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Date ArticleType
11/6/2017 Regulatory
Residential Care Citations - September 2017

There was a total of four surveys performed with 2 of the four resulting in deficiency-free status or 50%.  A total of ten Offense tags were cited and a total of thirty-eight residential tags cited in the month of September.  Offensive tags for September as follows:

Tag 052 (5 times) – Residents’ Rights Offense – Failure to ensure residents right to be free from abuse was upheld.  Types of abuse are Sexual, physical, mental, corporal punishment, neglect, and involuntary seclusion.

Tag 0241 (4 times) – Health Services Offense – Failure to ensure the administration of medications and provisions of residential nursing care shall be as ordered by the physician and supervised by a licensed nurse on the premises or on call as follows: (1) Medication shall be administered by licensed nursing personnel or qualified medication aides.

Tag 0245 (1 time) – Health Services Offense – Failure to ensure injectables are given only by licensed personnel.

Residential Deficiency tags for September as follows:

Tag 0273 (5 times) – Food and Nutritional Services Deficiency – Failure to ensure an organized food service department directed by a supervisor competent in food service management and knowledgeable in sanitation standards, food handling, food preparation, and meal service. 
1. The supervisor must be one of the following: (A) A dietician (B) A graduate or student enrolled in and within one year from completing a division approved, minimum 90 hour classroom instruction course that provides classroom instruction in food service supervision who has a minimum of one year of experience in some aspect of institutional food service management. (C) A graduate of a dietetic technician program approved by the American Dietetic Association. (D) A graduate of an accredited college or university with a degree in foods and nutrition or food administration with a minimum of one year of experience in some aspect of food service management. (E) An individual with training and experience in food service supervision and management.  
2.  If the supervisor is not a dietician, a dietician shall provide consultant services on the premises at peak periods of operation on a regularly scheduled basis. 
3.  Food service staff shall be on duty to ensure proper food preparation, serving, and sanitation. 

Tag 090 (3 times) – Administration and Management Deficiency – Failure of the administrator to take responsibility to inform the division within twenty-four (24) hours of becoming aware of an unusual occurrence that directly threatens the welfare, safety, or health of a resident. 

Tag 0144 (3 times) – Sanitation and Safety Standards – Failure to ensure a clean, orderly, and a good state of repair of the facility and to provide reasonable comfort for all residents.

Tag 247 (2 times) – Health Services Deficiency – Failure to ensure medication errors are noted in the resident’s record.  Failure to ensure the physician is notified of error in medication administration when there are any actual or potential detrimental effects to the resident. 

Tag 036 (2 times) – Resident’s Rights Deficiency – Failure of the facility to immediately consult the resident’s physician and the resident’s legal representative when the facility has noticed: (1) a significant decline in the resident’s physical, mental, or psychosocial status; or (2) a need to alter treatment significantly, that is, a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.

Tag 029 (1 time) –  Residents’ Rights Deficiency -  Failure to ensure the right to be treated with consideration and respect, and recognition of their dignity and individuality was upheld.

Tag 117 (1 time) – Personnel Deficiency – Failure to ensure staff in sufficient number, qualifications, and training in accordance with applicable state laws and rules to meet the twenty-four (24) hour scheduled and unscheduled needs of the residents and services provided. 

Tag 118 (1 time) – Personnel Deficiency – Failure to ensure any unlicensed employee providing more than limited assistance with the activities of daily living must be either a certified nurse aide or a home health aide. 

Tag 145 (1 time) – Sanitation and Safety Standards – Failure to maintain equipment and supplies in a safe and operational condition and in sufficient quantity to meet the needs of the residents. 

Tag 148 (1 time) – Sanitation and Safety Standards – Failure to maintain buildings, grounds, and equipment in clean condition, in good repair, and free of hazards that may adversely affect the health and welfare of the residents or the public as follows: (1) Each facility shall establish and implement a written program for maintenance to ensure the continued upkeep of the facility. (2) The electrical system, including appliances, cords, switches, alternative power sources, fire alarm and detection systems, shall be maintained to guarantee safe functioning and compliance with state electrical codes.  (3) All plumbing shall function properly and comply with state plumbing codes.  (4) At least yearly, heating and ventilating systems shall be inspected. 

Tag 214 (1 time) -  Evaluation Deficiency – Failure to ensure an evaluation of the individual needs of each resident initiated prior to admission and updated at least semiannually and upon known substantial change in the resident’s condition, or more often at the resident’s or facility’s request.  A licensed nurse to evaluate the nursing needs of the resident. 

Tag 271 (1 time) – Food and Nutritional Services Deficiency – Failure to ensure all modified diets prescribed by the attending physician. 

Tag 302 (1 time) – Pharmaceutical Services Deficiency – Failure to ensure over-the-counter medications identified with the following: (A) Residents name (B) Physician name (C) Expiration date (D) Name of drug € Strength
Tag 414 (1 time) – Infection Control – Failure to require staff to wash their hands after each direct contact for which hand washing is indicated by accepted d professional practice.