department of health and human services centers for medicare ...

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PRINTED: 10/24/2011
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
______________________
B. WING _____________________________
(X3) DATE SURVEY
COMPLETED
295037 03/04/2011
NAME OF PROVIDER OR SUPPLIER
HENDERSON HEALTHCARE CENTER
STREET ADDRESS, CITY, STATE, ZIP CODE
1180 E. LAKE MEAD DRIVE
HENDERSON, NV 89015
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
ID
PREFIX
TAG
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
F 311 Continued From page 47 F 311
services - will benefit from RA (restorative nursing
assistant) program for PROM (passive range of
motion) of right position of right UE (upper
extremities) to prevent further contracture at this
time."
There were sections on the Screening form to
document information about Mobility and
ROM/contractures - including location, function
affected, and whether existing or new - but this
part of the form was left blank.
Another Rehabilitation Services Screening was
conducted by a Physical Therapy Assistant (PTA)
on 3/24/10, who wrote, "Appears to be at PLOF
(previous level of functioning). Recommend RA
for ROM of B (both) UE (upper extremities) and B
LE (lower extremities), and bed mobility." The
Mobility section, indicating impairment of bed
mobility, balance, transfers, and ambulation, was
checked off by the PTA. The ROM/Contractures
section was left blank. The PTA checked the box
for "Need for skilled therapy not warranted at this
time."
Review of Resident #19's record revealed a
Nursing Rehab/Restorative Plan of Care ROM to
All Extremities, with a goal to "maintain/improve
adequate AROM (Active ROM)/PROM to all
extremities to maintain mobility." The duration of
the plan was for 7 times per week, 5 minutes
each shift for 90 days, beginning 3/29/10.
Documentation for the April and May 2010 Plan
of Care ROM showed the resident received RA
nursing services for five days during each month.
For the month of June 2010, RA services were
provided to the resident each day of the month,
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J8O811
Facility ID: NVS263S If continuation sheet Page 48 of 68