Chinle Nursing Home Inspection Report

8/9/2019 Chinle Nursing Home Inspection Report

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DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED:12/17/2014FORM APPROVEDOMB NO. 0938-0391

STATEMENT OFDEFICIENCIESAND PLAN OFCORRECTION

(X1) PROVIDER / SUPPLIER/ CLIAIDENNTIFICATIONNUMBER

035242

(X2) MULTIPLE CONSTRUCTIONA. BUILDING ______B. WING _____

(X3) DATE SURVEYCOMPLETED

09/27/2013

NAME OF PROVIDER OF SUPPLIER

CHINLE NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 910CHINLE, AZ 86503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORYOR LSC IDENTIFYING INFORMATION)

F 0167

Level of harm - Minimalharm or potential for actualharm

Residents Affected - Some

Allow residents to easily view the results of the nursing home's most recent survey.

According to observation and interview, the facility failed to ensure that residents had the right to examine the resultsof the most recent survey of the facility and to make the results available for examination and post the survey in a placethat is readily accessible to residents. Findings include: 1. On 9/26/2013 at 4:00 PM, an observation was made in the frontlobby of the facility regarding the most recent Federal survey results. A binder containing the survey results was lying onthe flat surface at the top of the bottom half door. The binder would not be noticeable to anyone unless they happened tobe standing at that doorway, looking downward. There was no sign in the lobby area that indicated where the results of themost recent Federal survey could be found. 2. On 9/26/2013 at 4:15 PM, an observation was made of the door leading into theoffice of Social Services staff who is responsible for the residents on Unit B. There was a plastic holder on the front ofthe door; it contained a binder that was labeled, Reports of CMS Survey done by Arizona Department of Health Services ofApril 12-16, 2006 for review. This binder did not contain any current Federal survey results. The most recent Federalsurvey had been conducted in 2011. When Administrative staff were asked how the residents would obtain information on themost recent Federal survey, staff did not know.

F 0172



Give the resident the right to receive visitors.

Based on observation and interview, the facility failed to provide reasonable access to any resident by any entity orindividual (including family) that provides health, social, legal, or other services to the resident, subject to theresident's right to deny or withdraw consent at any time. Findings include: On 9/26/2013 at 4:55 PM, during an observationof the front lobby, it was noted that a prominent sign was posted in plain sight for all visitors to the facility. The signincluded 'visiting hours' as 10:00 AM - 8:00 PM. Administrative staff, who were present during the observation, confirmedthat the visiting hours are from 10:00 AM - 8:00 PM. When asked if it were possible for visitors to see the residents atany time other than the visiting hours that were posted, Administrative staff stated that the doors to the lobby would be

locked and visitors would have to use a side door to get into the facility. Administrative staff acknowledged that therewere no signs posted at the front of the building or in the lobby entrance to indicate that the side doors could be used toenter the facility to visit with residents.

F 0203


Residents Affected - Few

Provide enough notice before discharging or transferring a resident.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on interview and document review, the facility failed to provide at least 30 days notice before the resident wasdischarged from the facility for 1 of 2 closed records reviewed (Resident 12). Finding includes: Resident 12 Review of thefacility's incident report revealed Resident 12 was an [AGE] year old male who had [DIAGNOSES REDACTED]. On 5/21/13,Resident 12 reportedly physically abused another resident by hitting the victim on his right cheek in the facility diningroom. This physical abuse was observed and initially reported to staff by a nursing assistant student (NAS). The NASreported Resident 12 attempted to close a window curtain where the victim was seated. When the victim requested Resident 12not to close the curtain as he was looking out of the window, he was hit by Resident 12. The facility report indicated theresidents were immediately separated to prevent further confrontation and their care plans were updated. Subsequently on5/21/13, the facility sent the resident home with a daughter until the investigation was completed and on 5/28/13 theinvestigation committee discharged the resident home to his other daughter. There was no documented evidence eitherdaughter agreed to the discharge and was prepared for the discharge and there was no evidence the facility provided a 30day notice. The facility's abuse policy revised on 11/6/12 (page 4) and subsequent interviews with the Director of Nursingand Social Worker, revealed residents who were alleged violators would be removed from the facility while the investigationwas in progress. Per CMS (The Centers for Medicare and Medicaid Services) regulation, before a facility transfers ordischarges a resident, the facility must notice the resident and family member least 30 days before the resident istransferred or discharged with the reason, the effective date, the location where the resident is being discharged , astatement that the resident has the right to appeal the action, the name, address, and telephone number of the state longterm care ombudsman. Complaint AZ 988

F 0226



Develop policies that prevent mistreatment, neglect, or abuse of residents or theft ofresident property.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on interview and document review, the facility failed to: ensure the 7 components of abuse were clearly delineated intheir abuse policy; correctly interpret in their policy what to do with residents with allegations of abuse; and reportincidents in a timely manner and results of reported incidents. The facility also lacked evidence of references in 5 of 5employee files prior to employment, lacked evidence of abuse training in 3 of 5 employee files prior to employment, andfailed to have fingerprint clearance in 3 of 5 employee files. Findings include: The facility's abuse policy was limited inthat the policy itself failed to be comprehensive and delineate how they would implement the required components asspecified in the regulation: Screening, Training, Prevention, Identification, Investigation, Protection, andReporting/Response. When the Director of Nursing (DON) was asked about other policies which may address the procedureswhich detail how the facility implemented the 7 components, she revealed a consultant had streamlined their morecomprehensive abuse policy which had included the 7 components. The DON subsequently printed out additional policiesincluding Swallowing Problems, Wanderers/Elopement, Nursing Assessment Documentation, Resident Complaints, UnusualOccurrences, Accidents and Incidents Policy, Use of Restraints, and Post mortem Care. These policies failed to cover all ofthe components. 1. The facility's abuse policy revised on 11/6/12, revealed the residents who were alleged violators shallbe removed from the facility immediately while the investigation is in process.Social Service Coordinator shall initiatenecessary transfer of the involved resident with family representative, designated case manager, Navajo Nation Adult

protective Service, Navajo Nation and State Ombudsman within required time frame based on severity of willfull act. Thispolicy was applied to Resident 12: Review of the facility's incident report revealed Resident 12 was an [AGE] year old malewho had [DIAGNOSES REDACTED]. On 5/21/13, Resident 12 reportedly physically abused another resident by hitting the victimon his right cheek in the facility dining room. This physical abuse was observed and initially reported to staff by anursing assistant student (NAS). The NAS reported Resident 12 attempted to close a window curtain where the victim wasseated. When the victim requested Resident 12 not to close the curtain as he was looking out of the window, he was hit byResident 12. The facility report indicated the residents were immediately separated to prevent further confrontation andwere care planned. Subsequently on 5/21/13, the facility sent the resident home with a daughter until the investigation was

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIERREPRESENTATIVE'S SIGNATURE

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that othersafeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following thedate of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the datethese documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)Previous Versions Obsolete

Event ID: YL1O11 Facility ID: 035242 If continuation sheetPage 1 of 11


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(continued... from page 1)completed and on 5/28/13 the investigation committee discharged the resident home with his other daughter. The regulation

for the component of Protection required facilities to demonstrate how they would protect the victim from the aggressor.The facility's policy Management of Verbal and or Physical Aggressive Behavior (no date) included interventions among thefollowing: - Remove other residents from the area where the aggressive resident is - Always approach the resident calmly;listen attentively, respond with comments that validate the resident's feelings, speak in calm and therapeutic voice. -Give the aggressive resident space. Avoid standing too close or touching the aggressive resident unless it is for safetyreasons. - Attempt to refocus the behavior on something positive when the resident is exhibiting verbally abusive behavior.- Convey the expected behavior. Firmly explain why the behavior is not acceptable. - Talk and listen to the resident andtry to identify and resolve stimulus for aggression. Discharge and /or removal of the resident from the facility was notone of the actions to take for an aggressive resident. There is no regulatory requirement to remove a resident from thefacility unless there was documented evidence of incidents in which the resident was a danger to himself or others. 2. Theregulation for the component of identification indicated the facility must have procedures to identify events, such assuspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine thedirection of the investigation. The facility's policy for Unusual Occurrences, Accidents and Incidents Policy originallydated 11/2/2003 and reviewed 8/2012 lacked information on injuries of unknown origin including falls and how to report suchoccurrences which may constitute abuse or neglect including required timelines. The following ERIs and Complaints weresubstantiated: Resident 20 A review of the ERIs revealed Resident 20 was admitted to the facility on [DATE]. The residentwas found on the floor, sustained a [MEDICAL CONDITION] femur due to the unwitnessed fall on 2/16/2013. The investigationresults were not sent to CMS until 3/7/13. ERI AZ 060 Resident 9 On 2/10/12, an ERI was reported to CMS regarding awitnessed fall on 2/8/12. After rolling himself from the front entrance of the facility onto the curb and pavement,Resident 9 fell from his wheelchair onto the pavement, necessitating transfer to an acute care facility. Notification ofthe incident was not within 24 hours and the facility failed to provide a follow-up investigation report. ERI AZ 5353. During interviews and document review with 2 different Adm. Staff on 9/27/13 at 1:08 PM and 1:30 PM, the following wasrevealed: a. 5 of 5 employee personnel files did not have documentation that previous employers or personal references thatwere listed were contacted prior to employment. b. 3 of 5 employee personnel files did not have verification of theirsignature (on the abuse policy and procedures document) to indicate that they had read the facility's abuse policy andprocedures prior to employment. c. 3 of 5 employee personnel files failed to have fingerprint clearances before anapplicant is interviewed per the facility's policy and procedures (reviewed on 9/27/13 in the early afternoon).

F 0246



Reasonably accommodate the needs and preferences of each resident.

Based on observation, the facility failed to ensure that a resident had the right to reside and receive services in thefacility with reasonable accommodations of individual needs and preferences for one of 18 residents (Resident 18). Findingsinclude: On 9/24/13 at approximately 8:30 AM, during the initial tour, Resident 18 was observed sitting in her wheelchairby her bed. It was noted that the call light for Resident 18 was attached to the back of her shirt. The call light was insuch a position that would make it impossible for the resident to be able to reach the call light and activate it shouldthe need arise. When the social services staff for Unit B was asked if the call light should be attached to the back of theresident's shirt, the call light was changed to another position that was within reach of the resident.

F 0252



Provide a safe, clean, comfortable and homelike environment.

Based on observation and interview, the facility failed to provide a clean and homelike environment. Findings include: 1.On 9/28/13 at approximately 9:45 AM, the shower rooms on both A and B units were observed. It was noted that there werebrown and black stains on the shower tiles and in the grout on the floors. When interviewed, the Maintenance Supervisorstated that he was not sure exactly what the stains were. 2. On 9/28/2013 at approximately 10:00 AM, the exterior of thefacility building was observed. It was noted that the upper wooden rim abutting the roof of the building had chipped paintand in some places the wood underneath the paint was chipped. 3. On 9/28/2013 at approximately 9:45 AM, resident room 12 onthe B unit was observed. It was noted that the faucet in that room was leaking water; the faucet was in the off position.The Maintenance Supervisor acknowledged these observations.

F 0253



Provide housekeeping and maintenance services.

Based on observation, the facility failed to provide maintenance and housekeeping services to maintain a sanitary, orderlyand cofortable interior. Findings include: 1. During the initial tour (on 9/24/13 beginning at 8:43 AM), the following wasobserved: a. 1B-2: --The bedside dresser drawer had dried liquid spills at the bottom of the top drawer/front edge and wornwood on the top. b. 3B-2: --Gouges in linoleum at foot of bed. c. Chunks of feces : --near foot of 3B-4, --in front oftoilet, --in back of toilet. d. Room 5B: --Ceiling heater made a constant loud noise. e. 7B-1: --Bedside dresser drawer haddried white liquid spills on left side; on front face of drawers #2, #3 were scratches; and wood was worn.

F 0278



Make sure each resident receives an accurate assessment by a qualified healthprofessional.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on interview and record review the facility failed to ensure assessments were completed by a staff member qualifiedto assess the relevant care areas for 2 of 10 sampled residents (residents 5 and 9). Assessments completed by non qualifiedstaff could lead to a lack of the provision of care in the relevant care area(s). Findings include: On 12/03/2013 atapproximately 3:33 P.M., Resident 5 was observed using a recumbent bike under the supervision a Restorative NursingAssistant. During a review of the last Physical Therapist Recommendations dated 11/24/2012 the document indicated Residentnot a candidate for skilled PT (Physical Therapy) services at this time. Resident to benefit from general exercise programto include (lower extremity) stretching with RNA(Restorative Nursing Assistant)/CNA (Certified Nursing Assistant). During aconcurrent interview, the RNA stated he/she had been completing the Functional Status portion of the Minimum Data Set (MDS)of the Resident Assessment for Resident 5. Additionally, he/she acknowledged he/she had been generating a nursing careplan, when applicable based on identified limitations of the Resident assessment. The RNA acknowledged he/she had generatedResident's 5 nursing care plans titled ADL (Activities of Daily Living) and Mobility. Further record review revealed theRNA had been completing care for the resident at least 2 times per week. During an interview on 12/05/2013 a licensed nursevalidated that the RNA was completing the Functional Assessment of the MDS and generating the care plan which incorporatedall the RNA interventions for Resident 5.

Resident 9: Review of Resident 9's record revealed the resident was admitted with dementia, diabetes, depression and[MEDICAL CONDITION] joint disease. The minimum data set (MDS - an assessment tool) dated 11/13/2013 indicated he/she walkswith a walker and needed minimal assistance with activities of daily living. He/she had limited range of motion (ROM) inthe lower extremity on one side. The resident required verbal/cueing for hand placement and step sequencing/safetyprecautions. The resident had a history of [REDACTED]. On 8/15/2012 the fall risk score was 65, indicating the resident wasat high risk for falls. There was no comment regarding why the resident's risk had increased. Review of physical therapy(PT) records revealed an initial PT evaluation was conducted on 04/14/2012. Review of the resident's Appt sheet w/Med/TX/other & Adv.Directives (Sic) a summary sheet of the residents current status, treatments [DIAGNOSES REDACTED].Review of the Incident Report: Falls form revealed the following two incidents: On 10/2/2013 at 2:13 A.M., the residentfell while staff was in the room assisting another resident. Resident 9 stated he/she slipped in the bathroom and hithis/her nose. He/she sustained a bloody nose, a bruise on the right knee and two skin tears on the right wrist. On

10/5/2013 at 3:30 A.M. the resident sustained [REDACTED]. He/she sustained no injury. Although licensed nurses (LN)assessed the resident after the falls, the investigation was incomplete. Review of the incident report for the fall dated10/5/2013 revealed the LN requested a physical therapy (PT) evaluation be conducted since the resident fell twice withinfour days. Review of the record indicated the last PT evaluation was a routine annual evaluation conducted on 08/09/2013.Review of the current Care Plan Problem for Resident 9 titled Activities of Daily Living (ADLs) indicated the RNA had lastedited the care plan on 11/21/2013. During an interview on 12/4/2013 at approximately 10 A.M., when asked who conducted theassessments for ADLs, range of motion and functional mobility, the MDS coordinator and the DON stated the RNA conducted




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(continued... from page 2)those assessments on all residents. The RNA was part of the treatment planning team and also created the care plan for ADLs

and mobility for all residents. Review of the Resident Census and Condition report (CMS form 672 -a form that accounts forthe conditions of each resident in the facility). The CMS 672 showed that out of 64 residents currently residing in thefacility, 61 had contractures with only four of these were admitted with contractures. Upon observation of residents in thefacility, there were approximately 14 residents with contractures. (Defined as a condition of fixed high resistance topassive stretch of a muscle in addition, contractures are the chronic loss of joint motion due to structural changes innon-bony tissue. These non-bony tissues include muscles, ligaments, and tendons. Symptoms include a significant loss ofmotion to any specific joint that results in immobility). The DON stated the RNA filled out the 672 for ADLs includingcontractures. During the recertification survey in September 2013, the RNA stated residents with any [DIAGNOSES REDACTED].During an interview on 12/5/2013, the contracted Physical Therapist (PT) stated he/she was surprised that the RNA wasconducting assessments. He/she stated the RNA is not qualified by certification to conduct assessments, especially formobility.

F 0279



Develop a complete care plan that meets all of a resident's needs, with timetables andactions that can be measured.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, interview, and document review, the facility failed to use the results of the assessment to develop,review and revise the resident's comprehensive plan of care for 5 of 16 sampled residents (#1, #4, #5, #6, #7). Findingsincluded: 1. Resident 4, 88-years-old, was admitted on [DATE] with [DIAGNOSES REDACTED]. 9/26/13 (in the morning) reviewofthe record revealed that the quarterly minimum data set (MDS), with an assessment reference date of 8/18/13, revealed thatthe resident could not answer correctly when questioned as to the current year, current month, and current day. Herthinking was disorganized and she had an altered level of consciousness. She was not steady when transferring between bed

and wheelchair, and was only able to stabilize with staff assistance. She was impaired on both sides of her lowerextremities. The record revealed that on 8/11/13 at 8:25 PM, the resident had fallen forward out of her wheelchair (w/c)and had sustained a 1/2 laceration to her right temple. Review of the care plan for Falls (edited on 8/8/13) that was inplace at the time of the fall revealed that one approach was to have the resident in view of staff at all times in thefacility. During an interview (on 9/27/13 at 8:30 AM) with one of the direct care staff (DCS) on duty in the A Wing (wherethe resident resided) during the time of the fall, she stated that the resident was sitting stretched slightly back in herspecial w/c, which was located on the left side of the shower door (located not too far from the right of the side exitdoor), and was set back away from the hallway, which caused her to not be in view of DCS and administrative staff (Adm.Staff) whenever they were in the hallway. The DCS said that after this fall, they are now placing the resident in her w/cin the hallway to the right of this shower door and next to the handrail, which allows the resident to be in full view ofstaff whenever they were in the hallway. However, the care plan was not revised to include this new approach. 2. Resident5, 70-years-old, was admitted on [DATE] with [DIAGNOSES REDACTED]. 9/26/13 (in the morning) review of the record revealedthat the significant change minimum data set (MDS), (with an assessment reference date of 11/7/12), and the most recentquarterly MDS completed (with an assessment reference date of 5/7/13) indicated that the resident had no short or long termmemory problems, had physical behavioral symptoms directed toward others, and had verbal behavioral symptoms directedtoward others. The following incidents were documented in the record: a. 11/6/12: Resident 5 hit a resident (who was in hisw/c) on his face when this resident would not move himself from the hallway to allow Resident 5 to pass through. b.11/12/12: Resident 5 and another resident were verbally abusive to each other in the dining room. Adm. Staff stated thatthat when Resident 5 wheeled himself to the dining room in preparation for dinner, a resident was seated in Resident 5'schair at the dining table he usually sat at. At this time, this resident and other residents were in the dining roomwatching a football game on the television. When Resident 5 told this resident to move out of his chair, the verbal

altercation began. c. 9/4/13: A DCS was about to wheel into Resident 5's room one of his roommates, as Resident 5 waswheeling himself out of the room. The DCS stopped and waited in the hallway outside the door with this resident. AsResident 5 wheeled himself out, Resident 5 accidentally bumped his w/c into the other resident's w/c. However, Resident 5thought that the resident intentionally bumped his w/c into Resident 5's w/c. Resident 5 immediately raised his left-handfist at the other resident. The DCS intervened. During interviews with a DCS, licensed staff (LS), and to Adm. Staff(interviews occurred on 9/25/13 and 9/26/13 in the afternoon), who have provided assistance to Resident 5, they allacknowledged that the care plan was not revised to include information of what would trigger physical and verbal aggressionand how to prevent it: ---when staff observes Resident 5 going down the hallways, ensure Resident 5 has room by assistingother residents to not block the hallways, especially when Resident 5 is going to or returning from [MEDICAL TREATMENT].---remind Resident 5 throughout the day and night that if he sees something that is not to his liking or might possiblyirritate him, to always first bring to the attention of staff. ---when Resident 5 is going into or out of his room, allowhim plenty of room to do so. ---when Resident 5 is going into the dining room for meals, ensure that no one is sitting inhis assigned chair.Resident 7: was admitted with [DIAGNOSES REDACTED]. ([MEDICATION NAME] is an antidepressant medication.) Review oftheresident's medical record and a concurrent interview with Administrative Staff on 9/27/2013 at approximately 1 PM, revealeda care plan titled [MEDICAL CONDITION] Drug Use dated 8/6/2013. The Approaches included the following: Medicate resident asordered; and Monitor for adverse reactions/side effects of Antidepressant. There were no other Approaches or specific sideeffects included. Review of the manufacturer's warning for potential side effects for [MEDICATION NAME] included thefollowing: [MEDICATION NAME] may cause side effects. Tell your doctor if any of these symptoms are severe or do not goaway: drowsiness, dizziness, anxiousness, confusion, increased weight and appetite, dry mouth, constipation, nausea,

vomiting. Some side effects can be serious. If you experience any of the following symptoms or those listed in theIMPORTANT WARNING section, call your doctor immediately or get emergency medical treatment: flu-like symptoms, fever,chills, sore throat, mouth sores, or other signs of infection, chest pain, fast heartbeat, [MEDICAL CONDITION] . Resident6: was admitted with [DIAGNOSES REDACTED].Fib), [MEDICAL CONDITION]- lower leg, and [MEDICAL CONDITION].Review of Resident6's medical record and a concurrent interview at on 9/27/2013 at approximately 1 PM, revealed a care plan titled, Exercisewith a goal date of 12/13/2013. The goal and the approaches were the same; Resident to benefit from restorative servicesfor general strengthening. The Administrative staff stated, (An unlicensced staff) was responsible to edit and update thecare plan. When asked how the care plan for exercise was developed and re-evaluated (an unlicensed staff) stated thePhysical Therapist (PT) developed the care plan, and (an unlicensed staff) was responsible to evaluate and edit the careplan. The PT came on the weekend and sometimes on Monday, however was not always available when the care plan needed to beupdated. When asked why specific approaches were not identified (a Nursing Staff) stated he/she was not sure.

F 0309

Level of harm - Immediatejeopardy


Provide necessary care and services to maintain the highest well being of eachresident**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**On 9/25/2013 at approximately 4:45 PM, an Immediate Jeopardy (IJ) situation was identified. Based on observation, interviewand record review the facility failed to maintain the highest practicable wellbeing for one of one resident who used aHoyer Lift (Un-sampled Resident 17). Administrative Staff did not repair or replace a broken manual Hoyer Lift (a hydraulicmachine to lift non-weight bearing residents for transfer from/to chair or bed) for two months after notification that theHoyer Lift was broken. The facility's deficient practice lead to actual harm of Resident 17 causing pain and abrasion tothe resident's buttocks when staff had to drag the resident across the hard side of a lip mattress (a mattress with raised

edges) and across wheel chair surfaces during transfer. The Direct Care staff continued to report the problem toAdministrative Staff that the Hoyer Lift did not fit under the bed when it was in the lowest position. The Hoyer Lift had anoticeable oil leak on the floor where the Lift was stored in Resident 17's room. The Administrative staff stated, he/shehad an in-service to teach the staff how to use the broken Hoyer Lift by using different loops on the sling that held theresident, thus pulling the resident progressively closer to the bars that held the sling (the support surface where theresident was placed while lifted) which allowed for better clearance over the bed and seat of the wheel chair; however asthe lift lost more oil the hydraulic pressure in the lift could not raise Resident 17 high enough to clear the wheel chair




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(continued... from page 3)seat or the hard sided lip mattress. Administrative Staff was able to locate an electric lift that needed a battery and

replaced the broken manual lift on 9/25/2013 at 6:35 PM. When asked why this electric lift was not provided when DirectCare Staff first reported the broken Hoyer Lift, Administrative Staff made no comment. After replacement of the Hoyer Lift,observation of Direct Care staff competence to use the electric lift, and an acceptable Plan of Correction (POC) thatincluded routine preventative maintenance and ordering new electric Hoyer Lifts, the IJ was abated on 9/26/2013 at 10:30AM. Findings: During observations on 9/25/2013 beginning at approximately 1 PM, a wet spot was observed on the floor undera Hoyer Lift in Resident 17's room. Direct Care Staff (DCS) stated the Hoyer Lift was leaking. Staff stated the Hoyer Liftwould not go up all the way. The staff had to, Drag (Resident 17) across the chair. (Resident 17) already has a red(buttocks). DCS said they had informed Administrative Staff about the broken Hoyer Lift several times over the prior twomonths. Administrative Staff told them to use the new lift. The DCS said they told Administrative Staff that the new liftwas not appropriate for Resident 17. The new lift was a Standing Lift (lifts the person to a standing position). Resident17 had bilateral amputations at the hip level and was therefore non-weight bearing and needed a Non-weight bearing lift.DCS proceeded to use the broken Hoyer Lift to transfer Resident 17 from the wheel chair to the bed. Three DCS were neededto assist with this transfer. One DCS was observed to pump up the Hoyer Lift; however it did not raise the resident highenough to clear the seat of the wheel chair. Two additional Direct Care Staff tried to manually lift resident by liftingthe canvas sling while the third DCS moved the Hoyer Lift to the bed. As the DCS dragged Resident 17 over the edge of theLip Mattress, the resident moaned. The edge of the Lip Mattress felt like hard plastic. Observation of the resident'sbuttocks revealed red excoriated skin. One of the DCS interpreted Navajo, when the surveyor asked the resident howtransferring with the Hoyer Lift felt. The resident said in Navajo, I hate it. When (staff) has to drag me, it rubs mybottom and makes it sore. The resident had tears in her eyes. On 9/25/2014 at approximately 4:45 PM during an interview,when asked what he/she knew about Resident 17's Hoyer Lift, Administrative Staff stated he/she received notice on 7/26/2013that the Hoyer Lift was broken. He/she stated he/she replaced the resident's bed with a lower bed so that the Hoyer Liftwould clear. When asked how the Hoyer Lift hydraulics worked the Administrative Staff stated there was a cylinder with oilin it and a series of rubber seals. As the handle was pumped the seal allowed small amounts of oil into the cylinder belowthe seals increasing the pressure to hold up the bar. He/she stated, The seals must be cracked, that is why the bar won'tgo up all the way. At this time Administrative Staff provided documentation of a work order titled, Maintenance WorkRequest dated 7/26/2013. The form indicated the room [ROOM NUMBER] Manual Lifter for (Resident 17) does not go up - it willonly go 1/4th of the way. (Resident 17) really needs this manual lifter to get (him/her) up for meals/[MEDICAL TREATMENT](sic). A box titled Emergency was checked. There were several areas on the form where corrective measures could be listed.Most of the form was blank; however the column titled Parts and/or Material column had a hand written note switch out thebed with 12A (sic). The column titled, Date Issued was blank. During a joint interview and observation on 9/25/2013beginning at 5:20 PM, Administrative Staff and surveyors observed three DCS lift the resident with the broken Hoyer Lift.The DCS were not able to lift the resident high enough to clear the wheel chair or lip mattress. There was a plastic bagwrapped around the bottom of the broken lift. The plastic bag had black oily substance in it. When asked what the substancewas, the Administrative Staff made several suggestions; however after feeling the substance acknowledged the lift wasleaking hydraulic fluid. The Administrative Staff acknowledged the Hoyer Lift was defective. They acknowledged the hardside of the Lip Mattress would cause further harm and pain to the Resident 17. Administrative Staff acknowledged they wereaware of the defective lift on 7/26/2013. They acknowledged that further use of the defective Hoyer Lift had the potentialfor further accident to Resident 17 and DSC should the hydraulics fail while the residents was in the lift. An IJ wasdeclared at 5:20 PM on 9/25/2013. The Administrative Staff removed the Lip Mattress and replaced it with a flat mattress.At 6:35 PM, the Administrative Staff was able to locate an electric Hoyer Lift in storage. The Administrative Staff stated,It just needed a new battery. When asked how long the electric Hoyer Lift had been available, the Administrative Staff madeno comment. On 9/26/2013 at 10:30 AM, the IJ was abated when the facility provided an acceptable plan of correction thatincluded 1. Removal of the defective manual Hoyer Lift; 2. Replace lip mattress; 3. Use of Electric Hoyer Lift to lift

Resident 17 from wheelchair to/from bed. 4. Staff were in-serviced; 5. Two new electric Hoyer Lifts were ordered; and 6.Routine Periodic Maintenance Program was established.

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Make sure that the nursing home area is free from accident hazards and risks andprovides supervision to prevent avoidable accidents**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, interview and record review the facility failed to assure the facility was free of accidents andhazards for 3 of 16 sampled residents (Residents 1, 4 and 8 and two unsampled residents(Unsampled residents 17 and 19) forresidents on Unit B. On 9/25/2013 at approximately 4:45 PM, an Immediate Jeopardy (IJ) situation was identified. Based onobservation, interview and record review the facility failed to maintain the highest practicable well being for one of oneresident who used a Hoyer Lift (Un-sampled Resident 17). Administrative Staff did not repair or replace a broken manualHoyer Lift (a hydraulic machine to lift non-weight bearing residents for transfer from/to chair or bed) for two monthsafter notification that the Hoyer Lift was broken. The facility's deficient practice lead to actual harm of Resident 17causing pain and abrasion to the resident's buttocks when staff had to drag the resident across the hard side of a lipmattress (a mattress with raised edges) and across wheel chair surfaces during transfer. The Direct Care staff continued toreport the problem to Administrative Staff that the Hoyer Lift did not fit under the bed when it was in the lowestposition. The Hoyer Lift had a noticeable oil leak on the floor where the Lift was stored in Resident 17's room. TheAdministrative staff stated, he/she had an in-service to teach the staff how to use the broken Hoyer Lift by usingdifferent loops on the sling that held the resident, thus pulling the resident progressively closer to the bars that heldthe sling (the support surface where the resident was placed while lifted) which allowed for better clearance over the bedand seat of the wheel chair; however as the lift lost more oil the hydraulic pressure in the lift could not raise Resident

17 high enough to clear the wheel chair seat or the hard sided lip mattress. Administrative Staff was able to locate anelectric lift that needed a battery and replaced the broken manual lift on 9/25/2013 at 6:35 PM. When asked why thiselectric lift was not provided when Direct Care Staff first reported the broken Hoyer Lift, Administrative Staff made nocomment. After replacement of the Hoyer Lift, observation of Direct Care staff competence to use the electric lift, and anacceptable Plan of Correction (POC) that included routine preventative maintenance and ordering new electric Hoyer Lifts,the IJ was abated on 9/26/2013 at 10:30 AM. Findings include: 1. During observations on 9/25/2013 beginning atapproximately 1 PM, a wet spot was observed on the floor under a Hoyer Lift in Resident 17's room. Direct Care Staff (DCS)stated the Hoyer Lift was leaking. Staff stated the Hoyer Lift would not go up all the way. The staff had to, Drag(Resident 17) across the chair. (Resident 17) already has a red (buttocks). DCS said they had informed Administrative Staffabout the broken Hoyer Lift several times over the prior two months. Administrative Staff told them to use the new lift.The DCS said they told Administrative Staff that the new lift was not appropriate for Resident 17. The new lift was aStanding Lift (lifts the person to a standing position). Resident 17 had bilateral amputations at the hip level and wastherefore non-weight bearing and needed a Non-weight bearing lift. DCS proceeded to use the broken Hoyer Lift to transferResident 17 from the wheel chair to the bed. Three DCS were needed to assist with this transfer. One DCS was observed topump up the Hoyer Lift; however it did not raise the resident high enough to clear the seat of the wheel chair. Twoadditional Direct Care Staff tried to manually lift resident by lifting the canvas sling while the third DCS moved theHoyer Lift to the bed. As the DCS dragged Resident 17 over the edge of the Lip Mattress, the resident moaned. The edge ofthe Lip Mattress felt like hard plastic. Observation of the resident's buttocks revealed red excoriated skin. One of theDCS interpreted Navajo, when the surveyor asked the resident how transferring with the Hoyer Lift felt. The resident saidin Navajo, I hate it. When (staff) has to drag me, it rubs my bottom and makes it sore. The resident had tears in her eyes.On 9/25/2014 at approximately 4:45 PM during an interview, when asked what he/she knew about Resident 17's Hoyer Lift,Administrative Staff stated he/she received notice on 7/26/2013 that the Hoyer Lift was broken. He/she stated he/shereplaced the resident's bed with a lower bed so that the Hoyer Lift would clear. When asked how the Hoyer Lift hydraulicsworked the Administrative Staff stated there was a cylinder with oil in it and a series of rubber seals. As the handle waspumped the seal allowed small amounts of oil into the cylinder below the seals increasing the pressure to hold up the bar.He/she stated, The seals must be cracked, that is why the bar won't go up all the way. At this time Administrative Staffprovided documentation of a work order titled, Maintenance Work Request dated 7/26/2013. The form indicated the Room 2




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(continued... from page 4)Manual Lifter for (Resident 17) does not go up - it will only go 1/4th of the way. (Resident 17) really needs this manual

lifter to get (him/her) up for meals/dialysis (sic). A box titled Emergency was checked. There were several areas on theform where corrective measures could be listed. Most of the form was blank; however the column titled Parts and/or Materialcolumn had a hand written note switch out the bed with 12A (sic). The column titled, Date Issued was blank. During a jointinterview and observation on 9/25/2013 beginning at 5:20 PM, Administrative Staff and surveyors observed three DCS lift theresident with the broken Hoyer Lift. The DCS were not able to lift the resident high enough to clear the wheel chair or lipmattress. There was a plastic bag wrapped around the bottom of the broken lift. The plastic bag had black oily substance init. When asked what the substance was, the Administrative Staff made several suggestions; however after feeling thesubstance acknowledged the lift was leaking hydraulic fluid. The Administrative Staff acknowledged the Hoyer Lift wasdefective. They acknowledged the hard side of the Lip Mattress would cause further harm and pain to the Resident 17.Administrative Staff acknowledged they were aware of the defective lift on 7/26/2013. They acknowledged that further use ofthe defective Hoyer Lift had the potential for further accident to Resident 17 and DSC should the hydraulics fail while theresidents was in the lift. An IJ was declared at 5:20 PM on 9/25/2013. The Administrative Staff removed the Lip Mattressand replaced it with a flat mattress. At 6:35 PM, the Administrative Staff was able to locate an electric Hoyer Lift instorage. The Administrative Staff stated, It just needed a new battery. When asked how long the electric Hoyer Lift hadbeen available, the Administrative Staff made no comment. On 9/26/2013 at 10:30 AM, the IJ was abated when the facilityprovided an acceptable plan of correction that included 1. Removal of the defective manual Hoyer Lift; 2. Replace lipmattress; 3. Use of Electric Hoyer Lift to lift Resident 17 from wheelchair to/from bed. 4. Staff were in-serviced; 5. Twonew electric Hoyer Lifts were ordered; and 6. Routine Periodic Maintenance Program was established.2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/26/2013 at 10:05 AM, during aninterview with the CNA taking care of Resident 1, the CNA stated that Resident 1 had gotten into her wheelchair by herselfearlier that same morning of 9/26/13. The CNA further stated that Resident 1 is a stand-by assist. The CNA also stated thatResident 1 takes her alarm off. The CNA stated that she was helping another Resident take a shower and was unable to assistResident 1 when she transferred to her wheelchair. The CNA stated that they do not always have enough CNAs on staff toensure that all of the residents can have their needs met. The care plan for Resident 1, which is dated 11/15/2013indicates under approaches to Supervise resident with all transfers. Resident 1 has a history of falls in the facility. Thedates of the falls include 1/27/13, 3/11/13, 7/8/13 and 9/9/13. The Incident Report: Falls, indicates that a fall occurredon 1/27/2013 and was an unwitnessed fall. 3. On 9/28/2013 at approximately 9:35 AM, the sewing room on Unit B was observed.Upon entering the sewing room, it was observed that the door was unlocked. The Maintenance Supervisor stated that the doorto the sewing room should be locked. The Maintenance Supervisor further stated that there was Clorox, Azores and othersharp objects in the room and that he would not want the residents to get into those items. 4. On 9/28/2013 atapproximately 9:40 AM, an observation was made of the water fountain located on the wall near the Maintenance Supervisor'soffice. Two screws that were there to hold the water fountain to the wall were very loose and not screwed securely into thewall. This posed an accident hazard in that residents or staff passing by the fountain could be injured if the waterfountain were to fall from the wall. 5. On 9/28/2013 at approximately 10:15 AM, the call light plate adjacent to the bed ofResident 8 was observed. There was no call light cord in place and the plate was noted to be loose and had loose wires inthe hole where the call light cord would normally be placed.6. During the initial tour (on 9/24/13 beginning at 8:43 AM), the linoleum floor at the foot of the bed of Resident 19 wasobserved to be raised. At this same area was where 2 pieces of linoleum came together. Where the section was raised, it wasobserved to be slightly splitting. When questioned, the resident said that he has gotten the top of his shoe caught in thisraised section and has almost tripped. 7. Resident 4, 88-years-old, was admitted on [DATE] with [DIAGNOSES REDACTED].9/26/13 (in the morning) review of the record revealed that on 8/11/13 at 8:25 PM, the resident had fallen forward out ofher wheelchair (w/c) and had sustained a 1/2 laceration to her right temple. Review of the care plan for Falls (edited on8/8/13) that was in place at the time of the fall revealed that one approach was to have the resident in view of staff at

all times in the facility. During an interview (on 9/27/13 at 8:30 AM) with one of the direct care staff (DCS) on duty inthe A Wing (where the resident resided) during the time of the fall, she stated that the resident was sitting stretchedslightly back in her w/c, which was located on the left side of the shower door (located not too far from the right of theside exit door), and was set back away from the hallway, which caused her to not be in view of DCS and administrative staff(Adm. Staff) whenever they were in the hallway. The care plan was not implemented.

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1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Eachresident's entire drug/medication is managed and monitored to achieve highest wellbeing.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, interview and record review, the facility failed to ensure that one resident received a gradual dosereduction (Resident 1), that one resident was fully informed of the side effects of an antipsychotic medication prior toits use (Resident 2) and that three residents (Residents 3, 4, and 5) had signed consent forms prior to the use ofantipsychotic medications. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSESREDACTED]. On 9/25/2013, during a review of the medical record for Resident 1, it was observed that Resident 1 had aphysician's orders [REDACTED]. po QHS (2.5 milligrams to be taken orally each evening) and a second physician's orders[REDACTED].@ 6am (2.5 milligrams to be taken orally at 6:00 AM). It was also noted that both of these orders for[MEDICATION NAME] had been increased from 1.25 mg. to 2.5 mg. on 6/22/12. There were no indications in the chart to showthat any dose reductions had been attempted for Resident 1. During the afternoon on 9/26/2013, an interview was conductedwith Administrative staff to determine if there were any records to indicate that a gradual dose reduction had beenattempted for Resident 1. The only record that was presented was a paper, Recommendations, which was a note from the

pharmacist to the resident's physician. The recommendation indicates a Report Dates of 1/1/2013 Through 1/31/2013 and thephysician's name. The recommendation itself read, CMS regulations suggest a taper of Antipsychotic every 6 months. A taperattempt is required every six months with the goal of achieving a minimum effective dose or discontinuation. If two taperattempts occur and there is failure, tapers are no longer required. Your patient is now at a six month period where notaper has occurred. Please address the issue of tapering. If you feel a taper is contraindicated at this time please stateso below. Suggest NMT 25% reductions in a one month per taper unless patient on very low dose. The document further reads,Medication: [MEDICATION NAME] ([MEDICATION NAME]) q am dementia 9/28/12. The form indicates several boxes thatcould bechecked by the physician, one box that, if checked, would indicate agree with dose reduction; another box to indicate,Disagree - I have reviewed the patient and have determined them to be stable and experiencing no adverse events related tothe drug regimen. The third box, Disagree (with a line for reasoning) was checked indicating that there was disagreement bythe physician for a dose reduction. However, the physician wrote, Forwarded to psychiatrist (MD name - different doctorthan named on the form by the pharmacist). The form was signed and dated 2/13/13. Then that psychiatrist wrote, Concur witha signature and date of 5/17/13. There was no rationale given as to why a dose reduction for [MEDICATION NAME] should notbe attempted. The original order for [MEDICATION NAME] was written on 5/5/12. No gradual dose reductions had been attemptedsince the medication was first ordered, but rather, the medication had been increased. There was no documentation as to whythe medication had been increased and no reductions had been attempted. The facility policy and procedure regarding, Use of[MEDICAL CONDITION] Medications Behavioral Monitoring, in part, reads: The resident's physician provides a justificationwhy the continued use of the drugs and the dose of the drug is clinically appropriate. This justification should include: Adiagnosis, but not simply a [DIAGNOSES REDACTED].g., why the resident's behavioral symptom is thought to be a result of adementia with associated [MEDICAL CONDITION] and/or agitated behaviors, and not the result of an unrecognized painfulmedical condition or a psychosocial or environmental stressor); a description of the justification for the choice of aparticular treatment, or treatments, and a discussion of why the present dose is necessary to manage the symptoms of theresident. This information need not necessarily be in the physician's progress notices, but must be a part of theresident's clinical record. Administrative staff, when interviewed indicated that there were no other medical recordsregarding the above policy and procedure requirements, gradual dose reductions for Resident 1 and no other Drug RegimenReviews.




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(continued... from page 5)

2. Resident 2 was admitted with Alzheimer's Dementia with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Reviewof the medical record and interview on 9/26/2013, revealed a form Consent to use Psychotherapeutic Medications (a form usedto inform the resident and/or responsible party of the reason for the use of and the potential adverse effects of themedication). The form was located in an Administrative Staff's office - not in the medical record. The consent, dated5/5/2012 and signed by Resident 2's responsible party, included potential side effects, Sedation, Stiffness, Uneven heartbeat. There were no other side effects listed so that the responsible party had sufficient information to make informedconsent. In addition the staff were not monitoring for the side effects listed in the Black Box warnings. Review of themanufacturer's warnings for potential side effects located in the Black Box (a highlighted area indicated potential seriousand/or fatal warnings the person taking the medication or the responsible party needs to be aware of when considering useof the medication.) included: Studies have shown that older adults with dementia (a brain disorder that affects the abilityto remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality)who take antipsychotics (medications for mental illness) such as [MEDICATION NAME] have an increased risk of death duringtreatment. Older adults with dementia may also have a greater chance of having a stroke or mini-stroke during treatment.[MEDICATION NAME] is not approved by the Food and Drug Administration (FDA) for the treatment of [REDACTED]. Talk tothedoctor who prescribed this medication if you, a family member, or someone you care for has dementia and is taking[MEDICATION NAME]. For more information visit the FDA website: When asked, why the BlackBoxwarning side effects were not included, the Administrative Staff stated it should have included the more significant andspecific side effects for this particular medication.

3. Resident 4, 88-years-old, was admitted on [DATE] with [DIAGNOSES REDACTED]. 9/26/13 (in the morning) review of therecord revealed that the resident has had an order (dated 8/3/12) for [MEDICATION NAME] for Alzheimer's dementia withbehavioral disturbance and [MEDICAL CONDITION], and an order (dated 3/21/13) for [MEDICATION NAME] for dementia andbehavior dyscontrol (sic). There were no signed informed consent forms by the responsible party for these medications inthe record. 9/26/13 interview (in the afternoon) with administrative staff (Adm. Staff) revealed that she did not know thatsigned informed consent forms by the responsible party were required. 4. Resident 5, 70-years-old, was admitted on [DATE]with [DIAGNOSES REDACTED]. On 9/26/13 (in the morning) review of the record revealed that the resident has had an order(dated 12/12/12) for [MEDICATION NAME] for dementia with behavior disturbance, an order (dated 12/29/12) for [MEDICATIONNAME] for history of depression/behavior dyscontrol (sic), and an order (dated 9/4/13) for [MEDICATION NAME] for depressionand dementia with behavior disturbance and depression. There were no signed informed consent forms by the responsible partyfor these medications in the record. On 9/26/13 interview (in the afternoon) with administrative staff (Adm. Staff)revealed that she did not know that signed informed consent forms by the responsible party were required.

5. Resident 3 was a [AGE] year old who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Among thecurrentmedications listed for the resident was an antipsychotic, [MEDICATION NAME] 0.25 milligrams by mouth at bedtime. Thefacility's [MEDICAL CONDITION] Drug Use Team Assessment and Analysis indicated use of the antipsychotic medication since1/25/13 with dose adjustments during the year and the resident also received psychiatric counseling services. The recordlacked documented evidence of a consent for the antipsychotic medication use to inform the resident/power of attorney forhealthcare decisions of indications for use including the targeted behavior as well has potential for harm and adverse sideeffects when used on an elderly resident who has Dementia. On 9/25/13 at approximately 6:05 PM, when asked to see a signed

informed consent for the use of the antipsychotic for Resident 3, the Director of Nursing indicated the facility did notobtain informed consents for residents receiving antipsychotics. It was explained by the surveyors the use ofantipsychotics in residents with Dementia is known to cause serious adverse reactions including death. On 9/26/13 atapproximately 10:45 am, a licensed staff nurse and the unit clerk indicated no consents were done prior to today. They areworking on getting consents done today for residents who are on antipsychotics.

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Residents Affected - Many

Have enough nurses to care for every resident in a way that maximizes the resident'swell being.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, interview and record review the facility failed to ensure sufficient nursing staff to 1. Preventavoidable falls for 2 sampled residents (Resident 1 and Resident 4); 2. Assure consistent wound care due to staffingissues; 3. Assure sufficient support services to allow nursing staff to provide quality nursing care; and 4. Failed toassure staff assigned to administrative duties received adequate training to function in their assigned roles as the ICP(Infection control Preventionist), and Restorative Nursing Assistant (RNA) was assigned as a Physical Therapy Assistant(PTA) without training. Findings: Review of the Schedule from 7/1/2013 - 9/28/2013 showed that the facility requiresnursing staff to work twelve hour shifts. Typically there were two licensed nursing staff and two or three direct carestaff on each resident care unit; Unit A and Unit B. 1. FALLS: During observations of the provision of care for un-sampledResident 17, on 9/24/2013 at approximately 12 Noon on Unit A, three Direct Care Staff (DCS) were needed to assist theresident to and from his/her wheelchair and bed. When asked how often the DSC had to transfer Resident 17, DSC statedseveral times per day. When asked how many DSC were assigned to the B wing, the DSC stated there were three on the dayshift and 2 on the night shift. During various interviews with different DSC on different days, the DSC stated they were

tired as they had to work 12 hour shifts up to seven (7) days in a row. Review conducted on 9/27/2013 of the actualstaffing hours and schedule for CNAs showed that over a two week period from June 29, 2013 - 9/27/2013 an average of 5 CNAsroutinely worked seven (7) twelve hour shifts in a row once per month. This type of scheduling has the potential to causestaff to be fatigued to the point of not being able to provide safe quality of care for the residents. During an interviewon 9/27/2013 at approximately 2:40 PM, the Administrative Staff confirmed that CNAs work seven (7) twelve hour shifts onceper month; however the facility was planning on changing this work schedule in the next month or two. 2. Wound Care: Duringinterviews conducted on 9/26/2013 Licensed Staff stated there was not enough staff to provide care on the weekends;therefore he/she stated, I prioritize which wound care to do. If the wound is not too serious, like a skin tear or a smallpressure ulcer, then I don't do the wound care. When asked about this, Administrative Staff validated that LN hadcomplained about the weekend LNs not providing wound care. 3. Support Staff: During observation and interview on 9/24/2013- 9/27/2013, Administrative Nursing Staff were observed most of the time doing Human Resource work, i.e., dealing withstaffing, scheduling and personnel issues. The DON was observed conducting Rounds on Unit A and Unit B each morning forapproximately one hour. Much of the rest of the time the DON was observed working on personnel issues. During an interviewon 9/26/2013 at approximately 11 AM, Administrative staff stated Nursing Services has a secretary; however Since HR (HumanResources) was decentralized (the DON) and nursing secretary are overwhelmed. Administrative Staff identified the followingproblems affecting the quality of resident care; a. Weekend and night LN will not consistently perform skin care onresidents b. The RNs will not supervise the LPNs or CNAs because, They don't have time. c. There is no Supervisor for theCNAs. The Senior CNA orients new CNAs for seven days. d. New RNs and LPNs have not been oriented since 1/2013. e. The WardClerk does medical transcription and order renewal, however the RNs inconsistently review these because the don't havetime. 4. Training and education of the ICP and RNA as PTA: RNA/PTA: On 9/25/2013 at approximately 3 PM, AdministrativeStaff provided the CMS form 671, the Application for continued CMS certification. The form has spaces where administrativestaff indicated how many hours' staff and contract staff worked in the last month. The list included hours worked by thePhysical Therapy Assistant; yet had no hours listed for a Physical Therapist. When asked about this another AdministrativeStaff stated, the person listed on the 671 was a RNA not a PTA. He/she stated, The (RNA) works as a PTA because the PT onlycomes one or two days per week if he/she has time. Review of the CMS form 672 titled Resident Census and Conditions Report,showed 61 of 64 residents currently with contractures and 28 of these were admitted with contractures. When asked aboutthis, the Administrative Staff stated, You'll have to ask the PTA (he/she) completed that section. When asked why he/shereported such high numbers for resident's with contractures the PTA/RNA stated the numbers were correct. When asked whathe/she defined as a contracture, the PTA/RNA listed [DIAGNOSES REDACTED]. After reading the definition of a contracture;Defined as a condition of fixed high resistance to passive stretch of a muscle; Contractures are the chronic loss of jointmotion due to structural changes in non-bony tissue. These non-bony tissues include muscles, ligaments, and tendons.




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(continued... from page 6)Symptoms include a significant loss of motion to any specific joint that results in immobility; The RNA/PTA stated he/she

did not realize what the definition of a contracture was. He/she recalculated the numbers of residents with contractures as14 and 9 of those were admitted with contractures. During interviews on 9/27/2013, when asked what training the personassigned as the PTA had, he/she stated he/she was trained and certified as a RNA not a PTA. He/she continued stating aPhysical Therapist from the hospital at Fort Defiance trained him/her to be a PTA; however he/she stated he/she did nothave any formal education for this position. Review of the Arizona Administrative Code for Physical Therapy from thefollowing website: , reads in part as follows regarding PhysicalTherapy Assistants: TITLE 4. PROFESSIONS AND OCCUPATIONS CHAPTER 24. BOARD OF PHYSICAL THERAPY Supp. 12-1 Authority: A.R.S. ? 32-2002 et seq. R4-24-207. Application for a PhysicalTherapist Assistant Certificate A. An applicant for an original physical therapist assistant certificate shall submit tothe Board an application packet that includes: 1. An application form provided by the Board, signed, dated, and verified bythe applicant that contains: . b. The name and address of the college or university where the applicant completed anaccredited educational program for physical therapist assistants, dates of attendance, and date of completion; c. Astatement of whether the applicant has ever been licensed or certified as a physical therapist assistant in any otherjurisdiction of the United States or foreign country; . . B. In addition to the requirements in subsection (A), anapplicant shall arrange to have directly submitted to the Board: 1. An official transcript or letter showing that theapplicant completed all requirements of an accredited educational program that includes the official seal of the school orcollege where the applicant completed the accredited educational program and signature of the registrar of the school orcollege; 2. Verification of passing a national examination for physical therapist assistants as evidenced by an originalnotice of examination results; and 3. Verification of passing a jurisprudence examination as evidenced by an originalnotice of examination results . ICP: During interviews conducted on 9/25/2013 beginning at 8:10 AM, when asked whattraining the ICP, an LPN received to prepare him/her for the position of ICP, the Administrative Staff stated he/she had noformal training as ICP. He/she stated the facility sent the ICP to be trained in wound care. The Administrative Staffstated they reminded the previous ICP to observe and in-service the new ICP on Infection Control before he/she left. TheICP was not aware of appropriate cleaning solutions for staff to use to clean personal care equipment, as a result DCS werenot trained for the proper cleaning of the personal care items and this resulted in the potential for serious harm forresidents. Cross Reference F441 for examples of deficient practice related to infection control.

2. Resident 4, 88-years-old, was admitted on [DATE] with [DIAGNOSES REDACTED]. 9/26/13 (in the morning) review of therecord revealed that on 8/11/13 at 8:25 PM, the resident had fallen forward out of her wheelchair (w/c) and had sustained a1/2 laceration to her right temple. Review of the document entitled 'Incident Report: Falls revealed that for the questionsWas fall preventable? Explain, the following was documented by Adm. Staff: No, due to short staff.

3. On 9/27/13 at approximately 10:55 AM, RNA provided Restorative Nursing Program forms completed from 9/3/13 through9/23/13 which the RNA saw an average of 10 to 13 resident per day by appointment and including walk-in. The RNA indicatedthere was another RNA who used to work with her but was pulled back to the floor. The RNA stated her duties included: -walks residents with assistive devices - worked with residents in the PT room on the equipment (treadmill, bicycle, pulleyweights, stepper, etc) - assists residents with meals - gets pulled to do transport of residents to the hospitals,appointments, etc. - does minor repairs of wheelchairs and sends out wheelchairs for major repairs - documents care in theresident's electronic record and care plans The RNA expressed being short staffed to accomplish the duties as oneindividual. She stated she works a 40 hour week and 8 hours per day, but times are usually staggered for residents' meals.Interview with a Certified Nursing Assistant on 9/26/13 at noon, revealed she was a RNA but was pulled from working withthe RNA in physical therapy, due to short-staffing.

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Give specialized rehabilitative services that are medically necessary by qualifiedpersonnel, when ordered by a doctor.

Based on interview and document review, the facility failed to provide a certified physical therapy assistant (PTA) andinstead provided a certified nursing assistant (CNA) trained as an RNA. There was no documented evidence the RNA wasfurther trained to be a PTA. Finding includes:

During an interview on 7/22/13 at approximately 10:55 am, with an employee working in physical therapy (PT), the followingwas revealed: The employee was hired as a certified nursing assistant (CNA) in February 1987, then became a RestorativeNursing Assistant (RNA). Her badge identified her as a RNA. The employee indicated being inappropriately referred to as aPTA (physical therapy assistant) by staff. The employee stated, I am not a PTA, I am an RNA. I never had any training to bea PTA. My supervisor is supposed to be the Director of Nursing. When asked who reviewed her work, the RNA indicated thephysical therapist who comes once a week most of the time. The PT does the evaluations and re-evaluations, writes ordersand places in a box for drivers to take the doctor at the nearby hospital to sign. Once the doctor signs the orders, thedriver brings the signed orders back. Sometimes I hand carry the orders to be signed and bring them back. Among her dutiesthe employee indicated she: - walks residents with assistive devices - worked with residents in the PT room on theequipment (treadmill, bicycle, pulley weights, stepper, etc) - assists residents with meals - gets pulled to do transportof residents to the hospitals, appointments, etc. - does minor repairs of wheelchairs and sends out wheelchairs for majorrepairs - documents care in the resident's electronic record and care plans The employee indicated there used to be 2 of ushere in physical therapy, but they took one away. On 9/27/13 at approximately 10:55 am RNA provided Restorative NursingProgram forms completed from 9/3/13 through 9/23/13 which the RNA saw an average of 10 to 13 resident appointments per day

including walk-ins. - A competency checklist dated 7/22/12 for RNA rated the employee satisfactory in all of the requiredskills, by a physical therapist. - A certificate of completion of 16 hours training for RNA dated 7/22/12 was signed by thephysical therapist and by the president of Arizona Medical Training Institute. - The employee's performance evaluationdated 1/14/13 indicated Job Location: Nursing, Job Title: Restorative Aide/CNA. The Physical Therapy Assistant Jobdescription provided, revealed the following duties and responsibilities: - scheduling and administering of physicaltherapy procedures as prescribed - assist in interpreting treatment plan on the PT procedures to family members and PTproviders as necessary - ensure safety in assisting resident while going to and from therapy room/facility units - assistin evaluating and implementing recommendations from the facility committees; care plan, infection control, safety onassistive devices and restraints - assist residents in ambulatory training and bed-ridden passive range of motion -maintain treatment records, files and daily entries of activities on residents activities - assist with serving of trays atmeal time - maintain confidentiality of all pertinent resident care information and records - ensure that therapy area ismaintained in a clean and safe manner as well as ensuring that necessary equipment and supplies are properly maintained -maintain inventory and recommend needed equipment and supplies are properly maintained - may serve as driver, floor duty orescort from time to time as needed - perform other duties as assigned Among the job requirements listed was certified PTassistant. Most of the duties listed were described by the employee is what she stated was required to do and verbalizedthat staff had referred to her as a PTA. However, there was no documented evidence to show the RNA was a certified PTA.

F 0425



Safely provide drugs and other similar products available, which are needed every dayand in emergencies, by a licensed pharmacist

Based on observation, interview and record review, the facility failed to assure the accurate acquiring, receiving anddispensing of all drugs to meet the needs of each resident. Findings include: On 12/4/13 at 1:35 p.m. during drug storage

inspection in Unit A, a blister pack of Ambien (a hypnotic) was observed with two tablet slots previously opened andretaped at the back of the blister pack. Interview with a licensed staff revealed no explanation for the previously openedslots for the two tablets of Ambien. When asked of the facility policy when for narcotics that were accessed but notadministered, the licensed nurse was unable to provide any policy. She stated that she had to call the pharmacist and




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(continued... from page 7)return the entire blister pack for credit.

F 0431



Maintain drug records and properly mark/label drugs and other similar productsaccording to accepted professional standards.

Based on observation, interview and record review the facility failed to assure resident's medications were labeled andstored according to manufacturer's recommendations and regulations. This had the potential for resident's receiving wrong,inactive and/or expired medications for residents receiving medications. Findings: During observations of medicationstorage on the A wing conducted on 9/26/2013 beginning at 3:15 PM with a licensed nurse (LN), the following was observed: AWing Medication Cart: Banophen Allergy Liquid was approximately one third full; the pharmacy label was partially torn offso that only the resident's name and the name of the medication was visible. A A Wing Medication/Treatment Room: There wereeleven packages of medicated wound dressing, Xeroform that were expired. Seven had an expiration date of 6/2013 and fourhad an expiration date of 7/2013; one of these four was opened. The LN stated the pharmacy labels should be intact and thedressings should have been thrown out before the expiration date. He/she stated they do not use Xeroform dressings veryoften. During observations of medication storage on the B Wing conducted on 9/27/2013 beginning at 8:25 AM with a LN, thefollowing was observed: B Wing Medication Cart: there was a pharmacy bottle with a standard plain label with a resident'sname and Ibuprofen 400 mg tabs hand written on the label. Numerous bottles of liquid medications had partially dried stickysubstances around the outside of the lid. House stock medications: [REDACTED]. A pharmacy bottle had a plain label with

Zofran 8 mg tablets one tablet every 6 hours as needed was hand written on the label. There was no name on the bottle. Abottle of Warfarin 1 mg, for Resident 9 had no expiration date listed on the label. The LN stated some of the medicationscome back from the emergency department (ED) when a resident is returned to the facility. The ED refuses to consistentlysend medication with a properly labeled bottle. He/she acknowledged the bottles with liquid medication should be kept cleanto prevent contamination of the medication. He/she also said expired medication should be discarded or returned to thepharmacy no later than the expiration date. When asked who was responsible to assure this was done, the LN stated thenurses who use the cart should make sure the medications were current.

F 0441



Have a program that investigates, controls and keeps infection from spreading.

An Immediate Jeopardy (IJ) situation was identified on 9/25/2013 at 9:30 AM. 1. Based on observation, interview and recordreview the facility failed to have an infection control program that assured staff were trained to clean resident careequipment according to manufactures guidance. Staff were observed cleaning soiled bedside commodes and single use washbasins improperly and sharing these commodes for multiple residents. The Infection Control Preventionist (ICP), a licensedparticle nurse (LPN), was not aware of appropriate cleaning practices for resident care equipment and was not effectivelytrained for the position of ICP. Direct Care Staff (DSC) were not trained by Administrative Staff to properly clean patientcare equipment. These practices had the potential to cause serious infections in all residents. After notification of theIJ on 9/25/2013 at 9:30 AM, the facility researched manufactures guidance on cleaning bedside commodes and single use washbasins. They identified the cleaning solution they were using was not recommended to be used on the commodes or washbasins, and obtained appropriate cleaning solutions. The wash basins were discarded and all bedside commodes were cleanedaccording to manufacturer's instruction. They developed a training plan and in-serviced all staff responsible for thecleaning of the personal care equipment. They revised their infection control policy and developed a monitoring tool toassure compliance. Two plans of correction were presented; however were not accepted until 9/26/2013 at 4:45 PM. Afterverification of implementation of the POC the IJ was abated. 2. In addition, staff did not consistently follow hand hygienepractices; did not handle linens properly and did not label personal care items; The facility did not assure all staffbathrooms contained a functional soap dispenser; Findings: 1. During observations on 9/24/2013 at 8:50 AM, a direct carestaff (DCS) was observed handling wet linens with bare hands. He/she came out of a resident room holding the wet linens atarm's length, and proceeded to place them in the soiled linen container in the hallway. He/she then went directly to theclean linen cart, removed clean linen and then went back into the resident's room. He/she immediately came back out of theresident's room and preceded down the hall to another resident's room without washing his/her hands. At this point thesurveyor asked the DCS what the procedure was after handling soiled linen, the DCS stated, Oh, I forgot to wash my hands.After washing his/her hands, the DCS continued into another resident's room - a room with four residents. In this room wasa pink plastic wash basin that was unlabeled. When asked about this the DCS stated, This (the wash basin) should becleaned. So we don't label them because other residents re-use them. He/she proceeded to take the wash basin to the A WingSoiled Work Room. He/she opened the door and placed the wash basin on a counter next to a large, double sink. On thecounter on the opposite side of the sink were several bedside commode bucket turned upside down on a towel. When askedabout this the DCS state the night shift DCS clean the commodes the resident's use at night. On 9/24/2013 at 4:30 PM, whenasked what DCS staff used to clean the commode buckets and basins, the DSC stated he/she was not sure. Observations of theB Wing soiled work room on 9/24/2013 at 4:38 PM revealed six pink wash basins in one side of the large, double sink. Therewas a printed noted on the paper towel dispenser that read, Night CNAs - Please wash out B.M. (fecal matter) beforethrowing it into the hamper. We put some back in the dirty work room for you to was off B.M. There were six commode bucketson a towel on the counter next to the sink. There was a Hopper described as a low, ceramic wash basin with a spray nozzle,a splash shield and flush feature next to the sink, near the wall. Above the Hopper was a wire rack with a spray bottle

labeled, Foamy Q & A Acid Disinfectant Cleaner. At 9/25/2013 at 6 AM, during observations on A Wing, a DSC was seen walkingdown the hall, returning a soiled commode to the soiled work room. He/she entered the work room and set the commode down.He/she then exited the workroom, went to the medication cart to obtain gloves and returned to the work room. He/she thenopened the lid on the commode and removed the commode bucket. There were brown smears on the sides of the bucket and asmall amount of yellow liquid in the bottom of the bucket. The DCS took the Foaming Q & A, sprayed the bottom and sides ofthe bucket and then placed the bucket in the sink. He/she leaned up against the sink with his/her abdomen touching the sinkand partially filled the bucket with water. He/she then took a hand held cleaning mop that was wood with a cotton mop headand rubbed the cleaning solution/water around the bucket. He/she then rinsed the bucket and set it on a towel on thecounter next to the sink. The DCS then removed his/her gloves, opened a metal trash can and through away the soiled gloves.He/she then opened the work room door and preceded to the nurse's station to wash his/her hands. When asked why he/she leftthe room to get gloves, the DCS stated there were no gloves in the work room. When asked how long he/she was supposed tolet the cleaning solution/disinfectant to stay on the surface of the bucket, he/she said, I don't know. I just leave it forabout 30 seconds, fill it water, scrub it, rinse it and let it air dry. When asked how he/she cleaned the pink wash basins,he/she said, the same way. When asked why he/she did not wash his/her hands in the work room, the DCS made no comment. Asthe first DCS was leaving the room another DCS brought in another commode bucket. He/she left the commode bucket in theroom and went back to resident rooms without washing his/her hands. The second DCS returned to the work room with anothercommode. Observations of that DCS revealed that he/she followed the same cleaning procedure as the first DCS. Both DCS wereinterviewed at 7:05 AM, when asked who instructed them to clean the commodes as listed above, they both said, Onorientation another (DCS) taught us to clean them like this. When asked if they knew the wet time for thecleaning/disinfecting solution, they both said, No. When asked to read the label on Foaming Q & A Acid DisinfectantCleaner, they read the following: .Five Minute Disinfection Action: For five -minute disinfection activity against bacteria

and viruses in the presence of organic soil. 1. Spray directly on soiled surface. 2. Allow foam to wet surface for fiveminutes. 3. Wipe off with a damp cloth or sponge. 4. Rinse surfaces thoroughly with water. Preliminary cleaning is requiredfor heavily soiled areas. Extremely heavy soils may require agitation with a mild scrubbing pad or brush. Further readingof the label included the following information: Foamy Q & A kills Staphylocidal, Pseudomonicidal, Salmonellacidal, andVirucidal; HIV-1, Herpes Simplex Type 2 and Influenza A/Hong Kong viruses and Pandemic 2009 H1N1 influenza A virus;Effective against antibiotic-resistant bacteria, MRSA and VRE There was no indication on the label that this product wouldkill Clostridium Deficile spores (a very dangerous potentially deadly infectious and contagious organism that is spreadthrough feces). A Note read

Chinle Nursing Home Inspection Report

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