I ! I I112/11/08 I ' !I · Employee #6 on April 6, 2009 at 11:30 AM, who acknowledged that the...

$Page 1: I ! I I112/11/08 I ' !I · Employee #6 on April 6, 2009 at 11:30 AM, who acknowledged that the quarterly MDS did not reflect I' the resident's hip fracture. The record was reviewed$
Health Reoulation Administration

PRINTED: 05/1212009FORM APPROVED

STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X1) PROVIDERISUPPLIERlCLIAIDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDINGB_ WING _

(X3) DATE SURVEYCOMPLETED

HFD02-0017

GRANT PARK CARE CENTER

I STREET ADDRESS, CITY, STATE, ZIP CODE

5000 BURROUGHS AVE. NEWASHINGTON, DC 20019

NAME OF PROVIDER OR SUPPLIER

! IL OOollnitial Comments i

! ii'! A Licensure and complaint investigations surveyi was conducted on April 6 through 9, 2009, Th,e Ii following deficiencies were .based on o.bservatlons, II record review, staff and resident mterviews. The iI sample included 30 residents based on a census of Ii 273 residents on the first day of survey and 30 i! supplemental residents. I

L 0511 3210.4 Nursing Facilities ij ,

I A charge nurse shall be responsible for the 1,'

I following:!i (a)Making daily resident visits to assess physical II and emotional status and implementing any i! required nursing intervention; I! Ii (b)Reviewing medication records for completeness, ii accuracy in the transcription of physiclan orders, 1.

1

'I and adherences to stop-order policies;! II (c)Reviewing residents' plans of care for .. I

"

Iappropriate goals and approaches, and revrsing II them as needed;

, (d)Oelegating responsibility to the nursing staff for Ij direct resident nursing care of specific residents; ,II! .. II (e)Supervisingand evaluating each nursing ,i

i employee on the unit; and iI !

1, (f)Keeping the Director of Nursing Services or his or I! her designee informed about the status of residents. II This Statute is not met as evidenced by: I1 jj Ii A. Based on record review and staff interview for six!

,_t (6) of 30 sampled residents, it was determined that I, the charge nurse failed to iI I

Health RegulatIon Administration/"> I

IF" Ii -0 I' i, ~ A j ....,')/1 J~~.A..J2A/G, /,I-'~·VVI../f/\...£.U;,:t-,t -== - .

SlATE FORM

IPreparation and/or execution of this Iplan of correction does not constitute iadmission or assent by the provider to Ito the truth, accuracy or veracity of the Ii

facts alleged or conclusions set forthin the Statement of Deficiencies (SOD);The plan of correction is prepared and Iexecuted solely because it is required i

under law'. IL 051 i1, Resident #1 5/8/09 scheduled Quarterly! 5/14/09MDS was updated to reflect a diagnosis of!COPO and obesity. I

iResident #4 quarterly 4/20/09 MDS was 15/14/09corrected to reflect a fractured hip, IResident #6 annual MDS is coded to I112/11/08Reflect the weight of 108. The 12109108 ,weight was the post dialysis weight dated !

12/11/08. Post dialysis weights are used IIfor dialysis patients because it is moreaccurate. The weight change was within !the 7 day assessment window for the MDSiand the difference of the admission weight Iand the MOS weight is due to dialysis 1-treatment. i

i5/14109

IjiiI15/14/09

II,i

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LOaD

L 051

Resident #8 3123109 60 days MDS wascorrected to reflect a stage II ulcer andResident #27 3/9109 annual MDS wascorrected to reflect healing ulcer on5/14/09.

Resident #12 2/05/09 significant changeMOS was corrected to reflect impairedVision.

04/09/2009

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Health Reaulation Administration

PRINTED: 05/12/2009FORM APPROVED


(X1) PROVIDERISUPPLIER/CLIAIDENTIFICATION NUMBER:

HFD02-0017


SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY

OR LSC IDENTIFYING INFORMATION)

(X5)COMPLETE

DATE


A. BUILDINGB WING _

04/09/2009STREET ADDRESS, CITY, STATE, ZIP CODE




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L 051 Continued From page 1 L 051I

accurately code the Minimum Data Set (MDS) for: Ione (1) resident for diagnoses; one (1) resident for

ia fall, one (1) resident for weight gain, two (2)residents for pressure ulcers, and one (1) residentfor vision. Residents #1, 4, 6, 8, 12 and 27.

The findings include:

1. The charge nurse failed to accurately code IResident #1's annual MDS completed February 11,2009 for a diagnosis of COPD [chronic obstructivepulmonary disease] and Morbid Obesity.

The annual history and physical assessment Icompleted December 24, 2008 listed working Idiagnoses: " ...COPD and Morbid Obesity."

According to the admission Minimum Data Set(MDS) assessment completed February 11, 2009,Section I [Disease Diagnosis] did not include COPDand Morbid Obesity.

A face-to-face interview was conducted on April 9,2009 at 4:15 PM with Employee#6. He/she acknowledged that the diagnoses were

Inot coded in Section I of the MOS. The record wasreviewed April 9, 2009.

I2. The charge nurse failed to accurately codeResident #4 for a fall on the quarterly MOS.

A review of the clinical record for Resident #4

Irevealed the resident sustained a fall on January 7,2009 with subsequent fracture according tophysician's progress notes dated January 21, I2009. The resident was hospitalized January 10through 15, 2009 wherein he/she underwent Isurgical (hemiarthroplasty) repair of the left

I

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2.The facility MDS Coordinator (MDSC) 5/22/09has conducted a review of residentsmedical records to ensure MDS isaccurately coded as well as acomprehensive assessment of eachResident was completed and MDS's wereupdated as needed.

3. MDS staff was reeducated on the ~/14/09MDS process and the importance ofaccurate coding on the MOS. MDSDirector or designee will do weekly QA toensure that the correct MDSassessments are completed, timely andcoded accurately.

6899

Health Regulation AdministrationSTATE FORM

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4. DON or designee will QA MDS'sweekly and report findings to thefacility Risk Management! QualityImprovement Committee monthly X 12months.

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L 051 Continued From page 2 I

A face-to-face interview was conducted with IEmployee #6 on April 6, 2009 at 11:30 AM, whoacknowledged that the quarterly MDS did not reflect I'

the resident's hip fracture. The record was reviewedApMI6, 2009. I

I,

femoral neck fracture.

A review of the quarterly Minimum Data Set (MDS)completed January 23, 2009, revealed Section J4(accidents) - "Hip fracture within the last 180 days" was blank.

3. The charge nurse failed to accurately code theAdmission MDS for Resident #6.

A review of the nursing notes dated December 9,2008 [admit date] revealed, " ...11-7 shift admission...wt [weight] 123 Ibs [pounds].

A review of the "Weight Record" revealed, "December 9, 2008- weight 123 Ibs "

A review Admission MDS dated December 15,2008, revealed, "Section K [Height and Weight]...b. wt (lb.) 108" IA face-to-face interview was conducted on April 7, I2009 at 10:30 AM with Employee #4. He/she Iacknowledged that the MDS was inaccurately Icoded for weight. The record was reviewed on April7, 2009. I

III

4. The charge nurse failed to accurately code apressure sore for Resident #8.

A review of Resident #8 ' s record revealed a 60day Prospective Payment System (PPS) MDSassessment completed March 23, 2009. The

L 051

Health Regulation AdministrationSTATE FORM 6899 CI6C11 If continuation sheet 3 of 62

Hea th Reaulation Administration



(Xl) PROVIDERlSUPPLIERlCLIAIDENTIFICATION NUMBER:


HFD02-0017 04/09/2009

I(X5)

i CO~:~~TE



A. BUILDING

B. WING _

STREET ADDRESS, CITY, STATE, ZIP CODE

5000 BURROUGHS AVE. NEWASHINGTON, DC 20019GRANT PARK CARE CENTER

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L 051 Continued From page 3

Stage I and one (1) Stage III pressure sores.

According to a nurse's note dated March 19, 2009,at 10:30 AM, "Resident remains in stable condition Ialert and verbally responsive. Resident's sacralpressure ulcer observed with 100% granulation ,tissue pinpoint area remains small amount serous Iexudate present without odor ...Observed right heelcontinues to present with redness ... "

The "MDS 2.0 User's Manual" page 3-159, "Forthe MDS assessment, staging of ulcers should becoded in terms of what is seen (i.e., visible tissue) Iduring the look back period. For example, a healingStage 3 pressure ulcer that has the appearance I'

(i.e., presence of granulation tissue, size, depth,and color) of a Stage 2 pressure ulcer must becoded as a "2" for purposes of the MDSassessment. "

A face-to-face interview with Employees #11 and#25 was conducted on April 8, 2009 at 9:30 AM.Employee #11 stated, "The resident initially cameinto the facility with a Stage III wound on [his/her]sacrum. It's healing now and it presents as aStage II, but I am not supposed to down stage thewound. "

Employee #25 stated, "I looked at the woundsheets when I code the MDS. The wound sheetscoded the sacral pressure sore as a Stage III. Itdidn't say a healing Stage III, just a Stage III. I Ididn't read the nurse's note describing thewound. It should have been coded as a Stage lionthe MDS." The record was reviewed April 7, 2009.1

I

5. The charge nurse failed to accurately codeResident #12 on MDS for Impaired Vision.


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(X1) PROVIDERISUPPLIERICLIAIDENTIFICATION NUMBER:

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II

IA review of Resident #12's record revealed IOphthalmology consult for glaucoma dated January I'

29, 2009 at 9:35 AM.

A face-to-face interview with Employee #7 wasconducted on April 6, 2009 at 10:00 AM. He/sheacknowledge that the resident was recentlyevaluated for glaucoma and it may be on the nextMOS. The record was reviewed April 6,2009.

A review of Resident #12's record revealed aQuarterly MDS completed November 11, 2008.Section 01, coded "0" indicating "AdequateVision, sees fine detail, including regular print innewspaper Ibooks "

6. The charge nurse failed to accurately codeResident #17's for pressure ulcers.

A review of nurse's progress notes datedDecember 17, 2008, 2:30 PM, for Resident #27,revealed the resident was readmitted to the facilitywith three (3) Stage II wounds between thebuttocks.

Physician's orders dated December 17, 2008directed the administration of wound treatmentsevery third day. The wound treatment orders werediscontinued on December 24, 2008 secondary toan assessment that the wound was healed.

The annual Minimum Data Set (MDS) completedMarch 9, 2009, revealed Section M3 (History ofResolved Ulcers) was coded as "0"representative of healed ulcers in the last 90 days.

A face-to-face interview was conducted with

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Employee #6 on April 8, 2009 at approximately12:30 PM. He/she acknowledged that the MDS wasnot reflective of the resident's history of alteredskin integrity. The record was reviewed April 8,2009. IB. Based on record review and staff interview for Ione (1) of 30 resident records reviewed, it was II

determined that the charge nurse failed to completean initial Minimum Data Set (MDS) assessment for 'I'

Resident #30.

IA review of Resident #30 ' s record revealed that I'

the resident was admitted to the facility on October24, 2008. The resident was admitted as a Medicare I'

participant under the Prospective Payment System(PPS). The initial PPS assessment was completed I'

on October 27, 2008. There was no evidence thatan initial OBRA (Omnibus Reconciliation Act) MDS 'assessment was completed.


According to the "MDS User's Manual" page 2-1, " The OBRA regulations have defined a scheduleof assessments that will be performed for a nursingfacility resident at admission, quarterly, andannually, whenever the resident experiences a Isignificant change in status, and whenever the ;facility identifies a significant error in a prior Iassessment. These are known as "OBRAassessments" ...When the OBRA and Medicareassessment time frames coincide, one assessment ,I

may be used to satisfy both requirements. "

I

I

According to the "MDS 2.0 User's Manual" ,Page 2-2, "An Admission assessment must becompleted within 14 days of admission. This

L 051 1. Resident #30 MDS could not be 1'1/4/09corrected due to time frame and Residentwas discharged to hospital on 1/4/09 and 'I

expired.

2. All other new admissions medical [5/13/09records were reviewed for a comprehensiveadmission MDS assessment to include IRAPS and corrected if needed. I

3. MDS coordinators were inserviced 5/14/09By Director of Case Mix on the importanceof the completion of the admissionassessment on all new admissions. TheMDS Director or designee will do weeklyQA of new admission MDS's to

ensure that the correct assessments withRAPS are completed within establishedguidelines.

4. DON or designee will QA MDS'sweekly and report findings to the Ifacility Risk Management! Quality IImprovement Committee monthly X 12months.





(Xl) PROVIDERISUPPLIER/CLIAIDENTIFICATION NUMBER:

HFD02-0017








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means that both the MDS and the RAPs [ResidentAssessment Protocol] (R2b and VB2 dates) mustbe completed by day 14. "A full assessment was completed on October 27,2008 and coded as the Medicare 5 dayassessment. However, no RAPS were completed.

A face-to-face interview with Employee #25 wasconducted on April 10, 2009 at 9:30 AM. He/sheacknowledged that the admission assessment withRAPs was missed. The record was reviewed April10,2009.

C. Based on observation, record review andresident and staff interview for four (4) of 30sampled residents and one (1) supplementalresident, it was determined that the charge nursefailed to initiate care plans with appropriate goalsand approaches for: two (2) residents for thepotential adverse interaction for the use of nine (9)or more medications; one (1) resident withhypertension, and incontinence; and one (1)resident for skin condition. Residents #2, 5, 12, 15,and SM2.The findings include:1. The charge nurse failed to initiate a care plan for I'

potential adverse drug reactions for the use of nine(9) or more medications for Resident #2. I

A review of the clinical record for Resident #2 Irevealed physician orders dated and signed, April 5, I2009 that included the following medications:

IIIIi

"Ascorbic Acid, Aspirin, Aranesp, Carvedilol,Citalopram, Novolin R, Renagel, Renocaps,Sensipar, Ferrous Sulfate, Diltiazem, Divalproex,Famotidine, Lisinopril, Risperidone, Diazepam,Haldol"

I L 051

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1. Resident #2 care plan for nine (9) ormore medications is in place.

!15/13/09

Resident #5 care plans for hypertensionand incontinence are in place.

5/13/09

Resident #15 care plan for dry scaly skinis in place.

5/13/09

b113/09Resident #SM2 care plan has beenupdated to include current woundtreatments and interventions. The woundassessments and notes pertaining to thewound are found in the TreatmentAdministration record which is maintainedon the unit where it is easily accessible.

IResident #12 care plans for nine (9) or 15/13/09more medications is in place.

2. Unit Managers reviewed the records of 15/22/09current residents to ensure that a care Planlis in place with appropriate goals and Iapproaches to meet the needs of eachResident. Records found out ofcompliance were updated to reflectResident current status.

3. Licensed staff have been educated on 5/22/09the importance of Completingcomprehensive Resident assessmentsand developing comprehensive 1individualized care plans with appropriategoals and approaches that will effectivelyaddress the current needs of each residenUnit Managers or MDScoordinators will update care plansquarterly and as needed to ensureappropriateness and compliance.Wound nurses will update Residents with






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L 051 Continued From page 7 IThere was no evidence in the record that a care Iplan with appropriate goals and approaches was Iinitiated for the potential for adverse drug reactionsfor the use of nine (9) or more medications. IOn April 6, 2009 at approximately 10:15 PM, a face-to-face interview was conducted with Employee#14. He/she acknowledged that the record lacked acare plan for the potential adverse reactions for theuse of nine (9) or more medications. The recordwas reviewed on April 6, 2009. I2. The charge nurse failed to initiate care plans Iwith goals and approaches for, hypertension and II'

incontinence for Resident #5.According to the resident's admission MinimumData Set (MDS) assessment completed November28, 2008, and the quarterly MDS assessment I'

completed February 20, 2009, the resident wascoded in Section H (Continence in last 14 days) asincontinent of bowel and bladder function, and wascoded in Section I (Disease Diagnoses) forDiabetes (OM) and hypertension (HTN).A face-to-face interview was conducted with theresident at approximately 3:00 PM on April 7, 2009.Resident acknowledged that he/she was wet andhad to wait to be changed, that he/she does notrequest to be changed.A review of the resident's care plans lackedevidence that facility staff initiated care plans withappropriate goals and approaches for bowel andbladder incontinence, and hypertension forResident # 5.A face-to-face interview conducted on April 8, 2009at approximately 4: 15 PM with Employee # 6.He/she reviewed the resident's clinical record andacknowledged that the resident's record

L 051 wounds care plans weekly. Wound carenurses have been instructed to placewound documentation in the treatmentadministration records. The treatmentadministration records are maintainedon the units. The Unit Managers willQA the treatment administration recordsto ensure compliance.

4. DON or designee will do randomQA of care plans and treatmentadministration records Monthly and reportfindings to the facility Risk Management!Quality Improvement Committee monthlyX 12 months.







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lacked evidence that care plans were initiated forincontinence and hypertension. He/she said, "I willinitiate the care plans right away." The record wasreviewed on April 8, 2009.3. The charge nurse failed to initiate a care plan forpotential adverse drug reactions for the use of nine(9) or more medications for Resident #12.A review of the clinical record for Resident #12revealed physician orders dated and Signed March1, 2009 that included the following medications:

I

III

There was no evidence in the record that a care Iplan with appropriate goals and approaches was .initiated for the potential for adverse drug reactions Ifor the use of nine (9) or more medications. IOn April 7, 2009 at approximately 11:15 PM, a face- 'I'

to-face interview was conducted with Employee #7.He/she acknowledged that the record lacked a careplan for the potential adverse reactions for the useof nine (9) or more medications. The record wasreviewed on April 7, 2009.

"Digoxin, Aricept, Namenda, Aspirin, Lisinopril,Lantus, Enulose, Famotidine, Furosemide,Prednisolone, Simvastatin, Valproic Acid,Metoprolol, Metformin, Novolin R and Tylenol.

4. The charge nurse failed to initiate a care plan tomanage the Resident #15's lower extremity skincondition.

A review of the clinical record for Resident #15revealed that the charge nurse failed to initiate aplan of care to manage the resident's lowerextremity skin condition. According to the historyand physical examination completed by the


Residnet #11 care plan has been amende~5/13/09To reflect the current wound status.

Resident #18 no longer resides in the /27/09facility.

2. Unit Managers will complete a 5/22/09comprehensive assessment of eachResident to develop an accurateindividualized care plans with appropri tegoals and approaches to meet the needsof each Resident. Records that werefound out of compliance were updatedto reflect Resident current status.

3. Licensed staff has been educated on OS/22/09the importance of Completingcomprehensive Resident assessments,developing comprehensiveindividualized care plans with appropriategoals and approaches as well asreviewing and revising each careplan to reflect and meet the needs ofcurrent status of Residents.Unit Managers or MDScoordinators will update care plansquarterly and as needed to ensureappropriateness and compliance.Wound nurses will update Residents with

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1. Resident #6 care plan has been 5/13/09updated to Reflect current foley size. Thebedside urine bag will be taken on everyurology appointments and the suprapubiccatheter will be changed by the urologist.

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physician on December 2, 2008, the resident'sdiagnoses included dementia, peripheral vasculardisease, degenerative joint disease, h/o pressuresores, hypertension, feeding dysfunction, asthmaand COPD. According to the quarterly MinimumData Set (MDS) signed February 11, 2009, theresident required maximum assistance with ADL'sand was dependent for transfer, positioning andmobility per Section G (Physical Functioning andStructural Problems) and received nutrition andhydration enterally Section K (Oral/NutritionalStatus) Hospice services were initiated February23,2009 per physician's order dated February 17,2009.

I

II

Resident #15 had a history of recurrent altered skin Iintegrity that required wound management. A I'

physician's order dated October 8, 2008 directed ,the following wound treatment: "Cleanse left ,.anterior foot excoriation with wound cleanser, pat ,dry, apply a thin layer of Zinc Oxide ointment, leave Iopen to air X 21 days."

A nursing progress note dated December 30, 2008,0900, revealed the wound was healed as follows:'Treatment to left anterior foot excoriation -discontinue due to area closed."

A review of the Treatment Administration Records(TAR) for the months of October and December2008 lacked evidence of the administration of thewound treatments. Facility staff was unable tolocate the TAR for November 2008 at the time ofthis review. .

A review of the December 2008 TAR revealed the Ifollowing wound treatment order dated December 9, I2008: "Wash bilateral shins with soap and water, '1

pat dry, apply Zinc Oxide cream daily X 21 days."The TAR was annotated I

L 051 wounds care plans weekly. Wound carenurses have been instructed to placewound documentation in the treatmentadministration records. The treatmentadministration records are maintainedon the units. The Unit Managers willQA the treatment administration recordsto ensure compliance.

4. DON or designee will do randomQA of care plans and treatmentadministration records Monthly and reportfindings to the facility Risk Management!Quality Improvement Committee monthlyX 12 months.



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"discontinue" on December 30, 2008.

A face-to-face interview was conducted withEmployee #4 who acknowledged the TAR lackedevidence of wound treatment to the left anterior foot Iexcoriation. IOn April 7, 2009 at approximately 11 :30 AM, an I'

observation was conducted of Resident #15 ' slower extremities, dorsal surface of bilateral shins I;

and feet. Upon observation, the dorsal surface of ,the resident's lower extremities lacked evidence of Iany open areas, however; the skin appeared very I'

dry and scaly. When queried regarding the .management of the resident's lower extremities, I'Employee #4 stated that body lotion was appliedduring routine ADL care, IA review of the care plan for Resident #15 lackedevidence of problem identification, objectives andapproaches to care for the skin of the resident'slower extremities. Employee #4 stated that a planof care was developed to address pressure sores, Ihowever; acknowledged that the care plan lackedproblem identification related to the resident's lower Iextremity skin condition. The record was reviewedApril 7, 2009.

IIIIII

5. The charge nurse failed to initiate a plan of careto manage Resident SM2's sacral pressure ulcerfrom March 7,2009 until April 8,2009.

Nursing note dated March 7, 2009 [no timeindicated] "Resident noted with stage 2 on [his/her]sacral measured 1 X 0.5 cm, red in color MD[Medical Doctor] made aware order given tocleanse area with normal Saline apply exodermpatch Q [every] 3 days and PRN [as needed]Responsible party notify."


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L 051 Continued From page 11 INursing note dated March 25, 2009 11:00 AM:"Talked about in PAR [Patients at Risk Meeting], Ithat [he/she] has stage 3 and SIP [special pressure]3000 mattress ordered for his/her bed and [he/she] Igo [got] a low bed yesterday."

II

Keep skin clean & dry IApply skin prep to elbows and heels for protectionClean skin & apply barrier cream after each episode Iof incontinenceEvaluate bowel and/or bladder continence program 'as indicatedFrequent re-distribution off areas of pressureProvide a pressure reduction surface for bed and/orwheelchair

Nursing note dated April 1, 2009 10:00 AM: "PAR-sacral ulcer stage 3 treatment stantyl and specialmattress."

Plan of Care: Pressure Ulcer Prevention initiatedMarch 8, 2009. High Risk Interventions identified:Evaluate areas of skin where the resident /patientmay have impaired sensationInspect skin daily for signs/symptoms of skinbreakdownBathe with mild soap, rinse and dry thoroughlyMoisturize skin with lotion, especially bonyprominences

On April 8, 2009 a Comprehensive Plan of Carewith problem identified as Resident has a PressureArea: Stage III Location Sacral was initiated.

This writer was unable to locate woundassessments or notes pertaining to the wound in ,.the clinical record.

A face-to-face interview was conducted on April 8,2009 at 1:10 PM with Employee #12. He/she

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stated, "The wound nurse has separatedocumentation in a book off the unit. We keep the II

measurements, the assessments and the progressnotes in our books. The unit managers documenton the care plans. The record was reviewed April 8, I2009.

D. Based on record review, interview andobservation for three (3) of 30 sampled residents, itwas determined that the charge nurse failed toamend the comprehensive care plan for: one (1)resident with a supra pubic catheter; one (1)resident's current wound status; and behaviors forone (1) resident. Resident # 6, 11 and 18.


1. The charge nurse failed to update the care planfor Foley catheter care for Resident #6 with a Suprapubic catheter.

A review of the " Report of Consultation" datedMarch 4, 2009 revealed, "Recommendations Flu[follow up] ... Levaquin 250 mg PO [by mouth] dailyfor 2 day. Bring 18 FR -Scc Foley Catheter andbedside urine bag on every urology follow up."

A review of the Care Plan entitled, "Foley Catheter... " last updated March 20, 2009 lacked evidencethat the Foley Catheter size was updated on thecare plan and that the resident will have thecatheter changed by the urologist for April 2009.

A face-to-face interview was conducted on April 7,2009 at 10:30 AM with Employee# 4. He/sheacknowledged that the care plan was not updatedto include the Foley catheter and to reflect theurologist changing the SP [supra pubic] Catheter.


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The record was review on April 7, 2009.

2. The charge nurse failed to amend the "PressureArea" care plan for Resident #11 to reflect thecurrent wound status.

A review of the "Skin Grid-Pressure" form last Iupdated on April 3, 2009 revealed, " ...Rightischium [pressure ulcer] Stage III, skin grid initiatedon February 16, 2009; Left Calcaneous [pressureulcer] skin grid initiated on March 6, 2009 ...Stage II;Right Calcaneous [Pressure ulcer] initiatedDecember 19, 2008; and Right Posterior Shin[arterial ulcer] initiated December 19, 2008.

A review of the "Pressure Area" care plan lastupdated February 24, 2009 revealed, "MultipleWounds pressure ulcers down grade to Stage II's

"

The care plan lacked evidence that the stage andlocation of the Right ischium, left and rightcalcaneous and right posterior shin ulcers wereidentified on the care plan.

A face-to-face interview was conducted on April 8,2009 at 1:10 PM with Employee #12. He/shestated, "I was told that the nurse manager issupposed to update the care plan. Additionallyhe/she acknowledged that the skin care plans werenot updated to reflect the resident's current woundstatus. The record was reviewed on April 8, 2009.

3. A review of the clinical record for Resident #18revealed that the charge nurse failed to amend theplan of care to address the exhibition of recurrentbehaviors of the possession and use of incendiary .devices I


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According to the history and physical examination Icompleted by the physician on February 2, 2009, 'I

the resident's diagnoses included hypertension,diabetes mellitus, substance abuse and neuropathy. IThe record revealed three (3) documented accounts Iof the resident either smoking, in possession ofsmoking paraphernalia and/or possession of illegal ,substance(s) in his/her room as follows: per nursing Iprogress notes, January 31, 2009, 2300, .....resident smoking and having lighter in room; " IFebruary 4, 2009, 1520, " ...smoking paraphernaliain room; .. April 5, 2009, 11 PM, ..... observedhaving illegal substance in room.."

A face-to-face interview conducted on April 7, 2009with Employee #13 revealed that Resident #18 wasassigned one (1) staff person to supervise him/her24-hours daily in accordance with physician'sorders initiated April 6, 2009; .. 1:1 monitoring everyshift for safety measures secondary to smokingparaphernalia/illegal drugs .....

A review of the care plan for Resident #18 revealedproblem identification, goals and approaches .entitled ..#11 Behavioral Issues: verbal/physicalaggression and resistance to care. "

The care plan lacked evidence ofamendments/modifications to the goals andapproaches developed to address behavioralissues. There was no evidence that the care planwas amended to identify strategies to address thebehaviors associated with the possession and useof incendiary devices and illegal substances

L 051

Health RegulatIDn AdministrationSTATE FORM 6899 If continuation sheet 15 of 62CI6C11





HFD02-0017



5000 BURROUGHS AVE, NEWASHINGTON, DC 20019




A. BUILDING

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.COMPLETE

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I

L 051 Continued From page 15 Iwithin the facility. The record was reviewed April 7, Ii

2009.

IE. Based on record review and staff interview for 131of 30 sampled records and two (2) of 30 'supplemental residents, it was determined that the Icharge nurse failed: complete the Bladder andBowel Incontinence Evaluation, Discomfort andPain Identification and Plan of Care and theBehavior Data Collection for one (1) resident; toaccurately document the behavior monitoring toolfor one (1) resident and consistently document thestatus of a wound, administration of woundtreatments for another resident and maintain woundassessment sheets and progress notes for 11'of 30sampled residents and two (2) of 30 supplementalresidents. Residents #1, 5, 6, 8, 10, 11, 13, 15, 16,18, 24, 28, 29, SM1 and SM2.


1. The charge nurse failed to complete the "Bladder and Bowel Incontinence Evaluation,Discomfort and Pain Identification and Plan of Careand the Behavior Data Collection" for Resident #6on admission.

A review of the Bladder and Bowel Incontinence II

Evaluation, Discomfort and Pain Identification and ,Plan of Care and the Behavior Data Collectionforms dated December 9, 2008 lacked any Idocumentation indicating that the forms were not .completed. i

I A face-to-face interview was conducted on April 10, I2009 at 11:00 AM with Employee #4. He/she I'

acknowledged that the evaluations were notcompleted. The record was reviewed on April 7, ,2009. I

Wound Assessments and progress notes ~re 5/13/09maintained on the record for current and IClosed records.

2.A review of Resident records completed 5/22/09to ensure that the Bladder and BowelIncontinence Evaluation, Discomfort and tPain Identification and Plan of Care and thBehavior Data Collection forms arecompleted. Records found out ofcompliance will be updated. IA review of all wound care documentation 15/22/09completed to ensure completion andaccuracy. Wound care documentation will j/13/09be maintained in the treatmentadministration record on the unit availableto staff.

L 051 !r/15/09

5/13/09

15/11/09

Ii


1.Facility staff has completed the" Bladder and Bowel IncontinenceEvaluation, Discomfort and PainIdentification and Plan of Care form andthe Behavior Data Collection form" forResident #6.

Resident #15 clinical record has beenupdated to reflect the status of theresident's wound and administration ofwound treatments.

Facility staff has accurately documentedThe behavior monitoring tool forResident # 24.





(X1) PROVIDERISUPPlIERlClIAIDENTIFICATION NUMBER:


HFD02-0017







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TAG OR LSC IDENTIFYING INFORMATION)

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2. A review of the clinical record for Resident #15revealed the charge nurse failed to consistentlydocument the status of the resident's wound anddocument the administration of wound treatments.

Physician's orders dated October 8, 2008 directedthe following wound treatment: "Cleanse leftanterior foot excoriation with wound cleanser, patdry, apply a thin layer of Zinc Oxide Ointment, leaveopen to air x 21 days. "

According to the nurse's progress notes, an entrydated October 8, 2008 revealed the initialidentification of " left anterior foot excoriation,unmeasurable due to multiple openings ... " Thenext entry related to the altered skin integrity of theleft anterior foot was October 16, 2008 and thesubsequent and final entry, documented greater .than 8 weeks later on December 30, 2008, denoted II

" ...area closed. "

A review of the Treatment Administration Records(TAR) for the months of October and December2008 lacked evidence of daily wound treatmentsadministered to the left anterior foot in accordance I'

with physician's orders.

A face-to-face interview was conducted with IEmployee #4 on April 7, 2009 at approximately11:30 AM. In response to a query regarding the Ifacility's practice as it relates to the documentationof wound management, he/she stated that the .wound treatment nurse documents the status of a Iwound on a weekly basis and evidence of woundtreatment orders carried out were documentedfollowing each treatment on the treatmentadministration record.

I L 051

IIIIIi

Staff to complete a record review of all ')/22/09other Residents with behaviors to ensurethat the behavior monitoring tool isdocumented accurately.Wound care nurses have submitted the 5/13/09wound assessments and progress notes toMedical records to be included with closedresident records and have placed the wour' dassessments and progress notes on thetreatment administration record for current Iresident to be available to staff.

3.Licensed staff have been reeducated on 15/22/09the importance of completing requiredadmission documents to include the IBladder and Bowel Incontinence Evaluatio~,Discomfort and Pain Identification andPlan of Care and the Behavior DataCollection forms and accuratelydocumenting the behavior monitoring tool.Wound care nurses have been instructed t D5/21/09maintain wound assessments and progresnotes on the treatment administration recoldfor current resident to be available to staff.Medical records staff have been instructed 5/22/09of the change to include wound Iassessments and progress notes in theclosed resident records.Unit Managers will QA admission recordsDaily times 5 days a week to ensurecompliance and make random visualrounds and review treatment administratiorrecords to ensure compliance. Medical Irecords will be randomly monitored byDON or designee to ensure wound caredocumentation is kept in the closed record.Behavioral specialist will make randomrecord QA to ensure that the behaviormonitoring tools are completed accurately

Health Regulation AdrnlnistrationSTATE FORM CI6C11 If continuation sheet 17 of 626899





HFD02-0017








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Employee #4 acknowledged inconsistencies in thedocumentation of the status of the wound and thelack of documentation on the TAR that woundtreatments were administered. The record wasreviewed April 7, 2009.

II

3. The charge nurse failed to accurately document Ithe behavior monitoring tool for Resident # 24. II

A review to the history and physical examinationcompleted by the physician December 9, 2008,Resident #24 ' s mental health diagnosis includedBipolar Disorder. According to physician's orderssigned April 1, 2009, Resident #24 ' s psychotropicmedication regimen included Seroquel 150mg podaily and Ativan 2mg every 4 hours as needed (prn)for agitation.

A review of the medication administration records(MAR) for February and April 2009, revealed Ativanhad been administered on more than ten (10)occasions during each of the months reviewed. Areview of the facility's behavior monitoring toolentitled ..Psychoactive Medication MonitoringRecord" for the months of February and April2009, revealed annotations of zeros with a linedrawn through or " N" for " no" and severalspaces left blank. The monitoring tool lackedevidence of the behaviors to be monitored. Therewas no evidence of a correlation between themonitoring tool and the .. prn" administration ofAtivan.

According to facility policy #3.8Psychopharmacological Medication Use, revisedJanuary 15, 2009; Item #3 - "Facility staff shouldmonitor the resident's behavior pursuant to facilitypolicy using a behavioral monitoring chart orbehavioral assessment record for residents

L 051 4.DON or designee and behavior specialiswill randomly QA Resident records toensure compliance andreport findings to the facility RiskManagement! Quality ImprovementCommittee monthly X 12 months.






HFD02-0017


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receiving psychopharmacological drugs for organicmental syndrome with agitated or psychoticbehaviors. "

A face-to-face interview was conducted with IEmployee #3 on April 9, 2009 at approximately 3:30 IPM who acknowledged the behavior monitoring toolwas inaccurately documented. The record wasreviewed April 9, 2009. I4. The charge nurse failed to maintain WoundAssessments and progress notes on current andclosed resident records.

A review of clinical records revealed that therecords lacked evidence that wound assessmentsand nursing progress notes were maintained on therecord in date order for Residents: 1, 5, 8, 10, 11,13, 15, 16, 18, 28, 29, SM1 and SM2.

A face-to-face interview was conducted on April 8,2009 at 1: 10 PM with Employee #12. He/she Istated, "The wound nurse has separatedocumentation in a book off the unit. We keep the ,measurements, the assessments and the progressnotes in our books."

L 052 3211.1 Nursing Facilities

Sufficient nursing time shall be given to eachresident to ensure that the residentreceives the following:

(a)Treatment, medications, diet and nutritionalsupplements and fluids as prescribed, andrehabilitative nursing care as needed;

(h\PrnnAr r~rA tn minimi7A nrA~~llrA IlIrAr~ ~nrl

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I6899 CI6C11 If continuation sheet 19 of 62







HFD02-0017NAME OF PROVIDER OR SUPPLIER



A. BUILDINGB, WING _

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L 052 Continued From page 19 L 052

contractures and to promote the healing of ulcers: I(c)Assistants in daily personal grooming so that the Iresident is comfortable, clean, and neat as Ievidenced by freedom from body odor, cleaned and ,trimmed nails, and clean, neat and well-groomed Ihair' ,, I(d) Protection from accident, injury, and infection; I(e)Encouragement, assistance, and training in self-care and group activities;

(f)Encouragement and assistance to: I(1)Get out of the bed and dress or be dressed in his 'I'

or her own clothing; and shoes or slippers, whichshall be clean and in good repair; I(2)Use the dining room if he or she is able; and I(3)Participate in meaningful social and recreational ,I

activities; with eating;

(g)prompt, unhurried assistance if he or sherequires or request help with eating;

(h)prescribed adaptive self-help devices to assisthim or her in eatingindependently; I(i)Assistance, if needed, with daily hygiene, i',

including oral acre; and ,

j)Prompt response to an activated call bell or call for Ihelp, I'

A. Based on observation, record review and staff I'

and resident interviews, for three (3) of 30


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sampled residents and two(2) supplementalresidents, it was determined that facility stafffailed to give sufficient nursing time to: assess one(1) resident for pain, follow up on a podiatry consultfor one (1) resident, follow up on a cardiac consultfor one (1) resident, discontinue Risperidone forone (1) resident and administer medication as perphysician's orders for one (1) resident. Residents#4, 7, 24, JH2 and S1.

IIIIIII

1. Facility staff failed to give sufficient nursing time Ito treat Resident S1 ' s complaint of pain. IA. Resident 81 was observed sitting in a wheelchair I'

on April 9, 2009 at 3:15 PM requesting pain .medication. Employees #26 and 27 were at the Imedication cart doing the narcotic shift count. !

Employee #27 reviewed the resident's "Controlled Substance Record" and stated, "Youreceived pain medication at 1:15 PM and you get itevery four hours." The resident stated, "I didn'thave anything for pain today." After no response I'

from Employee #27, the resident went to his/her~m. I

IIIIIIi


Employee #27 failed to assess the location,intensity, type and onset of the pain the residentwas experiencing when he/she asked for painmedication. There was no attempt to notify thephysician that the resident's pain was notcontrolled by the currently prescribed medication.

The resident was observed at 3:30 PM in his/herroom, lying in bed on the right side, knees drawnup, with facial grimacing. The resident stated, "Ihurt. " The resident patted his/her left side.

A review of the resident's record revealed that


L 052

6899



L 052

1. Resident S 1 currently receives 4/18/09medication per physician order.Employee #27 is no longer employed at 4/15/09facility.

2, Residents who are receiving pain 5/22/09Medication and the pain flow sheets will bereviewed by the Unit Managers to ensureresidents receive pain medication perphysician orders and have been assessedprior to medication administration and that Ithe documentation is timely and accurate.

3. Licensed staff has been reeducated on 5/22/09the importance of pain medicationadministration process. Unit managers to IQA residents MAR's and narcotic flowrecord daily to ensure appropriate pain Imedication is administered anddocumented.

4. DON or designee will do randomQA of pain medication administrationrecords Monthly and report findings to thefacility Risk Management! QualityImprovement Committee monthlyX 12 months.





(X1) PROVIDERlSUPPLIERlCLIAIDENTIFICATION NUMBER:

HFD02-0017


04/09/2009STREET ADDRESS. CITY. STATE. ZIP CODE






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the resident had returned from a hospitalization fora splenectomy on April 1, 2009. A physician'stelephone order dated April 2, 2009 directed, "Darvon 65 mg 1 tab by mouth every 4 hours asneeded for abdominal pain. "

The "Controlled Substance Record" for ResidentS1 documented that a Darvon 65 mg tablet wasremoved from the narcotics drawer at 1315 (1:15PM) on April 9, 2009. The narcotic shift count wasobserved at the time of this review and revealedthat 11 tablets had been administered to theresident from April 2 through April 9, 2009 leaving19 tablets available per the "Controlled SubstanceRecord". A review of the medication card revealed20 tablets of Darvon present.

Employee #27 was asked if the resident hadmedication prescribed for break through pain.He/she reviewed the April 2009 MAR and noted thatthe Darvon 65 mg tablet was not signed indicatingthat it was administered to the resident for April 9,2009. The last dose of Darvon the resident received Iwas documented as 10:00 PM on April 8, 2009 (17hours prior to the resident's 3:30 PM request on .April 9, 2009). .

Employee #26 stated, "I must have forgotten togive [Resident S1] the medication. I am very sorry."

A second review of the "Controlled SubstanceRecord" revealed that 1555 (3:55 PM) was writtenover the previous time of 1315 (1:15 PM) as thetime the Darvon 65 mg tablet was removed from thenarcotic drawer.

According to the April 2009 MAR the residentreceived the medication at 1540 (3:40 PM). On

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HFD02-0017 04/09/2009



A. BUILDINGB, WING _







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!

IPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

L 052,

Continued From page 22 Ithe back of the April 2009 MAR under "Medication I'

Exception and Hold Notes" was an entry dated"4/9/09 at 1428 (2:58 PM) Darvon 65 mg, Reason- I'

c/o (complaint of) abd (abdominal) pain; Result -helpful." I

II

II

A nurse I s note dated April 9, 2009 at 1515 (3:15PM) documented, " ...C/o abdominal pain.Medicated with Darvon 65 mg po (orally) at 1545(3:45 PM). "

According to the quarterly Minimum Data Setassessment completed December 24,2008, theresident was coded in Section B (CognitivePatterns) with no long or short term memory losswith independent cognitive skills for daily decisionmaking. The record was reviewed April 9, 2009,

2, A review of the clinical record for Resident #4revealed that facility staff failed to give sufficientnursing time to follow through on a physician's orderto obtain a podiatry consultation,

Resident #4 was admitted to the facility October 21,2008, According to the history and physicalexamination completed by the physician on October20, 2008, the resident's diagnoses included insulin'dependent diabetes mellitus (IDDM), hypertensionand dementia,

A physician's progress noted dated February 14, I'

2009 revealed the resident sustained a hip fractureand subsequent hemiarthroplasty in January 2009, I'

Additionally, the resident sustained an alteration in .the skin integrity of both heels as evidenced by the I',

following order dated March 19, 2009, "wash bothheels, pat dry, apply Neutrashield ...elevateresidents' heels at all times on pillows to prevent I'

opening on heels, "

i

10PREFIX

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L 052 1. Resident #4 has been seen by the 14/09/09Pod iatrist.

2. Unit Managers will conduct a chart '15/22/09review to determine which Residents havenot been evaluated by the podiatrist and Iobtain physician order for allcurrent Residents who have not beenevaluated to be evaluated,


3, Licensed staff will be re-educated on 5/18/09The facility process to place new orders inan accordion file for the Unit Managers to

daily review, Licensed staff will bereeducated on the facility policy regardingthe 24 hour chart review process. The IDTwill review in the daily lOT meeting the 24hour report and new orders to ensure neworders are acted on appropriately,

4, DON or designee will do random chartQA for podiatry visit compliancereport findings to the facility RiskManagement! Quality ImprovementCommittee monthly X 12 months






HFD02-0017




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A review of the physician's orders (POS) fromDecember 2008 through the current orders datedApril 1, 2009 directed "podiatry consult!care prn. "

I

II

Resident #4 had a history of 100M and a history ofan alteration in the integrity of skin of both feet in Ithe absence of a podiatry consultation as directedby the physician. The record was reviewed April 6, I'

2009.

A face-to-face interview was conducted withEmployee #6 on April 6, 2009. In response to aquery regarding the status of an evaluation by thepodiatrist. He/she stated that the resident was onthe podiatrist's list of resident's to be seen.Employee #6 acknowledged that Resident #4 hadnot been evaluated as of the date of this review.

3. Facility staff failed to give sufficient nursing timeto follow doctor's orders to discontinueRisperidone for Resident #7.

A review of Resident #7's record revealed aphysician's order dated October 23, 2008 thatdirected, "Risperidone F/C 0.5MG Tablet, 1 tab bymouth every 8 PM for Delusional Behavior. "

A review of a psychiatrist's progress note datedMarch 26,2009, revealed" Reevaluated residentbehavior and medication, no behavior managementissue in the last three (3) months, may discontinueRisperidone 0.5 MG order. "

A review of Physician Order Sheet (POS) revealedthat on March 26, 2009 at 10:00 AM, an order was 'written to "Discontinue Risperidone 0.5 MG." '1

II

A review of the Medication Administration Record

2. Unit Managers will conduct QA of 5/22/09orders written over the past 60 days toensure compliance. Unit Managers andADON will continue review new ordersdaily.

3. Licensed staff will be reeducated to p/22/09place new orders in an accordion file forUnit Managers to complete daily reviews5 times a week. Licensed staff will bereeducated regarding the 24 hour chartreview process and monthly MAR/TARturnover.

10PREFIX

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1. Resident #7 no longer receivesRisperidone.

14/08/09




L 052

4. DON or designee will QA 24 hourchart review process during morning lOTmeeting and MARIT AR turnover monthlyand report findings to the facility RiskManagement! Quality ImprovementCommittee monthly X 12 months ..





(X1) PROVIDERISUPPLIER/CLIAIDENTIFICATION NUMBER

HFD02-0017


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B. WING _

04/09/2009




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L 052 ~/27/09Continued From page 24

[MAR] revealed that on March 26,2009 at 8:00 PM Ithe nurse's initials in the area designated indicated I'that the last dose of the medication was given andthe word "Discontinued" written after the initials. IAccording to the March 2009 MAR, there were no I'

nurse's initial in the area designated for March 27,28,29, 30 and 31, 2009 indicating that the i

medication was not administrated to the resident. III

A review of April 2009 MAR revealed that the Iresident received Risperidone 0.5 mg on April 1, 2, I3,4, 5, 6 and 7, 2009 as evidenced by the nurses'initials in the designated areas documenting that themedication was administered to the resident.

A review of Physician Order Sheet (PaS) of April2009 revealed no order written to restartRisperidone.

A face-to-face interview was conducted withEmployee #14 at the time of the findings. He/Sheacknowledged the above mention medication wasdiscontinued. The record was reviewed March 5, I

:O:9reView of the clinical record for Resident #24 Irevealed facility staff failed to give sufficient nursing Itime to follow physician's orders to obtain acardiac consult.

According to the hospital discharge summary datedFebruary 20, 2009, Resident #24 ' s diagnosesincluded cardiomyopathy, hyperlipidemia, chronicobstructive lung disease, hypertension, congestive I'

heart failure and status post myocardial infarction. I

i

1.Resident #24 cardiology appointmenthas been rescheduled for 6/02/09.

5/07/09

5/07/09

Health Regulation Administration

STATE FORM 6899

2. A review has been done to identifyResidents with implanted cardiac devices.These Residents charts will have a yellowdocument stating "Resident has adefibrillator. The document will be locatedat the front of the chart. The Resident willalso have a yellow coordinating wrist bandwhich indicates that the Resident has adefibrillator. Unit Managers will QAPhysicians orders to ensure all Residentswith Internal cardiac devices (lCD)have been assessed.

3. Licensed staff have been educatedRegarding (lCD) Identification. All newAdmission with (ICD) implant will beassessed per facility protocol. UnitManagers will monitor the (ICD) processduring new admission chart reviews.

4. DON or designee will review (ICD)identification process weekly during caremanagement meeting and report findingsto the facility Risk Management! QualityImprovement Committee monthly X 12months.







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L 052 Continued From page 25 I L 052

He/she was hospitalized February 8 through 20, I2009 secondary to an acute exacerbation ofcongestive heart failure and underwent placement Iof an Internal Cardiac Defibrillator (ICD) during the Ihospitalization.

According to the hospital discharge instructions as it I'relates to the management of the ICD;recommendations included a device and wound ,surveillance assessment approximately six (6) Iweeks post implantation and a noninvasive reviewof the device parameters, function and cardiac I'

events every 3-4 months.

Physician's readmission orders dated February 20, I2009 and subsequent physician's orders signed I'

April 1, 2009 directed "Pacemaker check oncemonthly. " IA face-to-face interview was conducted withEmployee #4 on April 9, 2009 at approximately 11AM. In response to a query regarding the status ofResident #24 ' s ICD device assessment; he/shestated that the assessment would be conducted bythe cardiologist and that an appointment wasscheduled for April 27, 2009. When queriedregarding the physician's orders that directed Imonthly "Pacemaker checks," he/she stated thatthe order actually referred to the ICD and that theresident did not have a pacemaker. He/she statedthat a clarification of the order would be obtained.

Employee #4 acknowledged that the ICD deviceassessment had not been performed. The resident Iwas greater than six (6) weeks post implantation of "the ICD device without evidence of an assessment.The record was reviewed April 9, 2009.

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IL 052 Continued From page 26

,II

A physician's order, signed and dated on April 3, I2009, directed "Magnesium Oxide 400 mg tablet, 1 I'

tablet by mouth every day for supplement" .

On April 6, 2009, at approximately 10:50 AM, during I;

the medication pass for Resident JH2, Employee#33 did not administer Magnesium 400 mg tablet to .the resident.

5. Facility staff failed to give sufficient nursing timeto ensure that Resident JH2 was free frommedication errors.

When the Medication Pass worksheet wascompared with Medication Administration Recordand the physician's orders, the omission wasdiscovered.

A face-to-face interview was conducted on April 6, II

2009 at approximately 2:30 PM with Employee #33.He/she stated, "I'm not sure if I gave it or not, Ithought that I had given it."

B. Based on record review, observations and staffinterview for one (1) of 30 sampled residents, it wasdetermined that facility staff failed to give sufficientnursing time to implement interventions to restorebladder function and or initiate an incontinencetraining program for Resident #27.

IThe findings include: 1

Facility staff failed to give sufficient nursing time to Iimplemented interventions to restore bladder I'

function and or initiate an incontinence training .program for Resident #27.

t

A review of the clinical record for Resident #27

IDPREFIX

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L 052 1.Resident # JH2 is receiving medication . 4/06/09aso~ered. I2. Competencies for medication administration 5/22/09for licensed staff was completed. UnitManagers and pharmacy consultant will dorandom medication administrationassessments (Med Pass review) weekly x 4weeks to ensure accuracy and consistency.

3 Employee #33 and licensed nurses have 5/21/09been re-educated on medicationadministration.

4.The DON/ADON/SDC will do monthlymedication administration assessments anreport findings to the facility RiskManagement! Quality ImprovementCommittee monthly X 12 months.

1. Resident #27 has a bed/chair alarm in 13/22/09place.

Resident #27 has been assessed for 5/14/09the ability to participate in the restorativenursing Bowel and Bladder (B&B) programand was placed on a B&B program.

2. Unit Manager will screen Residents who 5/22/09are incontinent of B& B to determineappropriateness of the B&B trainingprogram. Residents who are identified willbe placed on a B&B program.

3.Licensed staff re-educated on facility fj/22/09Policy and procedure related to bowel andBladder management.Staff and Restorative Nursing Team.reeducated on how to assessResident for B&B program.






HFD02-0017 04/09/2009



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Continued From page 27

revealed that the resident sustained three (3) fallswithout injury during March 2009. Each of the fallswas associated with attempts to mobilize to thebathroom as evidenced by the following nursingprogress notes: March 12, 2009, "resident fell onto Ifloor in bedroom, out of bed to go to bathroom;March 19, 2009, resident found sitting on floor near Ibed, tried to go to the bathroom; March 22, 2009,found sitting on floor mat next to bed, trying to gothe bathroom. " ;



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4. DON or designee will random QA B&Bprogram monthly and report findings to thefacility Risk Management! QualityImprovement Committee monthlyX 12 months.

L 052

According to the comprehensive care plan updatedMarch 11, 2009, the interdisciplinary team identified" incontinent of bowel and bladder" as a problem.Approaches to address the incontinence included "place resident on a q 2 hr toileting program ifappropriate. "

According to the annual Minimum Data Setassessment completed date March 9,2009, theresident was coded with no long or short memoryproblems in Section B (Cognitive Patterns).Additionally, the "Resident Summary" datedMarch 27, 2009 revealed that Resident #27 wasalert, oriented and able to understand informationconveyed without difficulty.

C. Based on observation, staff interview and recordreview for three (3) of 11 supplemental residents, itwas determined that facility staff failed to givesufficient nursing time to provide necessaryservices to maintain good personal hygiene forthree (3) residents. Residents A1, A2, and A3.


Facility staff failed to give sufficient nursing time toprovide necessary services to maintain goodpersonal hygiene for Residents A1, A2, and A3.

I LOS2 Restorative nurse will do weekly QA ofResidents on bowel and bladder programto evaluated progress.

Health Regulallon AdministrationSTATE FORM 6899 CI6C11 If continuation sheet 28 of 62






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L 052 Continued From page 28 5/22/09

1. According to the resident's clinical record, theannual Minimum Data Set (MDS)completed on February 5, 2009, Resident A 1 wascoded in Section G (PhysicalFunctioning and Structural Problems) as beingtotally dependent for toileting andpersonal hygiene and unable to attempt test forbalance while standing. Resident isincontinent of bowel and bladder function accordingto Section H (Continence). Theresident's diagnoses according to Section I(Disease Diagnoses) included missing limb(amputation), stroke, and dementia.

On April 8, 2009 at approximately 09:20 AM,Resident A 1 was observed seated in wheelchair inhis/her room, He/she had a left below the kneeamputation. When asked about toileting, theresident responded; "I go to the bathroom bymyself but the bathroom in here was being used. Isometimes need help with loose bowel and had toclean myself when the staff failed to respond.Sometimes I can not clean up the mess completely.You do not always get the help when you call forsomeone so I try to do as much as I can. "

According to an incident report of February 23,2009 at 12:30 PM, the resident was found to besoiled and had not been toileted since the beginningof the shift.

2. According to the resident's clinical record, the ,quarterly MDS completed on March 13, 2009,Resident A2 was coded in Section G (PhysicalFunctioning and Structural Problems) as beingtotally dependent for toileting and personal hygiene I'

and unable to attempt test for balance whilestanding, Resident is incontinent of bladder I

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L 052 1.Residents A 1, A2, A3 are receivingtimely incontinent care.

2. Review of current residents coded asincontinent on MDS has been completedand assessments initiated as appropriate.

5/22/09

5/22/093. Nursing staff has been re-educated ontimely incontinent care, repositioning, andanswering call lights timely. UnitManagers/Supervisors/Charge Nurses willrandomly validate compliance throughobservation and daily rounds,

4. DON or designee will QA random timelyincontinent care, repositioning, andanswering call lights timely report findingsto the facility Risk ManagemenU QualityImprovement Committee monthlyX 12 months.

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function according to Section H (Continence). Theresident's diagnoses according to Section I(Disease Diagnoses) included stroke, andhemiplegia / hemiparesis.

On April 8, 2009 at approximately 1:30 PM,Resident A2 was observed seated in a wheelchairin the day room across from the nursing station.A face-to-face interview was conducted withResident A2 on April 8, 2009 at approximately 1:45PM. He/she said, "I was changed at 8:00 AM bythe morning shift, I am wet right now and will bechanged after lunch. I do need help with toileting. "3. According to the resident's clinical record, theannual Minimum Data Set (MDS)completed on March 16, 2009, Resident A3 wascoded in Section G (PhysicalFunctioning and Structural Problems) as beingtotally dependent for toileting andpersonal hygiene and unable to attempt test forbalance while standing. Resident isincontinent of bowel and bladder function accordingto Section H (Continence). Theresident's diagnoses according to Section I(Disease Diagnoses) included arthritis, stroke,glaucoma and dementia.

On April 7, 2009 at approximately 8:00 AM,Resident A3 was observed seated in a gerichair in Ithe day room across from the nursing station from8:00 AM to 1:30 PM. During the observation period,the resident was not offered incontinent care 'including checking for wet/soiled diaper. IA review of the resident's clinical record revealed .a "Bowel Incontinence Evaluation" Ilast reviewed on December 11, 2008. According tothe "Bowel Incontinence Evaluation" ,the resident have history of incontinence related I

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to cognitive impairment, unable totransfer to toileUcommode, and unable toconsistently communicate urge to eliminate.

A face-to-face interview was conducted withResident A3 on April 8, 2009 at approximately 2:45PM. He/she was unable to respond.There was no evidence that facility staff give .sufficient nursing time to consistently offered Iincontinent services necessary to maintain goodpersonal hygiene for Residents A1, A2, and A3.

A face-to face interview was conducted with I'

Employee #23 on April 8, 2009 at approximately ,3:10 PM. Employee #23 said, "My residents are Igiven incontinent care by the night nurses in theAM. I give them PM care after lunch when I putthem in bed just before my shift ends. When ask the :frequency of incontinent care Employee # 23 said, Ido not know. "A face-to-face interview was conducted withEmployee #24 on April 8, 2009 at approximately1:10 PM. When asked the frequency of incontinentcare for Resident A2, Employee #24 responded, "Igive incontinent care in the AM and before lunch.The resident was supposed to call for help buthe/she was not wet. " The records were reviewedApril 8, 2009.D. Based on observations of two (2) of three (3)wound treatments, it was determined that facilitystaff failed to give sufficient nursing time to maintain Iclean technique during the wound treatments forResidents #3 and 8. .

The findings include: I1. Clean technique was not maintained for a woundtreatment for Resident #3.

A wound treatment observation was conducted

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4. DON or designee will do random QAOf clean technique when providing woundcare, hand washing, and infection controlweekly during wound care rounds andreport findings to the facility RiskManagemenU Quality ImprovementCommittee monthly X 12 months.

L 052 1.Resident #3 and 8 did not sustain p/14/09adverse effect. Employee #11 and #12have been reeducated on clean technique,hand washing and infection control.

2.The infection control nurse and the Unit 5/22/09mangers will assess the knowledge, skillsand abilities of licensed staff regardinginflection control, clean technique andproper hand washing.

3.Licensed staff will be reeducated on the 5/22/09importance of practicing the cleantechnique when providing wound care,hand washing, and infection control.Return demonstration will be requiredduring retraining. Unit Managers ordesiqnee will make rounds weekly withwound care nurses/licensed staff toobserve for compliance.





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L 052 Continued From page 31 L 052

on April 7, 2009 at 2:30 PM to Resident #3' s left 'arm. Employee #12 failed to wash off the bedside Itable prior to establishing a clean field. A non-permeable barrier was placed on the bedside tableand wound care items were assembled.

The resident was sitting on the bed, feet on the floorand head resting on a pillow placed towards the footof the bed. The resident's left arm was resting onthe bed.

Employee #12 failed to place a barrier under theresident's left arm on top of the bedspread.Employee #12 removed a scissors from his/herpocket, did not clean the scissors, cut the gauzewrapped around the resident's arm and replacedthe scissors into his/her pocket.

The dressing was stuck to the resident's wound Iand Employee #12 sprayed "Skin Integrity" Iwound cleanser on the wound to loosen thedressing. A wet spot was observed on thebedspread underneath the resident's left arm afterthe wound dressing was removed. The soileddressing was observed with a small amount ofserous drainage on it.

During the wound treatment, Employee #12changed gloves four (4) times and failed to washhands between glove changes.

2. A wound dressing change was observed forResident #8 ' s sacral wound on April 8, 2009 at8:35 AM with Employee #11.

Employee #11 completed the wound treatment withfive (5) glove changes. Hands were not washedbetween glove changes.

Employee #11 was asked why he/she did notHealth Regulation AdministrationSTATE FORM

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L 052 Continued From page 32 Iwash hands between glove changes immediately Iafter the wound treatment observation. Employee#11 replied, "I forgot to take in the hand sanitizer. "

E. Based on observations, record review and staffinterviews for two (2) of 30 sampled residents, itwas determined that facility staff failed to givesufficient nursing time to provide appropriateservices to residents identified with a decline infunction for Residents #1 and 13.

The findings include: I

1. Facility staff failed to give sufficient nursing time Ito provide rehabilitation services for Resident #1after a noted decline in activities of daily living[ADLs] and Range of Motion [ROM].

A review and comparison of the last quarterly andannual Minimum Data Set assessments revealed Ithe following:

Quarterly MDS completed November 11, 2008: Ii

Section G1 [ADL self performance] coded residentas requiring limited assistance in bed mobility,personal hygiene and no set up help for eating.Section G 4 [Functional Limitation in Range ofMotion) leg and foot were coded as limitation onone side and partial loss.

Annual MDS completed February 12, 2009Section G1 coded resident as total dependence inbed mobility, extensive assistance in personalhygiene and supervision while eating. Section G 4leg and foot were coded as limitation on both sidesand partial loss.

The record lacked evidence that the resident hadbeen screened by the physical or occupational

L 052 1.Resident #1 and #13 were referred totherapy for screen by PT/OT/ST.

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2.A review of QI report indicating Residentwith ADL need for help increases anddecreases in Range of Motion wascompleted and list given to therapy forappropriate screening.

3.MDS Coordinator, Unit Manager, andnursing staff was reeducated on theimportance of following appropriateprocedure for referral to therapy whendeclines in functioning and change inclinical status of a resident occurs. UnitManagers will review resident statuschanges during daily rounds 5 times aweek and ADON or designee will reviewthose changes at the morning meeting withthe management team.

4.DON or designee will review the QIreport with the list of therapy screensmonthly and report findings to the facilityRisk Management! Quality ImprovementCommittee monthly X 12 months.






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L 052 Continued From page 33 Itherapist or the speech language pathologist after a "functional decline was identified.

A face-to-face interview was conducted on April 9, I,

2009 at 2:55 PM with Employee #16. He/she stated, that [he/she] was not aware of the decline in the i

ADL ' s and ROM and acknowledged that the Iresident was not seen by the rehabilitation I'

department after the noted decline on the annualMDS. The record was reviewed on April 9, 2009.

2. Facility staff failed to give sufficient nursing timeto provide rehabilitation services for Resident #13,who was identified with a decline in functionalability,

According to a quarterly Minimum Data Set (MDS)assessment completed November 28, 2008,Resident #13 was coded in Section G (PhysicalFunctioning and Structural Problems) as requiringlimited assistance with bed mobility and transfersand extensive assistance with eating, toileting andpersonal hygiene.

, A significant change MDS was completed onFebruary 23, 2009 and coded the resident in "Section G as being totally dependent for bedmobility, transfers, eating, toileting and personal .hygiene.

There was no evidence that the resident had been·screened by the physical, occupational or speech- I

. language therapists for rehabilitative services afterthe functional decline was identified.

Resident #13 was observed lying in bed on April 6,2009 at 11:30 AM. He/she was not able to turn onhis/her side when requested.



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A face-to-face interview was conducted on April 6,2009 at 2:00 PM with Employee #22. He/sheacknowledged that there was no rehabilitationscreen completed or rehabilitative services provided 'I'

for Resident #13 after a decline in function wasidentified. The record was reviewed April 6, 2009.

F. Based on record review and staff interview for Ii

one (1) of 30 sampled residents, it was determinedthat facility staff failed to give sufficient nursing timeto address Resident # 1's intended weight loss.


A review of Resident # 1's "Individual MonthlyWeight Report ... " dated March 27, 2009 revealedthe following:Weight date 11/01/0B weight 330.9 # [pounds)Weight date-12/01/0B weight 339.0 #Weight date-01/01/09 weight 0.0 #Weight date-02/01/09 weight 313.0 #Weight date-03/06/09 weight 312.B #Weight date-01/01/09 weight 0.0 # - refusedWeight date-02/01/09 weight 313.0 # - rewt [re-weight) 310.5 #

The resident lost 2B.5 # from December 1, 200Band February 1, 2009.

A review of the nutritional assessment last updatedDecember 29, 200B, revealed that Resident #1 ' sweight was 339 #.

There was no evidence in the record that thedietitian reviewed/assessed the resident's weightloss of 2B.5 pounds between December 1, 200Band February 1, 2009.


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L 052 1.Dieticain for that unit during that time is ~/01/09no longer employed at facility. Current .Dietician wrote a nutritional note for ,1Resident #1 nutrition on 4/6/09 and 4/15/0Regarding the significant weight loss

which was desired. Part of the weight losslwas due to fluid loss as Resident #1continues to receive 40 mg of lasix and theantipsychotic drug is indicated for weightloss as a side affect. I2. Dietician has reviewed the records of all ~/22/09Residents with significant weight loss andfound no other infractions.

3. Licensed staff reeducated on 1'5/22/09importance of communicating weightchanges to the dietician and physician.Weight team has been reeducated on theimportance of completing Resident weightsper physician order and recording them inthe record. Physicians have beenre-educated on the importance of followingthrough on all weight changes. During iquality rounds Unit Managers will review24 hour reports to identify weight changesand initiate follow up process. Unit Managerwill QA charts daily 5 times a week toensure that recommendations are carriedout per physician orders. Dietician willreview and address the records of allResidents with weight changes.

4.DON or designee and Dietician willQA Resident records to ensure consultsand recommendations are completed bythe disciplines involved and report findingsto the facility Risk Management! QualityImprovement Committee monthly X 12months.








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A review of the physician's progress note signedby the physician on March 4, 2009 revealed, "...Examination: ...Wt [weight]- 310.5 Ibs ... Reviewof Systems - Weight - stable ... "

There was no evidence on the record that thephysician addressed the intended weight loss onhis/her progress note.

According to the Report of Consultation datedDecember 16, 2008, " ...Has gained more weightup to 330, Not able to lose weight ...Recommendations: Will try Topamax for I'

neuropathy pain and weight 10SS ... Strict 1800calorie / day diet. No visitor food. No snack, no '

I

soda or juice." The consult was signed on IDecember 28, 2008 by the attending physician.

The physician's orders last signed March 4, 2009 Irevealed, "Dietary- NAS, NCS, Low FaUcholesteroldiet ..."

The record lacked evidence that the physician or ,.dietitian acknowledged the recommendation for thestrict 1800 calorie.

According to the Report of Consultation datedFebruary 13, 2009 revealed, "Findings- Pt [patient]with morbid obesity ...says has lost 40 lb. (310 now)...be sure pt ' s [patient's] diet is observed and nofood allowed from outside. "

A face-to-face interview was conducted withEmployee #6 at approximately 3:30 PM on April 6,2009. He/she stated, "The dietitian was no longerat [facility]. He/she left around the being of thisyear. He/she also stated, "[The Resident] is onLasix. Employee #6 acknowledged that there wasno follow up to the intended weight loss. Therecord was reviewed on April 9, 2009.

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L 091 3217.6 Nursing Facilities IThe Infection Control Committee shall ensure that I,

infection control policies and procedures areimplemented and shall ensure that environmental I

services, including housekeeping, pest control, Ilaundry, and linen supply are in accordance with therequirements of this chapter. I'

This Statute is not met as evidenced by:A. Based on observation and interview it was I'

determined that the facility failed to implement aninfection control program in which it investigates ,infections in the facility and failed to maintain ·1

records of incidents and corrective actions relatedto infections. II

The findings Include:

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Facility policies:"Infection Prevention and Control Program 1.1,Original Date 8/04, Revised Date 2/09 stipulated, "...The Program includes a system to monitor andinvestigate infection trends. "Infection Surveillance 8.4, Original Date 8/04,Revised Date 2/09 stipulated, " The facility will usea systematic method of collecting, consolidating,and analyzing data concerning the distribution anddetermining factors of a given disease event ...Thefacility will have baseline surveillance data on theincidence of nosocomial infections in order toidentify outbreaks ... Procedure: 1. GatherInformation from each unit at least once per week.2. Initiate a residenUpatient specific InfectionSurveillance Worksheet ...3. Summarize informationfrom the Infection Surveillance Worksheet on theMonthly Line Listing Report ...4. Tabulate infectiondata ...and document on the Annual Infection RateSummary ...5. Calculate incidence rates andcompare to previous rates ...7. Developconclusions, recommendations, actions and


L 091 L 0911.New Infection control nurse completed 4/07/09Infection control policy review and training.

Floor mats in rooms 213, 229 and 311 hav 4/06/09been cleaned and sanitized.

The interior surfaces of the ice machine '4/06/09water and ice chutes and trays were clears dof the accumulated mineral deposits, rustand other debris in nourishments rooms onthe Units 2nd North, 2 South and 4 North.

2.Hired Infection control nurse to oversee, 4/06/09implement and maintain the infectioncontrol program. Floor mats in all otherResident rooms have been cleaned andsanitized. Ice machines on all other unitshave been cleaned and sanitized.

3. Infection control nurse has been trained ~/07/09and oriented to infection control programand the importance of investigating andmonitoring infections in the facility;maintaining a record of incidents andcorrective actions related to infections;and adhering to the facility's InfectionControl Policies and Procedures.Housekeeping manager and staff hasbeen inserviced on the importance ofcleaning and sanitizing the floor matsdaily and ice machines weekly.The interior surfaces of the ice machinewater and ice chutes and trays will becleaned weekly of the accumulated mineradeposits, rust and other debris innourishments rooms on the Units.Housekeeping manager will monitorcompliance 5 times a week. DON ordesignee will QA weekly infectionControl logs to ensure proper tracking and






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IAn Infection Control interview was held with I'

Employee # 28 on April 9, 2009 at 1:10 PM,Employee #28 was asked about infection control Idata collected since the last survey, Employee #28 'stated that he/she had only been at the facility for I'

32 days and was just starting to implement the ,infection control policies and procedures, Employee I#28 reviewed the forms for the Infection Controlprogram with the surveyor and presented forms that I'

he/she had used to collect data as of March 2009,

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follow-up ..,

A sheet entitled "Monthly Line Listing Report "dated March 2009 was reviewed at the time of thisinterview, The listing contained 27 entries but thetype, site or source of the infection was notdocumented on the form, When asked how manyUTls [Urinary Tract Infections] did you have basedon your listing, Employee #28 stated he/she wouldhave to review the Individual Infection SurveillanceWorksheets as the line listing did not identify thetype, site or source of infection.Employee # 28 was unable to provide the AnnualInfection Rate Summary form or evidence thatincidence rates had been calculated and comparedto previous rates within the facility, Employee #28was unable to produce documentation that thefacility followed it's policies regarding infectioncontrol in monitoring and investigation of infectiontrends,

Employees #2 and 3 were asked to provide data onthe monitoring of infections in the facility sinceEmployee #28 was new, but no additional data wasprovided by to the surveyor by the end of thesurvey,

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trending is completed.

4, Housekeeping manager will monitorFloor mat cleaning compliance 5 times aWeek and Ice machines weekly. DON ordesignee will monitor progress Of infectioncontrol program weekly. Both will reportfindings to the facility Risk Management!Quality Improvement Committee monthlyX 12 months.






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There was no evidence that the Infection Control I'

Committee investigated and monitored infections inthe facility; maintained a record of incidents and Icorrective actions related to infections; and adheredto the facility's Infection Control Policies and I

:r::::~e:n observations during the environmental ,I'

tour on April 6, 2009 between 9:30 AM and 5:45PM, it was determined that three (3) of 51 resident Irooms with protective mats stored on floors andalong walls were soiled with spillages and three (3) ...1of eight (8) ice machine chutes and trays weresoiled with mineral deposits and other debris.

IThese findings were observed in the presence ofEmployees #15 and 32 who acknowledged thefindings at the time of the observations.


1. Floor mats used to protect residents who weresubject to falls were observed on floor surfacesbeside resident beds and along wall surfaces weresoiled with debris on the bottom and top surfaces inrooms 213, 229 and 311 in three (3) of 51 residentrooms with protective floor mats observed.

2. The interior surfaces of the ice machine waterand ice chutes and trays were soiled accumulatedmineral deposits, rust and other debris innourishments rooms on the Units 2nd North, 2South and 4 North in three (3) of eight (8) icemachines observed.


Food and drink shall be clean, wholesome, free I

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3. Dietary Manager inserviced staff on ~/06/09proper way of washing, rinsing, sanitizing,stacking and drying hotel pans as well asthe proper use of general sanitationpractices while serving, storage andcleaning the kitchen. Staff was alsore-educated on use of proper scoop sizesfor portion control, infection control andstorage procedures. Dietary Manager ordesignee will observe tray line during eachmeal to monitor accuracy of the diet orderssanitation practices and food temperatures


from spoilage, safe for human consumption, andserved in accordance with the requirements setforth in Title 23, Subtitle B, D. C. MunicipalRegulations (DCMR), Chapter 24 through 40.This Statute is not met as evidenced by:Based on observations during the tour of the mainkitchen, it was determined that the facility failed tostore, prepare, distribute and serve food undersanitary conditions as evidence by: 16 of 18 hotelpans stored soiled and wet and ready for reuse,four (4) of four (4) drains with no air gap above thedrain, four (4) of four (4) incorrect size scoops usedfor plating the breakfast meal on April 6, 2009, food Itemperatures on the tray line with three (3) of seven(7) hot foods below 140 Fahrenheit (F) and one (1)of two (2) cold foods above 40 F, five (5) of five (5.) I'opened items undated in the dry storage area, andone (1) of six (6) line servers used gloved hands to .serve pancakes and sausages and touchedcounter, cabinet handles with same gloved hands.

The tour of the main kitchen was conducted on April6, 2009 from 7:35 AM through 9:45 AM in thepresence of Employee #21, who acknowledged thefindings at the time of the observations.


1. 16 of 18 hotel pans were observed soiled and/orwet and stored ready for reuse as follows:

Five (5) of seven (7) 2" hotel pansFive (5) of five (5) 4" hotel pansFour (4) of four (4) 6" hotel pansTwo (2) of two (2) baking pans

2. No air gaps were observed above the drains inthe following areas: one (1) drain near the tray

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L 099 L 0991.AII of the hotel pans are stored clean ~/06/09and dry and ready for reuse.1a. Drain caps have air gaps per regulatior .5/22/091b.Correct scoop sizes are used duringserving all meals. 4/07/091c.Hot foods are served at 140 Fahrenheit.1d.Cold foods are served at 40 Fahrenheit.1e.Opened items are labeled and dated.1f.Servers are practicing sanitary conditionwhile serving.

2. A comprehensive environmental walk 4/07/09through was done in the kitchen to identifyareas of sanitary non compliance and thatequipment is in good working order.Deficient practices are resolved.

4.Administrator or designee will makerandom observation of tray line andenvironmental rounds in the kitchen toensure sanitary practices are incompliance and that equipment is in goodworking order and report findings to thefacility Risk Management! QualityImprovement Committee monthly X 12Months.










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line, one (1) near the pot and pan wash area, one(1) near the cook's preparation area and one (1)near the dish machine.

3. The incorrect scoop size was observed for thefollowing foods for the breakfast meal on Monday,April 6, 2009 at 7:40 AM:

Pureed bread: a 1 3/8 ounce scoop was used and a2 ounce serving was indicated on the productionsheet.

Chopped Meat: a 1 1/3 ounce scoop was used and I'

a 2 ounce serving was indicated on the production .sheet. IPureed Meat: a 1 1/3 ounce scoop was used and a2 ounce serving was indicated on the productionsheet.

Scrambled Eggs: a 2 ounce scoop was used.However, scrambled eggs did not appear on theproduction sheet.

4. Food temperatures on the tray line for hot foodholding were below 140 F and cold foods above 41F for the breakfast meal were observed on Monday,April 6, 2009 at 7:45 AM as follows: I

Sausage link: 122 FPancakes: 120 FTurkey Bacon: 120 FCranberry Juice: 70 F

5. The following opened undated items wereobserved in the dry storage areas:1 (one) gallon bottle of vinegar1 (one) gallon bottle of Worcestershire sauce1 (one) package of dry spaghetti1 (nn~\ n",,...k,,,,,~nf rln/ m",,...,,,rnni


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1 (one) package of dry three colored past

6. During the breakfast meal, the followingobservation was made of Employee #20.

Employee #20 was observed plating pancakes andsausage links with a gloved hand. His/her glovedpalms were observed placed on the steam table,opening the steam table cabinet to retrieve warmedplates, and opening packages of warmed pancakesthat were handed to him/her by another employeewith ungloved hands.


The supervising pharmacist shall do the following:

(a)Review the drug regimen of each resident atleast monthly and report any irregularities to theMedical Director, Administrator, and the Director ofNursing Services;

(b)Submit a written report to the Administrator onthe status of the pharmaceutical services and staffperformances, at least quarterly;

(c) Provide a minimum of two (2) in-service sessions Iper year to all nursing employees, including one (1) ,session that includes indications, contraindicationsand possible side effects of commonly usedmedications;

(d)Establish a system of records of receipt anddisposition of all controlled substances in sufficientdetail to enable an accurate reconciliation; and

(e)Determine that drug records are in order and thatan account of all controlled substances is

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maintained and periodically reconciled.This Statute is not met as evidenced by:Based on record review and staff interview for six(6) of 30 sampled residents and eight (8)supplemental residents, it was determined that thepharmacist failed to notify the facility that a dosereduction was not attempted for two (2) residentsreceiving antipsychotic medications, the facilityfailed to act upon the pharmacist'srecommendations for 13 residents and facility stafffailed to consistently the Medication AdministrationRecord for the administration of controlledsubstances for one (1) resident. Residents #3,6,7,11,13,14, JH2, JH6, JH7, JH8, JH9, JH10, JH11and JH12.


1. The pharmacist failed to notify the facility that agradual dose reduction for Resident #3 who wasprescribed antipsychotic medications.

A review of Resident #3 ' s record revealed thefollowing physician' s orders:" Remeron 15mg at bedtime by mouth" initiated

May 16, 2008." Seroquel 50 mg twice daily by mouth" initiated

June 19, 2008." Ativan 2 mg every 8 hours as needed by mouth

for agitation" for agitation initiated April 11, 2008.Ativan was discontinued October 13, 2008." Xanax 0.25 mg every 8 hours as needed for

agitation" initiated October 14, 2008." Ambien 5 mg at bedtime by mouth for insomnia"initiated June 22, 2008.

The above medications were renewed on July 29,September 2, October 14 and December 1, 2008 I.'

and January 1 and February 22, 2009.

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L 128L 128 11. The Pharmacist wrote recommendation 5/13/09for gradual dose reduction for Residents #who were prescribed antipsychoticmedications and notified Psychiatrist of theirecommendation. Recommendationinitiated. IThe facility has acted upon the 15/22/09Pharmacist's recommendations for the 13residents and #3, 6, 7,11, 13, 14, JH2, JH6,JH7, JH8, JH9, JH10, JH11 and JH12.

2.A chart review of all Resident records 5/22109was done to ensure pharmacistrecommendation were completedconsistently and timely. Records that werefound out of compliance were updated toreflect Pharmacist currentrecommendations.

3.Unit managers have been reeducated on 5/22/09the importance of acting upon Pharmacistrecommendations consistently and timely.Pharmacist has been reeducated on theimportance of communicatingrecommendations to the facility in a timelymanner. Pharmacist will communicaterecommendations with Unit Managersduring consultation visit and provide theactual report of recommendation to thefacility within one week of visit.Unit manager will reviewrecommendations and ensureimplementation within 72 hours ofnotification.

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The resident received no Xanax according to theOctober, November, and December 2008 andJanuary, February March and April 2009 MedicationAdministration Records.

The pharmacist reviewed the resident'smedications on April 5, May 14, June 9, July 23,August 20, September 23, October 31, November12 and December 12, 2008 and January 21,February 10, and March 5, 2009. There was noevidence that the pharmacist recommended anattempted dose reduction for the above citedantipsychotic medications.

A "Consultation Report" from the pharmacistdated March 9, 2009, recommended, "[Resident#3] has been taking Remeron 15 mg q hs (atbedtime) for depression, Risperidone 1 mg bid I'(twice daily) for psychotic disorder, Seroquel 50 mg ,bide for psychotic disorder and Zolpidem (Ambien)5 mg q hs for insomnia.

Suggest obtain a psych consult at this time toconsider a gradual dose reduction of the abovemedications. If therapy is to continue at the currentdose, please provide rationale describing a dosereduction as clinically contraindicated. " There wasno evidence that a prior recommendation was madeby the pharmacist.

A face-to-face interview with Employee #3 wasconducted on April 6, 2009 at 3:30 PM. He/sheacknowledged the above cited information. Therecord was reviewed April 6, 2009.

2. Facility staff failed to consistently act upon thePharmacist's recommendations in a timely mannerfor Resident #6.

A review of the consultant pharmacist


4.DON or designee, Behavioral Specialistand Pharmacy consultant will randomly

QA latest recommendations to ensuretimely and consistent implementation andreport findings to the facility RiskManagement! Quality ImprovementCommittee monthly X 12 months.

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L 128 Continued From page 44'I'

recommendations dated February 10, 2009revealed, "Comment: ...takes Lipitor and Zetia. I'

Recommendation: Please consider monitoring afasting lipid panel and hepatic function panel on thenext convenient lab day and every six monthsthereafter. Rational for Recommendation: ...monitora fasting lipid panel and hepatic function panel 12weeks after initiation of therapy or following anydosage increase, and periodically thereafter tomonitor efficacy and toxicity of this therapy."

The record lacked evidence that a fasting lipid andhepatic function panel were obtained and/or anylaboratory results obtained from dialysis were usedand reviewed at the time of this review.

A face-to-face interview was conducted on April 10, I2009 at 11:00 AM with Employee #4. He/she stated," The report was in my box [mail box] on Mondaymorning and I started working on therecommendations. Some of the recommendationswere done." The record was reviewed on April 10,2009.

3. Facility staff failed to consistently sign the IControlled Medication Utilization Record and the IMedication Administration Record (MAR) whenadministering controlled substances to Resident #7.

A review of Resident #7's record revealed aphysician's order dated January 7, 2009 thatdirected, " Tylenol w/ codeine #3 300-30 mg tablet,2 tab by mouth every four hours as needed for pain"

Tylenol #3 was signed on the Resident ControlledSubstance Record for February 27, 2009 at 6:00PM, March 2 at 6:00 AM and 6:00 PM, March 4 at

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11:20 AM and 5:30 PM, March 7 at 9:00 PM andMarch 16, 2009 at 3:00 PM, April 6,2009 at 12:00AM as being removed from the narcotics drawer.

According to the February 2009, March 2009 and IApril 2009 MAR, there were no nurse's initials in Ithe area designated for February 27, 2009, March i2, 4, 7, 16, 2009 and April 6, 2009 and no time Imentioned above indicating that the medication was iadministrated to the resident. There was nodocumentation on the back of the MAR under"Comments /Progress Notes" documenting theadministration of medication or the effectiveness of I'

the medication for the above cited dates and times.

II

I

There was no evidence in the nurse's notes thatdocumented that the medication was administeredto the resident for the above dates and times.

A face-to-face interview was conducted withEmployee #14 at the time of the findings. He/Sheacknowledged the above findings. The record wasreviewed April 7, 2009.

4. Facility staff failed to consistently act upon thePharmacist's recommendations in a timely mannerfor Resident #11 .

On April 8, 2009 it was noted that the consultantpharmacist wrote recommendations for the medicaland nursing staff dated October 1, 2008 and March1, 2009 for Resident #11.

A face-to-face interview was conducted on April 8,2009 at 12:00 PM with Employee #14. He/sheacknowledged that the consultant pharmacistrecommendations were not act upon.

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5. The pharmacist failed to notify the facility that agradual dose reduction for Resident #13 who wasprescribed antipsychotic medications.

A review of Resident #13 ' s record revealed thefollowing physician's orders:" Haldol 2 mg concentrate every 6 hours for

agitation as needed" initiated on April 28, 2008." Risperdal 0.5 mg daily by mouth" initiated July14,2008.

The above medications were renewed June 24,August 28, September 28, November 7, andDecember 30, 2008 and February 5 and 27 andMarch 24,2009.

An observation of the bottle of Haldol wasconducted on April 6, 2009 at 1:30 PM and revealedthat the bottle was unopened. The resident hadreceived no doses of Haldol since the initial order ofApril 28, 2008.

The pharmacist visited the resident on May 14,June 6, July 5, August 24, September 7, October22, November 12, and December 12, 2008 andJanuary 21, February 20 and March 9, 2009. Therewas no evidence that the pharmacist recommendedan attempted dose reduction for the above citedantipsychotic medications or to discontinue theHaldol.

A face-to-face interview was conducted withEmployee #3 on April 6, 2009 at 2:00 PM. He/sheacknowledged the above cited information. Therecord was reviewed April 6, 2009.

6. Facility staff failed to act upon the Pharmacist'srecommendations in a timely manner for






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Resident #14.

A review of the consultant pharmacistrecommendations for the medical and nursing staffdated February 26,2009 for Resident #14 revealed," ...Comment: The pharmacy recommendation(s)for [resident name] from November 24,2008 andDecember 29, 2008 have not been acted upon bythe intended recipient of the recommendation inaccordance with the State Operations Manualguidelines. Recommendation: ...1) ...dischargesummary stated to resume all preadmissionmedications and to increase the Coreg 12.5 mg pobid. Please review for a possible need to increase[resident] Coreg dose. Discussed with chargenurse. 2) ...has been taking Remeron 30 mg dailyfor management of major depressive disorder.Please consider documenting that GDR (gradualdose reduction) attempts are clinicallycontraindicated in this individual with majordepressive disorder ...Resubmitted February 26,2009. "

The record lacked evidence that the pharmacy "recommendations had been acted upon.

A face-to-face interview was conducted on April 7, II

2009 at 1:48 PM with Employee #9. He/sheacknowledged that the pharmacy recommendations,have riot been acted upon. The record wasreviewed on April 7, 2009.

7. Facility staff failed to consistently act upon thePharmacist's recommendations.

On April 7, 2009, at approximately 1:30 PM, it wasnoted that the consultant pharmacist wroterecommendations for the medical and nursing staffdated March 6,2009, summarizing reported I

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L 128 Continued From page 48\ Irecommendations that had not been acted upon forthe following residents: I

II

12/29/2008 I11/19/2008 '11/21/2008 I911712008 and 11/21/2008

1

'

12/12/2008111212009 .,

IIIIII

A telephone interview was conducted on April 7,2009 at approximately 1:10 PM with Employee #35.He/she stated that the consultant pharmacist wason vacation at the time of the survey.

A face-to-face interview was conducted on April 8,2009 at 4:30 PM with Employee #3. He/she statedthat the consultant pharmacist reports arrive at theend of each month and are distributed to the unitmanagers for follow-up.

A face-to-face interview was conducted on April 9,2009 with Employee #3. He/she stated, "Weidentified that the drug regimen reviews were notbeing submitted and we [the facility] discussed theconcern in the January 2009 Quality Assurancemeeting. Follow up was done. The pharmacist hada problem with his/her computer/laptop over the lastmonth and a half. When I received the reports theywere due back to the Director of Nursing by April 6,2009."

There was no evidence that additional interventionswere taken and/or initiated to

ResidentResident #3Resident JH2Resident JH6Resident JH7Resident JH8Resident JH9Resident JH10Resident JH11Resident JH12

Recommendation dates12/12/2008

11/512008 and 1112/200911/12/2008

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ensure that the pharmacist reports were received ina timely manner.

L 161 3227.12 Nursing Facilities IEach expired medication shall be removed from I'

usage.This Statute is not met as evidenced by: Ii

Based on observations of two (2) of eight (8)medication rooms, and staff interviews, it was Idetermined that the facility staff failed to remove .1'

expired medication from the currently datedmedications in the narcotic interim box andemergency boxes on Units 2 North and 4 South. '

The findings include: I1. The facility staff failed to remove expired I'

medication from usage from the narcotic interim boxand the emergency boxes on 2 North and 4 South. IA. On April 8, 2009 between 10:00 AM and 3: 00 IPM, during the inspection of the medication storage I

areas, the narcotic interim box located in the Inursing supervisor's office contained four (4) of 'seven (7) narcotic blister package medications that Iwere observed expired along with stock that was I'

current. The expired drugs included:

IOxycodone IR 5mg, Expired 2/28/2009Oxycodone IR 5mg, Expired 1/31/2009Morphine ER 30 mg, Expired 2/2009Morphine ER 30 mg, Expired 2/2009

B. The emergency box on 2 North contained four(4) Epinephrine 1:1000 (1mg/ml), 1 ml ampouleswhich expired March 1, 2009. The expiration datedocumented on the exterior of the box was March 1 I2009. '

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I L 128 L 1611.The facility staff has removed all expired 4/8/09medications from the currently datedmedications in the narcotic interim box andemergency boxes on Units 2 North and4 South. The lock box has beenreplenished.

L 161

2. Unit Managers have checked all other ~/08/09narcotics boxes for expired medication anddiscarded any found. The narcotic and lockboxes were replenished.

3.Unit Managers have been reeducated onl'4/08/09the Importance of discarding expiredmedications Unit managers will checkmedications on the carts, the narcoticboxes, lock boxes and refrigerators on aweekly basis and discard those that areexpired. Narcotics will be destroyedmonthly and reported to DEA. DON willreview narcotic box in nursing office weekiand discard those that are expired.Consulting pharmacist will review interimmedication and narcotiC boxes monthly toensure compliance and discard those thatare expired.

4DON or designee and Pharmacyconsultant will randomly QA medicationsprocess to ensure expired medications areremoved from the carts, narcotic boxes, 10'( kboxes and refrigerators and discarded perfacility practice and report findings to thefacility Risk ManagemenU QualityImprovement Committee monthly X 12months.




STATEMENT OF DEFICIENCIESAND PLAN OF-CORRECTION




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L 161 Continued From page 50 I L 161

The emergency box on 4 South contained two (2)Vitamin K 1Omg/ml, 1ml ampoule and Atropinesulfate syringe, O.Smg(0.1mg/ml, 5 ml syringe),

Iwhich both expired April 1, 2009. The expirationdate documented on the exterior of the box wasApril 1, 2009.

IA face-to-face interview was conducted at the timeof the observation with Employees #9 and 10. They Iacknowledged that the medications were expired.

IL 214 3234.1 Nursing Facilities I L 214

Each facility shall be designed, constructed,located, equipped, and maintained to provide afunctional, healthful, safe, comfortable, andsupportive environment for each resident, employee l-

and the visiting public.This Statute is not met as evidenced by: ,Based on observations, staff interview and record Ireview for two (2) of 30 sampled residents, it wasdetermined that facility staff failed to provide Iadequate supervision for Residents #3 and 9 who !had multiple falls, one with subsequent injuries. IAdditionally, facility staff failed to secure one (1) of I'

eight (8) toilets in shower rooms observed andcover the electrical wires on one (1) of eight (8) unitentrance double doors. Residents #3 and 9. I

I


1. Facility staff failed to provide adequatesupervision for Resident #3 who had multiple fallsand subsequent injury.

A review of Resident #3 ' s record revealed a nurse, s note dated December 10, 2008 at 10:00 AM, "Resident observed on the floor in a sitting

I5/15/09

L 2141.Resident #9 has been referred to thefacility's behavioral specialist.Resident #9 has agreed to participatein the A.A. program.

The toilet in the male shower room on unit ~ 5/22/09South was secured to floor surfaces and nclonger tilt back and forth.

5/22/09The fire emergency double door closuremechanism lacked a cover to concealexposed electrical wiring on unit 3 Northnear room 336 and 536.

2. Unit Managers will review care plans of 5/22/09each resident with incidents and accidentsto ensure appropriate goals andapproaches are established to helpminimize the occasion of incidents andaccidents for each Resident. Records thatare found out of compliance will beupdated to reflect Resident current needs.

3. Falls are evaluated daily by the 5/13/09Interdisciplinary team during daily standup Meetings five times a week. Duringthose meetings referrals are made totherapy services. An analysis of the eventsis done and appropriate interventions areimplemented. Interventions arereviewed weekly by the interdisciplinaryteam until resolved and care plan goalsand approaches are updated as needed.

4. DON or designee will do randomQA Of fall process during weekly caremanagement meeting weekly and reportfindings to the facility RiskManagement! Quality ImprovementCommittee monthly X 12 months.


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II

A care plan entitled, "Resident at risk for FALLS" Iwas reviewed by facility staff on December 11, I2008. Under the column "Status/Date" was handwritten "Cont [continue]. " IThere was no evidence that additional interventions Iwere initiated after the resident fell on December '10, 2008. IAn "Interdisciplinary Functional Status Form" was Icompleted by the occu,pational therapist on IDecember 11, 2008, The comment on the formwas, "Patient recently treated with OT/PT(occupational and physical therapy): reached max I'

potential. "

An "Interdisciplinary Functional Status Form" was Icompleted by the physical therapist on December I15, 2008, The comment on the form was, "Noinjuries noted. Patient has increased trunk flexion Ibut ambulating with limit assist. Has visual i

impairment No change since [unable to read] Itreatment. " ,


position in [another resident's room]. Range ofmotion to upper and lower extremities withoutdifficulty or complaint of pain, No skin abrasions,bruises noted at this time ... "

According to the quarterly Minimum Data Setassessment completed December 8,2008, theresident was coded in Section G (PhysicalFunctioning and Structural Problems) as beingindependent in walking in the room and corridor.

A face-to-face interview conducted on April 6, 2009at 3:30 PM with Employee #3. He/she stated, "Resident #3 has always wandered around the unit Ii

by [him/herself]. Sometimes [he/she] wanders intoother residents' rooms I


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L 214 1.Resident #3 is participating in more 1/15/09recreational therapy programs to assist witcloser monitoring.

2. Unit Managers will review care plans of b/22/09each resident with incidents and accidentsto ensure appropriate goals andapproaches are established to helpminimize the occasion of incidents andaccidents for each Resident. Records thatare found out of compliance will beupdated to reflect Resident current needs.

4. DON or designee will do randomQA Of fall process during weekly caremanagement meeting weekly and reportfindings to the facility RiskManagemenU Quality ImprovementCommittee monthly X 12 months.

3. Falls are evaluated daily by the 5/13/09Interdisciplinary team during daily standup Meetings five times a week. Duringthose meetings referrals are made totherapy services, An analysis of the eventsis done and appropriate interventions areimplemented. Interventions arereviewed weekly by the interdisciplinaryteam until resolved and care plan goalsand approaches are updated as needed.

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and needs to be redirected. "

A nurse's note dated March 25, 2009 at 8:00 AMdocumented, "Resident observed sitting on thefloor next to the wall near [his/her] bed. Blood at thistime was seen on left side of face ...Iaceration was Iobserved about 3 cm long on left side of around eye Iregion ...MD made aware and gave orders totransfer resident to the nearest ER via 911 ... " IThe resident was hospitalized from March 25 Ithrough March 30, 2009 and returned to the facilitywith a diagnosis of orbital fracture. IResident #3 was observed on April 6, 2009 at 10:00 IAM wandering on the nursing unit. The residentwalked around the day room and up and down thecorridors without assistance. The resident had ablue-yellow discoloration beneath the left eye.

A face-to-face interview was conducted withEmployee #3 on April 6, 2009, who acknowledgedthat there was no evidence that interventions were Iinitiated after the fall on December 10, 2008 or thatthe resident received limited assistance while ,.1

ambulating on the unit as identified by the physicaltherapist. The record was reviewed April 6, 2009. \1

2. Facility staff failed to supervise Resident #9 whohad multiple falls without injury.Resident #9 ' s diagnoses included DiabetesMellitus and bilateral above the knee amputationsaccording to Section I (Disease Diagnoses) of theadmission Minimum Data Set assessmentcompleted June 27, 2008 .. He/she was non-ambulatory, required extensive assistance fortransfer and self-propelled via wheelchair for

L 214

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mobilization as coded in Section G (PhysicalFunctioning and Structural Problems) of the sameMDS.

The resident sustained the following fall-relatedaccidents according to documentation reviewed inthe comprehensive care plan September 8, 2009revealed, "actual fall - observed on the floor. "

According to following nurses' progress notes: ISeptember 29, 2008, 2300, "observed on the floor Iat 11:00 PM;" November 14, 2008, 2330, " ...fellon the ground in a sitting position ...; " INovember 22, 2008, 2200, documented, " observed.lying on stomach in front of the elevator intoxicated Iwith alcohol; " ,March 23, 2009, 2000, "observed sliding out ofchair ...helped, accompanied resident into sittingposition on the floor. "

A review of the resident's comprehensive careplan, as it related to falls, revealed that facility staff :implemented monitoring for alcohol use onSeptember 29, 2008 and monitoring every 2 hourswhile off the unit on November 14, 2008 asdocumented under problem # "2. " IThe resident continued to sustain fall relatedaccidents and facility staff failed to implement any ,additional interventions or screenings related to the I.

resident's functional status. i

A face-to-face interview was conducted withEmployee #16 on April 9, 2009 at approximately2:30 PM, In response to a query regarding the role I'

of rehabilitative (rehab) services as it relates toresidents who sustain falls in the facility, he/she I'responded, "Meetings are held every morning tooverview the unusual incidents that occurred theday prior, inclusive of those related I'

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L 214 Continued From page 54 I

:::I:om the rehabilitative services division IIconduct screening assessments on residents whosustain falls within 24-hours of the fall incident and I'

document comments/recommendationsaccordingly, "

Employee #16 provided a document entitled " IInterdisciplinary Functional Status Form." He/she Istated that a rehabilitation screening was conducted ii'

on 11/28/09 (this document was not observed in theclinical record) for Resident #9. '

According to Employee #16, the rehabilitationservices division was not aware of the other fallssustained by Resident #9. The record was Ireviewed April 6, 2009,

The following observations were made during the Ienvironmental su,:,ey on April 7, 2009 between 9:20 IAM and 6:00 PM, In the presence of Employees ,#15 and 32 who acknowledged the findings at the Itime of the observations. I3, The toilet in the male shower room on unit 3South was not secured to floor surfaces and tiltedback and forth, when examined in one (1) of eight(8) toilets observed in shower rooms,

4. The fire emergency double door closure Imechanism lacked a cover to conceal exposed Ielectrical wiring on unit 3 North near room 336 and I536 in one (1) of eight (8) unit entrance doubledoors observed.

L 245 3238.1 Nursing Facilities,

Each piece of heating and air conditioningequipment and its installation shall comply with




L 245 ' j1.Boilers and mixing valves were adjusted 04/06/09maintain hot water temperatures below 11 anddegrees Fahrenheit (F) in resident rooms Ongoingand common areas 2nd Floor ShowerRoom blue side, 2nd Floor Shower Room-pink side, Room 213, Room 228Room 229 and Rehabilitation Department

L 214

Fire safety entry door for room 429 has bee n 5/22/09repaired and in safe operation. The smokealarm is also working properly,

2. Administration has developed and is Ongoingstrategically implementing a plan toaddress the overall environmental issuesof the facility.

3,Maintenance Director has obtained 08/30/09quotes for environmental repairs and havesubmitted them for approval. Contractorsare called in to make repairs as needed.Daily issues are identified and addressedwithin 24- 72 hours. Maintenance staff hasbeen authorized to work more hours whenneeded to address issues, Anticipatedcompletion of identified major projects isAugust 30, 2009, Maintenance staff hasbeen educated on the importance ofmaintaining all essential mechanical,electrical, and patient careequipment in safe operating condition,Maintenance staff take water temps dailytimes 5 days a week. Maintenance Directowill ensure that facility essential mechanical,electrical, and patient care equipment is insafe operating condition duringenvironmental rounds daily times 5 daysa week to ensure compliance.

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(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

L 245 Continued From page 55 Ithe 1996 BOCA International Mechanical Code I'

(Heating, Air Conditioning and Refrigeration), andall applicable District laws and regulations.This Statute is not met as evidenced by: IBased on observations during the environmental ,tour conducted on April 6, 2009 I'

between 9:30 AM and 6:00 PM, it was determinedthat boilers and mixing valves were not adjusted to I'

maintain hot water temperatures below 110 degreesFahrenheit (F) in resident rooms and common Iareas as evidenced by elevated temperatures infive (5) of 51 resident rooms and common areas Iobserved and facility staff failed to ensure the safeoperation of a fire safety door and smoke alarm for "one (1) of 51 resident rooms observed.

IIII

I

I


1. Boilers and mixing valves were not adjustedproperly to ensure that domestic hotwater temperatures were below 110 degrees F asfollows:

2nd Floor Shower Room, blue side-134 F2nd Floor Shower Room, pink side - 124 FRoom 213-120 FRoom 228-112 FRoom 229-112 FRehabilitation Department - 125 F

These findings were observed in the presenceEmployees #15 and 32 who acknowledged thefindings at the time of the observations.

2. During an initial tour of the facility on April 6,2009 at approximately 9:00 AM, it was determinedthat facility staff failed to ensure the safe operationof the entry door of resident room 429. Thesefindings were observed in the

L 245 4.Administrator or designee will monitorfacility essential mechanical, electrical, andpatient care equipment in safe operatingcondition daily times 5 days a week to ensi recompliance and report findings to thefindings to the facility Risk Management!Quality Improvement Committee monthlyX 12 months.


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IAn observation of the entry door of resident room I429 revealed the door was held open with plastic .trash bags tied to an interior door inside the room. A Ismoke alarm was observed in the ceiling of room I429 and periodically emitted an audible alarm. Four(4) residents resided in the room. IIn response to a query regarding the reason for the Idoor being held open with plastic bags, the staff .person stated that the door would not remain in an ,open position without the plastic bags. Employee #4\removed the plastic bags from the door.Subsequently, the door closed and did not remain Iopen without props. Employee #4 made a verbalrequest to the facility's maintenance staff for the "door to be repaired and placed a chair in front of thedoor to keep it open. IA face-to-face interview was conducted with ,.Employee #15, on April?, 2009 at approximately10:00 AM. He/she stated that the door was in the Iprocess of being repaired, however; a part was ,ordered and scheduled for delivery on April 8, 2009·1The door was designated as a fire safety door andin turn periodically triggered the smoke alarm due toits malfunctioning.

presence of Employee #4 who acknowledged thefindings at the time of the observations.


Each facility shall provide housekeeping andmaintenance services necessary to maintain theexterior and the interior of the facility in a safe,sanitary, orderly, comfortable and attractivemanner.This Statute is not met as evidenced by:Based on observation during the environmental tourof the of the facility on April 6, 2009 from

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L 410 Continued From page 57 I9:20 AM through 5:45 PM, it was determined that .1

housekeeping and maintenance services were notadequate to ensure that the facility was maintainedin a safe and sanitary manner as evidenced by thefollowing observations: damaged wall surfaces in 11of 51 walls, damaged and marred doors in 18 of 51doors in resident rooms and common area, soiledexhaust vents in six (6) of 25 exhaust vents inresident bathrooms and common areas, air supplyvents and louvers in two (2) of two (2) air supplyvents in the laundry, damaged floor tiles in four (4)of four (4) areas in the laundry, the top surfaces ofwashers were soiled in four (4) of four (4) washersin the laundry, dining room threshold missing in one i(1) of five (5) resident dining rooms, missinginsulation on the main entrance door in one (1) oftwo (2) sliding glass entrance doors, soiled anddamaged ceiling tiles in 16 of 51 ceilings in residentrooms and common areas, damaged floor surfacesin six (6) of 12 floor surfaces in resident showerrooms and the laundry, soiled sprinkler heads ineight (8) of 30 sprinkler heads in resident roomsand common areas, soiled and stained privacycurtains in four (4) of 30 privacy curtains in residentrooms, soiled bed frames in five (5) of 25 bedframes in resident rooms, soiled and unsecuredchair seats in two (2) of five (5) resident diningrooms, marred elevator jams and doors in three (3)of three (3) elevators, soiled lamp covers in two (2)of 25 lamp covers in resident rooms and commonareas, six (6) of eight (8) damaged lamp coves inthe Rehabilitation Department, boxes improperlystored on the floor in one (1) of eight (8) storage iareas, and personal items stored on floor surfacesin one (1) of 50 resident rooms.

These observations were made in the presence ofEmployees #15 and 32. These findings were




L 410 L 4101.Marred wall surfaces were repaired andwall paper repaired that was separating fromsurfaces adjacent to windows inresident rooms and common areas in rooms203,318,335,421,3 South Lounge, 2 SouthDay Room, Clean and Soiled Sides of theMain Laundry Room, RehabilitationDepartment, 3rd floor Soiled Linen Room,and 4th Floor Shower Room.The frontal and edge surfaces of residententrance and bathroom doors were repairedin rooms 203, 220, 229, Nourishment Room,2nd Floor Janitorial Closet, 305, 311,314,319, 325, 330, 515, 520, 529, 3rd TrainingToilet, 3rd Floor Soiled Linen Room, 4thSouth Shower Room and 5th Floor ShowerRoom.The interior surfaces of exhaust vents inresident bathrooms and common areas werecleaned in the Clean and Soiled Sides of theMain Laundry, Laundry Storage Room, 305,309 and 428 in six (6) of 25 exhaust ventsobserved.The air supply vent and louvers in the foldingarea of the Laundry Room and soiledreceiving area were repairedFloor tiles were replaced in the folding, dryer,storage and soiled laundry areas of the mainLaundry Room.The top surfaces of 4 washers in the mainLaundry Room were cleaned.The threshold was repaired at the entranceto the dining room on the first floor.

6899 If continuation sheet 58 of 62CI6C11

(X5)COMPLETE

DATE





HFD02-0017

I(XS)

COMPLETEDATE

Ij








(X4) IDPREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES I(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY

OR LSC IDENTIFYING INFORMATION) I


acknowledged at the time of these observations.


1. Wall surfaces were marred and wall paper wasseparating from surfaces adjacent to windows inresident rooms and common areas in rooms 203,318, 335, 421, 3 South Lounge, 2 South Day Room,Clean and Soiled Sides of the Main Laundry Room,Rehabilitation Department, 3rd floor Soiled LinenRoom, 4th Floor Shower Room in 10 of 51 wallsobserved ..

2. The frontal and edge surfaces of residententrance and bathroom doors were marred, scarredand splintered on the edges in rooms 203, 220,229, Nourishment Room, 2nd Floor JanitorialCloset, 305, 311, 314, 319,325,330,515,520,529, 3rd Training Toilet, 3rd Floor Soiled LinenRoom, 4th South Shower Room and 5th FloorShower Room in 18 of 51 doors observed.

3. The interior surfaces of exhaust vents in residentbathrooms and common areas were soiled withaccumulated dust in the Clean and Soiled Sides ofthe Main Laundry, Laundry Storage Room, 305, 309and 428 in six (6) of 25 exhaust vents observed.

4. The air supply vent and louvers in the foldingarea of the Laundry Room and soiled receiving areawere damaged in two (2) of two (2) air supply ventand louvers observed.

5. Floor tiles were damaged and sections of tilewere missing in the folding, dryer, storage andsoiled areas of the main Laundry Room in four (4)of four (4) areas observed.

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L 410 The insulation on the frontal edges of doublesliding entrance doors were repaired.Ceiling tiles in residents' rooms andcommon areas were replaced in Rooms 203,209,322,409,421,511,515,520,533,South Lounge, Folding and Soiled LaundryAreas of the Main Laundry Room, PhysicalTherapy, 3rd Floor Clean Utility Room, 3rdFloor Nourishment Room, 3rd Floor SoiledLinen Room and 3rd Floor Nourishment

Room.Painted floor surfaces in the 2 South and2 North Showers, 4 North and 4 SouthShowers, 5th Floor Shower room and washeand soiled areas of the Laundry Room wererepaired and painted.Sprinkler heads were cleaned in residentsrooms and common areas in Rooms 228,311, 314, 318, 2nd Floor Storage Room, 3rdFloor Soiled Utility Room, Folding,Dryer and Washer Areas of the LaundryRooms.Privacy curtains in resident rooms werecleaned and hooks were reattached in rooms209, 220, Rehabilitation Therapy and 304.The horizontal surfaces of resident bedswere dusted and cleaned in Rooms 209,220, 228, 229 and 305 in five (5) of 25 bedsobserved.The seat surfaces of straight back chairs inDay Rooms/Dining rooms were cleaned andunsecure chairs were removed, 2nd Floortwo (2) of six (6) chairs and 3rd Floor one(1) of six (6) chairs.






HFD02-0017








ISUMMARY STATEMENT OF DEFICIENCIES I

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY :OR LSC IDENTIFYING INFORMATION)

(X5)COMPLETE

DATE

(X4) IDPREFIX

TAG

9. Ceiling tiles in residents rooms and commonareas were soiled, stained and failed to fit securelyinto grids in Rooms 203, 209, 322,409,421, 511,515,520,533, South Lounge, Folding and SoiledAreas of the Main Laundry Room, PhysicalTherapy, 3rd Floor Clean Utility Room, 3rd FloorNourishment Room, 3rd Floor Soiled Linen Room ,and 3rd Floor Nourishment Room in 16 of 51 ceiling Itiles observed.


6. The top surfaces of washers in the main LaundryRoom were soiled with dust accumulation in four (4) ,of four (4) washers observed.

7. The threshold at the entrance to the dining roomon the first floor was missing in one (1) of five (5)dining rooms observed.

8. The insulation on the frontal edges of doublesliding entrance doors were damaged andseparated from door surfaces in one (1) of two (2)sliding glass entrance doors observed.

10. Painted floor surfaces in the 2 South and 2North Showers, 4 North and 4 South Showers, 5thFloor Shower room and washer and soiled areas of 'the Laundry Room were damaged and paint waspeeling in six (6) of 12 painted floor surfacesobserved.

11. Sprinkler heads were soiled with accumulateddust in residents rooms and common areas weresoiled with dust in Rooms 228, 311, 314, 318, 2ndFloor Storage Room, 3rd Floor Soiled Utility Room,Folding, Dryer and Washer Areas of the LaundryRooms in nine (9) of 30 sprinkler heads observed.

12. Privacy curtains in resident rooms were soiled

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2. Rounds will be conducted to identify 5/22/09environmental issues that are in need ofresolution such as marred and damageddoors and walls, soiled exhaust and airvents, damaged floors, soiled equipment,proper functioning doors, missinginsulation, damaged ceiling tiles, soiledbed frames, damaged lamp covers,items are being properly stored and the like.A master list will be maintained by theenvironmental staff and items from thatlist will be completed daily.

L 410 Elevator jams and doors were repaired in t ebasement and first floor areas.The interior surfaces of lamp covers inresident rooms and common areas werecleaned in room 209 and the Laundry Roo /l.Lamp covers in Rehabilitation Departmentwere repaired in six (6) of eight (8) lampcovers in the Rehabilitation Department. ,Storage area on 4 south is neatly packedand within storage guidelines.The five (5) boxes and bags of personal 'belongings in room 229 are properly stored.



PRI NTED: 05/12/2009FORM APPROVED



5000 BURROUGHS AVE. NEWASHINGTON. DC 20019

(Xl) PROVIDERISUPPLIER/CLIAIDENTIFICATION NUMBER

HFD02-0017NAME OF PROVIDER OR SUPPLIER





04/09/2009

(X4) 10PREFIX

TAG




with grease and hooks were detached in rooms209,220, Rehabilitation Therapy and 304 in four (4)of 30 privacy curtains observed.

13. The horizontal surfaces of resident beds weresoiled with dust in Rooms 209, 220, 228, 229 and305 in five (5) of 25 beds observed.

14. The seat surfaces of straight back chairs in DayRooms/Dining rooms were soiled and chairs werenot secure when examined, 2nd Floor two (2) of six(6) chairs and 3rd Floor in one (1) of six (6) chairs intwo (2) of five (5) dining rooms observed.

15. Elevator jams and doors were marred andscarred on the frontal surfaces in the basement andfirst floor areas in three (3) of three (3)observations.

16. The interior surfaces of lamp covers in residentrooms and common areas were observed to besoiled in room 209 and the clean soiled area of theLaundry Room in two (2) of 25 lamps observed.

17. Lamp covers in Rehabilitation Department weredamaged and were not secured to fixtures in six (6)of eight (8) lamp covers in the RehabilitationDepartment. .

18. Three (3) of three (3) boxes of supplies werestored directly on floor surfaces in the StorageRoom on unit 4 South in one (1) of eight (8) storageareas.

19. Five (5) boxes and bags of personal belongingswere stored on floor surfaces in room 229 in one (1)of 50 resident rooms observed.


I 10 iPREFIX

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L 410



3. A preventative maintenance process bS/21/09was developed to ensure that the facilitywill provide adequate housekeeping andmaintenance services necessary to mainta na sanitary, orderly, and comfortable interior.Environmental staff has been in-servicedOn how to make quality environmentalrounds as well as the importance of makinthe environmental rounds. Maintenanceand Housekeeping/Laundry shift leaderswill make rounds daily to ensure thatpreventative maintenance is done daily.

4. Maintenance and Housekeeping/Laundry Managers will make rounds Sdays a week to ensure that preventativemaintenance is done daily and will reportfindings monthly to the facilityRisk Management! Quality ImprovementCommittee monthly X 12 months.

(XS)COMPLETE

DATE

CI6C11 If continuation sheet '61 of 62





HFD02-0017


A. BUILDING

B. WING _

04/09/2009








(X5)COMPLETE

DATE

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Each facility shall be constructed and maintained sothat the premises are free from insects and rodents,and shall be kept clean and free from debris thatmight provide harborage for insects and rodents.This Statute is not met as evidenced by:

Based on observations during the survey conductedon April 6, 2009 between 9:20 AM and 6:00 PM, itwas determined that flying insects were observed intwo (2) of eight (8) nourishment rooms and roachescrawling on floor surfaces in one (1) of 50 residentrooms observed and one (1) of one (1) laundryroom observed.

These observations were observed in the presenceEmployees #4, 15 and 32 who acknowledged thefindings at the time of the observations.


1. Gnats were observed flying in the NourishmentRoom on the Unit 3 North and room 420 in two (2)of eight (8) nourishment rooms observed.

2. Roaches were observed crawling on floorsurfaces adjacent to washers in the Laundry Roomin one (1) of one (1) laundry room observed andcrawling along the wall and vanity surfaces ofresident room 410 in one (1) of 50 resident roomsobserved.

L426

L 426

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5/22/09

Health RegulatIOn AdmlnistrationSTATE FORM 6899



L4261.The facility maintains an effective pestcontrol program so that the facility is freeof pests and rodents.

Nourishment Room on the Unit 3 North,room 420, Laundry Room, vanity surfacesof resident room 410 were cleaned andtreated.

2.Pest Control company evaluated )/21/09property and did appropriate treatment offacility.

3.Staff reeducated on the importance of ~/22/09reporting sightings of pest in facility. Apest control log is in each department forstaff use. The pest control company is toreview and sign the logs on each visitto ensure the facility is properly treatedupon each visit. Pest control company willbe called in when needed to avoidinfestations. Residents, staff and visitorsinformed of proper food storage and todispose of trash properly.

4.Maintenance Director will monitor facilityand Pest control logs daily times 5 days aweek to ensure compliance and reportfindings to the findings to the facility RiskManagement! Quality ImprovementCommittee monthly X 12 months

CI6C11 If continualion sheet 62 of 62

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