Northside Health Care

Based on observations, interviews, review of the 2017 Food Code, and a facility policy titled, Tray Line and Meal Service Temperatures, dietary staff failed to ensure: 1) the temperatures of food items on the tray line were checked prior to service; 2) thermometers were accurately calibrated prior to use; 3) staff did not handle ready-to-eat food with bare hands; 4) staff washed their hands prior to the application of gloves; and 5) food found to be below recommended temperatures, was reheated to 165 degrees Fahrenheit (F) prior to service. These deficient practices had the potential to affect 87 residents for whom meals were prepared and served at the time of this survey. According to the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, the census at the time of the survey was 90. Findings Include: 1) A facility policy titled, Tray Line and Meal Service Temperatures, with an effective date of 08/01/12, specifies: .Temperatures of food items held on the service line will be recorded . All hot food must be held at temperatures above 135 degrees F; . All cold foods will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and review of the Assure Platinum Glucometer Study Guide, the facility failed to ensure a medication nurse, Employee Identifier (EI) #1, wore gloves while performing a finger stick blood glucose test on Resident Identifier (RI) #61 on 10/16/19, during the evening medication pass observation. Findings Include: Review of an undated Assure Platinum Glucometer Study Guide, revealed the following: BLOOD GLUCOSE TESTING Obtaining a Drop of Blood Note . We advise healthcare professionals to wear gloves during blood testing . RI #61 was admitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes Mellitus. RI #61's Order Summary Report for 10/2019, revealed RI #61 was to receive blood glucose testing before meals and at bedtime. On 10/16/19 at 3:50 p.m., the surveyor observed EI #1 gather supplies to check RI #61's blood sugar. After washing her hands, EI #1 wiped the third finger on RI #61's left hand with an alcohol prep. EI #1 removed a glucometer from a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, review of the 2017 U.S. (United States) Public Health Service Food Code and review of facility policies titled Dry Storage, Dietary Food Handling and Water Temperature for Dishwashing Machines, the facility failed to ensure: (1) dented cans were not stored with other canned goods; (2) an opened jar of jelly had a use by date on it; (3) a container of barbeque sauce did not have sauce on the outside of the container; (4) the tips of the thermometers were not touching the bottom of the glass and the thermometer was not submerged under water during calibration; (5) a cook did not place the handle of the tong on top of a pan of rolls after she touched the handle with her bare hands; (6) grease was not on top of the oven; (7) dust like particles were not on the back of the oven fan and on a book above the toaster; (8) plate warmers and covers were air dried; and (9) a cook did not place her bare hands on the inside of plate covers. These deficient practices were observed on two of three days of the survey, and had the potential to affect all 88…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #55's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/20/18, reflected RI #55 was receiving Dialysis services. This deficient practice affected RI #55, one of 40 residents whose MDS assessments were reviewed. Findings Include: RI #55 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses to include End Stage Renal Disease and Dependence on Renal Dialysis. A review of RI #55's Quarterly MDS assessment, with an ARD of 08/20/18, did not identify RI #55 as having received Dialysis services during this assessment period. A review of RI #55's September 2018 Physician Orders documented: . Dialysis @ (at) (name of Dialysis center) Tues (Tuesday)/Thur (Thursday)/Sat (Saturday) . 09/05/18 at 08:45 a.m., the surveyor conducted an interview with RI #55. RI #55 shared with the surveyor he/she went to Dialysis on Tuesdays, Thursdays and Saturdays. At…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure a care plan was developed for RI (Resident Indentifier) #241, a resident who required the use of Oxygen (O2). This deficient practice affected RI #241, one of three sampled residents who required the use of O2. Findings include: RI # 241 was re-admitted to the facility on [DATE] with a diagnosis of Respiratory Failure, Unspecified with Hypoxia. On 09/6/18 at 7:55 a.m., the surveyor observed the resident with O2 on. On 0 9/6/18 at 3:11 p.m., a review of RI #241's care plans revealed the facility had not developed a care plan to address RI #241's O2 use. On 09/06/2018 at 4:08 p.m., an interview was conducted with EI (Employee Identifier) #5, Director of Nurses (DON). EI #5 was asked if RI #241 used O2. EI #5 said, Yes. EI #5 was asked if RI #241 had a care for the use of O2. EI #5 said, No. EI #5 was asked what was the rationale for having a care plan. EI #5 said, To provided the care (he/she) requires.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and review of PERRY & [NAME], 9th Edition, Clinical Nursing Skills & Techniques, the facility failed to ensure Resident Identifier (RI) #3's nebulizer face mask and reservoir cup were rinsed and dried after receiving a nebulizer treatment from a Licensed Practical Nurse (LPN). This affected 1 of 1 resident observed receiving a nebulizer treatment and 1 of 6 nurses observed during medication administration pass. Findings Include: A review of PERRY & [NAME] 9th Edition, Clinical Nursing Skills & Techniques, Chapter 21, Page 564, documented .When medication is completely nebulized .Rinse nebulizer cup .Dry completely .Proper storage reduces transfer of microorganisms . RI #3 was admitted to the facility on [DATE]. RI #3's Order Review Report for September 2018 documented a diagnosis of Pnuemonitis Due To Inhalation Of Food and Vomit. RI #3's September 2018 Medication Administration Record documented orders for Duoneb nebulizer treatments every six hours. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility policy titled Refrigerated Storage, the facility failed to ensure raw beef shoulder, raw pork tenderloin, and open sandwich meat were not stored in the same container in the walk-in cooler, creating the potential for cross-contamination. This had the potential to affect 89 of 92 residents in the facility, identified by the facility as receiving meals from the dietary department. Findings include: Review of the facility's policy titled Refrigerated Storage, effective 06/01/2013, revealed the following: .PROCEDURE . 3. If it is necessary to store fresh and cooked food in the same refrigerator, the cooked foods should be . stored above the fresh foods. 4. Raw meats, poultry, and fish . each type of meat placed in a separate pan . On 08/15/2017, during the initial tour of the kitchen at 6:37 p.m., a plastic bin containing multiple types of meat was observed in the walk-in cooler. Dietary staff identified the meats as an uncooked beef shoulder, uncooked pork tenderloin, and multiple packages of luncheon meat. Two of the luncheon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure: 1) the residents and/or their representatives were informed of the risks and benefits related to the use of side rails prior to installation; and 2) Resident Identifier (RI) #8 did not have a full side rail up on the room/exit side of the bed on 08/15/2017 and a fall mat was placed at the bedside. These failures affected RI #s 1, 2, 3, 8, 10, and 11, six of six residents reviewed for side rail use, and had the potential to affect all 57 of 92 residents residing in the facility, identified by the facility as using side rails. Findings include: 1) A facility-provided list identified 57 residents in the facility utilizing side rails. When asked for a facility policy related to the use of side rails, Employee Identifier (EI) #4, the Director of Nursing Services, provided a signed document indicating the facility did not have a policy on side rails. This document also indicated the facility did not obtain informed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interviews, and review of the job description for the [NAME] President of Quality Management and Clinical Services, corporate staff failed to ensure a policy was developed and/or the facility procedure was revised for side rail use. This had the potential to affect all 57 of 92 residents in the facility, identified as utilizing side rails. Findings include: Cross Reference F323. Review of an undated job description for the [NAME] President of Quality Management and Clinical Services, Corporate Office, revealed the following: . KEY RESPONSIBILITIES . 4. Develops policies and procedures . A facility-provided list identified 57 residents in the facility utilizing side rails. When asked for a facility policy related to the use of side rails, Employee Identifier (EI) #4, the Director of Nursing Services, provided a signed document indicating the facility did not have a policy on side rails. This document also indicated the facility did not obtain informed consent/authorization prior to using side rails, unless it was considered a restraint. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure individualized care plan approaches were developed to address Resident Identifier (RI) #2's need for 3/4 (three quarter) side rails up times two. This affected one of 17 residents for whom care plans were reviewed. Findings include: RI #2 was readmitted to the facility on [DATE] with diagnoses of Unspecified Osteoarthritis and Pressure Ulcer. RI #2's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of 06/05/2017, indicated RI #2 was cognitively intact and was totally dependent on one person for bed mobility and transfers. RI #2's EVALUATION FOR USE OF SIDE RAILS(S) ., dated 06/05/2017, indicated RI #2 required 3/4 side rails up times two at all times when in the bed due to weakness, balance deficit, and to improve bed mobility. However, RI #2's undated Care Guide, did not indicate RI #2's need for side rails. RI #2's falls care plan, with an onset date of 12/23/2011, included an intervention of . May use bedside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure Resident Identifier (RI) #8's Care Guide was updated to reflect the need for 3/4 (three quarter) side rails up times two per the resident assessment. This affected one of 17 residents for whom care plans were reviewed. Findings include: RI #8 was readmitted to the facility on [DATE] with diagnoses of Muscle Weakness, Age-Related Osteoporosis, Unspecified Dementia, and History of Falling. RI #8's Significant Change in Status Minimum Data Set Assessment, with an Assessment Reference Date of 05/03/2017, indicated RI #8 had moderately impaired cognition and required limited assistance of one person for bed mobility. RI #8's most recent EVALUATION FOR USE OF SIDE RAIL(S) ., dated 05/08/2017, indicated RI #8 required the use of 3/4 side rails up times two at all times when in bed related to weakness, balance deficits, and to improve bed mobility. However, RI #8's current Care Guide (used by staff to know what care is needed) indicated RI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #8's interventions of 3/4 (three quarter) side rails up times two and a fall mat at bedside were implemented. This affected one of six residents sampled for falls and side rails and one of 17 residents for whom care plans were reviewed. Findings include: RI #8 was readmitted to the facility on [DATE] with diagnoses of Muscle Weakness, Age-Related Osteoporosis, Unspecified Dementia, and History of Falling. RI #8's Significant Change in Status Minimum Data Set Assessment, with an Assessment Reference Date of 05/03/2017, indicated RI #8 had moderately impaired cognition and required limited assistance of one person for bed mobility. RI #8's comprehensive care plans included an intervention dated 01/11/2016 for .fall mat to right side of bed . due to risk of falls. RI #8's most recent EVALUATION FOR USE OF SIDE RAIL(S) ., dated 05/08/2017, indicated RI #8 required the use of 3/4 side rails up times two at all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.