PRINTED: 02/12/2018 DEPARTMENT OF HEALTH AND HUMAN … · 2020-03-24 · (x1) provider/supplier/clia department of health and human services centers for medicare & medicaid services

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

02/12/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

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B. WING

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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

MERRILLVILLE, IN 46410

155362 01/12/2018

GOLDEN LIVING CENTER-MERRILLVILLE

8800 VIRGINIA PLACE

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey.

Survey dates: January 8, 9, 10, 11, & 12,

2018.

Facility number: 000253

Provider number: 155362

AIM number: 100266660

Census Bed Type:

SNF/NF: 109

Total: 109

Census Payor Type:

Medicare: 1

Medicaid: 89

Other: 19

Total: 109

These deficiencies reflect State Findings

cited in accordance with 410 IAC 16.2-3.1.

Quality review completed on 1/18/18.

F 0000

483.10(c)(6)(8)(g)(12)(i)-(v)

Request/Refuse/Dscntnue Trmnt;Formlte Adv

F 0578

SS=D

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: V89511 Facility ID: 000253

TITLE

If continuation sheet Page 1 of 33

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Dir

§483.10(c)(6) The right to request, refuse,

and/or discontinue treatment, to participate in

or refuse to participate in experimental

research, and to formulate an advance

directive.

§483.10(c)(8) Nothing in this paragraph

should be construed as the right of the

resident to receive the provision of medical

treatment or medical services deemed

medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with

the requirements specified in 42 CFR part

489, subpart I (Advance Directives).

(i) These requirements include provisions to

inform and provide written information to all

adult residents concerning the right to accept

or refuse medical or surgical treatment and,

at the resident's option, formulate an advance

directive.

(ii) This includes a written description of the

facility's policies to implement advance

directives and applicable State law.

(iii) Facilities are permitted to contract with

other entities to furnish this information but

are still legally responsible for ensuring that

the requirements of this section are met.

(iv) If an adult individual is incapacitated at

the time of admission and is unable to

receive information or articulate whether or

not he or she has executed an advance

directive, the facility may give advance

directive information to the individual's

resident representative in accordance with

State Law.

(v) The facility is not relieved of its obligation

to provide this information to the individual

once he or she is able to receive such

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information. Follow-up procedures must be in

place to provide the information to the

individual directly at the appropriate time.

Based on record review and interview, the facility failed to update a resident's code status in a timely manner for 1 of 24 residents whose records were reviewed. (Resident 88)Finding includes:Resident 88's record was reviewed on 1/9/18 at 1:26 p.m. Diagnoses included, but were not limited to, dementia, depression, anxiety, and seizures.

The current Physician Order Summary

indicated Resident 88 was a full code (all

measures to sustain life), and was to be

evaluated by (name) hospice.

In the resident's chart, a green paper located

in the front of the chart indicated "Full

Code."

A Nurses Note, dated 12/19/17 at 10:32 a.m., indicated the resident's responsible party met with (name) of hospice on 12/18/17, signed the consent and the resident was admitted into hospice care.The Physicians Orders for Scope of Treatment (POST) form was signed by the resident's responsible party on 12/18/17, and signed by the Physician on 12/22/17. The POST indicated the resident wished to have comfort measures, antibiotics for infection and long-term artificial nutrition.The Out of the Hospital Declaration and order for DNR (Do Not Resuscitate) was signed by the Physician on 12/18/17.Interview with the D Wing Unit Manager on 1/9/18 at 1:30 p.m., indicated the most current code status of the resident was in the computer, and should have been updated to a DNR but was not.Interview with LPN 6 on 1/12/18 at 11:56 a.m., indicated she would first assess the resident for vital signs and if no respirations or no pulse, she would then check her report sheet, check the computer and check the paper that is in the front of the resident's chart for the code status and begin CPR if needed. Resident 88's status was a full code on the report sheet.The policy titled, "Advance Directive Review," was provided by the Director of Nursing on 1/12/18 at 12:45 p.m. This current policy indicated, " Procedure: To ensure the Medical Record reflects the Resident's and/or the surrogate decision-maker's health care decision as to Advance Directives...Confirm that the Living Center has a system in place to quickly identify the code status of the Resident...." 3.1-4(5)

F 0578 F 578_____

Plan of Correction

A plan of correction ("POC") for

the deficiencies must be received

by the Division by February 3,

2018. Corrections are expected to

be completed by February 11,

2018. The POC must contain the

following:

·What corrective action(s) will be

accomplished for those residents

found to have been affected by the

deficient practice;

Resident’s 88 records were

reviewed and it was noted that the

current order in the computer was

for Full Code. The resident’s

POST sheet, the Out of the

Hospital Declaration, and the

signed physician order, were for

DNR. Resident 88’s code status

was updated in the computer to

reflect the DNR wishes.

·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;

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Audits were performed on Advance

Directives throughout the facility to

ensure that the signed orders in

the charts matched the orders that

were in the computer for all

residents.

·What measures will be put into

place or what systemic changes

will be made to ensure that the

deficient practice does not recur;

DCE or designee will provide

in-servicing to the nursing staff,

SS/ACU director and unit

manager’s on the policy of

Advance Directives review and

updating the code status in the

computer in a timely manner.

·How the corrective action(s) will

be monitored to ensure the

deficient practice will not recur,

i.e., what quality assurance

program will be put into place; and

Code status will be reviewed, with

admission and readmission,

during morning clinical meeting.

Social Services/ACU director will

audit Advance Directive orders

with 5 random residents 5x/wk for

4 weeks, then 3x/wk for 4 weeks,

then weekly for x 4 weeks, then

monthly x 3 months, and then

ongoing as needed. Audits will

be submitted to the DNS or

designee for review. Results will

be reviewed in QAPI monthly for 6





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months, and finding no trends, will

be reviewed again on an as

needed basis.

February 8, 2018

The facility is requesting desk

review for this tag.

483.10(g)(14)(i)-(iv)

Notify of Changes (Injury/Decline/Room, etc.)

§483.10(g)(14) Notification of Changes.

(i) A facility must immediately inform the

resident; consult with the resident's

physician; and notify, consistent with his or

her authority, the resident representative(s)

when there is-

(A) An accident involving the resident which

results in injury and has the potential for

requiring physician intervention;

(B) A significant change in the resident's

physical, mental, or psychosocial status

(that is, a deterioration in health, mental, or

psychosocial status in either life-threatening

conditions or clinical complications);

(C) A need to alter treatment significantly

(that is, a need to discontinue an existing

form of treatment due to adverse

consequences, or to commence a new form

of treatment); or

(D) A decision to transfer or discharge the

resident from the facility as specified in

§483.15(c)(1)(ii).

(ii) When making notification under paragraph

(g)(14)(i) of this section, the facility must

ensure that all pertinent information specified

F 0580

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in §483.15(c)(2) is available and provided

upon request to the physician.

(iii) The facility must also promptly notify the

resident and the resident representative, if

any, when there is-

(A) A change in room or roommate

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

(B) A change in resident rights under Federal

or State law or regulations as specified in

paragraph (e)(10) of this section.

(iv) The facility must record and periodically

update the address (mailing and email) and

phone number of the resident

representative(s).

§483.10(g)(15)

Admission to a composite distinct part. A

facility that is a composite distinct part (as

defined in §483.5) must disclose in its

admission agreement its physical

configuration, including the various locations

that comprise the composite distinct part,

and must specify the policies that apply to

room changes between its different locations

under §483.15(c)(9).

Based on record review and interview, the facility failed to notify the Physician in a timely manner for an accident for 1 or 2 residents reviewed for accidents. (Resident 58)Finding includes.Resident 58's record was reviewed on 1/11/18 at 10:06 a.m. Diagnoses included, but were not limited to, Alzheimer's, anxiety and depression.The Quarterly MDS (Minimum Data Set) assessment, dated 11/14/17, indicated the resident was cognitively impaired.An SBAR (Situation, Background, Assessment, Recommendation), dated 10/29/17 at 6:54 a.m., indicated the resident was found on the floor with a reddened, raised area 3.3 cm (centimeters) by 3.2 cm, on the left side of his forehead. The resident was assessed, ice applied and the son was notified.Nurses note, dated 10/29/17 at 7:57 a.m., indicated the Physician was contacted and ordered the resident to be sent to the Emergency Room to be evaluated and treated.The Physician Order Summary, indicated the resident received Aspirin, 81 mg (milligrams) 1 tablet a day.The October 2017 MAR (Medication Administration Record) indicated the resident received the Aspirin as ordered daily.Interview with the D Wing Unit Manager on 1/12/18 at 9:28 a.m., indicated the Physician should had been contacted immediately and he was not until an hour later after the injury.The policy titled "Notification of Change in Resident Health Status" was provided by the Director of Nursing on 1/12/18 at 2:30 p.m. This current policy indicated,"...The center will consult the resident's physician,...D. A decision to transfer or discharge the resident from the center...."3.1-5(a)(1)(4)

F 0580 Tag _F 580_____

Plan of Correction




deficient practice;

Unable to correct the alleged

deficient practice for the resident

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#58






Audits were performed on

residents with incidents and

changes in health status by

reviewing the SBAR’s and daily

notes with change of conditions for

the past 90 days to ensure that

there was notification occurring in

a timely manner.

.

What measures will be put into





in-servicing, to the licensed

nursing staff, on physician

notification in a timely manner.






Residents with a change of

condition will be reviewed for

notification in morning clinical

meeting. The DNS or designee will

review change of condition orders

and notes 5x/wk for 4 weeks, then

3x/wk for 4 weeks, then weekly for





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x 4 weeks, then monthly x 3

months, and then ongoing as

needed.

All audits will be reviewed and

discussed in QAPI for 6 months to

identify any trends, and finding no

trends, will be reviewed again on

an as needed basis.

·

·By what date the systemic

changes will be completed.

February 8, 2018


review for this tag

483.10(e)(1); 483.12(a)(2)

Right to be Free from Physical Restraints

§483.10(e) Respect and Dignity.

The resident has a right to be treated with

respect and dignity, including:

§483.10(e)(1) The right to be free from any

physical or chemical restraints imposed for

purposes of discipline or convenience, and

not required to treat the resident's medical

symptoms, consistent with §483.12(a)(2).

§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

F 0604

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freedom from corporal punishment,

involuntary seclusion and any physical or

chemical restraint not required to treat the

resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free

from physical or chemical restraints imposed

for purposes of discipline or convenience and

that are not required to treat the resident's

medical symptoms. When the use of

restraints is indicated, the facility must use

the least restrictive alternative for the least

amount of time and document ongoing

re-evaluation of the need for restraints.

Based observation, interview, and record review, the facility failed to ensure a resident was free from physical restraints for 1 of 1 residents reviewed for restraints. (Resident 310)Finding includes:

During an initial interview with the resident

on 1/8/18 at 10:53 a.m., he indicated, "They

have me on lock down, every time I move in

my chair this alarm goes off. It wakes me up

at night when I move in bed."

During an observation on 1/08/18 11:18

a.m., the resident was observed lying in bed

on his back with the head of the bed slightly

elevated. The resident attempted

repositioning himself 3 different times. Each

time the resident moved, the alarm sounded

and the resident would lie still. The resident

indicated, "See that? I can't move with that

thing on."

During an observation on 1/08/18 11:59

a.m., the resident was in the dining room on

F 0604

Tag 604

Plan of Correction




deficient practice;

Resident #310 was reassessed

and the alarm was removed, care

plan and care sheets were

updated, and notifications were

made




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the unit with his arms folded and head down

in his arms on a table. The resident raised his

head and attempted to sit back 2 different

times. When the resident moved, the chair

alarm sounded then would stop when

resident placed his head back on the table.

Record review was completed on 1/10/18

at 9:34 a.m. Diagnoses included, but were

not limited to malnutrition, hypertension (high

blood pressure), emphysema and low back

pain. The record reflected the resident had

one fall on 12/25/17 in the dining room.

The Admission Minimum Data Set (MDS)

assessment, completed on 12/25/17,

indicated the resident was cognitively

impaired. The resident required 1 person

assist for transfers and locomotion.

During an interview on 1/12/18 9:58 a.m.,

the resident was able to recall day of the

week, month, day, season, and the activities

he had attended the day before. The

resident indicated he was not sleeping well,

and indicated the alarm was too sensitive at

night and it was "jarring and it scares

me...takes me a long time to go back to

sleep, sometimes a long time."

Interview with the ADON (Assistant

Director of Nursing) on 1/11/18 at 3:51



Audits were performed with the

IDT on all residents with alarms

and they were discontinued with

monitoring. No other devices

related to restraints are being

used in the facility.






in-servicing on the restraint policy

and use of alarms in particular to

nursing staff. Any restraint use

will be evaluated through the IDT

process and orders reviewed

during Clinical meeting to ensure

no restraints were implemented.






The DNS or designee, will assess

residents restraints are not utilized

improperly 5x/wk for 4 weeks,

then 3x/wk for 4 weeks, then

weekly for x 4 weeks, then


ongoing as needed.

Audits will be reviewed and results

submitted to QAPI for any trends

for 6 months, and finding no





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p.m., indicated the facility does not complete

a formal assessment for use of alarms and

when the clinical team meets, they discuss

the least restrictive method for preventing

falls.

Interview with the DON (Director of

Nursing) on 1/12/18 at 10:15 a.m.,

indicated the alarm had been placed on the

resident's bed on admission in case he rolled

out of bed. The resident should have been

re-evaluated for the use of alarms but had

not been. The DON indicated the alarm

had restricted the resident from moving

freely.

A current policy titled "Restraint Evaluation

and Utilization Guidelines" was provided by

the DON on 1/12/18 at 10:44 a.m. The

policy indicated, "Guideline

Statement...Physical restraints include "any

method or physical or mechanical device,

material or equipment attached or adjacent

to the resident's body that the individual

cannot remove easily which restricts

freedom of movement or normal access to

one's body...."

3.1-3(w)

3.1-26(r)

3.1-26(s)


an as needed basis.



February 8, 2018







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483.12(c)(2)-(4)

Investigate/Prevent/Correct Alleged Violation

§483.12(c) In response to allegations of

abuse, neglect, exploitation, or mistreatment,

the facility must:

§483.12(c)(2) Have evidence that all alleged

violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse,

neglect, exploitation, or mistreatment while

the investigation is in progress.

§483.12(c)(4) Report the results of all

investigations to the administrator or his or

her designated representative and to other

officials in accordance with State law,

including to the State Survey Agency, within

5 working days of the incident, and if the

alleged violation is verified appropriate

corrective action must be taken.

F 0610

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Based on record review and interview, the facility failed to do a complete and thorough abuse investigation for a resident to resident altercation for 1 of 1 resident reviewed for abuse allegations. (Resident 60)Finding includes:Resident 60's record was reviewed on 1/10/18 at 8:36 a.m. Diagnoses included, but were not limited to, diabetes mellitus, Alzheimer's, and Bipolar disease.

A Facility Reported Incident was reported

to the ISDH (Indiana State Department of

Health) on 12/29/17 and a follow up was

completed on 1/2/18 for a resident to

resident altercation between Resident 60

and Resident 32. The report indicated a

housekeeper (unnamed) observed Resident

60 had pushed Resident 32 to the ground.

An SBAR (Situation, Background,

Assessment, Recommendation), dated

F 0610

Tag __F610____

Plan of Correction




deficient practice;

All involved staff was re-interviewed

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12/29/17, at 11:00 a.m., indicated a

housekeeper (un-named) observed Resident

60 push Resident 32, and Resident 32 fell to

the ground. Resident 32 was assessed and

Resident 60 was sent to the Emergency

Room via Physician's order's to be

evaluated.

The investigation failed to recognize and

interview another resident and other staff

members who were present during the

incident.

Interview with the Director of Nursing on 1/11/18 at 9:19 a.m., indicated there were not any other residents present at the time of the incident, no other staff was interviewed, and the Social Service (SS) Alzheimer's Manager received the statement from the housekeeper, and it was not in the folder.Interview with the SS Alzheimer's Manager on 1/11/18 at 9:30 a.m., indicated she did not write down the interview with the housekeeper and thought it was Housekeeper 2. Interview with Housekeeper 2 on 1/11/18 at 9:30 a.m., indicated she did not recall the incident in question. She had never been on the D Wing Unit until this week.Interview with the Environmental Services Director on 1/11/18 at 9:43 a.m., indicated he received a phone call from Housekeeper 3 that Resident 60 hit Resident 32 which resulted in Resident 32 falling to the ground. Interview with Housekeeper 3 on 1/11/18 at 9:45 a.m., indicated he was on D Wing at the time of the incident and there was another housekeeper, Housekeeper 4, on the floor by the small dining rooms cleaning. Housekeeper 3 indicated he observed Resident 60 attempt to move Housekeeper 4's cleaning cart, and witnessed Resident 60 use foul language. Resident 60 also had hit Housekeeper 3 in the back when reporting to the nurse that Resident 60 kicked his floor cleaning machine, and threatened him (he was going to "busted my a**" if the machine was not moved). Housekeeper 3 indicated, when he was was on his way to report the above incidents to the nurse, he observed Resident 60 throw a fake punch to Resident 32's stomach, then pushed her to the ground.Interview with the Environmental Assistant on 1/11/18 at 2:33 p.m., indicated he was present at the time of the incident between Resident 60 and Resident 32, but did not witness Resident 60 punch Resident 32. The Environmental Assistant did observe Resident 60 attempt to move Housekeeper 4's cleaning cart and using foul language and threaten Housekeeper 3 by Resident 60 said "I going to bust his a** if he doesn't move the machine." He was in the small dining room, when he heard a female scream and saw Resident 32 on the ground next to Resident 60.Interview with Housekeeper 4 on 1/12/18 at 8:53 a.m., indicated she was by the small dining room on D Wing, cleaning. She observed Resident 60 attempted to move her cleaning cart and used foul language and told her that he would "bust her a** if she didn't move the cart." Housekeeper observed Resident 60 follow Housekeeper 3 and punch him in the back, and observed Resident 60 push Resident 32 to the ground. Resident 104 was in the hallway when incident occurred and tried to help Resident 32 off the ground. The policy titled "Protection from Abuse" was provided by the Administrator on 1/8/18. This current policy indicated, "Policy Statement: All residents in the Living Center will be free from verbal, sexual, physical, or mental abuse, neglect, corporal punishment, and involuntary seclusion, as per the Living Center abuse prevention plan...The social services staff is bound by accepted standards of practice to intervene when abuse is suspected...Abuse Protection:...Investigation and Documentation...investigation and documentation for allegations of abuse will include the following: Who allegedly committed the abuse act?, who was abused?, what type of abuse was involved? when and where it occurred?, the results of the investigation,...."A Policy titled "Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Residents Property" was provided by the Administrator on 1/8/18. This current policy indicated,"...Investigation and Documentation....shall include interviews of employees, visitors, residents, volunteers and vendors who may have knowledge of the alleged incident...."3.1-28(d)

with statements added to the file.

Audit sheet initiated to ensure

compliance.






Audits were performed on

reportable incidents for the last 90

days to ensure that the

investigation was thorough and

complete and included witness

statements from staff and/or

residents.






in-servicing on the reporting and

completion of a thorough

investigation on an allegation of

abuse.






The ED/designee will review all

reportable incidents for

completeness and thorough follow

through, which will include

documented interviews with other





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staff and/or residents, on a

continued basis. Audits will be

5x/wk for 4 weeks, then 3x/wk for

4 weeks, then weekly for x 4

weeks, then monthly x 3 months,

and then ongoing as needed..

Reportable occurrences’ will be

reviewed for completeness and

trends during facilities monthly

QAPI meetings.



February 8, 2018



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

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

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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

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





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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 record review and interview, the

facility failed to ensure an assessment was

completed for a resident who required a

Preadmission Screening and Resident

Review (PASRR) Level II assessment for 1

of 2 residents reviewed for PASRR.

(Resident 40)

Finding includes:

Record Review for Resident 40 was

completed on 1/10/18 at 3:52 p.m.

Diagnoses included, but were not limited to,

major depressive disorder and delusional

disorder. The resident was admitted to the

facility on 1/27/17.

The Admission Minimum Data Set (MDS)

assessment, completed on 2/3/17, indicated

the resident was cognitively intact and had

mood problems.

F 0645 Tag __645_

Plan of Correction




deficient practice;

The Level II was completed for the

resident #40.






Audits were performed by the

Business Office Manager to

ensure that all PASRR

documentation was complete.

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A PASRR Level I screen, completed on

3/24/17, indicated a recommendation for a

PASRR Level II evaluation to be

conducted. "Level I outcome: Refer for

Level II onsite."

The record lacked any documentation a

PASRR Level II had been completed.

Interview with the Business Office Manager

on 1/11/18 at 1:41 p.m. indicated a Level I

had been completed at the hospital on

1/25/17, and indicated no Level II was

required. That Level I had been completed

with incorrect information, so a new Level I

was done which indicated a Level II was

needed. The Level II screening had not

been completed.

3.1-23(a)(2)





Re-education to the business

office staff on required

Preadmission Screening and

Resident Review (PASRR) Level

11 assessment for compliance

was completed by the Corporate

consultant.

DCE or designee provided

education on the PASRR process

to the admission director.






The Business office Manager

(BOM)/Admissions

director/designee will audit5x/wk

for 4 weeks, then 3x/wk for 4

weeks, then weekly for x 4 weeks,

then monthly x 3 months, and

then ongoing as needed to ensure

that required Preadmission

Screening and Resident Review

(PASRR) Level 11 assessment is

completed.

Results will be reviewed in QAPI

for 6 months and finding no trends,

will be reviewed again on an as

needed basis.






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February 8, 2018



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

Care Plan Timing and Revision

§483.21(b) Comprehensive Care Plans

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

must be-

(i) Developed within 7 days after completion

of the comprehensive assessment.

(ii) Prepared by an interdisciplinary team, that

includes but is not limited to--

(A) The attending physician.

(B) A registered nurse with responsibility for

the resident.

(C) A nurse aide with responsibility for the

resident.

(D) A member of food and nutrition services

staff.

(E) To the extent practicable, the

participation of the resident and the resident's

representative(s). An explanation must be

included in a resident's medical record if the

participation of the resident and their resident

representative is determined not practicable

for the development of the resident's care

plan.

(F) Other appropriate staff or professionals in

disciplines as determined by the resident's

needs or as requested by the resident.

(iii)Reviewed and revised by the

interdisciplinary team after each assessment,

including both the comprehensive and

quarterly review assessments.

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Based on interview and record review, the

facility failed to notify a resident's Power Of

Attorney (POA)of a change in condition for

1 of 1 resident reviewed for participation in

care planning. (Resident 58)

Finding includes:

Interview on 1/8/18 at 12:25 p.m. with

Resident 58's POA, indicated she was not

always notified with changes, labs or

medicine changes, or accidents which

happened with her husband. She would find

out later after having to ask staff what

happened.

Resident 58's record was reviewed on

1/11/18 at 10:06 a.m. Diagnoses included,

but were not limited to, Alzheimer's, anxiety

and depression.

The Quarterly MDS (Minimum Data Set)

assessment, dated 11/14/17, indicated the

resident was cognitively impaired.

A "General Durable Power of Attorney,"

was signed and notarized on 2/3/2005 for

his POA to make medical decisions on his

behalf.

The following SBAR's (Situation,

Background, Assessment,

F 0657 Tag 657__

Plan of Correction




deficient practice;

Resident #58 had his wife-POA,

added in the computer as the first

ER contact and the son/family

listed as second.






A whole house audit was

completed to ensure POA was

listed first in the computer.

No other residents were identified.





DCE or designee to re-educate on

the change of condition and

notification policy for unit

managers and licensed nursing

staff, to ensure compliance.

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Recommendation) indicated the POA was

not notified of the incidents that had

occurred:

- An SBAR dated 10/29/17, at 6:54 a.m.,

indicated the resident was found on the floor

with a reddened, raised area 3.3 cm

(centimeters) by 3.2 cm, on the left side of

his forehead. The resident was assessed,

ice applied and the son was notified. Nurse

note, dated 10/29/17 at 7:57 a.m., the

Physician was contacted and the Physician

ordered the resident to be sent to

Emergency Room.

- An SBAR dated 11/15/17, at 7:55 p.m.,

the resident had an altercation with another

resident. The "Family" was notified, without

an indication the POA was notified.

- An SBAR dated 12/29/17, at 6:05 a.m.,

the resident had an altercation with another

resident and was slapped in the face. The

resident's son was notified.

Interview with the D Wing Unit Manager on

1/12/18 at 9:23 a.m., indicated the POA

should have been called with any change in

condition or incident with Resident 58.

Interview with the Director of Nursing and D Wing Unit Manager on 1/12/18 at 12:45 p.m., indicated the son's name was listed first in the computer as ER (Emergency Room) contact #2 and the POA listed 2nd in the computer as the responsible party and ER contact #1. The POA should have been contacted first, then the son if needed.3.1-35(2)(c)

Education will include ensuring the

POA is contacted and that the

documentation reflects the correct

person was notified.






The DNS or designee will review

POA documentation,

notes/SBAR’s of residents with

change of condition during

morning clinical meetings and on

audit forms 5x/wk for 4 weeks,

then 3x/wk for 4 weeks, then

weekly for x 4 weeks, then


ongoing as needed..


discussed in QAPI to identify any

trends.



February 8, 2018



483.24(a)(2)

ADL Care Provided for Dependent Residents

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

carry out activities of daily living receives the

necessary services to maintain good

nutrition, grooming, and personal and oral

hygiene;

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Based on interview, observation, and record review, the facility failed to ensure a resident who required extensive to dependent assistance for activities of daily living (ADL's) received necessary services related to untrimmed nails for 1 of 2 residents reviewed for ADLs. (Resident 58)Finding includes:Interview with Resident 58's responsible party on 1/8/18 at 1:54 p.m., indicated the facility does not trim his nails.Observation on 1/8/18 at 1:54 p.m., indicated his nails were untrimmed and uneven.Observation on 1/12/18 at 10:59 a.m., indicated his nails were untrimmed and uneven.Observation on 1/12/18 at 2:32 p.m., indicated his nails were untrimmed and uneven.Resident 58's record was reviewed on 1/11/18 at 10:06 a.m. Diagnoses included, but were not limited to, Alzheimer's, anxiety and depression.The Quarterly MDS (Minimum Data Set) assessment, dated 11/14/17, indicated the resident was cognitively impaired and needed a 1 person assistance with personal hygiene, toileting and dressing. He was totally dependant upon staff for bathing.

The resident received bathing on the

following days and times:

- shower on 1/8/18 at 9:21 p.m.

- shower on 1/9/18 at 6:21 p.m.- partial bath on 1/101/8 at 8:30 p.m.- partial bath on 1/11/18 at 8:27 p.m.- partial bath on 1/12/18 at 1:54 a.m.The Nurse's Notes lacked indication that his fingernails were trimmed, or attempted to be trimmed.A revised care plan, dated 11/30/17, indicated the resident was physically unable to care for himself and was cognitively impaired. Interventions included, but were not limited to, limited to extensive assist with personal hygiene.Interview with CNA 10 on 1/12/18 at 2:36 p.m., indicated the resident was diabetic and the staff does not trim his nails.Interview and observation with the D Wing Unit Manager on 1/12/18 at 2:47 p.m., indicated on Sundays, the resident's nails are trimmed. If the resident refused or if the resident's nails are trimmed, it is not documented, unless there is a Physician's order. On non-shower days, the residents are to receive a partial bed bath, which includes cleaning of their nails. Resident 58's nails are jagged and need to be trimmed. Someone should have noticed that his nails needed to be trimmed.3.1-38(a)(3)

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Plan of Correction




deficient practice;

Resident #58 had nails trimmed

and cleaned immediately.






Audits were completed for

residents in need of ADL

assistance including nail care.

Assistance provided as applicable

with all care.





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DCE or designee to in-service staff

on ADL care for residents

including, cleaning and trimming

nails.







Audits on ADL care, including nail

care of residents 5x/wk for 4

weeks, then 3x/wk for 4 weeks,



ongoing as needed.

Results will be reviewed in QAPI

for 6 months and finding no trends,

will be reviewed again on an as

needed basis.



February 8, 2018



483.25

Quality of Care

§ 483.25 Quality of care

Quality of care is a fundamental principle that

applies to all treatment and care provided to

facility residents. Based on the

comprehensive assessment of a resident, the

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facility must ensure that residents receive

treatment and care in accordance with

professional standards of practice, the

comprehensive person-centered care plan,

and the residents' choices.

Based on observation, interview, and record review, the facility failed to assess and monitor a discoloration on a resident's thumbnail for 1 of 1 resident reviewed for non-pressure related skin issues and failed to administer a medication per the Physician's Orders for 1 of 6 residents reviewed for Unnecessary Medications. (Residents 58 and 105)Findings include:1. During an observation on 1/8/18 at 12:30 p.m., Resident 58's right thumbnail had a half moon shaped blackened area. Interview with the Power of Attorney at the time, indicated she was unaware of the discoloration, was not notified of the injury, and the resident did not remember how the thumb was injured. Observation on 1/12/18 at 10:59 a.m., Resident 58 was sitting in a chair near the Nurse's Station, his right thumbnail had a half moon shaped blackened area.Observation on 1/12/18 at 2:32 p.m., Resident 58 was sitting in a chair near the Nurse's Station, his right thumbnail had a half moon shaped blackened area.Resident 58's record was reviewed on 1/11/18 at 10:06 a.m. Diagnoses included, but were not limited to, Alzheimer's, anxiety and depression.

The Quarterly MDS (Minimum Data Set)

assessment, dated 11/14/17, indicated the

resident was cognitively impaired and

needed a 1 person assistance with personal

hygiene, toileting and dressing. He was

totally dependant upon staff for bathing.

The resident received bathing on the

following days and times:

- shower on 1/8/18 at 9:21 p.m.

- shower on 1/9/18 at 6:21 p.m.

- partial bath on 1/101/8 at 8:30 p.m.

- partial bath on 1/11/18 at 8:27 p.m.

- partial bath on 1/12/18 at 1:54 a.m.

The Weekly Skin sheet, dated 1/9/18,

indicated skin was intact with no noted

areas.

The record lacked documentation of the

discoloration to the right thumbnail.

The Physician Order Summary for January

2018 indicated to administer aspirin 81 mg

(milligrams), by mouth, one time a day.

F 0684 Tag 684

Plan of Correction




deficient practice;

Resident #58 had thumbnail

assessed and an investigation for

origin was initiated and reported to

the ISDH.






A full house Skin Sweep was

completed. Skin UDA and

missing administration audits were

performed to ensure compliance.





DCE or designee will re-educate

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Monitor for signs and symptoms of bleeding

while on aspirin therapy, report bruising,

tarry stools, apply prolonged pressure to

venipuncture sites every 12 hours for

anticoagulation.

The January 2018 Medication

Administration Record, indicated the aspirin

81 mg was given as ordered and was

documented at 9:00 a.m. and 9:00 p.m., to

indicate there were no signs and symptoms

of bleeding, bruises, or tarry stools.

A revised care plan, dated 11/30/17, indicated the resident was at risk for complications and bruising related to anticoagulant or antiplatelet medication due to the use of aspirin. Interventions included, but were not limited to, observe for signs and symptoms of bleeding: for example tarry stools, blood in urine, and bruising.A revised care plan, dated 11/30/17, indicated the resident was physically unable to care for himself and was cognitively impaired. Interventions included, but were not limited to, with limited to extensive assist with personal hygiene, and inspect skin with care, report reddened area, rashes, and bruises.Interview with CNA 10 on 1/12/18 at 2:36 p.m., indicated Resident 58 needed assistance with toileting, dressing and showering, and redirection.Interview with CNA 11 on 1/12/18 at 2:39 p.m., indicated he needed assistance with toileting, dressing and showering. Interview with the D Wing Unit Manager on 1/12/18 at 2:47 p.m., indicated the CNA's should have noticed his right thumbnail while giving assistance throughout the day and night and reported to the nurse. The Floor Nurse does a weekly skin inspection, and should have noticed his blackened thumbnail during medication pass or while redirecting him.Policy titled, "Skin Integrity Guideline," was provided by the Director of Nursing on 1/12/18 at 2:30 p.m. This current policy indicated, "...Documentation and Care Interventions for Skin Integrity.... evaluation/observation is to be completed within 24 hours of admission/quarterly/significant change of condition using the weekly skin review...."2. The record for Resident #105 was reviewed on 1/12/18 at 9:40 a.m. The resident's diagnoses included, but were not limited to, Alzheimers Disease, epilepsy (seizures), hypertension (high blood pressure), stroke and arthritis. The Physician Order Summary, dated December 2017, indicated orders for the following medications: Calcium 600 mg (milligrams) + D (Calcium supplement), one time a day.Carvedilol 6.25 mg tablet (blood pressure medication), two times a day.Clopidogrel Bisulfate (Plavix) 75 mg tablet (helps prevent blood clots), two times a day.Levetiracetam Solution (treatment for epilepsy) 100 mg/ml (milliliter), give two times a day. Folic Acid 1 mg (treatment for low iron), one time a day. Pravastatin Sodium tab 20 mg (lowers cholesterol), one time a day. The December 2017 Medication Administration Record indicated the medications above were not given on 12/9/17 and were documented as "other/see Nurse Note." The Pravastatin was also marked as not given, "other/see Nurse Note" on 12/10/17.The Nurse Notes from 12/9/17 through 12/10/17, indicated the medications were "unavailable."A list of medications available in the facility's ADU (Automatic Dispensing Unit), provided on 1/11/18 at 2:30 p.m., indicated the medications were available in the facility. An interview with the Director of Nursing (DON) on 1/12/18 at 10:14 a.m., indicated the medications were available in the ADU or the emergency drug kit, and should have been given per the Physician's orders but were not. The current policy provided by the DON on 1/12/18 at 12:07 p.m. titled, "Medication Administration - Preparation and General Guidelines ... A. Preparation ... 11) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units)...the pharmacy is contacted or medication is removed from the night box or emergency kit...." 3.1-373.1-48(a)(3)

on the Skin Integrity Policy, which

includes documentation of skin

issues, with nursing staff.

DCE or designee will also educate

licensed nurses on the protocol for

medication administration.







documentation of skin

assessments for 5 residents per

week to be assessed randomly.

Audit of E-MAR to be completed

to identify any medications that

are listed as “not available” to

ensure that medication was not

available in the e-box.

Audits will be completed 5x/wk for

4 weeks, then 3x/wk for 4 weeks,



ongoing as needed.


discussed in QAPI for 6 months to

identify any trend and finding no


an as needed basis.

·by what date the systemic


February 8, 2018





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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

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.

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Based on observation, interview, and record review, the facility failed to properly sanitize the puree blender for 1 of 1 meal preperation observations. This had the potential to affect 12 residents who receive a pureed meal. (Main Kitchen) Finding includes:Observation of the puree of foods on 1/12/18 at 9:59 a.m. with the Assistant Dietary Manager (ADM), the following occurred:- the macaroni noodles were pureed to a pudding like consistency, then the blender with the lid and the 2 measuring cups were placed in the 1st compartment of the 3 compartment sink,- the blender, lid, and 2 measuring cups were washed (1st sink), the rinsed (2nd sink) , then placed in the sanitizing (3rd sink) sink for:-black measuring cup: 4 seconds- puree blender: 4 seconds-puree blender lid: 4 seconds- glass measuring cup: 3 seconds-puree blender's blade: 3 secondsthen all were placed upside down on the drying rack.The ADM then gathered the supplies from the drying area, and went back to the prep area to puree the steak. She retrieved beef juice from the stove and placed the juice in the glass measuring cup and set aside. Next, she was picking up beef steaks when she was stopped.Interview with the Assistant Dietary Manager on 1/12/18 at 10:28 a.m., the equipment should have been sanitized for 15 seconds.Interview with the Registered Dietician on 1/12/18 at 10:28 a.m., indicated, while reading the sign by the 3 compartment sink, to submerge the dishes for at least 1 minute in the proper sanitization solution.Policy titled, "Pot and Pan Washing and Sanitation; Manual Warewashing and Sanitation," was provided by the Director of Nursing on 1/12/18 at 12:35 p.m. This current policy indicated, "...Three-Sink system:...Sanitize in dish machine...." There was no further direction in the policy presented which addressed the proper procedure for sanitizing.3.1-21(i)(3)

F 0812 Tag F812__

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deficient practice;

Observation of the pureed food

procedure was identified as an

improper sanitation time.

We were able to correct the

alleged deficit practice.






All residents have the potential to

be affected.

All dining services employees

were in-serviced on proper pot and

pan washing and sanitation via 3

compartment sink by the

registered dietitian on 1/29/18.

In-servicing included lecture and

demonstration of proper

techniques.





All dining service staff in-serviced

on proper pot and pan washing,

and sanitation via 3 compartment

sink per policy. The Registered

Dietitian/Dinning Service Manager

or designee will monitor sanitation

techniques during food preparation

5x/wk for 4 weeks, then 3x/wk for





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4 weeks, then weekly for x 4

weeks, then monthly x 3 months,

and then ongoing as needed.






The ED/ designee will review all

audits. Audit results will be review

monthly in QAPI x6 months

unless further monitoring is

deemed necessary at that time. If

no trends are identified it will be

reviewed as needed.



February 10, 2018



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

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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

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.





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(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, interview, and record review, the facility failed to ensure infection control practices were followed during 2 of 3 medication passes for 2 of 2 residents observed with Enteral Gastrostomy tubes (a tube placed into the stomach for nutrition and medications). (Residents 30 and 88)Findings include:1. Observation of a gastrostomy tube (G-tube) medication pass with LPN 7 on 1/9/18 at 4:23 p.m., with Resident 30, the following occurred:- LPN 7 turned off the tube feeding and placed the tubing on the resident's gown and foam wedge,- removed the G-tube's cap- placed the syringe in the G-tube and checked for residual by pulling back on the plunger, - removed the plunger and placed it on the resident's gown- poured 30 cc (cubic centimeters) of water into the syringe- then the medication/water mixtures, alternating with 5 cc's of water for 6 times- then poured the liquid medicine-then the final flush of 30 cc of water- placed the syringe on the resident's gown and recapped the G-tube- placed the tubing connecting to the feeding back onto the G-Tube- then finally, placed the plunger back into the syringe and put the syringe in the plastic bag to where it was originally storedInterview with LPN 7 and the C Wing Unit Manger on 1/9/18 at 4:50 p.m., indicated the syringe and plunger should have been placed on a clean towel.2. During a G-Tube medication pass on 1/10/18 at 1:50 p.m. with LPN 8 with Resident 88, the following was observed: - removed the plastic bag from the resident's bedside drawer and placed the bag on top of the medication cart- removed the syringe and plunger and placed the syringe in the G-tube and checked for residual by pulling back on the plunger, - placed the plunger on the plastic bag- completed the water flushes with the 2 medications mixture- then removed the syringe and placed the plunger back inside of the syringe - placed the syringe/plunger back into its original bag-then finally, placed plastic bag on top of the resident's bedside dresser.Interview with LPN 8 on 1/10/18 at 2:12 p.m., indicated she should not have laid the plunger on the outside of the plastic bag, she should have placed it on a clean towel.3.1-18(a)

F 0880 Tag F 880__

Plan of Correction




deficient practice;

The educator initiated in-servicing

and competency observation on

the medication administration

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policy and enteral feeding

protocol.






No other residents were identified

for g-tube medication

administration infection control

issues during observations.





DCE or designee to in-service

Licensed nurses on the infection

control policy and procedure

during medication administration,

including a competency

observation for G-tube/Peg Tube

medication administration.






The DCE or designee will perform

1 observation per shift weekly X 1

month, then 1 observation per shift

every other week X 2 months, then

1 observation per shift monthly X 3

months, then annually or as

needed. The results will be





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reviewed by the DNS or designee.

Audit results will be 5x/wk for 4

weeks, then 3x/wk for 4 weeks,



ongoing as needed and reviewed

monthly in QAPI X 6 months

unless further monitoring is

deemed necessary at that time. If

no trends are identified it will be

reviewed as needed.



February 8, 2018



483.90(i)

Safe/Functional/Sanitary/Comfortable Environ

§483.90(i) Other Environmental Conditions

The facility must provide a safe, functional,

sanitary, and comfortable environment for

residents, staff and the public.

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Based on observation and interview, the facility failed to maintain a functional, safe and homelike environment related to marred walls, holes in closet doors, and loose and dirty ceiling vents throughout the facility. (B Wing, C Wing, and D Wing)Findings include:During the Environmental Tour on 1/12/18 from 4:15 p.m.- 5:00 p.m. with the Interim Administrator, Environmental Service Manger and the Director of Maintenance, the following was observed:1. B Wing:a. Room 108's bathroom door was marred and had peeled paint. There were two residents who shared this bathroom.b. Room 120's closet door had a hole near the bottom. There was one resident who resided in this room.c. Room 124 had marred and stained bedroom walls. There were two residents who resided in this room.d. Room 111 had marred walls and the door knob was crooked. There were two resident who resided in this room.e. In the B Wing Dining Room, there were white patches on the walls above the cabinets, and peeled wallpaper.2. C Wing:a. Room 209 had a cracked floor tile next to the heater unit. This room was previously occupied upon initial tour by one resident that was recently discharged.3. D Wing:a. Floor tiles in front of the Nurse's Station and in front of the Shower Room door had holes.b. The Room "305" Dining Room had a chair with an exposed screw on the side of the chair, upholstery loose on the seat of the chair and a dirty and chipped paint on the heating unit. There were 3 residents observed on 1/10/18 at 11:51 p.m., who occupied these chairs during lunch service.c. In Room 310's bathroom, the drain stopper on top of the sink was broken in half and the bottom dresser drawer was marred. There were two residents who resided in this room.d. In Room 311's bathroom, the ceiling vent was loose, the floor was not flush with the walls, the bottom of the mirror was loose and the caulking on the corner of walls were cracked. There were two residents who shared this bathroom.e. In Room 315's bathroom, there was a crack between the wall and the door frame, dusty ceiling vent, debris build up on floor in the corners, cracked floor tile, and the resident's wheelchair seat and wheel spokes had debris. There was one resident who resided in this room.f. In Room 316's bathroom, the walls were marred, the caulking around the toilet was cracked, the toilet riser was discolored, and a container of Aquaphor ointment was on top of the dresser open and uncontained. The Aquaphor was originally observed on 1/9/18 at 10:02 a.m., open and on top of the bedside table. Aquaphor's label indicated to "keep out of reach of children." The Environmental Service Manager indicated that residents do wander into other residents' room on this Dementia Locked Unit.g. In Room 323's bathroom, there was a hole in the ceiling next to the fire sprinkler, a crack in the wall and on the ceiling, and patch marks on the wall by the paper towel dispenser. In the bedroom, the walls were marred, the last drawer in the dresser was broken and loose and had a broken floor tile next to the recliner. There was one resident who resided in this room.h. In Room 330's bathroom, the ceiling vent was loose and dirty. In the bedroom, the wall was marred and the resident's wheelchair arm cushions were cracked. There was one resident who resided in this room.i. In Room 334's bathroom, the toilet riser was discolored, between the ceiling and the wall had holes, the caulk around the sink had a yellow stain and was cracked and the area above the paper towel dispenser was marred. The top of the resident's dresser was marred. There were two residents who resided in this room.Interview on 1/12/18 at 5:00 p.m. with the Interim Administrator, Environmental Service Manger and the Director of Maintenance, agreed the above was all in need of being cleaned or repaired.3.1-19(e)

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Plan of Correction

·what corrective action(s) will be

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deficient practice;

Walls, doors, tiles, and chairs

were all requiring repairs, cleaning

and replacements. All identified

areas of disrepair; replacement

and/or cleaning have been

identified.

We were unable to correct the

alleged deficiencies.

·how other residents having the





All residents have the potential to

be affected by this deficit practice.

Audits were performed to ensure

that areas of concern were

addressed and cleaned, replaced

or repaired.

·what measures will be put into




ED/Designee will oversee

maintenance and environmental

issues on a weekly basis to

ensure compliance.





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·how the corrective action(s) will





Guardian Angel rounds will be

utilized to identify areas that need

correction. Identified issues will be

placed in building engines.

In-servicing for staff who do GA

rounds will occur. Work orders will

be evaluated for completeness by

the ED/designee every week for a

month, bi-monthly for 3 months

and monthly for 6 months.



February 10, 2018




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