PRINTED: 03/03/2020 DEPARTMENT OF HEALTH AND …

(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

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

FORT WAYNE, IN 46825

155479 02/11/2020

KINGSTON CARE CENTER OF FORT WAYNE

1010 W WASHINGTON CENTER RD

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey.

Survey dates: February 3, 4, 5, 6, 7, 10, and 11,

2020

Facility number: 000522

Provider number: 155479

AIM number: 100267040

Census Bed Type:

SNF/NF: 78

SNF: 39

Total: 117

Census Payor Type:

Medicare: 31

Medicaid: 74

Other: 12

Total: 117

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality review completed February 13, 2020.

F 0000 This Plan of Correction is being

prepared and executed because it

is required by the provisions of the

State and Federal regulations and

not because Kingston Care Center

of Fort Wayne agrees with the

allegations and citations listed on

the statement of deficiencies.

Kingston Care Center of Fort

Wayne maintains that the alleged

deficiencies do not individually or

collectively jeopardize the health

and safety of the residents, nor

are they of such character as to

limit our capacity to render

adequate care as prescribed by

regulation.

This plan of correction shall

operate as Kingston Care Center

of Fort Wayne written credible

allegations of compliance. This

plan of correction is not meant to

establish any standard of care

contract, obligation or position,

and Kingston Care Center of Fort

Wayne reserves all possible

contentions and defenses in any

civil or criminal actions or

proceeding. Please accept the

date of correction March 12th,

2020 as the facility’s credible

allegation of compliance.

We respectfully request paper

compliance for all deficiencies in

the following plan of correction.

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: 3D4511 Facility ID: 000522

TITLE

If continuation sheet Page 1 of 56

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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.

F 0686

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Based on observation, interview, and record

review, the facility failed to ensure the assessment

and treatment of a pressure ulcer was completed

for 1 of 5 residents reviewed. (Resident 253)

Findings include:

The record review for Resident 253 began on

2-6-2020 at 3:00 p.m. Diagnoses included but were

not limited to,

sepsis due to Escherichia coli (a bacteria),

Parkinson's disease, dementia with Lewy Bodies,

dementia with behavioral disturbance, high blood

pressure, spondylolysis (degeneration of spine)

thoracic region, unilateral inguinal hernia with

obstruction, delusional disorder, cognitive

communication deficit, and fracture of upper end

of the right humerus.

A MDS (Minimum Data Set) admission

assessment for Resident 253 was dated 1-15-2020.

Resident 253 had a BIMS (Brief Interview of

F 0686 It is the practice of Kingston

Healthcare Center to ensure

residents with pressure ulcers

receive necessary treatment and

services consistent with

professional standards of practice,

to promote healing prevent

infection and prevent new ulcers

from developing.

Resident 253 was assessed by

the certified wound nurse on

2/6/20. The assessment was

documented in the resident’s

record. Notification was made to

the provider, orders for wound care

were obtained et implemented,

and the care plan was

appropriately updated. The

resident no longer resides at

Kingston as he discharged to a

memory care facility on 2/7/20.

Residents who are identified with

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Mental Status) of 10/15, which indicated the

resident was moderately cognitively impaired.

The resident required an extensive assist of 1

person for bed mobility, locomotion on/off unit,

for dressing, toileting, and personal hygiene.

Resident 253 required an extensive assist of 2 staff

for transfers and supervision of 1 staff for walking

in the corridor. The resident required a limited

assist of one person for walking in the room and

supervision with set up help only for eating. He

was dependent on 1 person for bathing. Resident

253 had an impairment on one side of the upper

extremity and no impairment on lower extremities.

The resident was 62 inches tall and weighed 148

pounds. The resident was at risk for developing

pressure areas but no pressure areas and no other

open areas on the skin were present. The resident

had a pressure reducing device for the bed and

had applications of ointments/medications other

than to feet marked.

A review of the Weekly Skin Observation dated

2-3-2020 at 2:33 p.m., indicated the question new

wound identified, was answered no.

A review of the February 2020 TAR (Treatment

Administration Record) indicated prior to

2-6-2020, there was not any wound care

orders/treatments provided to the Resident 253's

sacral/coccyx area.

A review of Resident 253's progress notes was

completed on 2-4-2020 at 12:53 p.m. A progress

note dated 2-2-2020 at 6:02 a.m., indicated the

nurse found the resident to have three circular

bleeding skin tears on coccyx. The wounds were

cleaned and dressed with allevyn (a self adhering

dressing). The ADON/Wound Nurse 5 (Assistant

Director of Nursing) and NP (Nurse Practitioner)

were notified of wound. There were no orders

pressure areas.

Nursing staff will be In-serviced on

Nursing Documentation Quick

reference guide to Facility

Acquired pressure injury;

including, the procedure for

appropriately documenting the

presence of a new pressure area,

provider notification, and obtaining

and initiating a treatment order.

Staff will be instructed on the

required notification for new

identified areas to nursing

administration.

Utilizing the created QA tool for

ADON/designee to audit weekly

skin assessments and narrative

nurse’s notes for indications of

unidentified pressure areas 5

times weekly for four weeks, then

3 times a weekly for 8 weeks,

then continue weekly for 12

weeks. Following, weekly record

audits will continue ongoing.

Wound team will continue weekly

rounding of all identified pressure

areas, and quarterly skin sweeps

as part of the QAPI process. Any

discrepancies will be reported to

the QAPI committee. The results

of these audits will be reviewed by

the facility Quality Assurance

Performance Improvement (QAPI)

committee for patterns, trends,

and continued recommendations

for process monitoring on going

education and improvement.





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found for wound care and no assessment found

for the coccyx area in Resident 253's record as of

2-4-2020 at 1:01 p.m.

An interview with Nurse 6, who was Resident

253's nurse, on 2-6-2020 at 10:30 a.m., in indicated

she would have to check if the resident had a

wound care order. Further interview with Nurse 6

on 2-6-2020 at 11:10 a.m., indicated she informed

ADON/Wound Nurse 5 about the resident's skin

tears on his coccyx. The nurse indicated

ADON/Wound Nurse 5 was going to assess the

area after the resident finished with therapy.

An interview with ADON/Wound Nurse 5 on

2-6-2020 at 11:18 a.m., indicated he had not

assessed Resident 253's coccyx area. He indicated

when an open area appeared on a resident, it

should be reported to the NP and the DON

(Director of Nursing). He indicated he would then

assess the area and if it was found to be a

pressure area, he would make a referral to OT

(Occupational Therapy) for bed/chair cushion

evaluation.

An observation of Resident 253 on 2-6-2018 at

11:21 a.m., indicated the resident was sitting in his

wheelchair in his room. The resident's right arm

was in a sling and was positioned on a blanket.

The resident was observed to have a cushion in

the seat of his wheelchair. Resident 253 indicated

his backside area hurt when it came in contact

with other parts of his body. ADON/Wound

Nurse 5 and CNA 7 (Certified Nurse Aide) were

observed to transfer the resident from his

wheelchair into the bed and turned the resident on

his right side. ADON/Wound Nurse 5 was

observed to use hand sanitizer and then donned

gloves. CNA 7 donned gloves and held the

resident on his side The coccyx was observed





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and there was not a dressing on the coccyx as the

area was open to air. ADON/Wound Nurse 5 was

observed to measure the opened areas in the

sacral region as the areas were opened and red.

ADON/Wound Nurse 5 nurse was observed to

clean the area with a wound cleanser spray and

pat dry. The nurse was observed to remove his

gloves, used the hand foam and then donned

clean gloves. ADON/Wound Nurse 5 was

observed to apply a dry, self adhering dressing.

The nurse indicated Resident 253 had a stage 2

pressure area and wound care would be done on

Monday, Wednesday and Friday.

After the completion of the wound care for

Resident 253, an Unavoidable Pressure Ulcer

Review with an effective date of 2-2-2020 was

completed by ADON/Wound Nurse 5. The

review indicated the sacrum had two areas noted

related to friction and shearing.

A Pressure Injury Review with an effective date of

2-6-2020 was completed by ADON/Wound Nurse

5. The review indicated Resident 253's right sacral

region had an in house wound development of a

pressure injury with measurements of 1.2 cm

(centimeters) long, x 1.5 cm wide x 0.1 cm deep.

The wound bed was red, with a scant amount of

serous drainage. A second opened area on the

left sacral region was an in-house acquired stage 2

pressure injury with measurements of 1 cm long x

2 cm wide x 0.1 cm deep. The area was red with

scant serous drainage. ADON/Wound Nurse 5

updated the Braden Scale on 2-6-2020 with a score

of 12. This indicated the resident was at a high

risk for pressure ulcer development. He obtained

physician orders on 2-6-2020 for the wound care

as follows, cleanse area on right sacrum with

wound cleanser, pat dry, apply allevyn to area.

Change dressing Monday, Wednesday and





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Friday for optimal healing and cleanse area on left

sacrum with wound cleanser, pat dry, apply

allevyn to area. Change dressing Monday,

Wednesday, and Friday for optimal healing. The

care plan for impaired skin integrity was updated

on 2-6-2020 with the addition of a pressure injury

to the sacral region.


2-6-2020 at 3:20 p.m., indicated he was not made

aware of

Resident 253's impaired skin on his coccyx area

when it had been discovered. The ADON/Wound

Nurse 5 indicated there was a new nurse that

would need some education as he was unable to

locate an order for the wound care cleansing and

dressing application she completed on 2-2-2020.

During an interview with the DON on 2-6-2020 at

4:23 p.m., the DON was made aware of a progress

note entered on 2-2-2020 for Resident 253

regarding 3 skin tears on the coccyx and the

treatment provided. The DON was made aware

the note indicated ADON/Wound Nurse 5 and the

NP were notified, however, an order was not

found for the wound treatment, an assessment of

the wound was not found and the resident's nurse

on the hall this date, Nurse 6, was not aware the

resident had a wound.


2-6-2020 at 4:45 p.m., indicated the nurse should

have notified him by telephone of the open area

on the Resident 253's coccyx on the date it was

discovered, 2-2-2020. ADON/Wound Nurse 5

indicated had he been notified on 2-2-2020, he

would have assessed the area on 2-3-2020.

A facility policy was not provided.





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3.1-40

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

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.

F 0692

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Based on interview and record review, the facility

failed to ensure dietary assessments were

completed and/or weights were monitored as

recommended for 1 of 4 resident's reviewed.

Resident 89

Findings include:

On 2/7/2020 at 9:00 a.m. the record of Resident 89

was reviewed. Diagnoses included, but were not

limited to, the following: aphasia (loss of ability to

understand or express speech) following stroke,

dysphagia (difficulty swallowing foods or liquids),

hypothyroidism, type 2 diabetes mellitus and

F 0692 F692 Nutrition/Hydration Status

Maintenance

It is the practice of Kingston Care

Center to assess the nutritional

status of residents. The facility

has an established a plan of

correction to ensure dietary

assessments were completed and

weights are monitored.

The dietary assessment was

completed on 2/10/2020. The

resident was not affected by the

missed assessment. Nutritional

interventions were in place and a

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major depressive disorder.

The quarterly minimum data set (MDS)

assessment, dated 1/9/2020, included the

following: resident was rarely/never understood;

had signs and symptoms present of swallowing

disorder: loss of liquids/solids from mouth when

eating or drinking, holding foods in mouth/cheeks

or residual food in mouth after meals, cough or

choke during meals or when swallows

medications, complaints of difficulty or pain with

swallowing and no weight loss of 5 percent or

more in last month or 10 percent in the last 6

months.

The most recently documented quarterly, dietary

assessment, on 6/14/2019, included but was not

limited to, the following information: clinical

condition; alternate feeding orders;

data/calculations to include the resident's ideal

body weight was 160 lbs.; weight change and

history; nutritional and weight loss risk factors;

dietary needs; health plan and swallowing.

The resident's weights were reviewed on 2/7/2020

at 10:00 a.m. with the following observed for the

current year, 2020: 1/8: 183.1 lbs (pounds); 1/15:

182.4 lbs; 1/22: 182.6 lbs; 1/29: 169.4 lbs and 2/5:

170.1 lbs.

On 2/7/2020 at 4:31 p.m., the Director of Nursing

(DON) provided a current copy of the facility

policy and procedure for "Obtaining

Accurate...weight" dated April 2019. The policy

and procedure included, but was not limited to,

the following: "...nursing service will be

responsible for the initial determination and

documentation of...weight...subsequent weights

will be documented in the weight...and/or nursing

notes in the computer." The policy also indicated

reweight obtained during survey

established that there was not a

true weight loss.

All current residents have been

reviewed for missed

assessments.

Ongoing nutritional assessments

will be reviewed in conjunction with

MDS schedule.

Weights will be reviewed weekly

in nutrition assessment meeting

and audited for accuracy.

Questionable weights will be

followed by Dietitian.

To prevent a reoccurrence:


how to properly obtain weights

along with training to ensure

reweights are all by the same

means… i.e. lift vs wheelchair

Dietitian will be in-serviced on

MDS calendar and reports in PCC

to monitor all assessment

deadlines.

The Quality Assurance team will

be responsible for ensuring

compliance. Utilizing the MDS

calendar dietary assessments will

be monitored for completion by the

MDS nurse 5 times weekly for four

weeks, then 3 times a weekly for

8 weeks, then continue all records

weekly for 12 weeks. Following,

weekly random record audits will

continue ongoing. Any










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the dietary professional will assess the problems

related to inappropriate weight and determine

individual approaches for any identified problems;

monitor weight in electronic medical record and if

there is a greater than 3-5 pound discrepancy

report to nurse. This may require a reweigh (sic).

On 2/10/2020 at 12:02 p.m., the Dietician

documented a dietary note which indicated the

following: the resident ate in dining room, and

drank thin liquids. The residnet's oral intakes were

76-100 percent currently. Resident had recently

had pneumonia with a cough and had some

weight loss. Nursing had not noticed a decrease

in oral intake. The resident received mighty

shakes at bedtime.The note indicated the Dietician

would follow for any changes with diet tolerance.

A plan of care to address the potential for

alteration in nutrition and hydration status was

related to: decreased chewing and swallowing

ability, had a revision date of 1/19/2020. This was

reviewed on 2/10/2020 at 12:30 p.m. The goal was

documented the resident would achieve and

maintain a weight of 185 plus/minus 5 pounds.

Interventions included to monitor weights.

On 2/10/2020 at 2:57 p.m., the DON provided a

current copy of the facility policy and procedure

for "Nutrition Documentation" dated September

2018. The policy and procedure included, but was

not limited to, the following: Documentation of

resident's nutritional care is the responsibility of

the dietary professional. Re-assessment/Progress

Notes: As the re-assessment/progress notes

reflects progress made on goals set for the

resident's plan of care, the dietary professional

must review the previous plan of care to assess

this. Progress notes should reflect progress made

to meet goals. Progress notes and plans of care









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updates are completed according to facility policy

and state and federal guidelines, and as needed.

Generally this means every 90 days and with each

significant change.

On 2/10/2020 at 3:34 p.m. the Dietician was

interviewed. She indicated the last quarterly

dietary assessment the resident had completed

was 6/14/19. She indicated the resident should

have had a quarterly dietary assessment

completed in September and December 2019. She

indicated she began employment at the facility in

September 2019 and the quarterly dietary

assessments were not completed in September

and December 2019. She indicated the dietary

portion of the quarterly MDS assessments on

9/27/19, 11/20/2019 and 1/9/2020 were completed.

She indicated she was able to obtained

information to complete these, by reviewing the

resident's weight from the weight log. She

indicated she did not realized she had not

completed the quarterly dietary assessments.

Documentation was lacking of a quarterly dietary

assessment for the September 2019 and December

2019.

On 2/10/2020 at 3:35 p.m., the Dietician was

interviewed. She indicated on 1/22/2020 the

resident had a weight of 182.6 lbs, obtained in the

wheelchair. She indicated on 1/29/2020 she noted

a weight of 169.4 lb, which, per documentation,

had been obtained with the mechanical lift. She

indicated the facility had not notified her of the

weight of 169.4 lb from 1/29/2020 but she was

made aware of the weight loss by a report she had

reviewed. She indicated she had requested a

reweight on 2/7/2020. She indicated the resident

was reweighed on 2/10/2020 with a result of 179.2

lbs. She indicated she questioned if either the

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weight was accurate. She indicated she felt both

these weights, 1/29 and 2/5/2020, were not

accurate and the weight of 179.2 lb on 2/10/2020

was more in line with what the resident actually

weighed. The Dietician indicated the resident had

been started on Mighty Shakes (liquid nutritional

supplement) in the evenings on 1/22/2020. She

indicated she would continue to monitor the

resident.

On 2/10/2020 at 4:00 p.m., the DON was

interviewed. She indicated when the Certified

Nurse Aides (CNA) obtained the weight of 169.4

lbs on 1/29/2020, the nurse should have been

notified. She indicated since the prior weight on

1/22/2020 was 182.6 lbs, the nurse should have

directed the CNA to obtain a reweight. The DON

indicated the reweight should have either been

obtained the same day or the next morning. She

indicated the problem appeared be the method of

the weighing the resident and not the resident's

actual weight.

3.1-46(a)(1)

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

F 0755

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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.

§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.


review, the facility failed to ensure accurate

documentation of narcotic medication for 1 of 4

residents reviewed. (Resident 65)

Findings include:

The record review for Resident 65 began 2-10-2020

at 12:17 p.m. Diagnoses included but were not

limited to chronic pain syndrome, chronic

osteomyelitis of the left femur, osteoarthritis of

the left hip, intervetebral disc degeneration of the

lumbar region of the spine, diabetes and aplastic

anemia.

The most recent MDS (Minimum Data Set)

quarterly assessment for Resident 65 was dated

12-21-2019. The BIMS (Brief Interview for Mental

Status) indicated a score of 14/15, which indicated

F 0755 It is the practice of Kingston Care

Center to ensure pharmacy

ronciliation is maintained and

accurate.

F755 Pharmacy Services/

Procedures/Pharmacist/ Records

The facility has an established

system of records of receipt and

disposition of all controlled drugs

in sufficient detail to enable an

accurate reconciliation: and

determines that drug records are

in order and that an account of all

controlled drugs is maintained and

periodically reconciled. No

residents were affected by this

citation.

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the resident was cognitively intact. The resident

had no routine scheduled pain medications, had

prn (as needed) pain medications ordered, and

had frequent pain which did not interfere with

sleep but did limit day to day activities. The

resident rated her pain a 6 on a scale of 1 to 10 and

received 7 days of opioids in the 7 day look back

period.

A review of the current physician orders for

Resident 65 regarding pain medications indicated

to give hydrocodone acetaminophen 7.5/325 mg

(milligrams) 2 tablets po (by mouth) every 8 hours

as needed for pain with a maximum of 6 pills to be

administered in a 24 hour period. There was also

an order for hydrocodone acetaminophen 7.5-325

mg give 1 tablet by mouth every 6 hours as

needed for pain with a maximum of 6 pills in 24

hours.

A care plan for pain related to arthritis and chronic

left hip pain was created on 10-29-2018 and last

revised on 8-5-2019. The goal was last revised on

11-11-2018 for the resident to verbalize a decrease

or relief of pain with in one hour of receiving

intervention/medications. The approaches

included but were not limited to, monitor for

effectiveness of pain medications and notify M.D.

(physician) as needed, administer pain and other

medications as ordered note the effectiveness

acknowledge presence of pain and discomfort and

listen to resident's concerns.

During an interview with Resident 65 on 2-4-2020

at 5:13 p.m., the resident indicated she received

routine pain medications but sometimes had to

wait 4 hours to get the pain medication. The

resident indicated the pain medications were

obtained from the 400 hall medication room and

the nurse or the QMA would have to walk from

Resident # 65 Current controlled

substance Accountability sheets

were reconciled with the ADU

controlled dispenses report and

the MAR to ensure all doses were

accurately recorded.

Residents who have active

orders for PRN controlled

substances.


Controlled Substances Policy and

Medication Administration-

General Guidelines including the

procedure for appropriately

recording the inventory of all

controlled drugs. Staff will be

instructed on the required

documentation for the

administration of controlled

substances according to the

policy.


DON/designee to audit controlled

substance accountability sheets

with the ADU controlled dispenses

report and the MAR 5 times

weekly for four weeks, then 3

times a weekly for 8 weeks, then

continue weekly for 12 weeks.

Following, weekly random record

audits will continue ongoing. Any














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the 200 hall to the 400 hall to obtain the pain

medication. The resident indicated the pain

medication did reduce the pain level to a 5. The

resident indicated her pain level was high and the

medications she received helped to lower the

intensity of the pain.

During a medication pass observation of

Resident 65 on 2-10-2020 at 8:55 a.m., Nurse 20

was observed to prepare the resident's

medications and obtain a clear cellophane

package from the locked box inside the medication

cart. The cellophane package had the resident's

name and the medication order -

hydrocodone/APAP tablet 7.5/325 mg give 2 tabs

by mouth. An interview at this time with Nurse 20

indicated if the hydrocodone was not in the

locked metal box, she would have had to go to the

400 hall to retrieve the medication from the ADU

(Automatic Dispensing Unit).

An interview with Nurse 20 on 2-10-2020 at 1:58

p.m., indicated the hydrocodone acetaminophen

7.5/325 mg 2 tablets were already in the locked

metal box in her medication cart. The nurse

indicated it was there as someone else obtained it

the from the Automatic Dispensing Unit

yesterday. She indicated if it had not been there,

she would have had to go get it from the ADU in

the medication room in the 400 hall. The nurse's

narcotic count binder was reviewed and there

were 2 tablets of hydrocodone-acetaminophen

7.5/325 mg added to the Controlled Substance

Accountability Sheet on 2-9-2010 by one staff and

a different nurse administered the medication this

morning.

A review of the Controlled Substance

Accountability sheets which were provided by

the DON on 2-10-2020 at 4:10 p.m., indicated





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multiple missing documentation from 1-1-2020

through 2-7-2020. There were multiple missing

times of hydrocodone/acetaminophen acquisition

from the ADU, missing dose administration times,

medication documented as administered on the

MARs but the medication was not signed out on

the Controlled Substance Accountability sheet,

doses obtained from the ADU and administered

but not documented in the MARs. The missing

documentation on the Controlled Substance

Accountability sheets/MARs were as follows:

On 1-4-2020, hydrocodone-acetaminophen 7.5/325

mg 2 tablets were administered 3 times per the

January 2020 MAR, but were not documented on

the Controlled Substance Accountability sheet.

Between 1-5-2020 and 1-7-2020, 2 tablets of the

hydrocodone acetaminophen 7.5/325 mg were

obtained from the ADU with the date and time not

entered on the Controlled Substance

Accountability sheet. Another entry during this

time frame had 2 tablets documented as if they

were received from the ADU, but under the

quantity remaining on the Controlled Substance

Accountability sheet, 2 tablets were shown to

have been used.

There were 6 entries on the Controlled Substance

Accountability sheet from 1-7-2020 through

1-9-2020, which lacked times of the quantity

dispensed and amount administered of the

hydrocodone acetaminophen 7.5-325 mg tablets.

There was missing documentation of an

administration of 2 tablets of the

hydrocodone-acetaminophen 7.5/325 mg on the

Controlled Substance Accountability sheet on

1-8-2020, there was documentation on the MAR

for 1-8-2020 at 5:10 p.m. that the medication was

administered not documented on the





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Accountability Sheet.

On 1-11-2020, there were 2

hydrocodone-acetaminophen 7.5/325 mg tablets

documented as administered at 9:00 p.m. on the

Controlled Substance Accountability Sheet, but

not documented on the MAR for 1-11-2020.

On 1-12-2020 at 9:45 a.m., there were 2


documented as administered on the MAR but not

documented as dispensed or administered on the

Controlled Substance Accountability Sheet.

On 1-13-2020 at 12:06 a.m., there were 2





There were 2 hydrocodone-acetaminophen 7.5/325

mg tablets documented as being dispensed from

the ADU between 1-13-2020 and 1-14-2020 with no

date, time or nurse signature entered on the




documented as administered at 1:00 a.m. on the



Between 1-20-2020 5:00 a.m. and 1-21-2020 5:00

p.m., 4 hydrocodone-acetaminophen tablets were

obtained from the ADU, without a time or nurse

signature documented on the Controlled

Substance Accountability sheet.

On 1-21-2020 at 11:29 p.m., there were 2






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An entry on 1-23-2020 on the Controlled

Substance Accountability sheet indicated 4 as the

quantity remaining of the

hydrocodone-acetaminophen tablets at the

bottom of the page. The next page where

1-24-2020 was entered on the Controlled

Substance Accountability, the sheet did not

reflect the 4 tablets remaining of the

hydrocodone-acetaminophen from 1-23-2020 the

documentation indicated another 2 tablets were

obtained and administered with a "0" count left on

1-24-2020.



documented as administered at 8:00 a.m. on the



An entry on the 1-27-2020 MAR at 3:51 p.m.,

indicated there were 2


documented as administered, but were not



On 1-28-2020 at 11:16 p.m. and 8:58 p.m., there

were 2 hydrocodone-acetaminophen 7.5/325 mg

tablets documented as administered on the MAR

at each time but 2 tablets were not documented as

dispensed or administered on the Controlled

Substance Accountability Sheet.








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dispensed and/or amount administered of the


Documentation on the Controlled Substance

Accountability for 2-3-2020 indicated 2

hydrocodone acetaminophen 7.5-325 mg tablets

were dispensed from the ADU and 2 tablets were

administered. However, the quantity remaining on

the Accountability sheet was 2.

Documentation on the Controlled Substance

Accountability for 2-4-2020 lacked a time, whether

the hydrocodone acetaminophen 7.5-325 mg

tablets were dispensed or administered and had

"0" documented in the quantity remaining.




dispensed and/or amount administered of the


A statement on the Controlled Substance

Accountability sheet indicated: Charting on the

medication record was required for each dose

administered.

During an interview on 2-11-2020 at 8:45 a.m., the

Administrator was asked about whether there

were reports which could be pulled from the ADU

machine that would show what medications were

dispensed by resident. The Administrator

indicated she would have to check. The

Administrator was asked it there was a system in

place to reconcile between the narcotic

medications dispensed from the ADU, the


Accountability Sheet and the MAR. She indicated

she did not know and would have to check.





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a.m., indicated the Controlled Substance

Accountability sheet for the hydrocodone

acetaminophen 7.5/325 mg for Resident 65 had 2

tablets documented as of 2-10-2020 at 9:00 p.m.

There were 2 tablets in the medication cart on the

200 hall in the locked box inside the locked cart in

a package with the resident's name on it and the

medication name and amount. The nurse

indicated on the Controlled Substance

Accountability sheet, the night shift would obtain

the medications for the next day, document the

date, time and the amount obtained (number of

pills) from the ADU. This would be documented

under the quantity dispensed. Then if any of the

medication was administered, the number of pills

would be documented under the amount

administered column and the remaining amount

would be documented under the remaining

quantity. Nurse 19 indicated the nurse would sign

their name in the nurse signature column.

An interview with the DON on 2-11-2020 at 9:30

a.m., indicated on the Controlled Substance

Accountability sheet; the nurse would enter the

date the narcotic was obtained from the ADU, the

time it was obtained from the ADU, and the

number of pills obtained under the quantity

dispensed column. Then when the medication

was administered, the amount should entered

under the amount administered and then the

number remaining should be entered under the

quantity remaining. The DON indicated the nurse

signature should be entered under the nurse

signature line for each entry. The DON was asked

how the facility reconciled the narcotic

medications dispensed from the ADU, with the


Accountability sheet and the MAR to ensure the

documentation matched and supported each





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narcotic dispensed and administered. The DON

indicated the facility was provided weekly reports

from the pharmacy for the ADU. She would

randomly select a resident, review the medications

dispensed, the documentation on the Controlled

Substance Accountability sheet and the

documentation on the MAR. The missing


Accountability sheets for January 2020 and

February 2020 were reviewed with the DON. The

DON was also informed about the remaining 4

hydrocodone acetaminophen 7.5/325 tablets for

Resident 65 on 1-23-2020, the new page beginning

with 1-24-2020 with 4 tablets not entered and the

additional 2 tablets obtained and administered on

1-24-2020. The DON indicated she would have to

check to see if there were tablets dispensed on

1-23-2020. Also reviewed was the documentation

for several entries of the hydrocodone

acetaminophen 7.5/325 mg tablets which were

marked as administered on the Controlled

Substance Accountability sheet and were not

entered on the MAR.

On 2-10-2020 at 10:35 a.m., the DON returned with

the ADU Controlled Dispenses record from

1-20-2020 at 1:43 a.m. through 1-25-2020 at 8:16

a.m. Resident 65 had 20 of the hydrocodone

acetaminophen 7.5/325 mg tablets dispensed

during that time. The dates from 1-20-2020

through 1-25-2020 on the Controlled Substance

Accountability sheets and the resident's MAR

were reviewed. All 20 tablets were reconciled.

There were 2 tablets remaining on 1-25-2020 and

on 1-21-2020 at 11:29 p.m., there were 2 tablets that

were not documented as administered on the


A current, undated policy, titled Controlled

Substances, was provided by the DON on





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2-10-2020 at 5:35 p.m. The policy indicated:

standard policies and procedures for inventory as

previously outlined, including replenishment,

utilization, inspection, chain of custody, and

expired/unused/recalled medications, will be

followed for all controlled substances.

A current facility pharmacy policy, titled

Medication Administration-Preparation and

General Guidelines Controlled Substances",

revised August of 2014, was provided by the

DON on 2-11-2020 at 9:30 a.m. The policy

indicated, "...Medications included in the Drug

Enforcement Administration (DEA) classification

as controlled substances are subject to special

handling, storage, disposal, and recordkeeping in

the facility, in accordance with federal and sate

laws and regulations. Procedure A. The Director

of Nursing and the consultant pharmacist in

collaboration maintain the facility's compliance

with federal and state laws and regulations in the

handling of controlled medications. Only

authorized licensed nursing and pharmacy

personnel have access to controlled

medications...E. Accurate accountability of the

inventory of all controlled drugs is maintained at

all times. When a controlled substance is

administered, the licensed nurse administering the

medication immediately enters the following

information on the accountability record and the

medication administration record (MAR):

1) Date and time of administration (MAR,

Accountability Record)

2) Amount administered (Accountability Record)

3) Remaining quantity (Accountability Record)

4) Initials of the nurse administering the dose,

completed after the medication is actually

administered (MAR, Accountability Record)...."

A current policy, "Medication Administration-





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-General Guidelines" revised August 2014 was

provided by the DON on 2-11-2020 at 10:19 a.m.

The policy indicated "...the person who prepares

the dose for administration is the person who

administers the dose...Documentation 1) The

individual who administers the medication dose

records the administration on the resident's MAR

directly after the medication is given. At the end

of each medication pass, the person administer

the medications reviews the MAR to ensure

necessary doses were administered and

documented...5) When PRN medications are

administered, the following documentation is

provided:

a. Date and time of administration, dose, route...

b. Complaints of symptoms for which the

medication was given.

c. Results achieved from giving the dose and the

time results were noted.

d. Signature or initials of person recording

administration and signature or initials of person

recording effects, if different from the person

administering the medication...

7. The person who prepares the dose for

administration is the person who administers the

dose...."

3.1-25(b)(3)

3.1-25(e)(3)

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

F 0812

SS=E

Bldg. 00





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directly from local producers, subject to

applicable State and local laws or

regulations.

(ii) This provision does not prohibit or prevent

facilities from using produce grown in facility

gardens, subject to compliance with

applicable safe growing and food-handling

practices.

(iii) This provision does not preclude residents

from consuming foods not procured by the

facility.

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

serve food in accordance with professional

standards for food service safety.


review, the facility failed to ensure sanitation

practices were followed in the kitchen. This had

the potential to affect 115 of 117 resident who ate

their meals from the facility kitchen.

Findings include:

1. During the initial tour of the kitchen with the

CDM (Certified Dietary Manager) and Dietitian on

2-3-2020 at 9:08 a.m., the following was observed:

The high temperature dish machine was observed

to be running with an observed wash temperature

of 168 degrees F (Fahrenheit) and a rinse temp of

170 degrees F. The side of the dish machine was

observed to have a label which indicated the

wash temperature was to be at least 160 degrees F

and the rinse temperature was to be at least 180

degrees F.

At 9:15 a.m., three more wash/rinse cycles were

observed and the rinse thermometer, which was

the thermometer on top and in the far back per the

CDM, did not change from 170 degrees F.


Center to ensure all food will be

stored, prepared, distributed and

served in accordance with

professional standards for food

service safety.

1.Dishwasher Temp

During survey temperatures were

within acceptable range. The

malfunctioning temperature gauge

was replaced immediately on

2/5/2020. (invoice attached. No

Residents were affected.

To prevent a re-occurrence,

Kingston Purchased a Plate

Simulator as a fail- safe method to

verify dish machine temperature at

required temperatures per

regulation. (invoice and description

attached.)

In-service of all dishwashing staff

will be completed by compliance

date.

As part of systemic changes:

Maintenance will run plate

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At 9:25 a.m., the dish machine was observed again

during a wash/rinse cycle and the rinse

temperature was 170 degrees F. The dish machine

was observed to have had a large metal sheet pan

and dome covers run through the wash/rinse

cycle. An interview with the CDM at this time

indicated they just had the dish machine

temperatures checked by maintenance this

morning and the rinse temperature was 180

degrees F.

At 9:30 a.m., Maintenance 8 came in to the kitchen

and checked the hot water booster and indicated

it was on. He was observed to have a

thermometer (a stick type with a dial type gauge)

that he placed in the water at the bottom of the

dish machine after a wash/rinse cycle was

completed. He indicated that temperature would

not be accurate.

At 9:32 a.m., Maintenance 8 left the kitchen and

went across the hall to a utility room to check the

hot water heaters.

Maintenance 8 indicated these 2 water heaters

provided the hot water to the kitchen and the

temperature was set at 180 degrees F on each unit.

Maintenance 8 was asked how he knew what the

temperature the water was as the water was

leaving the hot water heaters, as there was not a

temperature gauge leading from the hot water

heaters to the kitchen. Maintenance 8 indicated

there was a gauge to set the hot water heater

temperature behind a panel that was secured by

screws and that was where the temperature of the

hot water heater could be adjusted. He indicated

he would have to get a screwdriver and check.

At 9:38 a.m., Maintenance 8 indicated he

contacted their service representative regarding

simulator through machine 5x per

week and record on maintenance

log.

Dietary staff will be trained on

reading gauge and expectations of

temperatures

Visual cues placed in kitchen to

help ease confusion on reading

temperatures

Rinse temperature will be read

daily 3 times per day and recorded

on temp log in kitchen.

QA will responsible for ensuring

ongoing compliance:

Maintenance will monitor 5 times

a week to ensure proper

temperatures

The CDM or designee will verify

temperature logs are accurate and

completed daily

Utilizing the maintenance log and

dish machine temperature log

audits will be completed daily for 8

weeks, then continue weekly for

12 weeks. Following, weekly

audits will continue ongoing. The

results of these audits will be

reviewed by the facility Quality

Assurance Performance

improvement (QAPI) committee for

patterns, trends, and

recommendations for process

monitoring and on-going education

and improvement.

2.Hand Hygiene

Dietary aide 16 and 17 were

in-serviced on 2/7/2020 on hand

washing/hand hygiene in

accordance with CDC

recommendations. No residents





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the hot water booster. Maintenance 8 indicated

the service representative instructed him on how

to adjust the temperature higher on the hot water

booster. Maintenance 8 was observed to open a

small area on the side of the hot water booster and

indicated he turned the setting about 1/8th of a

turn.

At 9:41 a.m., the dish machine rinse temperature

gauge was observed during the rinse cycle as a

large tray was placed through the cycle. The rinse

temperature was observed to be at 170 degrees F.

The dish machine was run 3 more times and the

rinse temperature gauge was not observed to

move from 170 degrees F.

At 9:43 a.m., Service Representative 10 arrived and

placed a Plate Simulating Dishwasher Tester

through the dish machine wash/rinse cycle with a

temperature reading of 165.7 degrees F. Service

Representative 10 indicated this device measured

the temperature of the dishes and the temperature

of the dishes had to be greater than 160 degrees F.

Service Representative 10 was asked how the

dietary staff could recognize the dishes were

sanitized if all they had observed was the rinse

temperature gauge reading of 170 degrees F. The

service representative indicated it was the dishes

that had to be 160 degrees F in order to be

sanitized. At this time, the CDM indicated she

was going with Service Representative 10's Plate

Simulating Dishwasher Tester for the temperature

of the dishes that ensured the dishware was

sanitized.

At 11:27 a.m., an interview with Maintenance

Man 8 indicated he provided a code regarding

equipment food contact surfaces and utensils

shall be sanitized in hot water mechanical

operations by being cycled through equipment

were affected.

To prevent a reoccurrence:

CDM or designee to complete

hand hygiene in-service with all

staff to ensure proper hand

hygiene is being performed as well

as a competency test with return

demonstration to be completed by

dietary staff before working in

kitchen.

For Systemic change Kingston

will require CDM or designee to do

daily rounds and direct

observations of hand hygiene

during meal service to ensure

proper hand hygiene is being

done. Reminders will be placed

through-out the kitchen as visual

cues and constant focus.



compliance. CDM or designee to

complete hand hygiene audit

weekly 7 times for 4 weeks, then

bi weekly for a month, then

monthly, then 6 times quarterly.

Will encompass all shifts until

continued compliance is

maintained for 2 consecutive

quarters. The results of these

audits will be reviewed by the

facility quality assurance

performance improvement (QAPI)

committee for patterns, trends and

continued recommendations for

process monitoring and ongoing


3. Vent

Maintenance #8 completed

detailed cleaning of the vent





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that was set up as specified under 4-501.15,

4-501.112 and 4-501.113 and achieved a utensil

surface temperature of 71 Centigrade (160 degrees

F) as measured by an irreversible registering

temperature. He indicated this was part of the

Food Code. Maintenance Man 8 was asked how

staff were supposed to know that the rinse

temperatures were able to sanitize the dishware if

the temperature did not reach 180 degrees F. He

indicated Service Representative 10 ordered a

new temperature gauge. At this time, Service

Representative 10 provided a copy of his visit

report which indicated an emergency call was

received that the final rinse was not reaching 180

degrees F and the surface temperature of the

dishes needed to be 160 to be sanitized.

Currently, the dish machine was running a 167.5

degree F surface temperature and the dish

machine was reaching temperature but the gauge

was bad. The note indicated they were ordering

new gauge. A copy of the Plate Simulating

Dishwasher Tester used to measure the

temperature of the dishes was provided with a

167.5 degree F temperature.

An interview with the CDM on 2-3-2020 at 12:15

p.m., indicated she was having staff run the

dishes through the dish machine and then

through sanitized water in the 3 compartment sink.

Then the dishes were being air dried. She

indicated with the rinse temperature gauge

reading below 180 degrees F, there was not a way

for staff to know for sure that the dishes were

sanitized as they do not have a Plate Stimulating

Dishwasher Tester to ensure the dishware

temperature was at 160 or greater. She indicated

she did not know how long it would take to get a

new temperature gauge.

An observation of the dishwashing room on

immediately on 2/7/2020. No

residents were affected.

Maintenance will update kitchen

lighting and vent cleaning PM

summary from monthly to

bi-monthly.

As part of Systemic changes to

assure alleged deficiency does not

recur

During kitchen rounds

maintenance director of designee

will observe all vents are free from

any buildup.



compliance. Maintenance or

designee to complete kitchen

lighting and vent cleaning

observation checklist 5 times for

4 weeks, then bi weekly for a

month, then monthly, then 6 times

quarterly. Will ensure continued

compliance is maintained for 2

consecutive quarters. The results


the facility quality assurance

performance improvement (QAPI)

committee for patterns, trends and





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2-3-2020 at 2:35 p.m., indicated the CDM was

using the sanitizer water to rinse the dishes after

they had been run through the dish machine. The

CDM was observed to check the chemical level of

the sanitizer water and it tested at 200 ppm (parts

per million, which was an adequate level to ensure

sanitation).

An observation of the dish machine rinse

temperature on 2-4-2020 at 9:51 a.m., indicated the

rinse temperature thermometer was at 180 degrees

F. An interview with the CDM at this time,

indicated they had been using sanitizer water to

rinse the dishes after they had been run through

the dishwasher since yesterday. She indicated

the breakfast dishes were done and the dishes

were observed drying on racks.

On 2-5-2020 at 10:00 a.m., the copies of the

December 2019, January and February 2020 Dish

Machine Temperature logs were reviewed. The

December 2019 Dish Machine Temperature log

had hot water rinse temperatures recorded less

than 180 degrees F, 43 times out of 93 checks at

the breakfast, lunch and dinner times as follows

(measured in degrees F):

Breakfast Lunch Dinner

12-1-2019 168

12-2-2019 170

12-3-2019 175 175

12-4-2019 175 175 175

12-5-2019 168

12-6-2019 175 175

12-7-2019 169

12-8-2019 175

12-9-2019 168

12-11-2019 175 172

12-13-2019 178

12-14-2019 175

12-15-2019 165

continued recommendations for

process monitoring and ongoing






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12-16-2019 175 175

12-17-2019 175 175

12-18-2019 166 165 175

12-20-2019 175

12-21-2019 175

12-22-2019 175 175

12-23-2019 170 166

12-24-2019 170

12-25-2019 175 175

12-26-2019 175 166

12-27-2019 166 165

12-28-2019 168 176

12-29-2019 175

12-30-2019 167

12-31-2019 169

The January 2020 Dish Machine Temperature log

had hot water rinse temperatures recorded less

than 180 degrees F, 43 times out of 93 checks at

the breakfast, lunch and dinner times as follows

(measured in degrees F):


1-1-2020 165

1-2-2020 175 170

1-3-2020 170

1-4-2020 170

1-5-2020 175

1-6-2020 175 175 175

1-7-2020 168

1-8-2020 175 165

1-9-2020 169

1-10-2020 175 165

1-12-2020 175 166

1-14-2020 176 179

1-15-2020 167

1-16-2020 170 175

1-18-2020 175 165

1-20-2020 175 175

1-21-2020 170 175





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1-22-2020 165 165 167

1-23-2020 175

1-24-2020 175 166 165

1-25-2020 175

1-26-2020 175

1-27-2020 175

1-29-2020 175

1-30-2020 170 166

1-31-2020 167 177

The February 2020 Dish Machine Temperature log

(through 2-4-2020 breakfast) had hot water rinse

temperatures recorded less than 180 degrees F, 3

times out of 10 checks at the breakfast, lunch and

dinner times as follows (measured in degrees F):


2-3-2020 167 175

2-4-2020 174

Statements on the bottom of each Dish Machine

Temperature log indicated "...please log wash and

rinse temperatures before the start of each meal.

Wash temperature should be no less that 160

degrees, and Rinse temperatures no less than 180

degrees. If temperatures are not at the correct

temperature, please notify supervisor

immediately...."

During an interview with the CDM on 2-4-2020 at

10:12 a.m., the December 2019 and the January

2020 Dish Machine Temperature logs were

reviewed. The CDM was asked if staff notified

her of the rinse temperatures below 180 degrees F.

She indicated staff did not notify her of the rinse

temperatures below 180 degrees F. Further

interview with the CDM, indicated she did review

the completed logs but Maintenance 9 checked

the dish machine water temperatures every day

and Maintenance 9 indicated the rinse





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temperatures were fine, so nothing more was

pursued.

An interview with Maintenance Man 9 on

2-4-2020 at 10:15 a.m., indicated he checked the

dish machine water temperatures in the morning

around 8:00 a.m. - 8:30 a.m. He indicated he did

not write down the wash and rinse temperatures,

but just put his initials on the Monthly

Maintenance Log form. He indicated his initials

were verifying the wash temperature was at least

160 degrees and the rinse temperature was 180

degrees. Maintenance Man 9 was asked how the

dietary staff were obtaining temperatures lower

than 180 degrees F for the rinse temperature on

the same day that the rinse temperature checked

by maintenance was at 180 degrees F.

Maintenance Man 9 indicated the dish machine

rinse temperatures must have been checked at

different times.

An interview with the Administrator and Regional

Director 4 on 2-4-2020 at 10:17 a.m., indicated they

had interviewed Dietary Aide 13, who had

documented dish machine rinse temperatures on

the log. The Administrator indicated Dietary Aide

13 was not sure if the temperatures she

documented on the Dish Machine Temperature

log were wash or rinse temperatures that were

entered under the rinse temperature column. The

Administrator indicated the dish machine wash

temperatures were on the thermometer labeled

wash and she did not think Dietary Aide 13 knew

where the rinse temperature thermometer was

located, so the Administrator indicated she

educated her. Further interview with Regional

Director 4, indicated she was unable to say how

the facility was able to ensure the dishes were

sanitized, if there were rinse temperature less than

180 degrees recorded on the Dish Machine





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Temperature Log multiple times in the last 2

months. Regional Director 4 indicated they were

getting the rinse thermometer fixed now.

An interview with Dietary Aide 13 on 2-4-2020 at

10:21 a.m., indicated she knew where the wash

and rinse temperatures were located on the dish

machine. She was observed to point to the

temperature dial in the front on top of the dish

machine which had wash written above it. She

indicated the rinse thermometer next to the wash

thermometer did not work and the dietary aide was

observed to point to the temperature dial in the

back on top of the dish machine as where the

rinse temperature was read. She indicated she

knew where the wash and rinse thermometers

were located when she filled out the temperatures

on the Dish Machine Temperature logs for

December 2019 and January 2020 where her initials

were located.

The Administrator provided a copy of the

Maintenance Work Order Request dated 2-3-2020

for the main kitchen location on 2-4-2020 9:35 a.m.

The work order indicated the temperature gauge

for the rinse cycle for the dish machine failed. It

was noted on the work order the gauge had been

ordered. Under remarks, a statement was written

contacted named equipment supplier to come

check gauge and the named supplier indicated

the rinse temperature was correct and the gauge

failed. The Administrator also provided the

December 2019, January and February 2020

Monthly Maintenance Logs. The logs indicated

the word "daily" was written on the left margin of

the each log. In the body of the Monthly

Maintenance Log the following was written,

"...Dish Machine Temps - Check the wash & rinse

temperatures daily and ensure correct temps. 160

degree wash, 180 degrees rinse. Initial when





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complete...." For December 2019, 21 days were

marked with initials and 10 days were marked the

an 'X'. (The days marked with an 'X' were the

weekend days and Christmas Day.) For January

2020, 22 days were marked with initials and 9 days

were marked with an 'X'. (The days marked with

an 'X' were New Year's Day and the weekend

days.) For February 2020, 2 days were marked

with initials and 2 days were marked with an 'X'.

(The days marked with an 'X' were weekend days.)

An interview with the Administrator on 2-4-2020

at 11:19 a.m., indicated she had documentation of

when the equipment supplier was here on 1-9-2020

and they tested the dish machine rinse temp at 188

degrees F. She also indicated the maintenance

man checked the dish machine wash and rinse

temperatures every morning at 8:00 a.m. and that

was what the facility went by for the hot water

rinse temperatures. Further interview with the

Administrator, indicated the documentation

provided on the maintenance man dish machine

water temperature checks were not daily. The

Administrator was asked how the facility ensured

the dishes were sanitized on the days the

maintenance man did not check the dish machine

rinse temperature and the dietary staff found the

rinse temperature below 180 degrees F. (An

answer was not provided.) The Administrator

was asked for any dish machine maintenance work

orders for past few months.

An interview with Service Representative 14 on

2-4-2020 at 11:20 a.m., indicated when he visits a

facility, the dish machine temperatures for wash

and rinse were documented and with a Plate

Simulating Dishwasher Tester which was put

through the dish machine to ensure the dishware

temps were above 160 degrees F. He indicated

there was not a place on their service report to





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document the dishware temperature. He indicated

that they found this facility's pressure regulator

on the dish machine was full of lime and that

affected the temperature of the water because the

water would not be flowing through the machine

as it should. He indicated the temperature of the

water could fluctuate high and low. The supplier

was asked then if the rinse temperature did not

meet the 180 degree F temperature, how would the

facility know the dishes were sanitized. The

supplier indicated the facility should have a daily

fail safe test that ensured the rinse water was

sanitizing the dishes beyond just checking the

temperature gauges such as the Plate Simulating

Dishwasher Tester or with the test strip testing.

An observation of the dish machine on 2-4-2020 at

11:25 a.m., indicated the new pressure regulator

during the rinse cycle read greater than 20 psi

(pounds per square inch, a measure of pressure)

and the rinse temperature went to 180 degrees F.

Service Representative 14 showed the old

pressure gauge and it was observed to be lined

with whitish, yellowish grit.

An interview with Dietary Aide 13 on 2-4-2020 at

11:27 a.m., indicated she was asked what she

would do if she had a wash or rinse temperature

less than the 160 degrees F for washing and 180

degrees F for rinsing on the dish machine. Dietary

Aide 13 indicated she would notify her manager or

maintenance.


at 11:33 a.m., indicated maintenance did not have

any dishwasher work orders for the last 6 months.

The Administrator provided 3 additional copies of

the food service representative's Chemical and

Beverage reports on 2-4-2020 at 2:25 p.m. For the





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12-2-2019 report, the dish machine rinse

temperature was documented at 180 degrees F.

For the 10-21-2019 report, the dish machine rinse

temperature was documented at 190 degrees F and

for the 9-12-2019 report, the dish machine rinse

temperature was documented at 180 degrees F.

The reports did not have times documented or the

results of the Plate Simulating Dishwasher Tester

or even if the Plate Simulating Dishwasher Tester

was used.

An observation and interview with Dietary Aide

15 on 2-6-2020 at 10:09 a.m., indicated he was

doing the dishes. He was observed to point to

the correct thermometer for the wash cycle on top

of the dish machine on the left for the temperature

for the wash cycle and pointed to the correct

thermometer on top of the dish machine in the

back for the rinse temperature. He indicated he

did take the wash and rinse temperatures in the

morning and wrote them down. He indicated he

would notify the kitchen manager or maintenance

if the temperatures did not reach the levels as

written on the bottom of the Dish Machine

Temperature Log.

An observation of the Dish Machine Temperature

Log in the dish washing room in the main kitchen

on 2-6-2020 at 11:30 a.m., indicated on 2-4-2020 the

dinner dish machine rinse temperature was

recorded as 175 degrees F. On 2-5-2020, the

dinner dish machine rinse temperature was

observed to be recorded at 170 degrees F and on

2-6-2020 at breakfast, the dish machine rinse

temperature was observed to be recorded at 178

degrees F. The Dietary Manager was made aware

of the recorded temperatures.

On 2-10-2020 at 9:55 a.m., the Administrator

provided a Job Description and performance





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standards dated 8-8-2016 and signed by Dietary

Aide 13 on 9-8-2016. An interview with the

Administrator at this time indicated, under the

essential functions and tasks column number 30,

the statement, assist in the proper care, use and

cleaning of kitchen equipment, the Administrator

indicated that pertained to the dish machine. A

number 2 was circled and the key indicated 2

equaled meeting expectations.

A current policy, "Dish Machine Temperature

Log" with an approval date of April 2014 was

provided by Regional Director 4 on 2-4-2020 at

2:35 p.m. The policy indicated, "...Dishwashing

staff will monitor and record dish machine

temperatures to assure proper sanitizing of dishes.

1. The dietary manager will provide the

dishwashing staff with a log to be posted near the

dish machine.

2. The dietary manager will train dishwashing

staff to monitor dish machine temperatures

throughout the dishwashing process.

3. Staff will be trained to record dish machine

temperatures for the wash and rinse cycles once

each shift.

4. The dietary manager will spot check this log to

assure temperatures are appropriate, and staff is

actually monitoring dish machine temperatures.

5. Dishwashing staff will be trained to report any

problem with the dish machine to the Dietary

Supervisor as soon as they occur.

6. The dietary manager will promptly assess any

dish machine problems and take action

immediately to assure sanitation of the dishes...."

2. During an observation of the main kitchen on

2-3-2020 at 9:20 a.m., Dietary Aide 16 was

observed in the prep room drinking out of a bottle

of water. She was observed to cap the bottle of

water and placed it in a pitcher of ice water. Then





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she used left her hand to wipe across her mouth.

Without washing her hands or using hand

sanitizer, Dietary Aide 16 was observed placing

plastic wrap over clean dishes on trays and

removing them from the prep room.

An interview with the CDM and the Dietitian on

2-3-2020 at 9:45 a.m., indicated they observed

Dietary Aide 16 drink out of the water bottle and

observed the aide use her hand to wipe across her

face. They both indicated they were aware she

handled clean dishes without washing her hands

or using hand sanitizer.


p.m., indicated Dietary Aide 16 should have

washed her hands prior to handling clean

dishware after she wiped her hand on her nose.

During an observation in the Crowne Kitchen on

2-6-2020 at 10:50 a.m., Dietary Aide 17 was

observed to bring in the hot food from the kitchen

on a cart. Dietary Aide 17 was observed to

unload the metal containers into the steam table

and she then donned an apron and washed her

hands. Dietary Aide 17 prepped for taking the

temperatures the food and then was observed to

wash her hands. Dietary Aide 17 was observed to

rub across her nose with her forearm and then

started taking the food temperatures. After

obtaining the temperatures of the food, Dietary

Aide 17 was observed to rub her nose with her

hand and then handled the serving utensils for

the meal without first washing her hands.

A current policy, "Hand Washing/Hand Hygiene"

with an approval date of September 2019, was

provided by Regional Director 4 on 2-4-2020 at

2:35 p.m. The policy indicated "...all personnel

shall follow the handwashing/hand hygiene





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procedures to help prevent the spread of

infections to other personnel, residents, and

visitors in accordance with CDC (Center for

Disease Control) recommendations for hand

hygiene...Employees must wash their hands for at

least twenty (20) seconds using antimicrobial or

non-antimicrobial soap and water under the

following conditions...after blowing or wiping

nose...."

3. During an observation of the main kitchen on

2-6-2020 at 10:18 a.m., a vent on the ceiling to the

left of where the ice machine sat was observed to

be rectangle in shape and the openings were grid

like. The surfaces of the grid like sides were

observed to be covered with a gray feathery type

debris on the flat surfaces of the grid like

openings.


a.m., indicated maintenance had a schedule for

the cleaning of the ceiling surfaces, lights and

vents.

An interview with Maintenance 8 on 2-6-2020 at

10:44 a.m., indicated he had monthly preventative

maintenance for the kitchen lights and vent

cleanings. He indicated the 3rd shift maintenance

person completed these tasks on his shift.

A copy of the Kitchen Lighting and Vent Cleaning

PM Summary was provided by Maintenance 8 on

2-6-2020 at 10:50 a.m. and indicated "...Complete

these items each month. Date and initial at right:

remove all dust from all light fixtures using hip vac

clean all vents using hip vac

clean return and supply vents with quarry cleaner

report any corroded/chipped vents to

Maintenance Manager...."

The report had varied dates of each month in 2019





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initialed and the last date marked on the 2020

calendar was 1-2-2020.

An interview with Maintenance 8 on 2-7-2020 at

9:55 a.m., indicated he was not aware of the build

up of debris on the vent slats on the vent to the

left of the ice machine. He indicated the cleaning

had not been done yet this month and the debris

build up could happen in a month's time.


p.m., indicated there were 2 residents who did not

get their meals from the facility kitchen as they

were NPO (Nothing by mouth).

3.1-21(i)(2)

3.1-21(i)(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

F 0880

SS=D

Bldg. 00





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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.

(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.





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§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.


review, the facility failed to ensure infection

control measures were followed for 2 of 3

residents reviewed with transmission based

precautions. (Resident 90 and Resident 354)

Findings include:

1. The record review for Resident 90 began

2-3-2020 at 4:00 p.m. Diagnoses included but were

not limited to,

Alzheimer's disease, encounter for palliative care,

atrial fibrillation, diabetes, hypertension, adult

failure to thrive, chronic kidney disease stage 3,

depression, history of falls and muscle weakness.

The last quarterly MDS (Minimum Data Set)

assessment was dated 11-1-2019. Resident 90's

BIMS (Brief Interview for Mental Status) was

12/15 which indicated the resident was moderately

cognitively impaired, required an extensive assist

of 1 person for bed mobility, transfers and toilet

use, required a limited assist of 1 person for walk

in room/corridor, locomotion on/off unit, dressing

and personal hygiene. Resident 90 was

independent with set up help for eating and

required physical help in part of the bathing

activity of one staff person. The resident had no

limitations of the upper or lower extremities and

used a wheelchair or a walker. There was no

F 0880 It is the practice of Kingston

Healthcare facility to established

an infection control program that

includes implementation of

standard and transmission based

precautions that are followed to

prevent the spread of infection.

Resident #90 was placed in

isolation on 2/3/20 utilizing both

signage on the resident’s door and

the caddy with appropriate PPE.

The documentation to support the

implementation was initiated on

2/4/20, but following the ER visit

on 2/5/20 was no longer needed

due d/c diagnosis requiring

isolation. The visitors for R 90

were provided education at the

time of the incident.

Resident #354 was placed in

isolation on 1/17/20 utilizing both

signage on the resident’s door and

the caddy with appropriate PPE.

The documentation to support the

implementation was initiated on

1/18/20. The resident’s isolation

was d/c on 2/6/20 due to d/c

diagnosis requiring isolation, and

discharged from the facility on

2/7/20.

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antibiotic use marked for the last 7 days and no

isolation at that time.

A review of the current physician orders indicated

a medication, acyclovir 800 mg (milligrams) was

ordered on 2-3-2020 at 12:00 p.m. to be given by

mouth 5 times per day for shingles for 7 days.

There was not a physician order for any type of

isolation as of 2-3-2020 at 4:00 p.m. The physician

order entered 2-4-2020 at 2:00 p.m. was for contact

isolation for shingles every shift the resident was

to stay in the room until rash/blisters are

dry/scabbed.

A review of a progress note dated 2-3-2020 at 4:58

a.m., indicated Resident 90 called the nurse to her

room about a "biting" pain on the right side of her

head and neck that extended into the scalp. The

note indicated the area was blistered, reddened,

itching, painful and localized to that particular

area. Medication for pain and itching was

administered by the nurse and the nurse

practitioner would be notified.

A review of the progress note dated 2-3-2020 at

10:15 a.m., indicated a nurse practitioner assessed

Resident 90's complaint of a rash which was

documented as a new, itchy rash on her right neck

and chest that had appeared overnight. The note

described the rash as confluent, irregular,

erythematous (red), vesicular, crusted, raised,

rough, scabbed, sores with random distribution,

with discharge from lesion and was pruritic (itchy)

and painful. The note indicated the condition was

affecting daily activities. The nurse practitioner

diagnosed the resident with zoster (shingles) with

other complications, cellulitis of right external ear,

and pruritis. The note indicated treatment with

acyclovir 800 mg 5 times per day for 7 days along

with Keflex (an antibiotic) 500 mg 4 times per day

Residents who are identified with

infections requiring transmission

based precautions.


the following Policies: Isolation-

Initiating transmission based

precautions, Isolation- Categories

of transmission based

precautions. Education including

the process for implementation of

transmission based precautions

ensuring appropriate equipment is

accessible, posting of appropriate

notice, ensuring appropriate waste

et linen receptacles are available,

and timely documentation in the

medical record will be included.


ADON/designee to audit identified

infections requiring transmission

based precautions 5 times weekly

for four weeks, then 3 times a

weekly for 8 weeks, then continue

all records weekly for 12 weeks.

Following, weekly record audits

will continue ongoing. Any














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for 7 days and hydrocortisone 1% solution (an

anti-itch medication) three times a day to help

sooth the itching.

A review of Resident 90's nursing progress note

dated 2-3-2020 at 12:58 p.m., indicated 2 new

orders received.

An observation of Resident 90's room on 2-3-2020

at 3:30 p.m., indicated a stop sign was posted on

the door frame and indicated to report to nurse

before entering. A contact precaution sign was

also observed with a stop sign on it and before

entering room see nurse for instructions. An

interview with Nurse 18 at this time indicated

Resident 90 was on contact precautions for

shingles. The nurse indicated to wear a gown,

gloves and a mask. An over the door caddie was

observed with yellow gowns, gloves and a

stethoscope in a cellophane wrapper. There were

no masks observed. The was also not a waste

disposal container observed except for a very

small trash can in the bathroom.

An observation of Resident 90's roommate on

2-3-2020 at 3:37 p.m., indicated the roommate was

in the room in her own bed with her eyes closed.

A observation of Resident 90's room on 2-4-2020

at 2:36 p.m., indicated the room door was open

and 2 unidentified visitors were observed

standing near the resident's bed without having

donned any of the PPE (Personal Protective

Equipment). The caddy on the door was

observed to have red bags along with gloves and

gowns. The visitors were observed to leave the

Resident 90's room. The visitors did not wash

their hands with soap and water or use a hand

sanitizer prior to or after leaving the room.





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A review of Resident 90's nurse progress notes

dated 2-4-2020 at 3:19 p.m., indicated the resident

continued with antibiotics for shingles to right

side of face, she was afebrile, and resting.The

resident voiced no complaints of discomfort or

pain.

An observation in a room down the hall from

Resident 90 on 2-4-2020 at 5:20 p.m., indicated

Resident 90's roommate had been moved out of

her room to another room. An interview at this

time with Resident 90's roommate indicated she

was moved out of her room today because her

roommate was ill. Resident 90's roommate

indicated Resident 90 was ill before today and she

was worried she might get what Resident 90 had.

A nurse practitioner note for Resident 90 dated

2-5-2020 at 8:59 a.m., was reviewed. The note

indicated Residnet 90 had zoster with other

complications, cellulitis of right external ear. The

resident was started on Acyclovir and Keflex on

2/3/20. Per nursing staff the symptoms had

increased over last 12 to 24 hours significantly.

Her skin was purple with blisters and sluffing skin.

The nurse practitioner wrote that she felt given

the significant increase in edema, pain, rash, and

skin changes to send Resident 90 to the hospital

for further evaluation and more aggressive

treatment/management.

A review of Resident 90's nurse progress notes

dated 2-5-2020 at 8:59 a.m., indicated the resident

had a rash with blisters that extended from the

neck and extended down to her right shoulder and

chest area. The nurse practitioner indicated for

staff to notify a non emergent ambulance transfer

to transport Resident 90 to the hospital. The

resident's sister was informed of change in

condition.





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An observation of Resident 90's room from the

hallway on 2-5-2020 at 10:58 a.m., indicated two

EMTs (Emergency Medical Technicians) were

observed to each don a gown, gloves and a mask

prior to entering the room. An interview with

Nurse 19 at this time, indicated the shingles area

had spread from her neck area to her front chest

and arm and the nurse practitioner wanted the

resident transferred to the hospital. Nurse 19 was

observed to don gloves, a gown and a mask and

entered the room to assist the EMTs. When the

resident was observed to be in the EMT cart, she

was covered up from head to toe with her face and

glasses exposed.

An observation of Resident 90's room on 2-5-2020

at 4:47 p.m., indicated the stop sign and contact

precaution sign remained posted on the door

frame but the caddy with the gowns, gloves,

masks and red trash bags were gone. The

resident was not observed in the room, but the

resident's belongings remained.

A review of the nurse progress note dated

2-6-2020 at 9:24 a.m., indicated Resident 90

returned from the hospital emergency room with a

new diagnosis of bullous pemphigoid and there

was no continued diagnosis of shingles. Isolation

precautions were discontinued. The resident was

to continue on Keflex (antibiotic) and a new order

for Prednisone (a steroid medication to help

reduce inflammation).


a.m., indicated Resident 90 had cellulitis and was

on Keflex and prednisone. She indicated it was

determined the skin lesions were not shingles

when she was transferred to the hospital.





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A care plan for shingles/cellulitis was initiated on

2-4-2020 for Resident 90 with approaches for the

nurse to assess the resident for pain/comfort,

administer all medications as ordered, notify

physician of worsening in condition or for signs

and symptoms not relieved by medication,

Observe for signs/Symtoms septicemia:

tachycardia, hypotension, altered LOC,

tachypnea, chills, oliguria/anuria, etc. and notify

physician if observed, Vital signs/pain

assessment as indicated, Assess color/ odor/

temperature/ appearance/ drainage, Temperature

daily while on ATB, Contact precautions and

nurses and CNAs were to encourage/assist

resident to maintain good hand hygiene.

A review of the February 2020 TAR (Treatment

Administration Record) for Resident 90 indicated

documentation was lacking until 2-4-2020 evening

shift when the TAR was marked as the resident

being in isolation. The nurse practitioner

diagnosed shingles per her report on 2-3-2020 at

10:15 a.m.

An interview with the DON on 2-7-2020 at 11:09

a.m.,. indicated she and the Regional Quality

Assurance Nurse looked at Resident 90's blisters

on 2-4-2020 and they did not feel the area looked

like shingles, the blisters did not run along a nerve

in a line andthe blisters were larger than the usual

shingles blisters. The DON indicated they kept

Resident 90 in contact isolation. She indicated the

resident was sent out on 2-5-2020 and came back

later that day with another skin diagnosis and it

was determined it was not shingles. The DON

was asked about the documentation to show the

resident was in contact isolation on 2-3-2020. The

DON was made aware the contact isolation order

was not written until 2-4-2020 at 10:23 a.m.,

documentation in the TAR (Treatment





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Administration Record) for isolation was not

present until the 2-4-2020 evening shift and the

care plan for shingles was created on 2-4-2020.

The DON was asked how the staff coming on the

next shifts would know the resident was on

contact precautions. She indicated she had been

trying to work with staff on documentation since

she has been here. She indicated they looked up

the CDC (Center for Disease Control and

Prevention) guidelines for shingles and if the

lesions could be completely covered for localized

herpes zoster, then standard precautions could be

followed. She indicated the resident's lesions

were on her neck area and it was difficult to keep

completely covered, so they kept the contact

precautions in place. The DON was made aware

of 2 unidentified visitors were observed in

Resident 90's room on 2-5-2020 prior to the

resident going to the hospital. These 2

unidentified visitors were not observed to not don

any personal protective equipment or gloves and

when they left the room, no handwashing or use

of hand sanitizer was observed.

A copy of the Notice of Room or Roommate

Change dated 2-4-2020 for resident Mary Shaffer

room 202-2 was provided by the Administrator on

2-11-2020 at 2:18 p.m. The reason for room and/or

roommate change on the form was marked with an

"X" next to the statement necessary to promote

resident safety, health or well-being. The

Administrator indicated the resident was moved

out of her room because the roommate was placed

in isolation.

An interview with ADON 11 (Assistant Director

of Nursing) on 2-11-2020 at 2:35 p.m., indicated

she provided a facility Infection Control Log for

February 2020. She indicated when a resident was

diagnosed with a type of infection, the





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information was recorded on this log. The log had

columns and the information entered was the

resident name, room number, admit date, unit, type

of infection, signs/symptoms, criteria met, date of

onset, culture type date, results/organisms isolate

1, results/organism isolate 2, precautions,

treatment, days of treatment and date resolved.

ADON 11 indicated for Resident 90, the

information on this form indicated the resident

was placed in contact precautions on 2-3-2020 (no

time listed) for shingles. ADON 11 indicated this

was a facility form and not part of Resident 90's

records.

On 2-11-2020 at 4:31 p.m., the concerns were

reviewed with the Administrator and the DON

regarding infection control and the lack of

documentation in the resident record when the

contact precautions were actually implemented,

the delay until the next day after Resident 90 was

diagnosed with shingles for moving the roommate

to another room and concern with the unidentified

visitors not observing the contact precautions,

handwashing or using hand hygiene after leaving

the room. The Administrator indicated Resident

90 had a sister who visited frequently. She tried to

educate the sister about the contact precautions.

The Administrator indicated the resident's sister

said she wasn't going to touch anything and they

would be fine. The Administrator indicated what

was she supposed to do if a resident's family

member refused to adhere to the contact

precautions or even washing their hands.

2. On 2/2/6/2020 at 10:30 a.m. the record of

Resident 354 was reviewed. Diagnoses included

but were not limited to, the following: pneumonia

due to methicillian resistant staphylococcus

aureus (MRSA) (a cause of staph infection that is

difficult to treat because of resistance to some

antibiotics).





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The admission Minimum Data Set (MDS)

Assessment, dated 1/23/20, included the

following: independent cognition; the resident

had intravenous medications and 7 days of

antibiotic medication received.

A Progress note, dated 1/17/2020 at 2:13 a.m.,

indicated the following: The resident entered from

an acute care hospital, arrived by ambulance.

Diagnosis included Pneumonia, unspecified

organism; continue Augmentin (antibiotic).

A Narrative progress note, from the Nurse

Practitioner, dated 1/17/2020 at 1:29 p.m., indicated

the Chief Complaint was cough. He was found to

have RLL (right lower lobe) pneumonia for which

he was treated with Levaquin, Zosyn and Vanco

(vancomycin), Rocephin and Azithromycin and

currently on Augmentin. He had a history of

cough, moist, productive - yellow sputum with the

duration of a couple of weeks, and pneumonia.

The progress note indicated the resident had

diagnosis of pneumonia, unspecified organism,

and to continue Augmentin.

Progress note, dated 1/17/2020 at 2:34 p.m.,

indicated The Dr.from the hospital called reporting

that sputum was positive for MRSA and it was

susceptible to vancomycin, an antibiotic, and to

give Vanco IV (intravenous) q (every) 12 hours -

the pharmacy was to dose.

On 2/6/2020 at 3:00 p.m., the Director of Nursing

(DON) was interviewed. She indicated on

1/17/2020, the Assistant Director of Nursing

(ADON), and the facility had been informed

Resident 354 had a sputum culture which was

positive for MRSA. The DON indicated the

ADON assisted in performing Infection Control





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practices at the facility. The DON indicated the

ADON/Infection Control Nurse, after being

informed, immediately went to Resident 354's room

and initiated isolation/droplet transmission based

precautions (used to prevent spread of infection

from lungs). The DON indicated she was unable

to find documentation in the record of the time

droplet precautions had been initiated on

1/17/2020. She indicated the ADON had initiated

precautions 1/17/2020 at about 2:30 p.m.

Documentation was lacking in the resident's

record of the date and time droplet precautions

were initiated for Resodnet 354.

On 1/18/2020 at 7:54 a.m., the January 2020

treatment administration record (TAR) indicated

droplet isolation precautions were to be followed

every shift for MRSA in sputum. The initial entry

for this order was on 1/18/2020.

A copy of the physician order, dated 1/18/2020 at

7:54 a.m. for Droplet isolation precautions every

shift for MRSA in sputum. was provided by the

DON on 2/6/2020 at 3:10 p.m.

On 1/18/2020 a plan of care to address infection of

the lower respiratory tract/pneumonia with MRSA

in sputum. was initiated. The intervention of

"Droplet Precautions" was dated 1/18/2020.

On 2/7/2020 at 11:40 a.m., the DON was

interviewed. She indicated the ADON/Infection

Control Nurse documented the droplet

precautions were initiated on 1/17/2020 in her

infection prevention log but this log was not part

of the resident's record.

On 2/7/2020 at 12:22 p.m., the DON provided a

copy of the ADON/Infection Control Nurse's





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"Infection Control Log." An entry for Resident

354 was documented with the following

information: date of infection onset was noted as

"in hosp (hospital)"; Precautions initiated:

Droplet 1/17.

On 2/11/2020 at 2:33 p.m. the ADON/Infection

Control Nurse was interviewed. She indicated the

only place the transmission based precautions,

droplet precautions were documented as to when

the precautions were initiated on 1/17/2020 were

on her infection control log. She indicated this

log was not part of the resident's clinical record.

On 2/11/2020 at 1:23 p.m. the ADON/Infection

Control Nurse and the Interim ADON were

interviewed. The ADON/Infection Control Nurse

indicated she monitored residents who were in

isolation/transmission based precautions. She

further indicated she monitored and educated

visitors and staff for non compliance with

isolation practices. She indicated upon her

notification of Resident 354's positive the sputum

culture, on 1/17/2020 at approximately 2:35 p.m.,

she immediately put up the "stop sign" , the

transmission based precaution magnet for droplet

precautions in addition to the door overlay (which

contained supplies) on the resident's door. She

indicated she also educated the staff on the

current shift regarding the resident's isolation.

They indicated the provider's order for isolation

was only to communicate to other departments, in

morning meeting, to keep everyone aware. She

indicated staff would be made aware of the

isolation due to the signage which was placed on

the door. When queried if they would expect the

documentation in resident's record to reflect when

the isolation was actually initiated, the

ADON/Infection Control Nurse indicated it would

be optimal. They indicated isolation had been





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implemented as a nursing measure.

On 2/7/2020 at 11:09 a.m., the DON provided a

current copy of the policy and procedure for

Infection Control/Administration, dated

November 1, 2017. The policy and procedure

included, but was not limited to, the following:

This facility's infection control policies and

practices are intended to facilitate maintaining a

safe, sanitary and comfortable environment and to

help prevent and manage transmission of diseases

and infections. This facility's infection control

policies and practices apply equally to personnel,

residents, visitors, volunteer workers and the

general public alike. The objectives of our

infection control policies and practices are to:

prevent, detect, investigate and control infections

in the facility; establish guidelines for

implementing Isolation Precautions, including

Standard and Transmission Based precautions

and maintain records of incidents and corrective

actions related to infections. The Quality

Assessment and Assurance Committee, through

the Infection Control Committee, shall oversee

implementation of infection control policies and

practices, and help department heads and

managers ensure that they are implemented and

followed.

On 2/7/2020 at 11:09 a.m. the DON provided a

current copy of the policy and procedure for

"Isolation - Categories of Transmission Based

Precautions" dated December 2019. The policy

and procedure included, but was not limited to,

the following: Transmission-Based Precautions

shall be used when caring for residents who are

documented or suspected to have communicable

diseases or infections that can be transmitted to

others. Transmission-Based Precautions will be

used whenever measures more stringent than





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Standard Precautions (may include the use of

personal protective equipment (may include

gloves, gown, mask) are needed to prevent or

control the spread of infection. Implement Contact

Precautions for residents known or suspected to

be infected with microorganisms that can be

transmitted by direct contact with the resident or

indirect contact with the environmental surfaces

or resident-care items in the resident's

environment. The decision on whether

precautions are necessary will be evaluated on a

case by case basis. Resident placement: place the

individual in a private room if possible. If a

private room is not available, the Infection

Preventionist will assess various risks associated

with other resident placement options (for example

cohorting, placing with a low risk roommate). In

addition to Standard Precautions, wear gloves

when entering the room. While caring for a

resident, change gloves after having contact with

infective material; remove gloves before leaving

the room and perform hand hygiene; after

removing gloves and washing hands, do not

touch potentially contaminated environmental

surfaces or items in the resident's room. Wear a

disposable gown upon entering the room. For

resident care equipment, when possible, dedicate

the use of non-critical resident-care equipment

items such as a stethoscope, electronic

thermometer, etc. to a single resident to avoid

sharing between residents. If common use of

common items is unavoidable, the adequately

clean and disinfect the before use on another

resident. Signs - the facility will implement a

system to alert staff to the type of precaution

resident requires. The facility will ensure the

resident's care plan and care specialist

communication system indicates the type of

precautions implemented for the resident.





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3.1-18(b)(1)

F 9999

Bldg. 00

3.1-14 PERSONNEL

(a) Each facility shall have specific procedures

written and implemented for the screening of

prospective employees. Specific inquiries shall be

made for prospective employees. The facility shall

have a personnel policy that considers references

and any convictions in accordance with IC

16-28-13-3.

This state rule was not met as evidenced by:

Based on interview and record review, the facility

failed to ensure criminal background checks were

completed prior to the start date for 3 of 11

employee records reviewed. (CNA 1, Activity

Director 2, and Nurse 3)

Findings include:

The employee record review began on 2-7-2020 at

2:20 p.m.

CNA 1 (Certified Nurse Aide) had a start date of

12-16-2019 and a criminal background check

completed on 1-20-2020.

Activity Director 2 had a start date of 8-26-2019

and a criminal background check completed on

9-11-2019.

Nurse 3 had start date of 9-30-2019 and a criminal

background check completed on 10-21-2019.

An interview with the Administrator and Regional


Center to screen prospective

employees. Surveyor was provided

with background checks for

employee #2 and #3 and provided

with an invoice showing evidence it

was ran timely. Employee #2 and

#3 did not have any findings on

background check and no

residents were affected.

HR team will be required to follow

Kingston Policy and we will now

require HR to print background

checks prior to new hire

orientation.

HR recruiter has been educated

and will complete back ground

checks according to policy and

HR director will be responsible for

ensuring task is completed prior to

onboarding staff.

QA will monitor the HR team for

compliance. HR will utilize state

form #5440 “Employee Records”

to check all new hires for back

ground screening. QA team will

review for compliance monthly.

03/12/2020 12:00:00AM





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Director 4 on 2-7-2020 at 4:37 p.m., indicated they

would have to obtain their facility policy on

criminal background check requirements.

Regional Director 4 indicated she thought there

was some time to secure the criminal background

check, but was not sure how long that was.


at 9:55 a.m., indicated for the criminal background

checks, the HR (Human Resource) Assistant

would log into the state system and run the check.

The Administrator indicated if the HR Assistant

did not get back into the system to get the report

within 72 hours of the request, the report was

unable to be obtained and had to be run again.

She indicated this happened to CNA 1, Activity

Director 2 and Nurse 3. The Administrator

provided invoices to show how many times the

Indiana criminal background check system was

accessed to get the criminal background checks

for the three staff.

For CNA 1, with a start date of 12-16-2019, the

facility provided an invoice dated 12-2-2019, in

which the report was not printed and was no

longer accessible. Another invoice for CNA 1

was dated 1-20-2020 and the facility provided a

report which indicated the system did not reveal a

limited criminal history record.

For Activity Director 2, with a start date of

8-26-2019, the facility provided an invoice dated

8-5-2019, in which the report was not printed and

was no longer accessible. Another invoice for

Activity Director 2 was dated 9-11-2019 and the

facility provided a report which indicated the

system did not reveal a limited criminal history

record.

For Nurse 3, with a start date of 9-30-2019, the





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facility provided invoices dated 9-9-2019 and

9-30-2019, in which the reports were not printed

and were no longer accessible. Another invoice

for Nurse 3 was dated 10-21-2020 and the facility

provided a report which indicated the system did

not reveal a limited criminal history record.

A current policy, "Indiana Criminal Background

Checks" with an approval date of February 2019

was provided by the Administrator on 2-10-2020

at 9:55 a.m. The policy indicated, "...All Kingston

facilities comply with State laws and company

policy regarding criminal background checks. In

Indiana, Kingston conducts a limited criminal

background check of all prospective employees.

All job offers in Indiana facilities are conditional,

based in part on the results of the post-offer

criminal background check. Prospective

employees who have a documented record of

criminal activity as defined in this policy are not

eligible for employment...A candidate may be

conditionally employed for a period of up to 60

days pending the receipt of a limited criminal

record. However, an employee who has been

allowed to work pending the results of a limited

criminal history must be terminated if the report

shows that s/he has been convicted of, pled

guilty or pled no-contest to any of the

disqualifying convictions listed at Section IV,

below...."

On page 6 of the policy, instructions indicated

"...once you click 'submit' your request will

process...upon completion this screen will

show...Note...You must click on the 'Get Record"

link and print the requested limited criminal

history record prior to leaving this page...If you

do not, you will be required to re-purchase the

record again...." The screen shot of the example

page indicated "...your transaction is

complete...NOTE If you close this window before





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getting and printing your record, you will lose the

purchased record and be required to purchase the

information again! The policy continued with this

statement at the bottom of page 6, "...You must

click 'Get Record' and print the report before

leaving the screen...If you do not, you will have to

start over and pay for another report...."


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