Lighthouse Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of Resident Identifier (RI) #29's medical record and the facility's policy with a subject of Standard Precautions, the facility failed to ensure Employee Identifier (EI) #5, the Licensed Practical Nurse (LPN) Treatment Nurse removed her gloves, sanitized her hands, and applied new gloves after cleaning RI #29's sacral pressure ulcer, before applying Santyl ointment, skin prep and a clean dressing to the pressure ulcer during wound care. This deficient practice affected RI #29, one of two sampled residents observed for wound care. Findings include: The facility's policy titled, BALL HEALTHCARE SERVICES, INC. ADMINISTRATIVE PROCEDURE with a subject of Standard Precautions dated December 2009, documented POLICY STATEMENT: Standard Precautions will be used in the care of all residents regardless of their diagnosis or presumed infection status. Standard Precautions apply to blood, body fluids, secretions, excretions, non-intact skin and mucous membranes regardless of the…

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 interviews and review of Resident Identifier (RI) #47's medical record and Mosby's 2017 NURSING DRUG REFERENCE 30TH EDITION, the facility failed to provide medical justification for the use of antipsychotic medication, Risperdal, for RI #47. This deficient practice affected RI #47, one of five sampled residents reviewed for unnecessary medications. Findings include: RI #47 was readmitted to the facility on [DATE] with an admit diagnosis of late onset Alzheimer's disease. RI #47 has a medical history to include a diagnosis of Unspecified Dementia with behavioral disturbance. RI #47's Physician Orders for January 2020 included an order dated 10/4/2019 for . RISPERDAL 0.5 MG (milligram) TABLET - GIVE ONE TABLET VIA TUBE EVERY MORNING . Page 1037 of Mosby's 2017 NURSING DRUG REFERENCE 30TH EDITION with a copyright date of 2017, indicatedRisperdal is an antipsychotic medication used to treat certain mental/mood disorders such as Schizophrenia, Bipolar Disorder, and irritability associated with Autism. In an…

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 facility policy titled, FOOD STORAGE LABELING, the facility failed to ensure: 1. a container of pureed slaw in the refrigerator was labeled with identifying label, date and use by date, 2. sliced ham in a zip lock bag in a second reach in refrigerator had an identifying label on it; and 3. kitchen staff while plating mixed vegetables did not rake vegetables that had spilled out of the pan on the side of the steam table back into the pan of mixed vegetables. This had the potential to affect 51 of 51 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled FOOD STORAGE LABELING with a revised date of 10/17 revealed: POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures. PROCEDURE: . 2. All food items that are not in their original containers must be labeled with the common name of the food and the date they are received .2. Suggested labeling includes: a. Common name b. Date of preparation or Use By Date . 1. On 2/25/19 3:30 PM, a storage…

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, interview and review of a facility policy titled, Resident Assessment Instrument, the facility failed to ensure a timely Minimal Data Set (MDS) assessment was completed for Resident Identifier (RI) #3. This affected one of four residents whose MDS assessments were reviewed for timely submission. Findings Include: A review of a facility policy titled, Resident Assessment Instrument, with a revised date of 10/2013 revealed: .PROCESS: . V. MDS Version 3.0 Quarterly Assessment . b) Quarterly assessments are due at least every 92 days, . RI #3 was admitted to the facility on [DATE] with a diagnosis of Cerebral Infarction due to unspecified occlusion or stenosis of right mid cerebral artery. A review of RI #3's MDS 30 day E assessment, with an Assessment Reference Date of 9/28/18, revealed: . SNF PPS (Skilled Nursing Facility Prospective Payment System) Part A Discharge Assessment was completed for end of therapy. On 2/27/19 at 3 :04 PM, further review of RI #3's assessments revealed no other…

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 review of facility policies titled, Hand Washing and Perineal Care, the facility failed to ensure a Certified Nursing Assistant (CNA) washed or sanitized her hands between glove changes during the provision of incontinent care for Resident Identifier (RI) #46. This was observed on 2/27/19 and affected one of one resident observed for incontinent care. Findings Include: A review of a facility policy titled, Hand Washing with a revised date of 3/2006 revealed: PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of the transmission of infections. STANDARD: Handwashing should be performed between procedures with residents. A review of a second facility policy titled, Perineal Care with a revised date of 02/2014 revealed: PURPOSE: Proper perineal care helps prevent infection . RI #46 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Unspecified Dementia. On 2/27/19 at 3:39…

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 facility Hand And Single Use Gloves Sanitation Practices policy, the failed to ensure the sanitation of handling of foods in the kitchen by: (1) dietary staff washing their hands after touching their face with bare hands prior to handling resident plates after they had been plated with food and (2) dietary staff not placing a bag of chicken strips on the floor while storing after a food delivery. This had the potential to affect all residents in the facility. Findings include: Facility policy for Hand And Single Use Gloves Sanitation Practices, originated date 10/08 read: Procedure: 1. Employees have access to proper handwashing facilities in the food service department and throughout the facility . 2. Hand Care a. Food service employees wash hands after the following activities: . iii. Touching the hair, face, or body . (1) On 01/09/18 at 11:17 am observations were conducted in the kitchen during the plating of the lunch meal. An observation was made of dietary staff, Employee Identifier (EI) #14, rubbing her chin with her bare left…

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 review of facility Daily Dumpster Monitoring policy, the facility failed to ensure the two outside dumpsters were maintained in a manner to prevent potential attraction of rodents and bugs to the dumpster site. This had the potential to affect all residents in the facility. Findings include: The review of the facility's policy for Daily Dumpster Monitoring read, Maintenance and Housekeeping staff will inspect all dumpster each day to ensure that the surrounding areas are free of debris and that the dumpster lids are closed . The policy did not include ensuring that garbage bags were secured to prevent spillage and odors. On 01/09/18 at 10:59 am an observation was made of the facility's two garbage dumpsters outside. Dumpster #1 and #2, was observed empty except for standing liquid and foul odor. On 01/10/18 at 9:12 am an observation was made in dumpster #1, closest to the building. Observed were 2 opened bags. In dumpster #2 observed were loose items, odor and an opened bag.…

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 and interview, the facility failed to ensure residents were cared for in a manner to maintain dignity. During the lunch meal on 1/09/2018, (Resident Identifiers) #s 5, 6, 213 and 32 were seated at the same table. RI #5 was provided with his/her meal tray. Employee Identifier (EI) #10 immediately began assisting RI #5 with eating. RI #s 6, 213 and 32 was not provided their meal tray until approximately 10 minutes later. This deficient practice affected 3 of 6 residents observed during the dining room observation. Findings include: On 01/09/18 at approximately 11:51 p.m. Residents 6, 213, 32 and 5 were seated at the same table in the dining room for lunch. EI #10 picked up RI #5's tray from the kitchen staff, brought the tray to the table and immediately started assisting RI #5 to eat the lunch meal as RI #s 6, 213 and 32 sat at the table without a tray. Other staff continued to serve meals to other residents in the room. Approximately 10 minutes later, RI #s 6, 213 and 32 were served their meals and began eating with staff assistance. EI #10, the Certified…

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 interviews, record review and review of the facility's Notice of Transfer form, the facility failed to honor a resident's desire not to move from her/his room when informed by the facility that she/he was being moved to another room. This affected Resident Identifier (RI) #31, one of one resident who expressed dissatisfaction with her/her room change. Findings include: RI #31 was admitted to the facility on [DATE] following a motor vehicle accident. RI #31 was cognitively intact and able to express her wants and desires. Review of the facility's Notice of Transfer form, dated 10/9/17, noted the reason for the transfer was, Room change necessary to facilitate compliance with turning and repositioning. On 10/9/17, RI #31 was moved from his/her room to the room next door. The same day the resident was given the notice. During the record review, a document (no date or title) revealed the Ombudsman had been informed by RI #31 that she/he did not want to change room. EI #9/DON also documented, . The writer…

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 3. RI #3 was readmitted to the facility with diagnoses including End stage renal disease, hypertension and muscle weakness. RI #3's Physician's orders for September 2017 revealed the resident received Hemodialysis on Tuesdays, Thursdays and Saturdays. RI #3's MDS was not coded to reflect the resident received Dialysis. On 01/11/2018 at 4:23 p.m., an interview was conducted with Employee Identifier/EI #15, Unit manager, RN (Registered Nurse). EI #15 reviewed RI #3's Quarterly MDS with a ARD of 09/18/2017 and was asked did that assessment reflect RI #3 receiving Dialysis. EI #15 said no. EI #15 was also asked why should Dialysis have been coded to reflect the resident's Dialysis treatment. EI #15 explained due to the resident receiving Dialysis the MDS should have been coded to reflect the treatment. 2. RI #44 was admitted to the facility on [DATE] with diagnoses to include Dementia with Behavioral Disturbance and Unspecified Psychosis. A review of RI #44's Physician Order List dated 07/01/2017 through 07/31/2017…

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 interview, the facility failed to ensure RI (Resident Identifier) #44's care plan was revised to reflect the discontinuation of the Antipsychotic medication. This deficient practice affected RI #44, one of 16 residents whose care plans were reviewed. Findings Include: RI #44 was admitted to the facility on [DATE], with diagnoses to include Dementia with Behavioral Disturbance and Unspecified Psychosis. A review of RI #44's Physician Order List dated 07/01/2017 through 07/31/2017, revealed Risperdal was discontinued on 07/27/2017. A review of RI #44's care plans revealed: .Problem Onset: 05/30/2014 Resident is at risk for side effects from antipsychotic (antipsychotic) drug use . Resident will maintain a normal/therapeutic blood drug range 3/07/18 .Approaches Administer Resident's medication as ordered by physician .Reviewed-09/18/2017 . On 1/11/2018 10:56 AM, an interview was conducted with EI (Employee Identifier) #11, RN (Registered Nurse)/Unit Manager on 200 Hall. EI #11 was asked…

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 reviews, observation and interviews, the facility failed to ensure Resident Identifier (RI) #3, a visually impaired resident, was provided an adaptive device (plate guard) as indicated on his meal tray card. This affected one of one sampled resident who required an adaptive device when eating. Finding include: RI #3 was readmitted to the facility on [DATE] with End stage renal disease, hypertension and legal blindness. A review of RI #3's most recent annual Minimum Data Set with an Assessment Reference Date of 12/25/2017 revealed the resident's vision was severely impaired. On 01/10/2018 at 8:14 a.m., during RI #3's breakfast meal, an observation of RI #3's breakfast meal tray card with a date of 01/10/2018 revealed the resident was to have received a plate guard as a feeding assistance device. A review of a document titled, Plan of Treatment for Outpatient Rehabilitation with a date of 10/24/2017 revealed the speech therapist/EI (Employee Identifier) #16's documentation stated RI #3 self fed…

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.