PRINTED: 06/08/2018 DEPARTMENT OF HEALTH AND HUMAN ...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

06/08/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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DATECROSS-REFERENCED TO THE APPROPRIATE

BLUFFTON, IN 46714

155726 05/04/2018

RIVER TERRACE HEALTH CARE CENTER

400 CAYLOR BLVD

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey. This visit included a State

Residential Licensure Survey. This visit also

included the Investigation of Complaint

IN00258677.

Complaint IN00258677 - Unsubstantiated due to

lack of evidence.

Survey dates: April 30, May 1, 2, 3, and 4, 2018

Facility number: 003575

Provider number: 155726

AIM number: 200395060

Census bed type:

SNF/NF: 28

Total: 28

Census payor type:

Medicare: 2

Medicaid: 12

Other: 14

Total: 28

These deficiencies reflect State findings cited in

accordance with 410 IAC 16.2-3.1.

Quality review completed May 10, 2018.

F 0000 By submitting the enclosed

material we are not admitting the

truth or accuracy of any specific

findings or allegations. We

reserve the right to contest the

findings or allegations as part of

any proceedings and submit these

responses pursuant to our

regulatory obligations. The facility

request that the plan of correction

be considered effective June 3,

2018 to the annual licensure

survey completed on May 4th

2018. The facility also request

that our plan of correction be

considered for paper review

compliance. The facility will

submit any evidence as requested

to validate compliance.

483.25(c)(1)-(3)

Increase/Prevent Decrease in ROM/Mobility

§483.25(c) Mobility.

§483.25(c)(1) The facility must ensure that a

resident who enters the facility without limited

range of motion does not experience

reduction in range of motion unless the

F 0688

SS=E

Bldg. 00

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: V7WV11 Facility ID: 003575

TITLE

If continuation sheet of 41

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resident's clinical condition demonstrates

that a reduction in range of motion is

unavoidable; and

§483.25(c)(2) A resident with limited range of

motion receives appropriate treatment and

services to increase range of motion and/or to

prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility

receives appropriate services, equipment, and

assistance to maintain or improve mobility

with the maximum practicable independence

unless a reduction in mobility is

demonstrably unavoidable.

Based on interview and record review, the facility

failed to ensure restorative services were provided

as recommended for 4 of 4 residents reviewed for

restorative services. The deficient practice had

the potential to effect 21 of 28 residents who had

recommendations for restorative services.

(Resident 25, Resident 12, Resident 21, and

Resident 6)

Findings include:

1. The record review for Resident 25 began on

5-1-2018 at 2:00 p.m. Diagnoses included but were

not limited to, Parkinson's Disease, lack of

coordination, weakness, diabetes with

neuropathy, difficulty in walking, and restless leg

syndrome.

The quarterly MDS (Minimum Data Set)

assessment dated 4-14-2018, indicated Resident 25

had a

BIMS (Brief Interview of Mental Status) score of

15/15 (cognitively intact). The functional

assessment indicated the resident required an

extensive assist of 2 for bed mobility, an extensive

F 0688 F688

It is the practice of this facility

to assure that residents

identified with limited range of

motion receive services to

increase range of motion

and/or prevent further

decrease in range of motion.

The correction action taken for

those residents found to be

affected by the deficient practice

include:

Residents #6, #12, #21, and #25

have been reviewed and are now

receiving restorative services in

accordance with the plan of care.

Other residents that have the

potential to be affected have

been identified by:

All residents have been reviewed

to assure that if there were

recommendations from

therapy/nursing for restorative

services that they are receiving the

services as recommended.

06/03/2018 12:00:00AM

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assist of 1 for transfers, locomotion on unit,

dressing, toileting, and personal hygiene, a limited

assist of 1 for walking in room/corridor, and

locomotion off unit. The assessment indicated

the resident was not steady, but able to stabilize

without staff assistance from moving from seated

to standing position, walking, turning around and

facing opposite direction while walking, moving

on/off toilet, and surface to surface transfers.

Assistive devices marked were a walker and a

wheelchair. No impairment of the upper or lower

extremities was marked. Physical and

Occupational therapy was marked from 3-5-2018 to

4-13-2018 and the restorative nursing program was

not marked.

The current physician orders, dated 5-2018,

indicated Occupational Therapy was for

therapeutic exercise, self care, neuromuscular

re-education, therapeutic activities, manual

therapy, wheelchair management, safety

awareness 5x week for 8 weeks for treatment

diagnosis of weakness and lack of coordination.

A copy of the PT (Physical Therapy) Progress &

Discharge Summary for Resident 25 was dated

4-13-2018 and was provided by OTA

(Occupational Therapy Assistant) on 5-18-2018 at

2:19 p.m. The summary indicated the "...Discharge

Plans & Instructions...Discharge planned for this

patient...Recommendations discussed with patient

and/or caregivers include following restorative

program and riding theracycle on his own...."

A copy of the OT (Occupational Therapy)

Progress & Discharge Summary for Resident 25

was dated 4-13-2018 and was provided by OTA

(Occupational Therapy Assistant) on 5-18-2018 at

2:19 p.m. The summary indicated the "...Discharge

Plans & Instructions...Resident to remain in

The measures or systematic

changes that have been put into

place to ensure that the

deficient practice does not recur

include:

The Therapy Department and or

nursing will be providing

recommendations for restorative

services. The recommendations

will be given to the MDS

Coordinator who is responsible for

assuring that a plan is written and

restorative services are initiated.

A copy of the recommendations

provided to the MDS/Restorative

Coordinator will be reviewed in the

morning IDT meeting to assure

that the plan is being implemented

and restorative services initiated.

The MDS Coordinator has been

in-serviced related to the

importance of restorative services

in correlation with the plan of care

based on the therapist or nursing

recommendations being

implemented in a timely manner

and completed per the plan of

care. The nursing staff has been

in-serviced related to providing the

services in correlation with the

established plan.

The corrective action taken to

monitor performance to assure

compliance through quality

assurance is:

A Performance Improvement Tool

has been initiated that randomly

reviews 5 residents for restorative

recommendations and proper

provision of services per the plan





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Health care setting with set up with FMP

(Functional Maintenance Program) to maintain

strength demo improve motor planning with

functional mobility/improve I (independence) with

ADLS (Activities of Daily Living) tasks...."

A copy of the "Therapy

Communication/In-Service to Nursing" form for

Resident 25 was provided by PTA (Physical

Therapy Assistant) on 5-2-2018 at 9:34 a.m. The

goals written for Resident 25 indicated

"...Resident to maintain UB /LB (upper body/lower

body) dressing tasks requiring min A/mod A

(minimum assistant/moderate assistance. 2)

Resident to maintain strength...theracycle machine

for 20 minutes to maintain strength...." There was

no signature on the form by the Restorative Nurse

Signature line. OTA signature was dated

4-13-2018.

A care plan was initiated on 1-6-2018 for Resident

25 for Parkinson's which placed the resident at risk

for medical complications and declines and

difficulty completing ADLS. An intervention

included "...Restorative programs as indicated

(See Restorative Care plan) date initiated

1-9-2018...."

A care plan was initiated on 1-6-2018 for Resident

25 for ADLS with an intervention of

"...Restorative Programs to be initiated by therapy

as indicated...."

A care plan for Resident 25 was initiated on

1-19-2018 for "...risk for declines in his ability to

complete AROM due to Parkinson...." The goal

indicated Resident 25 "...will complete active

range of motion exercises as indicated in

individualized restorative nursing program to

increase dependence, strength through next

of care. The Director of Nursing, or

designee, will complete this tool

weekly x3, monthly x3, then

quarterly x3. Any issues identified

will be immediately corrected.

The Quality Assurance Committee

will review the tools at the

scheduled meetings with

recommendations as needed

based on the outcome of the

tools.

The date the systemic changes

will be completed:

June 3, 2018





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review...." Interventions included "...Provide 1

assist to complete AROM (active range of motion)

to BLE/BLUE (bilateral lower and upper

extremities) using Parkinson exercise bike through

next review...Record minutes of task competed in

POC (Point of Care-computer program)...."

The POC documentation for the past 14 days for

Resident 25 indicated the following, "...Task: 3.

NURSING REHAB: AROM using parkinsons

exercise bike. Assist resident with getting on bike

and with positioning. Observe biking exercise and

assist as needed--Amount of minutes spent

providing Range of Motion (active)...." The only

dates marked with number of minutes were 4-18,

23, 24, 26 and May 1, 2018. All other dates were

marked NA (Not Applicable), except for 4-19-2018

where refused was marked. The question "...How

many reps did this resident complete with this

exercise (with arm/floor bike place N/A) the

answers were all marked NA except on 4-19-2018

where the resident refused.

The POC documentation for the past 14 days for

Resident 25 indicated the following: "...Task:

NURSING REHAB: Dressing/grooming. Assist

resident to pick out clothes. Set resident up in

bathroom or bedside per his choice. Allow

resident to complete upper body

dressing/grooming. Assist with lower body

dressing. Assist as needed...." All dates for the

last 14 days marked twice a day.

An interview with Resident 25 on 4-30-2018 at 2:25

p.m., indicated he received no restorative services

today and the Restorative aide was pulled quite a

bit from her restorative duties to cover the CNA

duties.






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p.m., indicated he had not gotten on his exercise

bike today and none of the staff offered to assist

him. He indicated "...sometimes they do and

sometimes they don't offer...."

An interview with the PT Supervisor on 5-2-2018

at 9:26 a.m., indicated "FMP" stood for

"functional maintenance program" which meant

Resident 25 would be getting restorative nursing.

PT Supervisor indicated the therapist created the

restorative plan and gave the plan to the

restorative nurse. PT Supervisor indicated the

Restorative CNA (Certified Nurse Aide) had been

working as a CNA due to staffing issues.

An interview with CNA 1 on 5-2-2018 at 2:28 p.m.,

indicated she was trained by the other Restorative

Nurse Aide who was presently on leave, to

provide restorative services to the residents.

CNA 1 indicated she had a list of residents on her

paper that required restorative services. She

indicated when she finished providing the

restorative services with the resident she would

chart in the computer program.


p.m., indicated he had not been on the bike today

and he was just going to ask CNA 1 about getting

on the bike.

An interview with CNA 1 on 5-2-2018 at 3:35 p.m.,

indicated she was working this shift as a CNA due

to the staff shortage. CNA 1 indicated she did not

work 1st shift as a RNA (Restorative Nurse Aide).

An interview with the MDS Coordinator on

5-2-2018 at 3:45 p.m., indicated she was

responsible for the Restorative Nursing Program.

She indicated the RNP (Restorative Nursing

Program) was typically completed 6 days a week.





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The RNA (Restorative Nurse Aide) working on

the floor this shift (CNA 1) was working as a CNA

due to staffing needs. The MDS Coordinator

indicated the other RNA was on leave. The MDS

Coordinator indicated the facility was trying to do

the best they could to meet the needs of the

residents who have Restorative Nursing

programs.

The" POC Response History" for Resident 25 for

the last 30 days was provided by the DON on

5-2-2018 at 2:15 p.m. The documentation was

reviewed with the MDS Coordinator. She

indicated the RNA and the CNA both had access

to charting on this form. She indicated the CNAs

marked the Not Applicable and the minutes

recorded were marked from the RNA. The

Nursing Rehab AROM task for "... using

parkinsons exercise bike..assist resident with

getting on bike and with positioning...observe

biking exercise and assist as needed..." had

documentation of minutes as follows:

4-3-2018 15 minutes

4-8-2018 15 minutes

4-10-2018 15 minutes

4-11-2018 15 minutes

4-12-2018 20 minutes

4-16-2018 10 minutes

4-18-2018 10 minutes

4-23-2018 20 minutes

4-24-2018 20 minutes

4-26-2018 25 minutes

5-1-2018. 15 minutes

Since the therapy discharge on 4-13-2018,

Resident 25 had this restorative nursing program 6

times, where the the restorative nursing program

should have been provided at least 13.

2. The record review for Resident 12 began

5-3-2018 at 2:04 p.m. Diagnoses included





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osteoarthritis, contracture of muscle, right lower

leg and left lower leg, lack of coordination,

weakness, depression, and hypertension.

The quarterly MDS for Resident 12 was dated

2-21-2018 and indicated a BIMS score of 15/15.

The score indicated Resident 12 was cognitively

intact. The resident required an extensive assist

of 2 persons for bed mobility, an extensive assist

of 1 person for transfers, locomotion, dressing,

toileting, personal hygiene and bathing. Walking

in room/corridor did not occur. The resident

required the supervision of 1 person for

locomotion off unit. The resident was not steady

and only able to stabilize with staff assistance for

moving from seated to standing position, moving

on/off toilet, and surface to surface transfers. For

the tasks, walking and for turning around and

facing opposite direction while walking, did not

occur. There was no upper extremity impairment

marked and an impairment on one side of lower

extremity was marked. Resident 12 has a

wheelchair. Resident 21 had a wheelchair and OT

and PT services had end dates of 2-21-2018.

Restorative services were not marked.

A care plan for Resident 12 was in place for right

and left leg contractures and was last revised on

1-24-2017. The goal was for the contractures to

not increase and the interventions included

"...Restorative programs as indicated...."

A care plan for Resident 12 was in place for "...risk

for declines in the her <sic> ability to complete

AROM due to contracture..." which was last

revised on 1-24-2017. The goal was for resident

not to experience declines in decreased muscle

mass or contracture. Interventions included "...3

sets of 10 reps...apply warm compress to right

knee 15 min prior to Prom...nurse to review





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program routinely along with progress toward

meeting goals...Record minutes of task completed

in POC...rest breaks as needed...Therapy eval et

(and) tx (treatment) as needed...."

The PT Supervisor provided OT and PT discharge

instructions for Resident 12 on 5-3-2018 at 10:25

a.m. for therapy services that ended on 2-21-2018.

The PT discharge instructions indicated "patient

is being discharged with restorative nursing

program training with correct hand positioning...."

The OT discharge indicated "...res continues to

have decrease strength BUE. Continue assistance

with grooming tasks...."

A copy of the Therapy Communication/In-Service

to Nursing was provided on 5-3-2018 by the PT

Supervisor. The PT supervisor indicated the

restorative plan was not updated and the plans

were not usually updated. The PT supervisor

indicated they just go back to the same plan. The

treatment recommendations were for "...1.

therapeutic exercises with a number 3 dowel rod

as directed with HEP (home exercise program)...2.

w/c (wheelchair) mobility > (greater than) 100 ft

(feet) with SPV (supervision)...3. 5x (times) pull up

'butt-lift' at grab-bar...." The note indicated

resident had BLE (bilateral lower extremity)

contractures, HOH (hard of hearing) and

decreased posture due to kyphosis (curvature of

the spine). The form was signed by the

restorative level 1 aide in 3-28-2018 and by OTA

on 3-25-2018.

A review of the POC response history for the last

30 days for Resident 12 indicated "...task

2...Nursing Rehab-AROM BUE 3 sets of 10

reps...PROM RLE 10 reps...apply warm compress

to right knee 15 min prior to PROM...." A review

of the last 30 days (from 4-5-2018 through





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5-3-2018) of documentation indicated the

restorative aide provided 15 minutes of restorative

services on 4-11, 17, 18, 19, 23, and 4-26. For

Resident 12 to receive restorative nursing services

for this task at 6 times a week, 24 dates should

have been marked as receiving the services.


a.m., indicated she did not get exercises for her

knees or a warm compress applied to her knees.

The resident indicated that "...costs too much, so

I don't get it.... "

An interview with the PT supervisor on 5-3-2018

at 10:30 a.m., indicated she could only find a

"Therapy Communication/In-Service to Nursing"

form from the OT dated 3-25-2016. The treatment

recommendations written at that time did not

match what the resident was receiving from the

current restorative documentation.

3. The record review for Resident 21 began on

5-3-2018 at 3:04 p.m. Diagnoses included but not

limited to, Alzheimer's disease, difficulty in

walking, lack of coordination, weakness,

depression, anxiety and hypertension.

The quarterly MDS, dated 3-18-2018, indicated

Resident 21 has a BIMS score of 5/15 which

indicated

severe cognitive impairment. There was no

restorative nursing or therapy marked. Resident

21 required a limited assist of 1 for bed mobility

and locomotion on unit; an extensive assist of 1

for transfers, and toileting; and walk in

room/corridor activity did not occur. The resident

was not steady but able to stabilize with staff

assistance for moving from seated to standing

position, moving on/off toilet, and surface to

surface transfer. For the tasks, walking and for





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turning around and facing opposite direction

while walking, both did not occur. The impairment

on upper and lower extremities was marked "no."

The box for wheelchair was marked "yes" and the

box for walker was marked "no." The restorative

service was not marked.

A Therapy Communication/In-Service to Nursing

was provided by the PT Supervisor on 5-4-2018 at

9:34 a.m. for Resident 21. The current functional

status of the resident was supervision with

transfers and gait. The goals were to maintain

functional ambulation and LE (lower extremity)

strength and functional transfers. The treatment

recommendations indicated "...AROM in sitting, 2

x 20 with 2 # (pound) or leg bike, gait activity with

RW (rolling walker) 100 - 200...." The form was

signed by a Restorative level 1 aide on 2-5-2016

and by a PTA without a date marked. Therapy

services ended 2-2-2016.

A care plan for Restorative AROM was last

revised on 12-22-2017 with a goal of continued

participation in ADL functioning. The

interventions were for "...AROM BUE/BLE

(Active range of motion bilateral upper extremities

and bilateral lower extremities) 2 sets of 20 reps

using 2# (pound) weights in a sitting position.

Monitor for pain. Rest breaks as needed. Report

changes to charge nurse. Offer encouragement

and praise efforts...."

A review of the last 30 days of documentation for

the Restorative task AROM BUE/BLE for

Resident 21, beginning 4-5-2018 in the POC

response history, indicated 15 minutes of

restorative were provided on 4-11, 17, 18, 19, 20, 23

and 26, 2018 through 5-2-2018. For the restorative

services at 6 times a week, Resident 21 should

have received at the restorative services 24 times.





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Documentation indicated she had received the

services 7 times

A care plan for Resident 21 for the restorative

walking due to potential for decline in walking

skills was last revised on 12-22-2017. The goal

was "...Resident will walk minimum of 200 feet thru

next review...." The interventions were to

"...assist resident with gait belt and rolling walker.

Assist to standing position. Proper footwear.

Assist to walk 200 feet. Follow with wheelchair.

Rest breaks as needed. Report changes to charge

nurse...offer encouragement and praise efforts...."

A review of the last 30 days of documentation

beginning 4-5-2018 in the POC response history

indicated for the task "...walking. Assist resident

with gait belt and contact guard assist. Assist to

standing position. Ensure proper footwear.

Follow with wheel chair. Rest breaks prn (as

needed). Report changes to hall nurse. Goal is

100 - 200 feet. There was no documentation for

this program from 4-5-2018 through 5-3-2018 of

completion of this task. The "Not Applicable"

box was checked each day.

An observation of Resident 21 on 5-4-2018 at

11:22 a.m., indicated the resident was in her

wheelchair dressed in dark slacks, a white shirt

and had shoes on her feet. She was sitting in the

area outside the nurse station and was observed

to self propel her wheelchair.

An interview with CNA 2 on 5-3-2018 at 11:19

a.m., indicated she did assist the resident to get

dressed today, but did not chart in the Restorative

Nursing Program for ADL's. CNA 2 indicated the

restorative aide did that service. CNA 2 and CNA

5 both indicated the restorative nurse was the

only one who could chart in the restorative





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program.

An interview with QMA (Qualified Medication

Aide) 6 on 5-4-2018 at 9:02 a.m., indicated she had

not been trained as a restorative aide. QMA 6

indicated she can read instructions for the

restorative and provide the restorative care.

An interview with the DON (Director of Nursing)

on 5-4-2018 at 11:08 a.m., indicated CNA 4 was the

only staff trained in the Restorative Nursing

Program duties who was working this shift. The

DON provided copies of the training which was

dated 4-17. The DON indicated CNA 5, who was

working today, had not finished her Restorative

Nursing Program training.

An interview with CNA 5 on 5-4-2018 at 11:20 a.m.,

indicated she had not been trained to perform

restorative services. She indicated the facility had

yearly inservices but was not specifically trained

to perform restorative nursing services. She

indicated she will assist the residents in whatever

she can such as stretch a resident's arms and legs

when getting them up. CNA 5 indicated she

would do this if she had the time.

An interview with CNA 4 on 5-4-2018 at 11:21 a.m.,

indicated she had been trained to do restorative

services and will provide those to the residents

she was assigned. CNA 5 indicated she could not

do all of the restorative services for all the

residents as there was not a third CNA working.

CNA 4 indicated there was not enough time to do

restorative with only 2 CNAs working.

An interview with the DON on 5-4-2018 at 11:41

a.m., indicated there was not a specific policy for

who could provide the Restorative Nursing

Services. The DON indicated each CNA was





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provided

training during orientation. The DON provided

the current "Certified Nursing Assistant

orientation

checklist" and it indicated "...13. Restorative

Nursing...a) Pressure reducing devices b)

reporting skin c) Turning/positioning d)

PROM/ARON/AAROM <sic>...."

A current policy for "Range of Motion (ROM)

Splints, Braces, Orthotics" dated 8/2009, was

provided by the DON on 5-2-2018 at 3:45 p.m. The

policy indicated "...Residents identified as a risk

for contractures will have a ROM program a

minimum of 6 days/week unless that frequency is

contraindicated. The ROM includes the programs

provided to prevent contractures and keep joints

as limber as possible...This policy does not

include therapy delegated programs individually

designed for muscle strengthening, stretching and

other reasons...." The purpose was "...to maintain

a resident's ability to move a joint through its

normal range of movement and perform activities

of daily living (ADL)...To prevent pain,

discomfort, swelling and stiffness when joint

movement is limited or contracted...To prevent

contractures and to provide comfort and support

for a joint and prevent pain in an already

deformed/contracted, weak joint...." The

procedure described how to perform the range of

motion for all the joints.

4. On 5/2/18, the clinical record of Resident 6 was

reviewed. Diagnoses included, but was not

limited to, the following: difficulty in walking,

unspecified lack of coordination, weakness,

unspecified dementia with behavioral

disturbances, other cerebrovascular disease,

tremor and repeated falls.





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A quarterly MDS (minimum data set) assessment,

dated 4/25/18, included the following: severely

impaired cognition; transfer: extensive assistance

(resident involved in activity, staff provide weight

bearing support); walk in room and locomotion on

unit required limited assistance (resident highly

involved in activity; staff provided guided

maneuvering of limbs or other non-weight bearing

assistance); individual minutes of Physical

Therapy: 0176; physical therapy start date 4/13/18

and end date is blank; this therapy was

administered for 5 days in the last 7 days for at

least 15 minutes.

A "PT (Physical Therapy) - Therapist Progress

and Discharge Summary" dated 12/1/17 was

received from the PT Supervisor on 5/2/18 at 11:48

a.m. The form indicated the "start of care" was

11/1/17 and "end of care" was 12/1/17. The

"Discharge Plan and Instructions" indicated "DC

(discharge) with restorative nursing program."

The form had been electronically signed by the

therapist and had been dated 12/12/17.

A plan of care, revised on 2/2/18, addressed the

focus of "is at risk for ADL deficits in non late

loss ADL's due to...tremors,

diagnosis...Interventions...resident requires

limited assist of one for locomotion...

(2/10/17)...resident requires limited assist of one

for walking. Uses a walker (7/7/17)..."

The "Resident Council Minutes" dated 3/27/18,

were reviewed on 5/1/18 at 9:00 a.m. A

"Concern/Comment" was documented as "...will

be nice to have (CNA (Certified Nursing

Assistant) 1 name) back on restorative..." The

minutes replied to the comment "It would be nice

to have a restorative aide" with "As we fill our

CNA shortages, the restorative aide will have





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more time to focus on the restorative program."

The "Therapy Communication/In-Service to

Nursing...Physical Therapy...form, dated 5/19/17,

was provided by the DON (Director of Nursing)

on 5/2/18 at 2:00 p.m. The form included the

following: "...Level 1 Restorative Nursing

Program, Level 2 Restorative Nursing

Program...Current Functional Status:

Mod(moderate)/Min (minimum) A (assist) Bed

mobility, 100 ft. (feet) with RW (rolling walker)

mod (modified) (I) (independence) supervision

with transfers...Goals: continue LE (lower

extremity) strengthening, balance and gait without

risk for falls...Treatment Recommendations:

AROM (active range of motion) in sitting 2 x 20 (2

sets of 20 repetitions), all planes of motion, gait

with RW 100-200 feet to and from dining

room...Precautions/Problems/Approaches: poor

safety awareness, poor ability to follow

directions...In-Service/Training Level

1...Restorative nurse signature,

(unsigned)...Restorative Level 1 aide signature,

(unsigned)...Restorative level 1 aide's signature,

(unsigned)...Inservice/Training Level

2...Restorative nurse signature

(unsigned)...Restorative Level 2 aide signature

(unsigned)...Restorative level 2 aide signature

(unsigned)...Therapist Signature (signed by

Physical Therapy Assistant), date 5/19/17...Date

therapy decreased...(blank)...Date Therapy D/C'd

(discontinued)...(blank)..."

On 5/2/18 at 2:00 p.m., the MDS coordinator

provided a copy of the facility "Task" sheets from

the computer system the CNAs document

resident tasks on, dated December 2017, January

2018, February 2018, March 2018 and April 2018.

These form indicated the following: "Nursing

Rehab (Rehabilitation): AROM (active range of





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motion) all planes, 2 sets 15 reps provide rest

breaks as needed. Offer cueing and

encouragement..." The "Time" indicated

"Q(every) shift." Documentation was lacking of a

record of minutes of tasks completed.

Documentation further indicated the AROM was

completed once a day. Documentation was

lacking on the "Task" form of restorative

ambulation having been completed. The "Task"

sheet documented the resident had "walk in room,

walk in corridor...locomotion on unit, locomotion

off unit...every shift..." Documentation of these

tasks was indicated on the task sheet by initials of

a CNA and a time. Documentation was lacking as

to a distance completed and the amount of time

the task took to complete.

On 5/2/18 at 2:28 p.m., the DON provided a copy

of the "POC (point of care) Response History,

dated 4/3/18 to 5/3/18. The form indicated the

"task...Nursing Rehab: AROM all planes 2 sets 15

reps provide rest breaks as needed..." The form

"Task" indicated the date and time, and provided

the following documentation options: amount

(amount of minutes spent providing range of

motion (active), resident not available, resident

refused and "not applicable." The days of 4/3/18

to 4/12/18, indicated one day, on 4/4/18, the

resident completed 15 minutes of AROM. All of

the other days from 4/3/18 to 4/12/18,

documentation indicated "Not Applicable." The

DON indicated when the option of "Not

Applicable" was documented, this meant he

CNAs did not complete the restorative task on

those days. Documentation was lacking of

ambulation having been included in the nursing

rehab task from 4/3/18 to 4/12/18.

On 5/2/18 at 3:30 p.m., the MDS coordinator was

interviewed. At this time, she provided





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documentation of the "Restorative Nursing",

dated 12/1/17 to 4/12/18. Documentation from

12/1/17 to 4/12/18 was lacking on the forms of

restorative ambulation as even being an option to

have been attempted and/or completed.

Documentation for each day in December 2017,

indicated the daily documentation the following: a

time, initials and the numbers "8, 8." The MDS

coordinator indicate the initials were those of the

CNAs. The MDS coordinator provided a key

which indicate the number "8" could represent

"Resident not available," "Resident Refused"

and/or "Not applicable." The MDS coordinator

was unable to determine what each "8"

represented. She indicated if a resident was not

available and/or refused restorative services, the

staff was to reapproach the resident at a later time

and offer the services again. For December 2017,

it was documented 4 times, the resident was

reapproached regarding restorative services. For

February 1, 2018 to February 28, 2018, 26 of the 28

days had documented the numbers "8, 8" and

documentation was lacking on those days of

restorative services having been offered again.

For March 1, 2018 to March 31, 2018, 30 of the 31

days were documented the numbers "8, 8" and

documentation was lacking on those days of

restorative services having been offered again.

For April 1, 2018 to April 12, 2018, 12 of 12 days

were documented the numbers "8,8." One of those

12 days had documentation the restorative service

had been offered at a later time.

The "Restorative Plan Program" was provided by

the MDS Coordinator on 5/2/18 at 2:58 p.m. She

indicated this program had been implemented

May 2017 and would have "rolled over" when the

resident completed her therapy in December 2017.

The instructions indicated the following: "...will

complete AROM 2 sets of 15 reps (repetitions) to





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all planes daily 6 days a week...notify nurse of any

change..Amount of minutes spent providing

range of motion (active) not applicable..."

Documentation was lacking on the plan program

regarding the "Gait with RW (rolling walker)" as

was recommended on 5/19/17, on the "Therapy

Communication."

The MDS coordinator was interviewed on 5/2/18

at 3:00 p.m., She indicated most restorative

programs were to be completed 6 days a week.

She indicated she put the notation in the

"Restorative Plan Program" of 15 reps, "in case

they didn't think" the resident "would do 20

reps..."

The MDS coordinator was interviewed at 3:05 p.m.

and indicated the resident had recently fallen and

was placed back on Physical Therapy caseload on

4/13/18.

A Physical Therapy Plan of Care, dated 4/13/18,

was received from the Physical Therapy

Supervisor on 5/3/18 at 8:22 a.m. The form

included the following: "...start of care

4/13/18...Reason for referral: patient referral to

physical therapy due to recent decline in

functional mobility and strength...is on 2 liters

oxygen...experiences extreme shortness of breath

affecting activity tolerance...was assessed for

bilateral lower extremity strength, balance,

gait...and level of assistance needed for transfers

and gait...Therapy Necessity...skilled PT

necessary to assess for BLE (bilateral lower

extremity) strength, gait...current level of

function...identify weakness and

deficits...implementation (sic) of POC (plan of

care) for BLE strength, gait...reduced risk of falls

and safety...previous therapy...was given therapy

for BLE strength, gait and transfer...





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On 5/1/18 at at 9:00 a.m., the 2018 resident council

meeting minutes were reviewed. The March 27,

2018 meeting minutes indicated the following:

"...Concerns...will be nice to have ( CNA 1 name)

back on restorative..." The response from facility

of concern was "We are in the process of trying

to hire additional CNAs to fill our staffing needs.

We are working with a company called (name of

company) that trains and places CNA's in a HC

(healthcare) setting...as we fill our CNA shortages

the restorative aide will have more time to focus

on the restorative program..." The April 24, 2018

minutes were also reviewed with the following

observed: "...do (sic) to lack of staff there are

things not getting done or not getting done

right..." The facility response to "Do (sic) of staff

there are things not getting done or not getting

done right...We are trying to improve staffing, as

new staff is hired we will make sure training is

properly completed..."

On 5/3/18 at 9:35 a.m. the Physical Therapy (PT)

Supervisor was interviewed. She indicated the

resident has finished PT on 12/1/17. The PT

supervisor indicated after PT was completed, the

restorative program had been recommended to

begin. She indicated if a prior restorative plan was

in place before PT had been started, the resident

was to continue with the prior restorative

program. The PT supervisor indicated the

program that would have rolled over was the

5/19/17 "Therapy Comm/inservice to nursing."

The PT Supervisor indicated the

treatment/recommendations documented on

5/19/17, did not include a "frequency" for the

AROM and the gait with the rolling walker

because the restorative CNA 1, had been trained

on the program and was aware of the "frequency"

of the program. She indicated she thought CNA 1





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was the "Restorative CNA" but CNA 1 had been

working as a CNA and not as a Restorative CNA.

The PT Supervisor indicated the resident's

cognition did vary. She indicated Resident 6

would need to be reminded to ambulate to and

from the dining room, but the resident was able to

ambulate independently in her room with her

walker. The PT Supervisor indicated the resident

started back with physical therapy on 4/13/18.

She indicated "about every 3 months," the

residents in the restorative program were reviewed

to see if anyone had experienced a decline. She

indicated physical therapy had observed this

resident as this resident was cognitively unable to

tell if she had declined. The Physical Therapy

Supervisor indicated in the facility "Morning

meetings", the status of residents were reviewed

and anyone with a potential decline would be

screened.

On 5/3/18 at 9:55 a.m. the DON (Director of

Nursing) was interviewed. She indicated the

resident's ADL status had been reviewed in April

2018 and the resident had been started back on PT

on 4/13/18. She indicated this was a result of the

Quality Measure meeting where ADL

performances were reviewed for the residents.

The DON indicated staff were expected to go back

and offer restorative services again if the resident

initial

ly refused or was unavailable for restorative

services when initially offered. The DON

indicated she was unable to differentiate

what the "8" meant on the "POC Response

History" Task form. She indicated it was

important to know what specifically the "8"

represented as services would be reoffered

if the resident had been unavailable and/or





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refused. The DON indicated for

"supervision oversight" the resident has to be

in the staff's sight, not necessarily right

beside the resident. The DON indicated

CNA 1 had been providing restorative

services for close to a year. The DON

indicated due to staffing issues, CNA 1 had

been working second shift as a CNA and

not day shift, performing her restorative

duties. She indicated when CNA 1 worked

second shift, the day shift CNAs were to

provide restorative programs, as indicated,

for the residents they were caring for. The

DON indicated optimally, the restorative

CNA was to just perform restorative tasks.

On 5/3/18 at 11:12 a.m., CNA 2 was

interviewed. She indicated she worked 6:00

a.m. to 2:00 p.m. She indicated she was

caring for 9-10 residents today. She

indicated she was not providing restorative

services for her residents as she had never

been trained on how to perform restorative

services. She indicated the second shift

CNA, CNA 1, performed restorative

services but CNA 1 had been pulled to

work as a "regular CNA." On 5/3/18 at

1:24 p.m., the DON was interviewed. She

indicated today the day shift CNAs were to

provide restorative services for the residents

they were caring for as CNA 1 was now

working second shift as a CNA. On 5/3/18

at 1:00 p.m., the DON provided a copy of





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the current facility policy and procedure for

"Policy and Procedure, Ambulation" dated

8/2009. The policy and procedure included

the following: "...Policy: Residents will be

screened by therapy and evaluated by

nurses during...and ongoing...program will

be started based on the resident's

individualized ambulation capabilities and

needs. Residents determined to need

therapy intervention initially will be

reevaluated for appropriate program

towards the end of therapy. Purpose: To

identify residents who could benefit by an

ambulation program. To enhance a

resident's ability to maintain strength and

endurance...Procedures...Follow the

individualized walking plan for each

resident...document according to facility

policy...Individualized walking programs are

based on resident's capabilities. As

endurance increases, there should be

corresponding increase in frequency...when

ambulation is affected by the aging and

disease processes, walking programs may

be reduced to match the resident's status

and tolerance..."3.1-42(a)(1)3.1-42(a)(2)

483.60(i)(1)(2)

Food

Procurement,Store/Prepare/Serve-Sanitary

§483.60(i) Food safety requirements.

The facility must -

§483.60(i)(1) - Procure food from sources

approved or considered satisfactory by

F 0812

SS=E

Bldg. 00





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federal, state or local authorities.

(i) This may include food items obtained

directly from local producers, subject to

applicable State and local laws or

regulations.

(ii) This provision does not prohibit or prevent

facilities from using produce grown in facility

gardens, subject to compliance with

applicable safe growing and food-handling

practices.

(iii) This provision does not preclude residents

from consuming foods not procured by the

facility.

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

serve food in accordance with professional

standards for food service safety.

Based on observation, interview, and record

review, the facility failed to ensure sanitary

practices were followed for food preparation and

food service. This deficiency had the potential to

affect 28 of 28 residents who ate their meals from

the facility kitchen.

Findings include:

1. During an observation of the walk in kitchen

refrigerator with the Dietary Manager on 4-30-2018

at 7:50 a.m., a box of eggs were observed on the

bottom shelf without the "P" printed on the eggs.

An interview with the Dietary Manager at this

time indicated, the eggs were used for fried eggs

and over easy eggs as the residents order. The

Dietary Manager indicated the eggs were

pasteurized. An observation at this time indicated

the Dietary Manager picked up several eggs,

looked at the labeling on the box and was unable

to find the "P" printed on the eggs and unable to

find "pasteurized" printed on the box. The box

label indicated 30 dozen eggs (360) inside the box

F 0812 F812


to assure that sanitary practices

are in place related to food

storage and preparation.




include:

No specific residents were

identified. The areas identified in

the 2567 have been corrected as

follows:

The residents are only receiving

pasteurized eggs

The blender as well as other

kitchen devices are being

sanitized between uses.

Dietary staff are washing hands

appropriately between dirty/clean,

or if changing task for the

appropriate amount of time in

accordance with appropriate

06/03/2018 12:00:00AM





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and there were 155 eggs left in the box. A date of

"4/20" was written on the box and the Dietary

Manager indicated the "4/20" date was the date

the eggs were delivered.

An interview with the Dietary Manager on

4-30-2018 at 7:55 a.m., indicated the residents in

healthcare ordered the eggs as fried or however

they would like them.

An interview and observation on 4-30-2018 at 8:21

a.m., indicated a resident at breakfast in the

healthcare dining room had ordered and eaten an

over easy egg. The yellow yolk color was

observed on the resident's plate.

On 4-30-2018 at 2:42 p.m., the Dietary Manager

provided the most recent egg orders. The orders

indicated on 3-11-2018, 3-25-2018 and 4-15-2018

the brand choice medium Grade A shell eggs,

loose, refrigerated, 30 Ct tray, 12/case item number

209003. The information provided did not indicate

"pasteurized" anywhere in the description. An

interview at this time with the Dietary Manager

indicated she ordered the wrong eggs.

An interview with the Dietitian on 5-2-2018 at

10:45 a.m., indicated she did not know the facility

did not use pasteurized eggs. She indicated the

current Dietary Manager took over the job of

ordering and thought she was ordering

pasteurized eggs. .

An interview with Dietary Staff 13 on 5-2-2018 at

11:40 a.m., indicated he hadn't seen the "P" on the

eggs before. Another Dietary Staff 12, who was

present, indicated the "P" meant the eggs were

pasteurized.

2. During an observation of the puree preparation

infection control.

Dietary staff are handling glasses,

dinnerware, and plates

appropriately in accordance with

infection control guidelines.



been identified by:

All residents could potentially be

affected. Please refer below to

systematic changes to prevent

reoccurrence





include:

All dietary staff has been

in-serviced related to using only

pasteurized eggs, sanitization of

blender and other cooking/prep

devices between uses, proper

handwashing, and handling of

dishes/serving residents in a

manner that is within acceptable

parameters of infection control.

The Dietary Manager is

responsible for assuring that the

above areas are monitored and in

compliance.




assurance is:


has been initiated that will be

reviewed by the

Administrator/designee 5 x a week

for random dietary preparation and

food services to ensure the above





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with Dietary Staff 12 on 5-2-2018 at 10:00 a.m., the

Dietary Staff was observed to puree the turkey in

a blender container. Once she was finished and

scraped out the contents of the turkey, Dietary

Staff 12 was observed to rinse the blender

container with water at a prep sink. Dietary Staff

12 was then observed to prepare the pureed

broccoli. The blender container was not observed

to be sanitized after use with the turkey and prior

to pureeing the broccoli.

An interview with the Kitchen Manager on

5-3-2018 at 2:36 p.m., indicated the following: The

blender container should have been washed and

sanitized after each use of the container.

3. An observation in the Healthcare Kitchen on

5-2-2018 at 12:20 p.m., indicated the Kitchen

Manager was observed to wash her hands while

soaping them under running water for less than 10

seconds. The Kitchen Manager was then

observed to resume plating residents' food.

An observation on 5-2-2018 at 12:23 p.m.,

indicated the Kitchen Manager was observed to

push her glasses up with her right arm and then

continued plating residents' food without washing

her hands.



Kitchen Manager indicated hands should be

washed 40 - 60 seconds and when staff would

change tasks. The Kitchen Manager indicated the

dietary staff did not make it a practice to use the

hand sanitizer.4. An observation of dining

services in the healthcare dining room on 5/2/18

from 12:30 p.m. to 12:45 p.m., indicated the

following:

At 12:35 p.m., Dietary Staff 7 was observed to

mentioned areas are corrected.

This review will cover all 3 meals

and will continue weekly for four

weeks. The Dietary

Manager/designee will complete

this tool weekly x 4 weeks, then

monthly x 4 months. The

Administrator/designee will

present the findings of the

Performance Improvement Tool

during the monthly Quality

Assurance Committee meeting for

6 months. Once substantial

compliance has been met after 6

months, the Committee will

determine the frequency, if any, of

additional reviews.


will be completed:

June 3, 2018





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BLUFFTON, IN 46714

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come out of the kitchenette caring several pieces

of dinnerware of food. Dietary Staff 7 carried 2

small plates, on was in the palm of her right hand

and the other balanced on her right inner right

wrist. A beverage in a plastic drinking glass with

a lid and plastic straw in the lid was carried

between the Dietary Staff 7's bare forearm and

against her uniform top. She also carried a small

bowl in the palm of her left hand. Dietary Staff 7

delivered the bowl of food to 1 resident, the two

plates of food to 2 other residents, and the

beverage in the plastic drinking glass to the fourth

resident.

At 12: 45 p.m., Dietary Staff 7 was interviewed and

indicated, drinking glasses should be handled

from the outside of the glass and also indicated

dinnerware and drinking glasses should not be

carried against her uniform nor between her arm

and uniform. She further indicated she was not

aware she had carried the plastic drinking glass

between her forearm and uniform and indicated

she must have been trying to carry to much at one

time.


5-3-2018 at 2:36 p.m., indicated the following:

For handling dishware and glasses, the Kitchen

Manager indicated for staff to carry cups or

glasses at the bottom and not by the rim or carry

the cups or glasses in the crook of their arm.

A current, undated policy "Purchasing" was

provided by the Dietary Manager on 5-3-2018 at

4:02 p.m. The policy indicated "...Food and

supplies are purchased in a standardized manner

to ensure quality and to control costs...Whole,

unbroken eggs are for limited use only and

pasteurized eggs are for general use...."





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A current, undated policy, "Hand Washing -

Healthcare, Assisted Living, Memory Support"

was provided by the Dietary Manager on 5-3-2018

at 3:33 p.m. The policy indicated "...Hand

Washing will take place before starting food

service and before starting any new task...1.

Hands must be washed before starting your

shift...2. Any time you enter the kitchen to start

working with food, hands must be washed...3.

Before service of meals and passing plates, hands

should be washed...4. Anytime you stop doing a

task and start doing another task that requires

clean hands you must rewash your hands...."

A current, undated policy "Handling of

Kitchen/Dining Room Utensils" was provided by

the Dietary Manager on 5-3-2018 at 3:33 p.m. The

policy indicated "...do not let your fingers touch

parts of the dished that people will drink or eat out

of...hold cups by the outer surface, not by the

rim...."

3.1-21(2)

3.1-21(3)

F 9999

Bldg. 00

410 IAC 16.2-5-1.4(h)(1-10) Personnel -

Nonconformance

(h) The facility shall maintain current and accurate

personnel records for all employees. The

personnel records for all employees shall include

the following:

(1) The name and address of the employee.

(2) Social Security number.

(3) Date of beginning employment.

(4) Past employment, experience, and education, if

F 9999 F9999


to assure that employees

receive orientation and job

descriptions.




include:

CNA #8 and Housekeeper #9 have

06/03/2018 12:00:00AM





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applicable.

(5) Professional licensure or registration number

or dining assistant certificate or letter of

completion, if applicable.

(6) Position in the facility and job description.

(7) Documentation of orientation to the facility,

including residents' rights, and to the specific job

skills.

(8) Signed acknowledgement of orientation to

residents' rights.

(9) Performance evaluations in accordance with

facility policy.

(10) Date and reason for separation.

This RULE: is not met as evidenced by:

Based on interview and record review the facility

failed to ensure employee records were completed

for 4 of 7 employee records reviewed. This

included 2 of 7 employee records reviewed for

orientation to the facility and 2 of 7 employee

records reviewed for their job description. This

practice had the potential to affect 28 of 28 of the

resident who resided in the facility's Health Care

Units. [CNA (Certified Nursing Aide) 8,

Housekeeping 9, DON (Director of Nursing) and

ADON (Assistant Director of Nursing)]

Findings include:

On 5/4/18 at 11:00 a.m., the employee records were

reviewed. The employee's orientation to the

facility were lacking for the employee files for

CNA 8 with a start date of 1/4/18 and

Housekeeping Staff 9 with a start date of 1/31/18.

The employee files for the DON and ADON were

lacking the signed Specific Job Descriptions for

the DON position and the ADON position. The

DON's start date was 3/13/2009, but started

working as the DON the first of March 2018 and

the ADON's start date was 7/24/2007, but started

facility orientation in their files.

The DON and ADON have Specific

Job Descriptions in their files.



been identified by:

All current employee files have

been reviewed to assure that there

are facility orientations and

specific job descriptions in their

files.





include:

All department heads have been

in-serviced related to assuring that

when they hire new employees

that facility orientation be

completed as part of the

orientation process. The

in-service also included that if

there was a change of position,

that the specific job description be

completed as part of any position

change. As a second review, the

HR Director will review all new

hires as well as employees that

have changed positions to assure

that facility orientations and

specific job descriptions are

present prior to filing their

employment record




assurance is:


has been initiated that randomly





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working as the ADON about 2 weeks ago.

An interview with the HR (Human Resource)

Director on 5/4/18 at 2:15 p.m., indicated the CNA

8's and Housekeeping Staff 9's facility orientations

were not done. The HR Director also indicated

the DON's and ADON's new job descriptions

were not done.

reviews 5 current employee

records to assure that they all

include facility orientations and

specific job description. The HR

Director, or designee, will

complete these tools weekly x3,

monthly x3, then quarterly x3.

Any issues identified will be

immediately corrected. The

Quality Assurance Committee will

review the tools at the scheduled

meetings with recommendations

for new interventions as needed

based on the outcomes of the

tools.


will be completed:

June 3, 2018

R 0000

Bldg. 00

This visit was for a State Residential Licensure

Survey.

Residential Census: 49

This State findings is cited in accordance with 410

IAC 16.2-5.

Quality review completed May 10, 2018.

R 0000 By submitting the enclosed

material we are not admitting the

truth or accuracy of any specific

findings or allegations. We

reserve the right to contest the

findings or allegations as part of

any proceedings and submit these

responses pursuant to our

regulatory obligations. The facility

request that the plan of correction

be considered effective June 3,

2018 to the annual licensure

survey completed on May 4th

2018. The facility also request

that our plan of correction be

considered for paper review

compliance. The facility will

submit any evidence as requested

State Form Event ID: V7WV11 Facility ID: 003575 If continuation sheet of 41




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to validate compliance.

410 IAC 16.2-5-1.4(h)(1-10)

Personnel - Nonconformance

(h) The facility shall maintain current and

accurate personnel records for all employees.

The personnel records for all employees shall

include the following:

(1) The name and address of the employee.

(2) Social Security number.

(3) Date of beginning employment.

(4) Past employment, experience, and

education, if applicable.

(5) Professional licensure or registration

number or dining assistant certificate or letter

of completion, if applicable.

(6) Position in the facility and job description.

(7) Documentation of orientation to the

facility, including residents' rights, and to the

specific job skills.

(8) Signed acknowledgement of orientation to

residents' rights.

(9) Performance evaluations in accordance

with facility policy.

(10) Date and reason for separation.

R 0123

Bldg. 00

Based on interview and record review the facility

failed to ensure employee records were completed

for 2 of 7 employee records reviewed for the

position's job description. This practice had the

potential to affect 49 of 49 of the resident who

resided in the facility's Assisted Living Unit.

[DON (Director of Nursing) and ADON (Assistant

Director of Nursing)]

Findings include:

On 5/4/18 at 11:00 a.m., the employee records were

reviewed. The employee files for the DON and

ADON were lacking the signed Specific Job

R 0123 R123


to assure that employees

receive job specific

orientations.




include:

The DON and ADON have

specific job descriptions in

their files for their positions



06/03/2018 12:00:00AM





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Descriptions for the DON position and the ADON

position. The DON's start date was 3/13/09, but

started working as the DON the first of March

2018 and the ADON's start date was 7/24/07, but

started working as the ADON about 2 weeks ago.

An interview with the HR (Human Resource)

Director on 5/4/18 at 2:15 p.m., indicated the

DON's and ADON's new job descriptions were

not done.

been identified by:

All current employee files have

been reviewed to assure that

there are job specific

orientations in place.





include:

The HR Director will review all

personnel files to assure that

specific job descriptions are

present for new hires as well

as employees that are

changing positions prior to

filing their employment

record. An in-service has been

completed for HR indicating

this process




assurance is:

A Performance Improvement

Tool has been initiated that

randomly reviews 5 current

employee records to assure

that they all include specific

job descriptions for their

positions. The HR Director, or

designee, will complete these

tools weekly x3, monthly x3,

then quarterly x3. Any issues

identified will be immediately

corrected. The Quality

Assurance Committee will

review the tools at the






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recommendations for new

interventions as needed based

on the outcomes of the tools.


will be completed:

June 3, 2018

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, interview, and record

review, the facility failed to ensure sanitary

practices were followed for food preparation and

food service. This deficiency had the potential to

affect 49 of 49 residents who ate their meals from

the facility kitchen.

Findings include:

1. Observation of dining services in The Orchard

(the Assisted Living Dining Room) on 4/30/18

from 11:45 a.m. to 12:40 p.m., indicated the

following:

At 11:45 a.m., several residents were seated or

arriving in the dining room for lunch meal and

beverage services had begun.

At 11:50 a.m., CNA (Certified Nursing Aide) 20

was observed with her hands in her uniform

pockets. She then retrieved 2 small plates and

used a server utensil to plate a brownie on each

plate and delivered the brownies to 2 residents.

CNA 20 was not observed to perform hand

hygiene prior to plating the brownie. CNA 20

then removed a bottle of hand sanitizer from her

uniform pocket and squirt a small amount on her

hand and rubbed her hand for 2 swipes and

R 0273 R273


to operate in compliance with

food/nutritional services.




include:

No specific residents were

identified. The areas identified

have been addressed.

Handwashing is occurring

properly by CNAs during food

service

Food is being served within

acceptable parameters of

infection control

Food items are identified,

dated and closed properly

Only pasteurized eggs are in

place

Food is being served in

accordance with the

spreadsheet



06/03/2018 12:00:00AM





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retrieved a wicker basket of pre-packaged creamer

and delivered the basket to a table for the

residents to use.

At 11:52 a.m., CNA 20 was observed to stand with

her hands touching the her uniform pants

pockets. She then took a resident meal order,

used a spoon and dished up fruit in a small bowl

and then served the fruit to the resident. CNA 20

was not observed to perform hand hygiene prior

to dishing up nor serving the bowl of fruit.

At 11:55 a.m., CNA 20 was observed to touch her

arms and clapped her hands as she visited with

the residents.

At 11:58 a.m., CNA 20 was observed to move a

resident's Rollator walker out into the hallway ant

then return to the dining room. CNA 20 was not

observed to perform hand hygiene upon returning

into the dining room.

At 12:04 p.m., CNA 20 was observed to have her

hands in her uniform pockets, she then removed

the plastic wrap covering the brownies, she was

not observed to perform hand hygiene prior to

unwrapping the brownies. CNA 20 then retrieved

the carafe of coffee and poured coffee to 2

residents and then put the carafe on the table for

the residents to use. CNA 20 was then observed

to touch the neck of her uniform top with her right

hand. She was not observed to perform hand

hygiene after touching her uniform. She then left

the dining room.

At 12:10 p.m., CNA 20 was observed to assist a

resident to be seated at a table. CNA 20 moved a

chair and a Rollator walker, she then proceeded to

pour a drinking glass of lemonade and then a cup

of coffee. CNA 20 asked if the resident wanted

cream. CNA 20 was not observed to perform hand

hygiene after touching the chair and walker, nor

before serving the resident a beverage.

At 12:11 p.m., CNA 20 was observed to pour a

resident a cup of coffee and was not observed to

been identified by:

All residents could potentially

be affected. Please refer

below to systematic changes to

prevent reoccurrence





include:

All dietary staff and nursing

staff have been in-serviced

related to assuring that food

items are properly labeled,

dated, and closed properly.

The in-service also includes

proper handwashing and

proper handling of food and

utensils in accordance with

infection control guidelines. In

addition, the in-service covers

utilizing the spread sheet when

serving food to our residents.

The Dietary Manager is

responsible for assuring that

only pasteurized eggs are

utilized during service to the

residents and has been

in-serviced related to assuring

only ordering proper eggs.




assurance is:

A Performance Improvement

Tool has been initiated that

randomly reviews 5 meal

services to include all meals to

assure that handwashing is

properly present, infection





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perform hand hygiene.

At 12:12 p.m., CNA 20 was observed to squirt

hand sanitizer gel onto her hand, she rubbed her

hands for 6 seconds and served a plate of food to

a resident. She then opened a condiments packet

for the resident to use. She was observed to

touch the resident's chair when asking if they

needed anything else.

At 12:13 p.m., CNA 20 was observed to wash her

hands with soap and water in the dining room

sink, she washed and dried her hands for a total of

15 seconds and then served a plate of food to a

resident.

At 12:15 p.m., CNA 20 was observed to serve

another plate of food. CNA 20 then opened the

butter and used the resident's knife to butter the

bread and then picked up the bread with her bare

hands and folded the buttered bread in half and

handed the bread to the resident. The resident

was missing a fork, CNA 20 was observed to

removed a fork from an already unwrapped set of

silverware on another table and gave it to the

resident and was heard to tell the resident the fork

was clean. CNA 20 was not observed to perform

hand hygiene in-between each plate served nor

before assisting the resident with her food nor

retrieving her silverware.

At 12:17 p.m., CNA 20 was observed to served

another plate of food to a resident and was not

observed to perform hand hygiene.

At 12:18 p.m., CNA 20 was observed to removed a

Pager (facility's call system) from her uniform

pocket, looked at it and returned it to her uniform

pocket. She then squirted a small amount of hand

sanitizer gel onto her hand and rubbed her hands

for 3 swipes and then delivered a plate of food to

a resident.

At 12:20 p.m., CNA 20 was observed to touch her

uniform top, then retrieved a plate of salad from

dietary staff. CNA 20 then removed the plastic

control practices are in place,

items are labeled, dated, and

closed properly, that the

spreadsheet is followed

appropriately, and that only

pasteurized eggs are being

utilized. The Dietary Manager,

or designee, will complete this

tool weekly x3, then monthly

x3. Any issues identified will

be immediately corrected. The

Quality Assurance Committee

will review the tools at the


recommendations as needed

based on the outcome of the

tools. Once 100% compliance is

achieved, the Committee will

determine if additional

monitoring is needed.


will be completed:

June 3, 2018





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wrap covering the salad and delivered the salad to

a resident. CNA 20 was not observed to perform

hand hygiene.

At 12:21 p.m., CNA 21 was observed to touched

her uniform pants, picked up a drinking glass and

poured ice water and delivered to a resident. CNA

21 was observed to assist a resident to cut her

meat with their silverware and put the silverware

on the table for the resident to use. CNA 21 was

not observed to perform hand hygiene after

touching her uniform pants nor before serving

and assisting a resident with their food.

Form 12:22 p.m. to 12:28 p.m., CNA 21 was

observed to washed her hand with soap and

water, she lathered her hands for 12 seconds

before rinsing with water, dried her hands and

delivered a plate of food to a resident. CNA 21

was observed to deliver total of 5 plates of food to

residents and was not observed to perform hand

hygiene in-between each plate.

At 12:26 p.m., CNA 20 was observed to touch her

uniform pants while talking with a resident, she

then used hand sanitizer and rubbed her hands for

5 seconds and then clapped her hands and

rubbed for 5 more swipes. She then retrieved a

small plastic cup and squirted ketchup into the

cup and took it to a resident.

At 12:27 p.m., CNA 20 was observed to deliver a

plate of food and was not observed to perform

hand hygiene.

At 12:28 p.m., CNA 20 was observed to removed

used dishes for a table.

At 12:29 p.m., CNA 20 delivered a plate of food to

a resident. CNA 20 was not observed to perform

hand hygiene after removing the used dishes nor

before delivering a plate of food to a resident.

CNA 20 then picked up the bottles of ketchup and

mayonnaise and put them on the countertop

above the steam table.

At 12:30 p.m., CNA 20 was observed to wash her





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hands with soap and water, she lathered for 10

seconds, rinses and dried her hands with process

taking less then 20 seconds. She then was

observed to deliver 2 plates of food to residents.

She was observed to put her hands on her hips,

touching her uniform while she talked with a

resident. CNA 20 was observed to retrieved an

ice cream sandwich from the dining room

refrigerator's freezer and delivered it to a resident.

She was observed to open the ice cream sandwich

wrapper for the resident and handed it to a

resident. CNA 20 was not observed to perform

hand hygiene after touching her uniform nor

before unwrapping the ice cream sandwich for the

resident.

At 12:34 p.m., CNA 20 was observed to leave the

dining room and retrieve several Rollator walkers

for the residents in the dining room.

At 12:38 p.m., CNA 20 was observed to return to

the dining room, she was not observed to perform

hand hygiene. she was observed to remove the

plastic wrap from a salad and delivered to a

resident. She was observed to touch the back of

the resident's chair as she delivered the salad to a

resident. CNA 20 was not observed to perform

hand hygiene prior to unwrapping nor serving the

resident's salad.

At 12:40 p.m., lunch service was completed and 31

residents were served lunch meal in the Orchard

Dining Room.



hands should be washed 40 - 60 seconds and

when staff would change tasks. The Kitchen

Manager indicated the dietary staff did not make it

a practice to use the hand sanitizer.2. During an

observation of the walk in kitchen refrigerator with

the Dietary Manager on 4-30-2018 at 7:50 a.m., a

box of eggs were observed on the bottom shelf





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without the "P" printed on the eggs. An interview

with the Dietary Manager at this time indicated,

the eggs were used for fried eggs and over easy

eggs as the residents order. The Dietary Manager

indicated the eggs were pasteurized. An

observation at this time indicated the Dietary

Manager picked up several eggs, looked at the

labeling on the box and was unable to find the "P"

printed on the eggs and unable to find

"pasteurized" printed on the box. The box label

indicated 30 dozen eggs (360) inside the box and

there were 155 eggs left in the box. A date of

"4/20" was written on the box and the Dietary

Manager indicated the "4/20" date was the date

the eggs were delivered.

An interview with the Dietary Manager on

4-30-2018 at 7:55 a.m., indicated there were usually

6 - 8 residents who ordered "over easy" eggs in

the residential dining room.

An interview with Dietary Staff 10 in the

Residential dining room on 4-30-2018 at 8:32 a.m.,

indicated there were 8 residents who had ordered

over easy eggs today.

An interview with CNA 11 in the Assisted Living

Memory Care unit on 4-30-2018 at 8:33 a.m.,

indicated no one had ordered or eaten any over

easy eggs today.

On 4-30-2018 at 2:42 p.m., the Dietary Manager

provided the most recent egg orders. The orders

indicated on 3-11-2018, 3-25-2018 and 4-15-2018

the brand choice medium Grade A shell eggs,

loose, refrigerated, 30 Ct tray, 12/case item number

209003. The information provided did not indicate

"pasteurized" anywhere in the description. An

interview at this time with the Dietary Manager

indicated she ordered the wrong eggs.





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10:45 a.m., indicated she did not know the facility

did not use pasteurized eggs. She indicated the

current dietary manager took over the job of

ordering and thought she was ordering

pasteurized eggs. .

An interview with Dietary Staff 13 on 5-2-2018 at

11:40 a.m., indicated he hadn't seen the "P" on the

eggs before. Dietary Staff 12 indicated the "P"

meant the eggs were pasteurized.

3. An observation of the kitchen in the Assisted

Living Memory Care unit on 4-30-2018 at 12:13

p.m., indicated a 35 ounce opened bag of raisin

bran was not dated or closes tightly. The bag was

located on a shelf above the counter. A plastic

squirt bottle was observed half filled with a yellow

liquid. There was not a label on the bottle to

identify the liquid, a date opened, or a use by

date.



yellow substance in the squirt bottles was liquid

butter alternative and should have been labeled.

The opened and unsecured cereal should have

been placed in a ziploc bag or a resealable

container and labeled.

4. During an observation of the noon meal service

in the Memory Care unit on 4-30-2018 at 12:13

p.m., indicated Nurse 14 served the fettuccine with

tongs. During the plating of the food, 4 residents

requested the fettuccine and the serving sizes of

the fettuccine were varied.

An observation of the noon meal in the residential

dining room on 4-30-2018 at 12:40 p.m., indicated a





06/08/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


BLUFFTON, IN 46714

155726 05/04/2018


400 CAYLOR BLVD

00

pair of tongs were observed in the container of

the fettuccine.


10:45 a.m., indicated the serving size for the

fettuccine should have been 4 ounces and served

with a 4 ounce spoodle and she indicated she was

not aware the fettuccine was served with tongs on

Monday.



Staff were to follow the spreadsheet for serving

size. The Kitchen Manager indicated for the

noodles, to use the size on the spreadsheet which

was a 1/2 cup. The Kitchen Manager further

indicated for the noodles, staff should just have

given their expectations of what 1/2 cup looked

like with the tongs, as it was easier.

A current, undated policy "Purchasing" was


4:02 p.m. The policy indicated "...Food and

supplies are purchased in a standardized manner

to ensure quality and to control costs...Whole,

unbroken eggs are for limited use only and

pasteurized eggs are for general use...."

A current, undated policy "Food Preparation" was


3:33 p.m. The policy indicated "...leftovers must

be dated, labeled and covered and immediately

refrigerated or frozen for later use...handle plates,

silverware, glasses so your hands do not touch

the areas where the food or mouth will be

placed...."

A current, undated policy "Following Menu Cycle

Spreadsheet" was provided by the Dietary





06/08/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


BLUFFTON, IN 46714

155726 05/04/2018


400 CAYLOR BLVD

00

Manager on 5-3-2018 at 3:33 p.m. The policy

indicated "...each kitchenette has a copy of the

cycle menu spreadsheet...the spreadsheet needs

to be pulled out every dining meal

service...spreadsheets must be followed according

to the cycle week, month, day, and meal

service...."

A current, undated policy, "Hand Washing -

Healthcare, Assisted Living, Memory Support"

was provided by the Dietary Manager on 5-3-2018

at 3:33 p.m. The policy indicated "...Hand

Washing will take place before starting food

service and before starting any new task...1.

Hands must be washed before starting your

shift...2. Any time you enter the kitchen to start

working with food, hands must be washed...3.

Before service of meals and passing plates, hands

should be washed...4. Anytime you stop doing a

task and start doing another task that requires

clean hands you must rewash your hands...."


PRINTED: 06/08/2018 DEPARTMENT OF HEALTH AND HUMAN ...

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