PRINTED: 08/29/2016 DEPARTMENT OF HEALTH AND HUMAN ... · Medicare: 16 Medicaid: 101 Other: 33...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

08/29/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46227

155327 08/05/2016

UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY

1380 E COUNTY LINE RD S

00

F 0000

Bldg. 00

This visit was for a Recertification and

State Licensure Survey. This visit

included the Investigation of Complaint

IN00205640.

Complaint IN00205640 -

Unsubstantiated due to lack of evidence.

Survey dates: July 31, August 1, 2, 3, 4,

& 5, 2016.

Facility number: 000220

Provider number: 155327

AIM number: 100267650

Census bed type:

SNF: 16

SNF/NF: 134

Total: 150

Census payor type:

Medicare: 16

Medicaid: 101

Other: 33

Total: 150

These deficiencies reflect State findings

cited in accordance with 410 16.2-3.1.

Q.R. completed by 14466 on August 12,

2016.

F 0000 This plan of correction is to

serve as University Heights

Health and Living Community's

credible allegation of

compliance. Submission of

this plan of correction does not

constitute an admission by

University Heights Health and

Living or its management

company that the allegations

contained in the survey report

is a true and accurate portrayal

of the provision of nursing care

and other services in this

facility. Nor does this

submission constitute an

agreement or admission of the

survey allegations.

We respectfully request a desk

review in lieu of a post-survey

revisit.

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

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

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

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

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

continued program participation.

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

_____________________________________________________________________________________________________Event ID: G3O411 Facility ID: 000220

TITLE

If continuation sheet Page 1 of 30

(X6) DATE




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483.15(c)(6)

LISTEN/ACT ON GROUP

GRIEVANCE/RECOMMENDATION

When a resident or family group exists, the

facility must listen to the views and act upon

the grievances and recommendations of

residents and families concerning proposed

policy and operational decisions affecting

resident care and life in the facility.

F 0244

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Based on record review and interview,

the facility failed to ensure that the

grievances being filed by residents,

resident council, and family were being

acted upon and resolved.

Findings include:

Review of the Resident Council Minutes,

with permission of the Council President

given 8/4/16 at 11:20 A.M., indicated

February of 2016 to July of 2016, The

residents had complained of call lights

not being responded to in a timely

manner.

1) Resident Council minutes for Feb 5,

2016... Residents have stated call lights

are not getting answered in a timely

manner on the 100, 400, 600, and 800

halls on afternoon and evening shifts...

Facility response was as follows: Call

light audits will be continued.

F 0244 F244 483.15(c)(6) LISTEN/ACT

ON GROUP

GRIEVANCE/RECOMMENDATI

ON I.Residents will have

their grievances resolved.

Administrator/designee will

follow up with residents #1,

#34, #73, #8, #35 to determine if

the grievance regarding call

lights has been resolved. II.All

residents have the potential to

be affected by the alleged

deficient practice.

Administrator/Designee will

review current resident council

minutes, as well as the

grievance log to determine if

there are unresolved,

grievances and ensure they

have been resolved. III.All

staff will be re-educated on

grievance resolution. The

systematic change includes the

Resident Council minutes will

be reviewed by the

Administrator and the

following resolution plans will

be put into place.

·Resident name, room

number, date of concern, time

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2) Resident council Minutes for April 8,

2016, Residents expressed call lights are

not being answered in a timely manner...

Facility response was as follows: In-

serviced staff on abuse prevention and

resident rights. Will follow up with

resident consistently to ensure

compliance completing QA assessment

for response times. ( to include action

plan if warranted)

3) Resident council Minutes for May 6,


not being answered in a timely manner on

afternoon or evening shifts... Facility

response was as follows:Community

initiated increased awareness of all lights

through "Lights, Cameras, Action"

initiative. Staff has been in-serviced & is

being monitored in call light response

times to improve overall satisfaction.

Will monitor progress.

4) Resident council Minutes for June 3,


not being answered in a timely manner on

afternoon and evening shifts... Facility

response was as follows: Random Call

light audits will continue to improve

response times.

5) Resident council Minutes for July 8,

2016, Residents expressed concern that

call lights need to be monitored and

of concern, person receiving

the concern and department

responsible for the concern

will be reviewed.

·Department head review and

action taken.

·Follow up with Resident

Council concern

·Concern must be referred to

the Administrator for approval.

Additionally,grievances will

be logged by the Social

Services Director/Designee and

assigned to the appropriate

department for follow up. The

Administrator/Designee will

audit to ensure resolution.

IV. Administrator/Designee will

audit systematic changes

utilizing an audit tool daily for 4

weeks, weekly for 4 weeks then

monthly for 4 months. Results

of this audit will be reviewed at

the monthly Quality Assurance

Committee meeting and

frequency and duration of the

reviews will be adjusted as

needed.





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answered in a timely manner from 2:00

P.M.- 3:00 P.M.... Facility response was

as follows: We continue to promote

"Lights Camera Action" and complete

call light audits.

6) On 4/8/2016 Resident #1 filed a

resident grievance form stating that Call

lights are not being answered timely.

Facility Staff's response was as follows:

Inservice given for staff implementing

lights camera action protocol.

7) On 4/8/2016 Resident #34 filed a

resident grievance form stating call lights

are not being answered timely. Facility

staff's response was as follows: Inservice

given for staff implementing lights

camera action protocol

8) On 6/2/16 at 10:00 A.M. a family

member of Resident #73 indicated she

visits 5-7 days a week on both day and

evening shifts and she observed Resident

#73 had to wait long periods of time for

call lights to be answered, it had been a

recurring issue for a couple of months.

9) On 8/4/16 at 11:20 A.M., Resident #8

indicated residents have discussed in

resident council meetings, for the last

several months, concerns of call lights

not being answered timely and that

although staff have been inserviced, and





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there had been audits done which

indicated it was still an ongoing issue.

Wait time for call light response, she

indicated, was up to an hour.

10) In an interview on 8/5/16, Resident

#34 indicated residents had discussed in

resident council meetings, for the last

several months, concerns of call lights

not being answered timely. She had also

filed a resident grievance form

concerning the issue but still felt it was

ongoing because she still has to wait an

extended period of time before her call

light is answered.

11) In an interview on 8/5/16 at 2:45

P.M. Resident #1 indicated residents had

discussed in resident council meetings,

for the last several months, concerns of

call lights not being answered timely and

he had filed a resident grievance form

concerning the issue. He still felt it was

an ongoing issue because wait times for a

call light response were 30 minutes to an

hour.

12) In an interview on 8/5/16 at 8:25

P.M. Resident #35 indicated residents

had discussed in resident council

meetings, for the last several months,

concerns of call lights not being

answered timely and she felt it was still

an issue. She indicated wait times for a





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call light response vary and she has to

wait the longest on nights. Weekends

are" just a mess."

In an interview on 8/5/16 at 4:45 P.M.

with the Administrator , Director of

Nursing (DON), and the Assistant

Director of Nursing, they indicated the

following interventions to improve the

call light response times are as follows:

- Call light Audits

- Staggering of staffing times to cover

high frequency times

- Implementation " Lights, Camera,

Action" initiative to heighten awareness

of call lights and response times.

-Created an evening shift supervisor

- An ongoing staff education

-Weekend supervisor audits call lights

- DON Staggers schedules to cover

weekend auditing.

The DON indicated staff was inserviced

on all above interventions except Lights,

Camera, Action, on 4/19/16. They were

inserviced on Lights, Camera, Action on

5/4/16. The DON did not indicate when

these interventions were implemented.

3.1-3(l)





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483.15(h)(7)

MAINTENANCE OF COMFORTABLE

SOUND LEVELS

The facility must provide for the

maintenance of comfortable sound levels.

F 0258

SS=D

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Based on observation and interview, the

facility failed to ensure comfortable

sound levels were maintained in all areas

for residents.

Findings include:

1) On 08/01/2016 12:45 PM, Resident

#201 indicated staff were loud during the

night. She indicated some halls were

worse than others. Housekeeping and

Certified Nursing Aide (CNA) staff, "act

like it's big party sometimes." Resident

had complained to staff who say they

would look into it. The resident indicated

there had been no change in the staff's

noise level. The noise level kept her

awake at night and/or woke her up and

she would have trouble going back to

sleep.

During the interview with Resident #201,

in the resident's room with the door

closed, very loud voices were heard

talking in the hallway. When the door

was opened a group of 4 housekeeping

staff were observed walking up the hall,

past the resident's room, talking very

loud, almost shouting. The resident

indicated the staff was loud like that at

F 0258 F258 483.15 (h)

(7)MAINTENANCE OF

COMFORTABLE SOUND

LEVELS I. The facility will

ensure comfortable sound

levels will be maintained in all

areas for

residents.DON/Designee will

follow up with resident #201 to

ensure that comfortable sound

levels have been achieved. II.

All residents have the potential

to be affected by the alleged

deficient practice. Full house

audit will be completed by

Caring Hearts

Representatives/Designee to

ensure comfortable sound

levels. III.All staff will be

educated on maintaining a

comfortable sound level in all

areas for residents. The

systematic change includes

educating all new staff in

general orientation and

annually thereafter on

maintaining an appropriate

sound level in all resident

areas. Signs will be posted in

non-resident areas to remind

staff to maintain comfortable

noise levels in resident areas.

IV. Administrator/Designee will

audit systematic changes



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night.

3.1-19(f)







needed.

483.20(g) - (j)

ASSESSMENT

ACCURACY/COORDINATION/CERTIFIED

The assessment must accurately reflect the

resident's status.

A registered nurse must conduct or

coordinate each assessment with the

appropriate participation of health

professionals.

A registered nurse must sign and certify that

the assessment is completed.

Each individual who completes a portion of

the assessment must sign and certify the

accuracy of that portion of the assessment.

F 0278

SS=D

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Under Medicare and Medicaid, an individual

who willfully and knowingly certifies a

material and false statement in a resident

assessment is subject to a civil money

penalty of not more than $1,000 for each

assessment; or an individual who willfully

and knowingly causes another individual to

certify a material and false statement in a

resident assessment is subject to a civil

money penalty of not more than $5,000 for

each assessment.

Clinical disagreement does not constitute a

material and false statement.


the facility failed to ensure a Minimum

Data Set (MDS) assessment accurately

reflected a resident's urinary continence

status for 1 of 3 residents reviewed for

urinary continence assessments.

(Resident #264)

Findings include:

The clinical record review for Resident

#264 was completed on 8/5/16 at 10:23

a.m. Diagnoses included, but were not

limited to, hypertension and chronic

kidney disease.

The Admission MDS assessment Section

H0300 completed on 4/7/16, assessed

Resident #264 as always being continent

of urine.

A review of the voiding record dated

4/1/16 through 4/7/16, for Resident #264

F 0278 F278 483.20 (g)-(j)

ASSESSMENT

ACCURACY/COORDINATION/C

ERTIFIED l. The MDS for

resident #264 was modified in

accordance with the Resident

Assessment Instrument

Comprehensive User Manual

and re-submitted. II. All

current residents will have

their most recent MDS

reviewed for accuracy of

urinary continence status and

any concern will be addressed.

III. Education will be provided

to MDS personnel and nursing

administration regarding

correct coding of the MDS for

urinary continence status. The

systemic change includes the

MDS coordinator /designee will

review the vital signs and the

Point of Care report for urinary

continence. Based on the RAI

manual guidelines, the MDS

coordinator/designee will

complete the assessment. IV.

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for 7 days prior to the Admission MDS

assessment, indicated Resident #264 had

1 urine incontinence episode on 4/2/16.

During an interview on 8/5/16 at 12:51

p.m., the MDS Coordinator indicated the

4/7/16 MDS assessment section H0300

for Resident #264 was coded incorrectly.

The MDS Coordinator indicated section

H0300 should have been coded as

occasionally incontinent of urine.

A review of Signature of Persons

Completing the Assessment or

Entry/Death Reporting section Z0400,

dated 4/12/16, indicated the MDS

Coordinator signed this section,

certifying that the accompanying

information accurately reflected resident

assessment information for Resident

#264.

The Resident Assessment Instrument

Comprehensive User Manual, Version

3.0, copy right 2009, page 352 indicated,

" ...H0300: Urinary Incontinence coding

instructions - code occasionally

incontinent: if during the 7-day look-back

period the resident was incontinent less

than 7 episodes. This includes

incontinence of any amount of urine...."

3.1-31(d)

The MDS coordinator will audit

for accuracy of urinary

continence status on the

assessment prior to any MDS

being submitted. This audit will

be ongoing at 100% x 2

months, then 10 assessments

per week x 1 month, then 5

assessments per week x 1

month, then 3 assessments per

week x 2 month. The MDS

consultant/designee will

randomly audit 5 residents for

MDS accuracy related to

continence weekly for 8 weeks

then monthly for 4 months.

Results of this audit will be

reviewed at the monthly

Quality Assurance Committee

meeting and frequency and

duration of the reviews will be

adjusted as needed.





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483.20(k)(3)(i)

SERVICES PROVIDED MEET

PROFESSIONAL STANDARDS

The services provided or arranged by the

facility must meet professional standards of

quality.

F 0281

SS=D

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Based on observation, interview, and

record review, the facility failed to ensure

services provided by the facility met

professional standards of quality, in that a

nurse did not remain with a resident to

observe that medications were

swallowed. (Resident #173)

Findings include:

During an observation on 8/1/16 at 11:42

a.m., Licensed Practical Nurse (LPN) #3

was observed administering medications

to Resident #173 in the resident's room.

LPN #3 was observed to walk into

Resident #173's room and hand him a

medicine cup with medications. LPN #3

then proceeded to leave the resident's

room without observing the resident

swallow the medications.


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

indicated a nurse is not to leave residents

during a medication administration

without observing the resident take the

medications.

F 0281 F281 483.20(k)(3)(i)SERVICES

PROVIDED

MEET PROFESSIONAL STAND

ARDS I. LPN #3 has

received 1:1 education related

to correct procedure with

medication administration.

Resident #173 is observed by a

licensed nurse when taking

medications. II. All residents

receiving medications from a

licensed nurse have the

potential to be affected by the

alleged deficient practice. On

08/05/2016 full house

inspection was conducted to

ensure no medications were

left at bedside. III.Education

will be provided to all licensed

nurses related to correct

procedures of medication

administration. The systemic

change includes all licensed

nurses will receive education

related to the correct

procedure for medication

administration upon hire and

annually thereafter. IV.The

DON/Designee will audit by

observation medication

administration on all shifts 5

times weekly for 4 weeks,

weekly for 4 weeks then

monthly for 4 months. Any

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On 8/5/16 at 9:30 a.m., the DON

provided an undated policy titled

Medication Administration General

Policies and Procedures, and indicated it

was the policy currently used by the

facility. The policy indicated, "...The

nurse or approved designee should

always remain with the resident to

observe that the medication is

swallowed...."

3.1-35(g)(1)

identified concerns from these

audits will be addressed

immediately. Results of this

audit will be reviewed at the

monthly Quality Assurance




needed.

483.25(h)

FREE OF ACCIDENT

HAZARDS/SUPERVISION/DEVICES

The facility must ensure that the resident

environment remains as free of accident

hazards as is possible; and each resident

receives adequate supervision and

assistance devices to prevent accidents.

F 0323

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the environment remained free of

accident hazards for 9 residents on the

800 hall, 8 residents on the 700 hall, 10

residents on the 600 hall, and 12

residents on the 900 hall.

Findings include:

During an initial tour of the facility on

7/31/16 at 7:00 p.m., the following were

observed:

F 0323 F323 483. 25 (h) FREE OF

ACCIDENT

HAZARDS/SUPERVISION/DEVI

CES I. · The medication cart

near room 807 was locked at

the time it was identified during

the tour. · The closet near

room 703 was locked at the

time it was identified during the

tour. · The electrical room near

room 600 was locked at the

time it was identified during the

tour. · The mechanical room

near room 916 was locked at

the time it was identified during

the tour. · The three millimeter

syringes of Heparin in room

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1. An unlocked, unattended medication

cart was observed near room 807.


p.m., Licensed Practical Nurse (LPN)

indicated the medication cart should have

been locked and not left unattended while

unlocked.

On 8/5/16 at 5:18 p.m., the Regional

Nurse Consultant provided an undated

policy titled Drug Storage, and indicated

it was the policy currently used by the

facility. The policy indicated,

"...Medication rooms, carts, and

medication supplies are to be locked or

attended by persons with authorized

access...."

2. An unlocked, unattended closet was

observed near room 703. The unlocked

closet contained the following:

a. 1 gallon Extraction Cleaner, with a

label indicating, "...may cause serious eye

irritation...."

b. 2.5 liters Neutral Cleanser, with a

label indicating, "...may be harmful, if

swallowed, call poison control...."

c. 1.5 liters Heavy Duty Prespray Plus,

with a label indicating, "...call physician

or poison control center if ingested...."

710 was removed and disposed

of. II.All residents have the


alleged deficient practice. Full

house safety inspection

conducted 07/31/2016 to

ensure environment was free

of accident hazards.

III.Education will be provided to

all staff that medications and

other drugs,including

treatment items need to be

stored in a locked cabinet or

room inaccessible to residents

and visitors. This education

will also include locking

closets that contain chemicals,

mechanical rooms and

electrical rooms.The systemic

change will include educating

all new hires of potential

hazards and storage of

potential hazards upon hire

and annually thereafter.

IV.Administrator/Designee will

audit by observation

medication carts, closets

containing chemicals, electrical

rooms and mechanical rooms









needed.





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

indicated the closet should have been

locked.

3. An electrical room near room 600 was

observed unlocked and unattended. The

room contained breaker boxes and cables.


p.m., the DON indicated the electrical

room should have been locked.

4. A mechanical room near room 916

was observed unlocked and unattended.

The room contained a furnace.


p.m., the DON indicated the mechanical

room should have been locked.

5. Three 5 millimeter syringes of heparin

(medication used to thin blood) were

observed unattended on a table in room

710.


p.m., the DON indicated the heparin

should not have been left unattended in a

resident room.

On 8/5/16 at 5:18 p.m., the Regional

Nurse Consultant provided an undated





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policy titled Drug Storage, and indicated

it was the policy currently used by the

facility. The policy indicated, "...All

medications and other drugs, including

treatment items, need to be stored in a

locked cabinet or room, inaccessible to

residents and visitors...."

3.1-45(a)(1)

483.25(m)(2)

RESIDENTS FREE OF SIGNIFICANT MED

ERRORS

The facility must ensure that residents are

free of any significant medication errors.

F 0333

SS=D

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the facility failed to ensure a resident

received the correct dose of medication,

for 1 of 4 residents reviewed for

receiving medications as ordered by their

physician. (Resident #A)

Findings include:

The clinical record of Resident #A was

reviewed on 8/2/16 at 4:40 p.m.

Diagnoses for the resident included, but

were not limited to, pain, anxiety and

neuropathy (nerve damage which can

cause pain).

F 0333 F333 483.25 (m)(2)RESIDENTS

FREE OF SIGNIFICANT MED

ERRORS I. Resident A is

receiving the dose of

Gabapentin as ordered. II. All

residents receiving Gabapentin

have the potential to be

affected by the alleged

deficient practice. All residents

on Gabapentin have been

reviewed to ensure they are

receiving the correct dose of

medication. III. 1:1 education

was provided to RN #1 related

to correct procedures for

medication administration

including the 5 rights and

monitoring for adverse

reactions if a medication error

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A care plan dated 7/7/16, indicated

Resident #A had a potential for pain.

Interventions included, "Administer

medications per MD orders..."

A physician's order dated July 7, 2016,

indicated Resident #A was to receive

gabapentin 100 mg (milligrams), 2 times

per day. Gabapentin is a medication used

to treat nerve pain.

A July, 2016 recapitulated physician's

order, with an original order date of

7/9/16, indicated Resident #A's

gabapentin was increased to 300 mg, 3

times per day.

RN #1 documented on the Medication

Administration Record (MAR) Resident

#A was given her evening dose of

gabapentin at 9:33 p.m.

A nurses's note, dated 7/13/16 at 9:29

p.m., indicated, "Resident's medication

was side by side in medication cart.

When I took the three capsules out of the

box I had taken them out I thought I had

checked and were the correct dosage, but

actually was incorrect causing her to

receive the wrong dosage..."

A nurse's progress note, dated 7/13/16 at

9:30 p.m.,(1 minute after the first note)

indicated, "Resident displayed no adverse

occurs. Education will be

provided to all licensed nurses

related to correct procedures

related to medication

administration. The education

will also include monitoring of

adverse reactions if a

medication error occurs. The

systemic change includes all

licensed nurses will receive

education related to the correct

procedure for medication

administration upon hire and

annually thereafter. IV. The

DON/Designee will audit by

observation medication

administration on all shifts 5



monthly for 4 months. Any









needed.





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medical changes as the result of receiving

increased dosage.."

An Event Report, dated 7/14/16, at 4:44

p.m., indicated Resident #A received the

wrong dose of medication, and there were

no adverse side effects. No other

documentation was found for 9/14/16

which indicated the resident had been

monitored for adverse side effects.

In an interview on 8/4/16 at 12:15 p.m.,

RN #4 indicated, "I realized I made a

mistake,"..."I missed reading the dosage

closely."


p.m., Resident #A indicated she was

aware the nurse made an error because

"...the 100 mg tablets of gabapentin are

white, and the 300 mg tablets of

gabapentin are yellow. I told her 2 or 3

times that the 3 pills she was giving me

were the wrong pills but the nurse just

kept telling me I was wrong...I finally

just thought, well maybe I am wrong and

I took them...I felt dizzy about 45

minutes later and the next day I was

woozy, tired, and fuzzy most of the day.

She gave me 3 yellow pills, which is 900

mg., instead of the 300 mg I was

supposed to receive."

On 8/5/16 at 9:30 a.m., the Director of





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Nursing (DON) provided an undated

policy, titled, "Medication

Administration: General Policies &

Procedures," and indicated it was the

policy currently used by the facility. The

policy indicated, "...The label on each

medication container shall be read 3

times and compared against the order on

the MAR: a) When taking from the shelf

or drawer b) Before pouring it c) When

putting it back onto the shelf or into the

drawer..."

On 8/5/16 at 9:30 a.m., the DON

provided an undated policy, titled,

"Medication Errors," and indicated it was

the policy currently used by the facility.

The policy indicated. "...8. Any adverse

effects from the medication error will be

noted in the resident's medical record..."

3.1-48(c)(2)

483.60(c)

DRUG REGIMEN REVIEW, REPORT

IRREGULAR, ACT ON

The drug regimen of each resident must be

reviewed at least once a month by a

licensed pharmacist.

The pharmacist must report any

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irregularities to the attending physician, and

the director of nursing, and these reports

must be acted upon.


the facility failed to ensure a consultant

pharmacist initiated a request for a

gradual dose reduction for a resident who

was taking an antipsychotic medication,

as indicated by their policy. (Resident

#137)

Findings include:

The clinical record of Resident #137 was



were not limited dementia, anxiety,

depressive episodes and delusional

disorders.

A recapitulated physician's order for

August, 2016, with an original date of

5/14/15, indicated Resident #137 was to

receive Risperdal, 0.25 milligrams (mg),

daily. Risperdal is an antipsychotic

medication used to treat mental/mood

disorders.

No documentation was found in the

Resident #137's record which indicated a

gradual dose reduction had been

attempted or considered since 5/14/16.

On 8/5/16 at 2:24 p.m., the Social

F 0428 F428 483.60 (c) DRUGREGIMEN

REVIEW, REPORT

IRREGULAR, ACT ON I.

Resident #137 is no longer

receiving Risperdal. Res

suffered no adverse effects

related to receiving medication.

II. All residents receiving

anti-psychotic medications


affected. Social Services

conducting full house audit of

psychotropic medications to

ensure the consultant

pharmacist initiated a GDR.

III. The consultant pharmacist

will receive 1:1 education

related to recommended drug

reduction guidelines. The

systemic change includes the

consultant pharmacist will

review all residents on

anti-psychotic drugs for

possible drug reductions per

the federal guidelines and

facility policy during the

monthly consultation visit.

Social Services/designee will

implement a log with all

anti-psychotic medications

being used within the facility

with order date, diagnosis for

use, and gradual dose

reduction history. Social

Services/Designee to monitor

for necessary GDR’s, and is to

notify pharmacy if not received.

IV. Social Services/Designee

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Services Director indicated Resident

#137 had been hospitalized on 5/8/15, at

which time her Risperdal dosage had

been decreased to 0.25 mg. She returned

to the facility on 5/14/15 with an order

for Risperdal 0.25 mg every day.

During an interview with the RNC

(Regional Nurse Consultant) on 8/5/16 at

4:35 p.m., the Regional Nurse Consultant

indicated it was the pharmacist's job to

notify the facility when a gradual dose

reduction was due, and the pharmacy

consultant had indicated to the RNC she

did not think a gradual dose

recommendation was necessary because

Resident #137 was taking, "the lowest

possible dose."

On 8/5/16 at 4:35 p.m., the RNC

provided an undated policy, titled,

"Psychotropic Drug Use," and indicated it

was the policy currently used by the

facility. The policy indicated, "The

facility will notify the attending physician

when a gradual dose reduction is due.

This may occur as a recommendation

from the consultant pharmacist" and

"After the first year, the gradual dose

reduction should be attempted at least

once a year..."

3.1-25(i)

will audit all anti-psychotic

medications for drug reduction

attempts that are due monthly.

These audits will occur for 12

months. Any identified

concerns from these audits will

be addressed immediately.






adjusted as needed.





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483.60(b), (d), (e)

DRUG RECORDS, LABEL/STORE DRUGS

& BIOLOGICALS

The facility must employ or obtain the

services of a licensed pharmacist who

establishes a system of records of receipt

and disposition of all controlled drugs in

sufficient detail to enable an accurate

reconciliation; and determines that drug

records are in order and that an account of

all controlled drugs is maintained and

periodically reconciled.

Drugs and biologicals used in the facility

must be labeled in accordance with currently

accepted professional principles, and

include the appropriate accessory and

cautionary instructions, and the expiration

date when applicable.

In accordance with State and Federal laws,

the facility must store all drugs and

biologicals in locked compartments under

proper temperature controls, and permit only

authorized personnel to have access to the

keys.

The facility must provide separately locked,

permanently affixed compartments for

storage of controlled drugs listed in

Schedule II of the Comprehensive Drug

Abuse Prevention and Control Act of 1976

and other drugs subject to abuse, except

when the facility uses single unit package

drug distribution systems in which the

quantity stored is minimal and a missing

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dose can be readily detected.



narcotic medications (controlled

substances) were double locked at all

times for 1 of 1 medication room

observed.

Findings include:

08/2/2016 at 9:30 a.m., During

medication storage observation, observed

two lock boxes in the refrigerator located

in locked medication room. The box on

the left was locked and secure, the box on

the right was easily pulled open by the

Director Of Nursing (D.O.N.). The

D.O.N. removed the contents (controlled

substances) of the unsecured box on the

right and put them in the box on the left

and locked the box on the left. Contents

removed by D.O.N: Three boxes of liquid

lorazepam 2 mg/ml (a controlled

substance Schedule: IV). One box had

been opened and currently being used the

other two boxes had not yet been opened.

On 8/5/2016 at 9:30 a.m., During

interview with D.O.N. indicated,

housekeeping did go into the locked

medication room, but a nurse stayed with

her until she was done mopping. The

maintenance staff had an emergency key

and could enter the medication storage

F 0431 F431 483.60(b), (d),(e) DRUG

RECORDS, LABEL/STORE

DRUGS BIOLOGICALS I. The

locked narcotic box in the

refrigerator was placed back

on the track on 8-2-16 during

the survey. II. All residents

receiving refrigerated narcotics


affected by the alleged

deficient practice. Full house

audit done of narcotic boxes

located in med room

refrigerators. III. All licensed

nurses have received

education on drug storage

including ensuring refrigerated

narcotics are secured. The

systemic change includes new

lock boxes with double locks

were purchased for the

refrigerated controlled

medication. IV. The

DON/Designee will audit all

refrigerated narcotics for

double locked storage 5 times

weekly for 4 weeks, weekly for

4 weeks then monthly for 4

months. Any identified

concerns from these audits will

be addressed immediately.






adjusted as needed.

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room at any time.

On 8/4/2016 at 2:41 p.m., During

interview with the D.O.N, The D.O.N.

indicated, the refrigerator was old and the

box was actually locked on 8/2/2016, "It

was just off track."

On 8/4/2016 at 9:30 a.m., During

interview with the D.O.N. indicated a

new box for the refrigerator has been

purchased. New box has two locked

units, side by side and will replace the

old box.

On 8/3/2016 at 11:30 a.m., The

Administrator provided Controlled

Substance Reconciliation dated

12/31/2011, indicated currently being

used by facility. Policy: "All facilities

should utilize the following procedure or

a similar procedure meeting the same

criteria to reconcile controlled substances

at the end of each nursing shift. ...6.

Refrigerated controlled substances should

be kept under double lock. A locked box

or refrigerator within a locked room or

cabinet would meet this criteria. If a

numbered, plastic lock is utilized, then

the lock number should be verified at the

change of each shift. changes in lock

number should prompt the off-going and

on-coming nurse to verify the quantity of

each refrigerated controlled substance on





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hand."

3.1-25(n)

483.70(h)

SAFE/FUNCTIONAL/SANITARY/COMFOR

TABLE ENVIRON

The facility must provide a safe, functional,

sanitary, and comfortable environment for

residents, staff and the public.

F 0465

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Based on observation the facility failed

provide a safe, functional, sanitary, and

comfortable environment for residents.

Findings include:

During initial tour of facility at 7:20 P.M.

on 7/31/16 the following was observed:

1) The stand-up lift located outside of

resident room #609 was observed to be in

an unkempt condition. The footrest had

dirt, debris,and multiple food crumbs on

it varying in size.

2) The stand-up lift located in the alcove

near room #401 that was observed to be

in the same condition with dirt, debris,

and crumbs on the footrest.

3) In the dinning room located on the 500

F 0465 F465 483.70

(h)SAFE/FUNCTIONAL/SANITA

RY/COMFORTABLE

ENVIRONMENT. I. The

stand-uplifts, dining room floor

and window in the dining room

were cleaned. II. All residents

using lift equipment or eating

in the 500 hall dining room


affected. All lifts, dining room

windows and floors were

cleaned. III. Education will be

provided to all staff related to

cleaning floors, windows and

lift equipment. The systemic

change includes education for

all staff related to maintaining a

clean environment and clean

equipment upon hire and

annually thereafter. A cleaning

schedule has been developed

for lifts, windows, and dining

room floors. IV.The

Administrator/designee will

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hall, the floor was observed to be

unsanitary. There were multiple areas

with spilled liquids in different stages of

drying up. There were food crumbs

littering the floor throughout. Potato

chips were observed scattered amongst

the liquids and a stringy unknown

substance. The window facing the

courtyard was covered with a thick film

of dirt making it difficult to get a clear

view of the courtyard outside.

3.1-19(f)

audit dining rooms, the dining

room windows and lift

equipment for cleanliness 5



monthly for 4 months.Any



immediately.Results of this






needed.

483.75(e)(5)-(7)

NURSE AIDE REGISTRY VERIFICATION,

RETRAINING

Before allowing an individual to serve as a

nurse aide, a facility must receive registry

verification that the individual has met

competency evaluation requirements unless

the individual is a full-time employee in a

training and competency evaluation program

approved by the State; or the individual can

prove that he or she has recently

successfully completed a training and

competency evaluation program or

competency evaluation program approved

by the State and has not yet been included

in the registry. Facilities must follow up to

ensure that such an individual actually

becomes registered.

Before allowing an individual to serve as a

nurse aide, a facility must seek information

from every State registry established under

sections 1819(e)(2)(A) or 1919(e)(2)(A) of

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the Act the facility believes will include

information on the individual.

If, since an individual's most recent

completion of a training and competency

evaluation program, there has been a

continuous period of 24 consecutive months

during none of which the individual provided

nursing or nursing-related services for

monetary compensation, the individual must

complete a new training and competency

evaluation program or a new competency

evaluation program.

Based on record review, and interview

the facility failed to ensure a Certified

Nursing Assistant (CNA #1) had

completed an evaluation program

approved by the State.

Findings include:

On 8/5/2016 at 10:30 a.m., During record

review, Ohio Department of Health Form

dated 3/10/2016, indicated Certified

Nursing Assistant (CNA) #1, was

certified through Ohio Department of

Health. Registry number:

322224340904. Original approval Date:

8/13/2007. Expires: 7/12/2017.

Employee records indicated CNA #1's

date of employment at the facility was

3/9/2016.

On 8/5/2016 at 11:00 a.m. during

interview with Director of Nursing

F 0496 F496 483.75(e)(5)-(7) NURSE

AIDE REGISTRY

VERIFCATION, RETRAINING I.

C.N.A. #1 is no longer

employed by the facility. All

other C.N.As employed in the

facility have had their

certifications verified and are

in compliance. II. In order to

identify others, a full house

audit of employee files was

completed. III. The Staff

Development Coordinator has

received 1:1 education related

to ensuring a C.N.A.registered

in another state completes

registration in Indiana within

the allotted time frame. The

systemic change includes any

C.N.A. hired with a certification

from out of state will be

tracked to determine the

Indiana registration is

completed within 120 days

and/or Facility will no longer

hire C.N.A’s from out of state

without an active Indiana

Certification. IV.The HR

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indicated CNA #1 did work on the day

that surveyors entered the building for

three hours. "Staff developer new." I

(D.O.N.) told the CNA to leave at that

time. "Explained to the CNA (CNA #1)

that she could not work without a

certificate."

On 8/5/2016 at 11:30 a.m. DON provided

time sheet #16195 dated July 7th -

August 5th 2016 for CNA #1, Indicated

CNA #1 worked July 7th from 3:07 p.m

.until 7:08 a.m., July 8th from 3:00 p.m.

until 7:03 p.m., July 12th from 2:44 p.m.

until 7:27 a.m., (no date) from 8:37 p.m.

until 7:08 a.m., July 13, 4:54 p.m. until

7:06 p.m., July 14th 2:58 p.m. until 11:54

p.m., July 15th from 7:52 a.m. until 7:13

p.m. and July 31st 3:38 p.m. until 7:29

p.m.

Records indicated, CNA #1 worked in

compliance from March 9th - July 7th.

CNA #1 worked after July 7th as

uncertified by the State of Indiana.

08/05/2016 2:06:08 PM during interview

with the Executive Director indicated no

written policy, they "follow regulations."

3.1-14(e)(1)

Director will audit any C.N.A.s

hired from out of state weekly

to ensure they become certified

in Indiana within 120 days. This

will be ongoing monitoring.






adjusted as needed.





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483.75(l)(1)

RES

RECORDS-COMPLETE/ACCURATE/ACCE

SSIBLE

The facility must maintain clinical records on

each resident in accordance with accepted

professional standards and practices that

are complete; accurately documented;

readily accessible; and systematically

organized.

The clinical record must contain sufficient

information to identify the resident; a record

of the resident's assessments; the plan of

care and services provided; the results of

any preadmission screening conducted by

the State; and progress notes.

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the facility failed to to ensure clinical

records were maintained accurately

regarding an admission weight for 1 of 3

residents reviewed for having accurate

documentation of admission weights.

(Resident #289

Findings include:

The clinical record of Resident #289 was



were not limited to, fractured femur and

fluid overload.

A Hospital Discharge Summary, dated

6/29/16, indicated Resident #289's

discharge weight was 99 lbs.

F 0514 F514 483.75 (I) (1)RES

RECORDS-COMPLETE/ACCUR

ATE/ACCESSIBLE I. Resident

#289 no longer resides in the

community. II. All new

admission residents have the


alleged deficient practice.

DON/Designee will complete

full house audit of admission

weights. III. Education will be

provided to all nursing staff

related to the weight policy

including admission weights,

weekly weights and when re

weights are indicated. The

systemic change will include

the following:

·New admissions to be

re-weighed within 24 hours of

admission.

·Medical records to audit

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A careplan for Resident #289, dated

7/7/16 and current through 11/9/16,

indicated the resident was a nutritional

risk. Interventions included,

"Monitor/record weight routinely..."

Resident #289 was admitted to the

facility on 6/30/16. A Nursing

Admission Assessment dated 6/30/16,

indicated her weight at the time of

admission was 148.3 pounds (lbs).

Weights on a Vitals Report indicated:

7/12/16 weight = 95.7 lbs

7/26/16 weight = 82.3 lbs

A Nutrition Assessment note, dated

7/26/16, indicated the admission weight

of 148.3 was a, "suspected" error in

documentation.

No other facility weights were found in

the resident's record.

On 8/5/16 at 9:48 a.m., the Director of

Nursing (DON) indicated Resident #289's

admission weight of 148.3 was not

accurate.

On 8/5/16 at 8:45 a.m. the Executive

Director provided an undated policy

admission weight and compare

to residents most recent

known weight.

IV. The Medical Records

Coordinator will audit weights

for completion 5 times weekly

for 4 weeks, weekly for 4 weeks

then monthly for 4 months. Any









needed.





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titled, "[name of facility] Weight

Management Policy, and indicated it was

the policy currently used by the facility.

The policy indicated, "New

admission/readmission residents will be

weighed at admission and weekly X 4...If

the resident has a previous weight in the

medical record that weight will be

compared to the current weight being

obtained to ensure that a reweigh is done

immediately if there is a significant

change in weight...if the resident's weight

100 lbs or less and there is a weight

change from the previous of +/- 3 lbs

then he/she will be reweighed..."

3.1-50(a)(2)


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