F 0000 - Indiana · 2020-03-24 · continued program participation. ... form to the POA/residents...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

FORT WAYNE, IN 46805

155255 03/09/2018

WOODVIEW A WATERS COMMUNITY

3420 EAST STATE BLVD

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey.

This visit included the Investigation of Complaint

IN00254575 and IN00255443.

This visit resulted in an Extended Survey -

Substand Quality of Care - Immediate Jeopardy.

Complaint IN00254575- Substantiated. Federal

/State deficiencies related to the allegations are

cited at F678.

Complaint IN00255443 - Substantiated.

Federal/State deficiencies related to the

allegations are cited at F677.

Survey dates: March 2, 5, 6, 7, 8, and 9, 2018

Facility number: 000158

Provider number: 155255

AIM number: 100291490

Census Bed Type:

SNF: 22

NF: 57

Total: 79

Census Payor Type:

Medicare: 18

Medicaid: 57

Other: 4

Total: 79

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

F 0000

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

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: Q4TB11 Facility ID: 000158

TITLE

If continuation sheet of 61

(X6) DATE




04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

Quality review completed March 15, 2018.

483.10(g)(17)(18)(i)-(v)

Medicaid/Medicare Coverage/Liability Notice

§483.10(g)(17) The facility must--

(i) Inform each Medicaid-eligible resident, in

writing, at the time of admission to the

nursing facility and when the resident

becomes eligible for Medicaid of-

(A) The items and services that are included

in nursing facility services under the State

plan and for which the resident may not be

charged;

(B) Those other items and services that the

facility offers and for which the resident may

be charged, and the amount of charges for

those services; and

(ii) Inform each Medicaid-eligible resident

when changes are made to the items and

services specified in §483.10(g)(17)(i)(A) and

(B) of this section.

§483.10(g)(18) The facility must inform each

resident before, or at the time of admission,

and periodically during the resident's stay, of

services available in the facility and of

charges for those services, including any

charges for services not covered under

Medicare/ Medicaid or by the facility's per

diem rate.

(i) Where changes in coverage are made to

items and services covered by Medicare

and/or by the Medicaid State plan, the facility

must provide notice to residents of the

change as soon as is reasonably possible.

(ii) Where changes are made to charges for

other items and services that the facility

offers, the facility must inform the resident in

writing at least 60 days prior to

implementation of the change.

F 0582

SS=D

Bldg. 00

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q4TB11 Facility ID: 000158 If continuation sheet of 61




04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

(iii) If a resident dies or is hospitalized or is

transferred and does not return to the facility,

the facility must refund to the resident,

resident representative, or estate, as

applicable, any deposit or charges already

paid, less the facility's per diem rate, for the

days the resident actually resided or reserved

or retained a bed in the facility, regardless of

any minimum stay or discharge notice

requirements.

(iv) The facility must refund to the resident or

resident representative any and all refunds

due the resident within 30 days from the

resident's date of discharge from the facility.

(v) The terms of an admission contract by or

on behalf of an individual seeking admission

to the facility must not conflict with the

requirements of these regulations.

Based on interview and record review, the facility

failed to ensure correct and complete Beneficiary

Protection Notification forms were issued to 3 of 3

residents reviewed. (Resident 500, Resident 56

and Resident 25)

Findings include:

1. A copy of the "Notice of Medicare

Non-Coverage" (NOMNC) form for Resident 500

was provided by the SSD (Social Service Director)

on 3-6-2018 at 2:59 p.m. The notice indicated the

"effective date coverage of your current services

will end: Nov 21, 2017...." The signature on the

form was dated "Nov 21, 2017." The NOMNC

form number was "CMS-10095" and not the "CMS

10123" form as required.

An interview with the SSD on 3-6-2018 at 3:00

p.m., indicated Resident 500 discharged on

11-21-2017 to home with Medicare benefit days

remaining.

F 0582 F582 Medicaid/Medicare

Coverage/Liability Notice

1. Corrective action for the

resident affected by the alleged

deficient practice:

Residents 500, 56 and 25 were

provided with incorrect NOMNC

with no negative outcomes.

SSD was educated on the

appropriate completion of the form

and the new ROP related to

Medicaid/Medicare Coverage

Liability.

2. Corrective action for those

residents having the potential to

be affected by the alleged deficient

practice:

All residents with Medicaid and

Medicare Coverage have the

potential to be affected by the

alleged deficient practice.

04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00


p.m., indicated Resident 500 was really shaky with

her writing, so the SSD indicated she dated it for

her. The SSD indicated she must have put the

wrong date on the form next to the resident's

signature. The SSD indicated she didn't

document in her notes when she gave a resident a

NOMNC, but would usually make a note about a

discharge plan prior to the discharge date.

The SSD progress notes indicated a discharge

note in Resident 500's record was dated

11-21-2017 at 4:21 p.m. The "Discharge Summary

Progress Note" indicated Resident 500 "...will be

discharging to her personal residence on Nov.

22...."

2. A copy of the NOMNC forms for Residents 56

and Resident 25 were provided by the SSD on

3-7-2018 at 2:01 p.m. Both forms were signed by

patient representatives 2 days prior to the ending

of the skilled services. The skilled services

ending date for Resident 56 was 10-13-2017 and

for Resident 25 was 9-18-2017. The NOMNC form

number was "CMS-10095" and not the "CMS

10123" form as required.


p.m., indicated Resident 56 and Resident 25 were

given NOMNC forms, signed at least 2 days prior

to services ending, had Medicare skilled benefit

days left and both still resided in the facility. The

SSD indicated neither resident was provided with

a SNF ABN CMS 10055 form (Skilled Nursing

Facility Advanced Beneficiary Notice - a form to

explain the cost of skilled services to be

discontinued, with the option for the resident to

choose to continue and pay for the services.).

The SSD indicated the facility did not have the

3. Measurements/Systemic

changes put in place to ensure the

alleged deficient practice does not

reoccur:

SS was reeducated on appropriate

completion of the correct NOMNC

form. She will provide the correct

form to the POA/residents within

48 hours of payor source

changes.

4. Corrective action will be

monitored to ensure the alleged

deficient practice will not reoccur:

BOM or designee will be

responsible for monitoring the

NOMNC weekly x 3 months, then

quarterly thereafter. Audits will

continue monthly for 6 months.

Audit results will be reviewed

monthly for at least 6 months by

the QAPI Committee and will

continue until at least 90%

compliance is established. Each

QAPI Committee will review for

compliance and any negative

patterns. An action plan will be

completed for any negative

patterns noted.

Date of compliance 4/8/18





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

SNF ABN CMS 10055 form.

3. Another copy of a NOMNC form for Resident

56 was provided by the SSD on 3-8-2018 at 9:35

a.m. The NOMNC form was the correct CMS

10123 but for "Medicare Advantage" plans (a

replacement plan for Medicare). The SSD

indicated Resident 56 had Medicare as her payor

source. Resident 56 remained in the facility after

discharge from the skilled services. The NOMNC

indicated Resident 56's skilled services would end

on 2-5-2018 and a note on the back of the form

indicated the information was communicated with

the patient representative via phone on 2-2-2018.

The was no patient representative signature on

the form or any indication the form had been

mailed to the representative for a signature.

Furthermore, the NOMNC forms (CMS 10095 and

10023) given to Residents 500, 56 and 25 lacked a

"QIO" (Quality Improvement Organization)

contact phone number to appeal the decision.

Without the QIO contact information, residents or

patient representatives signing the NOMNC were

unable to make an appeal regarding the ending of

their skilled services if they chose to do so.

The current policy provided by the SSD on

3-7-2018 at 2:20 p.m., was the undated "Form

Instructions for the Notice of Medicare

Non-Coverage (NOMNC) CMS - 10123." A

sample of the correct 10123-NOMNC form was

attached with hand written notes and a QIO name

and phone number included.

3.1-4(f)(3)

483.21(b)(1)

Develop/Implement Comprehensive Care Plan

§483.21(b) Comprehensive Care Plans

F 0656

SS=D

Bldg. 00





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

§483.21(b)(1) The facility must develop and

implement a comprehensive person-centered

care plan for each resident, consistent with

the resident rights set forth at §483.10(c)(2)

and §483.10(c)(3), that includes measurable

objectives and timeframes to meet a

resident's medical, nursing, and mental and

psychosocial needs that are identified in the

comprehensive assessment. The

comprehensive care plan must describe the

following -

(i) The services that are to be furnished to

attain or maintain the resident's highest

practicable physical, mental, and

psychosocial well-being as required under

§483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be

required under §483.24, §483.25 or §483.40

but are not provided due to the resident's

exercise of rights under §483.10, including

the right to refuse treatment under §483.10(c)

(6).

(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with

the findings of the PASARR, it must indicate

its rationale in the resident's medical record.

(iv)In consultation with the resident and the

resident's representative(s)-

(A) The resident's goals for admission and

desired outcomes.

(B) The resident's preference and potential for

future discharge. Facilities must document

whether the resident's desire to return to the

community was assessed and any referrals

to local contact agencies and/or other

appropriate entities, for this purpose.

(C) Discharge plans in the comprehensive

care plan, as appropriate, in accordance with





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

the requirements set forth in paragraph (c) of

this section.

Based on observation, interview, and record

review, the facility failed to ensure comprehensive

person-centered care plans were implemented for

1 of 8 residents reviewed for care plans.

(Resident 279)

Findings include:

A review of Resident 279's clinical record on

3/6/18 at 10:42 a.m., indicated a BIMS (Brief

Interview of Mental Status) was unable to be

completed due to severe cognitive impairment.

Diagnoses included, but were not limited to:

dementia.

On 3/5/2018 at 3:25 p.m., Resident 279 was

observed in his room, sitting in his wheelchair and

wheeled it backwards repeatedly hitting the wall.

Resident 279 was also pulling on the television

cord and taking clothing out of the dresser

drawers.

On 3/06/2018 at 11:47 a.m., Resident 279 was

observed in the main dining room, pounding his

fists on the table and had removed his clothing

protector. At 12:10 p.m., Resident 279 was

observed in the main dining room, pounding his

fists on the table, meal service had not yet started.


observed in the main nursing station, yelling out.

At 2:11 p.m., Resident 279 was observed being

wheeled in his wheelchair, down the hall by staff.

At 2:30 p.m., Resident 279 was observed in the

main lobby, yelling and banging his wheelchair

into the wall. At 3:49 p.m., Resident 279 was

observed in the Hope Springs unit, a therapist

was working with him. The resident was agitated

F 0656 F 656 Develop/Implement

Comprehensive Care Plan



deficient practice:

Resident #279 had his care plan

reviewed and updated by Social

Service prior to survey exit to

ensure appropriate behavior care

plans were put into place. There

were no negative outcomes

identified for the alleged deficient

practice.




practice:

Residents who have behaviors

have the potential to be affected

by the alleged deficient practice.

An audit was conducted to ensure

appropriate interventions are care

planned for residents who have

identified behaviors.




reoccur:

All staff will be in serviced by the

SSD or designee on procedure for

reporting and documenting

behaviors. In servicing to be

completed by date of compliance.




The SSD will audit 10 Behavioral

care plans weekly x 4 weeks, then

04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

and moved away from the therapist and other

residents. At 5:20 p.m., Resident 279 was

observed getting into the resident care supply

cart, a CNA (Certified Nurse Aide) moved the cart

out of reach and he swung a fist at her, but did

not make contact. At 5:32 p.m., Resident 279 was

observed sitting in his wheelchair, by the juke box

in the lounge area, his sweatpants were pulled up

over his knees and he was hitting his legs, and

yelling out.


observed sitting in his wheelchair, at the nurses

station, wheeling backwards into the wall and

fidgeting with a hair brush.

During an interview on 3/7/2018 at 3:35 p.m., the

SSD (Social Service Director) indicated no

behaviors had been turned in for Resident 279, he

had come back to Hope Springs (locked dementia

unit) that morning for activities and had done

fairly well. She also indicated Resident 279 had no

care plans in place for the behaviors, but was

going to implement one with some interventions

and one on one.

A review of Progress Notes indicated no

behaviors were documented for 3/7/2018.

On 3/6/2018 at 3:44 p.m., a Progress Note indicated

Resident 279 was having some increased agitation

and yelling out. "...Redirection attempted,

effective for short periods..."

A review of Care Plans indicated no behavior Care

Plans had been implemented for Resident 279.

A review of the MDS (Minimal Data Set) 5 day

admission assessment, dated 2/28/2018 indicated

no behaviors occurred during the assessment

10 residents behavioral care plans

monthly x 3 months, then

quarterly thereafter. Audits will

continue monthly for 6 months.










patterns.

Date of compliance: 4/8/2018





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

dates. The MDS 14 day assessment and the MDS

30 day assessment were both in progress and the

Behavior sections were not completed.

An undated form, "Mood/Behavior

Communication Form", provided by the SSD on

3/7/2018 at 3:35 p.m., was reviewed. The form

indicated staff were to complete the form when a

resident was having any behavior and they were

to give the completed form to the SSD or put it

outside her office door.

On 3/9/2018 at 10:30 a.m., a current facility policy,

dated 7/1/2011, "Care Conference Key Points" ,

provided by the DON (Director of Nursing)

indicated the following: "...Key Functions of Care

Plan Coordinator...Work cooperatively with

members of the interdisciplinary team to develop,

implement, and evaluate plan of care. The Clinical

Record face sheet and the resident's code status

are to be reviewed and updated with each care

conference..."

3.1-35(a)

483.21(b)(2)(i)-(iii)

Care Plan Timing and Revision

§483.21(b) Comprehensive Care Plans

§483.21(b)(2) A comprehensive care plan

must be-

(i) Developed within 7 days after completion

of the comprehensive assessment.

(ii) Prepared by an interdisciplinary team, that

includes but is not limited to--

(A) The attending physician.

(B) A registered nurse with responsibility for

the resident.

(C) A nurse aide with responsibility for the

resident.

(D) A member of food and nutrition services

F 0657

SS=D

Bldg. 00





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

staff.

(E) To the extent practicable, the

participation of the resident and the resident's

representative(s). An explanation must be

included in a resident's medical record if the

participation of the resident and their resident

representative is determined not practicable

for the development of the resident's care

plan.

(F) Other appropriate staff or professionals in

disciplines as determined by the resident's

needs or as requested by the resident.

(iii)Reviewed and revised by the

interdisciplinary team after each assessment,

including both the comprehensive and

quarterly review assessments.

Based on record review and interview the facility

failed to ensure care plan meetings were

completed in a timely manner for 2 of 2 residents

reviewed for quarterly care plan meetings.

(Resident D, and Resident 72)

Findings include:

1. The record review for Resident D began on

3/8/18 at 11:22 a.m. Diagnoses included but were

not limited to major depressive disorder, acute

osteomyelitis (infection of a bone), aplastic

anemia (the body stops producing enough new

blood cells), bacteremia (infection of the blood),

muscle weakness, low back pain, diabetes

mellitus, anxiety disorder, obstructive sleep apnea

and hypertension.

The most current MDS (Minimum Data Set)

Quarterly Assessment for Resident D was dated

12/13/17 and indicated the BIMS (Brief Interview

of Mental Status) score was 14/15, which

indicated the resident was cognitively intact.

F 0657 F657 Care plan Timing and

Revision



deficient practice:

SSD held care plan meeting for

Resident #D and Resident #72.

There were no negative outcomes

related to this alleged deficient

practice.




practice:

All residents residing in the facility






reoccur:

SSD will be reeducated by the ED

on the appropriate procedure for

scheduling care plan meetings to

04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

An interview with Resident D on 3/5/18 at 10:13

a.m., indicated the facility had not had a care plan

meeting with her since last year in August.

Resident D indicated her family member/POA was

present at the Care Plan Meeting in August 2017.

A review of Resident D's Social Service Progress

Notes indicated the following:

On 5/23/17 Care plan meeting...Attendees- SSD

(Social Service Director), P/T (Physical Therapy),

Therapy Manager, Family Member, Activities,

Dietary Manager, ADON (Assistant Director of

Nursing). The Social Service progress notes in

the electronic record were lacking additional

documentation for Care Plan Meetings.

A review of a paper record document, Care Plan

Meeting Note for Resident D, provided by the

SSD on 3/9/18 at 11:22 a.m., indicated a Quarterly

Care Plan Meeting met on July 31, 2017. Resident

D, POA and another family member was in

attendance.

An interview on 3/8/18 at 12:06 p.m., with SSD

(Social Service Director) indicated she was the

one who set up Care Plan Meetings for the

residents. The SSD indicated she invites the

resident and the resident's POA (Power of

Attorney) or the Resident's Representative

verbally to the Care Plan Meeting. After the SSD

checked Resident D's electronic clinical record,

she indicated Resident D's most current Care Plan

Meeting was in August 2017. The SSD indicated

all residents should have a Care Plan Meeting

done quarterly or every 3 months. The SSD also

indicated Resident D should have had a Care Plan

Meeting in November 2017, however, the resident

had not been on the schedule to have a Care Plan

Meeting. The SSD indicated Resident D was in

the hospital in October/November 2017, she had

include inviting resident and

family. SSD or designee will be

responsible for ensuring that this


recur.




MDSC or designee will be

responsible for monitoring the care

plan schedule to ensure that all

residents have had a care plan

meeting scheduled. An audit will

be conducted weekly x 4 weeks,

then monthly x 3, then quarterly

thereafter. Audits will continue for

6 months. Audit results will be

reviewed monthly for at least 6

months by the QAPI Committee

and will continue until at least

90% compliance is

established. Each QAPI

Committee will review for




patterns.






04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

interviewed Resident D for the MDS Assessment

questions for Section B, C, D, E, and Q in

November and December 2017, and she had

missed the November 2017 Quarterly Care Plan

Meeting. She indicated the resident was not

currently on the Care Plan Meeting schedule. The

SSD indicated she would talk with Resident D to

set a date and time for a Care Plan Meeting, would

call the Resident's family member, and invite them

to come to the Care Plan Meeting.

An interview with SSD on 3/9/18 at 11:22 a.m.,

indicated the facility policy had been for the MDS

Coordinator to send out letters and coordinate all

of the Care Plan Meetings. The SSD indicated the

prior MDS Coordinator stopped working at the

facility in November 2017 and indicated the new

MDS Coordinator found the former MDS

Coordinator had not been scheduling Care Plan

Meetings, so they were not being done. The SSD

further indicated, since November 2017 she was

arranging and conducting the Care Plan Meetings

for the residents and resident representatives.

An interview with SSD on 3/9/18 at 11:29 a.m.,

indicated the facility policy, titled, Care

Conference Key Points, was the only facility

policy found regarding Care Plan Meetings.

A current facility policy, "Care Conference Key

Points" dated 1-1-11, was provided by the DON

(Director of Nursing) on 3/9/18 at 10:30 a.m.,

indicated, "...The MDS Coordinator will oversee

the care plan process and coordinate resident care

conferences...Key Functions of a Care Plan

Coordinator: Work cooperatively with members of

the interdisciplinary team to develop, implement

and evaluate plan of care...schedule and attend

care conferences...ensure that the resident/family

invitations to the care conferences are





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

sent...Communicate resident concerns and

responses to interdisciplinary team

members...Coordinate the review and revision of

the resident's care plan by the interdisciplinary

team after each quarterly review or other

assessment, ensuring that the care plan is

evaluated and revised each time an assessment is

done or when there is a change in the resident's

status...All in attendance should sign and date on

the care conference attendance sheet....The

Clinical Record face sheet and the resident's code

status are to be reviewed and updated with each

care conference...."

2. A review of Resident 72's clinical record on

3/9/2018 at 12:11 p.m., indicated a BIMS (Brief

Interview of Mental Status) score of 11 out of 15,

meaning moderate cognitive impairment.


rhabdomyolysis (the rapid destruction of striated

muscle).

During an interview on 3/2/2018 at 9:45 a.m.,

Resident 72 indicated he had not been invited to a

Care Plan meeting since he had been admitted.


SSD (Social Service Director) indicated the

Resident 72 had been to the care plan meeting

held 11/14/2017.

A review of the form "Care Plan Meeting Notes",

dated 11/14/2017, provided by the SSD on

3/9/2018 at 8:30 a.m., indicated Resident 72 was in

attendance and signed the form.

During an interview on 3/9/2018 at 10:05 a.m., the

SSD indicated Resident 72 had a Care Plan

meeting in August and November, but had not

had one since. The SSD indicated the resident

had declined attendance for the meeting in





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

August, so she had talked with the resident about

his plan of care but there was no documentation.

The SSD indicated Resident 72's quarterly care

plan meeting should have been in February 2018.

The notifications were mailed out a week ago and

they will be setting up a meeting for next week.

3.1-35(c)(2)

3.1-35(d)(2)(B)

483.21(b)(3)(ii)

Qualified Persons

§483.21(b)(3) Comprehensive Care Plans

The services provided or arranged by the

facility, as outlined by the comprehensive

care plan, must-

(ii) Be provided by qualified persons in

accordance with each resident's written plan

of care.

F 0659

SS=E

Bldg. 00


review, the facility failed to ensure that Physician

Orders were obtained and followed for 5 out of 19

residents reviewed with Physician's Orders.

(Resident 61, Resident 4, Resident 283, Resident

60, and Resident 45)

Findings include:

1. The record review for Resident 61 began on

3-6-2018 at 9:39 a.m. Diagnoses included but were

not limited to, paranoid schizophrenia,

hypertension, cerebral infarction, diabetes,

encephalopathy, polyosteoarthritis,

hyperlipidemia, bipolar disorder, difficulty walking

and muscle weakness.

The MDS significant change of condition

assessment for Resident 61 was dated 2-21-2018

and indicated a BIMS score of "...resident is

rarely/never understood...." Resident 61 required

F 0659 F659 Qualified Persons



deficient practice:

Resident #61 and Resident #4 had

MD notification of failure to follow

physician orders related to g tube

feedings.

Resident #283, Resident #45 and

Resident #60 had MD notification

regarding no order present for

glucometer checks. The orders

for glucometer checks were

obtained.




practice:

All residents with orders for g tube

feedings and sliding scale insulin

have potential to be affected by

04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

extensive assistance of 2 persons for eating.

Hospice was marked.

A review of the current physician orders for

Resident 61 indicated "...flush G-tube

(Gastrostomy tube, a tube that delivers nutrition

and fluids directly to the stomach) with 40 ml

(milliliters) of water every hour...record total

amount of h2o [sic] (H2O, water) flush given this

shift (ml)....Glucerna 1.5 Cal Liquid (Nutritional

Supplements) give 45 ml/hr (hour) via G-tube

every shift...Continuous feed....record total

amount of feeding this shift...."

A review of Resident 61's March 2018 MARS

(Medication Administration Record) indicated the

following for the water flush amounts:

On March 1, 2, 3 and 4 for day and evening shift,

320 ml of water was entered, which was the most

amount that could be given per the physician's

order. On the March 4th night shift, 3-5 and 3-6 all

shifts, 420 ml was recorded in each shift area

which would have made the rate 52.5 ml hour,

which exceeded the physician's order.

A review of Resident 61's March 2018 MARS for

Glucerna 1.5 cal liquid indicated the following:

On March 1, 2 and 3; 320 ml was recorded each

shift. On March 4, 320 ml was recorded on day

and evening shift but on 3-4 night shift, and on

3-5 and 3-6 all shifts, 420 ml were recorded. The

feeding was documented as running at 45 ml per

hour each 8 hour shift. The most amount of

feeding infused should have been 360 ml.

A review of Resident 61's February 2018 MARS

for water flushes indicated water flushes at 30 ml

hour were discontinued on 2-15-2018 and 40 ml

the alleged deficient practice.

Residents with g tube feedings

and sliding scale insulin have been

audited by nursing administration

prior to date of compliance. No

negative outcome from the alleged

deficient practice was noted.




reoccur:

Licensed nursing staff and QMA’s

will be in serviced by the DNS or

designee regarding appropriate

documentation of g tube intake

and orders for glucometer check

by the date of compliance.




The DNS or designee will conduct

audit of the MARs and TARS 5 x

weekly for 4 weeks of documented

g tube intake, and glucometer

results. Audits will continue

monthly x 3, then quarterly

thereafter. Audits will continue for

at least 6 months. Audit results

will be reviewed monthly for at

least 6 months by the QAPI

Committee and will continue until

at least 90% compliance is






patterns.

Date of Compliance: 4/8/18





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

per hour had been ordered. The water flush

amounts were documented in the February 2018

MAR as follows:

Beginning February 12, 2018 evening shift, 240 ml

was documented in each shift area through

Monday 2-19-2018, night shift. 320 ml water

flushes should have begun on 2-15-2018 evening

shift.

On February 19, 2018 evening shift, the MAR

lacked documentation of water flush intake.

Beginning on February 20, 2018 day shift, 320 ml

was documented for each shift through February

28,2018.

On February 21, 2018, night shift, the MAR lacked

documentation of the water flush intake.

A review of the February 2018 MARS for the

Glucerna 1.5 cal liquid for Resident 61 indicated

the following:

On February 9, 2018, day shift, 360 ml was

documented.

Beginning February 9, 2018, from the evening shift

through all shifts through February 28, 2018, 300

ml was documented on each shift.

On February 12, 2018, day shift, the MAR lacked

documentation of the Glucerna intake.

On February 17, 2018, evening shift, the MAR

lacked documentation of the Glucerna intake.

The care plan for the G-tube was dated 2-12-2018

and had interventions which included but were

not limited to, tube feeding as ordered and water

flushes as ordered.

A dietary progress note completed by the

Dietitian on 2-14-2018 indicated "... discussed

slight increase in H2O (water) flush w/DON (with

Director of Nursing), and would recommend





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

increase H2O flush to 40 mls/hr. (from 30/hr), to

provide 960 mls flush; which w/free fluid in

formula (819 mls) will total 1779 mls/d, or ~30/kg

(kilograms)...."

During an observation on 3-6-2018 at 9:20 a.m.,

Resident 61 was observed in her bed with her

eyes closed and a continuous tube feeding

(Glucerna 1.5) was running at 45 ml (milliliters) per

hour via a enteral feed and flush pump. The

container of the feeding was labeled 3-5-2018 at

2:20 p.m.There was about 500 ml left in the

container. Calculations of the rate ordered times

the running time (45 ml x 19 hours) indicated

approximately 855 ml would have been infused out

of the 1000 ml container. There was also a flush

bag hanging which was running at 40 ml flush per

hour.

An observation of Resident 61's tube feeding on

3-6-2018 at 11:00 a.m., indicated the flush bag was

labeled with a hang date of 3-5-2018 at 12:00 p.m.

There was about 700 ml of water remaining in the

bag out of the 1000 ml bag. For the 11 hours the

flush would have been running, about 560 ml

should have remained.

An observation of Resident 61 on 3-6-2018 at 4:23

p.m., indicated the resident was in her room with

the tube feeding running. The feeding container

dated 3-5-2018 at 2:20 p.m. remained hanging and

actively running with 200 ml left in the container.

The feeding pump indicated 831 ml fed. The flush

solution dated 3-5-2018 had approximately 500 ml

left. The feeding pump indicated 720 ml of the

flush was infused.

An interview with the DON on 3-6-2018 at 4:43

p.m., indicated the tube feeding will run until

empty before a new container would be hung. An





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

observation with the DON of Resident 61's

feeding at this time indicated there was about 150

- 200 ml left in the container. With the feeding

pump set to run at 45 ml hour, the total feeding

infused should have been around 1170 ml for 26

hours. The DON indicated she was not able to say

one way or the other why the container was not

empty. With the flush bag having been hung on

3-5-2018 at noon, that would have been at least 28

hours running at 40 ml hour, the bag should have

been empty at least 3 hours ago and currently at

this observation time, had about 400 -500 ml left.

An interview with Nurse 5 on 3-7-2018 at 2:12 p.m.,

indicated she would check the pump for Resident

61 for the amounts infused of the feeding and the

flush, clear the pump and record the amounts at

the end of her shift. Nurse 5 demonstrated how

this was done by reading the amounts infused

and clearing the pump for Resident 61. Nurse 5

indicated there was 275 ml infused for the feeding

and 241 ml for the flush for her shift as shown on

the enteral feeding pump. Nurse 5 was asked

about the amount of 275 ml of the feeding and at

45 ml per hour, should Resident 61 had received

more. Nurse 5 was also asked about the amount

infused prior to the changing of the bottle of the

feeding at 7:40 a.m. Nurse 5 indicated Resident 61

would have had about 1/2 of 45 ml more. Nurse 5

was asked about the 420 ml that was already

documented prior to this time for the flush for day

shift on 3-7-2018 and Nurse 5 did not provide an

answer. Nurse 5 indicated the Nurse Consultant

had helped her get her tube feeding intakes and

had given her 690 ml as Resident 61's intake. The

Nurse Consultant demonstrated how she obtained

the number from Resident 61's enteral feeding

pump. The 690 ml was the total intake that flashed

on the pump. The Nurse Consultant indicated

she didn't realize the amounts for the flushes and





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

feedings needed to be documented separately.

Nurse 5 indicated the feeding pumps were the

property of the facility and the nursing staff had

been instructed on how to use the pumps.

An interview with Nurse 6 on 3-9-2018 at 11:10

a.m., indicated she was unable to say why the

documentation of the feeding amounts per shift

for Resident 61 were the same. She indicated it

was unlikely the nursing staff who documented

the feeding and flush amounts would read the

same amount infused on the pump at exactly

every 8 hours. Nurse 6 indicated she did not

know who was keeping track of the intake totals

per day. Nurse 6 indicated there could be some

math calculations being done for the

documentation, rather than documenting actual

amount infused. The March 2018 MAR flush and

feeding amount entries for the 5th and 6th for

Resident 61 were reviewed with Nurse 6. For the

March 5th and 6th entries, 420 ml was

documented for each shift for the flushes and for

the feedings. (The physician's order was for 40 ml

per hour for the flush (320 ml in 8 hours) and 45

ml per hour for the feedings (360 ml in 8 hours).

Nurse 6 indicated the flush and feeding amounts

were more than the ordered amount.

An interview with the DON on 3-09-2018 at 11:35

a.m., indicated it was not likely that the resident's

tube feeding amounts would be exactly the same

amount each shift every day. The DON indicated

she was not aware that anyone monitored the

total amounts of the daily feeding and flush

intakes to ensure the physician orders were

followed. The DON indicated the amounts

documented on 3-5-2018 and 3-6-2018 had

exceeded the amount of feeding and flush

ordered.

2. The record review for Resident 4 began on





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

3/7/18 at 9:20 a.m. Diagnoses included but were

not limited to multiple sclerosis, weakness,

dysphagia (difficulty swallowing), aphasia

(impairment of speech), convulsions,

gastroesophageal reflux disease, and contractures

of muscles in multiple sites.

The most current MDS Quarterly Assessment for

Resident 4 was dated 12/3/17 and indicated

Resident was rarely/never understood and the

BIMS (Brief Interview of Mental Status) was not

attempted. The MDS Assessment also indicated

Resident 4's Functional Status required required

total dependence of 1+ persons physical assist for

eating (e.g. tube feeding). Resident 4's

Swallowing/Nutritional Status indicated difficulty

while swallowing. Nutritional approach, Tube

feeding with 51% or more of total calories received

trough tube feeding with average fluid intake per

day for through feeding tube was 501 cc (cubic

centimeters, a measurement) or more.

A review of Resident 4's Physician orders

indicated the following:

Order Date 02/26/2018, "...Nothing by Mouth

(NPO) diet...."

Order Date 02/26/2018, "...G-tube Flush: Flush

G-tube with 150 ml of water every 4 hrs. for

G-tube...."

Order Date 01/15/2018, "...Jevity 1.5 Cal (a

nutritional supplement) at 55 ml/hr (hour) to run

CONTINUOUSLY every shift..."

Order Date 01/15/2018, "...Pro-Stat AWC (Amino

Acids-Protein Hydrolys, a liquid protein

supplement) Give 30 ml via G-tube one time a

day...Give 30 ml once a day...."

Order Date 05/18/17, "...G-Tube: Record total

amount of FEEDING given this shift every

shift...Document amount of feeding...."

Order Date 05/18/17, "...G-Tube: Record total





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

amount of h2o [sic] FLUSH given this shift (ml)

every shift...150 ml every 4 hours...."

A review of Resident 4's MAR for February 2018


"...Pro-Stat AWC Liquid...Give 30 ml via G-tube

one time a day...once a day...."

Hours 0900 (9:00 a.m.) The supplement was

documented as given every day in February 1st

through 28th, by a check mark and the nurses'

initials documented. The Amt (amount) of

supplement indicated the following:

On 2/1/18: 237 was documented.

On 2/2/18 through 2/8/18: 100 was documented.




"G-Tube: Record total amount of FEEDING given

this shift every shift ...Document amount of

feeding...." indicated the following:

Hours Day (day shift) Amount:

On 2/1/18 to 2/4/18: 520 was documented on each

date.


On 2/6/18 through 2/8/18: 520 was documented on

each date.

On 2/12/18: documentation was lacking.

On 2/14/18: 520 ml was documented.

On 2/15/18 through 2/19/18: 520 was documented

on each date.

Hours Evening (evening shift) Amount:


On 2/2/18 through 2/4/18: 520 ml was documented

on each date.

On 2/5/18 through 2/7/18: 520 was documented on

each date.

On 2/8/18: 520 ml was documented on each date.

On 2/11/18 through 2/14/18: 520 ml was





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

documented on each date.


On 2/16/18 520 ml was documented.


On 2/18/18 and 2/19/18: 520 was documented on

each date.



Hours Night (night shift) Amount:

On 2/1/18 through 2/13/18: 520 was documented

on each date.



each date.

On 2/10/18: 0 (Zero) was documented.



On 2/14/18 through 2/2/19/18: 520 was

documented on each date.


"...G-Tube: Record total amount of H2O FLUSH

given this shift (ml)...every shift...every 4 hours..."

indicated the following: Documentation for all

shifts every day 300 or 300 ml was documented.

Documentation was lacking on the following

days, 2/12/18 on Day Shift; 2/17/18 and 2/24/18 on

Evening Shift; 2/11/18 and 2/21/18 on Night shift.

"...G-Tube: FLUSH order-30 ml every 4

hours...every 4 hours for H2O order 150 ml every 4

hours. D/C (discontinue) Date 2/16/18...."


Hours 0000 (12:00 a.m., midnight) Amount:

On 2/3/18 and 2/4/18: 60 was documented on each

date.






04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

On 2/9/18 150 was documented.


each date.

Hours 0400 (4:00 a.m.) Amount:



each date.


each date.


Hours 0800 (8:00 a.m.) Amount:



each date.

Hours 1200 (12:00 p.m.) Amount:

On 2/1/18:100 was documented.



each date.




On 2/5/18 10: 150 was documented.







each date.

A review of Resident 4's MAR for March 2018


"...Pro-Stat AWC Liquid...Give 30 ml via G-tube

one time a day...once a day...." Hours 0900 (9:00





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

a.m.) The supplement was documented as given

every day thus far in March 2018, the 1st through

7th, by a check mark and the nurses' initials

documented. The Amt (amount) of supplement


On 3/2/18 through 3/7/18 100 was documented on

each date.

"G-Tube: Record total amount of FEEDING given

this shift every shift ...Document amount of

feeding...." indicated the following: The

supplement was documented as given every day

thus far in March 2018, the 1st through 7th, by a

check mark and the nurses' initials documented.

Hours Day (day shift) Amount:


The care plan for the tube feeding was dated

11-6-2017 and had interventions which included

but were not limited to, provide tube feeding and

flush as ordered, monitor Kangaroo Pump for

correct flow and monitor Kangaroo Pump for

proper function.

An interview with the DON (Director of Nursing)

on 3/8/18 at 10:22 a.m., indicated she would not

expect to see the same amount of tube feeding

documented every day and on every shift. She

indicated the amount should be documented as

the amount given during the shift. She indicated

she had found the tube feeding amounts were the

same and were not being totaled and reviewed for

each 24 hour period.

A current policy, "Enteral Nutrition" dated

February 2017 was provided by Nurse 15 on

3-7-2018 at 10:38 a.m.

The policy indicated "...Guidelines...intake...as

ordered by the physician...Documentation...fluid

intake...amount...."





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

A current policy, "Physician Orders" dated

2-15-2015 was provided by the DON on 3-9-2018

at 12:54 p.m. The policy indicated the procedure

on how to write orders and the communication

and filing of the physician orders. There was no

policy for following physician orders.


3/8/2018 at 1:45 p.m., indicated the resident was

interviewable and cognitively intact. Diagnoses

included, but were not limited to: diabetes.

On 3/2/2018 at 12:01 p.m., LPN (Licensed Practical

Nurse) 13 was observed obtaining blood from

Resident 283's finger with a glucometer

(equipment that checks blood sugar) to check the

residents blood sugar.

At 12:25 p.m., LPN 13 administered 4 units of

Humalog insulin per sliding scale to Resident

283's upper left arm.

A review of Resident 283's Physician Orders

indicated no order for glucometer checks. The

resident had an order to receive 6 units of

Humalog insulin subcutaneously with meals, this

was to be routinely administered in addition to the

sliding scale.


3/8/2018 at 1:50 p.m., indicated a BIM (Brief


meaning cognitively intact. Diagnoses included,

but were not limited to: diabetes.

On 3/2/2018 at 4:20 p.m., LPN 8 was observed

obtaining blood from Resident 60's finger with a

glucometer to check the residents blood sugar.





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00


indicated no order for glucometer checks.


3/8/2018 at 1:55 p.m., indicated a BIMS score of 14

out of 15, meaning cognitively intact. Diagnoses

included but were not limited to: diabetes.


administering insulin for a blood sugar of 116 that

was obtained by the QMA (Qualified Medication

Aide).


indicated no order for glucometer checks.

During an interview on 3/8/2018 at 4:03 p.m., LPN

15 indicated the blood sugar- accucheck was

incorporated in the Sliding Scale insulin order and

you had to enter the blood sugar amount that

appeared on the screen behind the insulin order.

LPN 15 indicated it would be double charting with

a separate line for the accuse and would only

allow a check mark.


DON (Director of Nursing) indicated they should

have an order for glucometer checks. She

indicated the computer system wouls not let you

chart giving the insulin until you had documented

the blood sugars, but there was no order which

indicated the blood sugars needed taken.

3.1-35(g)(2)

483.24(a)(2)

ADL Care Provided for Dependent Residents

§483.24(a)(2) A resident who is unable to

carry out activities of daily living receives the

F 0677

SS=D

Bldg. 00





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

necessary services to maintain good

nutrition, grooming, and personal and oral

hygiene;

Based on observation, interview and record

review, the facility failed to ensure residents

received showers and or bed baths as scheduled

for 3 of 19 residents reviewed for personal care.

(Resident B, Resident C, and Resident D)

Findings include:

1. On 3/6/18 at 2:00 p.m., the clinical record or

Resident B was reviewed. Diagnoses included,

but were not limited to, the following: Stroke,

Chronic Obstructive Pulmonary Disease, muscle

weakness, difficulty in walking.

The Admission Minimum Data Set (MDS)

Assessment, dated 2/14/18, indicated the

following: independent cognition; extensive

assistance (resident involved in activity, staff

provide weight bearing support)) required for

personal hygiene; total dependence for bathing.

On 3/05/18 10:11a.m., Resident B was interviewed.

He indicated he was currently unable to receive a

shower. He indicated he was admitted to the

facility on 2/7/18 and since that time, he's only had

2 bed baths. He indicated he's only had his beard

and hair washed twice since he'd been there. The

resident was observed to have dry, flaky skin on

his face around the upper part of his beard.

On 3/6/18 at 11:00 a.m., the shower book was

observed. It indicated the resident was scheduled

to have showers on Tuesday and Saturday on the

3-11 shift.

On 3/6/18 at 12:36 p.m., the Director of Nursing

F 0677 F677 ADL Care Provided for

Dependent Resident


residents found to have been

affected by the alleged deficient

practice:

Resident B and C are receiving

showers or bed baths as per

schedule and resident preference.

No negative outcome was

identified form alleged deficient

practice.

2. Corrective action taken for

those residents having the

potential to be affected by this

alleged deficient practice:

All residents who are unable to

carry out ADLs have the potential

to be affected by the alleged

deficient practice.

3. Measures/Systemic

changes put into place to ensure

the alleged deficient practice does

not reoccur:

Nurse management team has

updated the shower schedules to

ensure accuracy. Nursing staff

will be reeducated on completion

of shower sheets to include refusal

or acceptance of bed bath and

documentation in PCC system.

DNS or designee will obtain list of

resident preferences for bed bath

or showers to ensure that

preferences are being honored.

4. Corrective actions will be


04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

(DON) was interviewed. She indicated when staff

gave a resident a shower or bed bath, they were to

complete a "Shower Sheet" and also document

the shower/bath in the computer system. She

indicated the CNAs complete the shower sheet to

indicated if the resident had any skin issues. The

DON indicated once the CNAs completed the

shower sheets, they were to give them to the

nurse to review and then the sheets are to be

given to the DON. She indicated she was unable

to find documentation on "shower sheets"

Resident B had been given a shower and/or bed

bath since his admission.

On 3/8/18 at 9:00 a.m., the DON provided a copy

of the computer task "Task: ADL-bathing." The

form indicated the support provided during

bathing activity. The form had the following

dates listed with the support provided designated

as: 2/23/18 (Not applicable); 2/26/18: two person

physical assist; 2/27/18: one person physical

assist; 3/5/18 and 3/6/18 indicated two person

physical assist had been given.

On 3/8/18 at 12:35, p.m., Resident B was

interviewed. He indicated he had not gotten any

bed baths or showers within the last 7 days.

On 3/8/18 at 1:30 p.m., the CNA 20 was

interviewed. She indicated when she gave a

resident a bath, she would wash them "head to

toe, front and back."

On 3/8/18 at 12:05 p.m., CNA 3 was interviewed.

She indicated if she gave a bed bath of someone

that has a beard and hair, she washes it twice a

week by putting a soapy rag and washing the

beard and hair and then rinsing it again with a

clean rag with just water on it.


Nurse management team will audit

the shower schedule 5 x week for

4 weeks to ensure compliance is

occurring. Audits will continue


thereafter for at least 6 months.




continue at least 90% compliance

is established. Each QAPI





patterns noted.






04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

On 3/6/18 at 4:55 p.m., the DON provided a current

copy of the undated, facility policy and procedure

for "Routine Resident Care." The policy and

procedure included the following: "...Residents

receive the necessary assistance to maintain good

grooming and personal/oral hygiene...Showers,

tub baths, and/or shampoos are scheduled at least

twice weekly..."

On 3/8/18 at 10:13 a.m., CNA 3 was interviewed.

She indicated when she gave a resident a bath or

shower, she would complete a "shower sheet, skin

assessment." She indicated she would designate

on the sheet if she had given the resident a bath

or shower.

2. On 3/6/18 at 3:30 p.m., the clinical record of

Resident C was reviewed. Diagnoses included,

but were not limited to, the following: acquired

absence of toes, orthopedic aftercare following

surgical amputation.

The Quarterly MDS dated 2/5/18, indicated the

following: moderately impaired cognition;

extensive assistance required for personal

hygiene and bathing required physical help

limited to transfer only.

The plan of care, dated 1/30/18, addressed the

problem of "...requires assistance with

ADL's...had recent amputation of her left toes, and

has had amputation of her right toes in the

past...Interventions...Bathe (sic) per resident

preference 2 x week and prn (as needed)..."

On 3/6/18 at 11:32 a.m. the DON was interviewed

She indicated there is a spot to say resident

refused for shower or bath.





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

On 3/6/18 at 12:36 p.m., the DON provided copies

of all the "shower sheets" she had for the

resident. The DON was able to provide 3 shower

sheets since the residents admission on 12/7/17.

One shower sheet was dated 12/22/17, one 3/5/18

and the last shower sheet was undated.

On 3/8/18 at 11:53 a.m., Resident C was

interviewed. She indicated she had not had any

shower on 3/2/18 or 3/6/18 as was documented on

the computer bath record. There was no shower

sheet for either 3/2/18 or 3/6/18.

On 3/6/18 at 11:52 a.m. the documentation of

showers in computer was reviewed. ADL-Bathing

was documented on the following dates: 2/23/18,

2/27/18, 3/2/18 and 3/6/18. Each entry designated

the resident required one person physical assist.

On 3/06/18 at 11:00 a.m., the shower book was

reviewed. The schedule in the book indicated the

resident was to be showered on the 7-3 shift, on

Mondays and Thursdays. A note in the shower

book indicated "Turn shower sheets in to DON on

desk or table in office." 3. The record review for

Resident D began on 3/6/18 at 9:20 a.m.

Diagnoses included but were not limited to major

depressive disorder, acute osteomyelitis (infection

of a bone), aplastic anemia (the body stops

producing enough new blood cells), bacteremia

(infection of the blood), muscle weakness, low

back pain, diabetes mellitus, anxiety disorder,

obstructive sleep apnea and hypertension.

The most current MDS (Minimum Data Set)

Quarterly Assessment for Resident D was dated

12/13/17 and indicated the BIMS (Brief Interview

of Mental Status) score was 14/15, which

indicated the resident was cognitively intact. The

MDS also indicated Resident D's Functional





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

Status required total dependence of 2+ persons

physical assist for bathing.

An interview with Resident D on 3/5/18 at 9:35

a.m., indicated they had lived at the facility for

over a year, received a bed bath and not a shower,

because they were not to bear weight on their leg.

Resident D also indicated they had not received a

bed bath consistently and was not asked if they

wanted a bath. Resident D indicated their bath

was scheduled two times a week and did not

receive a bath on the scheduled days and further

indicated they rarely got a bath at all.

Resident D's electronic clinical record for Bathing

and Hygiene Task indicated the following:

Bathing Self Performance/Bathing Support

2/5/18 8:46 NA (Non applicable)/NA

2/6/18 8:49 Total Dependence/one person

physical assist

2/6/18 8:50 NA/NA


physical assist


physical assist

2/16/18 10:24 Physical help in part of bathing/one

person physical assist

2/20/18 10:29 Physical help limited to transfer

only/one person physical assist


physical assist

2/27/18 08:34 Physical help limited to transfer

only/one person physical assist


physical assist


physical assist

The electronic record did not indicated if a bed

bed bath was preformed for Resident D.





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

A review of Resident D's Nursing Care Plans,

provided by DON (Director of Nursing) on 3/8/18

at 1:58 p.m., indicated, "...Resident D requires

assistance with ADL's (Activity of Daily Living)

r/t (related to) Aplastic Anemia,

weakness...requires oxygen...Revised on

1/26/18...Goal...Resident 12 will have all ADLS met

by staff,,,Revision on

03/01/18...Interventions...Resident D needs

extensive assist of two for transfers. Resident 12

rarely transfers out of bed during a normal

day...Resident D requires extensive assist of one

to two for bed mobility....showers 2 times a week

and prn(as needed)...."

A review of a paper record documents for Shower

Sheet for Resident D, provided by the DON on

3/6/18 at 12:36 p.m., indicated the following:

"...Shower Sheet...Resident D's Name/Room

#...Date: 9/2/17...check mark beside Barrier

Cream...CNA Signature...Refused Bath got a

partial Bath!...."


#...Date: 9/9/2017...(marked with /) for Bed

Bath...Lotion...Barrier Cream...CNA Signature...."


#...Date: 9/16/17...(check marked) for Bed

Bath...Lotion...Barrier Cream...Linen

Change....CNA Signature...."


#...not Dated...Bed Bath...Lotion...Barrier

Cream...*Bed bath (hand written on

document)...CNA Signature...."


#...CNA Signature...date: 12/1/17...complete Bed

Bath (hand written)...linen changed (hand

written)...No New Area (hand written)...."

A review of Resident D's electronic clinical record,

provided by Nurse 15 on 3/8/18 at 1:25 p.m., the





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

Documentation Survey Report indicated only 1

entry for March 2018, "...ADL-Bathing...PRN (as

needed) Evening (3-11)...March 1/2018 4(total

dependence), 2 (limited to physical help limited to

transfers)...CNA initials...at 22:20 (8:20 p.m.)...."

A review of Resident D's electronic clinical record,

provided by the DON on 3/9/18 at 10:11 a.m., "The

Bathing: Self Performance," indicated the

following:

An entry, dated 2/9/2018 at 13:30 was check

marked for Total Dependence.


marked for Total Dependence.


marked for Physical help in part for bathing

activity


marked for Physical help limited to transfers only

An entry dated 2/23/18 at 08:30 was check marked

for Total Dependence.


for Physical help limited to transfers only


for Total Dependence


for Total Dependence


for Physical help limited to transfers only.

The electronic record did not indicate if a bed bath

was provided to the resident.

An interview with the DON (Director of Nursing)

on 3/9/18 at 10:09 a.m., indicated she had no

additional shower sheet(s) for Resident D.

An interview with CNA 22 on 3/9/18 at 10:20 a.m.,

indicated she had provided care for Resident D

who was totally dependent for bathing. CNA 22

indicated Resident D usually gets a bed bath on





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

the evening shift, but she would provide a bath if

the resident requested. CNA 22 indicated she had

just washed Resident D's legs and had put lotion

on them this morning, and when she gave a

resident a shower or a bed bath, she documented

the care provided in the computer by making a

checkmark for a shower or a bed bath, and also

marked if she had washed the resident's hair.

CNA 22 also indicated she documented if the

resident was totally dependent or if they could do

some of their own bath, she would complete a

shower sheet when she provided a shower for a

resident and would make a note on the shower

sheet if there were any problems found during the

shower. CNA 22 further indicated she would not

complete a shower sheet when she provided a bed

bath for a resident because a "shower" was not

given to the resident. She indicated she only

documents in the computer record when a bed

bath was given. CNA 22 indicated if a problem

was found during a bed bath, she would report it

directly to the nurse and not complete a shower

sheet.

An interview with the DON on 3/9/18 at 11:10 a.m.,

indicated the staff should have completed a

Shower Sheet for all showers and bed baths that

were provided to the residents.

This Federal tag relates to complaint IN00255443.

3.1-38(b)(2)

483.24(a)(3)

Cardio-Pulmonary Resuscitation (CPR)

§483.24(a)(3) Personnel provide basic life

support, including CPR, to a resident

requiring such emergency care prior to the

arrival of emergency medical personnel and

subject to related physician orders and the

F 0678

SS=J

Bldg. 00





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

resident's advance directives.


failed to provide basic life support, including CPR

(cardiopulmonary resuscitation), to a resident with

a physician order for a full code status (CPR) for 1

of 1 closed records reviewed for death. The

failure to provide basic life support, resulted in the

resident's death.

(Resident 131)

The Immediate Jeopardy was identified on 3/7/18

and began on 2/17/18 at (2043) 8:43 p.m., when

LPN 2 found Resident 131 in her room with no

vital signs, pupils fixed, no respirations or pulse,

and was unresponsive to verbal and painful

stimuli. CPR was not initiated. The Regional

Director of Operations and Health Care

Administrator were notified of the Immediate

Jeopardy on 3/7/18 at 10:54 a.m.

Findings include:

On 3/6/18 at 4:50 p.m., the record of Resident 131

was reviewed. Diagnoses included, but were not

limited to, the following: heart failure, alcohol

abuse, cirrhosis, cocaine abuse, failure to thrive,

cachexia, chronic pain and anxiety.

A review of physician's orders indicated an order

dated 2/16/18 at 13:41 (1:41 p.m.) for a "Full Code."

Nurses notes, dated 2/16/2018 1430 (2:30 p.m.),

(entered as a late entry on 2/18/18 at 10:24 a.m.),

indicated the following: Resident admitted from

(name of hospital) with alcohol induced dementia.

Unable to get history from resident. Historical

information obtained by report from nurse at

(name of hospital). Resident was admitted per WC

and assisted to bed. Call light in reach and

explained to resident. Alert but confused. Able to

F 0678 F678 Cardio-Pulmonary

Resuscitation


resident found to be affected by

the alleged deficient practice:

MD/POA were notified of the

alleged deficient practice

2. Corrective taken for those



practice:

All residents with full code orders



3. Measures/changes put into

place to ensure the alleged

deficient practice does not

reoccur:

Whole house audit of code status

orders was completed by nurse

management. All licensed staff

were reeducated on procedure to

follow when resident is found

unresponsive



deficient practice will not reoocur:

All licensed staff will be

interviewed weekly per the “code

status staff interview form”.

Ongoing education will continue.

Audits will continue monthly x 3,

then quarterly thereafter for a

minimum of 6 months. Audit

results will be reviewed monthly for

at least 6 months by the QAPI




04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

state her name with hard to understand speech.

Documentation was lacking in the nurse notes

entry on 2/16/18 at 2:30 p.m., of the resident's code

status.

Nursing notes, dated 2/17/2018 at 12:20 p.m.,

indicated "...is alert to self, resident refusing to eat

this shift. V/S (vital signs) stable, no distress

noted..."

The next nurses note entered was on 2/17/2018 at

20:43 (8:43 p.m.) and indicated "Writer found

resident in her room, in bed with no VS, pupils

fixed, no respirations, no pulse, and no (sic)

unresponsive to verbal and painful stimuli. DON

(Director of Nursing), NP (Nurse Practitioner) are

notified."

The next nurses note entered was on 2/17/2018 at

21:54 (9:54 p.m.) and indicated "(County Coroner)

has been notified...stated "This is not a coroner's

case". Order received from (name of nurse

practitioner) to release the body to (name of

funeral home).

In the paper clinical record, physician orders from

(Name of Hospital), were signed in "Physician

Signature" portion of the orders but were not

dated. The physician orders indicated

"Resuscitation Status...Full Code..."

Documentation on the physician orders indicated

"Admitted 2/16/18 at 12:45 p.m." There was no

documentation toindiate CPR should not be

started nor 911 should not be called.

On 3/7/18 at 9:12 a.m., LPN 2 was interviewed. She

indicated she came on duty on 2/17/18 at 3:00

p.m., saw the resident's name on a list but did not

get report on the resident from the prior shift. She


compliance any negative patterns.

An action plan will be completed

for any negative patterns noted.






04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

asked the prior shift QMA (Qualified Medication

Assistant) about the resident, the QMA indicated

"I don't know." The prior shift didn't tell her the

code status of the resident as they indicated they

were not aware. LPN 2 indicated around 8:00 p.m.,

she went to the resident's room to begin her

medication pass, she found the resident in bed

with no VS, pupils fixed, no respirations, no pulse,

and unresponsive to verbal and painful stimuli.

She indicated the resident appeared as though

she "had been like that awhile." There was no

CNA in the hall currently, so she went down the

hall to find the other nurse in the building, RN 1.

LPN2 and RN 1 arrived at the resident's room, RN

1 verified the resident's status as no pulse, no

respirations and unresponsive. She reviewed the

paper clinical record, the "code sheet" was not in

the front of the chart, like it was supposed to be.

She indicated the "code sheet" would have

indicated the resident's code status. She didn't

see the resident's code status in the physician

orders. Neither she nor RN 1 performed CPR on

the resident. LPN 2 looked through the resident's

paper chart and found the code status on hospital

papers, which were kept in the back of the chart.

She indicated the resident was a full code, CPR

status. The DON was notified (as she was out of

the building at this time) Resident 131 had been

found with no pulse, no respirations,

unresponsive to verbal and painful stimuli and

pupils fixed. The DON indicated to her, she had

looked on the computer and was unable to locate

a code status for the resident in the resident's

chart. The DON began speaking to her, regarding

the necessary paperwork to complete for a

deceased resident. LPN 2 indicated neither the

DON or RN 1 told her to perform CPR.

On 3/7/18 at 10:44 a.m., the DON was interviewed.

She indicated Resident 131 was a full code and





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

when she had been made aware of Resident 131's

condition (by RN 1 texting her, she (the DON)

replied via text, to do CPR and call 911. She was

notified approximately 15 minutes after the

resident had been found. She arrived to the

facility on 2/17/18 at approximately 11:30 p.m. The

DON indicated staff did not perform CPR on the

resident or call 911 for the resident. The resident

was a full code status, as reported to her by RN 1.

She indicated if the resident's chart didn't have a

code status form in the front of the chart, the staff

were instructed to perform CPR. After this

incident, she had provided education to staff in

regards to what to do if they find a resident

unresponsive, with no pulse and/or respirations

and there was no form specifying code status

available. Staff were educated to perform CPR in

such a circumstance.

On 3/7/18 at 3:12 p.m., the DON was interviewed.

She was reviewing the text messages on her

phone and indicated the following: Resident 131

had been found unresponsive, no pulse and/or

respirations at 8:43 p.m. on 2/17/18. She indicated

RN 1 texted her at 8:46 p.m. and told her the

resident had passed and the NP (Nurse

Practitioner) had been notified. The DON was not

aware what the NP had been made aware of and/or

what the NP's response was. The DON indicated

at 8:49 p.m. RN 1 texted her regarding the

resident's contacts. At 8:51 p.m., the DON texted

RN 1 as to what had happened. At 8:55 p.m., she

texted RN 1 regarding the resident's code status.

At 8:56 p.m., RN 1 texted the resident was a full

code. At 8:56 p.m.., the DON indicated she texted

RN 1 questioning if the EMS had been called and

had staff started CPR. RN 1 texted back "your

wishes, that's why I'm texting you." At 8:59 p.m.,

she texted to RN 1 "Policy states to start CPR and

call 911." The DON indicated she instructed RN 1





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

twice to start CPR and call 911. She arrived at the

facility at 11:30 p.m. on 2/17/18 and was made

aware CPR had not been started and/or 911 had

not been called. She thought the reason CPR was

not started or 911 was not called was because

LPN 2 felt like the resident "was already gone."

A policy and procedure for "Cardio-pulmonary

Resuscitation (CPR)" dated 7/1/11, included, but

was not limited to, the following: "Guideline: It is

the intent of the facility to ensure that all

resident's suffering a cardiac or respiratory arrest

will receive the treatment of CPR unless the

resident has a Do Not Resuscitate Order...Basic

CPR is defined as artificial respiration

accompanied by external cardiac

compressions...Responsibility: Licensed Nurses

or staff trained in CPR: CPR will be performed by

licensed nursing or staff trained in

CPR...Residents who request FULL CODE

STATUS will receive CPR is they

arrest...Procedure: Check chart for code status.

Assess resident to determine respirations have

ceased/palpate or auscultate for absence of

pulse/heartbeat. If a resident who wishes to be

resuscitated appears to be having an arrest, the

licensed nurse will assess the resident for absence

of heartbeat using a stethoscope or palpate

pulses and assess for absence of respirations.

Call for assistance...If the resident has a cassation

of heartbeat or cessation of respiration and if the

resident wished to be resuscitated, delegate a

person to page for assistance, call 911...All

available licensed nurses and staff trained in CPR

will respond promptly to the code and assist as

needed...clear the resident's airway, check for

respiration...initiate basic life support...use

ambu-bag and/or mouth to mouth...maintain party

of the change in condition and transfer. Complete

documentation in nurses notes..."





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

The immediate jeopardy that began on 2/17/18

was removed on 3/8/18 when the facility

completed record review of advance directives

and physician orders of advance directives, but

the nonompliance remained at the lower scope

and severity of isloated no actual harm with a

potential for more than minimal harm that is not

immedicate jeopardy, because clinical record

monitoring had not been completed.

This federal tag is related to complaint

IN00254575.

483.35(a)(3)(4)(c)

Competent Nursing Staff

§483.35 Nursing Services

The facility must have sufficient nursing staff

with the appropriate competencies and skills

sets to provide nursing and related services

to assure resident safety and attain or

maintain the highest practicable physical,

mental, and psychosocial well-being of each

resident, as determined by resident

assessments and individual plans of care and

considering the number, acuity and

diagnoses of the facility's resident population

in accordance with the facility assessment

required at §483.70(e).

§483.35(a)(3) The facility must ensure that

licensed nurses have the specific

competencies and skill sets necessary to

care for residents' needs, as identified

through resident assessments, and

described in the plan of care.

§483.35(a)(4) Providing care includes but is

not limited to assessing, evaluating, planning

and implementing resident care plans and

F 0726

SS=D

Bldg. 00





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

responding to resident's needs.

§483.35(c) Proficiency of nurse aides.

The facility must ensure that nurse aides are

able to demonstrate competency in skills and

techniques necessary to care for residents'

needs, as identified through resident

assessments, and described in the plan of

care.


review, the facility failed to ensure proper

technique was used for subcutaneous injections

for 1 out of 4 residents observed for

administration of subcutaneous injections.

(Resident 60)

Findings include:

A review of Resident 60's clinical record on



meaning cognitively intact. Diagnoses included,

but were not limited to: diabetes.

On 3/6/2018 at 4:23 p.m., LPN (Licensed Practical

Nurse) 8 was observed administering 8 units of

insulin by subcutaneous (fatty layer of skin

tissue) injection to Resident 60's abdomen without

pinching up the fatty layer of skin.


administering 8 units of insulin by subcutaneous

injection to Resident 60's abdomen without

pinching up the fatty layer of skin.

An undated form, "RN/LPN Check List", provide

by the Scheduler on 3/9/2018 at 12:40 p.m.,

indicated LPN 8 had a "Y" marked for Profiency

{sic} Demonstrated, meaning yes. A line was

drawn through the Orientee and Mentor initials

F 0726 F726 Competent Nursing Staff


residents found to be affected by

the alleged deficient practice:

Resident #60 receives insulin per

nursing staff, utilizing the proper

technique. No issues were

identified from the alleged deficient

practice.





All residents receiving sub q

injections have the potential to be


practice. No issues were

identified from the alleged deficient

practice.




not reoccur:

All licensed staff were reeducated

on proper technique for

administering a subcutaneous

injection.




Nurse management team will

04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

box. The date of review was 1/4/2018 and was

signed by LPN 8. The Instructors Name was

blank.


DON (Director of Nursing) indicated that

subcutaneous injections require pinching of the

fatty tissue before inserting the needle and

injecting the medication.

3.1-14(i)

conduct skills validation of

administration of subcutaneous

injections on random nurses

weekly x 4 weeks to ensure

proper technique is being utilized.

Audits will continue monthly x 3,

then quarterly thereafter and will

continue for at least 6 months.








patterns noted.


483.35(d)(4)-(6)

Nurse Aide Registry Verification, Retraining

§483.35(d)(4) Registry verification.

Before allowing an individual to serve as a

nurse aide, a facility must receive registry

verification that the individual has met

competency evaluation requirements unless-

(i) The individual is a full-time employee in a

training and competency evaluation program

approved by the State; or

(ii)The individual can prove that he or she has

recently successfully completed a training

and competency evaluation program or

competency evaluation program approved by

the State and has not yet been included in

the registry. Facilities must follow up to

ensure that such an individual actually

becomes registered.

§483.35(d)(5) Multi-State registry verification.

Before allowing an individual to serve as a

F 0729

SS=E

Bldg. 00





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

nurse aide, a facility must seek information

from every State registry established under

sections 1819(e)(2)(A) or 1919(e)(2)(A) of the

Act that the facility believes will include

information on the individual.

§483.35(d)(6) Required retraining.

If, since an individual's most recent

completion of a training and competency

evaluation program, there has been a

continuous period of 24 consecutive months

during none of which the individual provided

nursing or nursing-related services for

monetary compensation, the individual must

complete a new training and competency

evaluation program or a new competency

evaluation program.


failed to ensure the license of 1 of 5 staff reviewed

was not expired. This deficiency had the potential

to affect the 6 of 15 residents who resided in 1 of 5

units (North Hall) of the facility.

Findings include:

A review of the employee records and licenses

began on 3-8-2018 at 8:30 a.m. CNA (Certified

Nurse Aide) 11's license provided by Scheduler 7

indicated an "...Expiration Date: 3/4/2018...."

An interview with Scheduler 7 on 3-8-2018 at 10:30

a.m., indicated an updated license was needed to

be obtained by the facility from the online

licensing system.


a.m., indicated the most current CNA license for

CNA 11 was expired. Scheduler 7 indicated CNA

11 worked on 3-6-2018 and on 3-7-2018 on 2nd

shift and was scheduled to come in on this date,

F 0729 F729 Nurse aide registry


residents affected by the alleged

deficient practice:

C.N.A #11. Certification has been

updated. No negative outcomes

occurred related to the alleged

deficient practice.

2. Corrective action for




No Residents were affected by the


3.

Measurements/Systemic changes

put into place to ensure the


reoccur:

A whole house audit of C.N.A.

certification was completed with

no additional findings noted. A

mandatory in-service has been

04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

3-8-2018. Scheduler 7 indicated CNA 11 was

informed by the facility she would not be able to

work until her license was renewed.

An interview with Medical Records/Human

Resources 9 on 3-9-2018 at 10:16 a.m., indicated

they periodically review the licenses of the staff to

ensure the licenses were active and would notify

staff about license renewal. Medical

Records/Human Resources indicated it was about

2 months ago they went through the licenses.


a.m., indicated CNA 11 worked on 3-6-2018 and

3-7-2018 in the front half of North Hall and was

assigned 6 residents. Scheduler 7 indicated CNA

11 would not have assisted another staff member

outside of her assignment with other residents or

covered another hall for staff breaks.

An interview with CNA 10 on 3-9-2018 at 11:30

a.m., indicated she had the responsibility of the

front section of North Hall this shift. CNA 10

indicated she had 9 residents in her assignment.

CNA 10 indicated she worked together with the

other CNA assigned to the North hall to take care

of the residents. CNA 10 also indicated she

would cover other units of the facility when those

CNAs took a break or went to lunch. The facility

had 5 units, North Hall, South Hall, South West,

Rehab and Hope Springs.

A current, undated policy,

"Certification/Licenses" was provided by

Scheduler 7 on 3-9-2018 at 12:41 p.m.

The policy indicated "...All evidence of

appropriate licensure...must be furnished to

Facility...all employees must renew their licenses

as required by law, provide verification of such

renewal to supervisors and notify all appropriate

provided for the Director of Human

Resources to ensure their

responsibility of ensuring that

each employee has the proper

documentation in their employee

file related to their certification.

4. Corrective actions will

be monitored to ensure that

alleged deficient practice will not

reoccur:

ED or designee will audit

employee files weekly X 4 weeks

to ensure there is documentation

to support that each employee

has the required two-step PPD

process and/or a current chest

x-ray in their employee file. An

audit tool will be completed

weekly. Audits will continue

monthly X 3, then quarterly


Audit results will be reviewed for at





Committee will review monthly for



completed for any negative patters

noted.

Date of compliance: 4/08/18





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

agencies if names or addresses change...failure to

comply will result in disciplinary action up to and

including termination...."

3.1-14(e)

483.45(g)(h)(1)(2)

Label/Store Drugs and Biologicals

§483.45(g) Labeling of Drugs and Biologicals

Drugs and biologicals used in the facility

must be labeled in accordance with currently

accepted professional principles, and include

the appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and

Federal laws, the facility must store all drugs

and biologicals in locked compartments

under proper temperature controls, and

permit only authorized personnel to have

access to the keys.

§483.45(h)(2) The facility must provide

separately locked, permanently affixed

compartments for storage of controlled drugs

listed in Schedule II of the Comprehensive

Drug Abuse Prevention and Control Act of

1976 and other drugs subject to abuse,

except when the facility uses single unit

package drug distribution systems in which

the quantity stored is minimal and a missing

dose can be readily detected.

F 0761

SS=D

Bldg. 00


review, the facility failed to ensure medications

were properly dated, labeled, and stored

appropriately for 2 out of 2 medication carts

reviewed for medication storage.

F 0761 F761 Label/Store Drugs and

Bioligicals

1. Corrective action taken

regarding the alleged deficient

practice:

04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

Findings include:

On 3/7/2018 at 1:19 p.m., the North Hall medication

cart was observed for storage with LPN (Licensed

Practical Nurse) 5, and the following items were

found:

A bottle of Latanoprost Oph solution, with no

date opened, and a "do not use after label"

indicated 7/26 and no year.

A vial of Lantus insulin 100ml(milliliters) with no

date opened.

A vial of Lantus insulin 100ml unopened, had a

label "Refrigerate until opened". The fill date was

1/2/2018.

During an interview at this time, LPN 5 indicated

all newly opened medications should have a date

opened on them and the unopened insulin should

have been refrigerated..

On 3/7/2018 at 1:45 p.m., the South West Hall

medication cart was observed for storage with

LPN 14, and the following items were found:

A bottle of Latanoprost sol eye drops, with no

date opened.

A bottle of Alphagan 0.1% eye drops, with no

date opened.

A Proventil aerosol inhaler opened on 11/23/2017.

A Proventil aerosol inhaler opened on 11/24/2017.

Alka Seltzer Plus tablets with no opened date.


that is a long time for the inhalers from the date

opened and was unsure how long they are to be

kept before they are discarded.

A red zipper bag of medications were in the

bottom of the cart. They were a newly admitted

All medication has been properly

dated labeled and stored.





All residents receiving medication



All medications have been

properly dated, labeled and

stored. No adverse findings were

noted due to the alleged deficient

practice.




not reoccur:

All licensed staff and QMAs will

be reinserviced by date of

compliance. Inservicing will

include properly dating and storing

of medication and disposing of

expired medication.




DNS/designee will audit med carts

5 days per week x 4 weeks to

check for proper dating and storing

of medication. Will ensure that all

expired medication is properly

discarded. Audits will continue



Audit results will be reviewed for at









04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

residents home medications. The following items

were found in the bag with no date opened labels:

A bottle of Meloxicam 15 mg(milligrams)

A bottle of Loratadine 10 mg

A bottle of Cyclobenzapine 10 mg

A bottle of Vitamin D3 5000 no name on the label.

A bottle of Refresh optive eye drops.

A bottle of Promethazine 25 mg

A bottle of Oxybutynin 10 mg

A Proair aerosol inhaler

A bottle of Citalopram 20 mg

A bottle of Omeprazole 20 mg

A bottle of Levothyroxin100 mcg (micrograms)

Two bottles of trazodone 100 mg

A bottle of Ondansetron 4 mg

A foil card of Culturelle (digestive health tabs) 5

tablets were on the card with no label or date

opened.


the resident used the facility pharmacy and did

not use these medications.

During an interview on 3/7/2018 at 2 p.m., the

DON (Director of Nursing) indicated the bag of

medications should not be on the cart.


DON indicated that all medications should have

labels and dates opened. The expired inhalers

should have been disposed and not used.

A review of form Medication Expiration Dating,

dated 7/25/2016, provided by LPN 15 on 3/8/2018

at 12:30 p.m., indicated the following: Proventil

inhaler was to be discarded 3 months after date

opened and Latanoprost Ophthalmic Soln was to

be discarded 6 weeks after date dispensed.

3.1-25(j)(m)(n)

Committee meeting will review

monthly for compliance and any

negative patterns. An action plan

will be completed for any negative

patterns.






04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

483.70(e)(1)-(3)

Facility Assessment

§483.70(e) Facility assessment.

The facility must conduct and document a

facility-wide assessment to determine what

resources are necessary to care for its

residents competently during both day-to-day

operations and emergencies. The facility

must review and update that assessment, as

necessary, and at least annually. The facility

must also review and update this

assessment whenever there is, or the facility

plans for, any change that would require a

substantial modification to any part of this

assessment. The facility assessment must

address or include:

§483.70(e)(1) The facility's resident

population, including, but not limited to,

(i) Both the number of residents and the

facility's resident capacity;

(ii) The care required by the resident

population considering the types of diseases,

conditions, physical and cognitive disabilities,

overall acuity, and other pertinent facts that

are present within that population;

(iii) The staff competencies that are

necessary to provide the level and types of

care needed for the resident population;

(iv) The physical environment, equipment,

services, and other physical plant

considerations that are necessary to care for

this population; and

(v) Any ethnic, cultural, or religious factors

that may potentially affect the care provided

by the facility, including, but not limited to,

activities and food and nutrition services.

§483.70(e)(2) The facility's resources,

including but not limited to,

F 0838

SS=F

Bldg. 00





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

(i) All buildings and/or other physical

structures and vehicles;

(ii) Equipment (medical and non- medical);

(iii) Services provided, such as physical

therapy, pharmacy, and specific rehabilitation

therapies;

(iv) All personnel, including managers, staff

(both employees and those who provide

services under contract), and volunteers, as

well as their education and/or training and

any competencies related to resident care;

(v) Contracts, memorandums of

understanding, or other agreements with third

parties to provide services or equipment to

the facility during both normal operations and

emergencies; and

(vi) Health information technology resources,

such as systems for electronically managing

patient records and electronically sharing

information with other organizations.

§483.70(e)(3) A facility-based and

community-based risk assessment, utilizing

an all-hazards approach.


failed to ensure the facility assessment was

completed. This deficiency had the potential to

affect 79 of 79 residents who resided in the

facility.

Findings include:

1. On 3/2/18 at 9:15 a.m., the Administrator was

interviewed during the Entrance Conference for

the recertification survey. He indicated the facility

changed ownership on October 1, 2017. He

indicated he was unaware if the facility

assessment had been completed or not.

F 0838 F838 Facility Assessment

1. Corrective actions for the


A facility assessment has been

completed to determine what

resources are necessary to care

for our residents competently

during both day to day operations

and emergencies.

2. Corrective actions taken for

those residents to have been


practice:

All residents have the potential to


practice. No findings noted from

04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

On 3/5/18 at 8:30 a.m., the Administrator was

interviewed. He indicated he located the

information about the "Facility Assessment" on

the CMS (Center for Medicare and Medicaid

Services) website, but was unable to open the

attachments on 3/2/18. He indicated he would try

to get the attachments open today.

On 3/8/18 at 1:34 p.m., the Regional Director of

Operations was interviewed. He indicated the

company he worked for took over this building in

October of 2017. He indicated the Administrator

began employment at the facility in October 2017

and the DON (Director of Nursing) had been here

3-4 weeks.

On 3/8/18 at 9:29 a.m., the Regional Director of

Operations was interviewed. He indicated the

facility did not not have a Facility Assessment

completed at this time. He indicated he was

currently working on the facility assessment. The

Regional Director of Operations indicated he

understood the facility assessment should have

been completed.

the alleged deficient practice.




not reoccur:

The facility assessment was

completed by the Regional

Director of Operations. The ED

was educated on how to complete

the facility assessment.




Regional Director of Operations or

designee will audit completion of

the facility assessment weekly x

1 month. Audits will continue





the QAPI Committee for




patterns noted.


483.80(a)(1)(2)(4)(e)(f)

Infection Prevention & Control

§483.80 Infection Control

The facility must establish and maintain an

infection prevention and control program

designed to provide a safe, sanitary and

comfortable environment and to help prevent

the development and transmission of

communicable diseases and infections.

§483.80(a) Infection prevention and control

F 0880

SS=D

Bldg. 00





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

program.

The facility must establish an infection

prevention and control program (IPCP) that

must include, at a minimum, the following

elements:

§483.80(a)(1) A system for preventing,

identifying, reporting, investigating, and

controlling infections and communicable

diseases for all residents, staff, volunteers,

visitors, and other individuals providing

services under a contractual arrangement

based upon the facility assessment

conducted according to §483.70(e) and

following accepted national standards;

§483.80(a)(2) Written standards, policies,

and procedures for the program, which must

include, but are not limited to:

(i) A system of surveillance designed to

identify possible communicable diseases or

infections before they can spread to other

persons in the facility;

(ii) When and to whom possible incidents of

communicable disease or infections should

be reported;

(iii) Standard and transmission-based

precautions to be followed to prevent spread

of infections;

(iv)When and how isolation should be used

for a resident; including but not limited to:

(A) The type and duration of the isolation,

depending upon the infectious agent or

organism involved, and

(B) A requirement that the isolation should be

the least restrictive possible for the resident

under the circumstances.

(v) The circumstances under which the facility

must prohibit employees with a

communicable disease or infected skin





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

lesions from direct contact with residents or

their food, if direct contact will transmit the

disease; and

(vi)The hand hygiene procedures to be

followed by staff involved in direct resident

contact.

§483.80(a)(4) A system for recording

incidents identified under the facility's IPCP

and the corrective actions taken by the

facility.

§483.80(e) Linens.

Personnel must handle, store, process, and

transport linens so as to prevent the spread

of infection.

§483.80(f) Annual review.

The facility will conduct an annual review of

its IPCP and update their program, as

necessary.


review, the facility failed to ensure infection

control practices were not maintained for 1 of 2

residents observed in contact isolation (Resident

283) and 2 of 3 residents reviewed with foley

catheters. (Resident 25, and Resident 279)

Findings include:

1. On 3/6/18 at 3:00 p.m., the clinical record of

Resident 283 was reviewed. Diagnoses included,

but were not limited to, the following:

Enterocolitis due to clostridium difficile (a

bacterium that causes diarrhea with symptoms to

include watery diarrhea, at least 3 bowel

movements per day for two or more days).

A physician order, dated 2/27/18, indicated

"Vancomycin...every 6 hours for C-diff

F 0880 F880 Infection Prevention and

Control


residents found to have been


practice:

Resident 283 has had isolation

d/c’d. Resident 25 and 279 foley

catheter tubing and bag are being

maintained/positioned

appropriately and off the floor


those resident having the potential

to be affected by this alleged

deficient practice.

Residents who have orders for

contact isolation and catheters



04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

(clostridium difficile) until 3/8/18...).

On 3/02/18 at 10:22 a.m., the room of Resident 283

was observed with a sign on the door "Please see

nurse before entering." Outside the room in the

hall, was observed a cart, with 3 transparent

drawers. Observed in the drawers, were yellow

disposable gowns and red trash bags.

On 3/6/18 at 8:35 a.m., from the hall Resident 283

was heard to be hollering "help me, help me."

The Administrator was observed to walk to the

room, knock on the door, and enter the room

without gloves or gown. The Administrator was

observed, without gloves, to be moving the

resident's bedside table around as well and

handling the the resident's meal tray and it's

contents. The Administrator was observed to

carry the resident's tray out of the isolation room,

down the hall and place the resident's tray on a

cart outside the back entrance into the kitchen

The Administrator was then observed to use hand

sanitizer to cleanse his hands.

On 3/6/18 at 9:09 a.m., CNA 18 was observed to

enter the resident's room without a gown on.

Once in the room, she was observed to pull the

privacy curtain around the resident's bed.

On 3/6/18 at 9:22 a.m., CNA 18 was observed to

approach the door from inside the room, without a

gown on. She was then observed to leave the

room.

On 3/6/18 at 9:28 a.m., the Maintenance

Supervisor was observed to knock on the the

resident's door, put disposable gloves on and

enter the resident's room without a gown on. He

indicated to the resident "let's take a quick look at

that bed." At 9:29 a.m., the Maintenance

No negative outcomes were

identified by the alleged deficient

practice.



the alleged deficient practices do

not reoccur:

All staff will be in serviced on

policy for contact precautions by

DNS or designee. All nursing staff

will be in serviced on proper

placement of catheter bag and

tubing.




DNS or designee will audit

residents on contact isolation 5 x

weekly x 4 weeks to ensure all

staff are utilizing appropriate

personal protective equipment and

gloves as needed. DNS or

designee will audit catheter bags

and tubing 5 x weekly x 4 weeks

to ensure tubing and bags are in

proper position. Audits will

continue monthly x 3, then

quarterly thereafter for at least 6

months. Audit results will be

reviewed monthly for at least 6

months by the QAPI Committee

and will continue until 90% or

better compliance is established.

An action plan will be completed

for any negative patterns noted.






04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

Supervisor was observe to leave the room with

gloves on. After coming out of the room, he was

observed to go back into the room, remove the

glove and without handwashing, left the room.

The Maintenance Supervisor was not observed to

have had a gown on.

On 3/6/18 at 9:32 a.m., CNA 17 was observed to go

into the resident's room with a lift device

(mechanical device used to assist a resident to

move from surface to surface) with a fabric sling

laying over the lift. At this time, CNA 17 and

CNA 18 were observed to enter the resident's

room.

On 3/6/18 at 9:39 a.m., the lift was observed

removed from the isolation room with the sling

draped over the lift. CNA 17 was observed to

push the lift out of the room, down the hall and

into another resident's room on another hall.

On 3/6/18 at 9:42 a.m., the Resident 283 was

observed in a chair at bedside. The Maintenance

Supervisor was observed to again enter the room

and put gloves on, but no gown. He was

observed to be working on the resident's bed. At

9:43 a.m., the Maintenance Supervisor was

observed to leave the room with gloves on, then

went back into the room, took the gloves off and

left the room without handwashing.

On 3/6/18 at 10:18 a.m., Housekeeper 19 was

observed to sweep the room around the bed and

in the bathroom. At 10:28 a.m., Housekeeper 19

was observed to take the fabric string mop from

the mop bucket. She was observed to mop the

floor, around the resident's room, bed and

bathroom. At 10:31 a.m., Housekeeper 19 was

observed to put the used mop back into the mop

bucket. At 10:37 am., Housekeeper was observed





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

to push her cart down the hall to the south hall.

At 10:39 a.m. Housekeeper 19 was observed to

sweep a room in the south hall. Housekeeper 19

was not observed to change the fabric mop head

or mop water. At 10:57 a.m., she was observed to

remove the same fabric string mop from the mop

bucket she had used in the isolation room, and

mopped the floor.

On 3/6/18 at 10:58 a.m., Housekeeper 19 was

interviewed. She indicated she changed her mop

water after every 6 rooms cleaned. She indicated

the room she had just cleaned in the south hall

was the "6th" room she had cleaned. She

indicated she had not changed the mop and mop

water after cleaning the isolation room and before

cleaning the next room.

On 3/7/18 at 4:49 p.m., the Director of Nursing

(DON) was interviewed. She indicated whenever

staff would go into an isolation room, they should

wear a gown and put disposable gloves on. She

indicated staff should have had gloves on when

they touched the meal tray and should have

washed hands after glove removal. She further

indicated staff should have worn a gown when

care was provided for the resident. She indicated

the lift pad should not have left the room and

been used on another resident. The DON

indicated the used lift pad should have been put

in a red bag in the isolation room after use. She

further indicated the mop head and mop water

should have been changed after use in cleaning

an isolation room and prior to cleaning another

resident's room.

On 3/7/18 at 4:55 p.m., RN Nurse Consultant was

interviewed. She indicated the Administrator

should have washed his hands with soap and

water after removal of the meal tray from the





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

resident's room. She indicated staff should have

worn a gown and gloves when providing resident

care and the lift sling should have remained in the

isolation room and not used on another resident.

She indicated the Maintenance Supervisor should

have washed his hands after removing the gloves

and prior to leaving the room. The RN Nurse

Consultant indicated the housekeeper should

have changed the mop head and also changed the

water. The RN Nurse Consultant indicated the

dry mop brooms should have been changed.

On 3/7/18 at 6:09 p.m., the RN Nurse Consultant

provided a current copy of the facility policy and

procedure for "Contact Precaution," which was

undated. The policy and procedure included the

following: "...Purpose: It is the intent...to use

contact precautions in addition to standard

precautions for residents known or suspected to

have serious illnesses easily transmitted by direct

resident contact or by contact with items in the

resident's environment...two types of

transmission...transmitted directly from person to

person...transfer of the infectious agent through a

contaminated intermediate object or person...

hand hygiene should be completed prior to

donning gloves; gloves should be worn when

entering the room and while providing care for the

resident...Gloves should be removed before

leaving the resident's room and hand hygiene

should be performed immediately...a gown should

be donned prior to entering the room...dedicated

resident care equipment should be considered for

the resident...Contact Precautions will be

considered for (examples)...Clostridium difficile

and other infectious causes of diarrhea..."



Interview of Mental Status) of 12 out of 15,

meaning moderate cognitive impairment.





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00


kidney disease.

On 3/2/2018 at 10 a.m., Resident 25 was observed

sitting in his room, in his wheelchair, and his foley

catheter (a flexible tube that is inserted through

the urethra into the bladder to drain urine) tubing

and bag were laying on the floor.


observed sitting in his room, in his wheelchair,

and his foley catheter tubing was on the floor.


observed being wheeled to the main dining room

in his wheelchair and foley catheter bag was

dragging on the floor.


observed sitting in his wheelchair, in the main

dining room and his foley catheter bag was

touching the floor.


observed sitting in his room, in his wheelchair.

The foley catheter bag and tubing were on the

floor, under the wheelchair.

An MDS (Minimum Data Set) quarterly

assessment, dated 12/30/2017 indicated yes to an

indwelling catheter with an extensive assistance

of one person for bladder and bowel functional

status.

A review of Resident 25's Care Plans indicated a

Care Plan was initiated for a foley catheter,

included a goal and interventions, including keep

catheter tubing and bag off the floor.






04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

3/6/2018 at 11:43 a.m., indicated the resident was

unable to complete a BIMS due to severe

cognitive impairment. Diagnoses included but

were not limited to: dementia and bladder cancer.


observed in the main dining room. The resident's

foley catheter bag and tubing were on the floor.

On 3/7/2018 at 2:11 p.m., Resident 279 was being

wheeled in the hall by staff, the resident's foley

catheter bag and tubing was dragging on the

floor.


observed sitting in his wheelchair, in the lounge

of the Memory Care Unit, Hope Springs. The

resident's foley catheter bag and tubing were

dragging on the floor.


observed wheeling his wheelchair back and forth,

and foley catheter bag was run over by the

wheelchair wheel. The catheter tubing was on the

floor.

An MDS Admission Medicare 5 day assessment

dated 2/28/2018 indicated a yes to a urostomy (a

surgical construction of an artificial excretory

opening from the urinary tract) with extensive

assistance and two person physical assist for

toilet use.

A review of Resident 279's Care Plans indicated a

Care Plan was initiated for a urostomy, included a

goal and interventions, including keep catheter

tubing and bag off the floor.

During an interview with the DON (Director of

Nursing) on 3/9/2018 at 1:12 p.m., indicated the





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

catheter bag and tubing should not be on the

floor.

3.1-18(a)

3.1-18(b)(1)

F 9999

Bldg. 00

410 IAC 16.2-3.1-14 Personnel

(t) A physical examination shall be required for

each employee of a facility within one (1) month

prior to employment. The examination shall

include a tuberculin skin test, using the Mantoux

method (5 TU PPD), administered by persons

having documentation of training from a

department-approved course of instruction in

intradermal tuberculin skin testing, reading, and

recording unless a previously positive reaction

can be documented. The result shall be recorded

in millimeters of induration with the date given,

date read, and by whom administered. The

tuberculin skin test must be read prior to the

employee starting work. The facility must assure

the following:

(1) At the time of employment, or within one (1)

month prior to employment, and at least annually

thereafter, employees and non-paid personnel of

facilities shall be screened for tuberculosis. For

health care workers who have not had a

documented negative tuberculin skin test result

during the preceding twelve (12) months, the

baseline tuberculin skin testing should employ the

two-step method. If the first step is negative, a

second test should be performed one (1) to three

(3) weeks after the first step. The frequency of

repeat testing will depend on the risk of infection

with tuberculosis.

(2) All employees who have a positive reaction to

the skin test shall be required to have a chest

F 9999 F9999 Final Observation



No negative outcomes were

identified by the alleged deficient

practice. The Executive Director

will have a 2 step TB repeated

prior to the date of compliance.

All other mantoux text will be

updated by the date of

compliance.


those residents found to have

been affected by the alleged

deficient practice:

No residents were observed to

have been affected by the alleged

deficient practice.




not reoccur:

A mandatory in-service has been

provided for the Director of Human

Resources to ensure their

responsibility of ensuring that

each employee has the proper

documentation in their employee

file related to the administration of

the twostep PPD process.


04/08/2018 12:00:00AM





04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

x-ray and other physical and laboratory

examinations in order to complete a diagnosis.

(3) The facility shall maintain a health record of

each employee that includes:

(A) a report of the pre-employment physical

examination; and

(B) reports of all employment-related health

examinations.

(4) An employee with symptoms or signs of active

disease, (symptoms suggestive of active

tuberculosis, including, but not limited to, cough,

fever, night sweats, and weight loss) shall not be

permitted to work until tuberculosis is ruled out.

This requirement is not met as evidenced by:


failed to ensure staff completed TB (tuberculosis)

screening at hire for 3 of 5 employee records

reviewed. (DON, Administrator and Nurse 8)

Findings include:

A review of the employee records began on

3-8-2018 at 8:30 a.m. The TB screening for the

following staff, hired since the last survey date,

was not completed per state regulation:

The DON (Director of Nursing), with a start date

of 1-23-2018, had documentation of the

administration of a first step TB test on 1-22-2018

and the TB test was read on 1-25-2018. There was

not documentation of a second step TB test

provided and the facility was unable to provide a

copy of a TB test administered and read within the

last 12 months.

The Administrator, with a start date of 9-18-2017,

had documentation of the administration of a first

step TB test on 9-18-2017. The TB test was not

read as the form did not have a date read, a

millimeter size, or nurse's initials recorded.



ED or designee will audit

employee files weekly x 4 weeks

to ensure there is documentation

to support that each employee

has the required two-step PPD

process and/or a current chest

x-ray in their employee file. An

audit tool will be completed

weekly. Audits will continue












patterns noted.






04/09/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155255 03/09/2018



00

Documentation for a 2nd step TB test indicated

the test was administered on 11-1-2017 and read

on 11-3-2017. There was not documentation

provided for a TB screen completed within the last

12 months prior to the start date.

Nurse 8, with a start date of 1-2-2018, had

documentation of the administration of a first step

TB test on 1-15-2018 and the TB test was read on

1-17-2018. This was 15 days after the start date.

Documentation for a 2nd step TB screen indicated

the test was administered on 1-29-2018 and read

on 1-31-2018.

An interview with Medical Records/Human

Resources 9 on 3-8-2018 at 3:21 p.m., indicated the

start date was the day all the paperwork for the

employee was completed and not necessarily the

date they provided patient care. The facility did

not provide any different start date for the DON,

Administrator and Nurse 8.

A current, undated policy, "Maintaining a Safe

Workplace" was provided by Scheduler 7 on

3-9-2018 at 12:04 p.m. The policy indicated

"...upon commencement of employment all

employees must undergo a physical examination

and TB screening as indicated by applicable state

and federal regulations for health care workers.

Timely completion of all annual health

requirements is the responsibility of all employees

and must be completed as scheduled by the

supervisor to insure continued employment...."


F 0000 - Indiana · 2020-03-24 · continued program participation. ... form to the POA/residents...

Documents

Transcript of F 0000 - Indiana · 2020-03-24 · continued program participation. ... form to the POA/residents...