F 0000 - IN.gov · Aide left room, res then rang her light, [the] nurse answered and res states 'I just peed everywhere, I'm soaked.' Informed res that care would be provided shortly

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

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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)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

NORTH VERNON, IN 47265

155665 02/14/2019

MAJESTIC CARE OF NORTH VERNON

701 HENRY STREET

00

F 0000

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This visit was for a Recertification and State

Licensure Survey.

Survey dates: February 10, 11, 12, 13, and 14, 2019

Facility number: 010996

Provider number: 155665

AIM number: 200232210

Census Bed Type:

SNF/NF: 104

Total: 104

Census Payor Type:

Medicare: 10

Medicaid: 69

Other: 25

Total: 104

These deficiencies reflect State findings cited in

accordance with 410 IAC 16.2-3.1

Quality review completed on February 21, 2019.

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

resident with respect and dignity and care for

each resident in a manner and in an

environment that promotes maintenance or

F 0550

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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: 58WD11 Facility ID: 010996

TITLE

If continuation sheet Page 1 of 48

(X6) DATE




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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 record review and interview, the facility

failed to treat a resident with dignity related to

personal care. This deficient practice effected 1 of

21 residents reviewed for dignity. (Resident 35)

Findings include:

The clinical record for Resident 35 was reviewed

on 02/12/19 at 11:27 A.M. An Annual MDS

(Minimum Data Set) assessment, dated 11/19/18,

F 0550 Preparation and or/execution of

this plan does not constitute

admission or agreement by the

provider that a deficiency exists.

this response is also not to be

construed as an admission of fault

by the facility, its employees,

agents or other individuals who

draft or may be discussed in this

response and plan of correction.

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indicated the resident was cognitively intact.

Diagnoses included, but were not limited to, heart

failure and diabetes. The resident was always

incontinent of bladder and had no behaviors

during the 7 day look back period.

A progress note, dated 12/29/18 at 02:49 P.M.,

indicated "...Res [Resident 35] returned from

smoking activity, [an] aide went to assist [the] res

with coat and asked res if she needed to toilet.

Res states 'I don't have to pee and its lunch time, I

haven't had lunch yet.' CNA [Certified Nurse

Aide] reminded res that we have already eaten

lunch and that she just came in from 2 PM smoke

break. Res reiterates 'well I don't have to pee just

help me get to bed then.' Res assisted to sitting on

side of bed. Aide left room, res then rang her light,

[the] nurse answered and res states 'I just peed

everywhere, I'm soaked.' Informed res that care

would be provided shortly as aides and nurse

were currently tied up with other duties. Nurse

informs res 'don't lie down because we will be

back in just a moment to take you to the toilet.'

Res states 'I don't need to use the toilet.' Nurse

replied 'you need to sit on the toilet to get washed

up and change clothes.' nurse left [the] room,

entered [the] room next door and upon exiting res

had light back on. nurse entered room to check on

res, res lying down, nurse reminded res that I ahd

[had] just asked her to not lie down, she states

[well I want to be changed in bed.] Res is capable

of transferring with assist into w/c [wheelchair]

and onto the toilet. Res states 'then just don't

worry about me.' Staff waited 15 minutes to allow

res time to calm down, reentered room and asked

res to get up to go to the toilet. Res states 'if I cant

be changed here in bed then I don't want changed

at all.' Staff left area again..."

During an interview on 02/14/19 at 09:49 A.M., the

This plan of correction is Majestic

Care's credible allegation of

compliance.

Element 1:

All Residents have the potential to

be affected by this practice. Staff

member has been educated on

resident rights and choice of care.

Element 2:

Resident #35 was evaluated by

Social Services with no residual

impact or negative Psycho social

concern found.

Element 3:

The facility will complete Resident

Right and Dignity program care

audits weekly x4 and monthly

x6. Care Team members to be

educated on Resident rights, and

dignity with an emphasis around

person centered care. Resident

Rights will be reviewed in Resident

council. Progress notes will be

reviewed in daily clinical meeting

5x/week for 6 months.

Element 4:

Resident Right and Dignity

Program Care Audits will be

submitted for review and

recommendation monthly x6

months and results will be

forwarded to QA until substantial

compliance is achieved.





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DON (Director of Nursing) indicated if a resident

was capable of going to the bathroom and wanted

to be provided care in bed then the staff should

provide them care in bed. Resident 35 had

behaviors and was more than capable of getting

out of bed to go to the bathroom.

The current facility policy with a revision date of

December 2016 and titled "Resident Rights" was

provided by the DON on 02/14/19 at 10:19 A.M.

The policy indicated "...Policy

Statement...Employees shall treat all residents with

kindness, respect, and dignity...Policy

Interpretation and Implementation...1. Federal and

state laws guarantee certain basic rights to all

residents of this facility. These rights include the

resident's right to: b. be treated with respect,

kindness, and dignity..."

3.1-3(t)

483.10(i)(1)-(7)

Safe/Clean/Comfortable/Homelike

Environment

§483.10(i) Safe Environment.

The resident has a right to a safe, clean,

comfortable and homelike environment,

including but not limited to receiving

treatment and supports for daily living safely.

The facility must provide-

§483.10(i)(1) A safe, clean, comfortable, and

homelike environment, allowing the resident

to use his or her personal belongings to the

extent possible.

(i) This includes ensuring that the resident

can receive care and services safely and that

the physical layout of the facility maximizes

resident independence and does not pose a

safety risk.

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(ii) The facility shall exercise reasonable care

for the protection of the resident's property

from loss or theft.

§483.10(i)(2) Housekeeping and maintenance

services necessary to maintain a sanitary,

orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that

are in good condition;

§483.10(i)(4) Private closet space in each

resident room, as specified in §483.90 (e)(2)

(iv);

§483.10(i)(5) Adequate and comfortable

lighting levels in all areas;

§483.10(i)(6) Comfortable and safe

temperature levels. Facilities initially certified

after October 1, 1990 must maintain a

temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of

comfortable sound levels.

Based on observation and interview, the facility

failed to provide a safe and clean environment

related to a shower room. This deficient practice

effected 1 of 2 shower rooms observed. (shower

room for C and D Halls)

Findings include:

On 02/14/19 at 11:07 A.M., The following was

observed in the shower room shared by the C and

D halls:

-Shower stall one had cinder blocks and drywall

exposed leading into the stall. There were 16 four

inch x (by) four inch tiles and 9 two inch x four













compliance.

Element 1:

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inch tiles missing on the door frame leading into

the stall. Inside the stall there was a black

substance around the bottom of two interior walls.

There was missing and cracked caulk along the

same walls.

-Shower stall two had caulk missing on one half of

the left wall and two strips of duct tape holding a

piece of vinyl corner molding in place at the

entrance.

-Shower stall three had 3 four inch x four inch tiles

and 3 two inch x four inch tiles missing. There was

a black substance on the back wall. This stall had

a stack of chairs in the middle and had the

appearance of not being used.

-Shower stall four had 4 four inch x four inch tiles

and 7 four inch x two inch tiles missing. This stall

lacked a shower hose.

-Shower stall five had a black substance and caulk

missing in the back right corner.

During an interview on 02/14/19 at 11:21 A.M.,

CNA (Certified Nurse Aide) 6 indicated the

shower room was used by resident on both C and

D halls. Stall one was used most often, stall two

was only used if the CNA's had to because the

water pressure was not good. Stalls three and four

were not in working order. Stall five was used only

if absolutely necessary because the water did not

get hot.

During the Resident Council meeting on 02/12/19

at 02:01 P.M., Resident 84 indicated the shower

room had "black mold" in it.

An anonymous interview during the survey time

period from 02/10/19 to 02/14/19, indicated the

All residents have the potential to

be effected

Element 2:

The facility has renovated the

environment of the shower room to

provide a safe, clean and

comfortable environment. Vinyl

coverings were removed and

replaced with 13 inch ceramic tile.

Resealed and caulked all access

points and seams.

Element 3:

Environmental Audits will be

completed weekly x4 weeks and

monthly x6 months or until

substantial compliance is met.

Element 4:

Environmental Care Audits will be



months and results will be

forwarded to QA until substantial






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shower room was "gross".

An anonymous interview during the survey time

period from 02/10/19 to 02/14/19, indicated the

shower room had been in the current condition

since the last survey.


Administrator indicated when he started at the

facility in October of 2018 he instructed both the

housekeeping and the maintenance staff to use a

mildew blocking paint in the shower room. The

shower room needed a complete overhaul.

Estimates have been obtained. A defined start or

completion date were not identified.

3.1-19(f)

483.20(b)(2)(ii)

Comprehensive Assessment After Signifcant

Chg

§483.20(b)(2)(ii) Within 14 days after the

facility determines, or should have

determined, that there has been a significant

change in the resident's physical or mental

condition. (For purpose of this section, a

"significant change" means a major decline

or improvement in the resident's status that

will not normally resolve itself without further

intervention by staff or by implementing

standard disease-related clinical

interventions, that has an impact on more

than one area of the resident's health status,

and requires interdisciplinary review or

revision of the care plan, or both.)

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failed to complete a Significant Change MDS

(Minimum Data Set) assessment for 1 of 24

residents reviewed. (Resident 61)






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Findings include:


on 02/12/19 at 10:06 A.M. A Significant Change

MDS assessment, dated 12/21/18, indicated the

resident had diagnoses that included, but were

not limited to, deep vein thrombosis,

hypertension, hip fracture, dementia, depression,

and psychotic disorder. Section C (Cognitive

Patterns), and Section D (Mood) were not

completed.


Corporate MDS Coordinator indicated for a

Significant Change assessment, Sections C and D

should have been completed.


SSD (Social Services Director) indicated according

to the RAI (Resident Assessment Instrument)

manual, if the interview with the resident could

not be completed in the assessment time frame of

7 days it had to be documented as "not assessed"

and the staff portion of the assessment could not

be completed. The interview was unable to be

completed due to MDS staff transitioning taking

place at that time.

3.1-31(c)(3)








compliance.

Element 1:


be affected by this practice. MDS

staff have been educated on MDS

accuracy and assessment.

Element 2:

Resident #61 has had a significant

MDS correction and has been

transmitted.

Element 3:

The facility will audit MDS

accuracy weekly x4 weeks and

monthly x6 months or until

substantial compliance is

achieved

Element 4:

MDS Coding Accuracy audits will

be submitted for review and


months. Results will be forwarded

to the QA until substantial


483.20(g)

Accuracy of Assessments

§483.20(g) Accuracy of Assessments.

The assessment must accurately reflect the

resident's status.

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failed to accurately complete MDS (Minimum Data

Set) assessments related to death, PASRR (Pre

Admission Screening and Resident Review)

status, and medications for 2 of 24 residents

reviewed for assessments (Residents 110, 59)

Findings include:

1. The clinical record for Resident 110 was

reviewed on 02/13/19 10:21 A.M. An annual MDS

assessment, dated 11/23/18, indicated the resident

was moderately cognitively impaired. Diagnoses

included, but were not limited to, heart failure,

hypertension, and diabetes. The resident required

extensive assistance with all ADLs (Activities of

Daily Living).

During an interview on 02/13/19 at 03:43 P.M.,

LPN (Licensed Practical Nurse) 3 indicated that on

01/02/19, staff went to check on Resident 110 and

found her unresponsive. Staff started CPR

(Cardiopulmonary Resuscitation) and contacted

EMS (Emergency Medical Services). EMS arrived,

worked on the resident at the facility, and then

transported her to the hospital.

On 02/14/19 at 12:46 P.M., LPN 4 provided the

"Nursing Home to Hospital Transfer Form" for

Resident 110. The form indicated Resident 110

was sent to the local hospital on 01/02/19.

An MDS Death in the Facility assessment, dated

01/02/19, indicated Resident 110's discharge

status as deceased.

2. The clinical record for Resident 59 was reviewed

on 02/14/19 at 11:34 A.M. An Admission MDS


was moderately cognitively impaired. Diagnosis

included, but was not limited to, manic













compliance.

Element 1:


be affected by this practice. New

MDS Coordinator has been hired

and educated on MDS accuracy

and assessment.

Element 2:

Resident #110 no longer resides in

the facility. Resident #59 MDS

has been modified and transmitted

to accurately reflect Residents

status.

Element 3:

The Facility will audit the MDS

accuracy weekly x4 weeks and

monthly x6 months

Element 4:

MDS Audits will be submitted for

review and recommendation

monthy x6 months and results will

be forwarded to QA until


achieved.

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depression. Section A 1500-Preadmission

Screening and Resident Review indicated the

resident did not have a state level 2 PASRR.

A level 2 PASRR, dated 05/17/18, was provided by

the DON (Director of Nursing) on 02/14/19 at 12:10

P.M.

A 60 day Medicare assessment, dated 12/28/18,

indicated Resident 59 had received anticoagulants

for 7 out of 7 days during the 7 day look back

period.

The December 2018 MAR (Medication

Administration Record) had no indication the

resident had received an anticoagulant.


LPN 3 indicated the facilities home office had been

completing the MDS assessments for the past 5 to

6 months. Resident 110's MDS assessment should

have been a discharge-return not anticipated

instead of a death in the facility. Resident 59's

MDS should have indicated he had a PASRR level

2 and that he did not receive anticoagulants. The

facility refers to the RAI (Resident Assessment

Instrument) manual for all MDS assessments.

3.1-31(d)(3)

3.1-31(c)(1)

3.1-31(c)(13)

483.20(k)(1)-(3)

PASARR Screening for MD & ID

§483.20(k) Preadmission Screening for

individuals with a mental disorder and

individuals with intellectual disability.

§483.20(k)(1) A nursing facility must not

admit, on or after January 1, 1989, any new

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residents with:

(i) Mental disorder as defined in paragraph (k)

(3)(i) of this section, unless the State mental

health authority has determined, based on an

independent physical and mental evaluation

performed by a person or entity other than

the State mental health authority, prior to

admission,

(A) That, because of the physical and mental

condition of the individual, the individual

requires the level of services provided by a

nursing facility; and

(B) If the individual requires such level of

services, whether the individual requires

specialized services; or

(ii) Intellectual disability, as defined in

paragraph (k)(3)(ii) of this section, unless the

State intellectual disability or developmental

disability authority has determined prior to

admission-

(A) That, because of the physical and mental

condition of the individual, the individual

requires the level of services provided by a

nursing facility; and

(B) If the individual requires such level of

services, whether the individual requires

specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of

this section-

(i)The preadmission screening program under

paragraph(k)(1) of this section need not

provide for determinations in the case of the

readmission to a nursing facility of an

individual who, after being admitted to the

nursing facility, was transferred for care in a

hospital.

(ii) The State may choose not to apply the

preadmission screening program under

paragraph (k)(1) of this section to the





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admission to a nursing facility of an

individual-

(A) Who is admitted to the facility directly

from a hospital after receiving acute inpatient

care at the hospital,

(B) Who requires nursing facility services for

the condition for which the individual received

care in the hospital, and

(C) Whose attending physician has certified,

before admission to the facility that the

individual is likely to require less than 30

days of nursing facility services.

§483.20(k)(3) Definition. For purposes of this

section-

(i) An individual is considered to have a

mental disorder if the individual has a serious

mental disorder defined in 483.102(b)(1).

(ii) An individual is considered to have an

intellectual disability if the individual has an

intellectual disability as defined in

§483.102(b)(3) or is a person with a related

condition as described in 435.1010 of this

chapter.

Based on interview and record review, the facility

failed to obtain a PASRR (Pre Admission

Screening and Resident Review) Level II

assessment referral for a resident with a diagnosis

of a major mental illness. This deficient practice

effected 1 of 1 residents reviewed for PASRR.

(Resident 33)

Findings include:


on 02/12/19 at 09:50 A.M. A Quarterly MDS


indicated the resident was cognitively intact. He

required extensive assistance with ADLs

(Activities of Daily Living). Diagnoses included,













compliance.

Element 1:

All Resident have the potential to

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but were not limited to, psychotic disorder,

hypertension, diabetes, depression, and anxiety.

A PASRR Level I evaluation dated 01/15/16

indicated the resident had a diagnosis of a major

mental illness (Question 2), and had been

prescribed psychoactive medications on a regular

basis (Question 3b). The instructions page of the

PASRR Level I form indicated "Note: Level II is

always required if there is a concurrent diagnosis

of a major mental illness in Question 2 of the Level

I [PASRR evaluation]."

During an interview on 02/14/19 at 03:11 P.M., the

Social Services Director indicated Resident 33 did

not have a PASRR Level II assessment in his

clinical record.

The current facility policy, titled "Level I Screen",

and dated 04/01/2007, was provided by the

Director of Nursing on 02/14/19 at 10:55 A.M. The

policy indicated, "...Level II evaluations must be

completed prior to admission..."

3.1-16(d)(1)

be affected by this practice.

Element 2:

Resident #33 had a level of care

completed

Element 3:

The facility will complete an audit

on all new admissions and any

change of condition in diagnosis

weekly x4 weeks and monthly x6

months. Staff will be educated on

the policy and procedure for

preadmission screening.

Element 4:

Preadmission screening and

Resident Review Critical elements

audits will be submitted for review

and recommendation monthly x6


to QA until substantial compliance

is achieved.

483.21(b)(1)

Develop/Implement Comprehensive Care Plan

§483.21(b) Comprehensive Care Plans

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

implement a comprehensive person-centered

care plan for each resident, consistent with

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

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

objectives and timeframes to meet a

resident's medical, nursing, and mental and

psychosocial needs that are identified in the

comprehensive assessment. The

comprehensive care plan must describe the

following -

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(i) The services that are to be furnished to

attain or maintain the resident's highest

practicable physical, mental, and

psychosocial well-being as required under

§483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be

required under §483.24, §483.25 or §483.40

but are not provided due to the resident's

exercise of rights under §483.10, including

the right to refuse treatment under §483.10(c)

(6).

(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with

the findings of the PASARR, it must indicate

its rationale in the resident's medical record.

(iv)In consultation with the resident and the

resident's representative(s)-

(A) The resident's goals for admission and

desired outcomes.

(B) The resident's preference and potential for

future discharge. Facilities must document

whether the resident's desire to return to the

community was assessed and any referrals

to local contact agencies and/or other

appropriate entities, for this purpose.

(C) Discharge plans in the comprehensive

care plan, as appropriate, in accordance with

the requirements set forth in paragraph (c) of

this section.


failed to develop a Care Plan related to nutrition

related to significant weight loss and infection

related to cellulitis. This deficient practice effected

2 of 24 residents reviewed for Care Plans.

(Resident 55 and 40)

Findings include:










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on 02/12/19 at 03:03 P.M. A Quarterly MDS


indicated the resident was severely cognitively

impaired, and needed supervision and cueing

assistance of one staff member for eating.

Diagnoses included, but were not limited to,

peripheral vascular disease, hip fracture,

Alzheimer's disease, dementia, and depression.

The resident had coughing or choking during

meals or when swallowing medications.

The "Weights and Vitals Summary" for Resident

55 was provided by the DON (Director of Nursing)

on 02/13/19 at 10:26 A.M. The record indicated the

resident weighed 124 pounds on 12/04/18 and 117

pounds on 01/05/19. A significant weight loss of

5.65% (percent).

The complete Care Plan for Resident 55 was

provided by the DON on 02/14/19 at 10:19 A.M.

No Nutritional Care Plan was initiated or created

prior to 02/14/19.

During an interview on 02/14/19 at 12:37, P.M., the

DON indicated Resident 55, who had a significant

weight loss in January, should have had a

Nutrition Care Plan before 02/14/19.




was cognitively intact. Diagnosis included, but

was not limited to, hypertension.

A physician order, dated 01/31/19, indicated to

start doxycycline 100 mg (milligram) tablet, give 1

tablet by mouth, twice a day for 10 days, for a

diagnosis of cellulitis (a skin infection) to the left

abdomen.




compliance.

Element 1:

All residents have the potential to

be affected by this practice. All

staff educated on care planning,

IDT, Dietician, weight assessment

and intervention, and nutritional

assessment.

Element 2:

Resident #40 antibiotic has been

complete. Resident #55 has had a

nutritional care plan put in place

on 2/14/19.

Element 3:

The facility will complete an

interdisciplinary care plan audit


months.

Element #4:

IDT care plan audits will be





is achieved.





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The complete and resolved Care Plans for

Resident 40 was provided by the DON on 02/13/19

at 10:26 A.M. There was no Care Plan indicating

the resident has cellulitis to her abdominal fold.


DON indicated if a resident had a new infection

then a Care Plan would be created for the resident.

Care Plans were created as an issues arose. Care

Plans were initiated during the morning meetings.


September 2013 titled "Care Planning -

Interdisciplinary Team" was provided by the DON

on 12/14/19 at 10:19 A.M. The policy indicated

"...Our facility's Care Planning/Interdisciplinary

Team is responsible for the development of an

individualized comprehensive care plan for each

resident..."

3.1-35(a)

483.25(b)(1)(i)(ii)

Treatment/Svcs to Prevent/Heal Pressure

Ulcer

§483.25(b) Skin Integrity

§483.25(b)(1) Pressure ulcers.

Based on the comprehensive assessment of

a resident, the facility must ensure that-

(i) A resident receives care, consistent with

professional standards of practice, to prevent

pressure ulcers and does not develop

pressure ulcers unless the individual's clinical

condition demonstrates that they were

unavoidable; and

(ii) A resident with pressure ulcers receives

necessary treatment and services, consistent

with professional standards of practice, to

promote healing, prevent infection and prevent

new ulcers from developing.

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failed to provide treatment and services for a

resident with an identified skin impairment

resulting in a Stage 3 pressure ulcer

(Full-thickness skin loss, in which fat was visible

in the ulcer and granulation tissue and epibole

[rolled wound edges] are often present. Slough

[dead tissue] and/or eschar [black dead tissue]

may be visible). This deficient practice effected 1

of 3 residents reviewed for pressure ulcers.

(Resident 35)

Findings include:


on 02/12/19 at 11:27 A.M. An Annual MDS



Diagnoses included, but were not limited to, heart

failure and diabetes.

The December 2018 TAR (Treatment

Administration Record) indicated weekly skin

assessments were completed on 12/06/18 and

12/13/18, and indicated the resident had a red

coccyx.

The December 2018 progress notes lacked

documentation of the observation of a red coccyx

from 12/06/28 through 12/19/18 or that the

physician was notified.

A progress note, dated 12/19/18 at 11:36 A.M.,

indicated "...Res [Resident 35] has sheared area to

coccyx, NP [Nurse Practitioner] updated and new

order recd [received] to apply skin prep to coccyx

QHS [every bedtime]. All appropriate parties

aware..."

A "Wound- Weekly Observation Tool", dated













compliance.

Element 1:


be affected by this practice. All

nurses have been educated on the

policy and procedure for

identifying, documenting, and

providing treatments for newly

identified wounds.

Element 2:

Resident #35 continues to reside

in the center, with pressure ulcer

to the left buttock. Area is and has

shown improvement, currently

presenting as a stage 2 pressure

ulcer.

Element 3:



months.

Element 4:

Pressure ulcer prevention and

care, and Wound care audits will


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12/20/18, indicated "...left buttock...Stage 3

pressure ulcer...epithelial tissue present

[pink]...Granulation tissue present [beefy

red]...50% [percent] necrosis and/or slough in the

wound bed...Drainage: serosanguinous, small

amount...no odor...2.5 cm [centimeters] X [by] 0.5

X 0.1...Peri-wound tissue...blanchable

redness...irregular...Treatment: start duoderm to

open and change every 3 days..."



pressure ulcer...unchanged...Granulation tissue

present [pink]...slough tissue present [yellow, tan,

white, stringy]...25% necrosis and/or slough in the

wound bed...no drainage...no odor...2.3 X 1.4 X

0.1...Peri-wound tissue...blanchable

redness...irregular...Treatment: duoderm..."



pressure ulcer...improving...epithelial tissue

present [pink]...Granulation tissue present [beefy

red]...25% epithelial tissue, 75% gran

[granulation]...no drainage...no odor...0.6 X 0.3 X

0.1...Peri-wound tissue... intact, per normal hue

with blanchable redness...irregular...Treatment:

continue with duoderm..."



pressure ulcer...unchanged...epithelial tissue


red]...Drainage: scant, serous...no odor...1 X 0.3 X

0.1...Peri-wound tissue...intact, per normal

hue...irregular...Treatment: duoderm..."







is achieved until substantial






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red]...25% gran, 75% epithelial tissue...Drainage:

scant, serous...no odor...0.3 X 0.2 X

0.1...Treatment: duoderm..."




present [pink]...100% epithelization...no drainage...

0.2 X 0.2 X 0.1...Peri-wound tissue...blanchable





present [pink]...no drainage...no odor...0.1 X 0.2 X





pressure ulcer...unchanged...epithelial tissue

present [pink]...no drainage...no odor...0.1 X 0.2 X



During an interview on 02/13/19 at 10:34 A.M., RN

8 indicated every resident would get their skin

assessed weekly and the nurses sign it off in the

treatment book. If someone had a new skin

concern she would document it in a progress note

and complete a new wound/skin assessment

under the evaluation tab in the electronic health

record. The evaluation would include the color,

measurements, and initial treatment until a new

order was provided by the physician.


DON (Director of Nursing) indicated if a resident

had a reddened area on a bony prominence or a





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Stage 1 pressure ulcer then nurses should open a

new wound observation and implement a

treatment, if needed, and notify the physician and

the DON.

A current facility policy, with a revision date of

06/01/18, and titled "Pressure Ulcers/Pressure

Injury Prevention and Treatment - Clinical

Protocol", was provided by the DON on 02/14/19

at 10:19 A.M. The policy indicated, "...Based on

the comprehensive assessment of a resident, a

resident receives care, consistent with

professional standards of practice, to prevent

pressure ulcers and does not develop pressure

ulcers unless the individuals's clinical condition

demonstrates that they were unavoidable...9.

Change of condition/New skin alteration: a.

Complete head to toe assessment, document in

the medical record; b. Notify the physician; c.

Obtain new orders as needed..."

3.1-40(a)(1)

483.25(d)(1)(2)

Free of Accident

Hazards/Supervision/Devices

§483.25(d) Accidents.

The facility must ensure that -

§483.25(d)(1) The resident environment

remains as free of accident hazards as is

possible; and

§483.25(d)(2)Each resident receives

adequate supervision and assistance devices

to prevent accidents.

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Based on observation, record review, and

interview, the facility failed to maintain a secure

environment related to an open exit door and

complete neurochecks (Neurological

assessments). This deficiency had the potential to






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affect 3 of 3 residents wearing a Wander Guard (a

location monitoring device) and effected 2 of 3

residents reviewed for accidents. (Residents 14,

24, 51, 25, and 96)

Findings include:

1. During an observation on 02/10/19 at 11:17

A.M., a rock was propping the exterior door to the

A hall open. No residents were observed near the

door at this time.

During an observation on 02/11/19 at 10:49 A.M.,

a rock was propping the exterior door to the A hall

open. No residents were observed near the door

at this time.


LPN (Licensed Practical Nurse) 3 indicated when a

wanderguard (location alerting device) was near

an open door the alarm will sound. When the door

was closed the door locks. The A hall exterior

door lacks a code to enter or exit. The night shift

nurse locks the door during their shift.


Administrator indicated the exterior door on the A

hall should not be propped open.

On 02/11/19 at 10:45 A.M., the DON (Director of

Nursing) provided a list of residents who wore a

Wander Guard to prevent elopement.


on 02/11/19 at 11:45 A.M., a Quarterly MDS


indicated she was severely cognitively impaired

and propels herself in a wheelchair. A Quarterly

Wandering Assessment, dated 02/05/19, indicated

"no reports of wandering in the last 6 months".








compliance.

Element 1:


be affected as a result of this

practice. Nursing staff have been

educated on Exits, means of

egress, wanderings, unsafe

residents, Neurological

assessment, falls, falls risk, and

management of falls.

Element 2:

Resident #25 and #96 continue to

reside in the facility. Both

Residents have normal

neurological checks at this time.

Element 3:


x4 weeks and monthly x6 months.

Element 4:

Fall prevention care audits will be





is achieved.





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on 02/11/19 at 11:45 A.M., a Quarterly MDS

assessment, dated 11/21/18, indicated she was

moderately cognitively impaired and ambulated

with a walker. A Quarterly Wandering

Assessment, dated 02/11/19, indicated "no reports

of wandering in the last 6 months".


on 02/11/19 at 11:45 A.M., an Annual MDS

assessment, dated 12/15/18, indicated she was

cognitively intact and ambulated with a walker. A

Quarterly Wandering Assessment, dated 02/05/19,

indicated "no reports of wandering in the last 6

months".

The current "Wandering, Unsafe Resident" policy

with a revised date of August 2018, indicated

"...The facility will strive to prevent unsafe

wandering while maintaining the least restrictive

environment for residents who are at risk for

elopement..."




indicated Resident 25 was severely cognitively

impaired. Diagnoses included, but were not limited

to, dementia and psychotic disorder. The resident

required extensive assistance of two staff

members for bed mobility, transfers, and dressing.

The resident required the extensive assistance of

one staff member for toilet use and personal

hygiene. The resident was frequently incontinent

of urine and of bowel.

Progress Notes for Resident 25 were provided by

the DON (Director of Nursing) on 02/13/19 at 03:34

P.M. A note, dated 09/21/18 at 02:15 P.M.,

indicated the resident was yelling from her room





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and was found sitting on the floor. The resident

was incontinent of urine. Neurochecks were

initiated at that time.

The "NEUROLOGICAL ASSESSMENT FLOW

SHEET" for Resident 25 was provided by LPN 3

on 02/10/19 at 03:13 P.M. The flow sheet started

on 09/21/18 at 02:15 P.M.

Assessment instructions were printed in the top

right corner of the flow sheet and were to be

completed as follows:

-Every 15 minutes for 1 hour

-Every hour for 4 hours

-Every 4 hours for 19 hours

for a total of 24 hours

Assessments were complete from 02:15 P.M. to

07:15 P.M. on 09/21/18. No assessments were

completed between 07:15 P.M. on 09/21/18, and

02:15 P.M. on 09/22/18.

Assessments should have been completed from

02:15 P.M. on 09/21/18 though 02:15 P.M. on

09/22/18.



assessment, dated 01/11/19, indicated Resident 96

was cognitively intact. Diagnoses included, but

were not limited to, cerebral palsy, anxiety, and

depression. The resident required extensive

assistance of two staff members for bed mobility,

transfers, dressing, toilet use, and personal

hygiene. The resident was always incontinent of

urine and occasionally incontinent of bowel.

Progress Notes for Resident 96 were provided by

the DON on 02/12/19 at 08:49 A.M. A note, dated

12/29/18 at 10:15 P.M., indicated the resident was

found in her room sitting on the floor and had





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fallen.

The "NEUROLOGICAL ASSESSMENT FLOW

SHEET" for Resident 96 was provided by LPN

(Licensed Practical Nurse) 3 on 02/10/19 at 03:13

P.M. The flow sheet started on 12/31/18 at 10:15

A.M.

Assessments were to be completed as follows:

-Every 15 minutes for 1 hour

-Every hour for 4 hours

-Every 4 hours for 19 hours

for a total of 24 hours

Assessments were complete from 10:15 A.M. to

07:15 P.M. on 12/31/18. Then from 07:15 A.M. to

11:15 A.M. on 01/01/19.

No assessments were completed for 12 hours from

07:15 P.M. on 12/31/18 through 07:15 A.M. on

01/01/19.

The dates on the Progress Notes and the

Neurological Flow Sheet did not match in regard

to the date and time of the resident's fall. The

Progress Notes did not indicate the resident had

fallen on 12/31/18.


LPN 2 indicated Neurochecks should be

completed per the facility policy. The policy was

printed in the corner of the Neurocheck

Assessment Flow Sheet. All unwitnessed falls

and falls where a resident had hit their head

should have Neurochecks completed.

The current "Neurological Assessment" policy,

with a revised date of 06/01/18, indicated

"...Neurological assessments are

indicated...Following an unwitnessed





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fall...Following a fall or other accident/injury

involving head trauma...Perform neurological

checks with the frequency as ordered or per falls

protocol..."

3.1-45(a)(1)

3.1-45(a)(2)

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.

§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

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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.

Based on interview and record review, the facility

failed to provide adequate catheter care for a

resident with an indwelling urinary catheter. This

deficient practice effected 1 of 2 residents

reviewed for urinary catheter care. (Resident 33)


Resident 33 indicated he had a suprapubic

catheter. The nurses did not change his catheter

as often as they should. He was hospitalized for a

few days in December 2018 for a urinary tract

infection. His catheter was changed last week, but

that was the first time it have been changed since

he returned from the hospital in December. He had

not developed a urinary tract infection since

returning from the hospital.




indicated the resident was cognitively intact. He

required extensive assistance with ADLs

(Activities of Daily Living). The resident's

diagnoses included, but were not limited to,

hypertension, neurogenic bladder, diabetes,

psychotic disorder, and anxiety.

Resident 33's TARs (Treatment Administration

Records) for December 2018, January 2019, and

February 2019, were provided by LPN (Licensed

Practical Nurse) 4 on 02/14/19 at 03:28 P.M. The

resident's orders included, but were not limited to,

an order with a start date of 11/14/18 to change

the suprapubic catheter every month, and as

needed for occlusion. The December TAR













compliance.

Element 1:

Residents with indwelling

catheters have the potential to be

affected by this practice. All

Residents with catheters have had

a record review. All orders,

diagnosis, evaluations and care

plans are current. Nursing staff

re-educated on management of

the patient with an indwelling

catheter and closed drainage

system.

Element 2:


in the center at baseline status

without ill effect. Catheter/bladder

evaluation completed. Care plan is

current and includes diagnosis.

Element 3:

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indicated the resident's catheter was scheduled to

be changed on 12/26/18. There was no

documentation that indicated the catheter was

changed on that day, or any other day in the

month of December. The January 2019 TAR

indicated the resident's catheter was scheduled to

be changed on 01/20/19. There was no

documentation that indicated the catheter had

been changed on that day, or any other day in the

month of January 2019. The February TAR

indicated the resident's catheter had been

changed on 02/04/19. There was no other

documentation in Resident 33's clinical record

that indicated his indwelling catheter had been

changed since his most recent hospitalization

until it was changed on 02/04/19.


DON (Director of Nursing) indicated nursing staff

changed Resident 33's urinary catheter as ordered,

and when needed, but it wasn't documented in his

clinical record.

The current, undated, procedure guidelines titled

"Management of the Patient with an Indwelling

Catheter and Closed Drainage System" was

provided by the DON on 02/14/19 02:53 P.M. The

procedure guidelines indicated "...Change

catheter according to the needs of the patient..."

3.1-41(a)(2)

The facility will audit weekly x4

weeks and monthly x6 months

Element 4:

Foley catheter Audits will be





is achieved.

483.25(g)(1)-(3)

Nutrition/Hydration Status Maintenance

§483.25(g) Assisted nutrition and hydration.

(Includes naso-gastric and gastrostomy

tubes, both percutaneous endoscopic

gastrostomy and percutaneous endoscopic

jejunostomy, and enteral fluids). Based on a

resident's comprehensive assessment, the

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facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable

parameters of nutritional status, such as

usual body weight or desirable body weight

range and electrolyte balance, unless the

resident's clinical condition demonstrates

that this is not possible or resident

preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake

to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet

when there is a nutritional problem and the

health care provider orders a therapeutic diet.


failed to have a resident with a significant weight

loss assessed by a Registered Dietician in a timely

manner. This deficient practice effected 1 of 3

residents reviewed for nutrition. (Resident 55)

Findings include:





impaired and needed supervision and cueing

assistance of one staff member for eating.


peripheral vascular disease, hip fracture,

Alzheimer's disease, dementia, and depression.

The resident had coughing or choking during

meals or when swallowing medications.

The "Weights and Vitals Summary" for Resident

55 was provided by the DON (Director of Nursing)

on 02/13/19 at 10:26 A.M. The record indicated the

resident weighed 124 pounds on 12/04/18, and 117













compliance.

Element 1:



Nursing Staff have been

re-educated on dietician, weight

assessment and intervention, and

nutritional assessment.

Element 2:


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pounds on 01/05/19. A significant weight loss of

5.65% (percent).

The MAR (Medication Administration Record) for

Resident 55 was provided by the DON on 02/13/19

at 10:26 A.M. The record indicated the resident

had been on a medication to stimulate appetite

and a liquid supplement since 06/30/18. No other

supplements had been added since that time.

The "NUTRITIONAL REVIEW" form, completed

by the Registered Dietician, for Resident 55 was

provided by DON on 02/13/19 at 10:26 A.M. The

form indicated the resident had not been assessed

by the Registered Dietician since 07/18/18, when

the resident weighed 132 pounds.

The Progress Notes for Resident 55 were provided

by LPN (Licensed Practical Nurse) 3 on 02/14/19 at

11:08 A.M. The clinical record lacked a progress

note to indicated the Registered Dietician had

been notified of the resident's significant weight

loss.


LPN 2 indicated on 01/23/19 they had tapered

Resident 55's Sertraline medication because it

could cause weight loss, then started Citalopram.

The resident had been on the Citalopram a little

over a week. The Registered Dietician assessed

residents quarterly unless there was a weight loss

then they would assess them more frequently.


DON indicated if the Registered Dietician did an

assessment it would be documented in the

resident's paper chart.

The current "WEIGHT ASSESSMENT AND

INTERVENTION" policy, with a revised date of

in the center and had a RD

evaluation completed.

Element 3:

The facility will complete Weight

loss prevention care audit weekly

x4 weeks and monthly x6 months.

Element 4:

Weight loss prevention care

Audits will be submitted for review




is achieved.





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September 2008, was provided by the DON on

02/13/19 at 10:26 A.M. The policy indicated,

"...Any weight change of 5% or more since the

last weight assessment will be retaken the next

day for confirmation. If the weight is verified,

nursing will immediately notify the Dietician in

writing. Verbal notification must be confirmed in

writing...The Dietician will respond within 24

hours of receipt of written notification...weight

loss...greater than 5% is severe..."

The current "Dietician" policy, with a revised date

of October 2017, was provided by the DON on

02/13/19 at 11:20 A.M. The policy indicated, "...A

qualified, competent, and skilled Dietician will help

oversee the food and nutrition services in the

facility..."

3.1-46(a)(1)

483.25(i)

Respiratory/Tracheostomy Care and

Suctioning

§ 483.25(i) Respiratory care, including

tracheostomy care and tracheal suctioning.

The facility must ensure that a resident who

needs respiratory care, including

tracheostomy care and tracheal suctioning,

is provided such care, consistent with

professional standards of practice, the

comprehensive person-centered care plan,

the residents' goals and preferences, and

483.65 of this subpart.

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Based on observation, interview, and record

review, the facility failed to properly store and

lable the tubing and mask related to the resident's

Nebulizer treatments. This deficient practice

effected 1 of 2 residents reviewed for respiratory

care. (Resident 51)








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Findings include:


Resident 51 indicated she was currently on an

antibiotic for pneumonia. She recently had the flu

and had been receiving breathing treatments

through the Nebulizer machine that was laying on

her bed.

The breathing treatment (Nebulizer machine), with

the tubing and mouthpiece attached, was

observed laying on top of Resident 51's bed

spread, at the foot of the bed, on the following

dates and times:

02/10/19 at 01:38 P.M.

02/12/19 at 09:36 A.M.

02/12/19 at 11:12 A.M.

02/12/19 at 01:15 P.M.

02/12/19 at 03:07 P.M.

The tubing and mouth piece were not dated or

placed in a bag. The resident was observed to be

laying on top of the bed with the tubing and

mouth piece near her feet.

The Clinical Record for Resident 51 was reviewed

on 02/12/19 at 09:22 A.M.

A doctor's order, dated 02/01/19, indicated the

resident was prescribed Duonebs (a Nebulizer

breathing treatment) every 6 hours for 10 days

and Azithromycin (antibiotic), 250 mg tablet, give

2 tablets on day one, give 1 tablet on days 2

through 5 for pneumonia

A doctor's order, dated 02/06/19, indicated the

resident was prescribed Bactrim (antibiotic) twice

a day for seven days for sinusitis and bronchial

pneumonia.






compliance.

Element 1:


be affected by this practice. The

facility has educated on the policy

and procedure for changing

respiratory equipment and

documenting change.

Element 2:


in the center and is not affected by

this practice. New supplies have

been provided, labeled correctly,

and dated appropriately.

Element #3:

The facility will audit Respiratory

equipment weekly x4 weeks and

monthly x6 months.

Element #4:

Resident care Audits will be

submitted for recommendation and

review monthly x6 months.

Results will be forwarded to QA

until substantial compliance is

achieved.





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The MAR (Medication Administration Record) for

Resident 51 was reviewed on 02/12/19 at 11:20

A.M. An order for Duonebs, dated 06/30/18,

indicated the resident could get a duoneb

treatment every six hours as needed for COPD.

The last administration was dated 02/11/19 at

03:30 P.M.


LPN 2 indicated for breathing treatments, the

tubing had to be placed in a bag and dated, and

the mouthpiece should be stored in a bag and

dated.

The current "Aerosolized Medication Therapy"

policy, dated 2013, indicated following the

completion of a treatment, "...place the Nebulizer

in a labeled bag with the patient name and

date...Change the Nebulizer equipment weekly or

according to your company policy..."

3.1-47(a)(6)

483.25(l)

Dialysis

§483.25(l) Dialysis.

The facility must ensure that residents who

require dialysis receive such services,

consistent with professional standards of

practice, the comprehensive person-centered

care plan, and the residents' goals and

preferences.

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failed to adequately monitor the dialysis access

sites for a resident receiving dialysis treatments.

This deficient practice effected 1 of 1 residents

reviewed for dialysis. (Resident 106)

Findings include:








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Resident 106 indicated she went out for dialysis

treatments on Mondays, Wednesdays, and

Fridays. The nurses did not always check her

access site every day. The access site on her arm

was not functional at that time, but she had no

signs of infection or concerns with it, and no

concerns with the access site on her chest.


on 02/13/19 at 12:00 P.M. An Annual MDS




anemia, heart failure, hypertension, end stage

renal disease, and diabetes. The resident required

supervision for all ADLs (Activities of Daily

Living).


LPN (Licensed Practical Nurse) 7 indicated the

resident had a chest port and an AV

(arterio-venous) fistula (a surgically created

vascular access used for dialysis treatments). The

nurses documented monitoring of the access

sites, vitals, and weights in the pre and post

dialysis assessments in the computer before and

after the resident's dialysis treatments. In addition

to the pre and post dialysis assessments, they

documented daily monitoring of the chest site and

the AV site on the TAR (Treatment

Administration Record). They were to assess both

sites and document for signs and symptoms of

infection or bleeding, and assess the bruit and

thrill (the audible sound and palpable feeling

associated with turbulent blood flow) of the

fistula site each shift.

Resident 106's TARs for January and February






compliance.

Element 1:

All Residents with dialysis have

the potential to be affected by this

practice. An audit was has been

conducted on all Residents with

dialysis and all are receiving

evaluation for the shunt, per

policy. All nurses have been

educated on shunt evaluation and

documentation.

Element 2:


in the center, has been evaluated

and remains at baseline status

without ill effects.

Element 3:

The facility will complete and audit


months

Element 4:

Hemodialysis Audits will be





is achieved.





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2019 were provided by the DON (Director of

Nursing) on 02/14/19 at 02:35 P.M. The only

documented monitoring of the AV Fistula site for

bruit, thrill, signs of infection, and bleeding, on

day shift was on 02/11/19. There was no

documentation that indicated the chest site was

monitored for infection or bleeding on day shift in

January 2019.


DON (Director of Nursing) indicated nurses

should be monitoring resident 106's sites and

documenting in the TAR each shift.

3.1-37(a)

483.35(g)(1)-(4)

Posted Nurse Staffing Information

§483.35(g) Nurse Staffing Information.

§483.35(g)(1) Data requirements. The facility

must post the following information on a daily

basis:

(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours

worked by the following categories of

licensed and unlicensed nursing staff directly

responsible for resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed

vocational nurses (as defined under State

law).

(C) Certified nurse aides.

(iv) Resident census.

§483.35(g)(2) Posting requirements.

(i) The facility must post the nurse staffing

data specified in paragraph (g)(1) of this

section on a daily basis at the beginning of

each shift.

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(ii) Data must be posted as follows:

(A) Clear and readable format.

(B) In a prominent place readily accessible to

residents and visitors.

§483.35(g)(3) Public access to posted nurse

staffing data. The facility must, upon oral or

written request, make nurse staffing data

available to the public for review at a cost not

to exceed the community standard.

§483.35(g)(4) Facility data retention

requirements. The facility must maintain the

posted daily nurse staffing data for a

minimum of 18 months, or as required by

State law, whichever is greater.

Based on observation and interview the facility

failed to post the current nurse staffing

information for 2 of 5 days of the survey period.

Findings include:


the nurse staff posting located in the front hall

was dated 02/08/19.

During an observation on 02/10/19 at 01:46 P.M.,


was dated 02/08/19.



was dated 02/09/19.

During an observation on 02/12/19 at 01:20 P.M.,


was dated 02/09/19.


Director of Nursing indicated the scheduler













compliance.

Element 1:


be affected by this practice. Staff

have been educated on posting

direct care staffing hours.

Element 2:

Posted staffing hours have been

updated to reflect regulation.

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updates the staff posting daily when she arrives

and posts through the weekend on Fridays.

The current "Posting Direct Care Daily Staffing

Numbers" policy, with a revised date of July 2016,

indicated, "...Within two (2) hours of the

beginning of each shift, the number of Licensed

Nurses (RNs, LPNs [Licensed Practical Nurse])

and the number of unlicensed personnel (CNAs

[Certified Nurse Aide]) directly responsible for

resident care will be posted in a prominent

location (accessible to residents and visitors) and

in a clear and readable format ..."

Element 3:



months.

Element 4:

Direct care staff posting Audits will





is achieved.

483.45(a)(b)(1)-(3)

Pharmacy

Srvcs/Procedures/Pharmacist/Records

§483.45 Pharmacy Services

The facility must provide routine and

emergency drugs and biologicals to its

residents, or obtain them under an agreement

described in §483.70(g). The facility may

permit unlicensed personnel to administer

drugs if State law permits, but only under the

general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must

provide pharmaceutical services (including

procedures that assure the accurate

acquiring, receiving, dispensing, and

administering of all drugs and biologicals) to

meet the needs of each resident.

§483.45(b) Service Consultation. The facility

must employ or obtain the services of a

licensed pharmacist who-

§483.45(b)(1) Provides consultation on all

aspects of the provision of pharmacy services

in the facility.

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§483.45(b)(2) Establishes a system of

records of receipt and disposition of all

controlled drugs in sufficient detail to enable

an accurate reconciliation; and

§483.45(b)(3) Determines that drug records

are in order and that an account of all

controlled drugs is maintained and

periodically reconciled.


failed to ensure a psychotropic medication was

available. This deficient practice effected 1 of 6

residents reviewed for unnecessary medications.

(Resident 104)

Findings include:






to, anxiety, depression, psychotic disorder,

unspecified mood disorder, and non-Alzheimer

dementia.

A physician order, dated 11/05/18, indicated

Clozapine 25 mg (milligrams), take 1 tablet by

mouth daily, in the morning, for psychosis.

A physician order, dated 11/05/18, indicated

Clozapine 50 mg, take 1 tablet by mouth every

night at bedtime, for psychosis.

The January and February 2019 MAR (Medication

Administration Record) indicated the Resident

had not received Clozapine 25 mg in the morning

and the physician was aware for the following

dates:













compliance.

Element 1:

All Residents receiving prescribed

psychotropics by the REMS

program have the potential to be

affected by this practice.

Element 2:


in the facility and has experienced

no adverse or ill effect related to

not administering psychotropic

medication. Vanguard is now

certified in REMs program and

medication is available. Order

obtained to hold medication until

available date on 1/25/2019.

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01/25/19 through 02/14/19

A "Follow up Question Report" for

"Observe-Behavior Symptoms of Hitting", dated

01/01/19 through 02/14/19, indicated the resident

had behaviors of hitting for the following dates

and times:

02/03/19 at 11:49 P.M.

02/12/19 at 08:50 P.M.

A "Follow up Question Report" for

"Observe-Behavior Symptoms of Wringing

hands", dated 01/01/19 through 02/14/19,

indicated the resident had behaviors of wringing

hands for the following dates and times:

01/25/19 at 04:28 P.M.

01/25/19 at 09:05 P.M.

01/26/19 at 10:56 P.M.

01/28/19 at 03:32 P.M.

02/01/19 at 03:32 P.M.

02/02/19 at 02:21 A.M.

02/03/19 at 01:28 A.M.

02/03/19 at 11:51 P.M.

02/08/19 at 11:03 P.M.

02/10/19 at 02:15 A.M.


DON (Director of Nursing) indicated Resident 104

had been out of his medication because the

primary physician nor the psychiatric physician

was not certified in the REMS (Clozapine

medication program) so the pharmacy would not

dispense the medication to the facility. Both

physicians were currently getting certified to be

able to write the prescriptions for the medication.

The facility was monitoring the resident for

increased behaviors. The primary care physician

had been doing research to see if there were any

additional laboratory values to be obtained until

the medication was available.

Element 3:


on medications not available from

pharmacy x6 months. Staff

re-educated on pharmacy

services, tapering medications,

gradual dose reductions,

behavioral assessment and

intervention/monitoring.

Element 4:

Antipsychotic Medication Audits

will be submitted for the review




is achieved..





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April 2007 and titled "Pharmacy Services

Overview", was provided by the DON on 02/14/19

at 12:07 P.M. The policy indicated "...The facility

shall accurately and safely provide or obtain

pharmacy services, including the provision of

routine and emergency medications and

biological, and the services of a licensed

Pharmacist..."

3.1-25(a)

483.45(d)(1)-(6)

Drug Regimen is Free from Unnecessary

Drugs

§483.45(d) Unnecessary Drugs-General.

Each resident's drug regimen must be free

from unnecessary drugs. An unnecessary

drug is any drug when used-

§483.45(d)(1) In excessive dose (including

duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring;

or

§483.45(d)(4) Without adequate indications

for its use; or

§483.45(d)(5) In the presence of adverse

consequences which indicate the dose

should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the

reasons stated in paragraphs (d)(1) through

(5) of this section.

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failed to ensure a resident was free from receiving

unnecessary medications related to adequately

monitoring laboratory values. This deficient

practice effected 1 of 6 residents reviewed for

medications. (Residents 16)

Findings include:


on 02/12/19 at 01:30 P.M. A Significant Change

MDS (Minimum Data Set) assessment, dated

01/26/19, indicated the resident was severely

cognitively impaired. The resident required

extensive assistance for transferring, locomotion,

and eating; and was totally dependent on staff for

bed mobility, dressing, personal hygiene, and

toileting. Diagnoses included, but were not

limited to, heart failure, diabetes, and Alzheimer's

dementia.

A pharmacy "Note to Attending

Physician/Prescriber" document, dated 09/19/18,

recommended monitoring the resident's A1c

(blood test that would determine how well the

body has controlled blood sugars over the last

three months), CMP (Comprehensive Metabolic

Panel blood test), and lipids (blood test for

cholesterol and triglycerides) lab (laboratory)

tests. Resident 16's physician documented on the

form that he agreed with the recommendation on

09/22/18, and the labs were to be obtained.

A "Consultant Pharmacist's Medication Regimen

Review for recommendations created between

11/01/18 and 11/14/18" document indicated

Resident 16 had an order for the A1c, lipids, and

CMP labs to be drawn on 09/22/18 and the results

were not in the chart. The pharmacist

recommended placing the results in the chart for

review or obtaining the labs if they had not yet












compliance.

Element 1:



Element 2:

Resident #16 no longer resides in

the facility. Labs were obtained on

12/14/18 with no new orders

received.

Element 3:

Nursing staff re-educated on

pharmacy services overview.

Consultant pharmacist to review

charts monthly and report to DNS

any recommendations received

from previous month that were not

completed.

Element4 :

Pharmacy recommendation

/Medication Audits will be


recommendation monthly x 6



is achieved.





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been obtained.

On 02/13/19 04:12 P.M., LPN 3 indicated the

facility did not obtain the above mentioned labs

until 12/13/18.

The current facility policy, titled "Pharmacy

Services Overview", with a revision date of April

2007, was provided by the Director of Nursing on

12/14/19 at 12:07 P.M. The policy indicated,

"...The facility shall contract with a licensed

Pharmacist to help it...support residents' needs,

are consistent with current standards of practice,

and meet state and federal requirements..."

3.1-48(a)(3)

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;

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§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

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.


failed to to provided documentation of a resident's

behaviors related to psychotropic medication use.

This deficient practice effected 1 of 6 residents

reviewed for unnecessary medications. (Resident

104)

Findings include:

















compliance.

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to, anxiety, depression, psychotic disorder,

unspecified mood disorder, and non-Alzheimer

dementia.

A physician order for Resident 104, dated

11/05/18, indicated the resident was prescribed

clonazepam (an antianxiety medication) 0.5 mg

(milligrams), 1 tablet by mouth, twice a day.



effexor (an antidepressant medication) 225 mg, by

mouth every morning.



effexor 75 mg, by mouth every bedtime.

A pharmacy "Note to Attending Physician

/Prescriber", dated 12/14/18, indicated "...This

resident [Resident 104] has been taking

clonazepam 0.5 mg BID [twice a day]. Please

consider a gradual dose reduction, while

monitoring for re-emergence and/or withdrawal

symptoms. If therapy is to continue at the current

dose, please provide a statement of

rationale...Disagree...contraindicated d/t [due/to]

hitting & [and] yelling towards staff...", and

signed by a physician.

A pharmacy "Note to Attending Physician

/Prescriber", dated 12/14/18, indicated "...This

resident [Resident 104] has been taking

venlafafaxine [effexor] 225 mg QAM [every AM]

and 75 mg QHS [every bedtime]. Please consider a

gradual dose reduction, while monitoring for

re-emergence and/or withdrawal symptoms. If

therapy is to continue at the current dose, please

provide a statement of

Element 1:

All Residents receiving

psychotropic medication have the

potential to be affected by this

practice. Staff Reeducated on

tapering medication, gradual dose

reduction, behavioral assessment,

intervention and monitoring.

Element 2:


in the facility and continues to

exhibit multiple behaviors as

documented in the progress

notes. Gradual dose reductions

are in place and behaviors are

monitored per facility policy.

Multiple incidents of behavioral

outbursts are documented starting

from 1/1/2019 and forward in the

medical record.

Element 3:

The facility will compile an

Antipsychotic Medication audit

monthly x6 months and and

behavior documentation will be

reviewed 5x/week in daily clinical

meeting.

Element 4:

Antipsychotic Medication Audits

will be submitted for review and

recommendation monthly x 6



is achieved..





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rationale...Disagree...contraindicated d/t hitting &

yelling towards staff..", and signed by a

physician.

The November and December 2018

"Behavior/Intervention Monthly Flow Record"

lacked documentation of any behaviors for

Resident 104.

Progress Notes for November and December 2018

lacked documentation of any behaviors for

Resident 104.


Social Service Director indicated in December 2018

there was a pharmacy recommendation to

decrease clonazepam and effexor. The medications

were contraindicated due to behaviors of hitting

self and yelling. Prior to January 2019, the staff

would document behaviors on a green form in the

resident's chart.


DON (Director of Nursing) indicated every month

the pharmacy would send a list with

recommendations that included GDR's (gradual

dose reduction). There was a monthly meeting

that included psych services and they would

review all recommendations. They would discuss

the recommendations as a team. To determine if a

GDR was contraindicated they would look at

behaviors the resident had been having in the

behavior tracking logs and progress notes. Prior

to January 2019 the behaviors were monitored on

a paper form.


April 2007 and titled "Behavioral Assessment,

Intervention and Monitoring" was provided by

the DON on 02/14/19 at 12:07 P.M. The policy





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indicated, "...Policy Statement...1. Behavioral

symptoms will be identified using

facility-approved behavioral screening tools and

the comprehensive assessment..."

3.1-48(a)(3)

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

Infection Prevention & Control

§483.80 Infection Control

The facility must establish and maintain an

infection prevention and control program

designed to provide a safe, sanitary and

comfortable environment and to help prevent

the development and transmission of

communicable diseases and infections.

§483.80(a) Infection prevention and control

program.

The facility must establish an infection

prevention and control program (IPCP) that

must include, at a minimum, the following

elements:

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

identifying, reporting, investigating, and

controlling infections and communicable

diseases for all residents, staff, volunteers,

visitors, and other individuals providing

services under a contractual arrangement

based upon the facility assessment

conducted according to §483.70(e) and

following accepted national standards;

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

and procedures for the program, which must

include, but are not limited to:

(i) A system of surveillance designed to

identify possible communicable diseases or

infections before they can spread to other

F 0880

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persons in the facility;

(ii) When and to whom possible incidents of

communicable disease or infections should

be reported;

(iii) Standard and transmission-based

precautions to be followed to prevent spread

of infections;

(iv)When and how isolation should be used

for a resident; including but not limited to:

(A) The type and duration of the isolation,

depending upon the infectious agent or

organism involved, and

(B) A requirement that the isolation should be

the least restrictive possible for the resident

under the circumstances.

(v) The circumstances under which the facility

must prohibit employees with a

communicable disease or infected skin

lesions from direct contact with residents or

their food, if direct contact will transmit the

disease; and

(vi)The hand hygiene procedures to be

followed by staff involved in direct resident

contact.

§483.80(a)(4) A system for recording

incidents identified under the facility's IPCP

and the corrective actions taken by the

facility.

§483.80(e) Linens.

Personnel must handle, store, process, and

transport linens so as to prevent the spread

of infection.

§483.80(f) Annual review.

The facility will conduct an annual review of

its IPCP and update their program, as

necessary.

Based on observation and interview, the facility F 0880 Preparation and or/execution of 03/11/2019 12:00:00AM





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failed to administer medications in a sanitary

manner related to insulin injection and eye drop

administration. This deficient practice effected 1

of 6 residents reviewed for medication

administration. (Resident 7)

Findings include:


RN 5 sanitized her hands and prepared

medications for Resident 7. RN 5 entered Resident

7's room explaining she had her medications. She

assisted the resident with taking a sip of water.

The resident indicated she was cold and RN 5

pulled the blanket over her right shoulder using

her right hand. She used her right hand to

administer the medications to the resident,

followed by a drink. The RN removed the blanket

from the resident's right arm, wiped her upper arm

with an alcohol pad, and administered an insulin

injection using an insulin pen into the right upper

arm with her right hand. She then instructed the

resident that she was going to administer eye

drops into both of the resident's eyes. RN 5

opened the eye drop medication holding the

bottle with her right hand, and taking the lid off

with her left hand, she held the skin over the

cheek bone with her left hand and administered a

drop into the right and left eyes. She exited the

resident's room, put away the medications in the

medication cart, and sanitized her hands.


LPN (Licensed Practical Nurse) 4 indicated when

administering insulin injections the nurse should

verify the 5 checks, knock on the door, go in the

room, provide privacy, wash your hands, don

gloves, clean the area with an alcohol wipe, allow

to dry, give the insulin and check for bleeding. For

eye drop administration you would verify the 5












compliance.

Element 1:

All residents receiving eye drops

and insulin have the potential to be

affected by this practice. Nursing

staff have been re-educated on

medication administration,

specifically related to

subcutaneous and ophthalmic

administration.

Element 2:

Resident #7 continues to reside in

the facility and has not had any

adverse effects from the

administration of eye drops or

insulin.

Element 3:

Nursing staff re-educated on

administration of injections and

ophthalmic solution. The facility

will complete an audit weekly x4

weeks and monthly x6 months.

Element 4:

Medication administration in

relation to ophthalmic and





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checks, wash your hands, don gloves, pull down

on the bottom eye lid, and administer the drops.


12/29/17 and titled "Subcutaneous (SQ)

Medication Administration", was provided by the

DON (Director of Nursing) on 02/14/19 at 02:28

P.M. The policy indicated, "...8) Apply clean

gloves..."


12/28/17 and titled "Ophthalmic Drop

Administration" was provided by the DON on

02/14/19 at 02:28 P.M. The policy indicated, "...5)

Apply clean gloves..."

3.1-18(a)

injection Audits will be submitted

for review and recommendation

monthly x6 months. Results will

be forwarded to QA until


achieved.


Documents

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