printed: 12/21/2016 department of health and …printed: 12/21/2016 form approved omb no. 0938-0391...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

12/21/2016PRINTED:

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

SHELBYVILLE, IN 46176

155735 11/15/2016

ASHFORD PLACE HEALTH CAMPUS

2200 N RILEY HWY

00

F 0000

Bldg. 00

This visit was for a Recertification and

State Licensure Survey. This visit

included a State Residential Licensure

Survey. This visit included the

Investigation of Complaint IN00207707

Complaint IN00207707-Substantiated.

No deficiencies related to the allegations

are cited.

Survey dates: November 3, 4, 7, 9, 10, 14

&15, 2016

Facility number: 004268

Provider number: 155735

AIM number: 200504460

Census bed type:

SNF: 19

SNF/NF: 36

Residential: 28

Total: 83

Census payor type:

Medicare: 13

Medicaid: 27

Other: 15

Total: 55

These deficiencies reflect State findings

cited in accordance with 410 IAC

F 0000 Preparation or execution of this plan

of correction does not constitute

provider admission or agreement

related to the truth of the facts

alleged or conclusions set forth on

the Statement of Deficiencies. The

Plan of Correction is prepared and

executed solely because it is

required by the position of State

Law. The Plan of Correction is

submitted in order to respond to the

deficiencies cited during Indiana

State Department of Health

Recertification and State Licensure

Survey November 15, 2016.

Please accept this plan of correction

as the provider’s credible allegation

of compliance. The provider

respectfully requests a desk review

with paper compliance to be

considered in establishing that the

provider is in substantial

compliance.

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: YUO311 Facility ID: 004268

TITLE

If continuation sheet of 73

(X6) DATE




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16.2-3.1.

Quality review completed by 30576 on

November 18, 2016

483.13(c)(1)(ii)-(iii), (c)(2) - (4)

INVESTIGATE/REPORT

ALLEGATIONS/INDIVIDUALS

The facility must not employ individuals who

have been found guilty of abusing,

neglecting, or mistreating residents by a

court of law; or have had a finding entered

into the State nurse aide registry concerning

abuse, neglect, mistreatment of residents or

misappropriation of their property; and report

any knowledge it has of actions by a court of

law against an employee, which would

indicate unfitness for service as a nurse aide

or other facility staff to the State nurse aide

registry or licensing authorities.

The facility must ensure that all alleged

violations involving mistreatment, neglect, or

abuse, including injuries of unknown source

and misappropriation of resident property

are reported immediately to the

administrator of the facility and to other

officials in accordance with State law

through established procedures (including to

the State survey and certification agency).

The facility must have evidence that all

alleged violations are thoroughly

investigated, and must prevent further

potential abuse while the investigation is in

progress.

F 0225

SS=D

Bldg. 00

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YUO311 Facility ID: 004268 If continuation sheet of 73




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The results of all investigations must be

reported to the administrator or his

designated representative and to other

officials in accordance with State law

(including to the State survey and

certification agency) within 5 working days of

the incident, and if the alleged violation is

verified appropriate corrective action must

be taken.

Based on interview and record review,

the facility failed to ensure a resident's

injury of unknown source was reported

immediately to the administrator of the

facility, and also failed to thoroughly

investigate an allegation of a resident to

resident altercation for 3 of 3 residents

reviewed for abuse. (Resident 13

Resident 14 and Resident 41)

Findings include:

1.) The clinical record for Resident 14

was reviewed on 11/7/16 at 9:00 a.m.

The diagnoses for Resident 14 included,

but were not limited to: dementia and

delirium.

The 6/3/16 Incident Report, submitted to

the ISDH (Indiana State Department of

Health) read, "Staff noted bruising to

arms and underneath eyes. The resident

indicated an employee caused the

bruising while it was dark...An

investigation was initiated immediately

upon notification of the

allegation...family and physician

F 0225 F225

What corrective action(s) will

be accomplished for those

residents found to have been

affected by the deficient

practice?

The psychosocial needs of

resident #13 and #41 were

reviewed and no negative

outcomes including emotional

distress have been observed.

Resident #13 was assessed by

the Nurse Practitioner of the

Psychological services group.

In light of the resident’s ongoing

restlessness with psychomotor

agitation and wandering throughout

the facility, the Nurse Practitioner

determined that the current

medications she was receiving were

the most appropriate and least

restrictive dose in managing her

behavioral symptoms. The resident

is without signs or symptoms of

negative outcomes as related to the

current medication regimen.

The resident to resident interaction

in the findings of the 2567L has been

12/15/2016 12:00:00AM





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notified...The physician examined the

resident. The (name of local police

department) was notified of the allegation

and met with the Executive Director

(ED) Case (sic) 6/2/16..." The report

indicated CRCA (Certified Resident Care

Assistant) 9 and LPN (Licensed Practical

Nurse) 10 were suspended pending

outcome of the investigation and

subsequently discharged from

employment. The report read,

"Employee (name of LPN 10), LPN did

not take the necessary steps to ensure the

reporting and investigation of a resident

injury. A resident injury occurred while

under the care of the employee. (Name

of LPN 10) was discharged from

employment June 8, 2016. The conduct

of employee (name of CRCA 9), CNA

(Certified Nursing Assistant also known

as CRCA) does not meet the expectations

and education example required by the

employer. A resident injury occurred

while under the care of the employee.

There is potential that the employee's

care practices may have contributed to

the injury. (Name of CRCA 9) was

discharged from employment June 8,

2016."

The ED provided the investigative file for

the above incident on 11/7/16 at 9:39

a.m. At this time he stated, "The best I

can say is both employees had the

reviewed with the ED, DHS, and

Director of Social Services.

Education has been provided with

regard to ensuring completion of a

thorough investigation of resident

complaints of resident to resident

interactions [that may be construed

as resident to resident

altercations/abuse] and thorough

assessment prior to initiating

psychopharmacological

interventions. Since this interaction,

there have been no further resident

to resident interactions involving

Resident #13.

Resident #14 discharged from

the campus 10/02/2016 prior

to the certification survey.

How other residents having

the potential to be affected

by the same deficient

practice will be identified and

what corrective action(s) will

be taken?

All residents have the

potential to be affected by the

same alleged deficient

practice. Additionally,

residents with behavioral

symptoms/target behaviors or

who are involved in resident

to resident interactions have

the potential to be affected by

the same alleged deficient

practice. The resident to resident





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potential to be involved in what

happened to her....I did not substantiate

abuse."

The file included a Timeline of Events

and Communication. The timeline read,

"Executive Director was notified of

incident and initiated investigation at

2pm," on 6/2/16.

The file included a 6/2/16 typed

statement of CRCA 1. It read, "On

Thursday June 2nd, I (name of CRCA 1)

walked into (name of Resident 14's)

room with (name of CRCA 10). I went

over to (name of Resident 14's) bed and

go (sic) her dressed and as I put her in her

wheel chair I noticed blood on her sheets.

I told (name of CRCA 10) to come look

at (name of Resident 14). Her eyes had

bruises and what looked to be dried up

blood on her nose by her eyes. I then

lifted her sleeves on her arms to check

her for sores. (Name of Resident 14) had

bruises all up and down her arms. She

had dried blood on her arm. I then got

her up and took her to the bathroom. Got

her hair brushed, glasses on, and hearing

aid in then took her to breakfast. After

breakfast I laid her down. Before lunch I

got her back in her chair and she did not

need to use the bathroom so I took her to

(name of Certified Resident Medical

Assistant 2) to get medicine. I told

interaction in the findings of the

2567L has been reviewed with the

ED, DHS, and Director of Social

Services. Education has been

provided with regard to ensuring

completion of a thorough

investigation of resident complaints

of resident to resident interactions

[that may be construed as resident

to resident altercations/abuse] and

thorough assessment prior to

initiating psychopharmacological




Resident #13.

What measures will be put

into place or what systemic

changes will be made to

ensure that the deficient

practice does not recur?

Training for employees on

“Abuse, Neglect, &

Exploitation Procedural

Guidelines” and “Accident &

Incident Reporting

Guidelines” will be completed

by 12/15/2016.

Dementia training for staff is

completed to address residents with

Dementia and Dementia-Like

diagnosis and how to respond to

their behavioral symptoms.

Additionally, inservicing and

education has been done with

department leaders with regard to

investigation of allegations of abuse





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Assistant 2) around 1:30 about (name of

Resident 14's) bruises."

An interview was conducted with CRCA

1 on 11/7/16 at 11:50 a.m. She stated, "I

went in her room with (name of CRCA

10). I took off her gown and there was

dried blood on her left arm, a stream of it.

Her glasses were off. She never took her

glasses off. She had bruises on each side

of her nose, like glasses had been shoved

down, and blood. She had bruises down

both arms, but the left was worse....She

had geri sleeves on at the time, and when

I took them off is when I noticed the

blood. I was scared at this point. Later

in the day, when I talked to (name of

Certified Resident Medical Assistant 2)

about it and (name of LPN 14) went in

and seen (sic) it all. There was blood on

the sheet, just drops. I saw her bruising

about 6:30 or 7:00 a.m. She was one of

the first residents we got up....We got her

up and it was a couple hours later when

we told the nurse. It's kind of hectic in

the morning, no excuse, but it was a

couple hours before it was taken care

of....She refused to let you have her

glasses, so if you tried to take them, she'd

jerk them back on her face, but it never

left a mark. I don't think the bruising on

her arm could have been from her

behaviors. It was all the way from the

and investigations of resident to

resident interactions/allegations.

Resident and staff interviews were

conducted with no further negative

findings.

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 following audits and/or

observations will be

conducted two (2) times per

week for eight (8) weeks, then

monthly for four (4) months

to ensure compliance:

1.Interview of 5 staff

members regarding any

allegations of abuse, injuries

of unknown origin, or resident

to resident

interactions/allegations that

have been made; 2. A

thorough investigation,

including an assessment of

the resident is complete for

any allegation of abuse or

injury of unknown origin; 3.

Implementation and

monitoring of the “Abuse,

Neglect, and Exploitation

Procedural Guidelines” and

“Accident & Incident





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top of her arm to her thumb. It was a few

hours before I told anyone about the

bruising and blood, not right away....

(Name of Resident 14) had never accused

staff of hurting her before. She kept

saying the same story. Something

definitely happened...."


statement of CRCA 10. It read, "After

(name of CRCA 1) go (sic) (name of

Resident 14) off the toilet I asked where

her bed sheets were and she said they had

blood on them. I asked from where and

at that time we were looking on her and

saw bruising on the top of her nose and I

told (name of CRCA 1) it couldn't be

from that and that's when we lifted her

sleave (sic) a little and saw dry blood on

what looked like a skin tear."

A telephone interview was conducted

with CRCA 10 on 11/7/16 at 2:44 p.m.

She stated, "When I walked in there, she

had a bruise on her nose identical to

where her glasses rested. She even slept

in her glasses. She had an oval shaped

bruise on her left arm, covering 3 or 4

inches, right on top of her arm. She used

to put her arm in her bed rail." She

explained what she meant by her typed

statement that referenced "it couldn't be

from that" was the location of the blood

on the sheets being in the middle of the

Reporting Guidelines” will be

documented on Customer

Concern Forms. Customer

Concern Forms will be

reviewed five times weekly by

the Social Service Director or

designee.Results of the audit and

observations will be reported,

revivewed and trended for

compliance thru the campus

Quality Assurance Committee for

a minimum of 6 months then

randomly or as noncompliance is

identified thereafter for further

recommendations.





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bed, so she didn't think it could be from

her glasses. "This was 6:30 to 7:30 a.m.,

before breakfast. I did not tell anyone

about the bruising or blood right away. I

wasn't taking care of her that day. (Name

of CRCA 1) was....As far as behaviors,

she would stick her arm in between the

side rails and move it up and down. We

would try to take her glasses off to put

her shirt on and she would jerk them back

on her face, but it never left bruising or

tears."

The 6/2/16 MD Note read, "I was asked

to assess the patient. The patient is

alleging abuse...She cannot really give

much history, but says that a nurse hurt

her last night. She cannot identify who

this was. She alleges that she was

grabbed by the arms. Reading through

the nurse's notes, the patient was

apparently agitated and hitting the side

rails with her arms and manipulating her

glasses in a somewhat forceful way. I

went and saw the patient. She continues

to allege that she was hurt....Examination

reveals that she does have two tiny

superficial lacerations of the bridge of the

nose where the glasses rest and there is

some minimal bruising in that area as

well. Her forearms are both bruised, but

not particularly tender. She moves her

joints without difficulty. She is on

aspirin. Assessment: 1. Alleged abuse





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with some bruising..."


with Physician 15 on 11/7/16 at 2:43 p.m.

He stated, "...She said she was hurt by the

nurse, had a couple tiny lacerations

across the bridge of her nose, bruising

bilaterally, nothing I thought to be serious

injuries. It could be consistent with

someone yanking on her arms or pushing

her glasses. I can't say for certain...It

could be that someone pulled her by her

arms, but she was pretty consistent in her

complaints that someone hurt her. She

said several times someone pulled her by

the arms. She never made accusations

like this before. The lacerations could

be caused from anything that had her

glasses pushed against her face. The

bruising on the arms could have been

from the side rail....I think it's reasonable

what she said happened happened, as far

as someone grabbing her arms....I think

either explanation is possible, one not

more than other, but she never

complained about abuse before. I was

her doctor for 3 to 4 years. Her demeanor

at the time was angry and tearful. That

was common for her. She seemed more

agitated than at other times. It seemed to

me she believed what she was telling me

was correct."





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The Abuse and Neglect Procedural

Guidelines was provided by the ED on

11/7/16 at 1:00 p.m. It read, "Injuries of

unknown source-means an injury that

occurs when both of the following

conditions are met: The source of the

injury is not observed by any person or

the source of the injury could not be

explained by the resident AND The

injury is suspicious in nature because of

the extent of the injury or the location of

the injury...Identification...Any person

with knowledge or suspicion of suspected

violations shall report immediately,

without fear of

reprisal...IMMEDIATELY notify the

Executive Director....Investigation:

...Refer to the Incident and Accident

Program for investigation procedures."

The Accident and Incident Reporting

Guidelines policy was provided by the

ED on 11/10/16 at 9:55 a.m. It read, "All

accidents, incidents, and allegations of

abuse (see Abuse policy) including

injuries of unknown source, shall be

reported to the department supervisor as

soon as it is discovered or when

information of occurrence is learned.


was reviewed on 11/3/16 at 12:34 p.m.

The diagnosis for Resident 41 included,

but was not limited to: dementia. The

8/10/16 quarterly MDS (minimum data





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set) assessment indicated Resident 41 had

a BIMS (brief interview for mental

status) score of 12, indicating she was

cognitively intact.

An interview was conducted with

Resident 41 on 11/4/16 at 8:55 a.m. She

reported she had been hit by Resident 13,

and the staff had intervened during the

altercation.

There was no documentation in Resident

41's clinical record regarding an incident

between her and Resident 13 or an

investigation available regarding a

resident to resident altercation between

Resident 41 and Resident 13.

The clinical record for Resident 13 was

reviewed on 11/7/16 at 2:00 p.m. The

diagnoses for Resident 13 included, but

were not limited to: alzheimer's disease

and dementia with behavioral

disturbances. The 7/18/16 annual MDS

(minimum data set) assessment indicated

Resident #13 had a BIMS (brief

interview for mental status) score of 3,

indicating she was cognitively impaired.

A IDT (interdisciplinary team) note dated

10/27/16, indicated "Behavior noted

today, resident (Resident 13) frustrated

and grabbing at another resident's w/c

(wheelchair). Resident upset with another





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resident for unknown reason. Resident's

separated. Resident remained upset even

after being separated. 15 min (minute)

checks initiated. (name of nurse

practioner) notified. New order to

increase Depakote..."

A Social Services progress note dated

10/28/2016, indicated "On 10/27/2016

resident (Resident 13) had behavior of

grabbing at another resident's (Resident

41) arm and trying to push it away. Other

resident (Resident 41) informed staff and

staff redirected this resident (Resident

13) away from other resident (Resident

41) and was easily to redirect. Pysch

contacted regarding resident's (Resident

13) increase in behavior and new order

written to increase resident's Depakote.

15 minute checks were initiated and

nursing to complete urine dipstick to rule

out UTI (urinary track infection).

Resident has no further behaviors and has

been resting well. Resident does have

severe cognitive impairment. Resident

was unable to recall any of the incident.

Resident was talkative with staff after

incident."

A recorded video observation was made

on 11/9/16 at 10:19 a.m., of Resident 41

and Resident 13's altercation on

10/27/16. During the observation,

Resident 41 was riding in her electric





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wheelchair and Resident 13 was in her

wheelchair wheeling around the nurses

station. Resident 41 and Resident 13 had

stopped moving when they were

positioned side by side of eachother. It

appeared both residents were conversing.

Resident 41 who was in facial view of the

camera, placed her hand on her electric

wheelchair joystick and pushed it back

which caused her chair to move

backwards. As Resident 41 was moving

backwards, Resident 13's chair moved

forward. Resident 13 and Resident 41's

chair wheels appeared to have locked

together. Resident 41 reached over with

her hand and pushed Resident 13's arm of

her wheelchair. At that time, Resident 13

reached over with her hand and grabbed

Resident 41's arm. Resident 41 then

interlocked hands with Resident 13.

Resident 41 and Resident 13's wheels on

their wheelchairs broke free and both

residents pulled away. There was no

observation of staff intervening during

the incident.

An interview was conducted with Social

Services 7 on 11/7/16 at 4:01 p.m. She

stated the Director of Health Services

(DHS) notified her that something had

happened between Resident 41 and

Resident 13. She reported Resident 41

was holding her face, and it was possible

Resident 13 had hit Resident 41. Social





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Services 7 stated the incident had not

been witnessed, and she had spoken to

Resident 41 after speaking with the DHS.

Resident 41 reported to her that she had

not been hit by Resident 13, but she had

tried. Social Services 7 indicated during

the interview, Resident 41 did not appear

to show any signs of distress. Social

Services 7 stated she had not continued

an investigation on this incident, but she

had reported the incident to the ED. She

stated the ED told her he would look into

it.

An interview was conducted with the ED

and Social Services 7 on 11/7/16 at 4:07

p.m. The ED had indicated the incident

had not been presented to him in October

the same way it has been presented to

him now. He stated Resident 41 reported

to Social Services 7 she had not been hit,

so there was no indicators to proceed

with reporting or investigating the

incident any further.

An interview was conducted with the

Director of Health Services (DHS) on

11/9/16 at 9:54 a.m. She reported she

had not witnessed the incident between

Resident 41 and Resident 13. She

indicated both residents appeared to be

upset, so she thought something had

occurred and notified Social Services 7.

She stated at the time, Resident 41 had





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not voiced anything to her regarding what

had happened.

An interview was conducted with the ED,

Social Services 7 and Nurse Consultant 6

on 11/9/16 at 10:49 a.m. The ED stated

he had not reviewed the video involving

Resident 13 and Resident 41 until this

week. He stated he probably should have

but had not. The ED indicated it appeared

in the video the wheels on Resident 13

and Resident 41's wheelchairs had gotten

locked together. Social Services 7

reported she had not watched the video

until this week as well. Social Services 7

stated at the time of the incident, she had

believed Resident 13 had attempted to hit

Resident 41 and was acting out

aggressive behavior. She indicated after

reviewing the video she would not have

considered the incident as a behavior that

would have resulted in the notification of

the psych provider and an increase in

Resident 13's depakote medication. The

ED indicated that was something that

needed to be worked on, and Resident

13's medications would be reviewed to

determine if the depakote needed to be

decreased.

3.1-28(c)

3.1-28(d)





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483.13(c)

DEVELOP/IMPLMENT ABUSE/NEGLECT,

ETC POLICIES

The facility must develop and implement

written policies and procedures that prohibit

mistreatment, neglect, and abuse of

residents and misappropriation of resident

property.

F 0226

SS=D

Bldg. 00


the facility failed to operationalize it's

policy, regarding identification and

investigation, for 3 of 3 residents

reviewed for abuse. (Resident 13,

Resident 14 and Resident 41)

Findings include:



The diagnoses for Resident 14 included,


delirium.







F 0226 F226

It is the practice of this

provider to ensure that its

Abuse/Neglect policies and

procedures with regard to

identification and

investigation are

operationalized.





practice?

The psychosocial needs of

resident #13 and #41 were

reviewed and no negative

outcomes including emotional

distress have been observed.

Resident #13 was assessed by

the Nurse Practitioner of the

12/15/2016 12:00:00AM





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resident. The (name of local police

department) was notified of the allegation

and met with the Executive Director

(ED) Case (sic) 6/2/16..." The report

indicated CRCA (Certified Resident Care

Assistant) 9 and LPN (Licensed Practical

Nurse) 10 were suspended pending

outcome of the investigation and

subsequently discharged from

employment. The report read,

"Employee (name of LPN 10), LPN did

not take the necessary steps to ensure the

reporting and investigation of a resident

injury. A resident injury occurred while


of LPN #10) was discharged from


of employee (name of CRCA #9), CNA








the injury. (Name of CRCA #9) was


2016."


Psychological services group.

In light of the resident’s ongoing

restlessness with psychomotor

agitation and wandering throughout

the facility, the Nurse Practitioner

determined that the current

medications she was receiving was

the most appropriate and least

restrictive dose in managing her

behavioral symptoms. The resident

is without signs or symptoms of

negative outcomes as related to the

current medication regimen.

















Resident #13.

Resident #14 discharged from

the campus 10/02/2016 prior

to the certification survey.










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happened to her....I did not substantiate

abuse."

The file included a Timeline of Events

and Communication. The timeline read,

"Executive Director was notified of

incident and initiated investigation at

2pm," on 6/2/16.


statement of CRCA #1. It read, "On

Thursday June 2nd, I (name of CRCA

#1) walked into (name of Resident #14's)

room with (name of CRCA #10). I went

over to (name of Resident #14's) bed and



I told (name of CRCA #10) to come look

at (name of Resident #14). Her eyes had




her for sores. (Name of Resident #14)

had bruises all up and down her arms.

She had dried blood on her arm. I then

got her up and took her to the bathroom.

Got her hair brushed, glasses on, and

hearing aid in then took her to breakfast.

After breakfast I laid her down. Before

lunch I got her back in her chair and she

be taken?




practice. Additionally,

residents with behavioral

symptoms/target behaviors or

who are involved in resident

to resident interactions have

the potential to be affected by

the same alleged deficient

practice.














interventions.






Training for employees on

“Abuse, Neglect, &





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did not need to use the bathroom so I

took her to (name of Certified Resident

Medical Assistant #2) to get medicine. I

told (name of Certified Resident Medical

Assistant #2) around 1:30 about (name of

Resident #14's) bruises."


#1 on 11/7/16 at 11:50 a.m. She stated,

"I went in her room with (name of CRCA

#10). I took off her gown and there was






both arms, but the left was worse....She

had geri sleeves on at the time, and when

I took them off is when I noticed the

blood. I was scared at this point. Later

in the day, when I talked to (name of

Certified Resident Medical Assistant #2)

about it and (name of LPN #14) went in

and seen (sic) it all. There was blood on

the sheet, just drops. I saw her bruising

about 6:30 or 7:00 a.m. She was one of

the first residents we got up....We got her

up and it was a couple hours later when

we told the nurse. It's kind of hectic in

the morning, no excuse, but it was a

couple hours before it was taken care

of....She refused to let you have her

glasses, so if you tried to take them, she'd

jerk them back on her face, but it never

Exploitation Procedural

Guidelines” and “Accident &

Incident Reporting

Guidelines” will be completed

by 12/15/2016.














findings.






put into place?


observations will be

conducted two (2) times per


monthly for four (4) months

to ensure compliance:

1.Interview of 5 staff

members regarding any

allegations of abuse, injuries

of unknown origin, or resident





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left a mark. I don't think the bruising on

her arm could have been from her

behaviors. It was all the way from the

top of her arm to her thumb. It was a few

hours before I told anyone about the

bruising and blood, not right away....

(Name of Resident #14) had never

accused staff of hurting her before. She

kept saying the same story. Something

definitely happened...."


statement of CRCA #10. It read, "After

(name of CRCA #1) go (sic) (name of

Resident #14) off the toilet I asked where





told (name of CRCA #1) it couldn't be


sleave (sic) a little and saw dry blood on



with CRCA #10 on 11/7/16 at 2:44 p.m.









to resident

interactions/allegations that

have been made; 2. A

thorough investigation,

including an assessment of

the resident is complete for

any allegation of abuse or

injury of unknown origin; 3.

Implementation and

monitoring of the “Abuse,

Neglect, and Exploitation

Procedural Guidelines” and

“Accident & Incident

Reporting Guidelines” will be

documented on Customer

Concern Forms. Customer

Concern Forms will be

reviewed five times weekly by

the Social Service Director or

designee.Results of the audit and


reviewed and trended for




randomly or as noncompliance is

identified thereafter for further

recommendations.





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her glasses. "This was 6:30 to 7:30 a.m.,

before breakfast. I did not tell anyone

about the bruising or blood right away. I

wasn't taking care of her that day. (Name

of CRCA #1) was....As far as behaviors,

she would stick her arm in between the

side rails and move it up and down. We




tears."























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with Physician #15 on 11/7/16 at 2:43

p.m. He stated, "...She said she was hurt

by the nurse, had a couple tiny lacerations






























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was correct."















without fear of














2.) An Abuse policy was provided the ED

on 11/7/16 at 1:00 p.m. It indicated the

following: "...Purpose: (name of facility)





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had developed and implemented

processes, which strive to ensure the

prevention and reporting of suspected or

alleged resident abuse and neglect.

Purpose. 1. This has implemented

processes in an effort to provide a

comfortable and safe environment. 2. The

Executive Director and Director of

Health Services are responsible for the

implementation and ongoing monitoring

of abuse standards and procedures. 3.

Definitions:...c. physical abuse - includes

hitting, slapping, pinching, spitting,

holding or handling roughly, etc....i.

Resident to resident abuse with or

without injury...d. Identification..vi.

Complete an Accident and Incident

Report. Refer to the Accident and

Incident Program regarding investigation

procedures...f. Investigation...I. The

Executive Director is accountable for

investigating and reporting. II. Refer to

the Incident and Accident Program for

Investigation procedures..."

A "Policy. Guidelines for Investigation

Folder" was provided ED on 11/10/16 at

9:55 a.m. "Purpose. To provide

guidelines on completing an investigation

of accidents and incidents and compiling

the information into an organized folder.

Procedures. 1. An accident or incident

should be thoroughly investigated to

determine the root cause and implement





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interventions and approaches to mitigate

the risk of reoccurrence. 2. The

investigation should include but may not

be limited to: a. Review of nursing notes

and/or event. b. Interview of witnesses to

the incident. c. If no witness, all persons

that came into contact with the resident

within 3 days prior to the incident should

be interviewed. This should not be

limited to just nursing staff but

housekeeping, activities, family.

volunteers, ect. d. Review of

medications. e. Review of environmental

factors. f. Review of accident and

incident log for past history. g. Review of

physician orders. h. Review of Social

Service notes. I. Care plan review. 3. A

folder should be compiled of the above

information and: a. Resident face sheet.

b. Listing of like residents and steps

taken to prevent this occurrence from

happening to them. c. In-servicing

materials and sign in sheets. d. Audits

that have been performed. e. Completed

Episodic Event Form. 4. After

completion of the folder it should be

stored in the ED (Executive Director) or

DHS (Director Health Services) office

and available for review should the

incident result in a state survey. 5. Every

attempt should be made to determine the

root cause of the incident and ensure the

interventions and approaches are

applicable to the cause."





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on 11/9/16 at 10:19 a.m., of Resident #41

and Resident #13's altercation on


Resident #41 was riding in her electric

wheelchair and Resident #13 was in her


station. Resident #41 and Resident #13

had stopped moving when they were



Resident #41 who was in facial view of

the camera, placed her hand on her

electric wheelchair joystick and pushed it

back which caused her chair to move

backwards. As Resident #41 was moving

backwards, Resident #13's chair moved

forward. Resident #13 and Resident #41's


together. Resident #41 reached over with

her hand and pushed Resident #13's arm

of her wheelchair. At that time, Resident

#13 reached over with her hand and

grabbed Resident #41's arm. Resident

#41 then interlocked hands with Resident

#13. Resident #41 and Resident #13's

wheels on their wheelchairs broke free

and both residents pulled away. There

was no observation of staff intervening

during the incident.

The clinical record for Resident #41 was






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diagnosis for Resident #41 included, but

was not limited to: dementia. The

8/10/16 quarterly MDS (minimum data

set) assessment indicated Resident #41

had a BIMS (brief interview for mental

status) score of 12, indicating she was

cognitively intact.

An interview was conducted with

Resident #41 on 11/4/16 at 8:55 a.m.

She reported she had been hit by Resident

#13, and the staff had intervened during

the altercation.

There was no documentation in Resident

#41's clinical record regarding an incident

between her and Resident #13 or an

investigation available regarding a

resident to resident altercation between

Resident #41 and Resident #13.



diagnoses for Resident #13 included, but

were not limited to: Alzheimer's disease













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today, resident (Resident #13) frustrated










10/28/2016, indicated "On 10/27/2016

resident (Resident #13) had behavior of


#41) arm and trying to push it away.

Other resident (Resident #41) informed

staff and staff redirected this resident

(Resident #13) away from other resident

(Resident #41) and was easily to redirect.

Pysch contacted regarding resident's

(Resident #13) increase in behavior and

new order written to increase resident's

Depakote. 15 minute checks were

initiated and nursing to complete urine

dipstick to rule out UTI (urinary track

infection). Resident has no further

behaviors and has been resting well.

Resident does have severe cognitive

impairment. Resident was unable to

recall any of the incident. Resident was

talkative with staff after incident."

An interview was conducted with Social

Services #7 on 11/7/16 at 4:01 p.m. She





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stated the Director of Health Services

(DHS) notified her that something had

happened between Resident #41 and

Resident #13. She reported Resident #41

was holding her face, and it was possible

Resident #13 had hit Resident #41. Social

Services #7 stated the incident had not

been witnessed, and she had spoken to

Resident #41 after speaking with the

DHS. Resident #41 reported to her that

she had not been hit by Resident #13, but

she had tried. Social Services #7

indicated during the interview, Resident

#41 did not appear to show any signs of

distress. Social Services #7 stated she had

not continued an investigation on this

incident, but she had reported the

incident to the ED. She stated the ED told

her he would look into it.


and Social Services #7 on 11/7/16 at 4:07

p.m. The ED had indicated the incident

had not been presented to him in October

the same way it has been presented to

him now. He stated Resident #41

reported to Social Services #7 she had

not been hit, so there was no indicators to

proceed with reporting or investigating

the incident any further.


Director of Health Services (DHS) on

11/9/16 at 9:54 a.m. She reported she





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had not witnessed the incident between

Resident #41 and Resident #13. She

indicated both residents appeared to be

upset, so she thought something had

occurred and notify Social Services #7.

She stated at the time, Resident #41 had

not voiced anything to her regarding what

had happened.

An interview was conducted with the ED,

Social Services #7 and Nurse Consultant

#6 on 11/9/16 at 10:49 a.m. The ED

stated he had not reviewed the video

involving Resident #13 and Resident #41

until this week. He stated he probably

should have but had not. The ED

indicated it appeared in the video the

wheels on Resident #13 and Resident

#41's wheelchairs had gotten locked

together. Social Services #7 reported she

had not watched the video until this week

as well. Social Services #7 stated at the

time of the incident, she had believed

Resident #13 had attempted to hit

Resident #41 and was acting out






Resident #13's depakote medication. The

ED indicated that was something that

needed to be worked on, and Resident

#13's medications would be reviewed to





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determine if the depakote needed to be

decreased.

3.1-28(a)

483.20(g) - (j)

ASSESSMENT

ACCURACY/COORDINATION/CERTIFIED

The assessment must accurately reflect the

resident's status.

A registered nurse must conduct or

coordinate each assessment with the

appropriate participation of health

professionals.

A registered nurse must sign and certify that

the assessment is completed.

Each individual who completes a portion of

the assessment must sign and certify the

accuracy of that portion of the assessment.

Under Medicare and Medicaid, an individual

who willfully and knowingly 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 an individual who willfully

and knowingly causes another individual to

certify a material and false statement in a

F 0278

SS=D

Bldg. 00





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resident assessment is subject to a civil

money penalty of not more than $5,000 for

each assessment.

Clinical disagreement does not constitute a

material and false statement.

Based on record review and interview the

facility failed to ensure Minimum Data

Set Assessment (MDS) were completed

to accurately reflect the resident's status

and the care and services the resident

received in the areas of antipsychotic

medications, weight loss, pressure ulcers

and locomotion on unit for 3 of 3

residents' MDS reviewed. (Resident 56,

91, and 95)

Findings include:

1. Resident 95's record was reviewed on

11/9/16 at 6:51 a.m. The Discharge

MDS(Minimum Data Set) Assessment

dated 9/2/16 indicated the resident was

66 inches tall, weighed 134 pounds, no or

unknown weight loss of 5% or more in

the last month or loss of 10% or more in

the last 6 months, and the resident had

not received any antipsychotic

medications during the last 7 days.

Review of the EMAR (Electronic

medication Administration Record) from

8/27/16 to 9/2/16 indicated the resident

received prochlorperazine maleate (

antipsychotic medication used to treated

F 0278 F278





practice?

The MDS for resident #95 with

an ARD of 9/21/16 inaccuracy

of significant weight loss of

10% (K0300) and

antipsychotic medication 7

days (N0410A) were corrected

and submitted per the MDS

correction process in RAI.

Resident #95 had no ill effect

noted from the alleged

deficient practice. The MDS

for resident #91 with an ARD

of 7/18/16 inaccuracy of stage

II pressure ulcer (M0300B1-3)

was corrected and submitted

per the MDS correction

process in RAI. Resident #91

had no ill effect noted from

the alleged deficient practice.

The MDS for resident #56 with

an ARD of 7/1/16 inaccurate

representation of locomotion

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nausea, vomiting, anxiety and

schizophrenia) 10 mg one time a day

from 8/27 to 9/2/16.

The resident's weight on 8/14/16 was 149

and on 8/28/16 134. This was a 10%

weight loss in less than one month.

Interview with the Nurse consultant on

11/9/16 at 2:00 p.m. indicate the MDS

should have been coded with a weight

loss and the resident was not coded as

having received antipsychotic medication

and it should have been.

2. The record for resident 91 was

reviewed on 11/9/16 at 10:31 a.m. The 5

day MDS ( Minimum Data Set)

Assessment dated 7/18/16 indicated the

resident was as risk for pressure ulcers,

the resident did not have one or more

unhealed pressure ulcers at a Stage 1 or

higher.

Review of an Event Report dated 7/11/16

indicated, the resident had a Stage 2

(partial thickness/loss of skin layers that

presents clinically as an abrasion, blister,

or shallow crater) on the top of her right

ear measuring 0.6 cm (centimeters) by

1.3 cm by 0.0 cm. In the notes section of

the report dated 7/14/16 at 3:39 a.m. the

area to the ear noted, On 7/15/16 at 2:10

a.m. the area to the ear noted. On

on unit coding of extensive

assist (G01101E) was

corrected and submitted per

the MDS correction process in

RAI. Resident #56 had no ill

effect noted from the alleged

deficient practice.






be taken?

Current residents receiving

antipsychotic medications

would be at risk. All were

reviewed for the accuracy of

coding on the MDS per RAI

guidelines. All MDSs were

found to be in compliance.

Current residents coding for

ADL for locomotion on unit

were reviewed for accuracy

and no inaccuracies were

noted per the RAI guidelines.

All residents with significant

weight loss would be at risk.

All were reviewed for

accuracy of coding on the

MDS per the RAI guidelines.

All were found to be in

compliance. All residents with

stage II pressure ulcers would





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7/16/16 at 4:41 p.m. the area to the ear

noted. On 717/16 at 9:20 a.m. pressure

wound on right ear continues. On 7/18/16

at 1:53 a.m. area on ear remains and

shows signs of healing.

Interview with the Nurse Consultant on

11/9/16 at 12:28 p.m. indicated, the MDS

should have been coded to indicated the

resident has a pressure ulcer.

3. The clinical record for Resident 56 was

reviewed on 11/9/16 at 9:30 a.m. The


were not limited to: dementia, anxiety,

and depression.

The 7/1/16 Quarterly MDS assessment

indicated Resident 56 required extensive

assistance with locomotion on unit. The

10/1/16 Annual MDS assessment

indicated she declined to requiring total

dependence with locomotion on unit.

Observations of Resident 56 were made

on 11/9/16 at 9:37 a.m. and 11:07 a.m.

She was sitting in her geri chair. She was

not observed to ambulate in any way.

An interview was conducted with LPN

(Licensed Practical Nurse) 8 on 11/9/16

at 9:38 a.m. She stated, "She has never

assisted in ambulating at all. She has

always needed someone to push her for

the last year I've been here."

be at risk. All applicable MDSs

were reviewed for the

accuracy of MDS coding per

the RAI guidelines. All MDSs

were noted to be in

compliance.






The MDS Coordinator was

re-educated on 12/01/2016

on coding Section “G” ADLs,

“K” Nutrition, and “N”

Medications per RAI

guidelines. The MDS

Coordinator will review

residents with new ARDs that

receive antipsychotic

medications, have significant

weight loss, have pressure

ulcers, accurate ADL coding

for locomotion on unit for

accuracy per RAI guidelines.






put into place?The DHS or designee will review

all new assessments with ARDs





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MDS Coordinator on 11/9/16 at 10:47

a.m. She explained how Resident 56

switched from a Broda chair to a geri

chair a couple of months ago. She stated,

"I don't know what she was able to be

involved in that made her an extensive

assist in July...." She reported that staff

coded Resident 56 as requiring extensive

assistance on 2 different dates, and stated,

"I don't think it was correct. I never saw

her use a rail to ambulate in the Broda or

Geri chairs. I don't think she had a

decline in her ability to ambulate from

July to October. I usually catch that. I

don't know why I didn't...."

3.1-31(g)

after 12/15/2016 for 4 weeks for

those residents with antipsychotic

medications, significant weight

loss, locomotion on unit, and

pressure ulcers for accuracy per

RAI guidelines. After the first 4

weeks, 3 new assessments will

be reviewed weekly for another 4

weeks; then 5 new assessments

will be reviewed bi-weekly for 2

months; and then 5 new

assessments will be reviewed

monthly for 2 months. Results of

the audits will be reviewed in

QA&A process every month x 6

months. The Quality Assurance

committee will determine the

need for further monitoring.

483.25

PROVIDE CARE/SERVICES FOR

HIGHEST WELL BEING

Each resident must receive and the facility

must provide the necessary care and

services to attain or maintain the highest

practicable physical, mental, and

psychosocial well-being, in accordance with

the comprehensive assessment and plan of

care.

F 0309

SS=D

Bldg. 00


the facility failed to implement

F 0309 F-309

It is the practice of this provider to

12/15/2016 12:00:00AM





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appropriate interventions to address a

resident's behaviors and appropriately

assess a resident to resident interaction in

which resulted in an increase in a

resident's depakote medication for 2 of 3

residents reviewed for abuse. (Resident

#13 and Resident #14)

Findings include:

1. The clinical record for Resident #14


The diagnoses for Resident #14 included,


delirium.

The 4/18/16 Social Aspects care plan,

edited 5/24/16, read, "I have behaviors of

physically abusive/verbally

abusive/socially inappropriate AEB (as

exhibited by) slapping/hitting at staff,

yelling/being hateful to staff, and yelling

out loudly in a disruptive manner/banging

call light on side rail loudly." The goal

was, "I will have no/minimal negative

outcomes due to behaviors and will be

redirected when behaviors occur." There

was no intervention of padded side rails

to address the banging of the call light on

the side rail.




assess a resident’s behavioral

symptoms and implement

interventions to address a

resident’s behaviors and

appropriately assess resident to

resident interactions prior to

interventions with


interventions.

What corrective actions will be

accomplished for those residents

found to have been affected by the

deficient practice:

Resident #14: This resident no

longer resides in this facility. This

resident did not have Depakote as a

medication.

Resident #13: The resident to

resident interaction in the findings

of the 2567L has been reviewed with

the ED, DHS, and Director of Social

Services. Education has been

provided with regard to ensuring

completion of a thorough

investigation of resident complaints

of resident to resident interactions

[that may be construed as resident

to resident altercations/abuse] and

thorough assessment prior to

initiating psychopharmacological




Resident #13.

How other residents having the


same deficient practice will be

identified and what corrective

actions will be taken:

Residents who are involved in a





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resident. The report indicated CRCA

(Certified Resident Care Assistant) #9

and LPN (Licensed Practical Nurse) #10

were suspended pending outcome of the

investigation and subsequently

discharged from employment. The report

read, "A resident injury occurred while


of LPN #10) was discharged from


of employee (name of CRCA #9), CNA








the injury. (Name of CRCA #9) was


2016."






resident to resident interaction or

resident to resident altercation may

be affected by the alleged deficient

practice; Residents who display

behavioral symptoms such as

aggression, striking out,

slapping/hitting at staff have the


alleged deficient practice. Dementia

training for staff is being completed

to address residents with

Dementia-type diagnosis and how to

respond to their behavioral

symptoms. Additionally, inservicing

and education has been done with




resident interactions. Resident and

staff interviews were conducted

with no further negative findings.

What measures will be put in place

or what systemic changes will be

made to ensure that the deficient

practice does not recur:














findings.





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happened to her. I did not like the

coworkers statements about how the

CNA (CRCA #9) cared for the resident

while she was agitated...."

The file included the 6/2/16 interview

notes of CRCA #13. It read, "(Name of

CRCA #13) reported (name of CRCA

#9) said that to calm (name of Resident

#14) down is to grab her arms and shake

them and ask the res 'Are you ok?'

(Name of CRCA #13) reports that she

made this statement in the presence of

(name of CRCA #17). (Name of CRCA

#13) does not report observing (name of

CRCA #9) in this manner with any

resident.

The file included the 6/6/16 typed

statement of CRCA #17. It indicated,

"At report of my 2p-10p shift on to

(Name of CNA #9) that was starting her

10p-6a shift, a call light was going off...

We (name of CRCA #13 and I) said the

light has been going off all night and it

was probably the lady by the door.

(Name of CRCA #9) had said that it

could be (name of Resident #14) and she

would go to her and take her by the arms

(grabbing CRCA #13's arms) and loudly

say, "(name of Resident #14), (name of

Resident #14), are you ok?" shaking her

arms.

How the corrective actions will be

monitored to ensure the deficient

practice will not recur:

Reports of resident to resident

altercations/interactions and

allegations of abuse including

injuries of unknown origin will be

reviewed and investigated when

they occur and/or when reported

ensuring that a thorough and

accurate investigation is conducted

with appropriate resulting

interventions that meet the

resident’s needs.

Resident behavioral symptom trends

and allegations of abuse or injuries

of unknown origin are tracked on a

daily and weekly basis.

The pharmacy consultant reviews

medications for least restrictive and

most effective dosages for residents

within the campus monthly.


observations will occur as detailed:

Audits of Behavioral Resident Events

will be conducted two (2) times per


monthly for three (3) months;

Interviews of five (5) staff members

regarding allegations of abuse,

injuries of unknown origin and

resident to resident altercations will

be conducted.

The results of the audits and






randomly thereafter for further





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statement of CRCA #1. It read, "On

Thursday June 2nd, I (name of CRCA

#1) walked into (name of Resident #14's)

room with (name of CRCA #10). I went

over to (name of Resident #14's) bed and



I told (name of CRCA #10) to come look

at (name of Resident #14). Her eyes had




her for sores. (Name of Resident #14)

had bruises all up and down her arms.

She had dried blood on her arm....Before

lunch I got her back in her chair and she

did not need to use the bathroom so I

took her to (name of Certified Resident

Medical Assistant #2) to get medicine...."


#1 on 11/7/16 at 11:50 a.m. She stated,

"I went in her room with (name of CRCA

#10). I took off her gown and there was






both arms, but the left was worse. They

padded her side rails after this

incident....She had geri sleeves on at the

time, and when I took them off is when I

recommendation.





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noticed the blood. I was scared at this

point. Later in the day, when I talked to


Assistant #2) about it and (name of LPN

#14) went in and seen (sic) it all. There

was blood on the sheet, just drops....She

refused to let you have her glasses, so if

you tried to take them, she'd jerk them

back on her face, but it never left a mark.

I don't think the bruising on her arm

could have been from her behaviors. It

was all the way from the top of her arm

to her thumb....(Name of Resident #14)

had never accused staff of hurting her

before. She kept saying the same story.

Something definitely happened...."


statement of CRCA #1. It read, "After

(name of CRCA #10) go (sic) (name of

Resident #14) off the toilet I asked where





told (name of CRCA #1) it couldn't be


slave (sic) a little and saw dry blood on



with CRCA #10 on 11/7/16 at 2:44 p.m.







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her glasses. "...As far as behaviors, she

would stick her arm in between the side

rails and move it up and down. We




tears."

The file included the 6/2/16 typed

statement of CRMA #2. It read, "I got

shift change report from (name of LPN

#10) that (name of Resident #14) was

agitated all night and was awake yelling

majority of the night. She stated that

(name of Resident #14) slammed her own

glasses against her face in anger. I was

getting (name of Resident #14's) vitals at

1:30 p.m. and noticed bruises on the

inside of her nose and on her arms.

(Name of Resident #14) told (name of

LPN #14) and I that someone came in

last night and they were mad at her and

she said, 'They came in and (Name of

Resident #14 grabbed her own face hard





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& then grabbed her arms) then she

quickly pulled her sleeves down. (Name

of LPN #14) asked did it happen last

night? (Name of Resident #14) said yes.

(Name of LPN #14) asked was it by

someone who worked here (sic) she said

yes. I asked (name of CRCA #1) if the

bruises were new. She said she never

noticed them before and that when she

got (name of Resident #14) up there was

blood on her sheets. (Name of LPN #14

and I reported to (name of previous

Director of Nursing)"

The file included the 6/2/16 interview

notes of LPN #10. It read, "(Name of

LPN #10) reports that in the early

morning of June 2nd she observed (name

of Resident #14) yelling and banging and

shaking her side rails with her arms. The

resident wanted shoes and socks on. She

put shoes on the resident. (Name of LPN

#10) reported that the resident tossed her

glasses and that (name of LPN #10) had

to put them on and off the resident

repeatedly. (Name of LPN #10) stated

that no one reported anything to her

regarding injuries to the resident. (Name

of LPN #10) reports that the resident did

not strike staff. The resident stated, 'Dear

God help me" repeatedly throughout the

night. (Name of LPN #10) reports the

resident pulled the call light out of the

wall. It was noted that (name of LPN





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#10) had a scratch across her neck to

throat. (Name of LPN #10) indicated that

her cat caused the scratch." The 6/6/16

interview notes of LPN #10 read,

"During the second interview with (name

of LPN #10) she stated that she had

concerns regarding (Name of CRCA #9's)

transfer technique and how (name of

CRCA #9) placed hands on residents

arms. (Name of LPN #10) has not

brought this concern up to anyone

previously."


























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with Physician #15 on 11/7/16 at 2:43

p.m. He stated, "...She said she was hurt

by the nurse, had a couple tiny lacerations


























was correct."






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on 11/7/16 at 12:12 p.m. He indicated,

"As the intervention was described to me,

I felt like the intervention was

inappropriate, which was a primary

reason I pushed for termination. I asked

(name of CNA #9) about the

intervention, and she denied it. I asked

(name of LPN #10) about the

intervention, and she referenced issues

with transfers. I know she (Resident #14)

had geri sleeves, but I'm not sure about

whether there was padding to the side

rails...."


on 11/7/16 at 3:25 p.m. He indicated the

care practices described by 2 employees

was what he referenced in CNA #9's

termination. He indicated CNA #9

denied that she grabbed Resident #14's

arms, but that it could have caused the

bruising. He indicated, "I suspect the

bruising on the bridge of her nose

occurred in that she was putting them

(glasses) on and off."

The Employee Counseling Record Form

for CRCA #9 read, "...The conduct of the

employee and example does not meet the

expectations and education example

required by the employer....a resident

injury occurred while under the care of

the employee. Witness statement

included in Summary point to the





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potential for the employee's care to have

contributed to the injury....A resident

alleges that bruising on arms and under

eyes was caused by an employee. Type

of Disciplinary Action: Discharge."

Forty-six photographs of Resident #14,

taken on 6/3/16, were made available for

observation by Police Detective #17, on

11/15/16 at 9:17 a.m. The pictures

revealed bruising under both eyes, small

lacerations of on the bridge of the nose,

bruising on the left arm extending from

the elbow area to thumb, and a gash on

the left upper wrist area with dried blood.

LPN #10 and CRCA #9 were unavailable

for interview and unable to be reached at

last known telephone numbers.



















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without fear of














2. The clinical record for Resident #13

was reviewed on 11/7/16 at 2:00 p.m.

The diagnoses for Resident #13 included,

but were not limited to: Alzheimer's

disease and dementia with behavioral






A physician order dated 10/18/16,

indicated that staff was to administer 250

milligrams of depakote once a day to

Resident #13. The instructions indicated

to give 250 milligrams by mouth every

a.m., and 375 milligrams every night for

agitation.





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10/28/2016, indicated "On 10/27/2016

resident (Resident #13) had behavior of


#41) arm and trying to push it away.

Other resident (Resident #41) informed

staff and staff redirected this resident

(Resident #13) away from other resident

(Resident #41) and was easily to redirect.

Psych contacted regarding resident's

(Resident #13) increase in behavior and

new order written to increase resident's

Depakote. 15 minute checks were

initiated and nursing to complete urine

dipstick to rule out UTI (urinary track

infection). Resident has no further

behaviors and has been resting well.

Resident does have severe cognitive

impairment. Resident was unable to

recall any of the incident. Resident was

talkative with staff after incident."


indicated that staff was to administer 375

milligrams of depakote twice daily to

Resident #13.


on 11/9/16 at 10:19 a.m. of Resident #41

and Resident #13's altercation on


Resident #41 was riding in her electric

wheelchair and Resident #13 was in her






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station. Resident #41 and Resident #13

had stopped moving when they were



Resident #41 who was in facial view,

placed her hand on her electric



backwards. As Resident #41 was moving

backwards, Resident #13's chair moved

forward. Resident #13 and Resident #41's


together. Resident #41 reached over with

her hand and pushed Resident #13's arm

of her wheelchair. At that time, Resident

#13 reached over with her hand and

grabbed Resident #41's arm. Resident

#41 then interlocked hands with Resident

#13. Resident #41 and Resident #13's

wheels on their wheelchairs broke free

and both residents pulled away. There

was no observation of staff intervening

during the incident.


Executive Director (ED), Social Services

#7 and Nurse Consultant #6 on 11/9/16 at

10:49 a.m. The ED stated he had not

reviewed the video involving Resident

#13 and Resident #41 until this week. He

stated he probably should have but had

not. The ED indicated it appeared in the

video the wheels on Resident #13 and

Resident #41's wheelchairs had gotten





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locked together. Social Services #7


until this week as well. Social Services

#7 stated at the time of the incident, she

had believed Resident #13 had attempted

to hit Resident #41 and was acting out






Resident #13's depakote medication. The

Nurse Consultant #6 stated Resident

#13's depakote had been increased twice

in October due to behaviors. She reported

the incident on October 27th was the 2nd

depakote dosage increase for Resident

#13 in October. The ED indicated that

was something that needed to be worked

on, and Resident #13's medications

would be reviewed to determine if the

depakote needed to be decreased.

An interview was conducted with Nurse

Practioner #8 on 11/14/16 at 10:37 p.m.

She indicated she had increased Resident

#13's depakote medication on October

27th, because of an altercation Resident

#13 had with another resident. She stated

she was under the impression Resident

#13 was experiencing aggressive

behavior toward another resident that

day.





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3.1-37(a)

483.25(i)

MAINTAIN NUTRITION STATUS UNLESS

UNAVOIDABLE

Based on a resident's comprehensive

assessment, the facility must ensure that a

resident -

(1) Maintains acceptable parameters of

nutritional status, such as body weight and

protein levels, unless the resident's clinical

condition demonstrates that this is not

possible; and

(2) Receives a therapeutic diet when there is

a nutritional problem.

F 0325

SS=D

Bldg. 00

Based on observation, interview, and

record review, the facility failed to

provide the correct diet to a resident, as

ordered, for 1 of 4 residents reviewed for

nutrition. (Resident #16)

Findings include:



diagnoses for Resident #16 included, but

were not limited to, dysphagia.

The 11/3/16 Speech Therapy (ST) Daily

Treatment Note read, "...Initiated

dysphagia therapy. Initiated oral motor

exercises. Initiated safe swallowing

F 0325 F325





practice?

Inservice education for

“Resident Tray Cards for Diet

Orders” and “Communication

– Nursing to Dietary” will be

presented to dining services

and nursing staff by

12/15/2016.





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education. Initiated compensatory

strategy training. Completed a diet

texture analysis. Pt (patient) is to be on a

mechanical soft with ground meat with

thin liquid diet....Pt presents with

oropharyngeal dysphagia. Pt requires

skilled ST in order to increase the safety

of swallow and decrease the risk of

aspiration...."

The 11/3/16 Diet Order &

Communication form was provided by

the Therapy Director on 11/10/16 at 2:20

p.m. It read, "Diet Change...Mechanical

Soft...Ground meat (symbol for "with")

gravy...chewing/swallowing problems."

The 11/4/16 Nutrition progress note read,

"...Diet: CCHO+ Regular Mech Soft

w/ground meat &gravy...Nutrition

Interventions:. Clarify diet order to Diet:

CCHO; Diet Consistency: Mechanical

Soft w/ ground meat w/ gravy...."

The Physician Order Report read, "Diet:

CCHO (consistent carbohydrate)

mechanical soft w/ground meat w/gravy",

with a start date of 11/7/16.

The 6/21/16 nutrition care plan for

Resident #16 read, "Provide my

diet/supplements/medications as

ordered."


be taken?

All residents with altered

consistency diets have the



practice.






Inservice education for

“Resident Tray Cards for Diet

Orders” and “Communication

– Nursing to Dietary” will be

presented to dining services

and nursing staff by

12/15/2016.






put into place?

An audit for the

implementation and

monitoring of correct diets

will be completed periodically

by the Director of Dining

Services or designee. The

audit will be reviewed five

times weekly for four weeks





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(X3) DATE SURVEY

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(X5)

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An observation of Resident #16 eating

lunch in the Main Dining Room was

made on 11/10/16 at 12:17 p.m. He was

eating slices of ham, that were not

ground, with no gravy.

An interview was conducted with the DM

(Dietary Manager) on 11/10/16 at 12:28

p.m. in the Main Dining Room. She

stated, "Nursing or therapy should tell me

what the diet is. We have gravy for the

ham and we can serve it ground." The

DM reviewed Resident # 16's meal ticket

located next to Resident #16. It read,

"CC (Consistent Carbohydrate) Mech

(mechanical) soft." The ticket did not

indicate ground meat with gravy.

An interview was conducted with the DM

on 11/10/16 at 2:01 p.m. She stated, "I

talked to therapy and nursing and they

both said his diet is ground meat with

gravy."


Therapy Director on 11/10/16 at 2:13

p.m. He stated, "For his diet, he should

have had ground meat w/gravy."

3.1-46(a)(2)

then monthly for five (5)

months to ensure compliance.

The written results of the

audit observations will be

reported, reviewed, and

trended through the Quality

Assurance Performance

Improvement process for a

minimum of six months then

randomly thereafter for

further recommendation.





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483.25(l)

DRUG REGIMEN IS FREE FROM

UNNECESSARY DRUGS

Each resident's drug regimen must be free

from unnecessary drugs. An unnecessary

drug is any drug when used in excessive

dose (including duplicate therapy); or for

excessive duration; or without adequate

monitoring; or without adequate indications

for its use; or in the presence of adverse

consequences which indicate the dose

should be reduced or discontinued; or any

combinations of the reasons above.

Based on a comprehensive assessment of a

resident, the facility must ensure that

residents who have not used antipsychotic

drugs are not given these drugs unless

antipsychotic drug therapy is necessary to

treat a specific condition as diagnosed and

documented in the clinical record; and

residents who use antipsychotic drugs

receive gradual dose reductions, and

behavioral interventions, unless clinically

contraindicated, in an effort to discontinue

these drugs.

F 0329

SS=D

Bldg. 00


record review, the facility failed by

unnecessarily increasing a resident's

depakote medication for 1 of 3 residents

reviewed for abuse. (Resident 13)

Findings include:

The clinical record for Resident 13 was



were not limited to: Alzheimer's disease


F 0329 F-329

It is the practice of this provider to

ensure that residents receive only

the least restrictive, most effective

dose of abpsychoactive medication

is administered.

What corrective actions will be

accomplished for those residents

found to have been affected by the

deficient practice:

Resident #13: On 11.15.16 the

resident’s Nurse Practitioner for

psychological services assessed the

resident. In light of the resident’s

ongoing restlessness with

12/15/2016 12:00:00AM





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Resident 13 had a BIMS (brief interview

for mental status) score of 3, indicating

she was cognitively impaired.


indicated the staff was to administer 250

milligrams depakote once a day to

Resident 13. The instructions indicated to

give 250 milligrams by mouth every a.m.,

and 375 milligrams every night for

agitation.



today, resident (Resident 13) frustrated










10/28/2016, indicated "On 10/27/2016

resident (Resident 13) had behavior of


41) arm and trying to push it away. Other

resident (Resident 41) informed staff and

staff redirected this resident (Resident

13) away from other resident (Resident

psychomotor agitation and

wandering throughout the facility,

the Nurse Practitioner determined

that the current medications she

was receiving was the most

appropriate and least restrictive

dose in managing her behavioral

symptoms. The resident is without

signs or symptoms of negative

outcomes as related to the current

medication regimen.

How other residents having the


same deficient practice will be

identified and what corrective

actions will be taken:

Any resident displaying behavioral

symptoms, becomes involved in a

resident to resident interaction or

altercation and /or receiving

psychopharmacalogical medications

for target behaviors has the


alleged deficient practice. An audit

of residents receiving

psychopharmacalogical medications

will be completed to ensure

appropriateness of medication as

well as ensure target behavior

tracking and monitoring is in place if

indicated. Care plans will be

reviewed and updated.

What measures will be put in place

or what systemic changes will be

made to ensure that the










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41) and was easily to redirect. Psych

contacted regarding resident's (Resident

13) increase in behavior and new order

written to increase resident's Depakote.

15 minute checks were initiated and

nursing to complete urine dipstick to rule

out UTI (urinary track infection).

Resident has no further behaviors and has

been resting well. Resident does have

severe cognitive impairment. Resident

was unable to recall any of the incident.

Resident was talkative with staff after

incident."


indicated the staff was to administer 375

milligrams of depakote twice daily to

Resident 13.


on 11/9/16 at 10:19 a.m. of Resident 41

and Resident 13's altercation on


Resident 41 was riding in her electric

wheelchair and Resident 13 was in her


station. Resident 41 and Resident 13 had

stopped moving when they were

positioned side by side of each other. It


Resident 41 who was in facial view,

placed her hand on her electric











findings.

How the corrective actions will be

monitored to ensure the deficient

practice will not recur:

Reports of resident to resident

altercations/interactions will be

reviewed and investigated when

they occur and/or when reported

ensuring that a thorough and

accurate investigation is conducted

with appropriate interventions that

meet the resident’s needs.

Resident behavioral symptom trends

and resident to resident

interactions/altercations are tracked

on a daily and weekly basis.

The pharmacy consultant reviews

medications for least restrictive and

most effective dosages for residents

within the campus monthly.


observations will occur as detailed

to ensure ongoing compliance:

Audits of Behavioral Resident Events

will be conducted two (2) times per


monthly for three (3) months;

Interviews of five (5) staff members

regarding resdient to resident

interactions/altercations will be

conducted.

The results of the audits and





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backwards. As Resident 41 was moving

backwards, Resident 13's chair moved

forward. Resident 13 and Resident 41's


together. Resident 41 reached over with

her hand and pushed Resident 13's arm of

her wheelchair. At that time, Resident 13

reached over with her hand and grabbed

Resident 41's arm. Resident 41 then

interlocked hands with Resident 13.

Resident 41 and Resident 13's wheels on

their wheelchairs broke free and both

residents pulled away. There was no

observation of staff intervening during

the incident.


Executive Director (ED), Social Services

7 and Nurse Consultant 6 on 11/9/16 at

10:49 a.m. The ED stated he had not

reviewed the video involving Resident 13

and Resident 41 until this week. He

stated he probably should have but had

not. The ED indicated it appeared in the

video the wheels on Resident 13 and

Resident 41's wheelchairs had gotten

locked together. Social Services 7


until this week as well. Social Services 7

stated at the time of the incident, she had

believed Resident 13 had attempted to hit

Resident 41 and was acting out





compliance thru the campus Quality

Assurance Committee for a

minimum of 6 months then

randomly thereafter for further

recommendation.





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Resident 13's depakote medication. The

Nurse Consultant 6 stated Resident 13's

depakote had been increased twice in

October due to behaviors. She reported

the incident on October 27th was the 2nd

depakote dosage increase for Resident 13

in October. The ED indicated that was

something that needed to be worked on,

and Resident 13's medications would be

reviewed to determine if the depakote

needed to be decreased.

An interview was conducted with Nurse

Practioner 8 on 11/14/16 at 10:37 p.m.

She indicated she had increased Resident

13's depakote medication on October

27th, because of an altercation Resident

13 had with another resident. She stated

she was under the impression Resident

13 was experiencing aggressive behavior

toward another resident that day.

A Psychotropic Medication Usage and

Gradual Dose Reductions policy was

provided by Nurse Consultant 6 on

11/9/16 at 11:13 a.m. It indicated the

following: "Policy. Psychotic Medication

Usage and Gradual Dose Reductions.

Purpose. To ensure every effort is made

for residents receiving psychoactive

medications obtain the maximum benefit





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with minimal unwanted side effects

through appropriate use, evaluation and

monitoring by the interdisciplinary team.

Procedures. 1. Residents shall receive

psychotropic medications only if

designated medically necessary by the

prescriber, with appropriate diagnosis or

documentation to support its usage. The

medical necessity will be documented in

the residents medical record and in the

care planning process..."

3.1-48(a)(1)

483.35(i)

FOOD PROCURE,

STORE/PREPARE/SERVE - SANITARY

The facility must -

(1) Procure food from sources approved or

considered satisfactory by Federal, State or

local authorities; and

(2) Store, prepare, distribute and serve food

under sanitary conditions

F 0371

SS=F

Bldg. 00



ensure food was stored in a sanitary

manner related to food labeling. This

had the potential to impact 55 of 55

residents who eat meals which are

cooked in the facility's kitchen.

F 0371 F371





practice?

No negative outcome to any

12/15/2016 12:00:00AM





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Findings include:

1. During the initial kitchen tour on

04/03/2016, at 10:08 a.m., the

following concerns were noted:

- Five opened packages of bread with

no twist ties or opened dates.

- Spices without labels dating when

they were opened.

- An opened jar of peanut butter

without a label of date opened.

- Baking powder with an opened date

of 2013.

- Liquid butter with no opened label

date.

- A tub of vegetable oil without

opened label date.

- Maple syrup without an opened

label date.

2. During kitchen observation on

04/04/2016, at 11:32 a.m. the

following was observed:

- Brown sugar, raisins, and granola

were placed from their original

container into separate glass

containers without labeling.

- Five opened packages of bread

without twist ties or opened dates.


they were opened.

During an interview on 11/04/2016 at

11:32 a.m., the Dietary Manager

resident was identified by the

campus as a result of the

alleged deficient practice.






be taken?




practice.






Training for dining services

staff on the “Food Labeling

and Dating Policy” will be

completed by 12/15/2016.






put into place?

Implementation and

monitoring of the “Food

Labeling and Dating Policy”

will be documented on the

F371 Food Labeling and





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(DM) indicated the facility used

colored twist ties when bread should

be removed from use and that the

bread delivery drivers were

responsible for removing the old

bread. The DM could not explain how

the staff knew when the bread

without twist ties expired.


11:58 a.m., the DM indicated when a

food item was removed from its

original container and placed into a

separate one before serving, staff

was to label what the food item is,

date it from time opened until time

expired, and initial it.

The current facility policy, titled "Food

labeling and dating" dated

05/31/2016 states, "Any food product

removed from its original container,

has a broken seal, has been

processed in any way, must have a

label.

1. Item name.

2. Date and Time the food was

labeled.

3. Use by date.

4. Initials of the person labeling the

item.

5. Securely cover the food item.

6. The same label will be used at all

times and in all areas..."

Dating Policy audit form. The

Dining Services Director or

designee will complete the

audit two (2) times daily for

five (5) days a week for four

(4) weeks then monthly for

five (5) months to ensure

compliance. The written

results of the audit


reviewed, and trended

through the Quality Assurance

Performance Improvement

process for a minimum of six

months then randomly

thereafter for further

recommendation.





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dating guide" and dated 04/2013,

states under "Foods to be expired

within 72 hours (3 days) after

prepared or opened ... Bread, rolls,

and bun [sic] ..."

3.1-21(i)(3)

483.65

INFECTION CONTROL, PREVENT

SPREAD, LINENS

The facility must establish and maintain an

Infection Control Program designed to

provide a safe, sanitary and comfortable

environment and to help prevent the

development and transmission of disease

and infection.

(a) Infection Control Program

The facility must establish an Infection

Control Program under which it -

(1) Investigates, controls, and prevents

infections in the facility;

(2) Decides what procedures, such as

isolation, should be applied to an individual

resident; and

(3) Maintains a record of incidents and

corrective actions related to infections.

(b) Preventing Spread of Infection

(1) When the Infection Control Program

determines that a resident needs isolation to

prevent the spread of infection, the facility

must isolate the resident.

(2) The facility must prohibit employees with

F 0441

SS=E

Bldg. 00





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a communicable disease or infected skin

lesions from direct contact with residents or

their food, if direct contact will transmit the

disease.

(3) The facility must require staff to wash

their hands after each direct resident contact

for which hand washing is indicated by

accepted professional practice.

(c) Linens

Personnel must handle, store, process and

transport linens so as to prevent the spread

of infection.


record review, the facility failed to ensure

infection control practices were followed

with hand hygiene during an incontinent

care observation for 1 of 1 residents and

during a random dining observation of

Riley Cafe in which 13 residents dine.

(Resident 6, Resident 26 and Resident

56)

Findings include:

1. A dining observation was made on

11/3/16 at 11:51 a.m. Certified Resident

Care Assistant (CRCA) 3, CRCA 5, and

CRCA 4 was observed providing

assistance delivering plates with food and

drinks to each resident in this dining area.

There was no observation of CRCA 4 or

CRCA 5 using hand hygiene during the

dining time. During this observation,

CRCA 5 placed Resident 56's plate of

food on the table. CRCA 5 then using her

F 0441 F441





practice? .

Handwashing and hand

hygiene are observed by the

meal manager periodically at

meal service. Incontinent care

is observed periodically by the

DHS or designee. The

residents affected will be

cared for utilizing prescribed

infection control practices.






be taken?

All residents, while dining,

have the potential to be

12/15/2016 12:00:00AM





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bare hands touched Resident 56's

wheelchair handles and walked away

pushing her hair out of her face. There

was no observation of hand hygiene

observed. CRCA 5 then immediately

went to another resident's table. CRCA 5

was observed touching this resident's

handles on her wheelchair and eating

utensils to assist cutting up food on her

plate. There was no observation of hand

hygiene used prior or after. CRCA 3 was

observed hugging a family member and

than went immediately to Resident 26's

table using her bare hands touched

Resident 26's wheelchair handles, eating

utensils, and drinking glass. There was

no observation of hand hygiene at this

time. During the observation, CRCA 4

removed Resident 6's clothing protector.

At this time she had touched with her

bare hands Resident 6's wheelchair back,

shirt, hair and then immediately went to

Resident 56 and refilled her drinking

glass. There was no observation of hand

hygiene prior or after the assistance.


3 and CRCA 4 at 11/3/16 at 12:42 p.m.

CRCA 3 reported hand hygiene was to be

used if a resident was touched. She also

reported after every food tray the staff

person should use hand sanitizer and after

3 food trays are passed the staff person

should wash his or her hands with soap

affected by the same alleged

deficient practice. Residents

receiving perineal care have

the potential to affected by

the alleged deficient

incontinent care practice.

Handwashing and hand

hygiene are observed by the

meal manager periodically at

meal service. Incontinent care

is observed periodically by the

DHS or designee.






Training and education for

nursing and dining services

employees on, “Guidelines for

Handwashing/Hand Hygiene”

will be presented. Training

and education on “Perineal

Care for the Incontinent

Guideline” will be provided to

nursing staff. Training and

education will be completed

by 12/15/2016.










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and water. CRCA 3 and CRCA 4 stated

they had forgotten to use hand hygiene.

2. During an observation on 11/09/2016

at 1:39 p.m., CRCA (Certified Resident

Care Assistant) 1 prepared to do

incontinence care for Resident 56. She

donned gloves and wiped the perineal

area with cleansing wipes to remove

stool, then turned the resident and

cleaned the buttocks area. Using the dirty

gloves, with stool on the right index

finger, the CRCA touched the resident's

bed, knees and hip. CRCA 1 touched the

resident's drawer and a tube of

Nutrashield, which she laid on the bed.

Then, the CRCA removed her left glove

and wiped the dirty right glove with a

cleansing wipe, before cleansing the foley

catheter tubing. After finishing foley

care, CRCA 1 washed her hands for 17

seconds before emptying Resident 56's

foley catheter bag.


11:06 a.m., Certified Resident Medical

Assistant (CRMA) 2 indicated facility

policy was for employees to wash hands

for 3 minutes or sing the ABC's twice.

She further indicated that gloves were to

be changed when they became dirty.

The current facility policy, titled

"Guideline for Handwashing/Hand

Hygiene" dated 5/11/2016, was provided

put into place?

Observation of handwashing

and hand hygine practices

during meal service will

completed periodically by the

Director of Dining Services or

designee. Observation of

perineal care for incontinence

will by completed periodically

by the Director of Health

services or designee. The

observation results will be

reviewed five times weekly for

four weeks then monthly for


compliance.The written results of the audit


reviewed, and trended through

the Quality Assurance



months then randomly thereafter

for further recommendation.





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by the ADHS (Assistance Director of

Health Services) on 11/9/2016 at 2:37

p.m., and was reviewed at that time. The

policy indicated, "...Purpose.

Handwashing is the single most

important factor in preventing

transmission of infections. Inadequate

handwashing has been responsible for

many outbreaks of infectious disease in

LTCF (long term care facilities).

Implementation of PROPER

handwashing practices has interrupted

outbreaks in many settings.

Procedures:..Health Care Workers shall

wash hands at times such as... b.

Before/after preparing/serving meals,

drinks..c. Before/after having direct

physical contact with residents. d. After

removing gloves, worn per Standard

Precautions for direct contact with

excretions or secretions, mucous

membranes, specimens, resident

equipment, grossly soled linen, etc..."

The current facility policy, titled,

"Perineal Care for the Incontinent

Guideline" and dated 5/10/2016, was

provided by the ADHS (Assistant

Director of Health Services) on

11/9/2016 at 2:37 p.m. and was reviewed

at that time. The policy indicated, "...Pay

particular attention to infection control

techniques when performing pericare to

not introduce contamination that may





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lead to urinary tract infection..."

3.1-21(i)(3)

3.1-18(l)

F 9999

Bldg. 00

3.1-14 Personnel

(k) There shall be an organized ongoing

inservice education and training program

planned in advance for all personnel.

This training shall include, but not be

limited to, the following:

(1) Residents' rights.

(2) Prevention and control of infection.

(3) Fire prevention.

(4) Safety and accident prevention.

(5) Needs of specialized populations

served.

(6) Care of cognitively impaired

residents.

(l) The frequency and content of inservice

education and training programs shall be

in accordance with the skills and

knowledge of the facility personnel as

follows. The nursing personnel, this shall

include at least twelve (12) hours of

inservice per calendar year and six (6)

F 9999 F999





practice?





Employees 2, 10, 11, 12, 13,

14, 15, and 16 will have

completed the Dementia

Inservice 12/15/2016.






be taken?


12/15/2016 12:00:00AM





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hours of inservice per calendar year for

nonnursing personnel.

(u) In addition to the required inservice

hours in subsection (l), staff who have

regular contact with residents shall have

minimum of six (6) hours of

dementia-specific training within six (6)

months of initial employment, or within

thirty (30) days for personal assigned to

the Alzheimer's and dementia special

care unit, and three (3) hours annually

thereafter to meet the needs or

preferences, or both, of cognitively

impaired residents and to gain

understanding of the current standards of

care for residents with dementia.

This state rule was not met as evidenced

by:


the facility failed to provide dementia

in-service training for 9 of 10 employees'

files reviewed. (Certified Resident

Medical Assistant (CRMA) 2, Certified

Resident Care Assistant (CRCA) 10, 11,

12, 13, 14, License Practical Nurse(LPN)

15 and 16, and Registered Nurse (RN)

17)

Findings include:


Administrator on 11/10/16 at 2:39 p.m.



practice.






Hiring managers will review

the dementia inservice

training requirement by

12/15/2016. On an ongoing

basis, new employees will

receive initial dementia

inservice training upon hire.

Current employees will

receive ongoing dementia

inservice training annually

December 5th through

January 31st.






put into place?

Completion of initial and

ongoing dementia inservice

training will be audited by the

Payroll Coordinator or

designee. An audit for

completion of the training will

be conducted monthly for six





12/21/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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COMPLETED


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DEFICIENCY)

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155735 11/15/2016


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He indicated the facility was behind

providing staff with dementia

in-servicing training.

The Administrator on 11/14/16 at 11:17

a.m., provided a document titled,

"..Regarding Campus Dementia

Training" dated 11/14/16. It indicated 9

employees in which dementia training

was incomplete or expired with the

employees' hours worked since

expiration. The employees were the

following:

CRMA 2 - past due date 5/27/16 - hours

worked 882

CRCA 11 - past due date 9/9/16 - hours

worked 338

LPN 15 - past due date 9/9/16 - hours

worked 272


worked 1040


worked 234

LPN 16 - past due date 10/20/16 - hours

worked 124


worked 1011


worked 832

RN 17 - past due date 10/20/16 - hours

worked 174

A policy "Summary of Educational

(6) months to ensure

compliance. The written

results of the audit


reviewed, and trended




months then randomly

thereafter for further

recommendation





12/21/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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B. WING

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Requirements for States.." provided by

the Administrator on 11/14/16 at 10:35

a.m. It indicated, "Indiana: All nursing

home staff with regular resident contact

must receive six hours of

dementia-specific training within six

months of hire. Three hours of

dementia-specific training is required

annually thereafter...."

R 0000

Bldg. 00

This visit was for a State Residential

Licensure Survey.

Residential Census: 28

Sample: 9

This deficiency reflects State findings

cited in accordance with 410 IAC 16.2-5.

R 0000 Preparation or execution of this plan

of correction does not constitute

provider admission or agreement

related to the truth of the facts

alleged or conclusions set forth on

the Statement of Deficiencies. The

Plan of Correction is prepared and

executed solely because it is

required by the position of State

Law. The Plan of Correction is

submitted in order to respond to the

deficiencies cited during Indiana

State Department of Health

Recertification and State Licensure

Survey November 15, 2016.

State Form Event ID: YUO311 Facility ID: 004268 If continuation sheet of 73




12/21/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



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Please accept this plan of correction

as the provider’s credible allegation

of compliance. The provider

respectfully requests a desk review

with paper compliance to be

considered in establishing that the

provider is in substantial

compliance.

410 IAC 16.2-5-5.1(f)

Food and Nutritional Services - Deficiency

(f) All food preparation and serving areas

(excluding areas in residents ' units) are

maintained in accordance with state and

local sanitation and safe food handling

standards, including 410 IAC 7-24.

R 0273

Bldg. 00



ensure food was stored in a sanitary

manner related to food labeling. This

had the potential to impact 28 of 28

residents who eat meals which are

cooked in the facility's kitchen.

Findings include:

1. During the initial kitchen tour on

04/03/2016, at 10:08 a.m., the

following concerns were noted:

- Five opened packages of bread with

no twist ties or opened dates.


they were opened.

- An opened jar of peanut butter

without a label of date opened.

- Baking powder with an opened date

R 0273 R273





practice?










be taken?




12/15/2016 12:00:00AM





12/21/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155735 11/15/2016


2200 N RILEY HWY

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of 2013.

- Liquid butter with no opened label

date.

- A tub of vegetable oil without

opened label date.

- Maple syrup without an opened

label date.

2. During kitchen observation on

04/04/2016, at 11:32 a.m., the

following was observed:

- Brown sugar, raisins, and granola

were placed from their original

container into separate glass

containers without labeling.

- Five opened packages of bread

without twist ties or opened dates.


they were opened.


11:32 a.m., the Dietary Manager

(DM) indicated the facility used

colored twist ties when bread should

be removed from use and that the

bread delivery drivers were

responsible for removing the old

bread. The DM could not explain how

the staff knew when the bread

without twist ties expired.


11:58 a.m., the DM indicated when a

food item was removed from its

original container and placed into a

practice.






Training for dining services

staff on the “Food Labeling

and Dating Policy” will be

completed by 12/15/2016.






put into place?Implementation and monitoring of

the “Food Labeling and Dating

Policy” will be documented on the

F371 Food Labeling and Dating

Policy audit form. The Dining

Services Director or designee will

complete the audit two (2) times

daily for five (5) days a week for

four (4) weeks then monthly for


compliance. The written results of

the audit observations will be

reported, reviewed, and trended




months then randomly thereafter

for further recommendation.





12/21/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155735 11/15/2016


2200 N RILEY HWY

00

separate one before serving, staff

was to label what the food item is,

date it from time opened until time

expired, and initial it.


labeling and dating" dated

05/31/2016 states, "Any food product

removed from its original container,

has a broken seal, has been

processed in any way, must have a

label.

1. Item name.

2. Date and Time the food was

labeled.

3. Use by date.

4. Initials of the person labeling the

item.

5. Securely cover the food item.

6. The same label will be used at all

times and in all areas..."


dating guide" and dated 04/2013,

states under "Foods to be expired

within 72 hours (3 days) after

prepared or opened ... Bread, rolls,

and bun [sic] ..."


printed: 12/21/2016 department of health and …printed: 12/21/2016 form approved omb no. 0938-0391...

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