PRINTED: 07/22/2021 DEPARTMENT OF HEALTH AND HUMAN ...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

07/22/2021PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

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B. WING

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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

VINCENNES, IN 47591

155042 06/28/2021

WILLOW MANOR

3801 OLD BRUCEVILLE ROAD, BOX 136

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey. This visit included the

Investigation of Complaints IN00356525 and

IN00355590.

Complaint IN00356525-Substantiated.

Deficiencies related to the allegations were cited

at F554, F561, F623, F625, F684, F698, and F725.

Complaint IN00355590-Substantiated.

Deficiencies related to the allegations were cited

at F554, F561, F623, F625, F684, and F698.

Survey dates: June 22, 23, 24, 25, & 28, 2021

Facility number: 000016

Provider number: 155042

AIM number: 100291500

Census Bed Type:

SNF/NF: 119

Total: 119

Census Payor Type:

Medicare: 5

Medicaid: 99

Other: 15

Total: 119

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality review completed on July 2, 2021.

F 0000 The creation and submission of

this Plan of Correction (POC) does

not constitute an admission by

this provider of any conclusion set

forth in the statement of

deficiencies, or of any violation of

regulation.

This provider respectfully requests

this this CMS-2567 Plan of

Correction be considered the

Letter of Credible Allegation of

Compliance and requests a desk

review in lieu of a post-survey

review on, or after July 28, 2021.

483.10(a)(1)(2)(b)(1)(2)

Resident Rights/Exercise of Rights

F 0550

SS=E

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: B62B11 Facility ID: 000016

TITLE

If continuation sheet of 76

(X6) DATE




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§483.10(a) Resident Rights.

The resident has a right to a dignified

existence, self-determination, and

communication with and access to persons

and services inside and outside the facility,

including those specified in this section.

§483.10(a)(1) A facility must treat each

resident with respect and dignity and care for

each resident in a manner and in an

environment that promotes maintenance or

enhancement of his or her quality of life,

recognizing each resident's individuality. The

facility must protect and promote the rights of

the resident.

§483.10(a)(2) The facility must provide equal

access to quality care regardless of

diagnosis, severity of condition, or payment

source. A facility must establish and

maintain identical policies and practices

regarding transfer, discharge, and the

provision of services under the State plan for

all residents regardless of payment source.

§483.10(b) Exercise of Rights.

The resident has the right to exercise his or

her rights as a resident of the facility and as

a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that

the resident can exercise his or her rights

without interference, coercion, discrimination,

or reprisal from the facility.

§483.10(b)(2) The resident has the right to be

free of interference, coercion, discrimination,

and reprisal from the facility in exercising his

or her rights and to be supported by the

facility in the exercise of his or her rights as

Bldg. 00

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required under this subpart.

Based on observation, interview, and record

review, the facility failed to maintain resident

dignity, and to protect and promote the rights of

the residents. Staff did not wear name tags visible

to residents, residents were served meals on

disposable plates during 2 of 2 meals observed,

and staff did not address a resident by their

preferred name. (Resident 32, Resident 83,

Resident 69, Resident 41, Resident 68, Resident

90, Resident 66, Resident 119, Resident H)

Findings include:

1. During an interview on 6/22/21 at 10:35 A.M.,

Resident H indicated staff did not wear name tags,

so the resident could not tell the name of the

person providing care.

On 6/22/21 at 11:45 A.M., Activities 1 was

observed working with a resident on B Hall with

no name tag on.

On 6/22/21 at 12:02 P.M., RN 25 was observed on

A Hall with a name tag hanging backward from a

lanyard around her neck.

On 6/24/21 at 11:32 A.M., CNA 3 was observed on

A Hall wearing a name tag with the name faded.

On 6/25/21 at 12:04 P.M., LPN 21 was observed at

the nurses station of C/D Hall with a name badge

pinned to her uniform top. The name on the

badge was covered with keychains that hung from

the badge, covering the name.

On 6/25/21 at 12:10 P.M., CNA 21 was observed

walking from D to C Hall with a uniform jacket on.

A name tag was not visible. At that time, CNA 17

was observed walking from C to D Hall with a

F 0550 What corrective actions will be

accomplished for those

residents found to be affected

by the deficient practice:

Resident H is now being

addressed by their preferred

name. RT 8 has been educated

07/20/21 on addressing each

resident by their preferred name in

accordance with resident’s rights.

All residents are being served on

appropriate dishware. Dietary staff

has been educated 07/20/21 on

when disposable dishware is

appropriate.

How other residents having the

potential to be affected by the

same deficient practices will

be identified and what

corrective action will be taken:

All residents have the potential to

be affected by this deficient

practice. No further concerns

noted.

What measures will be put in

place and what systemic

changes will be made to

ensure that deficient practice

does not recur:

An in-service on 07/20/21 &

07/22/21 has been provided for all

staff on resident’s rights with a

focus on addressing each resident

by their preferred name and

serving appropriate dishware at

meals.

07/28/2021 12:00:00AM





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name tag clipped to the bottom pocket of her

uniform top, turned backward.

2. On 6/22/21 at 12:09 P.M., the following was

observed during lunch service on A Hall:

Resident 32 served on a disposable plate, with

plastic cutlery.

Resident 69 served on a disposable plate.

Resident 41 served with plastic cutlery.


At that time, CNA 1 and Speech Therapist 32 both

indicated there was no medical indication for any

of the residents that received disposable plates or

cutlery to have received them. They further

indicated the residents on that unit had been

served on disposable plates frequently, and did

not know why.

On 6/23/21 at 12:04 P.M., the following was

observed during lunch service on A Hall:



Resident 41 served on a disposable plate with

plastic cutlery.


plastic cutlery.


plastic cutlery.


plastic cutlery.

During an interview on 6/25/21 at 9:55 A.M., the

A/B Hall Unit Manager indicated there was one

resident on the unit that had an order for

disposable cutlery, but there was no reason that

any other resident should have been served with

disposable plates or plastic cutlery.

During an interview on 6/25/21 at 10:00 A.M.,

Cook 19 indicated sometimes the kitchen ran out

How the corrective actions will

be monitored to ensure the

deficient practices will not

recur:

An audit tool has been developed

and implemented to monitor staff

performance o ensure that the

staff is addressing each resident

by their preferred name. This tool

is being completed by Social

Service and/or Designee weekly

for four weeks, then monthly for

three months, and then quarterly

for three quarters.


to ensure that appropriate

dishware is being served. This

tool is being completed by Dietary

Manager and/or Designee weekly

for four weeks, then monthly for

three months, and then quarterly

for three quarters.

Any concerns identified will be

addressed if observed. Results on

monitoring will be further reviewed

in QAPI and if trends are identified

then another action may be

developed. Any action plan

written by the QAPI committee will

be monitored by the Administrator

weekly until resolution.





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of plates, and since the A/B Hall was the last unit

to be served, those residents ended up with

disposable items. 3. During record review on

6/25/21 at 10:15 A.M., Resident H's most recent

Quarterly MDS (Minimum Data Set) assessment,

dated 5/24/21, indicated the resident was totally

dependent with transfers and cognitive skills were

severely impaired.

Resident H's diagnoses included, but were not

limited to; spinal stenosis, chronic heart failure,

chronic respiratory failure, cognitive

communication deficit, depression, and anxiety.

Resident H's care plan included but was not

limited to; Resident displays inappropriate

behavior such as screaming, moaning, call out for

family... Interventions included, staff to provide

highest form of medical, physical, and

psychosocial care...

During an observation on 6/25/21 at 3:00 P.M., RT

8 (Respiratory Therapist) was providing care to

Resident H. RT 8 addressed the Resident by

"baby" eight times, "honey" one time, and

"angel" one time. RT 8 did not address the

resident by their name during care.

During an interview on 6/28/21 at 9:56 A.M., LPN

24 indicated staff should address residents by

their name, unless they are care planned to be

called another name. Staff should not address

residents as "sweetie, baby, or honey" unless the

resident was care planned for it.

On 6/28/21 at 12:30 P.M., a current Name Badge

policy, revised 8/6/18, was provided and indicated

"Employees will wear name badges while on duty

... It is the employee's responsibility to request a

replacement badge if the badge is lost or





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destroyed"

On 6/28/21 at 12:30 P.M., a current non-dated

Nursing Skills policy was provided, and indicated

"Greet Resident by name and check identification"

A policy related to serving residents with

disposable items was requested, and not

provided.

3.1-3(t)

483.10(c)(7)

Resident Self-Admin Meds-Clinically Approp

§483.10(c)(7) The right to self-administer

medications if the interdisciplinary team, as

defined by §483.21(b)(2)(ii), has determined

that this practice is clinically appropriate.

F 0554

SS=D

Bldg. 00


review, the facility failed to ensure a self

administration of medications assessment was

completed for 1 of 1 residents reviewed for

medications stored at the bedside. (Resident B)

Finding includes:

On 6/22/21 at 11:30 A.M., a bottle of Equate Cold

and Flu was observed to be on Resident B's

bedside table. Resident B indicated he took the

medication when he needed it.

On 6/24/21 at 2:15 P.M., a bottle of Equate Cold


bedside table.

On 6/24/21 at 1:31 P.M., Resident B's clinical

record was reviewed. The Quarterly MDS

(Minimum Data Set) assessment, dated 5/23/21,

indicated Resident B had no cognitive impairment,


accomplished for those residents

found to be affected by the

deficient practice:

A review of Resident B physician

order was completed and a

self-administration of medication

was completed. Physician order

was obtained for

self-administration of meds.

Family education was provided

that medication was to be given to

the nurse and orders would be

received from the physician based

on the self-administration

assessment. These assessments

will follow the quarterly schedule of

assessments completed on

residents or as needed with a

change of condition.



07/28/2021 12:00:00AM





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a diagnosis of end stage renal disease, and

received dialysis.

The Physician's Order lacked an order to self

administer medications or an order for Equate

Cold and Flu.

On 6/25/21 at 12:22 P.M., LPN 21 indicated

Resident B did not have any medications he self

administered.

On 6/28/21 at 1:00 P.M., the DON provided the

current "Bedside Medication Storage" policy.

The policy included, but was not limited to:

Bedside medication storage is permitted for

residents who wish to self-administer medications,

upon the written order of the prescriber and once

a self-administration skills have been assessed

and deemed appropriate in the judgment of the

facility's interdisciplinary resident assessment

team.

On 6/28/21 at 1:00 P.M., the DON provided the

current "Medications Brought to the Facility by a

Resident" policy. The policy included, but was

not limited to: Medications brought into the

facility by a resident or responsible party are used

only upon written order by the resident's

attending physician...

This Federal tag relates to Complaints IN00356525

and IN00355590.

3.1-11(a)

same deficient practices will be

identified and what corrective

action will be taken:


be affected by the deficient

practice. The facility completed

room rounds and no other

residents were identified.


place and what systemic changes

will be made to ensure that

deficient practice does not recur:

License Nurses and QMA’s will be

in-serviced 07/20/2021 &

07/22/2021 regarding Beside

Medication Storage and

Medications brought to the facility

by a Resident. Assessments will

be completed quarterly or as

needed. Nursing Administration is

making random rounds throughout

the facility to identify medication

found at bedside.

How the corrective actions will be

monitored to ensure the deficient

practices will not recur:

A performance improvement tool

has been initiated that randomly

review medications found at

bedside and document findings.

The DON and/or Designee will

complete this tool weekly x3,

monthly x3, and then quarterly x3.












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483.10(e)(3)

Reasonable Accommodations

Needs/Preferences

§483.10(e)(3) The right to reside and receive

services in the facility with reasonable

accommodation of resident needs and

preferences except when to do so would

endanger the health or safety of the resident

or other residents.

F 0558

SS=D

Bldg. 00


review, the facility failed to ensure call lights were

within reach for 1 of 1 residents observed without

a call light within reach during the initial tour and

resident sample. (Resident B)

Finding includes:

On 6/22/21 at 11:34 A.M., Resident B was

observed to be sitting in his recliner. Resident B's

call light was not within reach. Resident B

indicated that if he needed assistance he had to

yell for help.

On 6/25/21 at 12:26 P.M., Resident B was


call light was not within reach.





was dependent upon two persons for bed

mobility, transfers, and toilet use, and required

extensive assistance of two persons for dressing

and personal hygiene.





Resident B that was found to be

affected by the alleged deficient

practice was addressed

immediately.






A complete audit of every call light

button and pull cord to ensure

there is nothing preventing it from

being within resident reach and

easily accessible.





does not recur:

All nursing staff in-serviced

07/20/2021 & 07/22/2021 related

to assuring that residents have

call lights accessible in

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On 6/28/21 at 12:15 P.M., the Administrator

provided the current "Call Light" policy, undated.

The policy included, but was not limited to: The

resident's call light is to be within reach of the

dependent resident and answered promptly.

3.1-3(v)(1)

accordance to the policy. In

addition, all staff in-serviced

07/20/2021 & 07/22/2021 related

to observing to assure that call

lights are in place as all personnel

can observe for call lights as they

are performing their duties in

accordance with the facility

policy. In addition, nursing

administration is making random

rounds throughout the facility to

assure that call lights are

accessible.




recur:


has been initiated that randomly

review 5 residents to assure that

the call light is accessible per

observation. The Administrator

and/or designee will complete this

tool weekly x3, monthly x3, and

quarterly x3.










483.10(f)(1)-(3)(8)

Self-Determination

§483.10(f) Self-determination.

The resident has the right to and the facility

F 0561

SS=D

Bldg. 00





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must promote and facilitate resident

self-determination through support of resident

choice, including but not limited to the rights

specified in paragraphs (f)(1) through (11) of

this section.

§483.10(f)(1) The resident has a right to

choose activities, schedules (including

sleeping and waking times), health care and

providers of health care services consistent

with his or her interests, assessments, and

plan of care and other applicable provisions of

this part.

§483.10(f)(2) The resident has a right to make

choices about aspects of his or her life in the

facility that are significant to the resident.


interact with members of the community and

participate in community activities both inside

and outside the facility.


participate in other activities, including social,

religious, and community activities that do

not interfere with the rights of other residents

in the facility.


review the facility failed to ensure a resident's

choices to receive two or more showers a week

were honored for 1 of 3 residents reviewed for

choices.

(Resident F)

Findings include:


Resident F indicated she had two showers in the





A review of shower schedule for all

residents was completed to

ensure that each resident is

offered at least 2 showers per

week. Shower schedules were

reviewed and updated to reflect

changes if necessary. C.N.A.

assignment sheets were reviewed

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last month and that she would like more showers.

The shower schedule was reviewed on 6/24/21 at

10:00 A.M. Resident F was scheduled for a

shower at 10:00 P.M. to 6:00 A.M. on Mondays,

Wednesdays, and Fridays.

During an interview on 6/24/21 at 10:00 A.M., Unit

Manager 1 indicated she could only find a shower

sheet documenting a shower was given on 5/20/21

and on 6/20/21.

The clinical record of Resident F was reviewed on

6/24/21 at 10:10 A.M. The record indicated the

diagnoses for Resident F included, but were not

limited to, cerebral vascular accident and

Pseudobulbar Affect.

The Annual MDS (Minimum Data Set)

assessment, dated 4/30/21 indicated Resident F

experienced no cognitive impairment. The

assessment indicated Resident F required the

assistance of two staff for transfers, was totally

dependent for bathing activity, and was

occasionally incontinent of bladder. The

assessment further indicated Resident F found it

very important to choose between shower, bed

bath, sponge bath, and tub bath.


Manager 1 indicated that the resident had not had

a shower between 5/20/21 and 6/20/21.

An undated policy titled, "Showering a Resident

while using a shower bed", was provided by the

Administrator, reviewed on 6/25/21 at 10:50 A.M.,

and read as follows: "...Residents will receive a

shower at least two times a week..."

This Federal tag relates to Complaint IN00355590

and updated to reflect shower

scheduled days.






A complete review of all residents

shower schedules was completed

to ensure that each resident was







scheduled days.





does not recur:

An in-service will be completed on

07/20/2021 & 07/22/2021 with all

nursing staff regarding providing

showers at a minimum of 2 times

per week for each resident. The

C.N.A.’s will complete a shower

worksheet indicating the type of

bathing given and reason for

refusal, if any. The Charge Nurse

will review the shower worksheets

and, if any refusals, will attempt

an additional approach, with

documented explanation if

continued refusal. DON and/or

Designee will review worksheets

during daily rounds for completion

and notification given to Social

Service if continued refusal of





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and IN00356525.

3.1-3(u)(1)

showers, in an effort to further

involve other disciplines and/or

family members, as appropriate.




recur:


complete audits on previous days

shower sheets to ensure a shower

was given and, if any refusal

documentation will be reviewed to

determine reason why and findings

will be documented. Interviews of

alert and oriented residents will

also be conducted to validate that

the residents did receive their

showers in accordance with their

individual plan of care. These

audits will be completed 5 times a

week for four weeks, then 3 times

weekly for 8 weeks, and then

monthly for 3 quarters, to identify

any concerns and take corrective

measures. Shower sheets will be

reviewed on Saturday by the

Charge Nurse of each unit to

ensure showers were given and, if

any refusal documentation will be

completed to show attempts

given.














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483.10(h)(1)-(3)(i)(ii)

Personal Privacy/Confidentiality of Records

§483.10(h) Privacy and Confidentiality.

The resident has a right to personal privacy

and confidentiality of his or her personal and

medical records.

§483.10(h)(l) Personal privacy includes

accommodations, medical treatment, written

and telephone communications, personal

care, visits, and meetings of family and

resident groups, but this does not require the

facility to provide a private room for each

resident.

§483.10(h)(2) The facility must respect the

residents right to personal privacy, including

the right to privacy in his or her oral (that is,

spoken), written, and electronic

communications, including the right to send

and promptly receive unopened mail and

other letters, packages and other materials

delivered to the facility for the resident,

including those delivered through a means

other than a postal service.

§483.10(h)(3) The resident has a right to

secure and confidential personal and medical

records.

(i) The resident has the right to refuse the

release of personal and medical records

except as provided at §483.70(i)(2) or other

applicable federal or state laws.

(ii) The facility must allow representatives of

the Office of the State Long-Term Care

Ombudsman to examine a resident's

medical, social, and administrative records in

accordance with State law.

F 0583

SS=E

Bldg. 00


review, the facility failed to maintain resident F 0583 What corrective actions will be


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privacy. A privacy curtain was left open and a

resident was exposed during a random

observation, and a computer screen was left open

with access to all residents residing on B Hall,

information was visible for 1 of 8 medication carts

observed. (Resident 41, B Hall)

Findings include:

1. During a random observation on 6/24/21 at 1:52

P.M., Resident 41 was lying in bed with her

backside facing the hall. She was not covered

with a blanket, and not wearing an incontinence

brief or pants. The privacy curtain was not pulled

all the way, and she was exposed to the hall and

anyone passing by the room. At that time, CNA 3

indicated Resident 41 had an alarm in bed, but did

not like to pull the privacy curtain all the way as to

keep an eye on her when walking down the hall.

CNA 3 indicated residents should stay covered in

bed at all times as to not be exposed to other

people.

2. On 6/22/21 at 11:45 A.M., the computer on the B

Hall medication cart was open and logged into,

with all resident information visible on the screen.

There were no staff in that area at that time. At

12:02 P.M., RN 4 indicated she was "back from

break", and was observed to log out of the

computer. 16 residents resided on the B Hall.

On 6/24/21 at 11:22 A.M., the computer on the B

Hall medication cart was open and logged into,

with all resident information visible on the screen.

RN 4 was in the common area bathroom with a

resident. At 11:27 A.M., RN 4 came back to the

computer and logged out. At that time, RN 4

indicated staff should log out of the computer

before walking away from it.



Social Service met with Resident

41 to provide psychosocial

support. This resident was not

found to have been affected by the

alleged deficient practice. CNA

#41 was in-serviced on nursing

skills policy. The RN 4 was

in-serviced logging off the

medication cart computer at any

time walking away from it. No

residents were adversely affected

by the cart being left unattended.






Nursing Administration conducted

facility wide observations to

determine if other residents were

affected by these alleged deficient

practices. Per this review there

were no other residents found to

have been affected by the alleged

deficient practices.





does not recur:

License Nurses and QMA’s will be


07/22/2021 regarding securing

medication cart computer when

left unattended. All staff will be


07/22/2021 regarding providing

resident privacy.





07/22/2021PRINTED:

FORM APPROVED

OMB NO. 0938-039




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On 6/28/21 at 12:30 P.M., a current non-dated

Nursing Skills policy was provided, and indicated

"Close curtains, drapes, and doors. Keep

Resident covered"

A facility policy related to using the Electronic

Health Record was requested but not received.

3.1-3(t)




recur:


has been initiated that random

observations to ensure medication

cart computers left unattended are

secure and resident privacy is

maintained. The DON and/or

Designee will complete this tool

weekly x3, monthly x3, and then

quarterly x3.










483.15(c)(3)-(6)(8)

Notice Requirements Before

Transfer/Discharge

§483.15(c)(3) Notice before transfer.

Before a facility transfers or discharges a

resident, the facility must-

(i) Notify the resident and the resident's

representative(s) of the transfer or discharge

and the reasons for the move in writing and in

a language and manner they understand. The

facility must send a copy of the notice to a

representative of the Office of the State

Long-Term Care Ombudsman.

(ii) Record the reasons for the transfer or

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discharge in the resident's medical record in

accordance with paragraph (c)(2) of this

section; and

(iii) Include in the notice the items described

in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.

(i) Except as specified in paragraphs (c)(4)(ii)

and (c)(8) of this section, the notice of

transfer or discharge required under this

section must be made by the facility at least

30 days before the resident is transferred or

discharged.

(ii) Notice must be made as soon as

practicable before transfer or discharge when-

(A) The safety of individuals in the facility

would be endangered under paragraph (c)(1)

(i)(C) of this section;

(B) The health of individuals in the facility

would be endangered, under paragraph (c)(1)

(i)(D) of this section;

(C) The resident's health improves sufficiently

to allow a more immediate transfer or

discharge, under paragraph (c)(1)(i)(B) of this

section;

(D) An immediate transfer or discharge is

required by the resident's urgent medical

needs, under paragraph (c)(1)(i)(A) of this

section; or

(E) A resident has not resided in the facility

for 30 days.

§483.15(c)(5) Contents of the notice. The

written notice specified in paragraph (c)(3) of

this section must include the following:

(i) The reason for transfer or discharge;

(ii) The effective date of transfer or discharge;

(iii) The location to which the resident is

transferred or discharged;

(iv) A statement of the resident's appeal





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rights, including the name, address (mailing

and email), and telephone number of the

entity which receives such requests; and

information on how to obtain an appeal form

and assistance in completing the form and

submitting the appeal hearing request;

(v) The name, address (mailing and email)

and telephone number of the Office of the

State Long-Term Care Ombudsman;

(vi) For nursing facility residents with

intellectual and developmental disabilities or

related disabilities, the mailing and email

address and telephone number of the agency

responsible for the protection and advocacy

of individuals with developmental disabilities

established under Part C of the

Developmental Disabilities Assistance and

Bill of Rights Act of 2000 (Pub. L. 106-402,

codified at 42 U.S.C. 15001 et seq.); and

(vii) For nursing facility residents with a

mental disorder or related disabilities, the

mailing and email address and telephone

number of the agency responsible for the

protection and advocacy of individuals with a

mental disorder established under the

Protection and Advocacy for Mentally Ill

Individuals Act.

§483.15(c)(6) Changes to the notice.

If the information in the notice changes prior

to effecting the transfer or discharge, the

facility must update the recipients of the

notice as soon as practicable once the

updated information becomes available.

§483.15(c)(8) Notice in advance of facility

closure

In the case of facility closure, the individual

who is the administrator of the facility must

provide written notification prior to the





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impending closure to the State Survey

Agency, the Office of the State Long-Term

Care Ombudsman, residents of the facility,

and the resident representatives, as well as

the plan for the transfer and adequate

relocation of the residents, as required at §

483.70(l).

Based on interview and record review, the facility

failed to ensure a notice of transfer or discharge

was given to the resident or resident

representative for 3 of 3 residents reviewed for

hospitalizations. There was no documentation of

residents receiving a notice of transfer or

discharge form prior to hospitalization. (Resident

G, Resident H, Resident E)

Findings include:

1. During record review 6/24/21 at 2:13 P.M.,

Resident G's hospital records indicated the

resident was admitted from the facility to the

hospital on 6/10/21 and discharged from the

hospital back to the facility on 6/13/21.

Resident G's records did not contain a notice of

transfer/discharge given the resident or a

representative at the time of the transfer.

2. During record review on 6/24/21 at 11:00 A.M.,

Resident H's progress notes included but were

not limited to; 5/16/21 - Resident admitted to

hospital with diagnoses of pneumonia and

respiratory failure.

During an interview on 6/23/21 at 11:04 A.M.

Resident H's family member indicated the resident

was admitted to the hospital recently and that

they had not receive a notice of transfer or

discharge form.





Resident G, Resident H, and

Resident E have been provided

transfer/discharge/bed hold

policy. The facility copy has been

placed in the medical record.






All residents who reside in the

facility have potential to be

affected by the alleged findings.





does not recur:

SSD/Designee to provide

education to nursing staff

07/20/2021 & 07/22/2021 to

ensure proper notice requirements

before transfer/discharge. Nursing

staff also to be educated on

ensuring state

transfer/discharge/bed hold policy

is sent with resident and/or

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During an interview on 6/28/21 at 12:45 P.M., LPN

24 indicated Resident H returned from the hospital

on 5/18/21 and that transfer/discharge forms were

sent in the hospital transfer paperwork but were

never filled out and should have been.

3. On 6/24/21 at 12:58 P.M., Resident E's clinical

record was reviewed. The Annual MDS


indicated Resident E had no cognitive impairment.

The Progress Notes included, but were not limited

to:

6/2/21 at 1:35 A.M., Resident sent to emergency

room due to penis swelling and drainage.


room related to penis swelling.

The clinical record lacked a Notice of

Transfer/Discharge.


indicated the facility was unable to locate a Notice

of Transfer/Discharge for Resident E's

hospitalization and transfer.

A checklist for sending residents to ER form was

supplied on 6/28/21 at 12:00 P.M. The check list

included, "Fill out transfer form... keep a copy for

chart."


and IN00355590.

3.1-12(a)(6)(A)

representative as well as a facility

copy entered in the resident’s

health records.




recur:

SSD/Designee will ensure

compliance 5x week x 4 weeks,

then 3x week x 4 weeks, then

ongoing basis by auditing all

discharges to ensure proper

notices are given upon

transfer/discharge of residents.

Any staff who fail to comply with

the points of the in-service will be

further educated and/or

progressively disciplined as

indicated. The results of the

monitoring will be presented to the

QAPI committee at the monthly

meeting. Any concerns will have

been addressed. However, any

patterns will be identified and if

needed an Action Plan will be

written by the committee. Any

Action Plan will be monitored

weekly by the Administrator until

resolution.

483.15(d)(1)(2)

Notice of Bed Hold Policy Before/Upon Trnsfr

§483.15(d) Notice of bed-hold policy and

return-

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§483.15(d)(1) Notice before transfer. Before a

nursing facility transfers a resident to a

hospital or the resident goes on therapeutic

leave, the nursing facility must provide written

information to the resident or resident

representative that specifies-

(i) The duration of the state bed-hold policy, if

any, during which the resident is permitted to

return and resume residence in the nursing

facility;

(ii) The reserve bed payment policy in the

state plan, under § 447.40 of this chapter, if

any;

(iii) The nursing facility's policies regarding

bed-hold periods, which must be consistent

with paragraph (e)(1) of this section,

permitting a resident to return; and

(iv) The information specified in paragraph (e)

(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer.

At the time of transfer of a resident for

hospitalization or therapeutic leave, a nursing

facility must provide to the resident and the

resident representative written notice which

specifies the duration of the bed-hold policy

described in paragraph (d)(1) of this section.


failed to ensure a bed hold policy was given to the

resident or resident representative for 3 of 3

residents reviewed for hospitalizations. There was

no documentation of residents receiving a bed

hold policy form prior to or during hospitalization.

(Resident G, Resident H, Resident E)

Findings include:

1. During record review 6/24/21 at 2:13 P.M.,







Resident G, Resident H, and

Resident E have been provided

transfer/discharge/bed hold

policy. The facility copy has been

placed in the medical record.




07/28/2021 12:00:00AM





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Resident G's records did not contain a bed hold

policy given the resident or a representative at the

time of the transfer.









they had not receive a bed hold policy.

During an interview on 6/28/21 at 12:45 P.M., RN


on 5/18/21 and that bed hold policy forms were

sent in the hospital transfer paperwork but were

never filled out and should have been.




indicated Resident E had no cognitive impairment.

The Progress Notes included, but were not limited

to:


room due to penis swelling and drainage.


room related to penis swelling.

The clinical record lacked a Notice of Bed Hold

Policy.





All residents who reside in the

facility have potential to be

affected by the alleged findings.





does not recur:

SSD/Designee to provide

education to nursing staff

07/20/2021 & 07/22/2021 to

ensure proper notice requirements

before transfer/discharge. Nursing

staff also to be educated on

ensuring state

transfer/discharge/bed hold policy

is sent with resident and/or

representative as well as a facility

copy entered in the resident’s

health records.




recur:

SSD/Designee will ensure

compliance 5x week x 4 weeks,

then 3x week x 4 weeks, then

ongoing basis by auditing all

discharges to ensure proper

notices are given upon

transfer/discharge of residents.

Any staff who fail to comply with

the points of the in-service will be

further educated and/or

progressively disciplined as

indicated. The results of the





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of Bed Hold Policy for Resident E's hospitalization

and transfer.

A bed hold policy, dated 2/23/18, was supplied on

6/28/21 at 12:00 P.M. The policy included,

"Federal regulations require a nursing facility to

provide written information to the resident and a

family member or legal representative that

specifies the duration of the bed hold policy

under Medicaid state plan during which the

resident is permitted to return and resume

residence in the facility. This notice must be

provided in advance of any transfer and the time

of transfer. The first notice of bed hold policy is

given [to] residents at the time of admission to the

facility. Another notice will be given at the time of

transfer. In the event a resident requires an

emergency transfer to a hospital, the resident, a

family member or a the legal representative will be

provided with a copy of the "Bed

Hold/Readmission Policy" as soon as it is

practicable."


and IN00355590.

3.1-12(a)(25)(A)

monitoring will be presented to the

QAPI committee at the monthly




needed an Action Plan will be


Action Plan will be monitored

weekly by the Administrator until

resolution.

483.25

Quality of Care

§ 483.25 Quality of care

Quality of care is a fundamental principle that

applies to all treatment and care provided to

facility residents. Based on the

comprehensive assessment of a resident, the

facility must ensure that residents receive

treatment and care in accordance with

professional standards of practice, the

comprehensive person-centered care plan,

and the residents' choices.

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review, the facility failed to ensure resident's care

was provided to ensure their highest practicable

well being for 1 of 1 residents reviewed for

hospice services and 1 of 1 residents reviewed for

skin conditions. Showers were not provided per

resident preference and need, urinary catheters

lacked orders, and a fly was observed on an open

wound. (Resident C, Resident E)

Findings include:

1. On 6/23/21 at 11:04 A.M., Resident C indicated

hospice would not give her a shower. Resident C

indicated she only received bed baths. Resident

C further indicated she would like a shower

because her hair needed washed. Resident C was

observed to have an indwelling urinary catheter.

Resident C indicated she had the catheter because

she could not get out of bed.

On 6/25/21 at 9:53 A.M., CNA 12 and CNA 10

were observed to transfer Resident C via a

mechanical lift to a chair. CNA 12 indicated that

Resident C had requested to have a shower by

hospice. CNA 12 indicated the hospice aide had

indicated that Resident C could only have bed

baths because she was bed bound.

On 6/24/21 at 1:16 P.M., Resident C's clinical



indicated Resident C had mild cognitive

impairment, an indwelling urinary catheter, was

dependent on one person for bathing, and

received hospice services.

The Care Plans included, but were not limited to:

Self Care Deficit, Activities of Daily Living,





A review of shower schedule for all

residents was completed to

ensure that each resident is







scheduled days.

Resident identified during survey

with catheter placement has been

reviewed for appropriate physician

orders and plan of care updated to

reflect changes as needed.

Resident identified during survey

with fly in room. The pest control

company has provided service and

a fly light was installed to assist

with control of insect.







be affected by the alleged deficient

practice.


shower schedules was completed

to ensure that each resident was





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initiated 7/29/20. The interventions included, but

were not limited to:

Shower days per resident preference, initiated

7/29/20.

Transfers: Resident requires total assist of 2 for

transfers, Hoyer lift, initiated 7/29/20.

Resident is receiving hospice services, initiated

10/23/20. The interventions included, but were

not limited to:

Hospice aides to provide personal care including

showers 1-3 times weekly, initiated 10/23/20.

Resident has an indwelling catheter related to

urinary retention, initiated 11/2/20. The

interventions included, but were not limited to:

Change catheter per physician's orders, initiate

11/2/20.

I have MASD (Moisture Associated Skin

Damage) to my bilateral buttocks with areas of

scattered excoriation related to me scratching and

could be at risk for further problems, initiated

4/17/21. The interventions included, but were not

limited to:

Report all changes warranted to hospice, undated.

The Physician's Orders included, but were not

limited to:

Foley (urinary) catheter as needed for dysuria,

irrigate with 30 mL (milliliters) of normal saline,

ordered 5/4/21.

Hoyer (mechanical) lift to be used for transfers,

ordered 10/10/20.

The Hospice Visit Note Reports, indicated

Resident C only received bed baths from

5/4/21-6/17/21. Resident C received a bed bath on:

5/4/21, 5/6/21, 5/11/21, 5/13/21, 5/18/21, 5/20/21,

5/25/21, 5/27/21, 6/3/21, 6/10/21, 6/15/21, and



scheduled days.


with catheters has been

completed to ensure that

appropriate physician orders and

plan of care is in place and no

further issues identified.

Staff will notify the Maintenance

director of issues that require the

pest control service to be notified.





does not recur:


07/20/2021 & 07/22/2021 with all

nursing staff regarding providing

showers at a minimum of 2 times

per week for each resident. The

C.N.A.’s will complete a shower

worksheet indicating the type of

bathing given and reason for

refusal, if any. The Charge Nurse

will review the shower worksheets

and, if any refusals, will attempt

an additional approach, with

documented explanation if

continued refusal. DON and/or

Designee will review worksheets

during daily rounds for completion

and notification given to Social

Service if continued refusal of

showers, in an effort to further

involve other disciplines and/or

family members, as appropriate.






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6/17/21.

On 6/25/21 at 2:27 P.M., the Hospice Director

indicated on the hospice care plan Resident C was

a bed bath. The Hospice Director further

indicated that if Resident C could get up via a

mechanical lift there was no reason Resident C

could not have a shower.

On 6/28/21 at 9:31 A.M., the DON indicated the

facility had contacted the hospice provider for the

reason for Resident C's indwelling urinary

catheter. The DON further indicated she believed

the indwelling urinary catheter was for urinary

retention but the physician's order should not be

ordered as needed.

On 6/28/21 at 12:54 P.M., the C/D Unit Manager

indicated she had spoke to hospice. The C/D Unit

Manager indicated that the hospice nurse had

noticed in May that Resident C did not have an

order for the indwelling urinary catheter so the

order was placed on 5/4/21. The C/D Unit

Manager further indicated the indwelling urinary

catheter was for urinary retention.


record was reviewed. A Progress Note, dated

11/2/21 at 7:09 A.M., included, but was not limited

to, Hospice nurse was here and inserted

indwelling urinary catheter due to urine retention

and received 2800 mL (milliliters) return of tea

colored urine.....

The clinical record lacked any other

documentation related to Resident C's need for an

indwelling urinary catheter.


provided the current "Catheter Use Care Policy",

07/20/2021 & 07/22/2021 with

License Nurses regarding

physician orders for catheter

placement with appropriate

diagnosis.


07/20/2021 & 07/22/2021 with all

staff regarding pest control

services and notification for

needed services.




recur:



shower sheets to ensure a shower

was given and, if any refusal

documentation will be reviewed to

determine reason why and findings

will be documented. Interviews of

alert and oriented residents will

also be conducted to validate that

the residents did receive their

showers in accordance with their

individual plan of care. These

audits will be completed 5 times a

week for four weeks, then 3 times

weekly for 8 weeks, and then

monthly for 3 quarters, to identify

any concerns and take corrective

measures. Shower sheets will be

reviewed on Saturday by the

Charge Nurse of each unit to

ensure showers were given and, if

any refusal documentation will be

completed to show attempts

given.


review daily orders during clinical





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dated 7/19/20. The policy included, but was not

limited to: It is the policy of this facility to ensure

that a resident that enters this facility without an

indwelling catheter is not catheterized unless the

resident's clinical condition demonstrates that

catheterization was necessary.


indicated that their hospice policy for

communication was within the hospice contract.

The contract was reviewed at that time, and

included, but was not limited to: "2.5

Coordination of Services...The Hospice Designee

shall (a) provide overall coordination of Hospice

Services for each Resident Patient with Nursing

Facility representatives; (b) communicate with

Nursing Facility representatives and other health

care providers participating in the provision of

care for the Resident Patient to ensure quality of

care is provided...2.6 Manner of

Communication....All communications between

the Hospice and Nursing Facility pertaining to the

care and services provided to the Resident Patient

shall be documented in the Resident Patient's

clinical record..."




indicated Resident E had no cognitive impairment

and required extensive assistance of two persons

for bed mobility, personal hygiene, and toilet use.





Elevate penis up above abdomen on several

washcloths, no urinal, check every two hours, if

any change in color of head of penis or urinary

meeting to ensure appropriate

orders and diagnosis for catheter

placement and document findings

of the audit. These audits will be

completed 5 times a week for four

weeks, then 3 times weekly for 8

weeks, and then monthly for 3

quarters, to identify any concerns

and take corrective measures.

The Maintenance Director and/or

Designee will complete

documented rounds of the facility

with findings of pest control

concerns. And documented

notification of pest control service.

These audits will be completed 5

times a week for four weeks, then

3 times weekly for 8 weeks, and

then monthly for 3 quarters, to

identify any concerns and take

corrective measures.














07/22/2021PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


VINCENNES, IN 47591

155042 06/28/2021

WILLOW MANOR


00

issues send to emergency room, initiated 6/11/21

Potential for skin breakdown, resident keeps his

urinal propped up under his groin and refuses to

let staff move it, on 6/10/21 resident has an ulcer,

swelling, and cellulitis of his penis, originally

initiated on 5/7/18. The interventions included,

but were not limited to: assess groin area for skin

breakdown and encourage resident not to prop

urinal against skin/groin area, initiated 5/24/21.

Resident has a penile infection with cellulitis,

initiated on 6/1/21. The interventions included,

but were not limited to:

Administer antibiotics/medications per

physician's orders, assess for side effects and

effectiveness, initiated 6/1/21.

Resident was readmitted to facility with open

areas to the tip of penis and to the posterior

aspect of shaft related to cellulitis and an abscess

that had ruptured during hospitalization. At risk

for further problems, initiated 6/10/21.

On 6/24/21 at 10:00 A.M., the Wound Nurse

indicated that Resident E had kept his urinal

between his legs at night and refused to allow

staff to move the urinal. The Wound Nurse

indicated that she had tried to educate Resident E

about the potential issues that could arise with

keeping the urinal between his legs for extended

time periods. The Wound Nurse indicated that

Resident E's testicles and penis had become

swollen and he was sent to the emergency room.

The Wound Nurse indicated Resident E returned

with an order for antibiotics for cellulitis. The

Wound Nurse indicated that the area worsened

and the nurse practitioner sent the resident back

to the emergency room. The Wound Nurse

indicated that at some point an abscess opened





07/22/2021PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG




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TAG



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(X5)

COMPLETION


VINCENNES, IN 47591

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WILLOW MANOR


00

up on the shaft of Resident E's penis.

On 6/25/21 at 10:30 A.M., the Wound Nurse was

observed to change the dressing for Resident E's

wound. The Wound Nurse washed her hands

and donned clean gloves. The Wound Nurse

indicated that the dressing had previously been

removed because it was saturated. Resident E's

wound was observed at that time. A large circular

area was observed. A fly was observed to be

landing on Resident E's bed. LPN 22 was

observed to attempt to remove the fly. The

Wound Nurse removed her gloves, washed her

hands, and donned clean gloves. The Wound

Nurse cleaned the wound with normal saline. The

Wound Nurse removed her gloves, washed her

hands, and donned clean gloves. At that time, the

fly was observed to land on Resident E's open

wound. The Wound Nurse waved her hand in an

attempt to get the fly off of Resident E's open

wound. The fly landed on Resident E's leg and

then again on Resident E's open wound. The

Wound Nurse waved her hand again to remove

the fly. The Wound Nurse was observed to pack

the wound with calcium alginate with silver and

wrapped the wound with kerlix.


indicated that she was devastated over the fly

landing on the resident and was going to talk to

maintenance. The Wound Nurse further indicated

that the independent smokers used the patio on

that unit to smoke. The door to the patio on the

unit was across the hall from Resident E's room.


and IN00356525.

3.1-37(a)





07/22/2021PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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DEFICIENCY)

(X5)

COMPLETION


VINCENNES, IN 47591

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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


review, the facility failed to assess a dialysis

catheter for 1 of 1 residents reviewed for dialysis.

The resident had a fistula and a dialysis catheter,

the facility was unaware the dialysis center was

using a dialysis catheter for dialysis treatments.

(Resident B)

Finding includes:

On 6/22/21 at 11:24 A.M., Resident B indicated he

went to dialysis three days a week (Monday,

Wednesday, and Friday). Resident B indicated he

had a dialysis catheter.





had a diagnosis of end stage renal disease, and

received dialysis treatments.


The resident needs dialysis related to end stage

renal disease, initiated 2/12/21. The interventions

included, but were not limited to:

Dressing changes per physician's orders at access

site, initiated 2/12/21.

Monitor/document/report to physician any signs

or symptoms of infection to access site, redness,





Resident B has had a physical

assessment completed by a

license nurse. This assessment

is documented. Physician orders

have been reviewed. Plan of care

has been updated to reflect

changes. LPN #21 has been

educated regarding assessments

and communication worksheet

with Dialysis Center. During the

clinical review meeting during

business days, the dialysis

communication form will be

reviewed for completeness and if

any discrepancies are found

immediate action will be taken to

ensure compliance.






Residents that receive Dialysis

services have been reviewed to

assure that nursing staff are

completing assessments,

appropriate physician orders, and

07/28/2021 12:00:00AM





07/22/2021PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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(X5)

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swelling, drainage, or warmth, initiated 2/12/21.


limited to:

Resident's current dialysis access site is a dialysis

catheter in right chest, ordered 2/12/21.

The clinical record lacked any assessments of

Resident B's dialysis catheter site.


Resident B had a fistula.

On 6/25/21 at 12:26 P.M., Resident B indicated he

had a fistula but it did not work. At that time,

Resident B held out his left arm to show where the

fistula was located. There was not dressing

observed to the area. Resident B indicated he had

a catheter in his chest for dialysis.

On 6/28/21 at 8:56 A.M., LPN 21 indicated

Resident B had a fistula for dialysis. LPN 21

indicated that the fistula did have a thrill and bruit

and they checked it every day. LPN 21 indicated

she believed the dialysis center used the fistula

for dialysis treatments.

On 6/28/21 at 10:05 A.M., LPN 21 indicated she

spoke to the dialysis center and they were using

Resident B's dialysis catheter for dialysis

treatments. LPN 21 indicated she had no idea.


indicated she was unable to locate a policy related

to communication between the dialysis center and

the facility.

On 6/28/21 at 1:36 P.M., the DON indicated facility

staff should be assessing Resident B's access site

and should have known that the dialysis center

plan of care. No other areas

identified.





does not recur:

License Nurses were in-serviced

07/20/2021 & 07/22/2021

regarding physical assessment,

communication, and dialysis

worksheet. During the clinical

review meeting during business

days, the dialysis communication

form will be reviewed for

completeness and if any

discrepancies are found

immediate action will be taken to

ensure compliance.




recur:



for the completion of the physical

assessment, communication, and

dialysis worksheet. The DON

and/or Designee will document

findings and if any discrepancies

are found immediate action will be

taken to ensure compliance.













07/22/2021PRINTED:

FORM APPROVED

OMB NO. 0938-039




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B. WING

(X3) DATE SURVEY

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(X4) ID

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(X5)

COMPLETION


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was using the dialysis catheter instead of the

fistula for dialysis treatments.


and IN00356525.

3.1-37(a)


483.35(a)(1)(2)

Sufficient Nursing Staff

§483.35(a) Sufficient Staff.

The facility must have sufficient nursing staff

with the appropriate competencies and skills

sets to provide nursing and related services

to assure resident safety and attain or

maintain the highest practicable physical,

mental, and psychosocial well-being of each

resident, as determined by resident

assessments and individual plans of care and

considering the number, acuity and

diagnoses of the facility's resident population

in accordance with the facility assessment

required at §483.70(e).

§483.35(a)(1) The facility must provide

services by sufficient numbers of each of the

following types of personnel on a 24-hour

basis to provide nursing care to all residents

in accordance with resident care plans:

(i) Except when waived under paragraph (e) of

this section, licensed nurses; and

(ii) Other nursing personnel, including but not

limited to nurse aides.

§483.35(a)(2) Except when waived under

paragraph (e) of this section, the facility must

designate a licensed nurse to serve as a

charge nurse on each tour of duty.

F 0725

SS=E

Bldg. 00


review, the facility failed to ensure sufficient F 0725 What corrective actions will be


07/28/2021 12:00:00AM





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OMB NO. 0938-039




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B. WING

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staffing for 3 of 4 nursing units. Hospice

communication was not completed to ensure

residents received showers, dialysis catheter was

not assessed, medications were stored at bedside,

showers were not given, and Notice of

Transfer/Discharge and bed hold policies were

not completed. (Resident C, Resident B, Resident

F, Resident H, Resident G)

Findings include:

1. During the survey period of 6/22/21 through

6/28/21, the following comments were made while

random confidential interviews were conducted:

a. A staff member indicated sometimes do not

have enough staff.

b. A staff member indicated there was not enough

staff due to several residents required supervision

and assistance. At times, residents did not get

shaved due to lack of time.

c. A staff member indicated staff had been filling

shifts to cover, and no one wanted to work.

d. A staff member indicated many resident care

tasks were not completed in the mornings from

6-10 due to not enough staff. The staff member

indicated many residents were not checked and

changed, yet staff was working non-stop, and

would stay over their shift to get caught up.

e. A staff member indicated many days there was

not enough staff and resident care lacked because

of it. The staff member indicated many residents

were not turned and repositioned as often as they

were supposed to.

f. A staff member indicated many days, it was



HR Team Members (Clinical

Management, Administrator,

Human Resources Director,

Scheduler) will review the unique

characteristics of each unit

regarding resident census, acuity

and level of care needed in

establishing staffing rations

(staffing expectations/minimums

per unit per shift).






HR Team Members (Clinical

Management, Administrator,

Human Resources Director,

Scheduler) will review the unique

characteristics of each unit

regarding resident census, acuity

and level of care needed in

establishing staffing ratios (staffing

expectations/minimums per unit

per shift).





does not recur:

HR Team Members will review

staffing day sheets for the

upcoming week during the weekly

HR Meeting (agenda update) to

ensure that staffing expectations

are being met per above

guidelines.






07/22/2021PRINTED:

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OMB NO. 0938-039




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difficult to complete resident care due to being

short staffed.

g. A resident indicated there was not enough

staff.

h. A resident indicated there was not enough

staff.

i. A resident indicated sometimes it took longer

than 30 minutes to receive assistance, especially

in the mornings with dressing.

j. A resident indicated it "takes forever" for staff

to help up.

k. A resident indicated short on staff. Staff would

turn off call light and then forget.

l. A resident indicated not enough staff. Had to

wait six (6) hours to be assisted after a bowel

movement.

m. A resident indicated it took 3 hours for

assistance.

n. A resident indicated not enough staff. Must

wait over an hour for assistance, and were lucky if

it took less than 20 minutes.

o. A resident indicated at 9:48 A.M. had been

waiting to be changed since breakfast, and had

had bowel and bladder incontinence.

p. A family member indicated seemed short on

staff especially at supper time, and needed more

help cleaning.

2. On 6/28/21 at 9:20 A.M., the following

interviews about the resident census took place:



recur:

Day sheets with additional staffing

to be turned in to DON and

Administrator each week by

scheduler per POC.

Progress toward the successful

completion of this POC will be

monitored each week during HR

meeting using the day sheets

report. Progress toward the

successful completion of this POC

will be monitored daily on normal

business days for one month by

comparing posted hours report

with the day sheets, then weekly

x4 weeks, then semi-monthly x4

months for a total of 6 months

ensuring compliance.



reviewed each week day in stand

up and also by the QAPI

Committee meeting each month

for 6 months total. The

Administrator and/or designee will

be responsible for monitoring this

POC to ensure its successful

completion.





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OMB NO. 0938-039




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a. RN 2 indicated there were 15 residents on A

Hall, 5 with incontinence, and all residents had

behaviors that required supervision. RN 2 also

indicated there were 16 residents on B Hall, 11

with incontinence, and all residents had behaviors

that required supervision.

b. CNA 12 indicated there were 17 residents on C

Hall, 8 required 2 assist, 8 were incontinent, and 6

required lifts. CNA 12 also indicated there were 21

residents on D Hall, 13 required 2 assist, 15 were

incontinent, and 12 required lifts.

c. CNA 11 indicated there were 18 residents on E


required lifts. CNA 11 also indicated there were 19

residents on F Hall, 13 required 2 assist, 13 were

incontinent, and 10 required lifts.

d. LPN indicated there were 9 residents on G/H/I


required a lift.


the Staffing Coordinator indicated the following

goal for staffing:

A/B Hall: 2 nurses and 3 aids (days and evenings)

C/D and E/F Halls: 1 nurse and 2 aids per hall

(days and evenings)

G/H/I Hall: (if below 12 residents) 1 nurse and 1

aid. (if 12 or above) either 1 nurse and 2 aids, or 2

nurses and 1 aid (days and evenings)

Nigh shift for all halls: 1 nurse per hall, and 2 aids

per unit.

At that time, the Staffing Coordinator indicated

there had been several consistent call-ins, and

many staff have recently quit.

4. On 6/23/21 at 10:00 A.M., the "as worked"





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schedule from 6/13/21 through 6/19/21 was

reviewed with the following:

6/13/21

Day A/B Hall: 2 nurses, 2 CNAs

Day E/F Hall: 2 nurses, 3 CNAs

Night A/B Hall: 1 nurse, 2 CNAs

Night C/D Hall: 1 nurse, 2 CNAs

6/14/21

Day C/D Hall: 2 nurses, 3 CNAs (1 of the 3 in at

10a)

Evening C/D Hall: 2 nurses, 3 CNAs (1 until 6p,

and 1 until 8p) 1 CNA from 8p until 10p

Evening E/F Hall: 1 nurse (from 2p until 8p), 2

CNAs



Night E/F Hall: 1 nurse, 1 CNA

6/15/21

Evening A/B Hall: 2 nurses, 2 CNAs

Evening E/F Hall: 3 nurses (1 from 2p-6p, 1 from

2p-8p, and 1 from 6p-10p), 3 CNAs



Night E/F Hall: 1 nurse, 2 CNAs

6/16/21






6/17/21



Evening C/D Hall: 2 nurses, 3 CNAs (1 from 2p-8p)






07/22/2021PRINTED:

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OMB NO. 0938-039




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6/18/21


Evening C/D Hall: 2 nurses, 2 CNAs

Evening E/F Hall: 2 nurses (1 from 2p-8p), 3 CNAs


Night C/D Hall: 1 nurse, 2 CNAs (1 from 10p-2a)

Night E/F Hall: 1 nurse, 2 CNAs (1 from 2a-6a)

6/19/21


Day C/D Hall: 2 nurses, 3 CNAs (1 from 6p-10p)

Day E/F Hall: 2 nurses, 2 CNAs


Evening E/F Hall: 2 nurses (1 from 2p-8p), 5 CNAs

(1 from 2p-8p and floating to G/H/I Hall, 1 from

2p-6p, 1 from 6p-10p, and 1 from 6p-10p and

floating to G/H/I Hall)


Night C/D Hall: 1 nurse, 1 CNA


5. Insufficient staffing was indicated by Resident

F and Resident C not receiving showers

a. During an interview on 6/23/21 at 11:24 A.M.,

Resident F indicated she had two showers in the

last month.

A shower schedule, reviewed 6/24/21 at 10:00

A.M. indicated Resident F was scheduled for a

shower three times a week

The clinical record of Resident F was reviewed on

6/24/21 at 10:10 A.M. The annual MDS (Minimum

Data Set) Assessment, dated 4/30/21, indicated

Resident F experienced no cognitive impairment.

The 10/24/17 assessment indicated Resident F





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OMB NO. 0938-039




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required the assistance of two staff for transfers,

was totally dependent for bathing activity, and

was occasionally incontinent of bladder.


Manager 1 indicated that the resident had not had

a shower between 5/20/21 and 6/20/21.

b. On 6/23/21 at 11:04 A.M., Resident C indicated

hospice would not give her a shower. Resident C

indicated she only received bed baths. Resident

C further indicated she would like a shower

because her hair needed washed. Resident C was

observed to have an indwelling urinary catheter.

Resident C indicated she had the catheter because

she could not get out of bed.




indicated Resident C had mild cognitive

impairment, an indwelling urinary catheter, was

dependent on one person for bathing, and

received hospice services.





Shower days per resident preference, initiated

7/29/20.

Transfers: Resident requires total assist of 2 for

transfers, hoyer lift, initiated 7/29/20.

Resident is receiving hospice services, initiated

10/23/20. The interventions included, but were

not limited to:

Hospice aides to provide personal care including

showers 1-3 times weekly, initiated 10/23/20.





07/22/2021PRINTED:

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I have MASD (Moisture Associated Skin

Damage) to my bilateral buttocks with areas of

scattered excoriation related to me scratching and

could be at risk for further problems, initiated

4/17/21. The interventions included, but were not

limited to:

Report all changes warranted to hospice, undated.


limited to:

Foley (urinary) catheter as needed for dysuria,

irrigate with 30 mL (milliliters) of normal saline,

ordered 5/4/21.

Hoyer (mechanical) lift to be used for transfers,

ordered 10/10/20.

The Hospice Visit Note Reports, indicated

Resident C only received bed baths from

5/4/21-6/17/21. Resident C received a bed bath on:

5/4/21, 5/6/21, 5/11/21, 5/13/21, 5/18/21, 5/20/21,

5/25/21, 5/27/21, 6/3/21, 6/10/21, 6/15/21, and

6/17/21.

On 6/25/21 at 9:53 A.M., , CNA 12 and CNA 10

were observed to transfer Resident C via a

mechanical lift to a chair. CNA 12 indicated that

Resident C had requested to have a shower by

hospice. CNA 12 indicated the hospice aide had

indicated that Resident C could only have bed

baths because she was bed bound.

On 6/25/21 at 2:27 P.M., the Hospice Director

indicated on the hospice care plan Resident C was

a bed bath. The Hospice Director further

indicated that if Resident C could get up via a

mechanical lift there was no reason Resident C

could not have a shower.

6. Insufficient staffing was indicated by lack of

assessment of a dialysis catheter site, and lack of





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communication with the dialysis center for

Resident B.

On 6/22/21 at 11:24 A.M., Resident B indicated he

went to dialysis. Resident B indicated he had a

dialysis catheter.


record was reviewed. The clinical record lacked

any assessments of Resident B's dialysis catheter

site.


limited to:

Resident's current dialysis access site is a dialysis

catheter in right chest, ordered 2/12/21.


Resident B had a fistula.

On 6/25/21 at 12:26 P.M., Resident B indicated he

had a fistula but it did not work. At that time,

Resident B held out his left arm to show where the

fistula was located. There was no dressing

observed to the area. Resident B indicated he had

a catheter in his chest for dialysis.

On 6/28/21 at 10:05 A.M., LPN 21 indicated she

spoke to the dialysis center and they were using

Resident B's dialysis catheter for dialysis

treatments. LPN 21 indicated she had no idea.

7. Insufficient staffing was indicated by lack of

quality resident care related to a dressing change

for Resident E.

On 6/25/21 at 10:30 A.M., the Wound Nurse was

observed to change the dressing for Resident E's

wound. A fly was observed to be landing on

Resident E's bed. LPN 22 was observed to





07/22/2021PRINTED:

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attempt to remove the fly. The Wound Nurse

removed her gloves, washed her hands, and

donned clean gloves. The Wound Nurse cleaned

the wound with normal saline. The Wound Nurse

removed her gloves, washed her hands, and

donned clean gloves. At that time, the fly was

observed to land on Resident E's open wound.

The Wound Nurse waved her hand in an attempt

to get the fly off of Resident E's open wound. The

fly landed on Resident E's leg and then again on

Resident E's open wound. The Wound Nurse

waved her hand again to remove the fly. The

Wound Nurse was observed to pack the wound

with calcium alginate with silver and wrapped the

wound with kerlix.


indicated that she was devastated over the fly

landing on the resident and was going to talk to

maintenance. The Wound Nurse further indicated

that the independent smokers used the patio on

that unit to smoke. Resident E's room was across

the hall from the patio door.

8. Insufficient staffing was indicated by a lack of

discharge paperwork when a resident was

transferred to a hospital.

a. During record review 6/24/21 at 2:13 P.M.,





Resident G's records did not contain a Notice of

Transfer/Discharge or a Notice of Bed Hold policy

given the resident or a representative at the time

of the transfer.

b. During record review on 6/24/21 at 11:00 A.M.,





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they had not receive a bed hold policy.

During an interview on 6/28/21 at 12:45 P.M., RN


on 5/18/21 and that the Notice of

Transfer/Discharge and Bed Hold policy forms

were sent in the hospital transfer paperwork but

were never filled out and should have been.

c. On 6/2/21 and 6/4/21, Resident E was sent to

the emergency room.

The clinical record lacked a Notice of

Transfer/Discharge or a Notice of Bed Hold.



of Transfer/Discharge or a Notice of Bed Hold for

Resident E's hospitalization and transfer.

9. Insufficient staffing was indicated by failure to

ensure a a self medication administration

assessment was completed.

On 6/22/21 at 11:30 A.M., a bottle of Equate Cold


bedside table. Resident B indicated he took the

medication when he needed it.

The Physician's Order lacked an order to self

administer medications and Equate Cold and Flu.





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Resident B did not have any medications he self

administered.

10. Insufficient staffing was indicated by a lack of

ensuring residents that required assistance had a

call light within reach.

On 6/22/21 at 11:34 A.M., Resident B was


call light was not within reach. Resident B

indicated that if he needed assistance he had to

yell for help.

On 6/25/21 at 12:26 P.M., Resident B was


call light was not within reach.





was dependent upon two persons for bed

mobility, transfers, and toilet use, and required

extensive assistance of two persons for dressing

and personal hygiene.

During an interview on 6/28/21 at 12:20 P.M., the

Administrator indicated there was not a specific

staffing policy, but it was the facility policy to

staff based on resident needs.

This Federal tag relates to Complaint IN00356525.

3.1-17(b)

483.35(g)(1)-(4)

Posted Nurse Staffing Information

§483.35(g) Nurse Staffing Information.

§483.35(g)(1) Data requirements. The facility

F 0732

SS=C

Bldg. 00





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must post the following information on a daily

basis:

(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours

worked by the following categories of

licensed and unlicensed nursing staff directly

responsible for resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed

vocational nurses (as defined under State

law).

(C) Certified nurse aides.

(iv) Resident census.

§483.35(g)(2) Posting requirements.

(i) The facility must post the nurse staffing

data specified in paragraph (g)(1) of this

section on a daily basis at the beginning of

each shift.

(ii) Data must be posted as follows:

(A) Clear and readable format.

(B) In a prominent place readily accessible to

residents and visitors.

§483.35(g)(3) Public access to posted nurse

staffing data. The facility must, upon oral or

written request, make nurse staffing data

available to the public for review at a cost not

to exceed the community standard.

§483.35(g)(4) Facility data retention

requirements. The facility must maintain the

posted daily nurse staffing data for a

minimum of 18 months, or as required by

State law, whichever is greater.


review, the facility failed to ensure current staffing

sheets were posted daily for 3 of 5 days during

the survey.





07/28/2021 12:00:00AM





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Finding includes:

On 6/22/21 at 12:29 P.M., the staffing sheet posted

by A/B Hall had the date 6/21/21.

On 6/23/21 at 10:21 A.M., the staffing sheet

posted by A/B Hall had the date 6/21/21. At that

time, the staffing sheet posted by C/D Hall had

the date 6/21/21.

On 6/25/21 at 10:46 A.M., the staffing sheet

posted by C/D Hall had the date 6/24/21.


DON (Director of Nursing) indicated current

staffing sheets were supposed to be posted either

the previous night or the morning of the current

date.

On 6/28/21 at 12:15 P.M., a current Posting Direct

Care Daily Staffing Numbers policy, dated 7/16,

was provided and indicated "Within two (2) hours

of the beginning of each shift, the number of

Licensed Nurses (RNs, LPNs, and LVNs) and the

number of unlicensed nursing personnal (CNAs)

directly responsible for resident care will be

posted in a prominent location (accessible to

residents and visitors) and in a clear and readable

format"


be affected by the alleged findings.







be affected by the alleged

findings.





does not recur:

Staff education to be provided

07/20/2021 & 07/22/2021 to

ensure correct posting is available

to view in prominent locations by

residents and visitors.




recur:

Administrator and/or Designee will

audit daily nursing staff posting 5x

week x 4 weeks, then 3x week x 4

weeks, then weekly x 4 weeks

and continue on ongoing basis to

ensure posting reflects current

staffing of the shift. Any staff who

fail to comply with the points of

the in-service will be further

educated and/or progressively

disciplined as indicated. The

results of the monitoring tool will

be presented to the QAPI

Committee at the monthly






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needed, an Action plan will be


written Action Plan will be

monitored weekly by the

Administrator until resolution.

483.60

Provided Diet Meets Needs of Each Resident

§483.60 Food and nutrition services.

The facility must provide each resident with a

nourishing, palatable, well-balanced diet that

meets his or her daily nutritional and special

dietary needs, taking into consideration the

preferences of each resident.

F 0800

SS=D

Bldg. 00


review, the facility failed to ensure meals were

served to meet residents special dietary needs for

3 of 3 residents reviewed for diet orders.

(Resident 74, Resident B, Resident D)

Finding includes:

1. On 6/22/21 at 11:49 A.M., Resident 74 was

observed with a lunch tray in her room. Resident

74 indicated that she was allergic to carrots and

she was served carrots with her lunch meal.

Resident 74's lunch tray was observed to have a

vegetable medley with carrots present. At that

time, CNA 14 was notified. CNA 14 indicated that

Resident 74 had told her about the carrots but

went to check with the kitchen. CNA 14 told

Resident 74 that it was not on her meal tray card

and she would write it on there.

On 6/22/21 at 2:03 P.M., Resident 74's clinical

record was reviewed. The clinical record indicated

Resident 74 was allergic to carrots.





A review of Resident 74, B, and D

diet orders have been reviewed.

Tray cards have been updated.







be affected by the alleged deficient

practice. A complete review of

residents diet orders and tray

cards has been completed and no

further issues identified.





does not recur:

An in-service will be completed

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2. On 6/22/21 at 11:14 A.M., Resident B indicated

he did not get enough food to eat.


record was reviewed. The Physician's Orders

included, but were not limited to: Diet:

Consistent Carbohydrate-Renal diet, double meat

with meals, two boiled eggs with breakfast.

On 6/25/21 at 12:46 P.M., Resident B's lunch tray

was observed. Resident B received one piece of

fish. Resident B's tray card was reviewed at that

time. The tray card lacked information regarding

double meat with meals.

3. On 6/23/21 at 11:59 A.M., Resident D was

observed to have a piece of thick tortilla-like bread

with his lunch tray. RN 2 indicated at that time

Resident D was not to have bread due to choking,

and took it to the A Hall dining area. Resident D's

meal card on the tray was reviewed and indicated

"RESIDENT IS TO HAVE NO BREAD"

On 6/25/21 at 11:19 A.M., Resident D's clinical

record was reviewed. The most recent (quarterly)

MDS (Minimal Data Set) assessment, dated

5/20/21, indicated Resident D was severely

cognitively impaired and required supervision

with eating. Diagnoses included, but were not

limited to, autism, anxiety, and depression.

Current orders included, but were not limited to:

resident needs prompted to eat slowly during

meals, dated 5/8/20. The orders lacked anything

related to not eating bread.

A written progress note, dated 8/16/20, indicated

"Resident had an episode of chocking [sic] during

this meal hour. Resident was able to cough food

out without difficulty. Large piece of bread

07/20/2021 & 07/22/2021 with all

staff regarding diet orders and tray

cards. Upon the RD visit, she will

complete a random audit tray

prepared to diet assigned and

document findings in the

consultant RD report. If

discrepancy is found immediate

correction will be completed.




recur:

The Dietary Manager and/or

Designee will complete an audit

tool that randomly review 5

residents which will verify diet and

tray cards are served. This audit

will be completed weekly x3,

monthly x3, and quarterly x3.














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coughed out. Kitchen staff informed to avoid

sandwich bread for this resident".

The clinical record lacked any other notes related

to not eating bread.

On 6/28/21 at 12:30 P.M., a current Diet Orders

policy, dated 6/18, was provided and indicated

"Diet orders must be clarified in the Medical

Record as interpreted by the Dietary Department

... Any specialty diet must be clarified by the

Registered Dietitian Nutritionist. For diets where

spreadsheets are not routinely available, the

Dietitian will specify guidelines for providing

these diets"

On 6/25/21 at 2:52 P.M., a current Use of

Spreadsheets policy, dated 6/18, was provided

and indicated "Dietary employees working on the

food line must utilize spreadsheets that

correspond to the menu being served ... Staff

must follow the diets exactly as indicated on the

spreadsheet"

3.1-20(a)

483.60(a)(3)(b)

Sufficient Dietary Support Personnel

§483.60(a) Staffing

The facility must employ sufficient staff with

the appropriate competencies and skills sets

to carry out the functions of the food and

nutrition service, taking into consideration

resident assessments, individual plans of

care and the number, acuity and diagnoses

of the facility's resident population in

accordance with the facility assessment

required at §483.70(e).

§483.60(a)(3) Support staff.

F 0802

SS=E

Bldg. 00





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The facility must provide sufficient support

personnel to safely and effectively carry out

the functions of the food and nutrition service.

§483.60(b) A member of the Food and

Nutrition Services staff must participate on

the interdisciplinary team as required in §

483.21(b)(2)(ii).


review, the facility failed to provide sufficient staff

to carry out the functions of food service in an

accurate and timely manner for 2 of 2 facility

kitchens. Delivered frozen food items were not

moved to the freezer when delivered, food service

did not commence on time, hot food (which was

cold and not palatable) was delivered to some

residents' rooms, food was left uncovered, food

items were not documented with the open dates.

(Kitchen 1, Kitchen 2)

Findings include:

During the initial tour of the kitchens on 6/22/21,

dietary staff indicated Halls A, B, C, D were

served meals from Kitchen 1 and Halls E, F, G, H, I

were served from Kitchen 2.

1. During the survey the following resident

interviews were completed:


Resident 88 indicated the food was not good and

that the facility served fish three times a week.

During an interview on 06/22/21 at 11:54 A.M.

Resident 18 indicated the food was not good.


Resident 100 said, "The food is horrid." Resident





HR Team Members (Dietary

Manager, Administrator, and

Human Resources Director) will

review the unique characteristics

of each kitchen regarding resident

census needed in establishing

staffing rations (staffing

expectations/minimums per

kitchen).






HR Team Members (Dietary

Manager, Administrator, and

Human Resources Director) will

review the unique characteristics

of each kitchen regarding resident

census needed in establishing

staffing rations (staffing

expectations/minimums per

kitchen).





does not recur:

07/28/2021 12:00:00AM





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100 indicated she had family members who

brought food in so she could prepare food

themselves. Resident 100 indicated there was a

toaster at the nurses' station they could use.

Resident 100 indicated the food tasted bad, the

eggs were rubbery, and the potatoes were

uncooked in the middle.


Resident 106 indicated that the food quality had

deteriorated in the last month or two and that the

food was cold. Resident 106 indicated that the

facility had served a lot of the same foods lately,

(like burritos).


Resident 44 indicated the food was served cold

sometimes, but she didn't ask to have it warmed

up because it took too long to get it back.

Resident 44 indicated the chicken and meats were

too tough to eat.


Resident 36 said, "Yuck, the food doesn't taste

good."

During an interview on 6/23/21 at 11:00 A.M.,.

Resident C said, "The food is terrible."


Resident 95 said, "The food is not great, and it is

not hot."


Resident B indicated he did not receive enough

food. Resident B indicated he was supposed to

get a special diet, but that the staff did not know

which diet he was supposed to get. Resident B

indicated he did not say anything because he was

hungry, and he wanted to eat.

HR Team Members will review

staffing day sheets for the

upcoming week during the weekly

HR Meeting (agenda update) to

ensure that staffing expectations

are being met.




recur:

Day sheets with additional staffing

to be turned in to DON and

Administrator each week by

Dietary Manager per POC.



monitored each week during HR

meeting using the day sheets

report. Progress toward the

successful completion of this POC

will be monitored daily on normal

business days for one month by

comparing posted hours report

with the day sheets, then weekly

x4 weeks, then semi-monthly x4

months for a total of 6 months

ensuring compliance.



reviewed each week day in stand

up and also by the QAPI

Committee meeting each month

for 6 months total. The


be responsible for monitoring this

POC to ensure its successful

completion.





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2. During an interview on 6/25/21 at A.M. at 9:57

A.M., Cook 1 indicated Styrofoam plates were

used on the A and B Units because they ran out

of dinner plates. A and B Units were the last units

to be served lunch. Cook 1 indicated she opened a

new box of plates two days ago. Cook 1 indicated

the staff was unable to keep up with washing

dishes and serve too. Due to short staffing, Cook

1 indicated the staff was unable to furnish clean

plates during resident food service.


Cook 1 indicated resident food service was

supposed to begin at 11:30 A.M., but the facility

was short dietary staff, and the dietary staff was

serving all 116 residents in the entire building.

Hall trays left the kitchen at the following times:

The E Hall trays left the kitchen at 12:13 P.M.

The F Hall trays left the kitchen at 12:22 P.M.

The GHI Halls trays left the kitchen at 12:29 P.M.

The C Hall trays left kitchen at 12:36 P.M.

The D Hall trays left the kitchen at 12:45 P.M.

The A and B Halls trays left the kitchen at 1:06

P.M.

4. During an interview on 6/25/21 at 12:59 P.M.,

Cook 1 indicated the food delivery person left the

frozen food delivery on the floor in the storeroom.

Cook 1 indicated the delivery arrived around

noon, but the dietary staff did not have enough

staff to put the order away, because they had to

serve lunch.

Uncovered, plated lemon pie slices were stored on

an open metal rack.

5. During an interview on 6/25/21 at 1:10 P.M.,





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Cook 1 indicated she conducted all the necessary

tasks required to keep the kitchen functioning.

Cook 1 indicated the dietary staff typically had at

least 3 staff in each kitchen. Cook 1 said that all

day today, (for breakfast, lunch, and dinner) only

2 dietary aides and 1 cook were available to

conduct food service for the entire facility,

especially when the dietary staff typically

depended on operating 2 kitchens. Cook 1

indicated many staff had quit and many applicants

could not pass the background checks.

6. During an observation on 6/25/21 at 1:20 P.M.,

(one hour and twenty minutes after delivery)

Dietary Aide 1 and Dietary Aide 2 were observed

removing boxes from the floor of the food storage

room and placing them in the freezer.

7. During an observation on 6/25/21 at 12:34 P.M.,

residents were heard yelling from their rooms.

"Where's my food?"


Administrator indicated the cook was supposed

the follow the menu and spread sheet for all food

service preparation, including preparation of

special diets. The Administrator indicated that

food temperatures were always supposed to be

taken and documented before food service

commenced.

A policy titled, "Serving of Resident Trays",

dated 6/2018, was provided by the Administrator

on 6/25/21 at 2:29 P.M. and reviewed. The policy

read as follows: "...8. HAVE HOT FOOD HOT

AND COLD FOOD COLD WHEN THE TRAYS

REACH THE RESIDENT...PROMPT DELIVERY

OF TRAYS IS IMPERATIVE TO ASSURE HOT

FOOD FOR THE RESIDENT..."





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A policy titled, "Professional Staffing ", dated

6/2018, was provided by the Administrator on

6/28/21 at 12:30 P.M. and reviewed. The policy

read as follows: "...Policy: The Dietary Department

will employee sufficient staff, with appropriate

competencies and skills sets to carry out the

functions of the food and nutrition service..."

3.1-20(h)

483.60(c)(1)-(7)

Menus Meet Resident Nds/Prep in

Adv/Followed

§483.60(c) Menus and nutritional adequacy.

Menus must-

§483.60(c)(1) Meet the nutritional needs of

residents in accordance with established

national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's

reasonable efforts, the religious, cultural and

ethnic needs of the resident population, as

well as input received from residents and

resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's

dietitian or other clinically qualified nutrition

professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph

should be construed to limit the resident's

right to make personal dietary choices.

F 0803

SS=E

Bldg. 00

F 0803 What corrective actions will be 07/28/2021 12:00:00AM





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review, the facility failed to ensure kitchen staff

followed recipes for 10 of 10 pureed meals in 1 of 2

functioning kitchens. Kitchen staff did not follow

a recipe for fish, bow tie pasta, and peas in

accordance with the dietician signed recipes for 1

of 3 observations of pureed diets. (Kitchen 1,

Kitchen 2)

Findings include:


Cook 1 indicated resident food service was

supposed to begin at 11:30 A.M., but the facility

was short dietary staff, and the dietary staff in

Kitchen 1 was serving all 116 residents in the

entire building.

During an observation in Kitchen 1 on 6/25/21 at

11:05 A.M., Cook 1 indicated she would puree the

foods to be served at lunch today (fish, peas, and

pasta for 10 residents), but that she always pureed

more in case residents wanted a second serving.

Without consulting a recipe, Cook 1 placed 15

pieces of baked fish in the food processor bowl

and blended the fish. Cook 1 then poured hot

water into the food processor and said (referring

to the amount of water she added to the fish), "I

judge it myself. If it is too thick I just add more

water." Cook 1 then covered the pureed fish and

placed the pan on the steam table. Cook 1 washed

the food processor bowl in the 3-compartment

sink with soap and water and returned the bowl to

the prep table where she had been working. No

sanitation solution had been used while cleaning

the bowl.

Cook 1 removed a large pan of bow tie pasta from

the stove and drained the pasta in the sink. Cook

1 emptied the pan of bow tie pasta into a steam

table pan and then applied an unmeasured amount

accomplished for those residents

found to be affected by the

deficient practice:

No specific residents were

identified during the survey, any

resident on a pureed diet could be

affected by the deficient practice.

The residents who currently have

an order for pureed diets are now

having their meals prepared in

accordance with established

recipes for pureed food items.



same deficient practices will be

identified and what corrective

action will be taken:

The residents who currently have

an order for pureed diets are now

having their meals prepared in


recipes for pureed food items.


place and what systemic changes

will be made to ensure that

deficient practice does not recur:

The Dietary Manager has audited

the menus to ensure that there are

recipes on how to puree all food

items listed on the current

menus. An in-service on

07/20/2021 & 07/22/2021 has

been provided for all dietary staff

on their responsibility in following

the posted pureed recipes for all

resident who have an order for a

pureed diet.

How the corrective actions will be

monitored to ensure the deficient

practices will not recur:





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of died parsley flakes on the pasta. Cook 1

indicated she did not not use a recipe for the bow

tie pasta because, as Cook 1 indicated , it can

sometimes taste bitter with too much parsley.

Cook 1 said, "I like to judge for myself how much

butter and parsley." Cook 1 then took two pats of

butter, placed them on top of the pasta, covered

the steam pan with foil, and placed the pan on the

steam table.

Cook 1 took 15 4-ounce scoops of bow tie pasta

and placed them in the food processor. While the

pasta was processing, she added an unmeasured

amount of hot water, while saying," I'm just

judging how much water to put in there."

No butter was added to the puree. Cook 1 took the

food processor bowl to the 3-compartment sink,

washed the food processor bowl with soap and

water, and then returned the bowl to the food

processor. No sanitation solution had been used

while cleaning the bowl. Cook 1 took 15 4-ounce

scoops of peas and placed them in the food

processor and blended. No additional water was

added.

A policy dated 6/2018 titled, "Use of

Spreadsheets", was provided by the

Administrator on 6/25/21 at 2:52 P.M., and

reviewed. The policy read as follows: "Policy:

Dietary employees working on the food line must

utilize spreadsheets that correspond to the menu

being served ..."


Administrator indicated the meals should be made

according to the menus and spread sheets.

3.1-20(i)(4)


and implemented on monitoring

meal preparation to ensure that

pureed items are being prepared in


recipes that have been approved

by the dietician. This tool will be

completed by the Dietary Manager

and/or Designee weekly for four

weeks, then monthly for three

months, and then quarterly for

three quarters.










483.60(d)(1)(2)

Nutritive Value/Appear, Palatable/Prefer

F 0804

SS=E





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Temp

§483.60(d) Food and drink

Each resident receives and the facility

provides-

§483.60(d)(1) Food prepared by methods that

conserve nutritive value, flavor, and

appearance;

§483.60(d)(2) Food and drink that is

palatable, attractive, and at a safe and

appetizing temperature.

Bldg. 00


review, the facility failed to ensure hall trays were

served within the designated temperatures for 2 of

2 hall trays tested for food temperatures and

appetizing taste, and appearance. (Resident 88,

Resident 18, Resident 100, Resident 106, Resident

44, Resident 36, Resident 33, Resident 95,

Resident 85, Resident C)

Findings include:


Resident 88 indicated the food was not good, and

the facility served fish three times a week.

2. During an interview on 06/22/21 at 11:54 A.M.

Resident 18 indicated the food was not good.


Resident 100 said, "The food is horrid." Resident

100 indicated she had family members who

brought food in so she could prepare food

themselves. Resident 100 indicated there was a

toaster at the nurses' station they could use.

Resident 100 indicated the food tasted bad, the

eggs were rubbery, and the potatoes were

uncooked in the middle.





Residents identified during survey

have been interviewed for their

preferences and concerns. The

Dietary Manager will participate

with Resident Council with

permission to attend and discuss

menus and any other concerns

regarding meal service. Staff will

encourage resident to dine in the

dining room for the delivery of their

food tray directly from the kitchen

to ensure temperatures and

delivery time.







be affected by this deficient

practice.




07/28/2021 12:00:00AM





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Resident 106 indicated that the food quality had

deteriorated in the last month or two and that the

food was cold. Resident 106 indicated that the

facility had served a lot of the same foods lately,

like burritos.


Resident 44 indicated the food was served cold

sometimes, but she didn't ask to have it warmed

up because it took too long to get it back.

Resident 44 indicated the chicken and meats were

too tough to eat.


Resident 36 said, "Yuck, the food doesn't taste

good."

7. During an interview on 6/23/21 at 11:00 A.M.,.

Resident C said, "The food is terrible."


Resident 95 said, "The food is not great, and it is

not hot."

9. During the resident council meeting on 6/22/21

at 2:45 P.M., Resident 85 indicated the food was

"Nasty". Resident 85 indicated there were no

microwaves and no coffee pots available.

10. On 6/23/21 at 9:00 A.M., the resident council

minutes from April 2021 were reviewed and

indicated a resident did not care for the new

menus, and there was too much fish.

On 6/25/21 at 12:45 P.M., a C Hall lunch tray was

sampled for temperature, taste, and appearance:

Fish was 125 degrees Fahrenheit, and was dry and

bland.

Peas were 120 degrees Fahrenheit, and were

soggy and bland.


does not recur:

All staff will be in-serviced

07/20/2021 & 07/22/2021

regarding appropriate food temps

as they are to be delivered to the

residents. Once the carts are

delivered to the units, the dietary

staff will alert a staff member that

the carts have been delivered and

available to start service. Dietary

will place test trays on each cart

and temps will be taken at random

meal times and documented

results. During the Registered

Dietician visit, they will randomly

observe the test trays for meal

appearance and temps.




recur:

Unit Managers and/or Designee

will take 5 test trays per week at

random times and document

findings weekly for four weeks,

then monthly for three months,

and then quarterly for three

quarters. Any concerns identified

will be addressed if observed.

Results on monitoring will be

further reviewed in QAPI and if

trends are identified then another

action may be developed. Any

action plan written by the QAPI

committee will be monitored by

the Administrator weekly until

resolution.





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Lemon pie was 72 degrees Fahrenheit.

Noodles were unable to be temped, and were dry

and bland.

On 6/25/21 at 12:16 P.M. the Food cart for Hall E

was observed being delivered to Hall E. At 12:26

P.M., a lunch tray was sampled for temperature,

taste, and appearance:

Tray contained peas, fish and noodles.

Fish - 114 degrees

Noodles - 107 degrees

The peas were mushy, the fish was dry and bland,

and the noodles were bland.

A policy titled, "Serving of Resident Trays",

dated 6/2018, was provided by the Administrator

on 6/25/21 at 2:29 P.M. and reviewed. The policy

read as follows: "...8. HAVE HOT FOOD HOT

AND COLD FOOD COLD WHEN THE TRAYS

REACH THE RESIDENT...PROMPT DELIVERY

OF TRAYS IS IMPERATIVE TO ASSURE HOT

FOOD FOR THE RESIDENT."

A policy titled, "Food Temperatures on Service

Lines", dated 6/2018, was provided by the

Administrator on 6/25/21 at 2:29 P.M. and

reviewed. The policy read as follows: "...Policy:

Foods will be served at proper temperature to

ensure food safety...3. Record reading on "Food

Temperature Record" form at beginning of tray

line and end of tray line...pasta greater than 135

degrees...Cold salads and desserts less than 41

degrees..."

3.1-21(a)(1)

3.1-21(a)(2)

483.60(i)(1)(2)

Food

F 0812

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Procurement,Store/Prepare/Serve-Sanitary

§483.60(i) Food safety requirements.

The facility must -

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

approved or considered satisfactory by

federal, state or local authorities.

(i) This may include food items obtained

directly from local producers, subject to

applicable State and local laws or

regulations.

(ii) This provision does not prohibit or prevent

facilities from using produce grown in facility

gardens, subject to compliance with

applicable safe growing and food-handling

practices.

(iii) This provision does not preclude residents

from consuming foods not procured by the

facility.

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

serve food in accordance with professional

standards for food service safety.

Bldg. 00


review, the facility failed to ensure food was

served in a sanitary manner for 2 of 4 kitchen

observations. The temperature of the food on the

steam table was not checked before service

started, staff touched ready to eat food with their

hands, food was not discarded within 3 days of

preparation or opening, and food was not

covered. (Kitchen 1, Kitchen 2)

Findings include:

During the first observation of Kitchen 1 (upstairs

kitchen, serves Halls A, B, C, D) on 6/22/21 at 9:50

A.M., the following was observed:

Located in the reach in refrigerator were the





Unlabeled/Undated foods have

been corrected. Both kitchens

were reviewed to ensure food is

being stored and distributed in

accordance with professional

standards for food service safety.

Temperature logs have been

reviewed and identified problem

areas and staff education

provided. The storage of container

of clean cloths have been moved.

Personal items have been

removed from the kitchens and

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following items:

1. Two blocks of American cheese which were

partially used and no documentation of the date it

had been opened.

2. One half used package of sliced turkey which

was opened and no documentation of the date it

had been opened.

3. One half used package of sliced ham which was

opened and no documentation of the date it had

been opened.

4. One half pound of margarine with no date

documenting when it had been opened.

5. One gallon of Minestrone soup with a use - by

date of 6/17/21 which had not been discarded.

6. A trash receptacle located near the prep table

was overflowing with trash and was uncovered.

7. A white, plastic, 3 drawer cabinet located next

to the 3-compartment sink was splashed with

debris over the front and on top.

8. The evening shift documentation for the June

2021 dishwasher temperatures, cleaning schedule,

and refrigerator temperatures logs were not

completed.

9. A pan of baked corn bread located on the

service/prep table was observed to be uncovered.

10. One bowl of apple pie filling located on the

service/ prep table was uncovered with no one

attending.

11. During review of the kitchen cleaning schedule

staff education provided. The

Dietary Manager has cleaned

items in kitchen and staff

education provided on the cleaning

schedules. The Maintenance

director has clean a/c unit and

changed filter and has been added

to the monthly preventative

maintenance program. The

Maintenance Director has

sanitized the ice machine and has

been placed on a preventative

maintenance program.






All residents in the facility have

the potential to be affected by the

same alleged deficient practice.

Both kitchens have been reviewed

to ensure food is being stored and

distributed in accordance with

professional standards for food

service safety. Preventative

maintenance program has been

updated to include items.





does not recur:


07/20/2021 & 07/22/2021 on the

alleged deficient practice and will

be educated in accordance with

facility policy and the professional

standards of care.






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on 6/24/21 at 9:59 A.M., daily cleaning tasks were

reviewed from 6/2/21 to 6/27/21. Daily tasks were

missed 7 of 7 days and weekly cleaning tasks were

not documented as completed.

During an interview on 6/22/21 at 9:59 A.M., Cook

2 indicated the evening shift was responsible for

completing the documentation logs and that they

must have forgotten to complete them for their

shifts. Cook 2 indicated all items which were

opened and stored were supposed to be

documented with the date they were opened as

well as the disposal date.

During the first observation of the Kitchen 2

(downstairs kitchen, serves Halls E, F, G, H, I) on

6/22/21 at 10:20 A.M., the following was observed:

12. Located in the reach in refrigerator was one

package of partially used corn beef with an open

date of 6/17/21. Cook 2 indicated the package

should have been disposed of 6/21/21.

13. Five breakfast cereals (Captain Crunch Cereal,

Raisin Bran Cereal, Corn Flakes Cereal, Cheerio's

Cereal, Rice Crispy Cereal) were stored in plastic

storage bins which did not contain documented

date the cereals were opened and removed from

their original containers.

14. An uncovered plastic container containing

clean washcloths and towels was located next to

the hand sanitation sink. The container had

observable splash stains from the sink.

15. An air conditioning unit was suspended from

the ceiling on metal bars. Clumps of dust were

observed hanging on the metal bars. The air

conditioner filter was located on the side of the

unit and was brown and dusty.



recur:

Progress will be monitored on

business days for 1 month,

weekly for 4 weeks, and

semi-monthly for 4 months or until

substantial compliance is met.

Documentation of all activities

associated with this POC will be

noted on said audit tool. The


review the audit tool on business

days during stand up.














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16. Inside the reach in freezer, a red substance

was spilled on the shelves. The bottom shelf was

covered with ice covered cardboard which

contained unidentified substances frozen in the

ice.


Cook 1 indicated the 5 cereals stored in the plastic

storage containers were supposed to show the

documented dates when the cereals were placed

in the storage containers. Cook 1 indicated the

spilled red substance in the reach in refrigerator

was cranberry juice.

During a second observation of the Kitchen 1 on

6/25/21 at 9:57 A.M., the following was observed:

17. Two full Styrofoam drink cups were located in

the prep area. One Styrofoam cup had Dietary

Aide 1's name written on the side of the cup.

18. On 6/25/21 at 10:26 A.M., the ice machine

located between the G and H Units and the E and

F Units was observed to have a buildup of a white

unidentified substance on the ice guard. The ice

scoop holder mounted on the wall did not have a

cover and had a buildup of an unidentified, hard

white substance located in the bottom of the

storage unit.

During an observation and interview on 6/25/21 at

10:35 A.M., CNA 66 indicated the ice located in

the ice chest in the E and F snack room was full of

ice that she had obtained from the ice machine

located in the hall between the E and F Units and

the G and H Units. CNA 66 indicated she used the

ice in the ice chest to fill the residents' drink cups

in the morning.





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Maintenance Supervisor indicated he cleaned the

ice machine once every three months.

A policy titled, "Sanitizing Ice Machine and

scoops", was provided by the Administrator and

reviewed on 6/28/21 at 9:45 A.M. The policy read

as follows: "...Clean unit a minimum of once a

month...The ice scoop is stored in a clean covered

container ..."

During a third observation of the Kitchen 1 on

6/25/21 at 11:05 A.M., the follow was observed:

19. Uncovered, plated lemon pie slices were stored

on an open metal rack.

20. During an observation on 6/25/21 at 11:05

A.M., Cook 1 indicated she would puree the foods

to be served at lunch today (fish, peas, and pasta

for 10 residents), but that she always pureed more

in case residents wanted a second serving.

Without consulting a recipe, Cook 1 placed 15

pieces of baked fish in the food processor bowl

and blended the fish. Cook 1 washed the food

processor bowl in the 3-compartment sink with

soap and water and returned the bowl to the prep

table where she had been working. No sanitation

solution had been used while cleaning the bowl.

After Cook 1 pureed the bow toe pasta, Cook 1

washed the food processor bowl in the

3-compartment sink with soap and water and

returned the bowl to the prep table where she had

been working. No sanitation solution had been

used while cleaning the bowl.

21. Two radios were positioned on the food prep

table where Cook 1 processed the puree. Both

radios were covered with a sticky film.





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22. One Styrofoam drink cup was positioned on

the prep table where Cook 1 processed the puree.

23. Three dish racks were located on the floor of

the dishwashing room. A black, unknown

substance was observed on the back splash of

the dishwashing machine. The water supply pipes

and drainpipes under the dishwashing machine

were covered in accumulated dust and food

debris. The top and sides of the dishwasher had

accumulated dust and debris, and the floor under

the dish washer and the dish landing tables had

accumulated dirt and debris.

24. Without donning gloves, Dietary Aide 1 (DA

1) removed 3 sandwich bags from the prep table,

reached inside her pocket, pulled out a red marker,

and documented the date on the sandwich bags.

Without gloves on her hands, DA 1 retrieved 6

slices of bread from a bag, retrieved turkey from a

bag, and ham from a bag, and made two turkey

sandwiches and one ham sandwich.

25. Food service began at 11:59 A.M. in Kitchen 1,

Cook 1 prepared the first plate of food for E Hall.

Cook 1 was made aware she had not taken the

temperature of the food located on the steam table

before starting service. Cook 1 indicated she had

taken the temperature of the food when it came

out of the oven.

26. The uncovered lemon pie slices were placed

on residents' food trays which were placed in the

food carts for delivery to residents' rooms.

27. D Hall food delivery cart was filled with

residents' food trays. Dietary Aide 2 placed the

last 3 resident food trays on top of the food cart

and indicated to the delivery staff the cart was

ready to be delivered. The delivery staff inquired





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if the lemon pie on the 3 resident trays located on

the top of the cart should have been covered

before taking the cart. Dietary Aide 2 cut 3 pieces

of plastic wrap with scissors. The wrap became

tangled, and Dietary Aide 2 used her ungloved

hands to straighten the plastic wrap, touching all

surfaces of the wrap, and then covered the lemon

pie.

28. The food temperature log was reviewed and no

temperatures had been documented in the log for

breakfast or lunch for 6/25/21. The "...Temperature

Log" read as follows: "...Record food

temperatures PRIOR to service and AGAIN after

half the meal has been served..."

During an interview on 6/25/21 at 1:10 P.M., Cook

1 indicated she should have taken the temperature

of the food before service began on the steam

table, when the food service was finished, and

documented the temperatures in the Temperature

Log.

29. On 6/22/21 at 11:54 A.M., Resident 75 was

observed to be eating the noon meal in the D Hall

Common area. Multiple flies were observed to be

present. The flies were observed to be landing on

Resident 75's food while he was eating.

A policy titled, "Storage of Foods Under Sanitary

Conditions", dated 6/2018, was provided by the


reviewed. The policy read as follows: "... All food

items stored in the refrigerator must be labeled

and dated if NOT scheduled to be served at the

next meal ..."

A policy titled. "Proper Food Handling on the

Tray Line", dated 6/2018, was provided by the


reviewed. The policy read as follows: "...4. Food





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may not be served using bare hands..."

3.1-21(a)(1)

3.1-21(a)(2)

3.1-21(i)(3)

3.1-21(i)(5)

483.80(a)(1)(2)(4)(e)(f)

Infection Prevention & Control

§483.80 Infection Control

The facility must establish and maintain an

infection prevention and control program

designed to provide a safe, sanitary and

comfortable environment and to help prevent

the development and transmission of

communicable diseases and infections.

§483.80(a) Infection prevention and control

program.

The facility must establish an infection

prevention and control program (IPCP) that

must include, at a minimum, the following

elements:

§483.80(a)(1) A system for preventing,

identifying, reporting, investigating, and

controlling infections and communicable

diseases for all residents, staff, volunteers,

visitors, and other individuals providing

services under a contractual arrangement

based upon the facility assessment

conducted according to §483.70(e) and

following accepted national standards;

§483.80(a)(2) Written standards, policies,

and procedures for the program, which must

include, but are not limited to:

(i) A system of surveillance designed to

identify possible communicable diseases or

infections before they can spread to other

F 0880

SS=E

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persons in the facility;

(ii) When and to whom possible incidents of

communicable disease or infections should

be reported;

(iii) Standard and transmission-based

precautions to be followed to prevent spread

of infections;

(iv)When and how isolation should be used

for a resident; including but not limited to:

(A) The type and duration of the isolation,

depending upon the infectious agent or

organism involved, and

(B) A requirement that the isolation should be

the least restrictive possible for the resident

under the circumstances.

(v) The circumstances under which the facility

must prohibit employees with a

communicable disease or infected skin

lesions from direct contact with residents or

their food, if direct contact will transmit the

disease; and

(vi)The hand hygiene procedures to be

followed by staff involved in direct resident

contact.

§483.80(a)(4) A system for recording

incidents identified under the facility's IPCP

and the corrective actions taken by the

facility.

§483.80(e) Linens.

Personnel must handle, store, process, and

transport linens so as to prevent the spread

of infection.

§483.80(f) Annual review.

The facility will conduct an annual review of

its IPCP and update their program, as

necessary.

F 0880 What corrective actions will be 07/28/2021 12:00:00AM





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review, the facility failed to ensure infection

control practices were implemented for 5 of 8

residents observed for care. Catheter drainage

bags were observed on the floor, hands were not

washed, and gloves were not changed between

dirty and clean tasks. (Resident 58, Resident 84,

Resident H, Resident C, Resident 25)

Findings include:

1. During a random observation on 6/23/21 at 2:29

P.M., Resident 58 was observed in a wheelchair

pushing himself down C Hall with his catheter

tubing dragging on the floor.

During an observation on 6/24/21 at 10:31 A.M.,

Resident 58 was observed in his room sitting in

his wheelchair with his feet resting on his catheter

tubing, which was lying on the floor. Resident 58's

call light was on when CNA 11 walked into the

resident's room at which time Resident 58

requested water. CNA 11 returned to the

resident's room with water and placed it on his

bedside table. CNA 11 did not fix Resident 58's

catheter tubing which was resting on the floor.

During an observation on 6/24/21 at 10:49 A.M.,

CNA 66 entered Resident 58's room and did not

remove the catheter tubing from the floor.

During an observation on 6/25/21 at 2:58 P.M.,

Resident 58 was observed in his wheelchair

pushing himself down E Hall and F Hall with his

catheter tubing dragging the floor.

During an observation and interview with RN 5 on

6/25/21 at 3:01 P.M., RN 5 indicated Resident 58's

catheter tubing was not supposed to be touching

the floor, and RN 5 used a clip to elevate the




Resident #58, #84, #H, #C, and

#25 have not exhibited any

adverse effects. CNA #11 and

CNA #66 has been educated by IP

Nurse 07/20/2021 on proper

placement of catheter tubing and

catheter bag placement. CNA

#10, CNA #12, and CNA # 15 has

been re-educated by DON and/or

IP Nurse 07/20/2021 on proper

gloving hand washing during ADL

care, proper handling of clean and

dirty linens with direct observation

conducted.






All other residents have the


deficient practices. Education has

been provided.





does not recur:

Staff will be re-educated by the IP

Nurse/DON/IP Nurse Consultant

and/or designee on the following;

proper hand washing techniques

following policy “Hand Hygiene

Guidelines” and “Handling of clean

and dirty linens.





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tubing and attach the tubing to Resident's 58's

wheelchair.

2. On 6/22/21 at 11:34 A.M., Resident 84's urinary

catheter bag was observed to be on the floor.

3. On 6/23/21 at 9:48 A.M., Resident 25 indicated

he had been waiting on assistance since

breakfast. At 10:00 A.M., CNA 12 entered room

and indicated she would gather supplies and

return to assist Resident 25. CNA 12 returned to

the room and donned gloves. CNA 12 removed

the blankets and soiled linens from Resident 25's

bed. CNA 12 removed Resident 25's gown. CNA

12 removed her loves and exited the room. CNA

12 and CNA 15 returned to Resident 25's room.

CNA 12 and CNA 15 donned gloves. CNA 12

indicated they would wash Resident 25's body.

CNA 12 obtained a washcloth and washed

Resident 25's penis, assisted Resident 25 to roll to

the left, and cleansed his buttocks. A brown

substance was observed on the washcloth. CNA

12 obtained another washcloth and cleansed

Resident 25's back. No hand hygiene or glove

changes were observed. CNA 15 indicated they

would need to change Resident 25's bed linens.

CNA 12 placed the clean bed linens on the bed

and Resident 25's bed and assisted Resident 25 to

turn to the right. CNA 15 cleansed Resident 25's

bottom, back, and his bottom again. CNA 15 was

not observed to change washcloths. CNA 12 was

observed to be holding Resident 25's hand with

her gloved hand. CNA 12 and CNA 15 put a clean

gown on Resident 25 and changed his pillowcase.

CNA 12 removed her gloves and washed her

hands for 7 seconds before placing them under

running water. CNA 15 removed her gloves and

washed her hands for 12 seconds.

4. On 6/25/21 at 9:53 A.M., CNA 10 and CNA 12

were observed to provide care for Resident C.

The IP Nurse/DON and/or

Designee will observe a return

demonstration on proper hand

washing techniques by 07/20/2021

& 07/22/2021. Any staff member

that fails to comply with the points

of the in-service will be further

educated.




recur:


utilize the audit tools entitled

“Hand Washing Competency” and

“Handling of clean and dirty linen”

for 5 staff members on different

shifts and all departments daily for

6 weeks, then once a week for 2

weeks, then monthly for 4 months.














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CNA 10 washed her hands and donned gloves.

CNA 12 washed her hands and donned gloves.

CNA 12 obtained water from the bathroom faucet,

touching the faucet. CNA 12 removed her gloves

and donned clean gloves. No hand hygiene was

observed. CNA 12 handed a wet washcloth to

Resident C to ensure the temperature was

acceptable. CNA 12 and CNA 10 pulled back

Resident C's blankets, CNA 12 put soap on the

wash cloth and cleansed the area around Resident

C's urinary catheter. A brownish yellow

substance was observed on the washcloth.

Resident C indicated her perineal area itched.

CNA 12 and CNA 10 removed their gloves and

donned clean gloves. No hand hygiene was

observed. CNA 12 was observed to wash the

urinary catheter tubing. CNA 10 dried Resident

C's perineal area. CNA 12 was observed to

remove her gloves and donn clean gloves. No

hand hygiene was observed. Resident C was

assisted to roll to the right. CNA 10 cleaned

Resident C's buttocks. A brownish yellow

substance was observed on the wash cloth. CNA

10 rinsed Resident C's buttocks. CNA 12 and

CNA 10 removed their gloves and donned clean

gloves. No hand hygiene was observed. CNA 10

removed her gloves and exited the room. CNA 12

began placing clean incontinence pads on the

bed. CNA 10 returned and washed her hands.

CNA 12 tucked a clean incontinence brief

underneath Resident C. CNA 10 donned clean

gloves and indicated those were the last pair of

gloves. CNA 10 and CNA 12 assisted resident to

roll to the left and pulled the soiled linens out and

the clean linens through. Resident C was assisted

to her back. CNA 12 fastened the incontinence

brief and removed Resident C's gown. CNA 10

removed her gloves and exited the room. CNA 12

placed Resident C's pants on. At that time,

Resident C's urinary catheter bag was observed





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on the floor. CNA 10 returned to the room with

additional gloves. CNA 10 washed her hands.

CNA 12 assisted Resident C with her shirt and

pants and placed a mechanical lift pad underneath

the resident. CNA 10 donned clean gloves and

assisted CNA 12 with positioning the mechanical

lift pad. CNA 12 removed her gloves and exited

the room. No hand hygiene was observed. CNA

12 brought Resident C's chair into the room

followed by the mechanical lift. Resident C was

then assisted to the chair via mechanical lift.


Resident H's most recent quarterly MDS

(Minimum Data Set) dated 5/24/21, indicated the

resident had an indwelling catheter and was

totally dependent for transfers.

Resident H's diagnoses included, but were not

limited to; spinal stenosis, chronic heart failure,

chronic respiratory failure, and cognitive

communication deficit.

Resident H's physician orders included, but were

not limited to; change Foley catheter bag as

needed, ensure Foley catheter care is provided

every shift, and resident has indwelling Foley

catheter.

Resident H's care plan included, but was not

limited to; Resident has an indwelling catheter...

with interventions including, "Keep drainage bag

and tubing from touching the floor at all times

(initiated 3/23/21).

During an observation on 6/25/21 at 3:00 P.M.,

Resident H was observed lying in bed. Resident

H's catheter bag was clipped to the side of the bed

frame and resting on the floor.

During an interview on 6/28/21 at 9:56 A.M., LPN





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24 indicated catheter bags should not be touching

the floor.


supplied a facility policy dated 7/19/20 and titled,

Catheter Use Care Policy. The policy included, "6.

The drainage bag and tubing should not touch

the floor at any time."


provided the current "Handwashing" policy,

undated. The policy included, but was not limited

to: Following are instances when handwashing

must be done, after contact with resident blood or

body secretions, after removing gloves.

3.1-18(b)(1)

483.90(i)

Safe/Functional/Sanitary/Comfortable Environ

§483.90(i) Other Environmental Conditions

The facility must provide a safe, functional,

sanitary, and comfortable environment for

residents, staff and the public.

F 0921

SS=E

Bldg. 00


review, the facility failed to ensure a sanitary

environment for 4 of 9 halls observed. Urine

odors were present, floors were not clean, flies

were present, used linen was on the floor, used

gloves were on the floor, tiles were missing, dirt

and grime were built up, resident care equipment

was stored uncovered, call light cords were too

short, privacy curtains were not secured, floors

were cracked, and baseboards were not secured.

(C Hall, D Hall common room, C Hall Shower

Rooms, B Hall bathroom, A Hall, Room 15, Room

23, Room 52, Room 48, Room 56, Room 32,

Findings include:





A safe, sanitary and odor-free

environment will be maintained for

all residents. Alleged deficiencies

found in C Hall shower rooms, C

Hall, D Hall, Rooms 52, 48, 56,

32, 23, and 15 have been

corrected. Alleged deficiencies for

A Hall and B Hall flooring, a

contractor will be contacted for a

quote for repair and replacement if

needed.


07/28/2021 12:00:00AM





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1. On 6/22/21 at 10:03 A.M., a urine odor was

observed in the common area at the end of C Hall.

On 6/22/21 at 2:23 P.M., a strong urine odor was

observed at the end of C Hall.

On 6/23/21 at 10:19 A.M., a urine odor was


On 6/28/21 at 9:17 A.M., a urine odor was


2. On 6/25/21 at 9:50 A.M., the D Hall common

room was observed to have dried liquid on the

floor.

On 6/25/21 at 11:51 A.M., multiple flies were

observed to be flying around in the D Hall

common room.

3. On 6/24/21 at 11:27 A.M., the Shower Room 1

on the C Hall was observed to have black marks

throughout the shower room. A used disposable

glove was observed on the floor. Used linens

were observed to be on the floor. The shower

chair was observed to have a brown colored

substance on it. Dirt and black grime build up was

observed at the bottom of the shower wall tile.

Shower Room 2 was observed with black marks

throughout the floor. The shower water was

running, the tile by the toilet was missing, and

multiple chunks of wood were missing from the

doorframe. On 6/25/21 at 12:15 P.M., the Shower

Room 1 on the C Hall was observed to have trash

on the floor, used linens on the floor, and dirt and

black grim build up at the bottom of the shower

wall tile. Shower Room 2 was observed to have

black marks throughout the floor and the water in

the shower was running.

4. On 6/23/21 at 9:47 A.M., Room 52 was





All residents in the facility have

the potential to be affected by the

same alleged deficient practice. A

safe, sanitary and odor-free

environment will be maintained for

all residents. A complete facility

audit will be completed to ensure

the same and that the alleged

deficiencies referenced herein are

not present.





does not recur:


07/20/2021 & 07/22/2021 on the

alleged deficient practice and will

be educated in accordance with

facility policy and the professional

standards of care and

appearance.




recur:


completion of this POC will

monitored using an audit tool.

Progress will be monitored on

business days for 1 month,

weekly for 4 weeks, and

semi-monthly for 4 months or until

substantial compliance is met.

Documentation of all activities

associated with this POC will be





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observed with a brown liquid substance on the

floor. On 6/23/21 at 1:29 P.M., the brown liquid

was observed to be dried on the floor. On 6/25/21

at 12:05 P.M., the brown liquid was observed to be

dried on the floor.

5. On 6/23/21 at 10:47 A.M., Room 48 was

observed. Two oxygen concentrators were

observed to be stored in the bathroom. A wash

basin was observed to be uncovered and

unlabeled on the floor. On 6/25/21 at 9:53 A.M.,

the same was observed.

6. On 6/23/21 at 9:59 A.M., Room 56 was

observed. Dirt and debris was observed to be

scattered throughout the floor. On 6/25/21 at

12:07 P.M., the same was observed.

7. On 6/22/21 at 11:27 A.M., Room 32 was

observed with an uncovered urine measuring

device in the bathroom sink. A wash basin was

upside down sitting on the toilet seat. A used

disposable glove was underneath the bed closest

to the door. On 6/25/21 at 12:26 P.M., Room 32

was observed. An uncovered urine measuring

device with a name that did not belong to either

residents residing in the room was observed

sitting on top of a wet paper towel on top of the

toilet. Two wash basins were stacked uncovered

on the floor.

8. On 6/22/21 at 11:55 A.M., the call light cord in

the main bathroom on B Hall was too short to

reach the toilet area. At that time, CNA 1

indicated residents would sometimes go into that

bathroom without assistance from staff.

On 6/23/21 at 12:01 P.M., the shower curtain in the

main bathroom on B Hall was observed hanging,

falling off of the curtain rod.

noted on said audit tool. The


review the audit tool on business

days during stand up.














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9. On 6/24/21 at 11:25 A.M., Room 23 was

observed with a yellowish puddle in front of the

bathroom door. A urine odor was observed in the

room.

On 6/24/21 at 1:46 P.M., Room 23 was observed

with a yellowish puddle in front of the bathroom

door. A urine odor was observed in the room.

10. On 6/24/21 at 2:14 P.M., the floor in A Hall was

observed with cracks in the hall by the bathroom

and linen room, between rooms 1 and 2, between

rooms 2 and 3, and where the fire doors were.

On 6/25/21 at 10:22 A.M., the floor in B Hall was

observed with multiple cracks and scratches and

discoloration throughout the floor in the common

area, dining area, hallway, and resident rooms.

11. On 6/25/21 at 10:22 A.M., Room 15 was

observed with the baseboard under the air

conditioning unit off the wall and hanging on the

floor.

During an interview on 6/24/21 at 2:15 P.M.,

Housekeeper 28 indicated the housekeeping and

laundry departments have been severely short

staffed, and do not have enough staff to clean all

rooms daily as they should have been.

Housekeeper 28 indicated there was only enough

time to do a quick cleaning, but not enough time

to clean the rooms the way they needed to be

done.

A Housekeeping policy related to cleaning rooms

was requested, and not provided.

3.1-19(f)





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F 9999

Bldg. 00

3.1-14 PERSONNEL

(t) A physical examination shall be required for

each employee of a facility within one (1) month

prior to employment. The examination shall

include a tuberculin skin test, using the Mantoux

method (5 TU PPD), administered by persons

having documentation of training from a

department-approved course of instruction in

intradermal tuberculin skin testing, reading, and

recording unless a previously positive reaction

can be documented. The result shall be recorded

in millimeters of induration with the date given,

date read, and by whom administered. The

tuberculin skin test must be read prior to the

employee starting work. The facility must assure

the following:

(1) At the time of employment, or within one (1)

month prior to employment, and at least annually

thereafter, employees and nonpaid personnel of

facilities shall be screened for tuberculosis. For

health care workers who have not had a

documented negative tuberculin skin test result

during the preceding twelve (12) months, the

baseline tuberculin skin testing should employ the

two-step method. IF the first step is negative, a

second test should be performed one (1) to three

(3) weeks after the first step. The frequency

repeat testing will depend on the risk of infection

with tuberculosis.

This State rule was not met as evidenced by:


failed to ensure initial tuberculin skin tests were

completed for 2 of 10 employee files reviewed.

(Housekeeper 11, LPN 42).





Housekeeper #11 and LPN #42

have been given PPD and will

complete the series as directed in

the guidelines. No residents were

affected from the alleged deficient

practice.






The facility completed an audit

and no further discrepancies were

found. No residents were affected

from the alleged deficient practice.





does not recur:

HR, BOM, and hiring managers

will be in-serviced 07/20/2021 &

07/22/2021 regarding the hire

process and the required

paperwork that is to be

completed.




recur:

BOM and/or Designee will

complete an audit tool each month

on new hires and document

07/28/2021 12:00:00AM





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Findings include:

1. On 6/28/21 at 12:15 P.M., Housekeeper 11's

employee file was reviewed. Hire date was

3/19/21. The file lacked documentation that a new

hire tuberculin skin test had been completed.

2. On 6/28/21 at 12:15 P.M., LPN 42's employee file

was reviewed. Hire date was 9/18/20. The file

lacked documentation that a new hire tuberculin

skin test had been completed.


DON (Director of Nursing) indicated some

tuberculin skin tests had not been completed due

to the facility not giving them for a period of time

around September 2020.


Administrator indicated a tuberculin skin test for

Housekeeper 11 and LPN 42 could not be found.

On 6/28/21 at 2:11 P.M., a current Tuberculosis

Screening policy, dated 4/1/15, was provided and

indicated "A physical examination shall be

required for each employee of a facility within one

(1) month prior to employment. The examination

shall include a tuberculin skin test, using the

Mantoux method (5 TU PPD) ..."

The Covid-19 Emergency Orders and Waivers for

Comprehensive Care Facilities included, but were

not limited to: Comprehensive care facilities are

not required to screen employees for tuberculosis

within one month prior to employment but must

instead do so within ninety (90) days of their

employment, issued 3/20/20.

findings and if any discrepancies

are found immediate action will be

taken to ensure compliance.











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