Survey for Dixon Rehab

8/10/2019 Survey for Dixon Rehab

1/28


2/28

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 01/08/2014FORM APPROVE

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

145906 09/14/2012STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

800 DIVISION STREETDIXON REHAB & HCC

DIXON, IL 61021

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)

F 164 Continued From page 1 F 164

This REQUIREMENT is not met as evidencedby: Based on observation, interview and recordreview, the facility failed to ensure resident'sprivate body parts were not visible from thehallway and failed to ensure residents personalmedical information was not discussed in a public

area.

This applies to 1 resident (R1) in the sample of14 reviewed for privacy and 7 residents (R4, R 11,R30, R32, R38, R58 & R59) in the supplementalsample.

The findings include:

On 9/12/12 at 3:00 PM, a group meeting wasconducted with R4, R30, R32, R38, R58 andR59. During this meeting all residents verbalizedthat Staff "typically" need to be reminded to shut

the curtains or doors when providing personalcares. One resident stated she travels throughoutthe building and many times see's CertifiedNursing Assistant's (CNA's) providing personalcares to residents with the doors open andcurtains not closed. This resident stated "therethey lay in their all-together" in plain view to thehallway. One resident stated he has beenexposed with the door open and curtains notpulled on multiple occasions and has to tell theCNA's to close the door. All residentsacknowledged they felt provision of privacy wasan afterthought for the staff. All residents in thegroup also stated the staff openly discuss otherresident's private information/medical business infront of them.

On 9/4/12 at 10:15 AM, R1 was lying on her bed

ORM CMS-2567(02-99) Previous Versions Obsolete 0RZD11Event ID: Facility ID: IL6005276 If continuation sheet Page 2 of 28


3/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 164 Continued From page 2 F 164nearest the door. The door was opened and R1had her right breast exposed. On 9/11/12 at 1:45PM, R1 was observed to be lying in bed on herleft side with her bare buttocks in view of thedoorway. E13 (Licensed Practical Nurse-LPN)stated, "I just had her covered but she movesaround and exposes herself."

On 9/13/12 at 10:05 AM, Z3 (Physician) wasstanding at the nurses station talking on thephone. Z3 was heard mentioning residentsnames, diagnoses and orders. At 10:55 AM, Z3was observed speaking to and assessing R11's

just inside of R11's room with the door open andno curtains drawn. Z1 could be heard clearlyfrom the hallway.

The Resident's Rights Pamphlet given to allresidents on admission to the facility states;"Your medical and personal care are private .Facility staff must respect your privacy when you

are being examined or given care."F 241SS=E

483.15(a) DIGNITY AND RESPECT OFINDIVIDUALITY

The facility must promote care for residents in amanner and in an environment that maintains orenhances each resident's dignity and respect infull recognition of his or her individuality.

This REQUIREMENT is not met as evidencedby:

F 241 10/4/12

Based on interview and record review, the facilitystaff failed to respect residents dignity by usingpersonal cell phones when giving personal care.

This applies to 6 residents (R4, R30, R32, R38,



4/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 241 Continued From page 3 F 241R58 & R59) in the supplemental sample.


On 9/12/12 at 3:00 PM, a group meeting wasconducted with R4, R30, R32, R38, R58 andR59. During this meeting all residents verbalizedfeeling that Staff were preoccupied with texting

and using their personal cell phones than inresponding to call lights and providing necessarycares. One resident stated a Certified Nursing

Assistant (CNA) "snuck into my room and pulledthe curtain and began texting. She (CNA) wasnot aware I was in my room behind the curtain."Three residents stated they observe CNA's andNurses at the nurses station while lights areringing texting on their phones. One residentstated "just the other day there are two bathroomlights and a call light going off and 3 CNA's werestanding at the nursing station. I asked them,aren't you going to answer those lights? They

(CNA's) told me it wasn't their hallway.) Oneresident stated his cares have been interruptedfor the staff to respond to a text.

The facility policy and procedure on cell phoneuse, undated, states: "Unless approved forfacility business, the possession or use of cellularphones, pagers, and other portablecommunication devices is strictly prohibited whileon duty except during the employee's scheduledbreak periods. Use of these devices will berestricted to the employee break room or outsideof the facility. While the employee is on duty,these devices will be stowed in the employee'slocker, purse/backpack, or vehicle. If thepurse/backpack is stowed in a work area thesedevices must be in an off position."



5/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 248 Continued From page 4 F 248F 248SS=E

483.15(f)(1) ACTIVITIES MEETINTERESTS/NEEDS OF EACH RES

The facility must provide for an ongoing programof activities designed to meet, in accordance withthe comprehensive assessment, the interests andthe physical, mental, and psychosocial well-beingof each resident.


F 248 10/4/12

Based on observation, interview, and recordreview the facility failed to provide an activityprogram to meet the needs, interests, andcognitive abilities of the residents residing on the

Alzheimer's unit.

This applies to four of 17 residents (R 67, 68, 75,& 76 ) reviewed for activities in the sample of 17and 19 residents ( R 63-66, R 69-74, & R 77-86)

in the supplemental sample.


On 9/18/12 from 11:00 AM through 4:00 PM, the Alzheimer unit was observed. The only activitywas at 3:55 PM. E14 (Activity Aide) had a groupof residents gathered around a table, in the diningroom. E14 was softly discussing/readingobituaries in the newspaper, with the group ofresidents. There were 7 other residents seated invarious areas of the dining room, unable to hearwhat was being said and were not engaged in anyother activity.

The posted, undated, Activity Schedule is asfollows: 7:45 AM Breakfast, 8:15 AM Gettingready for our day (hair, nails, shaving), 9:30 AM



6/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 248 Continued From page 5 F 248Current Events (News, Menu, Weather), 10:00

AM Morning Social Hour, 10:30 AM Let's getcreative (Arts and Crafts), 11:15 AM Clean up forlunch, 11:45 AM Lunch, 1:00 PM Senior Smarts(Trivia and Word Games), 2:30 PM ExerciseGroup, 3:00 PM Afternoon Social, 4:00 PM Musicand Dancing (Sing Along and Dancing, 5:00 PMCleanup for Dinner, 5:45 PM Dinner, 6:30 PM

Evening Group Walk and TV Time, 7:00 PMEvening Social Hour. The activity schedule doesnot show that there are any special groups heldfor those residents who could not benefit from theactivity. The schedule is always the same, theactivities are not specific or varied.

The Activity Consultant notes dated 8/14/2012,under the Special Care Unit heading states,"Changes to the activity calendar have not yetbeen made. (E6 Certified Nursing Assistant - UnitCoordinator) reports that she has beendiscussing the changes with the Activity Assistant

and is going to be individualizing the calendar inthe future."

There unit are 24 residents (R 63-86) living on the Alzheimer's unit, according to the unit censussheet. Each of the resident's cognitive scoreswere reviewed. Out of the 24 residents, 1resident scored a #14 (R 83), showing theresident is cognitively intact. All of the rest of theresident's (R 63-82 & R 83-86) scored 7 or under,showing severe cognitive impairment.

R 67, 68, R 75, 76, 77 & 81 were observed on9/11/2012 from 11:00 AM - 4:00 PM. None of theresidents were engaged in any activities. R 75was observed pacing much of the time. Sittingonly for short periods of time. There was noattempt to engage her in any activities. R 75' s'



7/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 248 Continued From page 6 F 248 Activity Assessment of 8/11/20122 documents theresident is active all day long. She has behaviorsof wandering and physical aggression. Her pastoccupation was Home Care. The assessmentshows the resident requires low functioningprogramming.

R 67 was observed on 9/11/2012 from 11:35 AM

to 4:00 PM. The resident is seated in a high backwheel chair. His Physician Order Sheet shows hehas diagnoses including Dementia with Psychosisand Agitation, Right Hemiparesis, MacularDegeneration of the right eye and his left eye hasbeen enucleated (removed). His Activity

Assessment and Plan, dated 10/8/09, documentsthe resident displays behaviors of physical andverbal aggression. The assessment says hisbehaviors require him to be removed fromactivities so he doesn't disturb others.

R 76 was observed on 9/11/2012 from 11:00 AM

through 4:00 PM. The resident was observed ina reclining geriatric chair with a tray on the chair.The resident was not given anything to look at orto do with her hands. On 9/12/2012 at 8:30 AM,E6 (Certified Nursing Assistant/Unit Director) saidR 76 loves to do things with her hands.

R 68 was observed on 9/11/2012 from 11:00 AMthrough 4:00 PM. The resident never left a highback chair in the Activity/Dining Room. He did notgo to the table for his noon meal. R 68' s' Activity

Assessment of 3/8/2012 documents the residentcan talk, write, and read. He has a diagnosis ofDementia. He does not display behaviors. R 68requires cueing and direction when involved in anactivity. He enjoys being outdoors.

R 77 was observed from 11:00 AM to 1:30 PM,



8/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 248 Continued From page 7 F 248on 9/11/2012. The resident was not engaged inany activities. R 77 was continually asking ifanyone had seen his wallet. Staff response to R77 was his wallet was locked in the safe. On9/12/2012 at 7:45 AM, E6 said R 77 always asksfor his wallet and for his wife. She said the stafftell him his wallet is locked up in the safe and hiswife went to the doctor and will return in 1 hour.

E6 said they had never tried to give him a walletwith a picture of his wife in it, to ease his anxiety.His 9/7/2012 Activity Careplan states the residentis dependent on staff for activities, cognitivestimulation, and social interaction. Interventionsincluded on the care plan are to assure theactivities he attend are compatible with hisphysical and mental capabilities,and compatiblewith his interests. He is to be provided withmaterials for individual activities. The careplandocuments he likes to listen to music, watch thenews and read the newspaper.

R 81 was never observed engaged in activities.He was observed seated in a high back chair inthe main room from 11:00 AM to 4:00 PM. Hisonly activity was being fed his lunch. The rest ofthe time he was observed with his eyes closed.On 9/12/2012 at 7:45 AM, E6 said he spendsmuch of his time in bed. She said his pastoccupation was a band teacher. E6 said they hadnever tried to do activities with him geared to hispast occupation. His 2/17/2012 careplan states R81 needs Therapeutic Recreation, he has limitedinterest in activities. His goal is that he willpassively participate in a one-one individualizedprogram 3 times a week.

On 9/12/2012 at 7:45 AM, E6 said there are no1:1 activities done with residents who cannotparticipate in group activities due to severe



9/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 248 Continued From page 8 F 248cognitive impairment. E6 said she is not aCertified Activity Director. She said E8 (facility

Activity Director) oversees the activity program ofthe special care unit. On 9/12/2012 at 9:30 AM,E8 said, "I just found out I am actually overseeingthe Alzheimer Unit's Activities." E8 said she hasbeen employed with the facility for over 1 year.

The facility's Courtyard Special Care Unit Admission policy and Procedure (7/04) states, "Itis the policy of the Courtyard Special Care Unit tomaintain a comfortable and harmonious livingenvironment with residents who participate in,and benefit from, the therapeutic activityprogram...".

F 279SS=D

483.20(d), 483.20(k)(1) DEVELOPCOMPREHENSIVE CARE PLANS

A facility must use the results of the assessmentto develop, review and revise the resident'scomprehensive plan of care.

The facility must develop a comprehensive careplan for each resident that includes measurableobjectives and timetables to meet a resident'smedical, nursing, and mental and psychosocialneeds that are identified in the comprehensiveassessment.

The care plan must describe the services that areto be furnished to attain or maintain the resident'shighest practicable physical, mental, andpsychosocial well-being as required under483.25; and any services that would otherwisebe required under 483.25 but are not provideddue to the resident's exercise of rights under483.10, including the right to refuse treatmentunder 483.10(b)(4).

F 279 10/4/12



10/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



This REQUIREMENT is not met as evidencedby: Based on observation, interview and recordreview, the facility failed to identify behaviors of aresident who removes her clothing and covers topromote privacy.

This applies to 1 of 17 residents (R1) reviewedfor care plans in the sample of 17.


1. On 9/4/12 at 10:15 AM, R1 was lying in herbed, nearest to the door, with the door open andno privacy curtains drawn. R1's right breast wasexposed. On 9/4/12 at 10:30 AM, E2 (Director ofNursing) stated R1 moves around in her bed anddoes pull off her covers and removes her clothingon occasion.

On 9/11/12 at 1:45 PM, R1 was observed lying inher bed on her left side with her bare buttocksexposed and in full view of the hallway. E13(Licensed Practical Nurse-LPN) stated "I justcovered her up. She (R1) moves around and isknown to pull her covers off."

R1's care plans printed 8/31/12 identify she has"behaviors" related to her Alzheimer's Dementia.None of the behaviors listed identified herremoval of clothes or linens resulting in privatebody part exposure. No interventions wereidentified for protecting R1's privacy. Anintervention listed in the care plan forincontinence states R1 is to be dressed in loosefitting clothing.



11/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 279 Continued From page 10 F 279On 9/4/12 at the lunch meal and again on 9/12/12at the breakfast meal, R1 was observed eatingwithout her dentures in. E11 (LPN) wasinterviewed on 9/4/12 and E17 was interviewedon 9/12/12 at the time of the observations. E11stated R1 takes her teeth out and two days priorwas observed attempting to cut them with a knife.E11 stated R1 very clearly expressed she did not

want her dentures in. E17 stated R1 is constantlyremoving her dentures and been observed tryingto hide them or throw them away.

Review of R1's medical records shows she hashad a swallow evaluation completed. The POS of9/12 shows she is ordered a pureed diet with thinliquids. R1's care plans identified a nutritionalconcern. There are no interventions listed normention of R1's dentures or her refusal to usethem.

F 312SS=E

483.25(a)(3) ADL CARE PROVIDED FORDEPENDENT RESIDENTS

A resident who is unable to carry out activities ofdaily living receives the necessary services tomaintain good nutrition, grooming, and personaland oral hygiene.


F 312 10/4/12

Based on observation, interview, and recordreview the facility failed to ensure toileting,complete peri-care, dining assistance and handhygiene were provided to residents.

This applies to 4 of 17 residents (R67, 68, 75 &R76) reviewed for peri-care, dining, and hand



12/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 312 Continued From page 11 F 312hygiene, in the sample of 17.


1. R76's Minimum Data Set (MDS) of 9/15/12documents the resident requires assistance withtoileting, transfers with 2 assist, and is frequentlyincontinent of urine.

On 9/11/2012 at 11:00 AM, E5 and E7 wereobserved getting R76 out of bed. The resident'slinen and shirt were very wet with urine. Theresident's room smelled strongly of urine. Theresident was sat on the edge of the bed. E7washed the resident's peri-area with her sitting onthe edge of the bed. The perineal area was notexposed to allow a thorough cleaning of the innerand outer labia. The resident was then stood upand her buttocks was washed. E7 did not washthe resident's back or inner and outer thighs. Theresident was transferred to a geriatric chair. She

was not toileted to ensure the resident wasfinished voiding. The resident was taken to thedining room. The resident's hands were notwashed in preparation for lunch.

The facility's policy and procedure forIncontinent/Perineal Care (4/09) states, "It is thepolicy of the facility to provideincontinent/perineal care for the residents asindicated by the resident condition and ability toprovide self-care. Perineal care will cleanse theperineum and prevent infections and odors.Incontinent care will include all skin surfacesexposed to urine or feces. The procedure states,"...Expose perineal area and drape the resident toavoid any unnecessary exposure, cleanse areawith no rinse cleaners, wipe front to back to avoidthe spread of germs...Cleanse all skin areas that



13/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 312 Continued From page 12 F 312were exposed to urine or feces with no rinsecleaner (or soap and water)..."

2. R67's MDS of 7/30/12 documents the residentrequires assistance with toileting and he isfrequently incontinent of urine. The resident'sbladder incontinence careplan of 5/18/2012states the resident will be toileted every 2 hours

and as needed. On 9/11/2012 at 11:35 AM, E5(Certified Nursing Assistant) was observedgetting the resident out of bed. R67's roomsmelled strongly of urine. The resident's linenswere soaked with urine. After completingperi-care the resident was not offered the toilet tosee if he needed to void. The resident wastransferred to his wheelchair and taken to thedining room for lunch. R67's hands were notwashed in preparation for the noon meal.

R67's Physician Order Sheet of 9/2012 shows theresident has Macular Degeneration of his right

eye and his left eye has been enucleated(removed). His MDS of 7/30/2012 shows herequires supervision with eating. R67 receivedhis meal tray at 12:15 PM on 9/11/2012. Theresident was observed from 12:15 PM to 1:30PM. The resident was seated in his wheel chair.His chin was approximately 4 inches away fromhis plate. His wheel chair was not locked. Theresident kept moving farther and farther awayfrom the table, causing him to extend his armcompletely in an attempt to reach his food. R67'sclothing protector was on the table. The residentthought the clothing protector was food and triedto put a fork in it. Through out the observationthere was a staff member (unknown name)seated at the table assisting 2 of R67'stablemates. She did not offer or oversee R67while he was trying to eat. When R67 completed



14/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 312 Continued From page 13 F 312his meal, there was a large amount of food debrison the resident's lap and on the floor, around him.

3. R68's Minimum Data Set of 8/29/2012 showsthe resident has severe cognitive impairment.The resident requires set-up assistance but isable to feed himself. His careplan of 9/5/12documents the resident is a nutrition risk because

he refuses meals at times. His goal is that he willeat 75-100% of his food. R68 was observed from12:07 PM through 1:30 PM, during the noonmeal. He was seated in a high back living roomchair, away from the other resident's who wereeating lunch. Several staff members asked theresident is he wanted anything to eat. Theresident would not leave the chair and go to thetable. No one brought his tray or other food tohim, in an effort to encourage him to eat.

4. R75's MDS of 8/20/2012 shows the residentrequires supervision with dining and hygiene.

The resident was observed from 11:00 AM to1:30 PM. R75 frequently gets up from her chairand wanders the unit. Her lunch tray was servedto her 12:15. The resident was not assisted withhand hygiene prior to being served.

On 9/12/2012 at 7:45 AM, E6 (unit director) saidR76 and R67 will void when put on the toilet. Shesaid the resident's are to be toileted every 2hours. E6 verified R76 should have been lyingdown or standing up when receiving peri-care, notsitting on the edge of the bed. She said allresident's hands should be washed before eachmeal. E6 verified R67 doesn't sit up to the tablevery good in his wheelchair. E6 said she hadnever tried to place him in a stationary chair toassist him with correct positioning at the table.



15/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 315 Continued From page 14 F 315F 315SS=D

483.25(d) NO CATHETER, PREVENT UTI,RESTORE BLADDER

Based on the resident's comprehensiveassessment, the facility must ensure that aresident who enters the facility without anindwelling catheter is not catheterized unless theresident's clinical condition demonstrates that

catheterization was necessary; and a residentwho is incontinent of bladder receives appropriatetreatment and services to prevent urinary tractinfections and to restore as much normal bladderfunction as possible.


F 315 10/4/12

Based on observation, interview, and recordreview the facility failed to keep indwellingcatheter tubing off the floor for a resident at highrisk for infection. The facility also failed to toilet

incontinent residents as scheduled. This is for 3of 11 residents (R50, R67, & R76) reviewed forcatheter care and incontinent care in the sampleof 17.


1. On 9/11/12 at 2:40 PM, R50 was in bed.R50's indwelling catheter tubing was resting onthe floor.

On 9/11/12 at 2:40 PM, E12 & E13 (both CertifiedNursing Assistants) stated that the catheter tubingshould never be on the floor. The catheter needsto be kept as sanitary as possible.

On 9/11/12 at 2:45 PM, E2 (Director of Nursing)confirmed that indwelling catheter tubing should



16/28


17/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 315 Continued From page 16 F 315states the resident will be toileted every 2 hoursand as needed. On 9/11/2012 at 11:35 AM, E5(Certified Nursing Assistant) was observedgetting the resident out of bed. He wastransferred to his wheelchair. R67 was nottoileted. He was taken to the dining room forlunch.

On 9/12/2012 at 7:45 AM, E6 (unit director) saidR76 and R67 will void when put on the toilet. Shesaid the resident's are to be toileted every 2hours.

F 323SS=D

483.25(h) FREE OF ACCIDENTHAZARDS/SUPERVISION/DEVICES

The facility must ensure that the residentenvironment remains as free of accident hazardsas is possible; and each resident receivesadequate supervision and assistance devices toprevent accidents.


F 323 10/4/12

Based on observation, interview and recordreview the facility failed to ensure staff follow thefacility's procedure for performing a safe transfer.This applies to 1 of 14 residents (R40) reviewedfor transfer in the sample of 17 and 1 resident(R18) in the supplemental sample.


R40 is a 78 year old male on contact isolationprocedures due to bowel infection. E9 (CertifiedNursing Assistant -CNA) and E10 (CNA) were in



18/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 323 Continued From page 17 F 323R40's room with gown, gloves and face mask toput R40 into bed. E9 and E10 transferred R40from his wheelchair to the bed by picking him upunder his arms. A transfer belt was not used forthis transfer.R40's care plan of 6/7/12 states that R40 is a 2person stand and pivot transfer. The care planshows that a transfer belt is to be applied. E9

stated that she had a transfer belt in her pocketbut did not want to use it because of R40's bowelinfection. E2 verified that if a resident is a 2person transfer, a transfer belt is to be used.

On 9/13/12 at 8:30 AM, R18 stated "I have hadto have the waistbands of my pants repairedbecause the girls were picking me up by mypants." When asked if the aides had ever put abelt around her waist to assist her with thetransferring, R18 stated "no, and I can not affordto keep replacing my pants."

The facility transfer technique policy dated8/30/01 states that as part of preparing a patientfor transfer, a transfer belt is to placed around theresident's waist.

F 325SS=D

483.25(i) MAINTAIN NUTRITION STATUSUNLESS UNAVOIDABLE

Based on a resident's comprehensiveassessment, the facility must ensure that aresident -(1) Maintains acceptable parameters of nutritionalstatus, such as body weight and protein levels,unless the resident's clinical conditiondemonstrates that this is not possible; and(2) Receives a therapeutic diet when there is anutritional problem.

F 325 10/4/12



19/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



This REQUIREMENT is not met as evidencedby: Based on observation, interview, and recordreview the facility failed to implementinterventions and assist a visually impaired

resident who has experienced an unplanned 16pound weight loss.

This applies to 1 of 17 residents (R67) reviewedfor weight loss in the sample of 17.

The finding includes:

R67's careplan of 7/31/12 shows the resident isat risk for nutritional deficits. His 7/30/2012Minimum Data Set (MDS) documents R67 needsset up assistance and supervision with dining.

R67's weight monitoring record shows he hashad a 16 pound (#) weight loss from March 2012(170#) to September 2012 (154#). R67 has lostweight consistently every month for the past 6months. On 8/21/2012, the dietician documents,"Resident has Dementia which contributes to hisgradual decline." She documents R67 needs2155 calories daily to maintain and not loseweight.

R67's Physician Order Sheet of 9/2012 shows theresident has Macular Degeneration of his righteye and his left eye has been enucleated(removed). According to his 5/2/2012 AnnualDietary History he has been receiving 60cc of anutritional supplement 3 times daily. There wereno other interventions used in an effort to stabilizethe resident's weight.



20/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



R67 received his meal tray at 12:15 PM on9/11/2012. The resident was also given hisnutritional supplement of 60cc. The resident wasobserved from 12:15 PM to 1:30 PM. Theresident was seated in his wheel chair. His chinwas approximately 4 inches away from his plate.His wheel chair was not locked. The resident

kept moving farther and farther away from thetable, causing him to extend his arm completelyin an attempt to reach his food. R67's clothingprotector was on the table. The resident thoughtthe clothing protector was food and tried to put afork in it. Through out the observation there wasa staff member (unknown name) seated at thetable assisting 2 of R67's table mates. She didnot offer or oversee R67 while he was eating.When R67 completed his meal, there was a largeamount of food debris on the resident's lap andon the floor, around him. R67 did not drink hisnutritional supplement and was not encouraged

to finish it.

On 9/13/2012 at 2:00 PM, E2 (Director ofNursing) verified R67 has experienced weightloss.

There is no documentation in the resident'srecord showing R67's physician has been notifiedof his ongoing weight loss.

The facility's undated Weight Monitoring policyand procedure does not address how staff are toaddress resident weight loss. The policy andprocedure states, "All residents shall be weightedmonthly, or more frequently, if prescribed by thephysician...The weight team will evaluate theresident's needs based on the categories of theassessment form and any other pertinent



21/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 325 Continued From page 20 F 325information. The physician will be notified of thegain or loss within 48 hours, along with arecommendation to address the concern.

F 327SS=E

483.25(j) SUFFICIENT FLUID TO MAINTAINHYDRATION

The facility must provide each resident withsufficient fluid intake to maintain proper hydrationand health.


F 327 10/4/12

Based on observation, interview and recordreview, the facility failed to have a fluid plan for aresident on a fluid restriction to meet his ordereddaily intake and failed to make fluids available toresident's on the Alzheimer's Unit.

This applies to 5 residents (R19, R67, R68, R75,R76) in the sample of 14 reviewed for hydration

and 20 residents (R63-R66, R69-R74 &R77-R86) in the supplemental sample.


1. R19 was admitted to the facility on 9/1/12 withdiagnosis to include Congestive Heart Failure(CHF), Pulmonary Hypertension (HTN), DiabetesMellitus (DM) and Renal Failure with Dialysisaccording to the Admission History and Physical(H&P). The H&P (9/1/12) also documents R19was hospitalized prior to facility admission withthe diagnosis of Exacerbation of CHF. ThePhysician Order Sheet (POS) of 9/2012 showedR19 is on Lasix 80 mg (diuretic) twice daily and isto be on a 1500 cc/day fluid restriction.



22/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 327 Continued From page 21 F 327On 9/13/12 at 9:20 AM, E15 (Licensed PracticalNurse - LPN) was observed to be passingmedications on the hallway of which R19 resides.E15 acknowledged she was taking care of R19.When asked about R19's fluid restriction, E15stated she was aware she was on a 1500 cc/dayrestriction but had no idea how much of that wasto come from meals and which portion was

allotted for the nurses to use during themedication passes. E15 stated, "Dietary usuallytakes care of that." On 9/13/12 at 9:20 AM, E2(Director of Nursing) verified their was nothing inplace to monitor intakes on R19. At 11:15 AM,E2 acknowledged with no documentation, therewas no way for the facility to ensure R19 wasreceiving sufficient fluid intake to maintain herhydration status. E2 also verified that by notmonitoring R19's fluid intake, the facility could notensure R19's fluid consumption did not exceedthe 1500 cc's/day as ordered. E2 said, "we havenot been monitoring her intake."

R19's care admission care plan identified aproblems of "potential fluid volume overload r/t(related to) Kidney Failure. She is on a 1500ml/24 hour fluid restriction," and "on diuretictherapy." The interventions included "Ensure thatall the resident's snacks and beverages offered atactivities comply with diet and fluid restriction,"and "Administer medications as ordered." Nospecific information on fluid amounts that are tobe given and/or limited were identified.

The 9/6/12 Nutritional Progress Note documentedthe fluid restriction was to be given in thefollowing manner: 1200 cc's/fluid through theDietary/meals; and Nursing would supply theadditional 300 cc's/day.



23/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 327 Continued From page 22 F 327On 9/13/12 at 9:20 AM, E2 stated the facilityusually gives the fluid restrictionrecommendations to the dietary department whois responsible for generating the trackingpaperwork. E2 stated this had not been done forR19.

The facility policy for Monitoring Fluid Restrictions

dated 07/07 states at #7: "The fluid restrictionpattern is documented in the Nutrition ProgressNotes, clearly detailing the exact amount of fluidsdietary will serve and when as well as nursingfluids for medications. Nursing staff isresponsible for monitoring fluid intake anddocumenting it on the I & O sheet."

2. On 9/11/2012 at 9:30 AM, a tour wasconducted of the facility's Alzheimer unit. All ofthe rooms were observed, there was no wateravailable to the resident's in their rooms or in themain activity area.

On 9/12/2012 at 7:45 AM, E6 (Unit Director) wasasked why there was no glasses of wateravailable to the resident's in their rooms. E6 said,"We have never kept glasses of water in theresident's rooms." When asked how theresident's would get a drink during the night, E6



24/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 327 Continued From page 23 F 327said, "That's a good question."

The facility's undated Passing Ice Water Policyand Procedure states, "This facility will pass icewater three (3) times a day by the nurses' aides.

All residents shall have ice water available at thebedside at all times. Residents will be offered adrink every time a nursing staff member enters

the room. This promotes the increaseconsumption of fluids which is important for goodhealth..."

According to a facility room listing R63-R66,R69-R74 & R77-R86 reside on the Alzheimer'sunit.

F 371SS=F

483.35(i) FOOD PROCURE,STORE/PREPARE/SERVE - SANITARY

The facility must -(1) Procure food from sources approved orconsidered satisfactory by Federal, State or local

authorities; and(2) Store, prepare, distribute and serve foodunder sanitary conditions


F 371 10/4/12

Based on observation, interview, and recordreview, the facility failed to sanitize foodpreparation/service pans and equipment prior touse. This has the potential to affect all 85residents in the facility.




25/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



The facility's 9/11/12 Resident Census andCondition Form CMS- 672 show a census of 85.

On 9/11/12 at 9:45 AM, E4 (Cook), removed sixsteam table pans from the rinse water of thethree compartment sink. E4 then dipped thepans in the sanitizer compartment for less than 5

seconds before removing and placing them todry. E4 stated, "I usually leave things in thesanitizer 30 to 40 seconds." At 11:15 AM and11:30 AM, E4 washed the food processor andthen placed it in the sanitizer compartment for 15seconds.

On 9/11/12 at 3:15 PM, E3 (Dietary Manager),said items washed in the 3 compartment sinkshould be fully immersed for at least a minutebefore removing to dry.

The facility's July 2007 Manual Cleaning with a

3-Compartment Sink policy states, "Equipmentand utensils are sanitized in the thirdcompartment sink by immersion for at least 1minute."

F 441SS=E

483.65 INFECTION CONTROL, PREVENTSPREAD, LINENS

The facility must establish and maintain anInfection Control Program designed to provide asafe, sanitary and comfortable environment andto help prevent the development and transmissionof disease and infection.

(a) Infection Control ProgramThe facility must establish an Infection ControlProgram under which it -(1) Investigates, controls, and prevents infections

F 441 10/4/12



26/28


27/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 441 Continued From page 26 F 4411. On 9/11/2012 at 11:00 AM, E7 and E5(Certified Nursing Assistants) were observedperforming pericare with R76. R76's MinimumData Set (MDS) of 9/5/2012 shows the residentrequires extensive assistance with hygiene andbathing. R67's bed was visually soaked withurine. Both staff donned gloves. E7 performedpericare with the resident. She removed R76's

wet shirt. With her gloves still on, E7 dressed theresident, contaminating her clothing. Theresident was transferred from the bed to thewheel chair. E7 still did not remove her soiledgloves and wash her hands. E7 contaminateR76's wheel chair with her soiled gloves. E7removed her gloves and cleaned her hands afterthe resident was placed into her wheelchair.

2. On 9/11/2012 at 11:35 AM, E5 was observedgetting R67 out of bed. R67's bed linens andshirt were visually soaked with urine. E5 donneda pair of gloves and performed peri care. After

completing the peri-care, R67 was rolled to hisleft side to wash his buttocks. E5's name tag wason a lanyard, around her neck. As E5 waswashing R67's buttocks and back, E5's name tagwas swept across the wet linens, contaminatingher name badge and her scrub top. When E5completed the hygiene, she did not remove hergloves and clean her hands. She assisted theresident to a sitting position by holding onto hishands, with her soiled gloves on. E5 then went tothe resident's dresser and obtained a clean shirtout of the drawer, contaminating the dresser, thedrawer, and other clothes in the drawer. E5finished dressing the resident, with her soiledgloves still on. She then removed her gait belt,with the soiled gloves on, and put it around theresident. The resident was transferred into hiswheel chair, contaminating the gait belt, the



28/28

A. BUILDING ______________________






B. WING _____________________________




DIXON, IL 61021



(X5)COMPLETIO

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG


F 441 Continued From page 27 F 441resident's clean clothing, E5's clothing, and thewheel chair.

The facility's Handwashing/Hand hygiene policyand procedure (6/2012) states, "This facilityconsiders hand hygiene the primary means toprevent the spread of infections...All personnelshall follow the handwashing/hand hygiene

procedures to help prevent the spread ofinfections to other personnel, residents, andvisitors...Employee must wash their hands for atleast fifteen (15) seconds using antimicrobial ornon-antimicrobial soap and water under thefollowing conditions: ...Before and after directresident contact...Before and after assisting aresident with personal care...After contact with aresident's mucous membranes and body fluids orexcretions; After handling soiled or used linens,dressings, bedpans, catheters and urinals..." Thefacility's Personal Protective Equipment - Glovespolicy and procedure (8/2009) states, "...Wash

your hands after removing gloves..."


Date post:	02-Jun-2018
Category:	Documents
Upload:	saukvalleynews
View:	220 times
Download:	0 times

Survey for Dixon Rehab

Documents