 | ||
| 6331 | 6331 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 464 | E | X6TY11 | Based on observation and resident and staff interview, it was determined the facility failed to provide sufficient space to accommodate all residents who ate in the dining room resulting in the disruption of resident dining and resident crowding. This was true for 1 random resident (#11) and all other residents in the facility. Findings include: On 8/24/10 at 7:30 a.m. observations of the breakfast meal in the dining room were conducted. The meal service started at 7:00 a.m. and by 7:30 a.m. several independent residents were concluding their meals and leaving the dining room. No posted seating chart was visible during the meal observation. During the noon meal observations on 8/24/10 from 12:10 p.m. through 12:50 p.m. the dining room was full. Residents who had not been present at the breakfast meal, choosing to eat in their rooms, sleeping in etc., were all present for the lunch meal. For the first 30 minutes of the observation, residents and staff were continuously moving around the room. The presence of 4 residents in large, reclining wheelchairs in the dining room created a narrowing of walkways in the room, creating some difficulty for staff and ambulatory residents carrying trays to get to and from tables. On 8/24/10, at 12:20 p.m., Random Resident #11 was observed carrying a lunch tray into the dining room from the adjoining service area where residents were served their meals. The resident entered the dining room and noticed another resident sitting where he had eaten breakfast that morning. Random Resident #11 then took a step in another direction, turned toward the seat where he had sat for breakfast, stood motionless for a a few seconds, then placed his tray on the table between two other residents and exited the dining room. The resident did not consume any food on the lunch tray, and no staff attempted to redirect the resident from leaving the dining room. Random Resident #11 appeared confused and agitated during the observation. The resident's lunch tray was left untouched staff for the remainder o… | 2014-04-01 | ||
| 6332 | 6332 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 328 | D | X6TY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents received adequate respiratory care in accordance with physician's orders [REDACTED].#s 1 and 2) sampled for respiratory therapy. Findings include: 1. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent annual MDS assessment, dated 7/15/10, documented the resident received oxygen therapy. A physician progress notes [REDACTED].#2) has been requiring less O2 (oxygen) lately 1-1.5 L (one to one-and-a-half liters per minute) has maintained him instead of the 3L he had been needing." The resident's recapitulated physician orders [REDACTED]. Change to titrate O2 to keep O2 sats above 90%." The start date for the order was 8/23/10. Resident #2's Alteration in Health Maintenance Care Plan, dated 11/25/09, documented, "Medications and treatments per doctor orders." Throughout the survey from 8/23/10 through 8/26/10, Resident #2 was observed in a wheelchair with a portable oxygen tank delivering oxygen via nasal cannula at 3L/min. On 8/26/10, at approximately 4:00 p.m., the facility's Administrator and DON were informed of the observation. On 8/27/10, at approximately 9:00 a.m., the resident's physician, Administrator, DON, and other staff members met with surveyors. During the meeting, Resident #2's physician stated the resident's oxygen flow should have been reduced to 1 to 1.5 L/min and that the 8/23/10 oxygen order was not explicitly clear. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 8/24/10 at 6:45 a.m. Resident #1 was observed in bed with oxygen being administered via NC at 1 LPM. At 7:30 a.m. the resident was observed in a reclining wheelchair in the dining room with oxygen being delivered via NC at 1 LPM with use of a portable tank attached to the back of the chair. Subsequent observations… | 2014-04-01 | ||
| 6333 | 6333 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 163 | C | X6TY11 | Based on record review, resident interview, and staff interview, it was determined the facility failed to inform residents of their right to choose their own attending physician. This was true for all residents admitted to the facility who were provided with the facility's admission packet. Findings include: A review of the facility's admission packet was conducted on 8/24/10. Information indicating residents had the right to choose a personal attending physician was not included in the materials reviewed. The facility was affiliated with the adjacent psychiatric hospital, and it was not documented in the admission agreement whether or not the residents were limited in choice of physician by those circumstances. On 8/25/10, at 11:00 a.m., six male and six female residents were interviewed in a group meeting. When asked whether they were aware that they were entitled to chose their own personal physicians, none of the residents present stated they were aware of this right. The Administrative Assistant was interviewed on 8/26/10 at 10:00 a.m. and confirmed the information on the resident's right to choose their own physician was not included in writing in the packet, or communicated to residents upon admission. | 2014-04-01 | ||
| 6334 | 6334 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 167 | C | X6TY11 | Based on observation and staff interview, it was determined the facility failed to make the most recent life fire safety code survey, and re-certification and licensure surveys available for resident review. This had the potential to affect all residents at the facility. Findings include: On 8/23/10, when surveyors first entered the facility at 2:45 p.m., the binder which contained the most recent life-fire safety and re-certification and licensure surveys was observed in a locked area inaccessible to residents. On 8/23/10, at 3:15 p.m., the DON was interviewed and informed that inhibiting residents from accessing the most recent surveys violated federal regulation. The DON stated, "Well, that's an easy fix." At 5:30 p.m., surveyors exiting the facility observed the survey binder located in the same location as at 3:15 p.m., where it remained throughout survey. No further information was provided by the facility. | 2014-04-01 | ||
| 6335 | 6335 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 174 | E | X6TY11 | Based on observation, staff interview, and resident interview, it was determined the facility failed to provide residents with a telephone that afforded privacy. The two phones available for resident use were located in public areas frequented by other residents and staff, were not operable when tested , and were affixed to walls at a height not readily accessible to wheelchair-bound residents. This affected 6 of 10 sampled residents (#s 3, 4, 5, 7, 8, and 9) and had the potential to affect all residents who required and were able to use facility telephones for outside communication. Findings include: On 8/25/10, at 6:54 a.m., Resident #9 approached the facility's Administrator and surveyor and stated that the telephone in the Lazy Day Lounge was "turned off." The Administrator stated, "We'll get it fixed," while the surveyor accompanied the resident into the lounge and attempted to call the out-of-town number to which the resident stated she could not connect. The surveyor dialed the number twice and each time received a recorded message that stated, "This call cannot be completed as dialed ..." Resident #9 stated she had called the number twice the previous week with success, but had been unsuccessful in placing the call twice the week of survey. The telephones in the Lazy Day and outside the Red Wing lounges, each of which were located on a wall approximately five feet from the floor and out-of-reach for wheelchair-bound residents, were tested again by the surveyor at 8:04 a.m. and 8:30 a.m. - both attempts to place out-of-town and local calls were unsuccessful. On 8/25/10, at 11 a.m., surveyors met with six male and six female residents. When asked whether they and other residents could place phone calls in private, several of the residents stated the telephones were often not working and that they could not speak privately when the phones were operational. The facility's admission packet was reviewed during survey. Under Resident Rights, the facility informed residents that, "The resident has the right to ha… | 2014-04-01 | ||
| 6336 | 6336 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 253 | E | X6TY11 | Based on observation and staff interview, it was determined the facility failed to ensure maintenance and housekeeping services adequately maintained resident areas in a comfortable and orderly manner. This was evidenced by dirty windows and window blinds in the two resident lounges, and heavy scratching on two second-floor hallway doors, and a broken armoire in which a television was stored for resident viewing. This had the potential to affect all residents in the facility that used either of the two lounges or the second floor hallway. Findings include: On 8/24/10, during an environmental tour of the facility at 1:08 p.m., the following was observed: * Heavy water stains on the windows of the Lazy Day Lounge. The stains obscured residents' view to the outside. * Window blinds of the Lazy Day Lounge were covered with a thick layer of sticky dust. * Broken cupboard door on the Red Wing Lounge armoire that held a television for resident viewing. * Heavy water stains on the windows of the Red Wing Lounge. The stains obscured residents' view to the outside. * Window blinds of the Red Wing Lounge were covered with a thick layer of sticky dust. * Second Street Soiled Utility door had scratches which measured approximately one inch wide and ran the entire width of the door. * Second Street Clean Linen door was observed with scratches measuring approximately two inches wide running the entire width of the door. On 8/26/10, at approximately 4:00 p.m., the facility's Administrator and DON were informed of the observations. No further information was received by the facility. | 2014-04-01 | ||
| 6337 | 6337 | SYRINGA CHALET NURSING FACILITY | 135111 | 700 EAST ALICE STREET (83221-4925) | BLACKFOOT | ID | 83221 | 2010-08-30 | 323 | E | X6TY11 | Based on observation and staff interview, it was determined the facility failed to ensure the residents' environment was as free from accident hazards as possible when one cabinet with hazardous materials was left unlocked within an unlocked tub room. This had the potential to affect any independently ambulatory residents who were cognitively impaired. Findings include: On 8/25/10, while touring the facility with the Physical Plant Director, the First Street tub room was found unlocked at 2:40 p.m. Upon entry, the surveyor and Physical Plant Director confirmed that a cabinet with shampoo, conditioner, and lotion had been been left unlocked and accessible to cognitively impaired ambulatory residents. Each container of shampoo, conditioner, and lotion included labels with the warning, "Keep out of the reach of children." The Physical Plant Director immediately called down the hall to another staff member and asked why the tub room door had been left unlocked. The surveyor heard the second staff member respond that the room was left unlocked for a resident who was preparing for a bath. No resident who was ready for bathing was observed when the Physical Plant Director and surveyor exited the First Street tub room. | 2014-04-01 |
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CREATE TABLE [cms_ID] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );