PRINTED: 02/02/2018 DEPARTMENT OF HEALTH AND HUMAN ...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

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

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

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DATECROSS-REFERENCED TO THE APPROPRIATE

ROSSVILLE, IN 46065

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MILNER COMMUNITY HEALTH CARE

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F 0000

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This visit was for a Recertification and State

Licensure Survey. This visit included a State

Residential Licensure Survey. This visit included the

Investigation of Complaint IN00228805.

Complaint IN00228805- Substantiated. Federal

deficiencies related to the allegations were cited at

F157 and F309.

Survey Dates: August 15, 16, 17, 18 and 21, 2017.

Facility number: 000299

Provider number: 155676

AIM number: 100286940

Census Bed Type:

SNF/NF: 59

Residential: 13

Total: 72

Medicare: 9

Medicaid: 48

Other: 2

Total: 59

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality Review was completed on August 25, 2017.

F 0000 Submission of this Plan of Correction and Credible Allegation of Compliance does not constitute an admission by the certified and licensed provider at Milner Community Health Care, Inc., that the allegations contained in this survey report a true and accurate portrayal of the provisions of nursing care and services at this health care facility. Milner Community Health Care, Inc., as a licensed and certified provider, recognizes its obligation to provide legally and medically required care and services to our residents in an economical and efficient fashion. Please accept this Plan of Correction as the Credible Allegation of Compliance.

483.10(g)(14) NOTIFY OF CHANGES

F 0157

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

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

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

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

continued program participation.

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

_____________________________________________________________________________________________________Event ID: WV5511 Facility ID: 000299

TITLE

If continuation sheet of 48

(X6) DATE




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(INJURY/DECLINE/ROOM, ETC) (g)(14) Notification of Changes.

(i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is-

(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;

(B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);

(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).

(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.

(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-

(A) A change in room or roommate assignment as specified in §483.10(e)(6); or

(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.

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(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Based on interview and record review, the

facility failed to notify a resident's family

member of a discontinued medication, to

notify the physician when a medication

was not given as ordered and to notify the

physician when a referral for a speech

therapy screening was not completed for 3

of 3 resident's reviewed for notification.

(Residents D, B and C).

Findings include:

1. During an interview on 8/16/17 at

10:57 a.m., Resident D's family indicated

Buspar (an anxiolytic medication used to

treat anxiety) was decreased recently and

she was not notified. The family member

indicated she had asked about the

medications during a visit at the facility

and found out the Buspar was changed.

The record for Resident D was reviewed

on 8/17/17 at 1:07 p.m. Diagnoses

included, but were not limited to, anxiety

disorder, depressive episodes and

cognitive communication deficit.

A physician order dated 6/15/17,

indicated to discontinue buspirone

(Buspar) 5 mg daily.

F 0157 1. Resident D's Daughter/POA has been made aware of all changes.Resident B no longer resides in the facility.Resident C was admitted to hospice.2. All residents have the potential to be affected by this alleged deficient practice.3. All licensed staff will be in-serviced on notification policy to ensure compliance to facility protocol.4. DON/MDSC will audit new physician orders for 30 days to ensure notifications have been made. After 30 days they will audit 3 times weekly for 3months and there after QAA team recommended.

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A nurse progress note dated 6/15/17 at

1:49 p.m., indicated the resident was

discussed in the Behavior Meeting due to

the use of Buspar. The resident had

tolerated a GDR (gradual dose reduction)

of the Buspar in the past and the MD

(medical doctor) ordered the Buspar to be

discontinued.

There was no documentation the

resident's daughter had been notified of

the discontinued Buspar.

During an interview on 8/18/17 at 1:32

p.m., the Director of Nursing (DON)

indicated the nurse taking the order for

any medication changes should also notify

the family. The DON indicated he could

not find any documentation of Resident

D's daughter being notified of the

discontinued Buspar.

2. The record for Resident B was

reviewed on 8/18/17 at 1:30 p.m.

Diagnoses included, but were not limited

to, unspecified convulsions, chronic atrial

fibrillation, type 2 diabetes mellitus with

hyperglycemia, and essential hypertension.

Medications included, but were not limited

to: Vimpat (lacosamide-an

anticonvulsants) 50 milligrams (mg) orally

daily at 10:00 a.m., also Vimpat 100 mg

daily at 10:00 p.m.

A review of the nurses notes for 4/22/17





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at 10:56 p.m., indicated "... Resident

received 50 mg of this medication tonight

which is 1/2 dose. Resident and family

aware...." The physician was not notified

of the reduced dosage of the medication at

this time.

3. The record for Resident C was



to, unspecified dementia without

behavioral disturbance, insomnia,

hydrocephalus, anxiety disorder, adult

failure to thrive and heart failure.

A nursing note dated 7/5/2017 at 8:23

a.m., indicated the ADON had notified the

MD of the resident's poor appetite, refusal

of supplement and her pocketing

medications. The "...MD recommended

ST (speech therapy) to screen. Therapy

aware."

An email from the ADON to therapy

dated 7/5/2017 at 8:23 a.m., indicated the

resident needed a screen. "...Staff is

stating that she is pocketing medications

and has had wt [weight] loss and poor

appetite...."

An email from the ADON to the RD dated

7/5/2017 at 8:52 a.m., indicated the

resident "...is refusing Med Pass 2.0 at

times, cont [continue] with poor intake,

and noted to be pocketing meds

[medications]. I have contacted speech





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for a screen and notified MD...."

No documentation was found the speech

therapy had screened the resident.


a.m., PT 8 indicated Resident C did not

have a speech evaluation completed and a

doctor's order was not necessary to

complete the screen.


a.m., the DON indicated a speech

evaluation was not completed.


a.m., the RD indicated she was unaware a

speech evaluation was recommended.

During a phone interview on 8/18/2017 at

2:33 p.m., Resident C's doctor indicated

he was not made aware the speech


A facility policy dated 1/30/16 titled

"Change of Condition Notification"

received from the DON on 8/17/17 at

2:29 p.m., indicated "...It is the policy of

this facility to notify the Resident,

Resident's Physician, Resident's legal

representative of [sic] interested family

member when there is a change in the

Resident's condition...Areas that require

notification of the Physician, Resident,

Resident's legal representative and/or





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interested family member:...Need to alter

treatment significantly...D/C [discontinue]

an existing form of treatment.... Notify if

medication is not available within 24

hours...The resident, resident's legal

representative and/or interested family

member must be kept informed of the

resident's status...."

This Federal tag relates to complaint

IN00228805.

3.1-5(a)(2)

3.1-5(a)(3)

483.10(a)(1) DIGNITY AND RESPECT OF INDIVIDUALITY (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident.

F 0241

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Based on observation, interview and

record review, the facility failed to ensure

a cognitively impaired resident was

assisted to eat in an individualized manner

to preserve the resident's dignity while

dining in the assisted area of the main

F 0241 1. Resident C admitted to hospice services.2. All residents needing assistance with meals have the potential to be affected by this alleged deficient practice.3. All C.N.A. and licensed staff will

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dining room for 1 of 14 residents observed

in the assisted area of the main dining

room. (Resident C)

Findings include:

During an observation in the main dining

room on 8/15/17 at 11:06 a.m., CNA

(Certified Nursing Assistant) 2 was

observed to feed Resident C. The CNA

gave Resident C a bite of spaghetti. The

resident had a long string of spaghetti

hanging out of her mouth and the CNA

did not assist the resident to remove the

spaghetti. The resident was able to use her

mouth and lips to maneuver the spaghetti

inside her mouth. CNA 2 gave the resident

a second bite of spaghetti and long strings

of spaghetti hung out of the residents

mouth again. The resident was able to tilt

her head down towards her clothing

protector and wipe the long strings of

spaghetti off her mouth and chin by

rubbing her chin on the clothing protector.

The CNA gave the resident a third bite of

spaghetti and there were long strings of

spaghetti which hung out of the resident's

mouth and all over the resident's clothing

protector. The CNA did not assist the

resident to get the spaghetti in her mouth

or to wipe it off of her mouth. The staff in

the assisted area of the main dining room

who were feeding other residents had cut

the spaghetti in small bite sized pieces. No

other residents in the assisted area of the

be in-services on dignity issues. 4. Different meal times will be observed 3 times a week for 4 weeks, 1 time a week for 3 months, then at the discretion of QAA.F241: Completion date 9-20-17 and ongoing.





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main dining room had long strings of

spaghetti hanging out of their mouths.

Resident C's record was reviewed on

8/16/17 at 2:43 p.m. Diagnoses included,

but were not limited to, dementia without

behavioral disturbance, generalized muscle

weakness and adult failure to thrive.

A care plan dated 6/28/17, indicated the

resident had dementia and was not feeding

herself. The goal was to maintain intakes

to prevent a further significant weight loss.

Interventions included, but were not

limited to, provide tray set up, cues and

full assistance with meals if needed.


p.m., CNA 3 indicated before feeding a

resident she would cut the food into

smaller pieces and cut up the spaghetti to

make it less messy for the resident's face

and clothes. CNA 3 indicated if a long

string of spaghetti was hanging out of a

resident's mouth, she would use the

silverware to catch the long noodle and

put in the resident's mouth or remove it.


p.m., LPN 4 indicated the staff should cut

up the spaghetti before assisting to feed a

resident. He indicated if he saw a resident

with a long string of spaghetti hanging out

of their mouth, he would ask the staff to

cut up the spaghetti or offer the resident





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another food choice.


p.m., CNA 2 indicated Resident C was

difficult to get to eat and normally the

resident liked spaghetti. CNA 2 indicated

the food should be cut up in bite sized

pieces and spaghetti was difficult to feed

to a resident. CNA 2 indicated Resident C

did not like to be dirty and she had to wait

for Resident C to wipe off the spaghetti

noodles from her mouth before she could

give her another bite.

A current procedure titled "Procedure #59:

Assist To Eat", obtained from the Director

of Nursing on 8/21/17 at 12:48 p.m.,

indicated "...Offer assistance if resident

appears to be having difficulty during

meal...Residents may refrain from 'asking'

for assistance, thus staff should be

pro-active in observing the need for

assistance and offer the same...."

3.1-3(t)

483.20(d);483.21(b)(1) F 0279





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DEVELOP COMPREHENSIVE CARE PLANS 483.20(d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan.

483.21(b) Comprehensive Care Plans

(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -

(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).

(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record.

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(iv)In consultation with the resident and the resident’s representative (s)-

(A) The resident’s goals for admission and desired outcomes.

(B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.

(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Based on observation, record review and

interview, the facility failed to complete an

individualized plan of care related to

dental for 1 of 3 residents reviewed for

dental services, to monitor the signs and

symptoms of mood, depression and

insomnia and to monitor for a high risk

medication for 2 of 5 residents reviewed

for unnecessary medications. (Resident 6,

82 and 50).

Findings include:

1. On 08/16/17 at 10:50 a.m., Resident 6

was observed to be edentulous.

Resident 6's record was reviewed on

08/16/17 at 2:46 p.m. Diagnoses included,

but were not limited to, dementia without

behavioral disturbance, depressive

F 0279 1. Resident 6 has had dental care plan updated. Resident 82 has had care plan updated to observe for side effects. Resident 50 has had care plan updated to monitor signs and symptoms of insomnia, psychosis and mood.2. All residents with dentures, diuretics and a GDR have had their care plans reviewed and revised when appropriate. 3. Licensed staff will be in-serviced on the development and updating of care plans as needed.4. Orders will be audited to ensure proper care plans have been put in place or updated 2 times a week for 4 weeks and then weekly for 3 months, then at discretion of QAA.

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episodes, muscle wasting and atrophy and

dysphagia.

An Annual Minimum Data Set (MDS)

Assessment dated 09/12/16, was marked

as "no natural teeth or tooth fragments" in

the Section L- Oral/Dental Status. The

Section V- Care Area Assessment (CAA)

Summary, indicated the dental care area

triggered and a care plan was needed.

No care plan related to Resident 6's dental

status was located.


a.m., the MDS coordinator indicated

Resident 6 did not have a dental care plan

and she should have been care planned.2.

The record for Resident 50 was reviewed

on 8/17/2017 at 9:42 a.m. Diagnoses

included, but were not limited to, other

specified mental disorders due to know

physiological condition, mixed

receptive-expressive language disorder,

anxiety disorder, sleep disorder,

unspecified dementia with behavioral

disturbance, unspecified psychosis not due

to a substance or known physiological

condition and vascular dementia with

behavioral disturbance.

On 12/16/2016, a physician's order

indicated Resident 50 was to receive one 5

mg (milligrams) tablet of celexa

(antidepressant) at bedtime for anxiety.





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mg capsule of melatonin (natural

supplement used to treat insomnia) every

day at 4:00 p.m. for vascular dementia

with behavioral disturbance. This order

was discontinued on 8/3/2017 and a new

order for melatonin 3 mg capsule every

day at 4:00 p.m. for sleep disorder was

placed on 8/3/2017.


indicated Resident 50 was to receive 125

mg depakote sprinkles (mood stabilizer)

twice a day for unspecified dementia with

behavioral disturbance. This order was

discontinued on 8/2/2017 and a new order

for 125 mg depakote sprinkles twice a day

for unspecified psychosis not due to a

substance or known physiological

condition was placed on 8/2/2017.


indicated the resident should have a

"...psyche eval and tx [psychiatry

evaluation and treatment]...."

A care plan dated 9/5/2013, with an

effective date of 6/12/2017, indicated the

resident was at risk for symptoms of

anxiety as evidenced by "...intrusive

wandering the facility and into my peers

rooms, exit seeking, pacing, trying to help

others even when they ask resident not





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to..." The goal was the resident will show

no symptoms of anxiety through the next

review. Interventions included, and were

limited to, "...Offer redirection, 1 on 1,

activities, toileting, food, or fluids if

symptoms of anxiety are noted. Offer to

take me outside for a walk (weather

permitting), ask me to help you with a

task, ask me to help take care of the

babies. Speciality consult as needed.

Administer medications as ordered.

Observe me for side effects of

medications and notify my doctor if noted.

Review for reduction every 6 months and

prn [as needed]. Notify my doctor if

medications are ineffective...."

No care plans were found to monitor for

signs and symptoms of insomnia,

psychosis or mood.

The Nursing Facility Psychiatric Initial

Consult dated 8/2/2017, section titled

"Assessment/Treatment plan and

Recommendations, indicated

"...Depression-GDR [Gradual Dose

Reduction]-discontinue celexa 5 mg

daily...Recommend tracking for changes

in mood and document

accordingly...Refer to psychology for

evaluation. Will continue behavioral

health services to assure that the

psychotropic plan remains efficacious for

the resident's mental health needs...."





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p.m., the DON indicated only physical

abuse, verbal abuse, wandering, or other

are charted in the electronic

documentation and the CNA's are

responsible for charting these behaviors.

Additionally, he indicated that nursing

staff does not regularly chart or track for

signs and symptoms of mood: including

depression, psychosis or insomnia, unless

the resident has had a recent GDR. He

also indicated Resident 50 has not had

monitoring for psychosis, depression or

insomnia.


p.m., the DON indicated nurses should be

monitoring for signs and symptoms of

depression, psychosis and insomnia. 3.

The record for Resident 82 was reviewed


included, but were not limited to, edema,

atrial fibrillation and hypertension.

Physician orders included, but were not

limited to, hydrochlorothiazide (a diuretic

used to treat high blood pressure and

swelling due to fluid build up and

promotes excretion of potassium) 25 mg

(milligram) daily ordered on 7/31/17 and

potassium chloride 20 meq

(milliequivalent) ordered on 7/31/17.

The care plan did not include the use of a

diuretic or the observation of side effects





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of a diuretic.


a.m., the MDS(Minimum Data Set)

Coordinator indicated she does the

treatment plans for general medications.

She also indicated she usually does add a

treatment plan for the use of diuretics

including the risk for fluid volume excess

or fluid volume overload and did not add

this care plan for Resident 82.


p.m., the MDS Coordinator indicated the

facility did not have a Care Plan policy.

3.1-35(a)

483.24, 483.25(k)(l) PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING 483.24 Quality of lifeQuality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care.

483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to

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facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following:

(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.

(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.Based on record review and interview, the facility

failed to provide an ordered anticonvulsant

medication at prescribed time and dosage and failed

to send correct medication with a the resident for a

leave for 1 of 1 resident reviewed for

anticonvulsant medications. (Resident B)

Findings include:

The record for Resident B was reviewed on 8/18/17

at 1:30 p.m. Diagnoses included, but were not

limited to, unspecified convulsions, chronic atrial

fibrillation, type 2 diabetes mellitus with

hyperglycemia, and essential hypertension.

Medications included, but were not limited to:

Vimpat (lacosamide-an anticonvulsants) 50

milligrams (mg) orally daily at 10:00 a.m., also

Vimpat 100 mg daily at 10:00 p.m.

F 0309 1. Resident B no longer resides in this facility.2. All residents have the potential to be affected by alleged deficient practice. No residents were found to be affected at this time.3. New policy has been developed for notification of physician for missing medications. All staff will be in-serviced on this new policy.4. DON/Designee will monitor all missing medications to make sure physician was notified and their commendation was followed. Monthly DON and pharmacists will report issues from missing medications.

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A review of admission information indicated the

Resident admission time was 11:28 a.m. A review

of the nurse's notes dated 4/15/17 at 5:11 a.m.

indicated "...Resident has Vimpat ordered for 2200

(10:00 p.m.). Pharmacy was faxed and called

regarding this medication and assured (nurse on

duty) that the medication would be in no later than 4

hours. Medication has yet to arrive to facility,

spouse kept updated throughout the night, and

assured that writer would be in to give medications

as soon as it arrives...."

A nurses' notes written on 4/15/17 at 1:51 p.m.

indicated the pharmacy delivered Vimpat at 6:30

a.m.

A nurse's notes written on 4/22/17 at 10:56 p.m.

indicated the writer "... called (previous shift nurse)

regarding resident's Vimpat medication. She stated

that pharmacy (Name of pharmacy) was called

several hours ago ("early afternoon"). (Name of

pharmacy)

told her they may have to source out the order: 7

days (21 tablets). She stated that, "it should be taken

care of", resident received 50 mg of this medication

tonight, which is 1/2 dose. Resident and family

aware...."

The physician did not order the 1/2 dose of the

Vimpat and had not been notified only a 1/2 dose

had been given without the order to do so.

A nurse's note written on 4/23/17 at 12:50 .p.m.,

indicated "...(Name of pharmacy) returned call

regarding Vimpat medication. Stated it is in route

from secondary pharmacy; no ETA (estimated time

of arrival) offered. Resident and family aware."

During an interview with LPN 6 on 8/18/17 at 10:20

a.m.,she indicated Resident B left early with his





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family for an leave, the medication was sent with

family, family did come back to get correct

medication since they noted the wrong medication

was sent with the resident. She was unable to

recall whether the medication was correct and in a

bag with his name on it when it was sent with him

on leave.

During an interview with the Director of Nursing

(DON) on 8/18/17 at 2:15 p.m., he indicated there

have been problems with medications being

available and staff were to contact him with

problems regarding medications. He also indicated

he was not aware of the problems with this resident.

A current policy titled "Medication Administration",

dated 2/10/16, received from the DON on 8/18/17 at

3:13 p.m. indicated "...12. If medication is given at a

time different from the scheduled time, note that in

the electronic MAR (Medication Administration

Record)...."

This Federal tag relates to complaint IN00228805

3.1-37(a)

483.25(g)(1)(3) MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE (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-

(1) Maintains acceptable parameters of nutritional status, such as usual body weight

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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;

(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.


interview, the facility failed to reassess

interventions, implement new

interventions and follow physician's

recommendations which resulted in a

significant weight loss for 1 of 1 resident

reviewed for nutrition. Resident C had a

15% weight loss in 49 days. Resident C

was not evaluated by speech therapy as

recommended by the doctor and new

interventions were not implemented to

prevent weight loss.

Finding includes:

During the initial dining observation on

8/15/2017 at 11:48 a.m., Resident C was

observed to be in the dining room, at a

table with three other residents being aided

to eat by a CNA. Her lunch consisted of

spaghetti. Resident C was observed to

only eat three bites of her spaghetti.

On 8/18/2017 at 11:30 a.m., Resident C

was observed to be in the dining room, at

a table with three other residents and a

staff member assisting her. The resident

was served a salmon steak, waffle fries, a

F 0325 1. Resident C was admitted to hospice.2. All residents have the potential to be affected by this deficient practice.3. Residents with significant weight loss will continue to be reviewed weekly by NAR team. NAR team will continue to reassess all the prior weeks interventions to insure follow ups occur according to facility protocol as well as determine if other dietary/nursing interventions are warranted at time of review. 4. RD/DON will audit NAR interventions weekly for 3 months, and then as QAA determines appropriate.

We as a facility are requesting an IDR on this tag based on the following facts:1. There was not a physicians order for a speech evaluation, it was a nursing measure requesting a speech screen. The assessment coordinator made the physician aware.2. The facility interventions were being implemented, reassessed and new interventions implemented as needed.3. The family was aware of the

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small side salad and a small side of vanilla

ice cream. No supplement was observed

on her tray. The resident was observed to

eat 100 % of the ice cream and nothing

else.

On 8/21/2017 at 7:37 a.m., Resident C

was observed in the dining room during

breakfast service. The resident was

served a cheese omelette, a side of toast,

orange juice and chocolate milk. The

resident ate one bite of the omelette and

refused all other solid foods. She drank

one and a half servings of orange juice

and sips of her chocolate milk. During

this service, the staff assisting the resident

was observed to go into the kitchen and

get a small dish of strawberry ice cream.

The resident was observed to eat

approximately 50% of her strawberry ice

cream.

The record for Resident C was reviewed


included, but were not limited to,

6/21/2017- unspecified dementia without

behavioral disturbance, insomnia,

hydrocephalus, anxiety disorder, and heart

failure. On 7/20/2017 the diagnosis of

adult failure to thrive was added to the

resident's current diagnoses.

During Stage I of the survey on 8/16/2017

at 2:49 p.m., the Registered Dietitian

(RD) provided weights for Resident C.

residents deteriorating condition since admission to this facility on 6-21-17.4. On July 27, 2017 the diagnosis of Adult Failure to Thrive was added.The facility does not believe that this weight loss was avoidable.





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The weights for this resident were:

a. Weight at Admission: 134 pounds.

b. Weight on 7/07/2017: 126 pounds

(which was 8 pounds less than her

admission weight or a 6.0% weight loss

since her admission)

c. Weight on 7/17/2017: 120 pounds


admission weight or a 10% weight loss


d. Weight on 8/09/2017: 114 pounds


admission weight or a 15% weight loss



p.m., indicated Resident C "...Wt# [weight

in pounds] 133.6...Assisted/supervised

with feeding self...."

A physician's order dated 6/21/2017,

indicated the resident was to receive a

regular diet.

An assessment note dated 6/30/2017 at

1:53 p.m., indicated "...Res [resident] wts

[weights] are being monitored in NAR

[Nutrition at Risk Team] and discussed

with IDT [Interdisciplinary Team] et [and]

RD. Res has had approx. [approximately]

3# [pound] loss since admission and has

had a poor appetite. Res has a hx

[history] of refusal of ... and meals before

this admission. MD [medical doctor]

notified of wt loss and N.O. [new order]





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rec'd [received] to being [sic] Med Pass

2.0 po [by mouth] 90 mL's [milliliters]

TID [three times a day] as a dietary

supplement per RD recommendation.

Will continue to monitor wts weekly et

discuss in NAR. Res requires heavy

cueing and encouragement with total assist

at times and she is resistive to most

interventions...."

A physician's order dated 6/30/2017,

indicated the Resident was to receive Med

Pass 2.0 90 mL's TID for weight loss and

poor appetite.

From 6/30/2017 through 7/5/2017, the

resident received the supplement 8 out of

13 times and 2 of the 8 times the

supplement was given, it was consumed at

less than 90 mL's.


a.m., indicated the ADON had notified the

MD of the resident's poor appetite, refusal

of supplement, and her pocketing

medications. The "...MD recommended

ST (speech therapy) to screen. Therapy

aware."

An email from the ADON to therapy

dated 7/5/2017 at 8:23 a.m., indicated the

resident needed a screen. "...Staff is

stating that she is pocketing medications

and has had wt loss and poor appetite...."





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An email from the ADON to the RD dated

7/5/2017 at 8:52 a.m., indicated the

resident "...is refusing Med Pass 2.0 at

times, cont [continue] with poor intake,

and noted to be pocketing meds

[medications]. I have contacted speech

for a screen and notified MD...."

No documentation was found that speech

therapy had screened the resident.

A nutritional status note dated 7/5/2017 at

4:35 p.m., indicated the RD had spoken to

Resident C's family about her food

preferences and the information was

shared with nutrition services.

Additionally, "...Weights monitored

closely with poor intakes. Supplements

are about 50% hit or miss. We will

continue the strawberry ice cream L&D

[lunch and dinner]. Will try some

different breakfast options, but (Resident)

has never been a brkfst [breakfast] eater.

She likes noodles and pasta. Enjoys

sweets and lemonade. Loves pizza. Will

update POC [plan of care] and follow

with NAR. UBW [usual body weight]

around 130-135#. PW [patient weight]

125.8#, down 4.8# (3.6%)/week [in one

week]...daughter is aware. She (daughter)

also voiced that she does not want a tube.

Any food she gets will be po. RD

supportive of wishes and will continue to

strive to find something she will eat...."





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From 7/5/2017 through 7/25/2017 the

supplement was given 63 out of 74 times,

or 75% of the time. Of the 64 times the

supplement was consumed, 9 times the

supplement consumed was less than

90mLs.

On 7/20/2017 at 11:33 a.m., a nursing

note indicated the MD was notified of the

resident's significant weight loss and a

diagnosis of "adult failure to thrive D/T

[due to] Dementia" was added as a

diagnosis for the resident.

On 7/26/2017 at 3:08 p.m., a nutritional

status note indicated dietary increased

Resident C's supplement from 90 mL's

TID to 120 mL's TID.

On 7/26/2017 at 3:11 p.m., a nutritional

status note indicated "...Per NAR review,

[Resident] is 117.8#, down 2.2# in a week

and down 15.8#(11.8%)/ 1 month. She

has dementia and despite continued

interventions, she won't eat or eats very

little and weight loss is insidious at this

point. Team discussed and since she

AFTT [adult failure to thrive], we note

she is taking her [supplement] 85% of the

time. Since she is accepting, we will

increase to 120 ml TID and orders are

received. Her family has indicated she

likes strawberry ice cream, so we plan to

offer a strawberry shake at noon and offer

strawberry ice cream at HS. If she





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consumes the additional supplements, the

increase will be approx. [approximately]

1140 kcal [kilocalorie] and 3 gm [grams]

pro [protein]. DON planning to discuss

advance direction and feeding direction

with family. BMI is 20.2, down from

22.9 last month. RD remains available...."

A care plan initiated on 6/28/2107 and

updated 7/26/2017 indicated the resident

has "...dementia and am not feeding

myself. I will occasionally hold a cup. I

have a poor appetite and have had a

significant weight loss in the past month. I

am usually 130-135#. I have a diagnosis

of Adult Failure to Thrive...." The goal

was to maintain intakes to prevent a

further significant weight loss through the

next review. Interventions, included and

were limited to, "...[effective 6/28/2017]

Provide me tray set up, cues, and full

assistance if I need it. I lke [sic] rice

krispie treats. Notify my family and MD

of significant weight changes...[effective

7/5/2017] Supplement as ordered. I like

pasta and noodles. I am not a breakfast

eater, just toast or danish and juice. I will

occasionally eat eggs. I enjoy Sprite and

potato chips and may accept as a snack. I

like Lemonade. I like cheesecake...

[effective 7/26/2017] Offer me a

strawberry ice cream shake at Lunch and

offer me strawberry ice cream at

dinner...."





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indicated the resident's Med Pass 2.0

should be increased from 90 mL's three

times a day to 120 mL's three times a day.

On 7/27/2017 at 4:08 a.m., an assessment

note indicated the resident "...Requires

total assist with meal intake with heavy

cueing and much encouragement to

consume meal...Res has no issues with

chewing or swallowing and has a very

limited list of foods that she likes per

family...."

On 7/27/2017, a physician's ordered

indicated the resident should have Med

Pass 2.0, strawberry ice cream at dinner

and a strawberry milkshake at lunch.


a.m., indicated the resident was "...still

resisting care, difficult time getting resident

to take medications...."


5:29 a.m., indicated "...Res current wt is

114.2 a loss of 9% in 1 month. Res has a

Regular diet with ice cream and shakes

and Med Pass 2.0 as a dietary supplement

d/t [due to] poor appetite and wt loss.

Res consumes Med Pass 2.0 approx.

[approximately] 50% of the time, res avg [

average] meal intake is 25% avg snack

intake is 70% avg fluid intake is 1000 cc

[cubic centimeter]...Res has dx of





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dementia with adult failure to thrive with

anticipated wt loss. Res requires assist

with meal intake with poor intake.

Family is aware of wt assessment. MD is

aware of wt assessment. Will monitor wts

weekly et discuss in NAR."

On 8/18/2017 during lunch service, the

tray card for Resident C was reviewed. A

strawberry milkshake supplement was not

listed on the tray card.


p.m., the Registered Dietitian indicated

there was little documentation for the

resident.


a.m., PT 8 indicated the Resident did not

have a speech evaluation completed.


a.m., the DON indicated a speech



a.m., the RD indicated she was unaware a

speech evaluation was recommended.


a.m., the Dietary Services Director

indicated the Med Pass 2.0 strawberry

shake supplement should have been listed

on the resident's tray card.





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During a phone interview on 8/18/2017 at

2:33 p.m., the Resident's doctor indicated

he was not made aware the speech

evaluation was not completed and he

would have expected the facility to follow

his recommendation for a speech

evaluation before the Resident was

diagnosed with adult failure to thrive.

A current facility policy, dated 2/13/2016,

received from the DON on 8/16/2017 at

11:17 a.m., indicated it is "...the policy of

this facililty to review and address those

residents at risk for significant weight

change and skin breakdown. Those

residents will be monitored by the NAR

Team on a weekly basis involving all

applicable disciplines in an effort to

improve each resident's nutritional

status...Procedure: 1. NAR Team

members will meet weekly to monitor and

discuss the applicable resident(s), address

current interventions and determine if

other dietary or nursing interventions are

warranted at the time of review. A 2.5%

or more loss in one week will reuire a

written assessment and/or appropriate

intervention(s)...."

3.1-46(a)(1)

3.1-46(a)(2)





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483.45(d)(e)(1)-(2) DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used--

(1) In excessive dose (including duplicate drug therapy); or

(2) For excessive duration; or

(3) Without adequate monitoring; or

(4) Without adequate indications for its use; or

(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

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facility failed to monitor for signs and

F 0329 1. Resident 50 had care plan updated to include monitoring for

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symptoms of psychosis, insomnia and

mood, failed to provide documentation

specific to behaviors resulting in a failed

gradual dose reduction (GDR), follow

through with a recommended GDR and

failed to monitor for a high risk medication

for 2 of 5 resident's reviewed for

unnecessary medications (Resident 50 and

82).

Findings include:

1. The record for Resident 50 was

reviewed on 8/17/2017 at 9:42 a.m.


to, other specified mental disorders due to

know physiological condition, mixed

receptive-expressive language disorder,

anxiety disorder, sleep disorder,

unspecified dementia with behavioral

disturbance, unspecified psychosis not due

to a substance or known physiological

condition and vascular dementia with

behavioral disturbance.



mg (milligrams) tablet of celexa

(antidepressant) at bedtime for anxiety.



mg capsule of melatonin (natural

supplement used to treat insomnia) every

day at 4:00 p.m. for vascular dementia

signs and symptoms of insomnia, psychosis and mood. Resident 82 had care plan updated for use of diuretics and to obtain labs are ordered by the physician. Facility will continue to follow physicians recommendations on labs to be drawn with certain medications. 2. All residents have the ability to be affected by this deficient practice.3. All licensed staff will be in-serviced on appropriate monitoring on change of resident's behavior following a GDR. 4. Social Service Director will monitor nursing documentation following GDR trials. DON will monitor and assure that residents receiving medications that require labs are being followed per physician instructions. Each will report monthly to QAA/Behavior committee.





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with behavioral disturbance. This order

was discontinued on 8/3/2017 and a new

order for melatonin 3 mg capsule every

day at 4:00 p.m. for sleep disorder was

placed on 8/3/2017.


indicated Resident 50 was to receive 125

mg depakote sprinkles (mood stabilizer)

twice a day for unspecified dementia with

behavioral disturbance. This order was

discontinued on 8/2/2017 and a new order

for 125 mg depakote sprinkles twice a day

for unspecified psychosis not due to a

substance or known physiological

condition was placed on 8/2/2017.


indicated the resident should have a

"...psyche eval and tx [psychiatry

evaluation and treatment]...."

A care plan dated 9/5/2013, with an

effective date of 6/12/2017, indicated the

resident was at risk for symptoms of

anxiety as evidenced by "...intrusive

wandering the facility and into my peers

rooms, exit seeking, pacing, trying to help

others even when they ask resident not

to..." The goal was the resident will show

no symptoms of anxiety through the next

review. Interventions included, and were

limited to: "...Offer redirection, 1 on 1,

activities, toileting, food, or fluids if

symptoms of anxiety are noted. Offer to





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take me outside for a walk (weather

permitting), ask me to help you with a

task, ask me to help take care of the

babies. Speciality consult as needed.

Administer medications as ordered.

Observe me for side effects of

medications and notify my doctor if noted.

Review for reduction every 6 months and

prn [as needed]. Notify my doctor if

medications are ineffective...."

No care plans were found to monitor for

signs and symptoms of insomnia,

psychosis, or mood.

On 6/15/2017 at 1:08 p.m., a nursing note

indicated a new order was received to

"...decrease Depakote from BID [two

times a day] to daily at noon...."

The Behavior Detail Report from

6/15/2017 to 6/28/2017 indicated the

resident had one behavioral episode on

6/27/2017 at 3:00 p.m.

No behavioral episodes were documented

in the nursing notes from 6/15/2017 to

6/28/2017.


p.m., indicated a new order was received

for depakote 125 mg by mouth twice a

day.






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10:08 a.m., indicated the resident "...had a

GDR of Depakote on 6-15-17. In last

few days resident has been exhibiting and

[sic] increase in behaviors AEB [as

evidenced by] refusal of ADL [activities

of daily living] care, verbally abusive

towards staff, general agitation with those

around her. MD was notified and

Depakote 125 mg was reinstated as a

FDR [failed dose reduction]...."

The Nursing Facility Psychiatric Initial

Consult dated 8/2/2017, section titled

"Assessment/Treatment plan and

Recommendations, indicated

"...Depression-GDR-discontinue celexa 5

mg daily...Recommend tracking for

changes in mood and document

accordingly...Refer to psychology for

evaluation. Will continue behavioral

health services to assure that the

psychotropic plan remains efficacious for

the resident's mental health needs...."

A social services note dated 8/9/2017 at

2:40 p.m., indicated "...Resident was seen

by [name of psychiatric service provider]

on 8/2/2017. Recommendations:

GDR-discontinue Celexa for Depression.

Continue Depakote for Psychosis.

Continue Melatonin for Sleep D/O

[disorder]. Will continue with psych

[psychiatric service provider] services.

The medication record from 8/1/2017





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through 8/16/2017 indicated Resident 50

continued to receive celexa at 8:00 p.m.

after the recommended discontinue date

of 8/2/2017.


p.m., the DON indicated only physical

abuse, verbal abuse, wandering, or other

are charted in the electronic

documentation and the CNA's are

responsible for charting these behaviors.

Additionally, he indicated that nursing

staff does not regularly chart or track for

signs and symptoms of mood: including

depression, psychosis or insomnia, unless

the resident has had a recent GDR. He

also indicated that Resident 50 has not had

monitoring for psychosis, depression or

insomnia.


p.m., the DON indicated that the depakote

should not have been reinstated to twice a

day with only one behavior and the nurses

should be monitoring for signs and

symptoms of depression, psychosis and

insomnia. In addition, he indicated the

Celexa should have been discontinued

with the recommended GDR.


p.m., the MDS Coordinator indicated

there was no psychotropic medication use

policy.






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to, edema, hypertension and atrial

fibrillation.

Physician orders included, but were not

limited to, hydrochlorothiazide (a diuretic

used to treat high blood pressure and

swelling due to fluid build up) 25 mg

(milligram) daily ordered on 7/31/17 and

potassium chloride 20 meq

(milliequivalent) ordered on 7/31/17.

The care plan did not include the use of a

diuretic or the observation of side effects

of a diuretic.

The resident's chart did not have a

potassium level included and did not have

a physician order to complete a potassium

level.

A physician progress note dated 8/21/17 at

11:08 a.m. did not include an order for a

potassium level.

A pharmacy review completed on 8/1/17

indicated, "Resident's medication regimen

upon admission was reviewed, and no

major issues found concerning medication

therapy problems."

The Nursing 2016 Drug Handbook

indicated, the nursing considerations for

hydrochlorothiazide included, but were





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not limited to, monitor fluid intake and

output, watch for signs of hypokalemia

(low potassium level) such as muscle

weakness and cramps and monitor elderly

patients who are especially susceptible to

excessive diuresis.

The Nursing 2016 Drug Handbook

indicated, the nursing considerations for

potassium chloride included, but were not

limited to, monitor electrolyte (potassium,

sodium and chloride) levels. The

handbook also indicated an adverse

reaction of the medication included

hyperkalemia (elevated potassium level).


a.m., the Director of Nursing (DON)

indicated he would expect the residents on

a diuretic to have a potassium level

completed. He also indicated it was the

consulting pharmacy's responsibility to

note if a potassium level was completed

and to make recommendations to the

facility if a potassium level needed

completed.


p.m., the Minimum Data Set Coordinator

indicated the facility does not have a

policy regarding high risk medications.

3.1-48(a)(3)

3.1-48(a)(2)





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483.35(g)(1)-(4) POSTED NURSE STAFFING INFORMATION 483.35(g) Nurse Staffing Information(1) Data requirements. The facility must post the following information on a daily basis:

(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed vocational nurses (as defined under State law)

(C) Certified nurse aides.

(iv) Resident census.

(2) Posting requirements.

(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.

(ii) Data must be posted as follows:

(A) Clear and readable format.

F 0356

SS=C

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(B) In a prominent place readily accessible to residents and visitors.

(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.


interview, the facility failed to post the

correct number of RN's (Registered

Nurses), the total number of hours and the

facility census on the staff posting for 2 of

5 days during the annual survey. This has

the potential to affect 59 of 59 residents

residing in the facility.

Finding includes:

On 08/15/17, the staffing posted for the

6:00 a.m. to 2:00 p.m. shift did not

include the facility's census and listed two

RN's had worked for a total of 16 hours.

One RN was scheduled for a total of 8

hours. The 6:00 p.m. to 6:00 a.m. staffing

was not posted.

On 08/21/17, the staffing posted for the

6:00 a.m. to 2:00 p.m. shift did not

include the facility's census and listed 2

LPN's (Licensed Practicing Nurse) had

worked for a total of 8 hours and zero

F 0356 1. Report was completed and posted immediately.2. All residents have the potential to be affected by this deficient practice.3. All nursing staff will be in-serviced on posting daily hours.4. Administrator/Designee will audit posted hours daily for 4 weeks to ensure accuracy of information posted. Will report to QAA.

09/20/2017 12:00:00AM





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RN's. One LPN worked for a total of 8

hours and one RN worked for a total of 8

hours. The 6:00 p.m. to 6:00 a.m. staffing

was not posted.


a.m., the Director of Nursing (DON)

indicated the staff posting dated 8/15/2017

and 08/21/17 was inaccurate and

incomplete and the 6:00 a.m. to 6:00 p.m.

should have been posted.

483.45(b)(2)(3)(g)(h) DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who--

(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

F 0431

SS=D

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(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

(g) Labeling of Drugs and Biologicals.Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

(h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.Based on observation, interview and record review,

the facility failed to dispose of a scheduled II (a

controlled medication with a high potential for

abuse) medication according to guidelines

established in 1 of 4 medication carts reviewed (D

hall cart).

Findings include:

During the medication storage review on 8/17/17 at

9:22 a.m.,with Qualified Medications Aide (QMA) 5

the following was observed:

The D hall medication cart had a Controlled Drug

F 0431 1. Resident 2 controlled drug II was disposed of according to regulatory procedure.2. All residents have the potential to be affected by this deficient practice.3. All licensed staff will be in-serviced on the medication disposal policy.4. Controlled drug disposal records will be audited by the DON/Designee 3 times a week for 4 weeks, weekly for 3 months, then reported to QAA for

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Administration Record which indicated one

Phenobarbital (a barbiturate used to treat seizures)

32.4 mg (milligrams) was destroyed for Resident 2

and the record had the signature of one Licensed

Practical Nurse (LPN) 6.

The record for resident 2 was reviewed on 8/12/17

at 12:59 p.m. Diagnoses included, but were not

limited to, spastic quadriplegic cerebral palsy and

unspecified convulsions (seizures).

During an interview on 8/17/17 at 10:01 a.m.,the

Director of Nursing (DON) indicated a drug

disposition form for the destroyed Phenobarbital

should have been in the resident's chart and the

form should have included the signatures of two

licensed staff. The DON was not able to locate the

drug disposition form in the resident's chart.

A current policy titled "Expired Medication

Disposal" dated 2/04/16, obtained from the DON on

8/17/17 at 10:01 a.m., indicated "....All medications

to be disposed of will have a drug disposition form

filled out...Medications require 2 licensed nurses to

sign for distruction [sic] of medication, if medication

is a narcotic then 1 nurse must be a RN [registered

nurse]...."

3.1-25(o)

recommendations.

R 0000

Bldg. 00

This visit was for a State Residential Licensure

Survey. This visit included a Recertification and

State Licensure Survey. This visit included the

Investigation of Complaint IN00228805.

R 0000 Submission of this Plan of Correction and Credible Allegation of Compliance does not constitute an admission by the certified and

State Form Event ID: WV5511 Facility ID: 000299 If continuation sheet of 48




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Complaint IN00228805- Substantiated. Federal

deficiencies related to the allegations are cited at

F157 and F309.

Survey dates: August 15, 16, 17, 18, and 21, 2017

Facility number: 000299

Residential Census: 13

These State Residential Findings are cited in

accordance with 410 IAC 16.2-5.

Quality Review was completed on August 25, 2017.

licensed provider at Milner Community Health Care, Inc., that the allegations contained in this survey report a true and accurate portrayal of the provisions of nursing care and services at this health care facility. Milner Community Health Care, Inc., as a licensed and certified provider, recognizes its obligation to provide legally and medically required care and services to our residents in an economical and efficient fashion. Please accept this Plan of Correction as the Credible Allegation of Compliance.

410 IAC 16.2-5-2(c)(1-4)(d) Evaluation - Noncompliance (c) The scope and content of the evaluation shall be delineated in the facility policy manual, but at a minimum the needs assessment shall include an evaluation of the following:(1) The resident ' s physical, cognitive, and mental status.(2) The resident ' s independence in the activities of daily living.(3) The resident ' s weight taken on admission and semiannually thereafter.(4) If applicable, the resident ' s ability to self-administer medications.(d) The evaluation shall be documented in writing and kept in the facility.

R 0216

Bldg. 00

Based on interview and record review, the R 0216 1. Self Medication Assessment 09/20/2017 12:00:00AM





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facility failed to ensure medication

self-administration evaluations were

completed for 2 of 2 residents reviewed

for self medication administration

(Residents 94 and 97).

Findings include:



Diagnoses included but were not limited

to, pain, rheumatoid arthritis and dry eye

syndrome.

A "Resident's Ability To Self Administer

Medications" evaluation was opened on

06/26/17 and was not completed. The

previous evaluation was completed

06/2016.




to, mental disorders due to known

physiological condition, anxiety disorder

and osteoarthritis.

A "Resident's Ability To Self Administer

Medications" evaluation was opened on

03/13/17 and was not completed. The

previous evaluation was completed

03/2016.


p.m., the Director of Nursing (DON)

immediately completed for Residents 94 and 97.2. All residents have the ability to be affected by this deficient practice.3. All Assisted Living licensed staff will be re-educated on policy for Self Medication Assessments.4. Bi-annual Self Medication Assessments will be reviewed Monthly to ensure all residents schedule is followed. Reviews will be brought to QAA for to assure compliance followed.





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indicated the facility should complete the

medication self-administration evaluations

yearly and the evaluations should have

been completed the day the assessments

were opened.

A current facility policy titled "Right to

Self Administer Medications" dated

revised on 02/17, received from the DON

on 08/21/17 at 1:15 p.m., indicated "...If

the resident chooses to self-administer

medications, it will be the responsibility of

the interdisciplinary team to assess the

resident's cognitive, physical and visual

ability to safely and adequately carry out

this function and determining if the

resident is clinically appropriate...A

'Residents ability to self -administer

medications' UDA [User Defined

Assessment] will be completed also...."

410 IAC 16.2-5-5.1(f) Food and Nutritional Services - Deficiency (f) All food preparation and serving areas (excluding areas in residents ' units) are maintained in accordance with state and local sanitation and safe food handling standards, including 410 IAC 7-24.

R 0273

Bldg. 00

Based on observation and interview, the

facility failed to ensure staff used proper

hand hygiene during a dining service for 8

of 14 residents being served food in the

assisted living dining room.

Finding includes:

During a dining observation on

R 0273 1. Staff member was educated on facility Glove Policy and proper hand washing procedure.2. All residents could be affected by this deficient practice.3. All Assisted Living Staff will be re educated on the facility Proper glove use Policy and hand washing procedure.4. Assisted Living meal service will be observed 2 times weekly for 4

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08/15/2017 at 11:25 a.m., LPN 7 took a

hairnet off of the second shelf of the food

cart and proceeded to use his gloved left

hand and his right hand with another glove

wrapped inside the hand to put on his hair

net. He then continued to put the right

glove on and served the food. LPN 7 was

observed to open drawers on the buffet

cart while he looked for something. He

moved from task to task and did not wash

his hands or change his gloves.


p.m., the Director of Dining Services

indicated the facility did not have a

specific glove policy and the facility

followed the federal/state regulations.


p.m., the Director of Nursing indicated

gloves would need to be changed after

touching anything foreign.

weeks to assure compliance. Results will be reported to monthly QAA meeting for recommendations.

410 IAC 16.2-5-12(d) Infection Control - Noncompliance (d) Prior to admission, each resident shall be required to have a health assessment, including history of significant past or present infectious diseases and a statement that the resident shows no evidence of tuberculosis in an infectious stage as verified upon admission and yearly thereafter.

R 0409

Bldg. 00

Based on interview and record review, the

facility failed to ensure a resident had an

annual health assessment which included a

statement to indicate the resident was free

of infectious disease completed yearly for

R 0409 1. Resident 101 began Hospice care on 8/31/17. Statement from Hospice indicates resident is free from infectious disease.2. All residents have the potential to be affected by this deficient

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1 of 7 residents reviewed for an annual

health statement (Resident 101).

Finding includes:

The record for Resident 101 was



to, bacterial pneumonia, malignant

neoplasm of the left main bronchus, acute

upper respiratory infection and disease of

the blood and blood-forming organs.

An Annual health statement was not

located in Resident 101's record.


p.m., the Director of Nursing indicated he

could not locate an annual health

statement for Resident 101.

practice. All resident have a current Free from infectious disease statement.3. All Assisted Living staff will be in-serviced on completing monthly assessment forms.4. Director of Nursing will monitor EHR for completed assessments and to assure accuracy for 6 months. QAA will review report and evaluate compliance.


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