printed: 10/13/2017 department of health and …-cpr skills validations were initiated immediately...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

10/13/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

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B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

NEWBURGH, IN 47630

155273 09/19/2017

CYPRESS GROVE REHABILITATION CENTER

4255 MEDWELL DR

00

F 0000

Bldg. 00

This visit was for the Recertification

and State Licensure survey. This

visit resulted in an Extended

Survey-Substandard Quality of

Care-Immediate Jeopardy.

Survey dates: September 11,12, 13,

14, 18, 19, 2017

Facility number: 000173

Provider number: 155273

AIM number: 100290920

Census Bed Type:

SNF/NF: 74

Total: 74

Census Payor Type:

Medicare: 4

Medicaid: 43

Other: 26

Total: 74

These deficiencies reflects State

Findings cited in accordance with 410

IAC 16.2-3.1.

Quality review completed on

September 26, 2017.

F 0000 Plan of Correction for Cypress

Grove Rehabilitation Center’s 2017

Recertification and State Licensure

Survey

The creation and submission of this

Plan of Correction does not

constitute an admission by this

provider of any conclusion set forth

in the statement of deficiencies, or

of any violation of regulation.

This provider respectfully requests

that the 2567 Plan of Correction be

considered the Letter of Credible

Allegation and requests a Post

Certification Desk Review in lieu of

the Post Survey Revisit on October

19, 2017.

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 determined that

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

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 disclosable 14

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: 5SU111 Facility ID: 000173

TITLE

If continuation sheet of 60

(X6) DATE




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483.10(c)(6)(8)(g)(12), 483.24(a)(3)

RIGHT TO REFUSE; FORMULATE

ADVANCE DIRECTIVES

483.10

(c)(6) The right to request, refuse, and/or

discontinue treatment, to participate in or

refuse to participate in experimental

research, and to formulate an advance

directive.

c)(8) Nothing in this paragraph should be

construed as the right of the resident to

receive the provision of medical treatment or

medical services deemed medically

unnecessary or inappropriate.

(g)(12) The facility must comply with the

requirements specified in 42 CFR part 489,

subpart I (Advance Directives).

(i) These requirements include provisions to

inform and provide written information to all

adult residents concerning the right to

accept or refuse medical or surgical

treatment and, at the resident’s option,

formulate an advance directive.

(ii) This includes a written description of the

facility’s policies to implement advance

directives and applicable State law.

(iii) Facilities are permitted to contract with

other entities to furnish this information but

are still legally responsible for ensuring that

the requirements of this section are met.

F 0155

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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5SU111 Facility ID: 000173 If continuation sheet of 60




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(iv) If an adult individual is incapacitated at

the time of admission and is unable to

receive information or articulate whether or

not he or she has executed an advance

directive, the facility may give advance

directive information to the individual’s

resident representative in accordance with

State law.

(v) The facility is not relieved of its obligation

to provide this information to the individual

once he or she is able to receive such

information. Follow-up procedures must be

in place to provide the information to the

individual directly at the appropriate time.

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

resident’s advance directives.

Based on interview and record

review, the facility failed to administer

Cardiopulmonary Resuscitation

(CPR) to a resident who had a full

code status for 1 of 1 residents

reviewed with a Physician's order for

a full code status, with the potential

to affect 42 residents with a full code

status in the facility. (Resident 97)

The Immediate Jeopardy began on

6/27/17 when the staff failed to

provide CPR for a resident who had a

full code status. The Administrator,

DON (Director of Nursing, Nurse

Consultant, and AIT (Administrator in

F 0155 What corrective action will be

accomplished for those residents

found to have been affected by the

deficient practice.

-Staff involved with incident were

immediately suspended pending

investigation.

-Code blue drills were immediately

completed on all shifts by DNS/CEC

-CPR skills validations were initiated

immediately for all licensed staff by

DNS/CEC.

-DNS/designee has completed audit

of CPR certifications for all staff. Any

09/19/2017 12:00:00AM





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training) were notified of the

Immediate Jeopardy on 9/12/17 at

4:20 p.m. The Immediate Jeopardy

was removed, and the deficient

practice corrected on August 11,

2017, prior to the start of the survey

and was therefore Past

Noncompliance.

Findings include:

On 9/12/17 at 11:15 a.m., Resident

97's clinical record was reviewed.

Resident 97 was admitted to the

facility on 6/13/17. Resident 97's

diagnosis included, but was not

limited to: Acute and chronic

respiratory failure, atherosclerotic

heart disease of native coronary

artery without angina pectoris,

cerebral infarction, unspecified atrial

fibrillation, dysphagia, atelectasis,

encephalophathy. The Admission

MDS (Minimum Data Set)

Assessment, dated 6/20/17,

indicated Resident 97 had severe

cognitive impairment.

Resident 97's Care Plans lacked a

care plan and interventions for code

status.

A Physician's Order, signed and

dated on 6/15/17, indicated Resident

97 had a "Full Code" status.

nursing/QMA staff without current

CPR certification were scheduled for

CPR certification class by July 16th.

How other residents having the

potential to be affected by the

same deficient practice will be

identified and what corrective

action will be taken.

All residents have the potential to be

affected by this practice.

-On 6/27/17 the SSD/designee

completed an audit of all resident’s

code status was completed to

ensure code status was

appropriately identified on face

sheet/ physician orders/care plans,

and that DNR forms

present/completed for those

residents that have chosen a DNR

status.

-CPR Skills validations have been

completed for all nursing staff.

During orientation, licensed Staff

have been educated on CPR Skills

validation and revised Code Blue

Drill policy.

-During Monthly Code Blue Drills a

skills validation will be completed for

participating licensed staff.





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Resident 97's medical record lacked

an Advanced Directive by the

resident or representative.

A Progress note, dated 6/27/17 at

3:15 a.m., indicated "Noted resident

in bed with eyes closed, no distress

noted ...Noted Glucerna feeding with

approx.[sic] 45 minutes remaining.

Noted good amount of humidifier

water, good mist noted. Will replace

feeding in approx. [sic] 30-45

minutes."

A Progress Note, dated 6/27/17 at

4:05 a.m., indicated: "Entered room

noted resident left eye fixed, staring

blankly. Pale skin, cyanosis (blue

discoloration) around the lips. Did not

respond to verbal or tactile stimuli.

Noted no pulse, respirations. Warm

to touch, no pooling of blood noted in

lower extremities. Call placed RN in

house to confirmed [sic] by RN no

pulse no respirations. Resident noted

to be full code."

A Progress Note, dated 6/27/17 at

4:20 a.m., indicated: "EMT arrived at

facility, assessed resident, applied

monitor for internal data. Informed

will call in for further instructions d/t

(due to) death. Noted call placed to

coroner [Coroner Name], information

-DNS/designee will continue to

complete Code Blue Drills monthly

for all licensed staff.

-Licensed staff were re-educated on

location, contents, and check off list

of all crash carts in the facility. Nurse

manager has been assigned to

ensure crash cart check off list is

completed daily including AED

function/extra pads.

What measures will be put in place

or what systemic changes will be

made to ensure that the deficient

practice does not recur

-The Code Blue Drill policy was

revised to include new AHA

guidelines for cardiopulmonary

resuscitation.

-CPR Skills validations have been

completed for all nursing staff.

During orientation, licensed Staff will

be educated on CPR Skills validation

and revised Code Blue Drill policy.

-During Monthly Code Blue Drills a

skills validation will be completed for

participating licensed staff.





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given of health condition. Coroner

inform [sic] EMT to call death and

have attending MD sign death

certificate, no s/o (signs of) foul play.

On 9/12/17 at 12:50 p.m., a

physician's note, dated 6/29/17,

indicated: "Cause of death: Patient

was found in bed without a pulse or

respiration at about 4:05 a.m. on

6/27/17. Patient reportedly was

mottled, with perioral cyanosis. The

patient progress notes appeared to

be okay at about 3 a.m. paramedics

were called, but CPR was not initially

initiated in the facility. Paramedics

found the patient pulseless and

without respirations. It is unlikely that

CPR initiated at the time the patient

was found by the nursing staff would

have been successful. This morning I

signed the patient's death certificate

and listed acute on chronic

respiratory failure as the cause of

death."

On 9/12/17 at 12:55 p.m., a review of

a written statement by RN 1, dated

6/27/17, untimed. It indicated: "... I

was going to do a treatment when

LPN 1 called over and asked me to

verify a death with her ...We both

went in the room, no pulse, no

respirations, no breath sounds, or

heartbeat. The resident's eyes were

-DNS/designee will continue to

complete Code Blue Drills monthly

for all licensed staff.

-Licensed staff were re-educated on

location, contents, and check off list

of all crash carts in the facility. Nurse

manager has been assigned to

ensure crash cart check off list is

completed daily including AED

function/extra pads.

-An additional in-service was

conducted on September 12, 2017

by the CEC/designee to ensure

understanding of the revised Code

Blue policy.

-SSD/designee will review code

status, DNR/POST forms and

advance directive acknowledgment

with responsible parties at time of

admission, with quarterly

assessments, and with any

significant changes.

How the corrective action will be

monitored to ensure the deficient

practice will not recur, i.e. what





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glazed over, no signs of life, skin was

bluish discoloration. LPN 1 and I

closed the door, she went to call

triage, family, and coroner. I

proceeded back to my unit and

notified the DON (Director of

Nursing)."

An interview with the DON on 9/12/17

at 11:27 a.m., indicated the facility

policy was to initiate a code on all full

code residents, even if found

cyanotic, with rigor, or pulseless. She

indicated staff was to check code

status, if a DNR (Do not Resuscitate)

to verify time of death and vitals, and

if a Full Code to initiate CPR and

grab the AED (Automatic External

Defibrillator). She indicated the

facility terminated a nurse for not

following this policy and not initiating

CPR (Cardiac Pulmonary

Resuscitation) when finding a

resident unresponsive in her room.

During interviews of 11 nursing staff,

on 9/12/17 at 11:23 a.m. through 11:

56 a.m., all were able to appropriately

respond to a Code Blue, except for

LPN 2. LPN 2 was currently working

her last shift at the facility, and

indicated on 9/12/17 at 11:46 a.m.

she did not know the facility policy

and did not know what she would do

in the situation of finding a resident

quality assurance program will be

put into place and by what date the

systemic changes will be

completed.

-Code Blue Drills and CPR Skills

Validations will be continue to be

completed monthly and for all

new hires by DNS/designee and

reviewed by QA committee to

ensure 100% compliance with

policy and procedure

-Advanced Directives/Code

Status QA tool to be completed

weekly x4 and monthly for 12

months and quarterly thereafter.

100% threshold must be achieved

or Plan of action implemented.

The QA committee will review

monthly for 12months and

determine need for further action,





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unresponsive in their room. She

attempted to ask a fellow nurse

during the interview.

During a review of the facility training

inservices, dated 6/29-7/7/17, on

9/12/17 at 12:10 p.m., all facility staff

were trained in Code Blue, CPR

initiation, and honoring code status.

During an interview on 9/12/17 at

12:31 p.m., the Nursing Consultant

indicated: The facility followed the

AHA (American Heart Association)

guidelines when it came to finding a

deceased resident. If a resident was

found in rigor, cyanotic, or mottled

that CPR was not initiated. He further

indicated the nurse was to contact

the physician to get an order to

discontinue the CPR order, and

indicated this was not followed with

Resident 97.


1:20 p.m., the SSD (Social Services

Director) indicated Resident 97 did

not have an Advanced Directive due

to not being able to make the

decision herself, due to her cognitive

status. She further indicated the

family had not yet made a decision

on her code status so she was

defaulted to a "Full Code" status. The

clinical record lacked documentation





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that the SSD had attempted to obtain

the family's declaration of code

status.


1:28 p.m., the DON (Director of

Nursing) indicated RN 1 did not

document her findings in the clinical

chart because the chart was closed

after the death. When questioned

about the late entries by LPN 1 she

indicated she did not know why RN 1

did not enter her documentation as a

late entry instead of a written

statement.


1:33 p.m., the Nursing Consultant

indicated RN 1 did not document her

assessment of Resident 97 in the

clinical record due to being

uncomfortable due to the death and

chose to come in and write a written

statement. He acknowledged the

discrepancies of LPN 1 and RN 1's

assessments and indicated RN 1 was

the correct assessment. He

acknowledged the written statement

was not part of the clinical record.

A review of the current policy, "Code

Blue Drill," revised 6/2016, on

9/12/17 at 1:12 p.m., indicated:..."

AHA urges all potential rescuers to

initiate CPR unless: 1) a valid DNR





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order is in place, 2) obvious signs of

clinical death (e.g. rigor mortis,

dependent lividity, decapitation,

transection, or decomposition) are

present; or 3) initiating CPR could

cause injury or peril to the rescuer."

A review of the current policy,

"Advanced Directives," revised

11/2016, on 9/12/17 at 2:52 p.m.,

indicated: "...the facility's care will

reflect the resident's wishes as

expressed in the Directive, in

accordance with state law. The

signed form will be kept in the

medical record. In the event that an

adult is incapacitated at the time of

admission, information regarding

Advanced Directives may be given to

the resident's representative.

Advanced Directives will be reviewed

quarterly in the care plan conference

with the IDT and resident/responsible

party as applicable."

The Past Noncompliance Immediate

Jeopardy began on 6/27/17. The

Immediate Jeopardy was removed

and corrected on 8/11/17 when the

facility completed inservicing of all

nursing staff for CPR competency

and Code Blue, and institituted

random audits of all nursing staff for

Code Blue. The correction date was

prior to the start of the survey and





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was therefore Past Noncompliance.

3.1-4(f)(5)

483.10(g)(14)

NOTIFY OF CHANGES

(INJURY/DECLINE/ROOM, ETC)

(g)(14) Notification of Changes.

(i) A facility must immediately inform the

resident; consult with the resident’s

physician; and notify, consistent with his or

her authority, the resident representative(s)

when there is-

(A) An accident involving the resident which

results in injury and has the potential for

requiring physician intervention;

(B) A significant change in the resident’s

physical, mental, or psychosocial status (that

is, a deterioration in health, mental, or

psychosocial status in either life-threatening

conditions or clinical complications);

(C) A need to alter treatment significantly

(that is, a need to discontinue an existing

form of treatment due to adverse

consequences, or to commence a new form

of treatment); or

(D) A decision to transfer or discharge the

resident from the facility as specified in

§483.15(c)(1)(ii).

(ii) When making notification under

paragraph (g)(14)(i) of this section, the

F 0157

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facility must ensure that all pertinent

information specified in §483.15(c)(2) is

available and provided upon request to the

physician.

(iii) The facility must also promptly notify the

resident and the resident representative, if

any, when there is-

(A) A change in room or roommate

assignment as specified in §483.10(e)(6); or

(B) A change in resident rights under

Federal or State law or regulations as

specified in paragraph (e)(10) of this section.

(iv) The facility must record and periodically

update the address (mailing and email) and

phone number of the resident

representative(s).

Based on record review and interview,

the facility failed to ensure a physician

was notified of a resident being non

compliant with their diet for 1 of 6

residents reviewed for nutrition.

(Resident 111).

Findings include:

On 9/18/17 at 11:00 a.m., Resident 111's

clinical record was reviewed. Diagnoses

included, but not limited to, dysphagia,

pharyngoesophageal phase. The resident's

admission date was 8/31/17. The

resident's BIMS (brief interview for

mental status) was a 15, which indicates

no cognitive impairment.

F 0157 F157 Notify of Changes

(Injury/Decline/Room, Etc.)

What corrective action(s) will

be accomplished for those

residents found to have been

affected by the deficient

practice?

·For Resident #111, MD has

been notified of the resident’s

choice to decline ordered altered

diet.

How will you identify other

residents having the potential

to be affected by the same

deficient practice and what

corrective action will be taken?

·All residents that choose to

decline altered diet

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A progress note dated 9/9/17, indicated

the resident was currently on a dysphagia

3 diet with nectar thickened liquids, with

no straws, and was non compliant with

the diet.

The order was started on 9/8/17.


the resident was non-compliant with her

diet, and refused to drink nectar

thickened liquids.


the resident continued not to adhere to

her diet, especially to the thickened

liquids order.


the resident refused to drink nectar

thickened liquids most of the time.

On 9/18/17 at 3:00 p.m., the resident was

interviewed on use of straws, she

indicated she wants to use straws, and is

not sure what her orders are.

On 9/18/17 at 10:30 a.m., LPN 4

indicated that she could not find in the

clinical record where the physician had

been notified of Resident 111's non

compliance with her diet and that she

would notify him.

On 9/18/17 at 11:24 a.m., the current

policy was provided on resident refusal

of medications and treatments. The

policy indicated if a resident refuses

recommendations have the


alleged deficient practice

·An audit will be completed by

DM/DNS to identify residents that

have altered diet orders, and MD

notification will be completed for

any resident that has chosen to

decline recommended diet

orders.

·Licensed staff will be

re-educated on notification of MD

for any resident choosing to

decline recommended altered

diet orders.

What measures will be put into

place or what systemic

changes you will make to

ensure that the deficient

practice does not recur?

·Daily audits of MARs and

progress notes will be completed

by DNS/designee to ensure that

MD notification is completed for

any resident choosing to decline

recommended altered diet orders.

How the corrective action (s)

will be monitored to ensure the

deficient practice will not recur,

i.e., what quality assurance

program will be put into place?

·The DNS/designee will be

responsible for the completion of

the Change of Condition Quality

Assurance Tool and the Refusal

of Medications/Treatments

Quality Assurance Tool weekly





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administration of a medication or

treatment three consecutive days, the

physician will be contacted and made

aware of the refusals, and documentation

of the physician notification and any new

orders will be charted in the nursing

progress notes.

The current policy titled, "Resident

Change of Condition" was provided by

the Nursing Consultant on 9/18/17 at

2:02 p.m. The policy stated, "It is the

policy of this facility that all changes in

resident condition will be communicated

to the physician and family/responsible

party, and that appropriate, timely, and

effective intervention takes place."

3.1-5(a)(1)

times 4 weeks, bi-monthly times 2

months, monthly times 4 and then

quarterly until continued

compliance is maintained for 2

consecutive quarters. The results

of these audits will be reviewed

by the QAPI committee overseen

by the ED. If threshold of 100% is

not achieved, an action plan will

be developed. Deficiency in this

practice will result in disciplinary

action up to and including

termination of responsible

employee.

Date of Compliance 10/19/2017

483.10(a)(1)

DIGNITY AND RESPECT OF

INDIVIDUALITY

(a)(1) A facility must treat and care for each

resident in a manner and in an environment

that promotes maintenance or enhancement

of his or her quality of life recognizing each

resident’s individuality. The facility must

protect and promote the rights of the

resident.

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Based on observation, interview, and

record review, the facility failed to

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provide dignity while providing care

for 2 of 9 residents observed for care.

(Resident 64, Resident 90)

Findings include:

1. During an observation on 9/18/17

at 9:10 a.m., LPN 3 entered Resident

90's room to restart his tube feeding.

LPN 3 did not pull the curtain around

the bed or close the blinds before

exposing Resident 90's j-tube

(feeding tube surgically inserted

through the abdomen). Resident 90's

window looked out to the parking lot.

2. On 9/18/17 at 9:49 a.m., CNA 1 was

observed assisting Resident 64 with

bathing in the shower room. The

Activity Director knocked on the door

and CNA 1 told her she could come in.

The curtain was not pulled around

Resident 64. The Activity Director had

to tell CNA 1 to pull the curtain as she

was entering the room.

During an interview on 9/18/17 at 12:05

p.m., CNA 1 indicated you should

provide privacy when providing care by

pulling the curtain, shutting the door, and

closing the blinds.

During a review of the current policy, "

Resident Rights," revised 11/16, on

9/18/17 at 2:00 p.m., it indicated all or in




practice?

·Staff are ensuring dignity

provided during care, including

utilizing privacy curtains for

Resident #64 and Resident #90.






·All residents under the care of

the facility have the potential to be

affected by the alleged deficient

practice.

·Observations were completed

on all shifts by DNS/designee to

ensure dignity and privacy

provided during delivery of care.






· All licensed staff will be

re-educated regarding the

facility’s Resident Rights policy

and procedure by DNS/designee.

·Observational rounds will be

completed by DNS/designee daily

on all shifts to ensure dignity and

privacy are provided during

delivery of care.





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part, but not limited to: All staff members

recognize the rights of residents at all

times and residents assume their

responsibilities to enable personal

dignity, well being, and proper delivery

of care.

3.1-3(t)








the Dignity and Privacy Quality

Assurance Tool weekly times 4

weeks, bi-monthly times 2













employee.


483.20(g)-(j)

ASSESSMENT

ACCURACY/COORDINATION/CERTIFIED

(g) Accuracy of Assessments. The

assessment must accurately reflect the

resident’s status.

(h) Coordination

A registered nurse must conduct or

coordinate each assessment with the

appropriate participation of health

professionals.

(i) Certification

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(1) A registered nurse must sign and certify

that the assessment is completed.

(2) Each individual who completes a portion

of the assessment must sign and certify the

accuracy of that portion of the assessment.

(j) Penalty for Falsification

(1) Under Medicare and Medicaid, an

individual who willfully and knowingly-

(i) Certifies a material and false statement in

a resident assessment is subject to a civil

money penalty of not more than $1,000 for

each assessment; or

(ii) Causes another individual to certify a

material and false statement in a resident

assessment is subject to a civil money

penalty or not more than $5,000 for each

assessment.

(2) Clinical disagreement does not constitute

a material and false statement.


record review, the facility failed to ensure

a comprehensive assessment was

accurate for 1 of 31 residents reviewed.

A resident did not have an accurate MDS

(Minimum Data Set) assessment for his

BIMS (Brief Interview for Mental

Status), mood, behaviors, and oral/dental

status. (Resident 57)

Findings include:

On 9/12/17 at 8:59 a.m., Resident 57 was

F 0278 F278 Assessment

Accuracy/Coordination/Certifie

d





practice?

·Annual MDS dated 3/7/2017

was modified to include accurate

dental status information.

·MDS for Resident #57 was

completed with accurate

assessment of mental status,

mood and behavior patterns.

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observed with missing teeth. Resident 57

indicated he had recently had a dental

visit. Resident 57 resided on a secured

unit at the facility.

The clinical record for Resident 57 was

reviewed on 9/13/17 at 9:52 a.m.

Diagnoses included, but were not limited

to, major depressive disorder,

non-Alzheimer's dementia, alcohol

dependence, cerebral infarction, diabetes

mellitus type 2, left hemiplegia and

hemiparesis, and dysphagia. A quarterly

MDS, dated 6/3/17, indicated the resident

was not assessed for mental status, mood,

or behaviors. The annual MDS, dated

3/7/17, indicated the resident had no

issues with his oral or dental status.

On 9/13/17 at 10:11 a.m., the RAI

(Resident Assessment Instrument)

Specialist indicated the facility did not

have a social worker or MDS

Coordinator from April 2017 through

September 2017. The RAI Specialist

indicated that the facility had been doing

the RAI (Resident Assessment

Instrument) from the home office.

(located in another town) The RAI

Specialist indicated she had been training

the new social service and MDS

coordinator persons.

On 9/19/17 at 11:07 a.m., the Memory






·All residents have the potential

to be affected by the alleged

deficient practice.


MDSC/designee of all residents

to ensure accurate MDS coding

of dental status, mental status,

and mood/behavior patterns.






·An in-service will be completed

by RAI Specialist with MDSC

regarding accuracy of MDS

coding.

·The MDS will be reviewed for

accuracy during the weekly IDT

care plan review utilizing the care

plan review tool by the

MDSC/designee.






·The MDSC/designee will be


the MDS Accuracy Quality






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Care Facilitator indicated the resident did

have missing teeth.

The current facility policy, dated 1/2016,

and obtained from the Administrator on

9/19/17 at 1:57 p.m., indicated it was the

policy of the facility to conduct

comprehensive assessments which

identifies the resident's functional

capacity and health status.

3.1-31(c)(7)














employee.


483.20(d);483.21(b)(1)

DEVELOP COMPREHENSIVE CARE

PLANS

483.20

(d) Use. A facility must maintain all resident

assessments completed within the previous

15 months in the resident’s active record

and use the results of the assessments to

develop, review and revise the resident’s

comprehensive care plan.

483.21

(b) Comprehensive Care Plans

(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

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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 the requirements set forth in paragraph

(c) of this section.





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a comprehensive care plan was developed

for 3 of 31 residents reviewed. A urinary

incontinent care plan and a medication

care plans were not developed. (Resident

7, 33, and 108)

Findings include:

1. On 9/11/17 at 11:42 a.m., a strong

urine odor was noticed in Resident 7's

room.

On 9/13/17 at 8:36 a.m., Resident 7

indicated he was incontinent at times.

On 9/13/17 at 2:04 p.m., the clinical

record for Resident 7 was reviewed.


to, morbid obesity, anxiety disorder,

depressive disorder, generalized muscle

weakness, and chronic obstructive

pulmonary disorder.

The admission MDS (Minimum Data

Set) assessment, dated 9/4/17, indicated

Resident 7 had a BIMS (Brief Interview

for Mental Status) of 15, indicating no

cognitive impairment. The MDS

indicated the resident was not on a

bladder training program and was

frequently incontinent of urine. The

MDS further indicated the resident had

F 0279 F279

DEVELOPE COMPREHENSIVE

CARE PLANS





practice?

·An incontinence care plan was

completed for Resident #7.

·A care plan was completed for

side effects of anti-depressant

and anti-anxiety medications for

Resident #33.

·A care plan was completed for

side effects of anti-depressant

medication for Resident #108.






·All residents that are at risk for

incontinence, or receive

anti-depressant or anti-anxiety

medications have the potential to

be affected by the alleged

deficient practice.

·A review of all residents to

identify anyone at risk for

incontinence, or anyone receiving

anti-depressant or anti-anxiety

medications was conducted by

the MDSC/designee to ensure

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received an antidepressant medication

and an antianxiety medication for 7

(seven) out of 7 days during the

assessment period.

The "Bladder/Bowel POC (Plan of Care)

Response" form, dated 8/28/17 through

9/18/17, indicated the resident had been

incontinent of urine on 18 (eighteen)

different occasions.

The facility lacked documentation of a

care plan for the resident's urinary

incontinency.

On 9/18/17 at 8:33 a.m., the DON

(Director of Nursing) indicated she

would create a urinary incontinent care

plan immediately.

The most recent physician's

recapitulation orders, dated 9/1/17

through 9/30/17, and signed on 9/6/17,

included, but were not limited to,

Lorazepam (an antianxiety medication)

0.5 mg (milligram) tablet 1 po (orally) tid

(three times a day) for anxiety, ordered

8/28/17.

Paroxetine (an antidepressant) 40 mg

tablet 1 po daily for depression, ordered

8/28/17.

The facility lacked documentation of a

care plan for the resident's antidepressant

that care plans were in place.







by RAI specialist /designee with

MDSC regarding care plan

development for residents that

are at risk for incontinence, or

receive anti-depressant or

anti-anxiety medication.

·All resident’s care plans will be

reviewed for accuracy and

appropriateness by the IDT team

a minimum of quarterly per the

MDS assessment schedule.

Care Plans will be updated as

appropriate at the time of review.






·The MDS Coordinator or

designee will be responsible for

the completion of the Care Plan

Updating Quality Assurance Tool

weekly times 4 weeks, bi-monthly

times 2 months, monthly times 4

and then quarterly until continued







be developed.





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medication and antianxiety medication.

On 9/19/17 at 1:05 p.m., the Nursing

Consultant indicated the resident should

have a care plan for antidepressant and

antianixety medications.

2. On 9/18/17 at 11:30 a.m., Resident



to, depression and mood disorder. The

most recent signed physician's orders,

dated from 9/1/17 through 9/30/17,

included an order for Celexa 10 mg

(antidepressant) by mouth for four days,

then Celexa 20 mg every day, order date

of 8/29/17. The resident's BIMS (Brief

Interview for Mental Status) was a 6,

which indicates moderate impairment.

There was not a care plan for the

antidepressant medication in Resident

33's clinical record.

3. On 9/14/17 at 9:05 a.m., Resident

108's clinical record was reviewed. The

most recent signed physicians' orders

dated from 9/1/17 to 9/30 /17 included an

order for Celexa 20 mg every day by

mouth for depression, start date of

8/23/17. The resident's BIMS (Brief

Interview for Mental Status) was a 13,

which indicates cognitively intact.

There was not a care plan for the






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antidepressant medication in Resident

108's clinical record

On 9/19/17 at 11:00 a.m., the DON

indicated that a care plan for

antidepressants would be initiated within

24 hours after the order was reviewed.

The current facility policy, dated 4/2014,

and obtained from the Nursing

Consultant on 9/19/17 at 3:15 p.m.,

indicated it was the policy of the facility

that each resident have a comprehensive

care plan developed based on the

comprehensive assessment.

3.1-35(b)(1)

483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2)

RIGHT TO PARTICIPATE PLANNING

CARE-REVISE CP

483.10

(c)(2) The right to participate in the

development and implementation of his or

her person-centered plan of care, including

but not limited to:

(i) The right to participate in the planning

process, including the right to identify

individuals or roles to be included in the

planning process, the right to request

meetings and the right to request revisions

to the person-centered plan of care.

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(ii) The right to participate in establishing the

expected goals and outcomes of care, the

type, amount, frequency, and duration of

care, and any other factors related to the

effectiveness of the plan of care.

(iv) The right to receive the services and/or

items included in the plan of care.

(v) The right to see the care plan, including

the right to sign after significant changes to

the plan of care.

(c)(3) The facility shall inform the resident of

the right to participate in his or her treatment

and shall support the resident in this right.

The planning process must--

(i) Facilitate the inclusion of the resident

and/or resident representative.

(ii) Include an assessment of the resident’s

strengths and needs.

(iii) Incorporate the resident’s personal and

cultural preferences in developing goals of

care.

483.21

(b) Comprehensive Care Plans

(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





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the resident.

(C) A nurse aide with responsibility for the

resident.

(D) A member of food and nutrition services

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.


record review, the facility failed to revise

care plans for 3 of 31 residents with diet

changes, non-compliance with turning

and repositioning, and following diet

orders. (Residents 46, 73, and 111)

Findings include:

1. On 9/13/17 at 9:16 a.m., Resident 73's

record was reviewed. A new physician's

order, dated 7/19/17, indicated a diet

F 0280 F280 Right to Participate

Planning Care-Revise CP





practice?

·The nutrition care plan was

revised to indicate mechanically

altered diet for Resident #73.

·The at risk for skin breakdown

care plan for Resident #46 was

revised to indicate

non-compliance with turning and

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change to mechanical soft diet with thin

liquids. The MDS (Minimum Data Set)

dated 7/13/17 indicated no swallowing

disorder, no weight loss, and BIMS

(Brief Interview for Mental Status) was

not conducted.

On 9/13/17 at 10:00 a.m., Resident 73's

care plans were reviewed. Care plans last

reviewed/revised on 8/9/17 at 12:58 p.m.

by RN 3 were reviewed. Care plan

interventions indicated, but were not

limited to, "cue to continue eating, Reg

(Regular) diet thin liquids."

During an observation on 9/18/17 at 8:43

a.m., Resident 73's tray card at the

breakfast table indicated a mechanical

soft diet.

2. On 9/14/17 at 10:30 a.m., Resident



to Parkinson's disease. He had a BIMS

(Brief Interview for Mental Status) score

of 14 which indicates cognitively intact.

An MDS (minimum data set), dated

6/29/17, indicated Resident 46 was an

extensive assist of two for bed mobility.

A progress note, dated 6/12/17, indicated

that staff encouraged the resident to stay

off his back due to his pressure ulcer, and

that he was non-compliant at times.

repositioning.

·A care plan was revised to

indicate resident preference to

decline altered diet

recommendations for Resident

#111






·All residents that are

non-compliant with treatment

recommendations/physician

orders, or have altered diets have

the potential to be affected by the

alleged deficient practice.

·An audit was completed by

DNS/designee to ensure all

residents with documented

non-compliance with treatment

recommendations or altered diets

have accurately revised care

plans.







by RAI specialist/designee with

IDT regarding IDT care plan

review policy.

·The IDT will review physician

orders daily to ensure care plans

are revised for diet changes.

·The DNS/designee will review

progress notes daily to ensure





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the resident was encouraged to lay on his

side and was non-compliant with this

request.


that the resident was encouraged to lay

down on his side between meals, and was

not always compliant with this request.

The resident had a care plan indicating he

was at risk for skin breakdown, or further

breakdown related, but not limited to, a

history of pressure ulcers.

A care plan for Needs Assistance with

Activities of Daily Living including bed

mobility, with an approach of assist with

bed mobility as needed. The care plan

was not revised due to non-compliance

with turning and repositioning.

On 9/19/17 at 8:40 a.m., CNA 2

indicated Resident 46 was encouraged to

lay down after meals on his side in bed,

but was not always compliant with

staying on his side.

3. On 9/18/17 at 9:30 a.m., Resident



to, dysphagia, pharyngoesophageal phase.

A signed physicians order from 9/8/17

through 9/30/17, indicated she was on a

care plans are revised with any

documented non-compliance with

treatment recommendations.






·The SSD/designee will be


the Care Plan Updating Quality















employee.






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dysphagia 3 diet with nectar thickened

liquids with no straws. The resident's

BIMS (Brief Interview for Mental Status)

was a 15, which indicates no cognitive

impairment.

On 9/18/17 at 10:14 a.m., an observation

was made of Resident 111's room. Two

cups of thickened liquids were observed

on the bedside table with straws in both

cups. At 10:20 a.m., Student CNA 1

indicated she had just passed water on the

hallway including to Resident 111's room

. She further indicted she had put straws

in Resident 111's water cup.


the resident was currently on a dysphagia

3 diet with nectar thick liquids with no

straws, and that the resident is

non-compliant with her diet.


the resident is non-compliant with her

diet and refused to drink nectar thickened

liquids.

A progress note, date 9/15/17, indicated

the resident continued not to adhere to

her diet , especially to thickened liquid

orders.

The resident had a care plan for

nutritional status which included an





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approach to provide diet per MD order,

mechanical soft , nectar thickened

liquids, no straws.

The care plan was not revised due to the

resident being non compliant with her

diet.


a.m., the DON indicated that when

someone refused a meal or fluids, the

CNA notified the nurse on the hall, and

the nurse will document in the progress

notes, and the amount of food and fluid

consumption is recorded on the point of

care response form. She further indicated

that it will be discussed in the morning

team meeting, and that dietary will talk to

the resident about their preferences. She

said the care plan would be updated the

next business day.


p.m., the DON (Director of Nursing)

indicated care plans are updated during

morning meeting. During morning

meeting, the staff reviews the facility

activity report which shows any changes

and what has been documented. The IDT

(Inter Disciplinary Team) goes through

the facility activity report, including

orders. IDT reviews changes in therapy,

diet, etc, and update the care plans

Monday through Friday. If there are





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significant issues on holidays or

weekends an IDT note can be done over

the phone. The DON assigns certain

people to update care plans each day.

A policy revised in 4/2014 titled, "IDT

Care Plan Review" was provided by the

Nursing Consultant on 9/18/17 at 2:02

p.m. The policy indicated, "Care plan

problems, goals and interventions will be

updated based on changes in resident

assessment/condition, resident

preferences or family input."

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

483.21(b)(3)(ii)

SERVICES BY QUALIFIED PERSONS/PER

CARE PLAN

(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 0282

SS=D

Bldg. 00

Based on record review, observation, and

interview, the facility failed to ensure

services were provided according to the

plan of care for 2 of 31 residents

reviewed. A resident with a physician's

order for no straws was observed with

F 0282 F282 Services by Qualified

Persons/Per Care Plan





practice?

10/19/2017 12:00:00AM





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NEWBURGH, IN 47630

155273 09/19/2017


4255 MEDWELL DR

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straws at bedside and a resident's

dressings were not re-applied

immediately after a shower was

completed. (Residents 111 and 64)

Findings include:

1. On 9/13 17 at 8:30 a.m., Resident

111's clinical record was reviewed. The

signed physicians orders dated from

9/8/17 through 9/30/17 indicated the

resident was on a dysphagia 3 diet with

thickened liquids and no straws. The

resident had a care plan for nutritional

status that had an approach to provide

diet per MD order, mechanical soft,

nectar thickened, no straws. The

resident's BIMS(Brief Interview for

Mental Status ) was a 15, which indicates

cognitively intact.

On 9/18/17 at 10:14 a.m., an observation

was made of two cups with straws sitting

on Resident 111's bedside table. At

10:20 a.m., Student CNA 1 indicated she

had passed water on the hallway

including to Resident 111. The Student

further indicated she had spoken to the

Scheduler and wasn't given information

on any special restrictions for the

residents.

On 9/18/17 at 10:30 a.m., LPN 4

indicated she did not know Resident 111

·Resident #111 is receiving her

physician ordered diet and her

preference.

·Resident #64s is receiving

treatments per physician order.






·All residents with dietary

restrictions, and treatment orders

for impaired skin have the



·Staff were immediately

re-educated on location of

information regarding special

dietary restrictions and scope of

practice regarding treatment

changes







by DNS /designee with all

licensed nursing staff regarding

location of resident specific

information on Resident Profile,

and scope of practice for CNAs

regarding wound care.


completed daily by DNS/designee

to ensure all special dietary





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had an order for no straws, or how it was

communicated to the staff who passed

water. She further indicated it would be

on the resident's profile if there were any

special instructions. Resident 111's

profile was reviewed and indicated the

resident was not to have straws.

On 9/18/17 at 11:37 a.m., the Scheduler

was interviewed. She indicated that she

gave Student CNA 1 a list of the

residents. She further indicated she went

through the resident profiles to see if any

one had any special orders first, and told

her to double check with the nurse on the

hall.

2. During a random observation on

9/18/17 at 9:49 a.m., CNA 1 was

observed assisting Resident 64 with a

bath in the shower room. CNA 1 was

observed removing Resident 64 Kerlix

and dressings to right heel and right shin

to bathe him. CNA 1 indicated they

always remove the dressings before

Resident 64 takes a bath.

On 9/18/17 from 10:41 a.m. to 11:10

a.m., Resident 64 was observed with no

dressings on his right lower leg.


p.m. Resident 64 indicated RN 2 had

performed wound care to right lower leg

orders are being followed.


completed daily by DNS/designee

to ensure treatment orders are

being followed.








A Skin Management Quality















employee.






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4255 MEDWELL DR

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"about 15 minutes ago".



indicated if a dressing is intact when

going to shower, CNAs should leave

dressings on unless a nurse is present and

monitoring dressing removal. DON

further indicated if a dressing order is

daily with no order to leave open to air, it

must be put back on immediately by a

nurse.

Resident 64's medical record containing

the current physician orders and care

plans were provided by the DON on

9/18/17 at 4:05 p.m. and reviewed at that

time. Resident 64's current physician

orders indicated on 9/11/17 a new order

to apply non-adhesive foam to closed

diabetic ulcer on right heel. Secure with

Kerlix daily. Cleanse skin tear to right

anterior lower leg with wound cleanser.

Cover with Optifoam daily.

The MDS (Minimum Data Set) dated

6/11/17 indicated Resident 64 had

diabetic foot ulcers with applications of

dressings to feet. The MDS lacked a

BIMS (Brief Interview of Mental Status).

The facility was unable to provide a

policy regarding following physician's

orders and care plans.





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4255 MEDWELL DR

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3.1-35(g)(2)

483.25(b)(1)

TREATMENT/SVCS TO PREVENT/HEAL

PRESSURE SORES

(b) Skin Integrity -

(1) Pressure ulcers. Based on the

comprehensive assessment of a resident,

the facility must ensure that-

(i) A resident receives care, consistent with

professional standards of practice, to

prevent pressure ulcers and does not

develop pressure ulcers unless the

individual’s clinical condition demonstrates

that they were unavoidable; and

(ii) A resident with pressure ulcers receives

necessary treatment and services,

consistent with professional standards of

practice, to promote healing, prevent

infection and prevent new ulcers from

developing.

F 0314

SS=D

Bldg. 00



a resident received care for a pressure

ulcers in 1 of 4 residents reviewed. The

facility did not have preventative

measures in place to prevent further

decline and promote wound healing.

(Resident 22)

Findings include:

F 0314 F 314 Treatment SVCS To

Prevent/Heal Pressure Sores





practice?

·Resident 22 was provided a

low air loss mattress and

pressure reducing cushion for

chair.

·Treatment orders were

10/19/2017 12:00:00AM





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155273 09/19/2017


4255 MEDWELL DR

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On 9/11/17 at 11:13 a.m., Resident 22

was observed to be lying in bed on his

back. The resident was not on a air loss

mattress.

On 9/11/17 at 3:12 p.m., Resident 22 was

observed lying on his back with grab bars

on the bed. The resident was not on a

low air loss mattress.

On 9/18/17 at 9:37 a.m., the right ischial

tuberosity of Resident 22 was observed.

Resident 22 was lying on his back in bed.

No air loss mattress was observed on the

resident's bed. The pressure wound and

peri-wound area was red and the Wound

Nurse indicated the resident had returned

from the hospital on Saturday evening.

The wound nurse indicated she needed to

notify the resident's physician for orders

for treatment of the wound. The Wound

Nurse indicated she did not know why

the facility had not notified the physician

for treatment orders when the resident

returned on Saturday.

On 9/18/17 at 10:36 a.m., the Wound

Nurse indicated the measurements were

as followed: 2.6 cm (centimeter)(length)

x 2.2 cm (width) x 2.6 cm (depth.) She

indicated the wound on 9/11/17 was 2.2

cm x 2.4 cm x 0.2 cm.

On 9/18/17 at 11:01 a.m., Resident 22

obtained from the physician for

resident’s wound.

·Registered Dietitian made

recommendation as indicated by

her review of the resident’s

clinical record.

·Care plans have been updated

related to resident refusing to be

turned and repositioned every 2

hours.






·All residents that have

pressure ulcers have the potential


deficient practice.

·An audit of residents with

current pressure ulcers was

completed by DNS/designee to

ensure that treatment orders,

dietitian recommendations, low

air loss mattresses (as indicated),

and pressure reducing cushions

are in place.






·Licensed Staff will be

in-serviced by DNS/designee on

Skin Management Policy to

include low air loss mattresses

(as indicated) and pressure

reducing cushions, and





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OMB NO. 0938-0391




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was observed to be sitting on a chair. No

pressure reducing device was observed in

the seat.

On 9/13/17 at 4:34 p.m., Resident 22's

clinical record was reviewed. Diagnoses

included, but not limited to, paraplegia,

generalized muscle weakness, depressive

episodes, pneumonia, fracture of shaft of

right femur from motor vehicle accident,

and scoliosis.

The admission MDS (Minimum Data

Set) assessment indicated Resident 22

had a BIMS (Brief Interview for Mental

Status) of 15, indicating no cognitive

impairment. The MDS indicated the

resident was at risk for pressure ulcers,

and had an unstageable pressure injury on

admission to the facility on 6/26/17. The

MDS further indicated treatments

included pressure reducing device for the

bed, honor food preferences, pressure

ulcer care, application of nonsurgical

dressing, and application of

ointment/medications.

A "Pressure Ulcer" care plan, started

6/28/17 and reviewed/revised 9/11/17,

included, but was not limited to, the

following interventions:

Assess for pain, treat as ordered. Notify

physician for unrelieved or worsening

pain, dated 8/8/17.

Assess wound weekly, documenting

appropriate documentation

related to turning and

repositioning.

·Licensed staff have been

in-serviced on obtaining treatment

orders for new admission and

readmissions.

·The DNS/designee will audit

admission and readmission

reviews daily to ensure treatment

orders are obtained, low air loss

mattresses and pressure

reducing cushions are in place if

indicated.

·The IDT will ensure during

weekly nutrition meeting that the

dietitians recommendations

reflect the residents current

condition.






·The Wound Skin CQI Audit

Tool will be completed for six

months with audits being

completed once weekly for one

month and monthly for 5 months

by the DNS or designee. The

Skin Management CQI Audit Tool

will be reviewed monthly by the

CQI Committee for six months

after which the CQI team will

re-evaluate the continued need

for the audit. If a 95% threshold is

not achieved an action plan will








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measurements and description, dated

8/8/17.

Encourage resident to eat at least 75% of

meals, start date 8/8/17.

Float heels while in bed, start date 8/8/17.

Incontinent care as needed, start date

8/8/17.

Labs as ordered, start date 8/8/17.

Notify physician of worsening or change

in wound or for signs of infection, start

date 8/8/17.

Powered [name of mattress] air mattress,

start date 8/8/17.

Pressure reducing/redistribution cushion

in chair, start date 8/8/17.

Registered dietician to assess routinely,

start date 8/8/17.

Resident has wound on right ischial

tuberosity,start date 8/8/17.

Treatment as ordered,start date 8/8/17.

Turn and reposition every 2 hours,start

date 8/8/17.

Wound healing vitamins as ordered, start

date 8/8/17.

A progress note, dated 9/12/17 at 6:28

p.m., indicated the resident had been sent

to the hospital after choking on a piece of

hotdog at a restaurant while he was on

LOA (leave of absence) with his family.


p.m., indicated Resident 22 had returned

to the facility from the hospital. The note

termination of the responsible






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indicated the facility received a new order

for Amox-Clav (an antibiotic.)


a.m., indicated the resident had a

significant change due to his weight

being 108 lbs. The note was entered by

the dietary service manager.

The Registered Dietician note, dated

7/3/17 at 9:41 a.m., indicated the

resident's usual body weight was 139

pounds. The note indicated the resident

weight was 123 pounds with his

oral/nutritional intake (food) being

76-100%. The note further indicated the

resident's BMI (Body Mass Index) was

19.3.

Review of food intake from 8/1/17 to

9/1/17 indicated the resident received a

supplement twice on 8/3/17 and one (1)

time on 8/4/17. No further nutritional

supplements were documented.

The facility lacked any further

documentation by the Registered

Dietician.

The facility lacked documentation of the

resident being turned and repositioned

every 2 (two) hours or of the resident's

refusal.





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On 9/18/17 at 10:15 a.m., the DON

(Director of Nursing) indicated the

resident's weight was incorrect on 9/1/17.

The DON indicated she had spoke with

the dietary manager regarding the

documentation.

A telephone physician's order, dated

9/18/17 with no time listed, indicated the

resident was to have a low air loss

mattress to the bed, a Roho (a type of

pressure reducing pad) cushion in his

wheelchair, and the wound was to be

cleansed with Normal Saline, Collagen (a

protein dressing) applied, covered with a

Calcium Alginate (an absorbent) and a

borderfoam dressing daily and prn (as

needed) for soilage and dislodgement.

The current facility policy for skin

management, dated 9/2016 and obtained

from the Nursing Consultant on 9/18/17

at 2:02 p.m., included, but were not

limited to, the following:

All resident beds will have a pressure

reducing mattress.

All resident who utilize a wheelchair will

have a pressure reducing cushion in the

chair.

Treatment orders would be obtained.

All residents who require assistance with

mobility will be encouraged and assisted

to turn and reposition at a minimum of

every 2 hours.





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A care plan would be developed specific

to the resident's needs, including

prevention interventions.

A plan of care would be initiated to

include resident specific risk factors with

appropriate interventions.

3.1-40(a)(2)

3.1-40(a)(3)

483.45(d)(e)(1)-(2)

DRUG REGIMEN IS FREE FROM

UNNECESSARY DRUGS

483.45(d) Unnecessary Drugs-General.

Each resident’s drug regimen must be free

from unnecessary drugs. An unnecessary

drug is any drug when used--

(1) In excessive dose (including duplicate

drug therapy); or

(2) For excessive duration; or

(3) Without adequate monitoring; or

(4) Without adequate indications for its use;

or

(5) In the presence of adverse

consequences which indicate the dose

F 0329

SS=D

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should be reduced or discontinued; or

(6) Any combinations of the reasons stated

in paragraphs (d)(1) through (5) of this

section.

483.45(e) Psychotropic Drugs.

Based on a comprehensive assessment of a

resident, the facility must ensure that--

(1) Residents who have not used

psychotropic drugs are not given these

drugs unless the medication is necessary to

treat a specific condition as diagnosed and

documented in the clinical record;

(2) Residents who use psychotropic drugs

receive gradual dose reductions, and

behavioral interventions, unless clinically

contraindicated, in an effort to discontinue

these drugs;

Based on observation, record review, and

interview, the facility failed to ensure

residents were free from unnecessary

medications for 1 of 5 residents

reviewed. A behavior monitoring

program was not established by the

facility. (Resident 57)

Findings include:

On 9/13/17 at 8:57 a.m., Resident 57 was

observed walking in the hall on a locked

secured unit.

F 0329 F329

DRUG REGIMEN IS FREE

FROM

UNNECESSARY DRUGS





practice?

·A care plan is in place to

monitor depressive symptoms for

Resident #57.

·Resident #57 no longer

receives anti-anxiety medication

10/19/2017 12:00:00AM





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On 9/13/17 at 9:52 a.m., the clinical

record for Resident 57 was reviewed.

Resident 57's diagnoses included, but not

limited to, major depressive disorder,

non-Alzheimer's dementia, and alcohol

dependence.

A quarterly MDS (Minimum Data Set),

dated 6/3/17, indicated Resident 57 had

active diagnoses including, but not

limited to, non-Alzheimer's dementia,

alcohol dependence, and depression. The

MDS further indicated the resident had

received an antidepressant for 7 (seven)

out of 7 days during the assessment.

The most recent physician's

recapitulation orders, dated 9/1/17

through 9/30/17, included but were not

limited to,

Sertraline (an antidepressant) 100 mg

(milligram) tablet 1 (one) po (orally)

daily for depression and

Sertraline 50 mg tablet 1 po daily for a

total dose of 150 mg, ordered 1/30/17.

Resident 57 also had a physician's order,

dated 4/22/17, for Lorazepam (an

antianxiety) 0.5 mg tablet 1 po (orally)

every 8 hours as needed for anxiety.

The Lorazepam had been discontinued on

7/10/17. The facility lacked

documentation of a behavior monitoring

program from April 22, 2017 through

July 10, 2017.







diagnosed with depression or

anxiety symptoms have the




SSD/designee to identify all

residents that are being treated

for anxiety or depression

symptoms to ensure behavior

tracking is in place.






·IDT will review all new orders

for anti-anxiety or anti-depression

medication to ensure appropriate

behavior monitoring is in place.


by RDCS/designee with IDT

regarding behavior monitoring

policy.






·The SSD/designee will be






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On 9/18/17 at 2:15 p.m., the RN 3

indicated the resident should have a

behavior monitoring form on the chart for

the antidepressant and the antianxiety

medications.

The facility lacked documentation of

behavior monitoring program.

The current facility policy, dated 1/16

and obtained from the DON (Director of

Nursing) on 9/18/17 at 3:00 p.m.,

indicated all residents who were taking

(either routinely or as needed)

antipsychotics, anxiolytics,

sedative/hypnotics, or anticonvulsant

medications (used for behaviors) were to

have a behavior monitoring program.

3.1-48(a)(3)

the Behavior Management Quality















employee.


483.45(b)(2)(3)(g)(h)

DRUG RECORDS, LABEL/STORE DRUGS

& BIOLOGICALS

The facility must provide routine and

emergency drugs and biologicals to its

residents, or obtain them under an

agreement described in §483.70(g) of this

part. The facility may permit unlicensed

personnel to administer drugs if State law

F 0431

SS=E

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permits, but only under the general

supervision of a licensed nurse.

(a) Procedures. A facility must provide

pharmaceutical services (including

procedures that assure the accurate

acquiring, receiving, dispensing, and

administering of all drugs and biologicals) to

meet the needs of each resident.

(b) Service Consultation. The facility must

employ or obtain the services of a licensed

pharmacist who--

(2) Establishes a system of records of

receipt and disposition of all controlled drugs

in sufficient detail to enable an accurate

reconciliation; and

(3) Determines that drug records are in

order and that an account of all controlled

drugs is maintained and periodically

reconciled.

(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.

(h) Storage of Drugs and Biologicals.

(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.

(2) The facility must provide separately

locked, permanently affixed compartments





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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.

Based on observation, record review,

and interview, the facility failed to

follow pharmacy procedures in

storing and dispensing medication for

4 of 7 residents medications

observed being administered.

Resident 12 and Resident 78 were

unavailable for the medication

administration, and the medications

were locked in the medication cart to

administer at a later time. The

medication carts had an outdated

bottle of eye drops in 1 of 3

medication carts reviewed. (Resident

12, Resident 16, Resident 78,

Resident 111, Willows medication

cart)

Findings include:


at 7:24 a.m., QMA 1 dropped

Resident 16's medication onto the

medication cart counter. QMA 1

scooped up the medication with her

bare hand and placed it back into the

medication cup. QMA 1 did not

F 0431 F431 Drug Records,

Label/Store Drugs &

Biologicals





practice?

·Staff preform proper hand

hygiene prior to administering

medications.

·Medications are

destroyed/disposed of per the

pharmacies recommendations.

·Residents #12 and #78

medications are administered per

the pharmacies

recommendations.

·Lantanoprost 0/005% (eye

drops), were destroyed/disposed

of per the pharmacies

recommendations.







administered medications have

the potential to be affected by the

10/19/2017 12:00:00AM





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DEFICIENCY)

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COMPLETION


NEWBURGH, IN 47630

155273 09/19/2017


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00

perform hand hygiene after scooping

up the medication from the

medication cart.


at 7:56 a.m., LPN 4 dropped

Resident 111's medication on the

floor, scooped up the medication

from the floor into a tissue, and

tossed it into a trash bin. LPN 4 did

not perform hand hygiene after

tossing the medication into the trash

bin.

During an interview with the DON

(Director of Nursing) on 9/18/17 at

2:35 p.m., she indicated she was

going to pull the medication out of the

trash bin to dispose of it properly.


at 8:23 a.m. of the Willows

medication cart, 2 (two) cups of

medications were found in the top

drawer. Resident 12 and Resident

78's last names were labeled on the

cups. LPN 3 indicated she had

prepared the medications to

administer at a later time and locked

them in the medication cart. She

indicated Resident 12 and Resident

78 were not in their rooms to have

the medication administered.


at 8:26 a.m., an box of Lantanoprost


·An audit was completed to

ensure medications are not past

the expiration date and

medications were destroyed/

disposed of per policy as

indicated by the audit.

·Licensed staff were in-serviced

on medication administration and

proper destruction/disposal of

medications.






·Observational rounds were

completed by the DNS/designee

with all staff that administer

medications to ensure

medications are being

administered per pharmacies

commendations.


completed daily to ensure

medications are administered per

pharmacies recommendations.

·Expiration dates will be

checked weekly on eyedrops to

ensure compliance.

·An in-service was completed

by DNS/designee with all nursing

staff regarding medication pass

procedure and medication

storage.








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0/005% (eye drops), located in the

top drawer of the Willows medication

cart, was labeled with an open date

of 7/17/17. LPN 3 indicated the

medication was outdated and was

only good for 30 (thirty) days after the

open date.

During an interview with the DON

(Director of Nursing) on 9/19/17 at

8:05 a.m., she indicated the facility

followed pharmacy recommendations

for medication storage and disposal.

During a review of the current policy,

" Medication Pass Procedure,"

revised 12/2016, on 9/18/17 at 2:00

p.m. , it indicated all or in part, but

not limited to: Wasted or dropped

medication destroyed properly and

documented per policy.

During a review of the current policy

of [Name of Pharmacy], revised

1/1/13, on 9/19/17 at 7:50 a.m., it

indicated all or in part, but not limited

to: Facility staff should destroy and

dispose of medication in accordance

with Facility policy and Applicable

Law and applicable environmental

regulations

During a review of the manufacturer's

recommendations on 9/19/17 at 8:25

a.m., it indicated all or in part, but





the Medication Storage Quality

Assurance Tool and medication

administration observations

weekly times 4 weeks, bi-monthly

times 2 months, monthly times 4

and then quarterly until continued











employee.






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not limited to: Discard unused portion

6 (six) weeks after opening.

During a review of the [Name of

Pharmacy]'s contract, provided by the

Nursing Consultant on 9/19/17 at

9:00 a.m., indicated the following

storage recommendations: the

medication Lantanoprost (eye drops)

storage recommendations are as

follows: Refrigerate until ready to

use. Date when opened. Discard

unused portion 6 (six) weeks after

opening.

3.1-25(m)

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

INFECTION CONTROL, PREVENT

SPREAD, LINENS

(a) Infection prevention and control program.

The facility must establish an infection

prevention and control program (IPCP) that

must include, at a minimum, the following

elements:

(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

F 0441

SS=D

Bldg. 00





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§483.70(e) and following accepted national

standards (facility assessment

implementation is Phase 2);

(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

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.





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(4) A system for recording incidents

identified under the facility’s IPCP and the

corrective actions taken by the facility.

(e) Linens. Personnel must handle, store,

process, and transport linens so as to

prevent the spread of infection.

(f) Annual review. The facility will conduct

an annual review of its IPCP and update

their program, as necessary.



infection control procedures were

followed for 2 of 9 residents reviewed for

care and 2 staff members observed

administering medications. Gloves were

not removed, hand hygiene was not

completed, and pericare was not provided

correctly. (Resident 16, Resident 64,

QMA 1, and LPN 4)

Findings include:

1. On 9/17/16 at 9:06 a.m., CNA 1 and

CNA 3 were observed to transfer

Resident 16 to her bed and perform

pericare. CNA 1 was observed to have a

bandage on her left hand. CNA 1

indicated she had cut her hand and had 10

(ten) sutures in it. Both CNAs were

observed to wash their hands and apply

gloves. Resident 16's shoes were

removed by the CNAs. The Hoyer lift

was placed in position and attached to the

F 0441 F441 Infection Control, Prevent

Spread, Linens





practice?

·Resident # 16's labial area was

cleaned and proper hand hygiene

was followed.

·Proper hand hygiene is

performed by staff after picking

medications up off the medication

cart or floor.

·CNA’s will not provide resident

care if proper hand hygiene

cannot be completed.

·Resident # 64’s wound

treatment was completed and the

dressing was applied.







10/19/2017 12:00:00AM





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sling. Resident 16 was then transferred

to her bed, CNA 3 was observed to

obtain a basin of water and place it on the

overbed table. CNA 1 was observed to

obtain a wet washcloth, apply soap and

wash the resident's groin. CNA 1 did not

wash the resident's labial area but drug

the cloth across the groins and upper

thighs. CNA 1 obtained a clean

washcloth to rinse the resident using the

same technique. The resident was dried

and assisted to her right side. CNA 1

obtained a clean washcloth, washed and

rinsed the resident's rectal area and

buttocks. The resident was dried. CNA

1 obtained a clean brief and placed it

under the resident. The resident was

assisted to her left side and the brief was

applied completely. The resident's slacks

were applied and the resident was

transferred to her wheelchair using the

Hoyer lift. CNA 1 had placed the

resident's shoes on her overbed table.

Both CNAs applied the resident's shoes.

CNA 3 removed her gloves and

performed hand hygiene. CNA 1

removed her gloves and washed her

hands, obtained the bags of dirty linen

and trash and exited the room.

On 9/18/17 at 2:30 p.m., CNA 3

indicated hands hygiene should be

performed before and after care and when

going from dirty to clean. CNA 3


deficient practice.


by the DNS/designee for all staff

regarding appropriate infection

control practices.


by the DNS/designee for all

nursing staff regarding on

perineal care.







completed by DNS/designee on

all shifts daily to ensure proper

hand washing technique is

performed.



ensure wound treatments are in

place



ensure proper perineal care is

provided.

·CNA’s will not provide resident

care if proper hand hygiene

cannot be completed.










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indicated a clean washcloth should be

used on the groin area and another clean

washcloth should be used on the periarea.

CNA 3 further indicated the resident's

labias should be separated and washed.


at 7:24 a.m., QMA 1 dropped a

medication onto the medication cart

counter. No hand hygiene or

sanitizing of the medication cart

counter was observed. QMA 1

scooped up the medication with her

bare hand and placed it back into the

medication cup. QMA 1 did not

perform hand hygiene after scooping

up the medication from the

medication cart.


at 7:56 a.m., LPN 4 dropped a

medication on the floor, scooped up

the medication from the floor into a

tissue, and tossed it into a trash bin.

LPN 4 did not perform hand hygiene

prior to removing the medication from

card or after tossing the medication

into the trash bin.

During an interview with LPN 5 on

9/18/17 at 2:13 p.m., LPN 5 indicated

if a medication was dropped, staff

was to discard the medication and if it

was a narcotic medication another

nurse would be needed to assist in

discarding. She indicated staff was to



the Infection Control Quality






consecutive quarters. The

DNS/Designee will responsible

for the completion of observation

rounds daily for 4 weeks and

weekly for 6 months. The results

of these audits and observations

will be reviewed by the QAPI

committee overseen by the ED. If

threshold of 100% is not

achieved, an action plan will be

developed. Deficiency in this




employee.






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perform hand hygiene prior to

administering medications and

between residents.

4. 9/18/17 at 9:49 a.m., CNA 1 was

observed washing right hand and tips of

left hand prior to giving a shower then

applying gloves to both hands. CNA 1

was observed to have Kerlix dressing

wrapped around her left hand. CNA 1

indicated she had cut her hand and now

had 10 (ten) stitches. CNA 1 was

observed removing Resident 64's Kerlix

and dressings to right heel and right shin.

CNA 1 then removed Resident 64 shirt,

tubigrips, and shorts. CNA 1 placed dirty

clothes in plastic bag, then adjusted the

thermostat in the room before washing

Resident 64 back. CNA 1 was then

observed removing gloves and washing

right hand and tips of left hand with soap

and water.

On 9/18/17 from 10:41 am to 11:10 a.m.,

Resident 64 was observed with no

dressings on his right lower leg.


p.m., Resident 64 indicated RN 2 had

performed wound care to right lower leg

"about 15 minutes ago."



indicated if a dressing was intact when





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going to shower, CNAs should leave

dressing on unless a nurse was present

and monitoring dressing removal. The

DON further indicated if a dressing order

was daily with no order to leave open to

air, it must be put back on immediately

by a nurse.

Resident 64's medical record including

physician's current orders and care plans

were provided by the DON on 9/18/17 at

4:05 p.m.. Resident 64 current

physician's orders indicated on 9/11/17 a

new order to "apply non-adhesive foam

to closed diabetic ulcer on right heel.

Secure with Kerlix daily. Cleanse skin

tear to right anterior lower leg with

wound cleanser. Cover with optifoam

daily."

The facility was unable to provide current

policy regarding CNA scope of practice

regarding removal of wound dressings.

During a review of the current policy,

"Hand Hygiene," on 9/19/17 at 10:57

a.m., it indicated: "... Five moments for

hand hygiene...Before touching a patient,

before clean/aseptic procedure, after body

fluid exposure risk, after touching a

patient, after touching patient

surroundings."

3.1-18(b)





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3.1-18(l)

483.90(i)(5)

SAFE/FUNCTIONAL/SANITARY/COMFOR

TABLE ENVIRON

(i) Other Environmental Conditions

The facility must provide a safe, functional,

sanitary, and comfortable environment for

residents, staff and the public.

(5) Establish policies, in accordance with

applicable Federal, State, and local laws and

regulations, regarding smoking, smoking

areas, and smoking safety that also take into

account non-smoking residents.

F 0465

SS=E

Bldg. 00

Based on observation, interview and


the environment was clean and free from

disrepair. Walls were observed to be

gouged and scuffed, urine odors observed

in rooms and hallways, dining room

chairs observed to be soiled and stained,

and black substances observed around

base boards on 3 of 6 halls observed.

(Rooms 151, 152, 157, 158, 159,

Cottages Unit, D Hall, E Hall, Main

Dining Room)

Findings include:

1. On 9/11/17 at 11:33 a.m., the Cottages

(locked unit) had a strong urine odor

noted.

F 0465 F465

Safe/Functional/Sanitary/Comf

ortable Environment





practice?

·The Cottage (locked unit) has

been cleaned and sanitized by

housekeeping and is free of

odor.

·The dining room chairs have

been cleaned and are free of

stains.

·The bathroom shared by

rooms157 and 158 has been

cleaned and sanitized and is free

of odors and the base board and

10/19/2017 12:00:00AM





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On 9/11/17 at 1:52 am, the same was

observed.

2. On 9/12/17 at 9:52 a.m., the dining

room chairs were observed to be soiled

and stained in Main Dining Room.

On 9/18/17 at 11:18 a.m., the same was

observed.

3. On 9/11/17 at 3:22 p.m., Room

151/152 bathroom was observed to have

a urine odor and visible black substance

around bottom of base boards. This

bathroom is shared by 4 residents.

On 9/18/17 at 11:26 am, the same was

observed.

4. On 9/12/17 at 10:16 a.m., Room

157/158 bathroom was observed to have

a black substance around bottom of base

boards and soiled floors.


observed. Bathroom also had foul odor,

toilet paper rolls were on the floor, and a

handwritten sign was on the door that

stated, "Do not use this toilet, it is not

working, use shower room toilet." This

bathroom is shared by 3 residents.

5. On 9/11/17 at 3:24 p.m., Room 158 B

was observed to have gouges in wall

behind bed.


observed.

floor has been cleaned/replaced

and is free of any substances.

The toilet paper rolls were

discarded, the toilet is operational

and the sign has been removed.

·The bathroom shared by

rooms151 and 152 has been

cleaned and sanitized and is free

of odors and the base board has

been cleaned/replaced and is free

of any substances.

·Maintenance repaired the

gouges in the wall behind the bed

B in room 158.

·Maintenance repaired the

scratches and gouges in the wall

behind the recliners in room 159.

·Halls D and E have been

cleaned and sanitized and are

free of odor.








deficient practice.

·The ED/ designee will

in-service all staff regarding a

safe, comfortable and sanitary

environment.

·The ED/designee in-serviced

the housekeeping and

maintenance staff on cleaning

schedules and maintenance

request.

·Inspection of all rooms was

conducted by ED/designee to

identify areas of non-compliance.





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6. On 9/12/17 at 9:50 a.m., Room 159

was observed to have the wall behind the

recliners scratched up and gouged.


observed.


at 9:04 a.m., a strong urine odor was

noted on Halls D and E.


at 9:27 a.m., a strong urine and feces

odor was noted on Hall D.


at 8:08 a.m., a strong urine odor was



at 2:22 p.m., a strong urine odor was



9:23 a.m., the Administrator indicated

work orders are kept at the nurses

station for staff to fill out when they

see a maintenance issue. The

Administrator and The Maintenance

Supervisor get a copy of work order.

The Maintenance supervisor

performed daily environmental walk

through's and randomly selected

rooms to look at.







·The ED/ designee will

in-service all staff on a safe,

comfortable and sanitary

environment.

·Daily rounds will be conducted

by the ED/designee to ensure

rooms are safe, comfortable and

sanitary.






·The ED/designee will be


the Laundry, Housekeeping,

Cleaning Schedule Quality















employee.





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9:39 a.m., the Housekeeping

Supervisor indicated rooms are deep

cleaned when residents are

discharged. There are 3 (three)

housekeepers per day and each are

assigned a room to deep clean, as

well as a regular cleaning schedule.

Deep cleaning includes: cleaning

walls, vertical surfaces, bed frames,

baseboards, commodes, and walls.

Everything in room and bathroom

should be cleaned during a deep

clean. Regular cleaning includes:

bedside tables, legs, horizontal

surfaces, bed lights, televisions,

picture frames, and window sills. The

dining room is to be deep cleaned

weekly - walls, tables, chairs, and

legs.

A current policy titled,

"Housekeeping" was provided by the

Administrator on 9/18/17 at 3:51

p.m.. This policy indicated, "The

Housekeeping department shall

maintain a clean, orderly, and

sanitary environment within the

facility.

The facility was unable to provide

current maintenance policy.

3.1-19(f)






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printed: 10/13/2017 department of health and …-cpr skills validations were initiated immediately...

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