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THE SPRINGS – Resident had been SOB (Short of Breath) all day...

THE SPRINGS, A GRACE LIVING CENTER COMMUNITY LOCATED: 5800 WEST OKMULGEE, MUSKOGEE, OK 74401 THE SPRINGS, A GRACE LIVING CENTER COMMUNITY was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT. LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 05/02/17 an Immediate Jeopardy (IJ) was determined to exist due to the facility’s failure to assess, monitor, and intervene for resident #1 who was experiencing respiratory distress. The resident was in respiratory distress for five hours before being transported to the hospital. A hospital record, dated 10/05/16, documented at 7:32 p.m. the resident was pulseless. The record documented the resident’s time of death was 7:36 p.m. The IJ situation was verified with the Oklahoma State Department of Health. On 05/02/17 at 5:01 p.m., the administrator (ADM) and the director of nurses (DON) were notified of the IJ situation regarding the resident not being transported to the hospital when experiencing respiratory distress. Based on interview and record review, it was determined the facility failed to provide necessary care and services for one (#1) of five residents reviewed for highest levels of well-being. The facility failed to assess, monitor, and intervene for a resident experiencing respiratory distress. The resident was experiencing respiratory distress with an oxygen saturation of 55%. The resident was in respiratory distress for five hours prior to being transported to the hospital. A hospital record, dated 10/05/16, documented at 7:32 p.m. the resident was pulseless. The record documented the resident’s time of death was 7:36 p.m. The emergency management services (EMS) dispatch record, dated 10/05/16, documented at 7:18 p.m. upon arrival to the nursing facility the resident’s mental status was altered, the resident was experiencing SOB, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The narrative documented the nurse reported the resident had been experiencing SOB the day before with low oxygen saturation. The narrative documented the nurse had ordered an Xray of the patient’s chest and it came back clear. The nurse stated when she arrived at work that day, the resident was again experiencing SOB and low oxygen saturation. The narrative documented upon the resident’s initial assessment the resident was unresponsive which was not normal for the resident. The...

Res #6, “he/she had to pee on myself multiple times due to staff not answering call lights on time.”...

SIGNATURE HEALTHCARE OF GLASGOW REHAB & WELLNESS CENTER LOCATED: 220 WESTWOOD STREET, GLASGOW, KY 42141 SIGNATURE HEALTHCARE OF GLASGOW REHAB & WELLNESS CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO MAKE SURE THAT EACH RESIDENTS’ ABILITIES IN ACTIVITIES OF DAILY LIVING DO NOT DECLINE, UNLESS UNAVOIDABLE. LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of Lippincott’s Nursing Procedures, fifth edition; it was determined the facility failed to provide appropriate treatment and services to ensure residents’ abilities in toileting do not diminish for one (1) of six (6) sampled residents (Resident #6), Resident #6 was assessed as continent of bowel and occasionally incontinent of bladder and required the assistance of staff for toileting: however, staff failed to toilet the resident in a timely manner which caused the resident to have incontinent episodes. Resident #6 stated it made him/her feel dirty, ashamed and humiliated when it happens which is at least five (5) times a week. Interview with Resident #6, on 02/07/16 at 3:30 PM, revealed he/she had to pee on myself multiple times due to staff not answering call lights on time. The resident stated it mostly happens on night shift between the hours of 2:00 AM and 5:00 AM. The resident revealed it takes forty-five (45) minutes to over an hour for the call light to be answered at night. The resident stated he/she would not be incontinent if call lights were answered in a timely manner and he/she has called the nurses station by cell phone to reach the nurse and tell her he/she needs to go to the restroom. Resident #6 further stated it makes him/her feel dirty, ashamed and humiliated when it happens which is at least five (5) times a week. Interview with Certified Nurse Aide (CNA) #1, on 02/08/17 at 6:05 AM, revealed she works short on nights most nights. CNA #1 stated there was only two (2) CNA’s and two (2) licensed staff this past week and it is impossible to care for sixty (60) residents timely especially when there are multiple residents that require two (2) assist. She revealed staff cannot answer call lights in a timely manner and revealed residents may have to wait over...

The Brian Center in Waynesville, North Carolina, was the scene of the two rapes for which Luis Gomez was convicted....

No one believed he would rape nursing home residents. Now he is going to prison By Blake Ellis and Melanie Hicken, CNN Updated 1:30 PM ET, Sun August 20, 2017 (CNN)At first, no one believed them when they said the charming, well-liked aide in the nursing home where they lived had raped them. Claims like theirs are often dismissed as drug-induced hallucinations, signs of dementia or attempts by lonely residents to get attention. And even when the cases of nursing home residents get to court, they can fall apart when victims’ memories prove unreliable — or they are no longer alive to testify. This time was different. The two women made their way to the courthouse in Waynesville, North Carolina, last week to testify against the man entrusted with their care. One entered the courtroom in her wheelchair, two oxygen tanks behind her, and defiantly described the February night when 58-year-old Luis Gomez lifted up her nightgown. He had entered her room at the Brian Center, a nursing home in the center of town, when she was alone and asked if she needed to go the bathroom. She said she did, and climbed out of bed. As she entered the bathroom and faced the toilet, she heard the door close and lock. Then, she said, Gomez raped her. At first, no one acted on her accusation, and she feared Gomez might appear in her room again at any moment. But when a nurse insisted on notifying police — against the wishes of her boss — the call triggered an investigation. And women just down the hall from the resident came forward, with their own allegations against Gomez. Now he has been sentenced to at least 23 years behind bars. “What this man has done for a period of almost a decade is … prey on Alzheimer’s patients because they’re forgetful and they can’t remember and oftentimes they die,” the prosecutor told the judge during sentencing. “In 2016, Your Honor, he made the grave mistake of hurting the wrong woman. She was brave enough to tell, and she wouldn’t be quiet until everybody listened. And because of her, that’s the only reason that we are finally able to put him in prison.” After a weeklong trial, Gomez was found guilty of raping both women who testified against him — convicted on six counts that included forcible rape with a physically helpless victim. He still maintains his innocence, and is appealing the verdict. What should we investigate next? Email Blake Ellis and Melanie Hicken At his sentencing, the prosecutor said the...

LEGEND OAKS HEALTHCARE AND REHABILITATION – NORTH (HOUSTON)...

LEGEND OAKS HEALTHCARE AND REHABILITATION – NORTH LOCATED: 12921 MISTY WILLOW, HOUSTON, TX 77070 LEGEND OAKS HEALTHCARE AND REHABILITATION – NORTH was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO PROVIDE CARE BY QUALIFIED PERSONS ACCORDING TO EACH RESIDENT’S WRITTEN PLAN OF CARE. LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provided care and services according to the comprehensive assessment and physician’s orders for one of seven residents on hall 200 (CR #3) who were reviewed for care provided according to physician’s orders The facility failed to order STAT laboratory tests for CR #3. Timely. CR#3’s BMP (Basic Metabolic Panel) STAT lab test was not ordered by facility staff for 10 ½ hours after the order was received from the NP (Nurse Practitioner). The resident had a critical Potassium laboratory value. CR #3 was found unresponsive 5.5 hours after the laboratory called the facility with the critical result Potassium level and she was pronounced dead 26 minutes after arrival to the emergency room . The facility failed to transfer CR #3 to the hospital as ordered by the NP for almost 14 hours. CR #3 was found unresponsive at 7:11 am on [DATE], was transferred to the hospital where she was pronounced dead 26 minutes later. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one (CR #3) and placed 23 residents at the facility at risk of having a delay in medical intervention or death due to staff not providing care per the physician’s orders. In an interview on [DATE] at 2:08 p.m. ADON A, stated she was the charge nurse for CR #3 on [DATE] when she was found unresponsive. ADON A said she arrived at the facility and started her rounds alone looking at the residents at around 6:30 a.m. and it was at that time she saw CR#3 sleeping. She said LVN B told her CR #3 had critical potassium levels during the night shift and the MD had not...

LEGEND OAKS HEALTHCARE AND REHABILITATION – NORTH...

LEGEND OAKS HEALTHCARE AND REHABILITATION – NORTH LOCATED: 12921 MISTY WILLOW, HOUSTON, TX 77070 LEGEND OAKS HEALTHCARE AND REHABILITATION – NORTH was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO PROVIDE CARE FOR RESIDENTS IN A WAY THAT KEEPS OR BUILDS EACH RESIDENT’S DIGNITY AND RESPECT OF INDIVIDUALITY.  LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat and care in a manner and in an environment that promoted maintenance or enhanced the quality of life for one of seven residents (Resident #1) reviewed for care provided to promote dignity. -The facility staff failed to provide timely incontinent care, bathing and personal care to Resident #1. Resident #1 did not have a shower for 37 days. She said she smelled herself and felt humiliated. She was angry, frustrated and felt like she was lied to. She was afraid that her wounds would become infected. Record review of Resident #1’s social progress notes dated 1/18/2017 at 1:30 p.m. revealed in part: Spoke with (Resident #1) and family member and (Resident #1) was very upset and frustrated. She stated that she was told by the Administrator that the facility has the staff and personnel to address her needs. (Resident #1) stated that she felt lied to because she sits in her own urine and feces for hours and that the urine and feces go into her wounds. (Resident #1) does not understand why it takes so long for the staff to come and clean her up. She stated that she needs to be cleaned up first to receive physical therapy which she has missed due to not being cleaned in a timely manner. (Resident #1) stated that her family member will go up to the front to ask for assistance but it still takes a very long time for the staff to come and clean her up. (Resident #1) is very angry and wants something to be done. In an interview and observation on 1/31/2017 at 8:58 a.m. with Resident #1 and her family member, revealed there was a pervasive smell of urine and stool upon entering her room. Resident #1 stated facility staff was only providing incontinent care at 9:00 p.m. and 3:00...

COLONIAL TYLER CARE CENTER-“HIS WOUNDS SMELLED BAD BECAUSE HIS DRESSINGS WERE NOT CHANGED”...

COLONIAL TYLER CARE CENTER LOCATED: 930 S BAXTER, TYLER, TX 75701 COLONIAL TYLER CARE CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES. LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided based on the comprehensive assessment to promote healing and prevent new injuries from developing for 1 of 2 residents reviewed for pressure injuries. (Resident #2) The facility did not provide treatments for Resident #2’s stage 4 pressure injuries on his left ischium (gluteal fold) and sacrum area for 2 days and did not provide weekly assessments. The pressure injuries worsened in size and had a foul odor. The resident developed a new stage 2 pressure injury on his right ischium (gluteal fold). This failure could place 7 residents who had pressure injuries at risk for worsening of existing pressure injuries and developing new pressure injuries. During an interview on 03/12/17 at 11:29 a.m., LVN B said she was the charge nurse for Resident #2. She said she had not performed wound care on Resident #2 today (03/12/17) because she did not have time yet. She said the treatment nurse provided treatments Monday through Friday and the charge nurses provided the treatments on the weekends. She said the treatment nurse was responsible for weekly skin assessments. During an interview on 03/12/17 at 1:48 p.m., Resident #2 said staff had not performed wound care on his 2 pressure injuries since Friday (03/10/17). During an observation on 03/12/17 at 3:31 p.m., Resident #2’s dressings on his sacrum and left ischium pressure injuries were dated 03/10/17. LVN B removed the soiled, yellow stained dressings that smelled of infection. LVN B removed the soiled packing from Resident #2’s sacrum and left ischium wound beds. The packing was stained brownish red and smelled of rotten flesh. Resident #2 said his wounds smelled bad because his dressings were not changed for 2 days. Resident #2’s stage 4 left ischium pressure injury wound bed was bright red and measured 5 cm x 3.1 cm x 5 cm. Resident #2’s stage 4 sacral wound bed was...