F 0000 - Indiana · 2020. 5. 20. · assistance with ADL's (activities of daily living), "Bra on daily." On 2/19/2020 at 01:16 p.m., Resident 37 was observed dressed in red plaid

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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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 COD

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(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)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

ZIONSVILLE, IN 46077

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This visit was for a Recertification and State

Licensure Survey. This visit included a State

Residential Licensure Survey.

Survey dates: February 18, 19, 20, 21, 24, and 25,

2020.

Facility number: 000538

Provider number: 155620

AIM number: 100267290

Census Bed Type:

SNF/NF: 88

Residential: 24

Total: 112

Census Payor Type:

Medicare: 1

Medicaid: 68

Other: 37

Total: 112

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality review completed on March 4, 2020.

F 0000

483.10(a)(1)(2)(b)(1)(2)

Resident Rights/Exercise of Rights

§483.10(a) Resident Rights.

The resident has a right to a dignified

existence, self-determination, and

communication with and access to persons

and services inside and outside the facility,

including those specified in this section.

§483.10(a)(1) A facility must treat each

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

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

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

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

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

continued program participation.

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

_____________________________________________________________________________________________________Event ID: 6Y8511 Facility ID: 000538

TITLE

If continuation sheet Page 1 of 38

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resident with respect and dignity and care for

each resident in a manner and in an

environment that promotes maintenance or

enhancement of his or her quality of life,

recognizing each resident's individuality. The

facility must protect and promote the rights of

the resident.

§483.10(a)(2) The facility must provide equal

access to quality care regardless of

diagnosis, severity of condition, or payment

source. A facility must establish and

maintain identical policies and practices

regarding transfer, discharge, and the

provision of services under the State plan for

all residents regardless of payment source.

§483.10(b) Exercise of Rights.

The resident has the right to exercise his or

her rights as a resident of the facility and as

a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that

the resident can exercise his or her rights

without interference, coercion, discrimination,

or reprisal from the facility.

§483.10(b)(2) The resident has the right to be

free of interference, coercion, discrimination,

and reprisal from the facility in exercising his

or her rights and to be supported by the

facility in the exercise of his or her rights as

required under this subpart.

Based on observation, interview, and record

review, the facility failed to ensure a resident

(Resident 37) was assisted to dress daily, in a

manner to maintain dignity, for 1 of 1 residents

reviewed for dignity.

F 0550 1. What corrective action(s) will

be accomplished for those

residents found to have been

affected by the deficient

practice;

Resident 37 care guide, care plan,

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Findings include:

On 2/18/20 at 10:09 a.m., Resident 37 was

observed in the Cottage (Memory Care Unit)

common sitting area, adjacent to the Nurses'

Station. She was wearing a short T-shirt (cropped

style), with her abdomen showing, no bra, and

black leggings. She was very animated in her

actions. As she jumped up and down, and

danced, clapping her hands, while constantly

moving about the room, her large sized breasts

were unrestrained.

On 2/18/2020 Licensed Practical Nurse (LPN) 13

provided a copy of the current Certified Nurse

Aide (CNA) assignment sheet. In bold letters the

assignment for Resident 37 indicated she required

assistance with ADL's (activities of daily living),

"Bra on daily."

On 2/19/2020 at 01:16 p.m., Resident 37 was

observed dressed in red plaid pajama pants, and a

long sleeved purple fleece top. She was dancing

in the common area to big band music. Her breasts

were unrestrained, she was not wearing a bra.


observed in the Cottage Activity/Dining Room

with Activity Assistant 14. The Resident was

wearing red plaid pajama bottoms, and a thin knit

pale yellow short sleeved sweater. She was not

wearing a bra.


observed eating breakfast in the Cottage Dining

Room. The Resident was wearing a green print

button down shirt. Resident 37 was seated at the

table, eating breakfast. Her shirt was gaping open,

around the buttons, the right breast fold was

visible, through the opening in her shirt.

profiles and preferences have been

updated to reflect preferences to

wear a bra.

2. 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 female resident has the

potential to be affected.

3. What measures will be put in

place and what systemic

changes will be made to ensure

that the deficient practice does

not occur;

An audit will be completed and

updated on residents for

preferences. All clinical staff will

be in serviced to follow their care

guides and profiles to ensure

resident preferences are followed.

4. How the corrective action(s)

will be monitored to ensure the

deficient practice will not occur,

i.e., what quality assurance

program will be put I place;

DNS/designee during daily rounds

will monitor to ensure residents

preferences are followed daily for 2

weeks, 3 x week for 2 weeks,

weekly thereafter until deemed

necessary. All results will be

presented to the Monthly Quality

Assurance Committee.

5. By what date the systemic

changes for the deficiency will

be completed.

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On 2/24/2020 at 10:46 a.m., during an interview, at

the Nurses' station, with 3 staff members, CNA18

indicated Resident 37 sometimes dressed herself.

The aides had to give her cueing. She did not

know if Resident 37 was supposed to wear a bra.

CNA 18 would have to check her care plan. The

other aide on the unit (unidentified) indicated, it

was her first day and she was agency staff. She

had not helped Resident 37 dress in the morning

and didn't know who had. Licensed Practical

Nurse 19, indicated she did not know who

assisted Resident 37 with dressing. She did not

know if she should have a bra on.

3.1-3(a)

3.1-3(t)

483.10(f)(5)(i)-(iv)(6)(7)

Resident/Family Group and Response

§483.10(f)(5) The resident has a right to

organize and participate in resident groups in

the facility.

(i) The facility must provide a resident or

family group, if one exists, with private space;

and take reasonable steps, with the approval

of the group, to make residents and family

members aware of upcoming meetings in a

timely manner.

(ii) Staff, visitors, or other guests may attend

resident group or family group meetings only

at the respective group's invitation.

(iii) The facility must provide a designated

staff person who is approved by the resident

or family group and the facility and who is

responsible for providing assistance and

responding to written requests that result

from group meetings.

(iv) The facility must consider the views of a

resident or family group and act promptly

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upon the grievances and recommendations of

such groups concerning issues of resident

care and life in the facility.

(A) The facility must be able to demonstrate

their response and rationale for such

response.

(B) This should not be construed to mean

that the facility must implement as

recommended every request of the resident

or family group.

§483.10(f)(6) The resident has a right to

participate in family groups.

§483.10(f)(7) The resident has a right to have

family member(s) or other resident

representative(s) meet in the facility with the

families or resident representative(s) of other

residents in the facility.

Based on interview and record review, the facility

failed to ensure resident council grievances

related to nurse staffing concerns, were

responded to in a timely manner for 3 of 6 months

of resident council minutes reviewed and 12 of 12

residents listed as participating in resident council

meetings.

Findings include:

On 2/21/2020 at 10:00 a.m., a Resident Council

Group Interview was conducted. Seven residents

who regularly participated in Resident Council

were present, including the Resident Council

President. As a whole, the present residents

indicated they were not pleased about the

facilities use of agency nursing staff, and found

the majority of the agency staff to be "rude",

"disconnected", "rushed", and had "bad

attitudes" that made the residents feel like the

F 0565 1. What corrective action(s) will be accomplished for those



practice;

All resident council grievances

related to nursing staff have been

addressed and completed.






taken;

All residents have the potential to

be affected.





not occur;

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staff did not care about the residents. The

residents indicated this issue had been brought

up and discussed a lot in Resident Council but

nothing seemed to change, and things never got

better. The responses they were provided, if any,

were always the same response. For example, "it

would be discussed in morning meeting." The

residents indicated, their biggest concerns were;

having to wait too long for call lights, staff not

taking the time to listen to resident preferences or

allowing residents to ask questions about their

medications, and being told, "You're not the only

resident I have to take care of."

During an interview on 2/21/2020 at 10:30 a.m., the

Resident Council President indicated, staffing

concerns were a constant struggle for the facility.

She understood they needed to use agency staff

so there would be enough people to take care of

the residents but she wished there was a way to

help them understand that a little pleasant attitude

would go a long way.

On 2/21/2020 at 11:30 a.m., the Resident Council

Meeting Minutes were reviewed:

On 11/6/2019: Eleven residents were present, and

complained, "...midnight staff are sleeping outside

the [facility staff] office. Residents state systems

are failing. Beds not made/linen not changed. Staff

not held accountable for performance, with no

follow up from Admin [Administrator]/DON

[Director of Nursing]...." No response form was

attached.

On 12/18/2019: Twelve resident were present and

complained, "...residents not happy with

agency...." No response form was attached.

On 2/5/2020: Seven residents were present and

All Managers will be in serviced on

timeliness of grievance resolution.

Activities Director and ED will

monitor monthly for timeliness of

grievance resolutions for the

resident council. This will be

ongoing.






All results will be presented the

Monthly Quality Assurance

Committee.



be completed.

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complained, "...nursing staff bedside manner is

bad. Call light response is slow...nursing staff are

throwing sanitary wipes in toilet causing back

up...." A blank response form was attached.


Activity Director (AD) indicated the process for

Resident Council was to have a meeting each

month, more if needed, and address resident

concerns. When concerns were shared, she would

fill out a "follow up" form and provide a copy to

the respective department head, who would then

write a response and return it to the AD so he

could take it back to the Resident Council, where

the residents would either accept or reject the

response. Depending on the nature and severity

of the concern, the department heads were

supposed to return the follow up forms within 72

hours to a week, after they had been provided. At

this time the AD looked through his Resident

Council binder and could not locate any response

forms for November, December, or February. The

AD indicated it was often a struggle to get the

other department heads to return the follow up

forms. The Administrator had addressed the delay

in responses in morning meeting a "while back,"

encouraging the department heads to take it more

seriously.

On 2/25/2020 at 10:00 a.m., the DON indicated

there was no policy for following up on Resident

Council Grievances, but provided a copy of an

undated documented, titled, "Resident Council

Best Practices". The Best Practices indicated, "...

President of Resident Council should call the

meeting to a start, review minutes from last

meeting, review pertinent information from each

department... open the floor to other residents,

staff directed to take minutes will record as Follow

Up...."





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3.1-3(l)

483.12

Free from Misappropriation/Exploitation

§483.12

The resident has the right to be free from

abuse, neglect, misappropriation of resident

property, and exploitation as defined in this

subpart. This includes but is not limited to

freedom from corporal punishment,

involuntary seclusion and any physical or

chemical restraint not required to treat the

resident's medical symptoms.

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Based on interview, and record review, the facility

failed to ensure residents' personal property was

protected from loss, or misappropriation for 12 of

12 months of grievances related to missing

personal items and 1 of 2 residents reviewed for

missing money (Resident 60).

Findings include:

During a confidential family interview, the family

member indicated the resident had several missing

items, over the past 3 months. At Christmas, the

family had decorated the resident's room for the

holiday. At the next family visit, the decorations

were missing. Upon inquiry to the staff, the family

member indicated he was told the residents were

confused and they took things from one another.

The missing items were never located. The family

member recalled another time when he had given

the resident $60 for spending money. The resident

was unable to locate the money on the next visit, a

week later, and had not purchased anything. The

family member found the wallet empty, under the

resident's bed. When he reported the incident, the

staff told him the resident was confused and

probably should not have money in the room, or




practice;

At the conclusion of the

investigation, Laundry Aide 16 was

terminated. Family and resident

were informed of missing items

and facility agreed to replace

items of similar value. As

indicated in Incident Report 368,

missing money was reported to

the local authorities.






taken;


be affected.





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on their person.

On 2/2/2020 at 10:00 a.m., grievances for the past

year were reviewed in the Facility Grievance

Binder. The following complaints of missing

personal items, and clothing were identified:

a. For the month of February 2020, there were 5

reports of missing personal items and clothing.

b. For the month of January 2020, there were 10

reports of missing personal items and clothing.

c. For the month of December 2019, there were 4

complaints of missing personal items and

clothing.

d. For the month of November 2019, there were 7


clothing.

e. For the month of October 2019, there were 10

complaints of missing person items and clothing.

f. For the month of September 2019, there were 7


clothing.

g. For the Month of August 1019, there were 3


clothing.

h. For the month of July 2019, there were 5


clothing.

i. For the month of June 2019, there were 3


clothing.

j. For the month of May 2019, there were 6


clothing.

k. For the month of April 2019, there were 10


clothing.

l. For the month of March 2019, there were 10


clothing.

m. For the month of February 2019, there were 7

not occur;

All staff will be in serviced on the

facility grievance policy and

procedure. The Grievance

Official/Executive Director will sign

off on all action plans and

resolutions within 72 hours.

Appropriate grievances will be

reported to ISDH per Reportable

policy and procedure.






Customer Care Coordinator or

Designee will report all new and

outstanding grievances in morning

meeting Monday – Friday and

assign appropriate department to

follow up. Grievance

Official/Executive Director will sign

off on all action plans and

resolutions within 72 hours.

Customer Care Coordinator will

complete monthly grievance

summary and results will be

presented to the Quality

Assurance Committee monthly,



be completed.

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clothing.

Incident 368 was reported to the Indiana State

Department of Health, on 2/10/2020, by the

Administrator. The incident form indicated an

allegation was made that the laundry aide

(Laundry Aide 16) was stealing resident clothing.

The employee was terminated after she admitted

to taking $1.00 from the laundry.

On 2/20/20 at 10:09 a.m., the investigation of the

Facility Reported Incident was reviewed.

Housekeeping Employee 28 indicated, in a

statement, a (unidentified resident) had a wallet go

missing and everything was returned by the

laundry, except $60.00. Laundry Aide 16 had been

seen taking boxes out of the laundry to the locker

room, several times. She reported it to her

Supervisor, Housekeeping Supervisor 17, and

together they went to the laundry room and found

resident clothing, which had been reported

missing, in boxes in the locker room. Several

empty boxes were seen hidden behind a wall, in

the same area.

Another statement indicated, on 2/2/2020,

Housekeeping Supervisor 17 had investigated

several boxes of clothing found in the locker

room, which had been reported as missing items.

Other employees had told her they saw Laundry

Aide 16 taking boxes from the Laundry to the

locker room. She had questioned Laundry Aide 16

about it. Laundry Aide 16 denied any knowledge

of the boxes of clothes.

A report on 12/9/19, indicated an unidentified

resident was missing 90-95% of her clothing. This

resident had come back from the hospital and was

in isolation, the clothes had been taken to the





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laundry for storage. Laundry Aide 16 denied

seeing the clothes. Later 5-6 boxes of resident

clothes were found in boxes in the locker room,

they were mostly Memory Care (Cottage) resident

clothing, and none belonged to the original

complainant.

A report from October, indicated Laundry Aide 16

had been seen wearing a resident's jacket. The

Administrator was not able to verify the jacket

belonged to a resident, several unidentified

employees said it did.

Laundry Aide 16 was allegedly reported to have

thrown away large bags of table linens, found in

the dumpster, after they were given to her to wash

and were not returned to the Dietary Department.

On another occasion, she had been seen taking

new linens to the locker room.

On January 17, 2020, a grievance investigation for

Resident 60 indicated he had accidentally sent his

wallet to the laundry. His Medicaid card, 6 $10.00

bills, and 2 $1.00 bills had been in the wallet. The

resident's wallet and Medicaid card were returned

to him.

On 2/24/2020 at 11:40 a.m., during an interview, the

Administrator indicated, they were never able to

identify the staff (Laundry Aide 16) was taking

clothing/belongings. Clothing was missing, but

there was never a way to prove she took the

jacket/coat she was seen in. It was checked, but

we were never able to prove it belonged to a

resident. The table clothes were missing, and

found in the trash a while back, it was never

proved that she threw them away either. The only

thing they were able to prove was the money

taken from the resident's wallet, and that was

because she admitted to taking it. She only





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admitted to taking $1.00. Then, she was

terminated. Their investigation was unable to

prove she was taking clothing, or anything else

from residents, or the facility.

On 2/24/2020 at 2:55 p.m., during an interview,

Housekeeping Supervisor 17 indicated the facility

had a lot of problems with missing clothing,

especially since October. The locker room had old

lockers, and a bathroom with 2 stalls which wasn't

used any more. They had a new locker area in the

break room. Laundry Aide 16 had been seen by

other employees taking boxes of clothing into the

locker room. Most of the missing clothes were

from residents on the cottage. They were not

reporting as clothes missing, because they didn't

know. When they found boxes in the locker room,

most of the clothing had names in them and were

able to be returned to the residents. Laundry Aide

16 was terminated after she admitted to taking

$1.00 she found in the laundry.

The Admissions agreement, provided on

2/18/2020, at the entrance conference, indicated

"...Community shall exercise reasonable care for

the protection of Resident's property from loss or

theft...."

3.1-28(a)

483.25(e)(1)-(3)

Bowel/Bladder Incontinence, Catheter, UTI

§483.25(e) Incontinence.

§483.25(e)(1) The facility must ensure that

resident who is continent of bladder and

bowel on admission receives services and

assistance to maintain continence unless his

or her clinical condition is or becomes such

that continence is not possible to maintain.

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§483.25(e)(2)For a resident with urinary

incontinence, based on the resident's

comprehensive assessment, the facility must

ensure that-

(i) A resident who enters the facility without

an indwelling catheter is not catheterized

unless the resident's clinical condition

demonstrates that catheterization was

necessary;

(ii) A resident who enters the facility with an

indwelling catheter or subsequently receives

one is assessed for removal of the catheter

as soon as possible unless the resident's

clinical condition demonstrates that

catheterization is necessary; and

(iii) A resident who is incontinent of bladder

receives appropriate treatment and services

to prevent urinary tract infections and to

restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal

incontinence, based on the resident's

comprehensive assessment, the facility must

ensure that a resident who is incontinent of

bowel receives appropriate treatment and

services to restore as much normal bowel

function as possible.


review, the facility failed to ensure Foley tubing

(part of a urinary collection system) was not on

the floor, for 1 of 2 residents observed for Foley

catheters (Resident 13).

Findings include:

During a continuous observation from 11:09 a.m.

to 11:29 a.m., Resident 13 was observed in her

wheelchair, her Foley tubing dragged on the floor.

She rolled her wheelchair down the hall, in front of

the nurse's station, turned around and went back




practice;

Resident 13 care plan and profile

updated to reflect support hooks

to hold the catheter tubing off the

floor.





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down the hall toward her room. Once at her room,

she turned again, and came back to the nurse's

station. Five unidentified staff members passed

Resident 13, and two of those staff members

spoke to her.

During an interview, on 2/21/2020 at 11:30 a.m., the

Floating Director of Nursing (FDNS) indicated

Resident 13's Foley catheter tubing should not be

on the floor.

On 2/21/2020 at 11:38 a.m., Resident 13's record

was reviewed. Her diagnoses included but were

not limited to, dementia, neuromuscular

dysfunction of the bladder (unable to control the

muscles of the bladder), and schizophrenia

(breakdown in the relationship between thought,

emotion, and behavior).

A care plan, updated on 1/20/2020, indicated

Resident 13 required an indwelling urinary

catheter related to neuromuscular dysfunction of

the bladder. The resident was at increased risk for

infection related to a history of UTI (urinary tract

infections). Several staff approaches were listed,

one approach indicated, "...Do not allow tubing or

any part of the drainage system to touch the floor

..."


Administrator indicated Foley catheter tubing

should not have been on the floor. Resident 13

was very mobile, and if staff saw it, staff should

have gotten it off the floor.


Director of Nursing indicated the facility did not

have a Foley catheter policy regarding Foley

tubing on the floor, but it was best practice not to

have had the tubing dragging the floor. It was an


taken;

All residents with catheters have

the potential to be affected.





not occur;

An audit has been completed to

ensure properly positioned and

covered and the tube not touching

the floor. All clinical staff will be in

serviced on securing catheter

bags/tubing to wheelchair and/or

bed frames appropriately.






DNS/Designee will monitor 5 X

week for 2 weeks, 3 x week for 2

weeks and then weekly x 5

months. All results will be

presented monthly to the Quality




be completed.

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infection control issues.

3.1-41(a)(2)

483.45(c)(3)(e)(1)-(5)

Free from Unnec Psychotropic Meds/PRN

Use

§483.45(e) Psychotropic Drugs.

§483.45(c)(3) A psychotropic drug is any

drug that affects brain activities associated

with mental processes and behavior. These

drugs include, but are not limited to, drugs in

the following categories:

(i) Anti-psychotic;

(ii) Anti-depressant;

(iii) Anti-anxiety; and

(iv) Hypnotic

Based on a comprehensive assessment of a

resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used

psychotropic drugs are not given these drugs

unless the medication is necessary to treat a

specific condition as diagnosed and

documented in the clinical record;

§483.45(e)(2) Residents who use

psychotropic drugs receive gradual dose

reductions, and behavioral interventions,

unless clinically contraindicated, in an effort

to discontinue these drugs;

§483.45(e)(3) Residents do not receive

psychotropic drugs pursuant to a PRN order

unless that medication is necessary to treat

a diagnosed specific condition that is

documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic

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drugs are limited to 14 days. Except as

provided in §483.45(e)(5), if the attending

physician or prescribing practitioner believes

that it is appropriate for the PRN order to be

extended beyond 14 days, he or she should

document their rationale in the resident's

medical record and indicate the duration for

the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic

drugs are limited to 14 days and cannot be

renewed unless the attending physician or

prescribing practitioner evaluates the resident

for the appropriateness of that medication.

Based on record review and interview, the facility

failed to ensure pharmacy recommendations were

followed for a resident (Resident 43), and failed to

ensure gradual dose reductions (GDR) were

properly documented for a resident, (Resident 39)

for 2 of 5 residents reviewed for unnecessary

medications.

Findings include:

1. On 2/20/2020 at 1:55 p.m., Resident 39's medical

record was reviewed. The most recent

comprehensive assessment was a Quarterly

Minimum Data Set (MDS) assessment, dated

1/1/2020, indicated Resident 39 was severely

cognitively impaired, had no recent behaviors

coded for the 7-day look back period, and required

total to extensive assistance from nursing staff for

all ADLS (Activities of Daily Living). The MDS

indicated Resident 39 had active diagnoses to

include, but were not limited to, Non-Alzheimer's

dementia, and he received antipsychotic

medications.

Resident 39 had a current comprehensive care

plan for behaviors, dated 7/18/2018 and most




practice;

Cannot correct incident that

occurred in the past






taken;


be affected.





not occur;

Pharmacist will present all

recommendations to the

DNS/ADNS monthly after visit.

DNS/ADNS will review

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recently revised 1/14/2020, indicated, "...behavior

#1: Resident is at risk for increased agitation or

changed in mood and behavior due to dx

[diagnoses] of dementia with behaviors, may have

episodes of being combative or verbally

aggressive towards staff. Residents is taking

anti-psychotic medication due to being at risk for

these behaviors...."

Resident 39 had a current comprehensive care

plan for behaviors, dated 7/18/2018 and most

recently revised 1/14/2020, indicated, "...behaviors

#2: Resident is at risk for behaviors due to dx

[diagnoses] of delusional disorder, sexual

disorder, and impulsive disorder. May make

inappropriate sexual comments...."

Resident 39 had current physician orders which

included, but were not limited to: Abilify (an

anti-psychotic medication) 5 mg (milligrams) once

a day.

A pharmacy recommendation, dated 4/9/19,

indicated Resident 39 had received Abilify with a

supporting diagnosis of depression, but had no

signs or symptoms of depression, and to consider

a GDR. The physician responded, Resident 39 had

a failed GDR on 1/4/2019, so a GDR was

contraindicated, and the resident was receiving

the optimal dose, and a reduction was likely to

impair the resident's function or increase

distressed behavior.


which requested a GDR of the resident's Abilify,

indicated Resident 39 was receiving the optimal

dose, and the physician declined a GDR at that

time due to a failed GDR on 10/22/2018.

The pharmacy recommendation, dated 10/22/2018,

recommendations and distribute to

the appropriate provider for follow

up.






All psych recommendation will be

reviewed during monthly behavior

meeting with the pharmacist,

psych provider, Social Service

Director, DNS and ADNS and

addressed as needed. DNS will

track completion of

recommendation and present all

results to the monthly Quality




be completed.

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which requested a GDR of the resident's Abilify,

indicated Resident 39 was receiving the optimal

dose, and the physician declined a GDR at that

time.


Director of Nursing Services (DNS) indicated she

was not here at the time of Resident 39's GDR's

and could not say why each one referred to a GDR

that was failed on different dates, but pharmacy

recommendations and GDR's should be followed

and recorded accurately.

2. On 2/19/2020 at 2:59 p.m., Resident 43's medical

record was reviewed. A most recent

comprehensive assessment was a Quarterly MDS

assessment, dated 1/8/2020, indicated Resident 43

was severely cognitively impaired, and had

recently coded physical behaviors and rejection

of care, and had active diagnoses to include but

were not limited to: non-Alzheimer's dementia,

Parkinson's disease, and received an

anti-psychotic medication.

She had a current comprehensive care plan for

behaviors, dated 7/23/19 and most recently

revised 1/17/2020, indicated, "Behaviors #1:

Resident is at risk for changes in mood or

behavior such as increased verbal or physical

aggression due to dx [diagnosis] of agitation. She

has orders for anti-psychotic medication...."

She had a discontinued physician order for

Seroquel, (an anti-psychotic medication) 25 mg

(milligrams). The order was originally received

3/12/2019, and discontinued on 10/28/2019, with

the indication for use listed as: "...agitation...."


indicated Resident 43 received Seroquel 25 mg





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without an adequate indication for use, and

recommended updating the order to include the

specific diagnosis, and a list of the symptoms or

target behaviors. The recommendation was

accepted by the physician with a note to update

the resident's order to: "...Dementia with

behaviors (hallucinations causing patient

distress)...."

During an interview on 2/24/2020 at 2:17 p.m., the

DNS indicated, the pharmacy recommendation

was accepted, but the order had not been updated

or clarified before it was finally discontinued on

10/28/19, six months after the recommendation had

been made.

On 2/24/2020 at 3:05 p.m., the DNS provided a

copy of current facility policy, titled, "Gradual

Dose Reduction (GDR) in Skilled Nursing

Facilities: Key Regulatory Concepts," dated,

3/2019. The policy indicated, "...Antipsychotic

medication: a GDR must be attempted in two

separate quarters (with at least one month

between attempts), unless clinically

contraindicated...a GDR must be attempted

annually, unless clinically contraindicated... a

GDR may be considered contraindicated if the:

Resident's target symptoms returned or worsened

after the most recent attempt at a GDR within the

facility, and, Physician has documented the

clinical rationale for why any additional attempted

dose reduction at that time would be likely to

impair the resident's function or increase

distressed behaviors...."

On 2/24/2020 at 3:00 p.m., the DON provided a

copy of current facility policy titled, "Medication

Regimen Review," (MRR) originally dated 12/2007

and revised 11/2016. The policy indicated,

"...facility should independently review each





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resident's medication regimen directly from the

resident's medical chart and with the

Interdisciplinary Care Team members, resident or

Responsible Party, as needed... facility should

encourage Physician/Prescriber or other

Responsible Parties receiving the MRR and the

Director of Nursing to act upon the

recommendation contained in the MRR... for those

issues that require Physician/Prescriber

intervention, Facility should encourage

Physician/Prescriber to either accept and act upon

the recommendations contained within the MRR,

or reject all or some of the recommendations

contained in the MRR and provide an explanation

as to why the recommendation was rejected...."

3.1-48(b)(2)

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

Label/Store Drugs and Biologicals

§483.45(g) Labeling of Drugs and Biologicals

Drugs and biologicals used in the facility

must be labeled in accordance with currently

accepted professional principles, and include

the appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

§483.45(h) Storage of Drugs and Biologicals

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

Federal laws, the facility must store all drugs

and biologicals in locked compartments

under proper temperature controls, and

permit only authorized personnel to have

access to the keys.

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

separately locked, permanently affixed

compartments for storage of controlled drugs

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listed in Schedule II of the Comprehensive

Drug Abuse Prevention and Control Act of

1976 and other drugs subject to abuse,

except when the facility uses single unit

package drug distribution systems in which

the quantity stored is minimal and a missing

dose can be readily detected.


review, the facility failed to label and store drugs

properly for 2 of 2 medication room observations.

Findings include:

On 2/24/2020 at 3:15 p.m., during a medication

storage room observation, in the Pine Hall

Medication Storage Room, with Registered Nurse

(RN) 20, 2 vials of tuberculosis testing serum were

stored in the refrigerator, in individual boxes. The

vials were both opened. Neither vial had an open

date, or initial on the box, or the vial.

On 2/24/2020 at 3:20 p.m., during an interview, RN

20 indicated the opened vials should have been

dated, and initialed, when they were opened. She

did not see any markings on the boxes, or vials.

On 2/24/2020 at 3:30 p.m., during a medication

storage observation, in the Sycamore Hall

Medication Storage Room, with Licensed Practical

Nurse (LPN) 21, 24 acetaminophen suppositories

were loose in a plastic bin of the refrigerator. They

were not contained in small Ziploc bags, like other

medications. There were no resident identifiers, or

labels, on the medication.


LPN 21 indicated the suppositories should have

been inside a package with the resident's name

and prescribing information on the label. She

believed someone had left the Ziploc bag open in




practice;

All open medications in

medication storage rooms and

carts have been labeled and

dated.






taken;


be affected.





not occur;

DNS/Designee will complete, and

audit of the medication storage

rooms for labeling and dating

medications. All nurses will be in

serviced on labeling of med vials,

bottles and pens, including

agency staff.





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the bin and had spill the 24 suppositories out of

the package when one was removed for

administration.


the Director of Nursing Services indicated the

medications were not properly stored.

On 2/25/2020 at 8:15 a.m., the Director of Nursing

Services provided a current policy, dated 4/5/19,

titled, "Storage and Expiration Dating of

Medications, Biologicals, Syringes and Needles."

This policy indicated "...Once any medication or

biological package is opened, Facility should

follow manufacturer/supplier guidelines with

respect to expiration dates for opened

medications. Facility staff should record the date

opened on the medication container has a

shortened expiration date once opened...Facility

should ensure that the medications and

biologicals for each resident are stored in the

containers in which they were originally

received...."

3.1-25(j)

3.1-25(k)(1)

3.1-25(k)(2)

3.1-25(k)(3)

3.1-25(k)(4)

3.1-25(k)(5)

3.1-25(k)(6)

3.1-25(k)(7)


DNS/Designee will complete

monthly audits of medication carts

and medication storage rooms 3 x

week for 4 weeks, 2 x week for 4

weeks and hen weekly x 4

months. All results will be present

monthly to the Quality Assurance

Committee.



be completed.

3-26-20

483.60(i)(1)(2)

Food

Procurement,Store/Prepare/Serve-Sanitary

§483.60(i) Food safety requirements.

The facility must -

§483.60(i)(1) - Procure food from sources

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approved or considered satisfactory by

federal, state or local authorities.

(i) This may include food items obtained

directly from local producers, subject to

applicable State and local laws or

regulations.

(ii) This provision does not prohibit or prevent

facilities from using produce grown in facility

gardens, subject to compliance with

applicable safe growing and food-handling

practices.

(iii) This provision does not preclude residents

from consuming foods not procured by the

facility.

§483.60(i)(2) - Store, prepare, distribute and

serve food in accordance with professional

standards for food service safety.


review, the facility failed to ensure the kitchen

storage area floors were clean, dry storage

shelves were clean and free from dust build up,

and kitchen floors were free from spills for 1 of 1

kitchen observation. The facility failed to prevent

potential contamination of brown sugar in the

memory care dining area for 4 of 4 observations,

and failed to ensure a clean area to serve food in

the memory care dining area for 5 of 5

observations.

Findings include:

1. On 2/18/2020 from 9:40 a.m., until 10:00 a.m., an

initial kitchen tour was completed with the "float"

Culinary Manager (CM).

The floors of the dry storage area were observed

to be severely scuffed, particularly around the

metal feet of the storage racks, were circles of rust




practice;

a. The floor in the dry storage

area in the kitchen has been clean

and buffed to remove the scuffs

and rust circles. Vendor has been

assigned to give quote to replace

flooring in the dry storage area.

b. The metal shelves in the dry

storage area has been cleaned

and are free of debris.

c. The red stain observed in the

walk-in freezer has been cleaned.

d. The trim along the bottom of

the unit in the middle walk in

cooler has been cleaned and

repaired.

e. The coffee stain on the floor by

the coffee machine has been

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build up were observed. The CM indicated the

rust circles were probably from where staff pulled

the racks back a forth as needed when they

cleaned around shelving units. Several cracks,

holes, and gouges were observed throughout the

surface of the floor, and several inches of flooring

were missing on the floor of the entrance to dry

storage. Because the CM was filling in, until a

permanent manager was hired, she could not

indicate how often the floors were cleaned, or how

old the dry storage floor was, or whether or not it

had been deep cleaned.

The dry storage room, tall metal wire shelving unit

were used to store boxes of food, food supplies,

and other miscellaneous kitchen items. The

bottom racks of the shelving units were observed

with a build up of dust, rust, and other

unidentified debris. The CM indicated she did not

know what it was, and the shelves needed to be

cleaned.

The walk-in freezer was observed, and there was a

large red stain was observed on the floor, it was

sticky to walk through. The CM indicated it

looked like some red juice/punch had spilled and it

should have been cleaned up.

The middle walk-in cooler was observed. A long

section of trim along the bottom of the unit was

missing. Inside the exposed areas left uncovered

by the missing piece, was a copious amount of

build up of unidentified debris. The CM indicated

she did not know about the missing piece, or how

long it had been missing.

The coffee station beside the chest ice machine

was observed. There was a very large spill of

coffee left on the floor, it covered the surface area

under the coffee station and chest ice machine.

cleaned.

f. The Memory care unit

kitchenette has been cleaned and

all open condiment packets have

been removed.

g. The popcorn machine observed

in the memory care kitchenette

has been removed.






taken;


be affected.





not occur;

a. The Memory Care Support

Specialist will complete during

daily rounds to ensure the

kitchenette area is clean and

sanitary.

b. The Culinary Manager will do

daily checks to ensure that the

floors and shelves in the dry

storage area and kitchen are

maintained for cleanliness.






The Memory Care Support

Specialist and Culinary Manager

will conduct daily, weekly audits of

the areas. All results will be





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The CM indicated she did not know how long the

spill had been there but it should have been

cleaned up immediately.

On 2/19/2020 at 8:52 p.m., the Administrator

provided a copy of current facility policy titled,

"Cleaning Floors, Tables, and Chairs," dated,

2/2002. The policy indicated, "...kitchen and

dining room floors, tables, and chairs will be kept

clean and sanitary... kitchen floors will be swept

and cleaned after each meal. Major appliances will

be moved in order to facilitate cleaning behind

and underneath them at frequency indicated on

the cleaning schedule...."

2. On 2/18/2020 at 10:32 a.m. during the initial tour

of the Cottage (Memory Care Unit), a bag of

brown sugar was observed, laying on counter top,

of the Dinning/Activity Room, torn open, with a

spoon sticking out of the bag. It did not contain

an open date.

On 2/20/20 at 11:18 a.m., during a random

observation, of the Cottage, the bag of brown

sugar was laying on counter top, in the

Dinning/Activity Room, it was torn open, with a

spoon sticking out of the bag.


observation of breakfast, in the Cottage

Dining/Activity Room, oat meal was observed in a

large black electric kettle. On the countertop was

the bag of brown sugar, previously observed, in a

torn open bag , a small black disposable

condiment cup was inside the bag.


observation, the torn open bag of brown sugar

was observed in a cabinet, above sink next to an

air diffuser, the bag was open to air. A small black

plastic condiment cup inside bag.

presented monthly to the Quality

Assurance Committee



be completed.

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On 2/25/20 at 8:46 a.m., during an observation, and

interview, the Memory Care Director indicated, the

bag of brown sugar should not have been sitting

open, unsealed in the cabinet, with a condiment

cup inside it. After opening, the brown sugar it

should have been placed in a closed container.

On 2/25/200 at 11:26 a.m., the Administrator

provided a current policy, dated 5/18, titled " Food

Storage Policy." This policy indicated "...scoops

are not stored in storage containers...containers

with lids must be used for storing ...sugar, dried

vegetables, and broken lots of bulk foods. These

containers should be labeled and dated on both

the container and the lid...."

3. On 2/18/2020 at 10:32 a.m., during the initial tour

of the Cottage (Memory Care Unit), a popcorn

machine was observed, as it sat on the Cottage

Dining Room counter. The exterior appeared dirty.

The glass inside, was greasy, with streaks, the

kettle was greasy with particles stuck to it.

Kernels and husks were present in the bottom, on

the grid.

On 2/18/2020 at 12:16 p.m., during a lunch

observation, in the Cottage Dining/Activity

Room, the soiled popcorn machine was observed

on the countertop, where meals were being

served.

On 2/20/20 at 11:18 a.m., the popcorn machine was

observed, on the Cottage Dining Room Counter,

still not cleaned, greasy streaks, husks, and

kernels remained present.


observation of breakfast, in the Cottage

Dining/Activity Room, the soiled popcorn





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machine was observed on the countertop, where

meals were being served.

On 2/24/2020 at 10:41 a.m., during an interview,

and observation, in the Cottage Dining/Activity

Room, Activities Assistant 14 indicated, the

Activity's Department was responsible for

cleaning the popcorn machine. The Activity

Employees on the other side (Long Term Care,

and Residential) cleaned their machine, after use.

The machine in the Cottage Dining/Activity area

had not been used in a month, since the prior

Activity Assistant left. She didn't know when it

was last used. The last time she served popcorn

she served from the other area's machine. That

was the only one she had used since becoming

the Activity Assistant on the Cottage, about a

month ago. When they have had popcorn it was

on a day the other areas had popcorn too, they

just shared the machine. The popcorn machine

was observed, with Activity Assistant 14, it

remained on the Cottage Dining Room counter,

uncleaned.

On 2/24/2020 at 1:50 p.m., during an interview, the

Director of Nursing Services indicated, the

popcorn machine on the Cottage had come

upstairs from the basement move out. It should

have been trashed, but the prior Activity Director

wanted it, for her church, and was going to take it,

but never did. They were not currently using it.

The Cottage shared the other area's popcorn

machine. She did not know it was still back there.

It was trash, and should have been thrown out,

everything in the basement was trash. It should

not have been where food was served.

On 2/24/2020 at 2:31 p.m., the popcorn machine

was observed, on the Cottage Dining Room

counter, where resident meals were served, it





05/20/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

Documents

F 0000 - Indiana · 2020. 5. 20. · assistance with ADL's (activities of daily living), "Bra on daily." On 2/19/2020 at 01:16 p.m., Resident 37 was observed dressed in red plaid