PRINTED: 04/11/2018 DEPARTMENT OF HEALTH AND HUMAN ...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

04/11/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

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B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

ELKHART, IN 46517

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GOLDEN LIVING CENTER-ELKHART

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F 0000

Bldg. 00

This visit was for the Investigation of Complaints

IN00256400, IN00256305 and IN00256573.

Complaint IN00256400 - Substantiated.

Federal/State deficiencies are cited at F609, F 610,

F655 and F698.


Federal/State deficiencies are cited at F609, F610,

F655 and F698.


Federal/State deficiencies are cited at F655, and

F698.

Survey dates: March 15, 16, 19, and 20, 2018.

Facility number: 000039

Provider number: 155685

AIM number: 100275130

Census bed type:

SNF/NF: 119

Total: 119

Census payor type:

Medicare: 1

Medicaid: 107

Other: 4

Total: 119

This deficiency reflects State findings cited in

accordance with 410 IAC 16.2-3.1.

Quality Review was completed on March 26, 2018.

F 0000 Preparation, submission and

implementation of this Plan of

Correction does not constitute an

admission of or agreement with

the facts and conclusions set forth

on the survey report. Our Plan of

Correction is prepared and

executed as a means to

continuously improve the quality of

care and to comply with all

applicable state and federal

regulatory requirements.

We respectfully request that you

consider our facility for paper

compliance as the severity of

citations was found to be of no

actual harm.

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: VMM611 Facility ID: 000039

TITLE

If continuation sheet of 21

(X6) DATE




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

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

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

(i) A facility must immediately inform the

resident; consult with the resident's

physician; and notify, consistent with his or

her authority, the resident representative(s)

when there is-

(A) An accident involving the resident which

results in injury and has the potential for

requiring physician intervention;

(B) A significant change in the resident's

physical, mental, or psychosocial status

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

psychosocial status in either life-threatening

conditions or clinical complications);

(C) A need to alter treatment significantly

(that is, a need to discontinue an existing

form of treatment due to adverse

consequences, or to commence a new form

of treatment); or

(D) A decision to transfer or discharge the

resident from the facility as specified in

§483.15(c)(1)(ii).

(ii) When making notification under paragraph

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

ensure that all pertinent information specified

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

upon request to the physician.

(iii) The facility must also promptly notify the

resident and the resident representative, if

any, when there is-

(A) A change in room or roommate

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

(B) A change in resident rights under Federal

or State law or regulations as specified in

paragraph (e)(10) of this section.

(iv) The facility must record and periodically

update the address (mailing and email) and

phone number of the resident

F 0580

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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet of 21




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representative(s).

§483.10(g)(15)

Admission to a composite distinct part. A

facility that is a composite distinct part (as

defined in §483.5) must disclose in its

admission agreement its physical

configuration, including the various locations

that comprise the composite distinct part,

and must specify the policies that apply to

room changes between its different locations

under §483.15(c)(9).

Based on record review and interview, the facility

failed to notify a resident's physician of a missed

dialysis appointment, and of resident reported

pain to his bilateral casts after tendon repair for 1

of 3 residents reviewed for dialysis and pain.

(Resident B)

Finding includes:

1. The clinical medical record for Resident B was

reviewed on 3/16/18 at 11:00 A. M. Resident B

was admitted to the facility on 3/8/18 with

diagnoses included, but not limited to, end stage

renal disease, repeated falls, spontaneous rupture

of other tendons, unspecified site, nontraumatic

hematoma of soft tissue and muscle weakness.

A local hospital history and physical, dated

2/26/18, indicated "...History of Present Illness:

The patient is 48 -year-old...dialysis dependant...."

During an interview, on 3/16/18, the Admissions

Director indicated the resident was to receive

dialysis on Monday, Wednesday and Fridays and

that on 3/9/18 the resident missed his scheduled

dialysis appointment because transportation had

not been set up. She indicated she thought he

received dialysis on his next scheduled day but

F 0580 THE FACILITY NOTIFIES

RESIDENTS’S PHYSICIANS OF

CHANGE IN CONDITION

Resident B no longer resides at

the facility.

All residents with change of

condition in the last 14 days were

reviewed to ensure that the

physicians were notified of change

in condition.

Licensed nursing staff has been

in-serviced on physician

notification of changes in

resident’s condition. Director of

Nursing or designee will review

nurse’s notes during clinical start

up to identify any resident with a

change in condition to ensure that

physician has been notified of

changes. These audits to be

completed 5 days a week x 4

weeks, then 2 times weekly x 2

months, then 1x week x 3

months.

The results of the review will be

brought to QAPI x 6 months to

track for trends. If any trends are

identified in the review, the QAPI

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was unsure.

A review of the nursing progress notes lacked

documentation that Resident B's physician had

been notified that he did not receive dialysis on

3/9/18 related to transportation difficulties.

During an interview, on 3/16/18 the DNS (Director

of Nursing Services) indicated a resident's

physician should be notified when a change

occurs in the resident's condition.

2. The clinical medical record for Resident B was

reviewed on 3/16/18 at 11:00A.M. Resident B was

admitted to the facility on 3/8/18 with diagnoses

included, but not limited to, end stage renal

disease, repeated falls, spontaneous rupture of

other tendons, unspecified site, nontraumatic


A Progress Note dated 3/8/2018 at 10:35 P.M.,

indicated "...He complained of cast to left upper

leg being uncomfortable and hurting his leg. He

stated that the hospital had "put a thick pad in

there but my leg swells too much and it made it to

tight so I took it out...."

A Progress Note, dated 3/9/2018 at 6:42 A.M.,

indicated "...Complained of the cast to this left leg

irritating his skin. Edges of cast at the top are

jagged. Placed washcloth around edge of cast for

additional protection...."

A Progress Note, dated 3/10/18 at 5:57 P.M.,

indicated "...SBAR [situation, background,

assessment and response]...Situation: Resident

c/o [complained of] cast being too tight to the

upper leg et left ankle/heel...Background: Resident

received dialysis 3x/wk. [times per week] Lasix [a

medication used for the elimination of excess

minutes will reflect the

recommendations. If no trends are

identified in 6 months; the review

will be completed on PRN basis.





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fluids] 80 mg [milligrams] bid [twice a day].

Non-Compliant with elevating legs.

Diabetic...Assessment: ABD [abdominal pad]

applied to upper cast to prevent rubbing.

Encouraged to elevate. Resident states that it

"hurts" when I elevated them. Pain pill given for

discomfort...Response: NP [Nurse Practitioner]

notified...


indicated "...NP did not return phone call...."


indicated "...Called into ro [room] resident.

Informed this nurse that the top of the leg cast

was too rough against his skin. ABD dressing

applied around the circumference of the cast.

Resident stated that ABD was helpful...."


indicated "...SBAR Change in Condition...

Situation: Resident c/o [complained] discomfort to

rt. [right] lower leg. Stated that he feels that his

legs has swollen...Background: Resident has end

stage renal disease...et bilat [bilateral] cast to

lower extremities from recent fall...Assessment:

Resident c/o rt lower leg swelling, general malaise

et [example] sob [short of breath]...Response: NP

notified of request to go to hospital...."


indicated "... Res. [resident] returned to facility

from hospital. hospital states they cut ble

[bilateral lower extremity] casts to relieve pressure.

at hosp [hospital] res K+ [potassium] was 6.1 so

res was given a injection of Vit [vitamin] k while

there. res states the pressure feels better...."

During an interview, on 3/16/18 at 10:30 A.M., the

MDS (Minimum Data Set) nurse indicated she was





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aware the resident was having discomfort with his

bilateral lower leg casts but nursing interventions

were put into place to protect the residents skin

and to treat his pain so she did not notify the

resident's physician as she knew they would make

a visit to the facility on Friday of that week.

During an interview, on 3/16/18 at 12:00 P.M., LPN

(Licensed Practical Nurse) 2 indicated she did

notify the doctor of the resident complaints of his

casts hurting but she felt the facility was doing

what they could for him by padding his casts and

medicating him for pain. LPN 2 indicated she

passed on to the next shift that the NP had not

called back. She indicated it would be up to them

to call the NP to follow up.

A policy titled " Cast Care, of Resident with

Plaster Cast" with an effective date of 3/23/2016

was provided by the DNS on 3/20/18 at 1:00 P.M.,

the policy indicated "...Procedure Purpose: To

give proper care of resident in a fiberglass or

plaster cast to prevent infection, irritation and

provide continuous immobilization... Procedure

Details: 2. Assess circulation and any areas of

irritation above and below cast every shift. Notify

physician promptly of any abnormalities: ask

about pain, tingling or tightness under or near

cast...."

This Federal tag is related to Complaint

IN00256305 and IN00256400.

3.1-35(a)(3)

3.1-35(g)(2)

483.12(c)(1)(4)

Reporting of Alleged Violations

§483.12(c) In response to allegations of

abuse, neglect, exploitation, or mistreatment,

F 0609

SS=D

Bldg. 00





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the facility must:

§483.12(c)(1) Ensure that all alleged

violations involving abuse, neglect,

exploitation or mistreatment, including

injuries of unknown source and

misappropriation of resident property, are

reported immediately, but not later than 2

hours after the allegation is made, if the

events that cause the allegation involve abuse

or result in serious bodily injury, or not later

than 24 hours if the events that cause the

allegation do not involve abuse and do not

result in serious bodily injury, to the

administrator of the facility and to other

officials (including to the State Survey

Agency and adult protective services where

state law provides for jurisdiction in long-term

care facilities) in accordance with State law

through established procedures.

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

investigations to the administrator or his or

her designated representative and to other

officials in accordance with State law,

including to the State Survey Agency, within

5 working days of the incident, and if the

alleged violation is verified appropriate

corrective action must be taken.


failed to report an allegation of abuse for a

resident whose family reported a CNA had come

into his room to provide care for him and cursed at

him. This deficient practice affected 1 of 1

allegations of abuse reviewed. (Resident B)

Finding includes:

The clinical medical record for Resident B was


F 0609 This facility does report all alleged

abuse, neglect, exploitation or

mistreatment.


the facility

The allegation has been reported

and investigated on 3-20-18

The aide was re-educated on

providing good customer service

and perceptions

The management staff was

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other tendons, nontraumatic hematoma of soft

tissue and muscle weakness.

A Grievance Form dated 3/10/18 was provided by

the Director of Nursing Services (DNS) on 3/16/18

at 3:00 P.M. The Grievance Form indicated the

following, "...Resident Name: [name of

resident]...Today's date: 3/10/18...Date Grievance

received by Grievance Official: 3/10/18...Statement

of Concern/Grievance: Res. was placed on bed

pan but could not go. Put on call light CNA

[Certified Nursing Aide] would take him off. Res

would want to try again res could not go this went

on for several times res on and off then cna stated

"shut it down and [sic] go to bed!" Roommate

[name of room mate] also heard cna speak to

[name of resident]. [roommate] said cna tried to

explain to [name of resident] that she is busy and

if he really needs the bed pan please let her know

but if he is only going to try again please wait...."

During an interview, on 3/16/18 at 3:15 P.M., the

BOM (Business Office Manager) indicated that

she was the person who received the allegation

from Resident B's family member on 3/10/18. The

following is a statement written and signed by the

BOM and provided by the DNS on 3/16/18 at 3:00

P.M. "...3/10/18...Family member came to me at

approximately 2:00 P.M. and stated that a "nurse"

came into his fathers room the previous night and

said " shut that s*** off and go to bed."... I told

the family that I would come speak with his

father... I spoke with [Resident B] and asked him

what happened--with the aide. [Resident B]

stated, " no one cursed at me, she was just short

with me." "the problem is I have to use the bed

pan, she put me on, I didn't have to go, so I

re-educated on recognizing and

reporting abuse timely to the

Executive Director and The

Director of Nursing on 3-20-18 &

4-5-18

All staff were re-educated on

recognizing and reporting abuse

timely to the Executive Director

and/or the Director of Nursing by

4-17-18.

All grievances will be

reviewed/audited 5 times weekly in

morning meeting to ensure any

allegations were reported per

policy.

Results of these daily audits will

be brought to the QAA committee

monthly for 6 months to ensure

any abuse reported was followed

up, reported and educated on.





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pushed the call light and she took me off again...."

He admitted this went on numerous times and

stated, "I'm sure she was frustrated with me."The

last time she went to his room, she stated, " put

on the call light when you really really have to go

because I have other people I need to take care

of...Resident's daughter also stated that [Resident

B's] roommate heard the "nurse" be short with her

father...." The BOM indicated she reported the

information she gathered to the Unit Manager that

was working. The BOM did not name the CNA

involved.


Unit Manager indicated she was told by the BOM

that a family member had come to her with an

allegation that a cna had swore at a resident and

she instructed the BOM to gather information

about who the cna was and what happened. The

Unit Manager indicated she did not feel there was

an allegation of abuse made. She indicated the

Assistant Director of Nurses (ADON) was

working and had been notified of the allegation

and she returned to her unit to work The Unit

Manager indicated she did not notify the

Executive Director. The Unit Manager did not

name the CNA involved.


Executive Director (ED) indicated she had not

been made aware of the allegations made with

regard to Resident B. The ED indicated she had

been notified by the ADON of a allegation that

had been made for another resident and had

instructed the ADON to report the allegation as

per protocol. The ED indicated had she been

notified of the allegation made with regard to

Resident B she would have instructed the ADON

to begin a investigation and to report the incident.





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ADON indicated she had been notified by the

BOM of an allegation that a family member had

made with respect to Resident B and she had

instructed her to find out who the CNA was and

to talk to the resident and the resident's roommate

as he was named as a witness and to put the

information on a grievance form. The ADON

indicated that she did not believe an allegation of

abuse had been made based on what had been

told to her by the BOM. She indicated she chose

to believe the the residents roommate who was

more cognitively intact than the resident. She

indicated she was working on another allegation

and was in the process of reporting it when this

allegation was brought to her. She indicated she

had spoken with both the DNS and ED but had

not notified them of the allegation with regard to

Resident B.

A late entry progress note dated 3/8/18 at 22:35

[10:35 P.M.], indicated "...He [Resident B] appears

to be adjusting well to room and roommate. Family

in to visit for awhile. He is alert and oriented x 3

able to make needs known...."

During an interview with Resident B's former

roommate, conducted on 3/19/18 at 10:50 A.M.,

the roommate indicated he was present when the

alleged incident of cursing occurred with regard to

Resident B. He indicated the resident had been

on and off the bedpan several times and was

unable to use the restroom when the CNA

attempted to explain to Resident B that she could

not keep coming into the residents room to put

him on the bedpan if he didn't have to go she

explained she was busy and had other residents

that required her assistance. The former roommate

indicated the CNA was very polite and never

cursed at Resident B but she did talk to him like a





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"little boy". Resident B's former roommate did not

name the CNA when asked.

A current policy titled, " Investigation and

Reporting of Alleged Violations of Federal and

State Laws Involving Mistreatment, Neglect,

Abuse, Injuries of Unknown Source and

Misappropriation of Resident's Property " was

provided by the DNS on 3/16/18 at 4:15 P.M., and

reviewed on 3/20/18 at 10:00 A.M. The policy

indicated "...All employees shall immediately

report the Executive Director all alleged violation;

If the Executive Director is not immediately

available, all alleged violations should be reported

to the Designated Supervisor in charge, who will

report to the Executive Director...2 Hour Reports:

An initial report to the State Survey agency and

law enforcement must be made within 2 hours if a

patient sustains: - Allegations of abuse, neglect,

exploitation, mistreatment, including injuries of

unknown origin, and misappropriation of resident

property...Reporting Responsibility: The

supervisor in charge who receives such a report

shall immediately communicate the report to the

ED...."


IN00256305 and IN00256400.

3.1-28(c)

483.12(c)(2)-(4)

Investigate/Prevent/Correct Alleged Violation

§483.12(c) In response to allegations of

abuse, neglect, exploitation, or mistreatment,

the facility must:

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

violations are thoroughly investigated.

F 0610

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

neglect, exploitation, or mistreatment while

the investigation is in progress.

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

investigations to the administrator or his or

her designated representative and to other

officials in accordance with State law,

including to the State Survey Agency, within

5 working days of the incident, and if the

alleged violation is verified appropriate

corrective action must be taken.


failed to investigate of an allegation of abuse for a

resident whose family reported a CNA had come

into his room to provide care for him and cursed at

him. This deficient practice affected 1 of 1

allegations of abuse reviewed. (Resident B)

Finding includes:






other tendons, unspecified site, nontraumatic


A Grievance Form dated 3/10/18 was provided by

the Director of Nursing Services (DNS) on 3/16/18

at 3:00 P.M. The Grievance Form contained the

following, "...Resident Name: [name of

resident]...Today's date: 3/10/18...Date Grievance

received by Grievance Official: 3/10/18...Statement

of Concern/Grievance: Res. was placed on bed

pan but could not go. Put on call light CNA

[Certified Nursing Aide] would take him off. Res

would want to try again res could not go this went

on for several times res on and off then cna stated

F 0610 This facility does report all alleged

abuse, neglect, exploitation or

mistreatment.


the facility

The allegation has been reported

and investigated on 3-20-18

The aide was re-educated on

providing good customer service

and perceptions

The management staff was

re-educated on recognizing and

reporting abuse timely to the

Executive Director and/or The

Director of Nursing on 3-20-18 &

4-5-18

All staff were re-educated on

recognizing and reporting abuse

timely to the Executive Director

and the Director of Nursing by

4-17-18.

All grievances will be

reviewed/audited 5 times weekly in

morning meeting to ensure any

allegations were reported per

policy.

Results of these daily audits will

be brought to the QAA committee

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" shut it down and [sic] go to bed!" Roommate

[name of room mate] also heard cna speak to

[name of resident]. [roommate] said cna tried to

explain to [name of resident] that she is busy and

if he really needs the bed pan please let her know

but if he is only going to try again please wait...."


BOM (Business Office Manager) indicated that

she was the person who received the allegation

from Resident B's family member on 3/10/18. The

following is a statement written and signed by the

BOM and provided by the DNS on 3/16/18 at 3:00

P.M. "...3/10/18...Family member came to me at

approximately 2:00 P.M and stated that a "nurse"

came into his fathers room the previous night and

said " shut that s*** off and go to bed."... I told

the family that I would come speak with his

father... I spoke with [Resident B] and asked him

what happened--with the aide. [Resident B]

stated, " no one cursed at me, she was just short

with me." "the problem is I have to use the bed

pan, she put me on, I didn't have to go, so I

pushed the call light and she took me off again...."

He admitted this went on numerous times and

stated, "I'm sure she was frustrated with me."The

last time she went to his room, she stated, " put

on the call light when you really really have to go

because I have other people I need to take care

of...Resident's daughter also stated that [Resident

B's] roommate heard the "nurse" be short with her

father...." The BOM indicated she reported the

information she gathered to the Unit Manager that

was working. The BOM did not name the CNA

involved.


Unit Manager indicated she was told by the BOM

that a family member had come to her with an

allegation that a cna had swore at a resident and

monthly for 6 months to ensure

any abuse reported was followed

up, reported and educated on.





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she instructed the BOM to gather information

about who the cna was and what happened. The

Unit Manager indicated she did not feel there was

an allegation of abuse made. She indicated the

Assistant Director of Nurses (ADON) was

working and had been notified of the allegation

and she returned to her unit to work The Unit

Manager indicated she did not notify the

Executive Director. The Unit Manager did not

name the CNA involved.


Executive Director (ED) indicated she had not

been made aware of the allegations made with

regard to Resident B. The ED indicated she had

been notified by the ADON of a allegation that

had been made for another resident and had

instructed the ADON to report the allegation as

per protocol. The ED indicated had she been

notified of the allegation made with regard to

Resident B she would have instructed the ADON

to begin a investigation and to report the incident.


ADON indicated she had been notified by the

BOM of an allegation that a family member had

made with respect to Resident B and she had

instructed her to find out who the CNA was and

to talk to the resident and the resident's roommate

as he was named as a witness and to put the

information on a grievance form. The ADON

indicated that she did not believe an allegation of

abuse had been made based on what had been

told to her by the BOM. She indicated she chose

to believe the the residents roommate who was

more cognitively intact than the resident. She

indicated she was working on another allegation

and was in the process of reporting it when this

allegation was brought to her. She indicated she

had spoken with both the DNS and ED but had





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not notified them of the allegation with regard to

Resident B.

A late entry progress note dated 3/8/18 at 22:35

[10:35 P.M.], indicated "...He [Resident B] appears

to be adjusting well to room and roommate. Family

in to visit for awhile. He is alert and oriented x 3

able to make needs known...."

During an interview with Resident B's former

roommate, conducted on 3/19/18 at 10:50 A.M.,

the roommate indicated he was present when the

alleged incident of cursing occurred with regard to

Resident B. He indicated the resident had been

on and off the bedpan several times and was

unable to use the restroom when the CNA

attempted to explain to Resident B that she could

not keep coming into the residents room to put

him on the bedpan if he didn't have to go she

explained she was busy and had other residents

that required her assistance. The former roommate

indicated the CNA was very polite and never

cursed at Resident B but she did talk to him like a

"little boy". Resident B's former roommate did not

name the CNA when asked.

A current policy titled, " Investigation and

Reporting of Alleged Violations of Federal and

State Laws Involving Mistreatment, Neglect,

Abuse, Injuries of Unknown Source and

Misappropriation of Resident's Property " was

provided by the DNS on 3/16/18 at 4:15 P.M., and

reviewed on 3/20/18 at 10:00 A.M. The policy

indicated "...All employees shall immediately

report the Executive Director all alleged violation;

If the Executive Director is not immediately

available, all alleged violations should be reported

to the Designated Supervisor in charge, who will

report to the Executive Director...2 Hour Reports:

An initial report to the State Survey agency and





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law enforcement must be made within 2 hours if a

patient sustains: - Allegations of abuse, neglect,

exploitation, mistreatment, including injuries of

unknown origin, and misappropriation of resident

property...Reporting Responsibility: The

supervisor in charge who receives such a report

shall immediately communicate the report to the

ED...."


IN00256305 and IN00256400.

3.1-28(d)

483.21(a)(1)-(3)

Baseline Care Plan

§483.21 Comprehensive Person-Centered

Care Planning

§483.21(a) Baseline Care Plans

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

implement a baseline care plan for each

resident that includes the instructions needed

to provide effective and person-centered care

of the resident that meet professional

standards of quality care. The baseline care

plan must-

(i) Be developed within 48 hours of a

resident's admission.

(ii) Include the minimum healthcare

information necessary to properly care for a

resident including, but not limited to-

(A) Initial goals based on admission orders.

(B) Physician orders.

(C) Dietary orders.

(D) Therapy services.

(E) Social services.

(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a

comprehensive care plan in place of the

F 0655

SS=D

Bldg. 00





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baseline care plan if the comprehensive care

plan-

(i) Is developed within 48 hours of the

resident's admission.

(ii) Meets the requirements set forth in

paragraph (b) of this section (excepting

paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the

resident and their representative with a

summary of the baseline care plan that

includes but is not limited to:

(i) The initial goals of the resident.

(ii) A summary of the resident's medications

and dietary instructions.

(iii) Any services and treatments to be

administered by the facility and personnel

acting on behalf of the facility.

(iv) Any updated information based on the

details of the comprehensive care plan, as

necessary.


failed to ensure a baseline care plan was initiated

for a resident who was admitted to the facility with

end stage renal disease, dialysis dependant and

required cast care. This deficient practice affected

1 of 3 residents whose careplans were reviewed.

(Resident B)

Findings include:

On 3/16/18 at 12: 20 P.M., the clinical medical

record of Resident B was reviewed. Resident B

was admitted to the facility on 3/8/18 with

diagnoses included, but not limited to, end stage

renal disease, repeated falls, spontaneous rupture

of other tendons, type 2 diabetes mellitus with

hyperglycemia, hyperkalemia, nontraumatic

hematoma of soft tissue, gastroparesis, essential

primary hypertension, background retinopathy

F 0655 The facility initiates baseline care-

plan for new residents admitted to

the facility


the facility.

All new admissions in the last 14

days were reviewed to ensure that

their baseline care plan was

initiated within 48 hours. Any

resident found to have been

affected by deficient practice had

a baseline care plan completed for

them.

IDT and all licensed nurses were

in-serviced on baseline care-plan

guidelines.

Director of nursing or designee will

review all new admissions 3

times/week for 4 weeks then

04/17/2018 12:00:00AM





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and hereditary and idiopathic neuropathy, and

anemia.




A local hospital transfer form, dated 3/8/18 at

12:35 P.M., indicated "...Nurse Discharge/Current

Problem: Bilateral Open Patella Tendon repair...."

A facility Clinical Health Status form, dated 3/8/18

at 3:00 P.M., indicated "...Current Diagnosis:

Bilateral open Patella Tendon...Preventative Foot

Care: Cast to feet and legs...."

A Resident Centered Baseline Care Plan, dated

3/8/18 at 3:00 P.M., indicated

"...Problem/Need/Concern: Admission or

re-admission...Baseline Care Plan...Goal:

Resident/Responsible party have an

understanding of...Baseline Care

Plan...Interventions: Provide a summary

of...Baseline Care Plan to resident/responsible

party. Initiate IPOC's [immediate plan of care] as

indicated...."

A review of care plans lacked documentation of a

care plan that addressed the residents dialysis,

and cast care.


DNS (Director Nursing Services) indicated the

facility followed the federal guidelines for the

initiation of baseline care plans. A policy titled "

Medical Record Guideline for Electronic

Careplans" dated effective on 12/10/2014 was

provided by the DNS but did not address baseline

care plans.

weekly x 5 months to ensure that

the baseline care plan was

initiated per guidelines until 100 %

compliance is achieved.

The results of the review will be

brought to QAPI for 6 months to

track trends. If trends are identified

in the review, the QAPI minutes

will reflect the recommendations. If

no trends are identified in 6

months; the review will be

completed on prn basis.





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OMB NO. 0938-039




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IN00256573, IN00256305 and IN00256400.

3.1-30(a)

483.25(l)

Dialysis

§483.25(l) Dialysis.

The facility must ensure that residents who

require dialysis receive such services,

consistent with professional standards of

practice, the comprehensive person-centered

care plan, and the residents' goals and

preferences.

F 0698

SS=D

Bldg. 00


failed to ensure a resident who was admitted

dependant on dialysis received dialysis as per the

physician's plan of care, and pre and post dialysis

assessments were completed for 1 of 3 residents

reviewed for dialysis. (Resident B)

Finding includes:


reviewed on 3/16/18 at 11:00 A.M. Resident B was




other tendons, nontraumatic hematoma of soft

tissue and muscle weakness.




The physician's orders lacked documentation of

when Resident B was to receive dialysis and

lacked any orders for post dialysis assessment.

During an interview, on 3/16/18 at 11:10 A.M., the

F 0698 The facility ensures that residents

who require dialysis receives

dialysis per plan of care


facility.

All residents who received dialysis

in the past 14 days were reviewed

to ensure that they received

dialysis as ordered and that pre

and post assessments were

completed.

The IDT and all licensed

nursing staff were in-serviced

about care of residents on

dialysis. Director of Nursing or

designee will review all

residents who are receiving

dialysis during clinical start-up

meeting to ensure that

residents received dialysis as

ordered including a pre and

post assessment being

completed. These audits to be

completed every business day x 4

weeks, then 3 times weekly x 4

weeks, then monthly x 4 months.

04/17/2018 12:00:00AM





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Admissions Director indicated the resident was to

receive dialysis on Monday, Wednesday and

Fridays and that on 3/9/18 the resident missed his

scheduled dialysis appointment because

transportation had not been set up. She indicated

she thought he received dialysis on his next

scheduled day but was unsure.

Nursing Progress Notes for 3/12/18 indicated the

facility was in communication with the dialysis

center regarding medications and that Resident B

had been transported to nephrology via a local

transportation company.

During an interview, on 3/16/18 at 11:12A.M., the

DNS (Director of Nursing Services) indicated that

Resident B was to go out for dialysis on Monday

Wednesday and Friday and that there is a

communication book in which the dialysis center

documents his labs, vitals and other bits of

information for the facility to follow up on, she

indicated she did not know if he had an order to

check for a thrill and bruit.

During an interview, on 3/19/18 at 4:10 P.M., LPN

(Licensed Practical Nurse) 1 indicated she

conducted the admission assessment for Resident

B and he had an access site for dialysis.

On 3/20/18 at 10:30 A.M., the current policy titled

" Dialysis Guideline" and provided by the DNS on

3/16/18 at 1:00 P.M. was reviewed. The policy

indicated "...Guideline Statement: The

interdisciplinary team must ensure that residents

who require dialysis receive such services,

consistent with professional standards of

practice...Pre Dialysis Protocol: Be cognizant of

medications ordered and timing of

administration..Be aware of any meals that may be

missed and arrange for routine boxed lunches to

The results of these audits will

be brought to QAPI for 6

months to track for trends. If

any trends are identified in the

review, the QAPI minutes will

reflect the recommendations. If

no trends are identified in 6

months; the review will be

completed on PRN basis.





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be provided by dietary if resident is transported

off site...Post Dialysis Protocol Review transfer

forms...for any pertienent information...Observe

for unusual symptoms such as lethargy, chest

pain, headache, unsteady gait or nausea...

Remove fistula/graft-dressing evening of dialysis

treatment...Check fistula for bruit (listening to

fistula) or feel for a thrill (by touching fistula.)

This must be done daily...."


IN00256305 and IN00256400.

3.1-37(a)


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