e99n11_2567.pdf - IN.gov

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

05/20/2011PRINTED:

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

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PERCEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

500 WALKERTON TRAIL

WALKERTON, IN46574

155574 04/29/2011

MILLER'S MERRY MANOR

00

F0000

This visit was for a

recertification and State

Licensure Survey. This visit

resulted in an extended survey,

Immediate Jeopardy.

Survey dates: April 25, 26, 27,

2011

Extended survey dates April

28, and 29, 2011

Facility Number: 000431

Provider Number: 155574

Aim Number: 100290380

Survey Team:

Sandra Haws RN TC

Vicki Manuwal RN

Bobbie Costigan RN

Census Bed Type:

SNF/NF: 79

SNF: 13

Total: 92

Census Payor Type:

F0000

_____________________________________________________________________________________________________

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.

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

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

Event ID: E99N11 Facility ID: 000431

TITLE

If continuation sheet Page 1 of 88

(X6) DATE




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Medicare: 12

Medicaid: 72

Other: 8

Total: 92

Sample: 19

Supplemental Sample: 18

These deficiencies also reflect

State findings cited in

accordance with 410 IAC 16.2.

Quality review completed 5-3-11

Cathy Emswiller RN

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E99N11 Facility ID: 000431 If continuation sheet Page 2 of 88




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WALKERTON, IN46574

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F0157 A facility must immediately inform the

resident; consult with the resident's physician;

and if known, notify the resident's legal

representative or an interested family member

when there is an accident involving the

resident which results in injury and has the

potential for requiring physician intervention; a

significant change in the resident's physical,

mental, or psychosocial status (i.e., a

deterioration in health, mental, or

psychosocial status in either life threatening

conditions or clinical complications); a need to

alter treatment significantly (i.e., a need to

discontinue an existing form of treatment due

to adverse consequences, or to commence a

new form of treatment); or a decision to

transfer or discharge the resident from the

facility as specified in §483.12(a).

The facility must also promptly notify the

resident and, if known, the resident's legal

representative or interested family member

when there is a change in room or roommate

assignment as specified in §483.15(e)(2); or

a change in resident rights under Federal or

State law or regulations as specified in

paragraph (b)(1) of this section.

The facility must record and periodically

update the address and phone number of the

resident's legal representative or interested

family member.

SS=D

Based on record review and interview, the

facility failed to ensure a resident's

physician and/or resident's legal

representative was immediately notified

of a significant change in the resident's

behavior related to intrusive, aggressive,

and sexual behaviors for 1 of 7 residents

reviewed with behaviors in a sample of

F0157 It is the policy of Miller’s Merry

Manor, Walkerton to promptly

inform the resident, consult with

the resident’s physician, notify

resident’s legal representative or

an interested family member

when there is a significant

condition change in the resident’s

physical, mental or psychosocial

status and/or the need to alter

05/28/2011 12:00:00AM





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WALKERTON, IN46574

155574 04/29/2011


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19. (Resident #16)

Findings include:

Resident #16's record was reviewed on

4/21/2011 at 2:00 p.m. Resident #16's

diagnoses include, but were not limited to,

Alzheimer's disease, Impulse Control

Disorder, and dementia with behavior

disturbances.

10/14/2010 at 9:40 p.m.- Behavior notes

indicated Resident #16 was found naked

in his doorway urinatng on his door.

There was no evidence that the physician

or POA (power of atorney) was notfed.

10/17/2010 at 4:37 a.m.- Behavior notes

indicated Resident #16 was atemptng to

enter other resident rooms, "...voided on

a night stand, tv, and foor of another

resident across the hall before the staf

could stop him." There was no evidence

that the physician or POA was notfed.


indicated Resident #16 entering other

resident's rooms, unzipping pants in hall

and in resident rooms, "...atemptng to

urinate where ever he may be,

undressing in hallway. Remains on 15

minute checks, bed alarm on for safety."

treatment significantly.

Resident # 16 was discharged

from the facility.

All residents are at risk to be

affected by the deficient practice.

The 24 hour condition report,

which includes nurse’s notes, will

be reviewed daily by the

DON/ADON or designated staff to

ensure physician notification is

done per policy and/or with any

new or exacerbation of previously

assessed behaviors. By May

28th all licensed nursing staff will

be inserviced on facility policy of

physician and family notification.

To ensure the system

implemented is effective, the

DON/ADON or designated

licensed staff will complete the

QA tool titled “24 Hour Condition

Report Review” weekly for four

weeks and monthly thereafter to

ensure compliance. (See

Attachment A).

Corrective action will be

completed by May 28, 2011.





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or POA was notfed.

10/20/2010 at 2:17 p.m.- Behavior notes,

"...up walking halls, all precautons in

place ...." There was no evidence that

the physician or POA was notfed.

10/20/2010 at 6:39 p.m.- General note,

"...atemptng to put hand down into

sharps container...Another res c/o

(complains of) that he went in her room

and tore her bed up ...." There was no

evidence that the physician or POA was

notfed.

10/20/2010 at 7:35 p.m.- Behavior note,

"...atempted to take walker from male

res (resident) sitng there. Other res

became angry and swore at (Resident #

16), separated residents, explained to

other res that he does not understand."


or POA was notfed.


indicated the Resident was on 15 minute

checks. The note further indicated

"...requires redirecton more ofen than

15 minutes while awake keeps trying to

walk in others rooms, was atemptng to

sit on females and one males lap in





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WALKERTON, IN46574

155574 04/29/2011


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w/cs(wheelchairs)...." There was no


notfed.


indicated Resident #16 atemptng to

urinate outside DON's (Director of

Nursing) ofce door. There was no


notfed.


"...on q 15 minute checks. Requires

redirecton more ofen than 15 minutes

while awake...trying to walk into others

rooms." There was no evidence that the

physician or POA was notfed.


"At 6 p.m. entered several other resident

rooms, redirected with difculty,

unzipped pants in hall and atempted to

urinate...." There was no evidence that



"...wandering about entering other

resident rooms picking up items

atemptng to move furniture, other

resident's upset with (Resident # 16) in

their rooms, telling him to get out but he

contnues to fddle with things. Resident





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entered another room, and urinate in

bed...." There was no evidence that the



"...atempted to take other Residents

wheelchairs (by the armrest). At one

tme, he atempted to pull the legs of

another table of resident's table apart

...required interventon q 5-15 minutes

(even with family members present)

entre shif to keep out of other

resident's rooms, atempted to unzip

pants...consume other's (sic) residents

food and drinkd (sic)." There was no


notfed.

10/23/2010 at 10:00 p.m.- Behavior

notes, "...Resident was moving pillows

around her head 129-A ...." There was no


notfed.


indicated Resident #16 made sexual

comments to CNA, "...pressed erect

penis into her thigh and made groaning

sounds, grabbed her groin region

wandered into others room. Requires

constant direct supervision to stay out of





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500 WALKERTON TRAIL

WALKERTON, IN46574

155574 04/29/2011


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rooms. Atempts to push w/cs

(wheelchairs) and pick up computers of

desks." There was no evidence that the


10/24/2010 at 10:57 p.m.- Behavior

notes, "CNA did not actvate the door

alarm to room. The residents in rm

(room) (room number documented) were

yelling and screaming. One of the

residents blankets were being taken of

of her." There was no evidence that the



"...res would not stay in his room. Door

sensor alarm on per policy. Within one

minute, female res on north hall yelling

"nurse, nurse." Entered her room to fnd

res with only T-shirt on, naked from waist

down, standing over her. Female

resident stated, "That's a scary thing to

wake up to"....he again would not stay in

his room." There was no evidence that



indicated Resident #16 returned from

psychiatric hospital today. Stated

"...dining room and in front of a lady

pulled down his pants exposing





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500 WALKERTON TRAIL

WALKERTON, IN46574

155574 04/29/2011


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himself...." There was no evidence that



"Found peeing in hallway with alarm

going of. Contnues to atempt to touch

staf in inappropriate areas. Atempted

to leave building by opening exit door."


or POA was notfed.


"Found in own bathroom atemptng to

exit thru jointng door. Atemptng to

void in hallway and in another resident's

room afer setng of door alarm (that

does not have an alarm-(room number

documented) Contnues to atempt

inappropriate touching of staf, in various

manners. Resident display new behavior

of atemptng to "outsmart" door alarms

ie (example)- in manner of atemptng to

leave own room." There was no evidence


11/21/2010 at 7:27 am- Behavior notes,

"During this shif Resident tried x2 (two

tmes) to urine (sic) in the hallways and at

nursing staton. He was sitng at nurses

staton, then got out of chair and started

to touch another resident's wife. Wife





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500 WALKERTON TRAIL

WALKERTON, IN46574

155574 04/29/2011


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did verbalize for him to leave her alone.

At that point, he was placed in his room

with the door alarm on. He atempted to

go into diferent resident's rooms that

did not have door alarms (room numbers

documented). Wondering (sic) out of his

room several tmes (about 8-10

tmes)...contnues to have a BM (bowel

movement) in room." There was no


notfed.


"res. (resident) moving about erradically

(sic) from room to room, redirected well,

did urinate on a pad beside a residents

bed. family here earlier, did eat supper

well, atempted to leave building x 3

(three tmes). at side doors also." There

was no evidence that the physician or

POA was notfed.


"resident has been wandering around

facility having to be rerouted out of other

residents room." There was no evidence


The DON (Director of Nursing) was

interviewed 4/28/2011 at 10:30 a.m. The





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DON indicated there was no other

documentaton regarding physician/POA

notfcaton.

The facility's policy and procedure ttled

"Physician & Family Notfcaton of

Conditon Changes" dated 3/1/03

indicated "...Purpose 1. To keep the

physician , resident and family appraised

of all conditon changes...telephone

notfcaton is required for all

emergencies or all conditon changes that

require an immediate response. b. Notfy

the physician of any change in conditon

that may or may not warrant a change in

the treatment plan...."

3.1-5(a)(2)

3.1-5(a)(4)(b)





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F0225 The facility must not employ individuals who

have been found guilty of abusing, neglecting,

or mistreating residents by a court of law; or

have had a finding entered into the State

nurse aide registry concerning abuse, neglect,

mistreatment of residents or misappropriation

of their property; and report any knowledge it

has of actions by a court of law against an

employee, which would indicate unfitness for

service as a nurse aide or other facility staff to

the State nurse aide registry or licensing

authorities.

The facility must ensure that all alleged

violations involving mistreatment, neglect, or

abuse, including injuries of unknown source

and misappropriation of resident property are

reported immediately to the administrator of

the facility and to other officials in accordance

with State law through established procedures

(including to the State survey and certification

agency).

The facility must have evidence that all

alleged violations are thoroughly investigated,

and must prevent further potential abuse while

the investigation is in progress.

The results of all investigations must be

reported to the administrator or his designated

representative and to other officials in

accordance with State law (including to the

State survey and certification agency) within 5

working days of the incident, and if the alleged

violation is verified appropriate corrective

action must be taken.

SS=D

Based on interviews and record review,

the facility failed to ensure incidents

involving unwanted sexual behaviors by

Resident #16 towards other residents had

been investigated and reported to the


Manor, Walkerton, that all

residents have the right to be free

from abuse of all forms. Miller’s

Merry Manor has policies and

procedures in place that ensures

05/28/2011 12:00:00AM





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Indiana State Department of Health for 2

of 19 residents reviewed exhibiting a

reportable behavior in a sample of 19.

(Residents #16 and #89)

Finding include:

1. Resident #16's record was reviewed on

4/21/2011 at 2:00 p.m. Resident #16's




disturbances.


"...entered a female resident's room and

was found to be touching residents

stomach over nightgown and

covers...resident had an erection and

resident rubbed it on this SN's (skilled

nurse) leg...while resident was being

initially put in bed and cleaned up he

kissed a CNA's neck."

10/18/2010 10:45 p.m.- Behavior notes,

"With q (every) 15 minute check found in

roommates bed. He was naked,

roommate had nightgown on. Residents

were in spooning position and this

resident was rubbing roommates thigh.

Staff separated residents immediately, and

when attempting to this resident stated

"where's the cookies?" and when this

resident was to side of bed attempted to

that all alleged violations are

reported immediately to

Administrator of the facility and to

other officials in accordance with

state law through established

procedures (including to the state

survey and certification agency).


from the facility

Resident # 89 currently receiving

medication and treatment for

behavior and has routine

psychiatric service and follow up.

Resident # 89 has not had any

further overt behavior of this

nature.



To ensure that this finding does

not reoccur, an inservice

education program will be given

to all licensed staff on May 19,

2011 and will be given for all

remaining staff members within

the facility on May 25th and May

26, 2011. Monitoring of the

effectiveness of this will be done

daily by reviewing the 24 Hour

Condition Report. In the event

that an occurrence occurs on the

weekend, the weekend manager

will contact the Administrator

and/or DON and reporting will be

done at that time to the ISDH.

Quality Assurance audits will be

completed on any unusual

occurrence weekly for four weeks

and then monthly per the Quality

Assurance Program to ensure





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kiss roommate, but staff further

intervened and no contact was made.

This resident was fondling his own penis

which was erect with the separation was

then taken to a private room and bed

alarm placed on his bed. Also continuing

q 15 minute checks. DON (Director of

Nursing) was then notified at 10:50 p.m.

and she notified administrator."


"...res (Resident) would not stay in his

room. Door sensor alarm on per policy.

Within one minute, female res on north

hall yelling "nurse, nurse." Entered her

room to find res with only T-shirt on,

naked from waist down, standing over

her. Female resident stated, "That's a

scary thing to wake up to"....he again

would not stay in his room."

During an interview with the Director of

Nursing and the Administrator on 4/28/11

at 10:30 a.m. regarding the incidents with

Resident # 16 if they had been reported to

the State agency, she indicated the

incidents had not been investigated or

reported to the State.


4/21/2011 at 2:00 p.m. Resident #89's


paraplegia.

compliance. (See Attachment A

and B)







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12/19/2010 at 12:01 a.m.- Behavior notes,

"This writer notified by QMA (Qualified

Medication Aide) that resident has made

inappropriate comments to her today. The

first being, "I haven't had a woman on top

of me in a long time," this was while staff

member was rolling resident et (and)

reaching across him to dress him today.

The other instance, resident stated, "well

sure I'll lay down if you want to get it on,"

this was after staff member asked resident

to lie back in bed to put a brief on him

before meal."

12/19/2010 at 12:05 a.m.-Behavior notes,

"In addition to previous note, this writer

was also informed that res (resident) had

made gestures with his tongue toward a

female resident et this female resident

stated he comes up behind her and she

feels like she's (sic) blocked in (sic) the

CDP (Certified Distinct Part) room and

can't get out."


"Res bumped into female res w/c

(wheelchair) with his scooter, female

began to cry and Resident #89 (Name)

kept is (sic) scooter lodged against w/c so

she could not move. Res needed to (sic)

me told to back up w/c so female res

could move her w/c."

Resident's record lacked documentation





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indicating the incident was reported to

State Agency.

The DON was interviewed on 4/28/2011

at 10:30 a.m. The DON indicated there

was no documentaton indicatng any

investgaton or reportable to the State

Agency related to this resident as they

were not reported.

Millers Merry Manor policy titled "Abuse

Prohibition, Reporting, and Investigation"

dated 8/23/10 indicated "...It is the policy

of Miller's Health Systems that all

residents have the right to be free from

verbal, sexual, physical and mental abuse,

corporal punishment, and involuntary

seclusion...Miller's Health Systems have

policies and procedures in place that

ensures that all alleged violations...are

reported immediately to the Administrator

of the facility and to other officials in

accordance with State law through

established procedures (including to the

State survey and certification agency).

3.1-28(a)

3.1-28(c)

3.1-28(d)

3.1-28(e)





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F0226 The facility must develop and implement

written policies and procedures that prohibit

mistreatment, neglect, and abuse of residents

and misappropriation of resident property.

SS=D

Based on interview and record review, the

facility failed to follow their policy related

to resident abuse by failing to investigate

and report incidents of abuse that had

occurred involving 2 of 2 residents with

incidents of abuse in a sample of 19.

(Resident #16 and #89)

Findings include:


4/21/2011 at 2:00 p.m. Resident #16's




disturbances.

Resident # 16's record indicated the

following notes:


"...entered a female resident's room and

was found to be touching residents







F0226 Miller’s Merry Manor, Walkerton

has a system and policies in

place that prohibit mistreatment,

neglect and abuse of residents

and misappropriation of resident

property. This policy is in

accordance with State and

Federal Law.


from the facility.

Resident # 89 is currently

receiving medication treatment

for behavior and has routine

psychiatric service and follow up.

Resident # 89 has not had any

further overt behaviors of this

nature.



To ensure that this finding does

not reoccur, an inservice

education program will be given

to all licensed staff on May 19,

2011 and will be given for all

remaining staff members within

the facility on May 25th and May

26, 2011. Monitoring of the

effectiveness of this will be done

daily by reviewing the 24 Hour

Condition Report. In the event

that an occurrence occurs on the

weekend, the weekend manager

will contact the Administrator

and/or DON and reporting will be

done at that time to the ISDH.

05/28/2011 12:00:00AM





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10/18/2010 10:45 p.m.- Behavior notes,
















q 15 minute checks. DON (Director of

Nursing) was then notified at 10:50 p.m.

and she notified administrator."


"...res (Resident) would not stay in his

room. Door sensor alarm on per policy.

Within one minute, female res on north

hall yelling "nurse, nurse." Entered her

room to find res with only T-shirt on,

naked from waist down, standing over

her. Female resident stated, "That's a

scary thing to wake up to"....he again

would not stay in his room."


indicating incident was reported to State

Agency.

Quality Assurance audits will be

completed on any unusual

occurrence weekly for four weeks

and then monthly per the Quality

Assurance Program to ensure

compliance. (See Attachment A

and B)







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(X5)

COMPLETION


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WALKERTON, IN46574

155574 04/29/2011


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The DON was interviewed 4/28/2011 at

10:30 a.m. The DON indicated there was

no documentaton indicatng any


Agency related to this resident.


4/21/2011 at 2:00 p.m. Resident #89's


paraplegia.

Resident # 89's record indicated the

following notes:

12/19/2010 at 12:01 a.m.- Behavior notes,

"This writer notified by QMA (Qualified

Medication Aide) that resident has made

inappropriate comments to her today. The

first being, "I haven't had a woman on top

of me in a long time," this was while staff

member was rolling resident et (and)

reaching across him to dress him today.

The other instance, resident stated, "well

sure I'll lay down if you want to get it on,"

this was after staff member asked resident

to lie back in bed to put a brief on him

before meal."

12/19/2010 at 12:05 a.m.-Behavior notes,

"In addition to previous note, this writer

was also informed that res (resident) had

made gestures with his tongue toward a





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female resident et this female resident

stated he comes up behind her and she

feels like she's (sic) blocked in (sic) the

CDP (Certified Distinct Part) room and

can't get out."


"Res bumped into female res w/c

(wheelchair) with his scooter, female

began to cry and Resident #89 (Name)

kept is (sic) scooter lodged against w/c so

she could not move. Res needed to (sic)

me told to back up w/c so female res

could move her w/c."


indicating incident was reported to State

Agency.

The DON was interviewed 4/28/2011 at

10:30 a.m. The DON indicated there was

no documentaton indicatng any


Agency related to this resident.



dated 8/23/2010 "...It is the policy of

Miller's Health Systems that all residents

have the right to be free from verbal,

sexual, physical and mental abuse,







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500 WALKERTON TRAIL

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155574 04/29/2011


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3.1-28(a)

F0248 The facility must provide for an ongoing

program of activities designed to meet, in

accordance with the comprehensive

assessment, the interests and the physical,

mental, and psychosocial well-being of each

resident.

SS=D

Based on observation, record

review and interviews, the

facility failed to provide

necessary activities to meet a

resident's needs who exhibited

numerous behaviors for 1 of 7

residents reviewed with

behaviors in a sample of 19.

(Resident # 16)

Findings include:

Resident # 16's record was


Manor, Walkerton that the Activity

Department will design and

implement a comprehensive

activity program. This program

will provide leisure education,

leisure therapy, and opportunities

for activity participation, based

upon the assessed needs and

interest of the facility population.

Resident #16 was discharged

from facility.


affected by this deficient practice.

To prevent a reoccurrence, the 24

Hour Condition Report will be

reviewed daily by the Activity

Director and/or designee and any

new or exacerbated behaviors

05/28/2011 12:00:00AM





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reviewed on 4/27/11 at 2:00

p.m. The resident's record

indicated diagnoses of, but not

limited to: Alzheimer's disease,

and impulse control disorder.

Resident # 16's record

indicated he was admitted to

the facility on 10/7/10. The

record indicated the resident

wandered in the facility. The

record indicated for the month

of October 2010, the resident

had wandered into other

resident rooms and exhibited

unwanted behaviors towards

other residents.

During an interview with the

Director of Nursing on 4/27/11

at 1:45 p.m. regarding Resident

# 16 wandering in other

resident rooms and exhibiting

unwanted behaviors, she

indicated the behaviors became

that are noted will have a

reassessment of that resident’s

activity program initiated. It will

be completed within seven (7)

days to determine root cause. If

after completion of the

assessment it is determined there

is a need to change/alter/update

the activity plan it will be

implemented.

To monitor effectiveness of this

system, all residents identified

who have specific activity

programs to assist with behavior

will be audited per Activity

Participation Review weekly for

six weeks, monthly for three

months and then quarterly per the

Quality Assurance Program. (See

Attachment C)







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more frequent in the evening

due to Sundowners syndrome.

During an interview with alert

and oriented Resident # 371

and Resident # 341 on 4/27/11

at 1:30 p.m. regarding residents

wandering in their room, they

both indicated Resident # 16

had recently wandered in their

room startling them and

touching their things. They

indicated he scared them when

he came into their room as

they did not like it. Resident #

371 indicated they had to

scream for the nurse to come

get him out of their room. Both

residents indicated it usually

happens in the evening or early

morning.

An observation was made on

4/27/11 at 3:30 p.m. of

Resident # 16 wandering the





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hallway having to be redirected

away from resident # 371's

room by staff. There wasn't any

type of activity observed for

Resident # 16 to become

engaged in at this time.

During an interview with

Activity Director # 5 on

4/28/11 at 4:30 p.m. regarding

any type of activity used or

attempted to help occupy

Resident # 16's time in the

evening hours when his

behaviors occurred, she stated

"No, we didn't put anything in

place for that, I suppose we

should have."

3.1-33(a)

F0250 The facility must provide medically-related

social services to attain or maintain the

highest practicable physical, mental, and

psychosocial well-being of each resident.

SS=D

Based on interview, and record

review, the facility failed to


provides medically related social

service to attain or maintain the

highest practical, physical, mental

05/28/2011 12:00:00AM





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ensure Social Services

provided the necessary

assistance to ensure a resident

who wandered about the

facility and had sexual

behaviors towards other

residents received the needed

care and treatment from Social

Services to ensure his

psychosocial needs were being

met for 1 of 7 residents

reviewed with behaviors in a

sample of 19. (Resident # 16)

Findings include:



p.m. The Resident's record

indicated diagnoses of, but not

limited to: Alzheimer's

dementia, insomnia and

impulse control disorder. The


was admitted to the facility on

10/7/10.

and psychosocial well being of

each resident per Indiana State

Regulations.

Resident #16 was discharged

from facility.



Review of the 24 Hour Condition

Report will be reviewed daily by

the Social Service Director and/or

designee and they will address

any new or exacerbation of

previously assessed behaviors at

that time. If applicable, any new

behavior will be monitored on

behavior tracking log for seven

(7) days to determine root cause.

If after completion of assessment

it is determined there is a need to

change/alter/update the resident’s

behavior plan, it will be

implemented.

To monitor effectiveness of this

system, a Social Service Needs

review will be done monthly per

Quality Assurance program. (See

Attachment D)


completed by May 28,

2011





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indicated he wandered, had

behaviors of a sexual nature

against other residents,urinated

and defecated in other resident

rooms and in common areas

visited by other residents.

The Resident's record indicated

for the months of October,

November, December 2010,

January, February, March and

April 2011, he had urinated and

or defecated in places other

than his bathroom 131 times.

The record also indicated he

had 16 episodes of sexual

behaviors and 159 episodes of

wandering.

Nurses note dated 10/14/10 at

9:40 p.m. indicated the

Resident was naked in the

doorway urinating on the door.





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Nurses notes dated 10/16/10

indicated the resident had

entered a female resident's

room and touching her stomach

over her nightgown and covers.

The note further indicated the

resident had an erection. The

nurses note dated the same day


urinated on another resident's

tv, floor and night stand.

Nurses note dated 10/18/10 at

10:45 p.m. indicated Resident #

16 was found without his

clothes on in another resident's

bed rubbing the other resident's

thigh.

The Resident's record lacked

documentation to indicate

Social Service had

implemented any type of

assistance with the Resident's





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behaviors.

The Resident's plan of care for

his behaviors the care plan

problem was documented

10/17/10. The problem

indicated " (Resident name) has

dx (diagnosis) Alzheimer's, is

using seroquel (antipsychotic

medication used for behaviors)

and may display behaviors of;

wandering, enter other resident

rooms, opening exits,

urinating/defecating on floor

and rummaging. He may

display inappropriate behavior

sexual behavior, date initiated

10/17/10...."

The interventions indicated:

"calm approach and redirect

from behaviors (10/13/10),

clean resident and area as

needed, (10/13/10), notify Dr.

and family PRN (as needed)





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10/13/10, facilitate any

treatment or referrals as

ordered such as psych services

ect. (sic) 10/13/10, accu-tag

placement and checks per

policy 10/13/10, bed alarm

while in bed 10/19/10, Use

door sensors when they arrive

10/19/10, Keep in private room

at this time 10/19/10, Direct

out or away from other resident

rooms 10/26/20, sensor alarm

on his door and doors of rooms

he most frequently wanders

into 11/22/10...."

During an interview with The

Director of Social Services # 6

on 4/29/11 at 1:10 p.m.

regarding the lack of Social

Service involvement for

Resident # 16's behaviors,

Social Service staff # 6

indicated he was aware of the

issues with Resident # 16, but





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he acknowledged he totally

missed addressing it for the

month of October and had not

been addressed as it should

have been.

3.1-34(a)





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F0279 A facility must use the results of the

assessment to develop, review and revise the

resident's comprehensive plan of care.

The facility must develop a comprehensive

care plan for each resident that includes

measurable objectives and timetables to meet

a resident's medical, nursing, and mental and

psychosocial needs that are identified in the

comprehensive assessment.

The care plan must describe the services that

are to be furnished to attain or maintain the

resident's highest practicable physical,

mental, and psychosocial well-being as

required under §483.25; and any services that

would otherwise be required under §483.25

but are not provided due to the resident's

exercise of rights under §483.10, including the

right to refuse treatment under §483.10(b)(4).

SS=D

Based on interview and record

review, the facility failed to

ensure care plans were updated

to reflect a resident's needs

related to behaviors and

activities for 1 of 19 residents

reviewed with care plans in a

sample of 19. (Resident # 16)

Findings include:




has a policy that states the facility

will develop a comprehensive

care plan for each resident that

includes measurable objectives

and timetables to meet a resident’

s medical, nursing, and mental

and psychosocial needs that will

be identified in the

comprehensive assessment.

Resident # 16 has been

discharged from the facility. All

residents are at risk to be


To ensure that this deficient

practice does not reoccur, all

residents in the facility with

identified behavior(s)/or behavior

monitoring programs, their health

care plans will be reviewed by

May 28, 2011 to ensure all

resident needs are identified and

05/28/2011 12:00:00AM





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p.m. The Resident's

record indicated diagnoses of,

but not limited to: Alzheimer's

disease and impulse control

disorder.


indicated he was admitted to

the facility on 10/7/10. The


wandered in the facility. The

record further indicated for the

month of October 2010, the

resident had wandered into

other resident rooms and

exhibited unwanted behaviors

towards other residents.

On 10/14/10 the Resident's

record indicated he was naked

and urinating on the floor, the

record lacked documentation

indicating the resident's plan of

care had been updated for this

behavior.

are up to date. To ensure health

care plans are kept up to date,

residents with identified behaviors

will have health care plans

reviewed by Activity Director,

Social Service Director and MDS

coordinator or designee using the

Care Plan Review Quality

Assurance Tool. (See Attachment

E) Corrective action will be






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tv, floor and night stand. The

Resident's record lacked

documentation indicating the

care plan had been updated.














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tv, floor and night stand.

The Resident's record lacked

documentation to indicate his

care plan had been updated.


record indicated he attempted

to put his hands in a sharps

container. The Resident's

record failed to indicate the

care plan was updated.


record indicated he entered

Resident # 337 room. Resident

# 337 yelled had to yell for

staff to remove Resident # 16

from the room. The Resident's

care plan lacked documentation

to indicate it had been updated.

On 10/23/10 nurses note

indicated Resident # 16 was

attempting to take other





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resident's wheelchairs. The care

plan lacked being updated.

On 10/24/10 nurses notes

indicated the CNA's failed to

activate Resident #16's door

alarm. Resident #16 then

entered Resident # 337's room

removing the resident's

blankets causing them to

scream for help. The facility

failed to update the plan of

care.

On 10/25/10 nurses note

indicated Resident #16 was

found in a female resident's

room (note did not indicate

who's room it was) naked from

the waist down standing over

her. The Resident's plan of care

failed to be updated with other

interventions to prevent this

behavior.





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at 1:45 p.m. regarding Resident

# 16 wandering in other

resident rooms and exhibiting

unwanted behaviors, she

indicated the behaviors became

more frequent in the evening

due to Sundowners syndrome.

The Resident's plan of care

dated 10/17/10 failed to

indicate anything had been put

into place for this problem.

During an interview with alert

and oriented Resident # 371

and Resident # 341 on 4/27/11

at 1:30 p.m. regarding other

residents wandering in their

room, they both indicated

Resident # 16 had recently

wandered in their room

startling them and touching

their things. Resident # 371

indicated they had to scream





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for the nurse to come get him

out of their room. Both

residents indicated it usually

happens in the evening or early

morning. Resident # 16's plan

of care lacked being updated to

prevent him from going into

other resident rooms and

scaring them.


Activity Director # 5 on


any type of activity used or

attempted to help occupy

Resident # 16's time in the

evening hours when his

behaviors occurred, she stated

"No, we didn't put anything in

place for that, I suppose we

should have." The Activity

Director further indicated a

care plan had not been

developed for this need.





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Social Service staff # 6 on


the lack of Social Service

involvement for Resident # 16's

behaviors, Social Service staff

# 6 indicated it was totally

missed for the month of

October and had not been

addressed as it should have

been. He further indicated the

Resident's care plan had not

been updated after the

behaviors occurred.

The facility's policy and

procedure Titled "Care Plan

Development & Review" dated

11/10, indicated "...3. Care Plan

Revision: A. Care plans will

be revised daily and prn (as

needed) as changes in the

resident's condition dictate.

Changes include but are not

limited to...behavior





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changes...."

3.1-35(a)

F0282 The services provided or arranged by the

facility must be provided by qualified persons

in accordance with each resident's written

plan of care.

SS=D

Based on record review and

interview, the facility failed to

ensure physician orders and plan of

care were followed related to blood

sugars and administration of insulin

coverage for 2 of 2 residents

reviewed with sliding scale insulin

coverage (Residents # 21 and # 87)

in a sample of 19.

Findings include:

1. The clinical record for Resident

# 21, reviewed on 4/27/11 at 11:15

A.M., indicated diagnoses of, but

not limited to: diabetes mellitus,

hypertension, renal failure, and

anemia.

A Physician Order, dated 11/16/10,


has a policy to ensure that

services provided or arranged by

the facility must be provided by

qualified persons in accordance

with each resident’s written plan

of care.

Residents #21 and #87 suffered

no ill effects from physician’s

orders not followed properly.

All diabetic residents with sliding

scale coverage in this facility have

the potential to be affected by the

deficient practice.

The DON/ADON or designee will

review all residents with sliding

scale coverage blood glucose

sheets daily for next 30 days

beginning 5/3/11 using the Insulin

and Blood Sugar Report (See

Attachment F), and Quality

Assurance Tool, Medication Error

Review (See Attachment G)

weekly and then monthly

thereafter. All professional

nursing staff will be inserviced on

May 19, 2011 or before May 28,

05/28/2011 12:00:00AM





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indicated, "...Inject Novolog...per

sliding scale: 150-200=3 units;

201-250=6 units; 251-300=9 units;

301-350=12 units; > (greater than)

350, give 15 units..."

Review of the February 2011,

Medication Administration Record

(MAR) indicated incorrect sliding

scale coverage for the following

Accu Check results:

2/17 at 4:30 P.M., Accu Check

result 146. The clinical record

indicated the Resident received 3

units but should not have received

any sliding scale coverage.



indicated the Resident received no

coverage but should have received

3 units.

Review of the April 2011, MAR

indicated incorrect sliding scale

coverage on 4/18 at 4:30 P.M.,

Accu Check result 109. The

clinical record indicated the

Resident received 3 units but

2011. The DON/ADON or

designee will be responsible for

completing the Quality Assurance

Tool Glucose Monitoring Review

(See Attachment H) daily for 30

days and monthly thereafter.







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should not have received any

sliding scale coverage.

Resident # 21's Care Plan, dated

6/5/10, indicated, "...Administer

Novolog per sliding scale..."


# 87, reviewed on 4/27/11 at 1:40

P.M., indicated diagnoses of, but


hypertension, acute pancreatitis,

and hypothyroidism.


indicated, "...Check BS (blood

sugar) 4 times daily...Inject Regular

Insulin...per sliding scale:...< (less

than) 200=0 units; 201-220 give 2

units; 221-250 give 4 units;

251-275 give 6 units; 276-320 give

8 units; 321 and up give 10 units..."




scale coverage a total of 6

occasions for the following Accu

Check results:





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2/8 at 4:30 P.M., Accu Check result

222. The clinical record indicated

the Resident received 2 units but

should have received 4 units.




units but should have received 8

units.





units.





units.





units.





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units.

Review of the March 2011,





Check results, 10 occasions that

lacked documentation of the Accu

Check being done, and 3 occasions

that lacked a part of the

documentation or unable to read

information:














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288. Unable to read clinical record

to verify accuracy of coverage.






not recorded. The clinical record


units.

3/10 at 11:00 A.M., Accu Check




units.



lacked documentation of coverage

but the Resident should have

received 4 units.

3/14 at 4:30 P.M., The clinical

record lacked documentation of the

Accu check being done.






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units.























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units.

Review of the April 2011,




occasions and 2 occasions that


Check being done for the following

Accu Check results:







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units.





units.








units.





11/11/10, indicated, "...Give insulin

as ordered...Monitor Blood sugar as

ordered..."





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155574 04/29/2011


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Interview with DON (Director of

Nursing) on 4/27/11 at 5:35 P.M.,

she indicated Resident # 21 and #

87 received incorrect sliding scale

coverage's and that the clinical

records lacked documentation of

Accu Check being done as ordered.

LPN # 3 on 4/28/11 at 3:30 P.M.,

indicated that sliding scale

coverage is not verified by another

nurse prior to administration.

Interview with DON on 4/28/11 at

3:40 P.M., she indicated the ADON

(Assistant Director of Nursing)

checks the sliding scale coverage's

at the end of the month to monitor

accuracy.

On 4/28/11 at 3:55 P.M., the DON

indicated that she did not have any

documentation that Accu Check

sliding scale coverage was checked

from the first of the year through

the current date.

A facility policy titled, "Blood

Glucose Monitoring", dated






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insulin coverage as

ordered...Document findings on the

appropriate Blood Glucose

Monitoring form...."

3.1-35(g)(2)

F0323 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.

SS=K

Based on observations, interviews, and

record review, the facility failed to ensure

a wandering male resident with sexual

behaviors towards other residents and

urinating and defecating in other resident

rooms and in common areas used by other

residents, was supervised to ensure other

residents were kept safe from these

unwanted behaviors for 3 of 19 residents

reviewed for abuse in a sample of 19

(Resident's # 16, # 301, and # 365 and for

11 of 18 residents reviewed for abuse in a

supplemental sample of 18, Residents:

#307, #340, #341, #344, #358, #367,

#368, #371, #380, #382, #386)

An Immediate Jeopardy was identified on

4/27/11 at 5:30 p.m.. The Immediate

Jeopardy began on 10/14/2010 with

Resident #16. The Administrator and


Manor, Walkerton that the

resident’s environment remains

as free as possible from

accidents and that each resident

receives adequate supervision to

ensure protection from harm

and/or injury.

On Wednesday, April 27, 2011, at

6:20 PM, resident #16 was

discharged from Miller’s Merry

Manor Walkerton into a

behavioral unit until other long

term placement can be secured.

On May 13, 2011, this facility was

notified by Laporte Hospital that

Resident #16 was placed at

another long term care facility.

All residents in this facility have


deficient practice.

05/28/2011 12:00:00AM





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Director of Nursing were notified of the

Immediate Jeopardy on 4/27/2011 at 6:00

p.m. related to the failure to supervise

Resident #16 and protect other residents

from abuse.

Findings include:

The clinical record of Resident #16 was

reviewed on 4/27/2011 at 2:00 p.m.

Resident #16 was admitted to the facility

on 10/7/2010. Resident #16's diagnoses

include, but were not limited to,


Disorder, dementia with behavior

disturbances, and sleep disturbance.

Nursing Notes:

10-14-2010 at 9:40 p.m.- Behavior notes

indicated Resident #16 was naked in the

doorway and urinating on his door.

10-15-2010 at 3:24 p.m.- Behavior notes,

"...difficult to redirect ...."

10-16-2010 at 10:19 p.m.- Behavior

notes, "...entered a female resident's room

and was found to be touching residents




A resident council meeting was

held at 10 AM on 4/28/11 and at

that time we will be asking open

ended questions related to safety,

supervision, and care delivered in

the facility. Any resident that was

unable to attend the meeting will

be interviewed individually by

assigned staff using the same

question format. Sponsor of

residents who are non-interview

able will be contacted by phone

and/or in person.

In-service education will be done

with all staff members on duty on

4/28/11 detailing how to identify

any resident conduct or unusual

behavior that is considered

inappropriate and may cause

jeopardy to the residents in the

facility. This will be completed by

1 PM on 4/28/11 and all

remaining staff will be in serviced

before they can come on duty.

(This will be completed by

Administrator, DON and/or

designee).

Going forward, a system is now in

place identifying the steps to take

if at any time a resident reports a

concern or staff member

becomes aware of a concern

related to supervision issues.

(See Attachment N).

To ensure that this deficient

practice does not reoccur, the 24

hour condition report will be

reviewed daily. **Any

documentation/ entry from any





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"...resident without his gown on and

entering into another residents room

(room number documented) directly

across the hall from his room and voided

on the night stand, tv, and floor before

staff could stop him...Continues with 15

minutes checks at this time."

10-17-2010 at 2:58 p.m.- Notification

indicated Dr (name) was contacted and

new orders were received.

10-17-2010 at 4:37 am- Behavior notes

indicated attempting to enter other

resident rooms, "...voided on a night

stand, tv, and floor of another resident

across the hall before the staff could stop

him."

10-18-2010 10:45 p.m.- Behavior notes,









discipline in the EMR becomes

part of the 24 hour condition

report. If any concerns/issues are

found, appropriate follow up will

occur with notification to Social

Services, Director of Nursing and

Administrator immediately upon

discovery and action will be taken

per facility policy depending upon

the situation. The reviewing of

the 24 hour condition report will

take place in the morning meeting

Monday thru Friday and

documented on the daily morning

meeting minutes form. On

weekends, the weekend manager

will be responsible for reviewing

the 24 hour condition report and

communicating any issues or

concerns to the Social Service

Director, Director of Nursing and

the Administrator via telephone.

Any reportable incidents will be

called into the State Department

of Health by the Director of

Nursing. **Group interviews will

continue monthly during the

Resident Council Meeting.

Twenty five percent of those

residents not in attendance will be

individually interviewed weekly for

six weeks and then monthly

thereafter.

The DON and ADON or designee

will complete the Quality

Assurance tool titled 24 hour

Condition Report review daily for

three weeks, weekly for three

weeks and then monthly

thereafter. (Attachment A). Any

issues related to





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q 15 minute checks. DON was then

notified at 10:50 p.m. and she notified

administrator."


"continues 15 minute checks."


indicated Resident #16 entering resident's

rooms, unzipping his pants in the hall and

in resident rooms, "...attempting to

urinate where ever he may be, undressing

in hallway. Remains on 15 minute

checks, bed alarm on for safety."

10-19-2010 at 12:53 p.m.- General note

indicated Resident #16 was transferred

from room (room number documented) to

(room number documented).


indicated Resident #16 urinated on

another residents door.


"...up walking halls, all precautions in

place...."

supervision/safety will be

immediately communicated upon

discovery to the Social Services

Director, Director of Nursing and

Administrator. Facility policies

and procedures will be initiated as

appropriate related to identified

concern. A summary of findings

will be presented during quality

assurance meeting for review.


completed by 4/28/11.





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10-20-2010 at 6:39 p.m.- General note,

"...attempting to put hand down into

sharps container...Another res (resident)

c/o (complains of) that he went in her

room and tore her bed up...."


"...attempted to take walker from male res

sitting there. Other res became angry and

swore at (Resident #16), separated

residents, explained to other res that he

does not understand."


indicated the Resident was on 15 minute

checks, "...requires redirection more often

than 15 minutes while awake keeps trying

to walk in others rooms, was attempting

to sit on females and one males lap in

w/cs (wheelchairs)...."


indicated Resident #16 was attempting to

urinate outside the DON's office door.


indicated the resident was found pushing

a shower room wheelchair in the North

hall.


"...on q 15 minute checks. Requires

redirection more often than 15 minutes

while awake...trying to walk into others





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rooms."


"...Feces was found in his chair and along

the floor."


"At 6 p.m. entered several other resident

rooms, redirected with difficulty,

unzipped pants in hall and attempted to

urinate...."


"...(Names) sisters room...They were

yelling for him to get out of their room.

At 8:00 he was found into Unit II. He

gropped (sic) a CNA's buttocks...."


indicated Resident #16 urinated two times

on his floor.


"wandering about entering other resident

rooms picking up items attempting to

move furniture, other resident's upset with

(Resident #16) in their rooms, telling him

to get out but he continues to fiddle with

things. Resident entered another room,

and urinate in bed...."

10-23-2010 at 2:53 am- Behavior notes,

"...required intervention q 5-15 minutes

entire shift to keep out of peers rooms, not

unzip pants in hall...attempted to kiss





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various staff members."


"...attempted to take other Residents

wheelchairs (by the armrest). At one

time, he attempted to pull the legs of

another resident's table apart...required

intervention q 5-15 minutes (even with

family members present) entire shift to

keep out of other resident's rooms,

attempted to unzip pants...consume other's

(sic) residents food and drinkd (sic)."

10-23-2010 at 10:00 p.m.- Behavior

notes, "...Resident was moving pillows

around her head (room number

documented)...."


indicated Resident #16 made sexual

comments to a CNA, "...pressed erect

penis into her thigh and made groaning

sounds, grabbed her groin region

wandered into others room. Requires

constant direct supervision to stay out of

rooms. Attempts to push w/cs and pick

up computers off desks."

10-24-2010 at 10:57 p.m.- Behavior

notes, "CNA did not activate the door

alarm to room. The residents in rm

(room) (room number documented) were

yelling and screaming. One of the





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residents blankets were being taken off of

her."


indicated Resident #16 urinated on the

floor and walls three times during the

shift.


"...res would not stay in his room. Door

sensor alarm on per policy. Within one

minute, female res on north hall yelling

"nurse, nurse." Entered her room to find

res with only T-shirt on, naked from waist

down, standing over her. Female resident

stated, "That's a scary thing to wake up

to"....he again would not stay in his

room."

10-26-2010 at 4:46 am- General note

indicated the resident urinated on the floor

and wall two times.

10-26-2010 at 10:27 p.m.- Behavior note,

"would leave room in tee shirt only after

continuously taken (sic) hospital gown

off, and go into Rooms (room number

documented) and (room number

documented). Resident would then leave

room and stay in hallway...."

10-27-2010 at 2:12 p.m.- General Note,

"psychiatric Hospital RN calls here.

Report given"





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"q 15 minute checks continues remained

under direct supervision this shift or in

room with bed alarm on. Has tried to

touch staff inappropriately wife here for

approx (approximately) one hour this

afternoon. came after lunch. She does not

turn his door sensor on when she leaves

room...."

10-27-2010 at 6:15 p.m.- Notification,

"...admitted to Psychiatric Hospital, d/t

(due to) continues to have aggressive

sexual behaviors...."


indicated Resident #16 returned from

psychiatric hospital at 2:15 p.m.


"...dining room and in front of a lady

pulled down his pants exposing

himself...."


"Staff reported that res attempted to kiss

her and told her he was going to get

"some rubbers" from his room."


"Found peeing in hallway with alarm

going off. Continues to attempt to touch

staff in inappropriate areas. Attempted to

leave building by opening exit door."





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11-19-2010 at 3:50 am- Behavior note,

"During this shift resident asked staff for a

kiss, also attempted to touch CNA's breast

and buttocks. Wondering (sic) out of his

room several times (about 7-8 times)...."


"Found in own bathroom attempting to

exit thru jointing door. Attempting to

void in hallway and in another resident's

room after setting off door alarm (that

does not have an alarm-(room number

documented)) Continues to attempt

inappropriate touching of staff, in various

manners. Resident display new behavior

of attempting to "outsmart" door alarms ie

(example)- in manner of attempting to

leave own room."


"During this shift Resident tried x2 (two

times) to urine (sic) in the hallways and at

nursing station. He was sitting at nurses

station, then got out of chair and started to

touch another resident's wife. Wife did

verbalize for him to leave her alone. At

that point, he was placed in his room with

the door alarm on. He attempted to go

into different resident's rooms that did not

have door alarms ((room number

documented) and (room number





05/20/2011PRINTED:

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documented)). Wondering (sic) out of his

room several times (about 8-10

times)...continues to have a BM (bowel

movement) in room."


"Urinated on the floor in his room twice

tonight. Wondering (sic) out into hallway

setting off doorway alarm, staff return him

to his bed. Several attempts to touch staff

inappropriately."


"Urinated on floor in his room, he slipped

on the wet floor but staff caught him

preventing a fall. Resident has gotten

OOB (out of bed) and urinated on the

floor 3 times tonight...."


"res. moving about erradically (sic) from

room to room, redirected well, did urinate

on a pad beside a residents bed. family

here earlier, did eat supper well,

attempted to leave building x3 (three

times). at side doors also."

2-16-2011 at 9:52 am-Notification,

"...another resident ran w/c in to back of

(Resident #16)'s leg the (sic) she kicked

him. no injury from incident...."


"...Resident attempted to grab the pelvic





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area of the saem (sic) nurse."


"resident has been wandering around

facility having to be rerouted out of other

residents room."


"...noted to be walking about facility with

no intent to a destination...."

4-27-2011 at 6:25 p.m.- Visualized Social

Service Director and CNA#1 assist

Resident #16 into facility van to be

transported to psychiatric hospital.

Psychiatric hospital findings:

A review of (Name) psychiatric hospital

Patient's Progress Notes dated from

11/11/2010 to 11/17/2010 on 4/29/2011 at

9:30 a.m. indicated Resident #16

continued to be intrusive to staff and other

patients and wander throughout the unit.

Review of the Behavior and Psychotropic

Monitoring Records dated from

10/13/2010 to 4/18/2011, Resident #16

had 131 episodes of urinating or

defecating in room or on floor.







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10/13/2010 to 3/28/2011, Resident #16

had 16 episodes of sexual behaviors.



10/13/2010 to 4/19/2011, Resident #16

had 159 episodes of wandering.

Physician Visits/Orders:

10-17-2010 at 3:03 p.m.- Physician order,

increase "...Melatonin 3 mg, give two tabs

po (by mouth) every hs (evening)...."


"...seroquel for dementia with

agitation...."

10-19-2010 at 12:38 p.m.- Physician visit,

"seen by Dr. (Name) new orders received,

facility psych services to follow progress

note written...."

10-19-2011 at 11:22 am- "...Provera 10

mg i (one) po daily for sexual behaviors

and increase Melatonin 3 mg to give 3

tabs po q HS Dx (diagnosis) Sleep

disturbances...."


"Facility psych services to follow."

10-21-2010 at 1:15 p.m.- Physician Visit,

"seen by (name) FNP from psychiatric

hospital. n.n.o. (no new orders)."





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10-23-2010 at 9:57 am- Physician Order,

"...Exelon patch 4.6 at 830 am daily...."

10-23-2010 at 9:58 am- Lab indicated

urine specimen obtained

10-24-2010 at 1:58 p.m.- Lab indicated

faxed "...basically normal...." urinalysis

lab to Dr. (name)

10-24-2010 at 10:16 p.m.- Lab indicated

urinalysis results faxed to Dr. (name)

12-7-2010 at 11:24 am- Physician Visit,

"seen by Dr.(name) nno...."




"Seen by Dr (name) no new orders"




"routine visit from (name), FNP from

psychiatric hospital, progress note written

and n.n.o."


"seen by Dr. (name) nno (no new

orders)...."


"Lexapro 5 mg po q daily at 830 am then

increase to 10 mg daily at 830 am for

Impulse Control Disorder."





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Health Care Plan Meeting Notes:

10-25-2010 at 9:53 am (late entry)-

"...Discussed new med of provera and

increase in melatonin. Using an exelon

patch...discussing recent behaviors such

as wandering, entering resident rooms,

kissing staff, and touching female

resident...." Wife stated, "...he had these

behaviors at home. (Name) (wife) stated

she didn't tell anyone about his sexual

behavior as she did not think he would do

it here, but only with her...."

Care Plans:

Behavior Care Plan initiated 10/17/2010,

stated, "Focus-(Resident #16) has dx

Alzheimer's, is using seroquel and may

display behaviors of; wandering, enter

other resident rooms, open exits,

urinating/defecating on floor and

rummaging. He may display

inappropriate behavior sexual

behavior...Goals-(Resident #16) will

accept redirection from behaviors and his

person and surrounding area will be kept

clean and have no adverse side effects

from seroquel...Interventions-Calm

approach and redirect from behaviors

(initiated 10/13/2010), Clean resident and





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area as needed (initiated 10/13/2010),

notify Dr. and family PRN (as needed)

(initiated 10/13/2010), facilitate any

treatment or referrals as ordered such as

psych services ect (initiated 10/13/2010),

accu-tag placement and checks per policy

(initiated 10/13/2010), Bed alarm while in

bed. Use door sensors when they arrive

(initiated 10/19/2010), Keep in private

room at this time (initiated 10/19/2010),

Direct out or away from other resident

rooms. (initiated 10/26/2010), sensor

alarm on his door and doors of rooms he

most frequently wanders into (initiated

11/22/2010)...."

Elopement Care Plan initiated

10/17/2010, stated, "Focus- (Resident

#16) at risk for elopement d/t several

attempts to exit the

facility...Goals-Resident will not leave

facility unaccompanied...Interventions-

Accutag at all times (initiated

10/13/2010), Will be redirected to

activities (initiated 10/13/2010), Keep

clear of doors (initiated 10/13/2010)...."

Memory Loss Care Plan initiated

11/17/2010, stated, "Focus- Needs

assisted to activities has long and short

term memory loss...Goals- (Resident #16)





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will be assisted to activities for

stimulation and

socialization...Interventions...Assist to and

from group as needed, Redirect and

encourage him to stay for a long duration

of activities, Provide snacks at table to

assist with sitting longer at act...."

Observation findings:

4/26/2011 at 1:30 p.m. Resident #16

observed walking down hall unattended

by staff.

4/27/2011 at 3:15 p.m. Resident #16

attempting to enter Resident #371's room,

staff was present and redirected.

4/27/2011 at 6:00 p.m. Resident #16

noted to be in dining room with no staff

aware of him attempting to open outside

door several times.

Interviews findings:

Resident #367 on 4/25/2011 at 2:15 p.m.

resident indicated that she has an alarm on

her door because another male resident

entered her room a couple months ago and

pounded on her stomach. Resident #367

also indicated she had to scream for staff

to remove him and she was scared of him.

Resident #367 indicates her room was





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also relocated but he still walks by and

looks in and at times has tried to come in

her new room this scares her. Resident

#367's mother (POA) was contacted on

10/19/2010 regarding her room relocation.

Staff indicated in the Nursing notes that

Resident #367 was upset that a male

resident was entering her room.

Resident #371 and Resident #341 on

4/26/2011 at 1:30 p.m. residents indicated

Resident #16 had come into their room

within the last two weeks and they were

startled by him. They indicated they were

scared of Resident #16 and had to scream

for the nurse to remove him.

Resident #301 on 4/28/2011 at 9:30 a.m.

resident indicated name (Resident #16)

comes in her room and she had to scream

for staff to remove him, "...I am glad he is

gone...he bothered me...."

During interview with Resident #380's

husband on 4/27/2010 at 2:00 p.m.

regarding Resident #16 entering his wife's

room uninvited. Her husband indicated it

scared his wife when Resident #16

entered the room.

Group Interview on 4/26/2011 at 1:30

p.m.. A total of 10 of 22 residents by





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show of hand indicated that there has been

a resident wandering into their rooms

recently against their will and expressed

they did not like it. (Residents #301,

#307, #340, #344, #358, #365, #368,

#367, #382, and #386).



with a policy start date of 8-23-2010 and

expiring on 4-25-2011, states, "...It is the

policy of Miller's Health Systems that all

residents have the right to be free from

verbal, sexual, physical and mental abuse,










Miller's Health Systems has policies and

procedures in place that all alleged

violations are thoroughly investigated,

and must prevent further potential abuse

while the investigation is in

progress...Definitions...B. Sexual





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Abuse-...B. Resident to resident

non-consensual sexual acts. C. Resident

to resident sexual acts when both parties

are considered mentally incompetent or

dependent, and injury is sustained..."

An immediate Jeopardy was identified on

4/27/11 at 5:30 p.m.. The immediate

Jeopardy began on 10/14/2010 when the

Resident's abusive behaviors first began.

The Administrator and Director of

Nursing were notified on 4/27/2011 at

6:00 p.m. of the Immediate Jeopardy

related to lack of supervision to protect

other resident's from sexual abuse from

Resident # 16. The IJ was removed on

4/29/2011 at 11:00 a.m. when through

observations, staff interviews and record

reviews, it was determined that the facility

had implemented the plan of action to

remove the immediacy of the problem.

Even though the immediate jeopardy was

removed, the facility remained out of

compliance at a level of pattern, no actual

harm with potential for more than

minimal harm that was not immediate

jeopardy. Inservices on abuse had been

conducted immediately by the Director of

Nursing for all staff on all three shifts.

Staff on all three shifts were interviewed





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and quizzed on abuse and neglect to

ensure they had the required knowledge.

The facility's corrective action plan was

reviewed. Inservice material that was used

to inservice the staff was reviewed.

Observations were made of staff and

resident interactions along with resident to

resident interactions. Even though the

facility's corrective action removed the IJ,

the facility remained out of compliance at

a reduced scope and severity level.

3.1-45(a)(2)





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F0333 The facility must ensure that residents are

free of any significant medication errors.SS=D

Based on record review and

interview, the facility failed to

ensure residents were free of

significant medication errors related

to administration of insulin

coverage for 2 of 2 residents

reviewed with sliding scale insulin

coverage (Residents # 21 and # 87)

in a sample of 19.

Findings include:


# 21, reviewed on 4/27/11 at 11:15

A.M., indicated diagnoses of, but


hypertension, renal failure, and

anemia.


indicated, "...Inject Novolog...per

sliding scale: 150-200=3 units;

201-250=6 units; 251-300=9 units;

301-350=12 units; > (greater than)

350, give 15 units..."



has a policy to ensure that

services provided or arranged by

the facility must be provided by

qualified persons in accordance

with each resident’s written plan

of care.

Residents #21 and #87 suffered

no ill effects from physician’s

orders not followed properly.

All diabetic residents with sliding

scale coverage in this facility have


deficient practice.

The DON/ADON or designee will

review all residents with sliding

scale coverage blood glucose

sheets daily for next 30 days

beginning 5/3/11 using the Insulin

and Blood Sugar Report (See

Attachment F), and Quality

Assurance Tool, Medication Error

Review (See Attachment G)

weekly and then monthly

thereafter. All professional

nursing staff will be inserviced on


2011. The DON/ADON or

designee will be responsible for

completing the Quality Assurance

Tool Glucose Monitoring Review

(See Attachment H) daily for 30

days and monthly thereafter.



05/28/2011 12:00:00AM





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scale coverage for the following

Accu Check results:




units but should not have received

any sliding scale coverage.



indicated the Resident received no

coverage but should have received

3 units.

Review of the April 2011, MAR

indicated incorrect sliding scale

coverage on 4/18 at 4:30 P.M.,

Accu Check result 109. The

clinical record indicated the

Resident received 3 units but

should not have received any

sliding scale coverage.



Novolog per sliding scale..."





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# 87, reviewed on 4/27/11 at 1:40

P.M., indicated diagnoses of, but


hypertension, acute pancreatitis,

and hypothyroidism.


indicated, "...Check BS (blood

sugar) 4 times daily...Inject Regular

Insulin...per sliding scale:...< (less

than) 200=0 units; 201-220 give 2

units; 221-250 give 4 units;

251-275 give 6 units; 276-320 give

8 units; 321 and up give 10 units..."






Check results:










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units.





units.





units.





units.





units.

Review of the March 2011,





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Check results, 10 occasions that


Check being done, and 3 occasions

that lacked a part of the

documentation or unable to read

information:










288. Unable to read clinical record

to verify accuracy of coverage.









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not recorded. The clinical record


units.





units.



lacked documentation of coverage

but the Resident should have

received 4 units.








units.







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units.

Review of the April 2011,




occasions and 2 occasions that


Check being done for the following

Accu Check results:





units.








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units.








units.





11/11/10, indicated, "...Give insulin

as ordered...Monitor Blood sugar as

ordered..."

Interview with DON (Director of

Nursing) on 4/27/11 at 5:35 P.M.,

she indicated Resident # 21 and #

87 received incorrect sliding scale

coverage's and that the clinical

records lacked documentation of

Accu Check being done as ordered.





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LPN # 3 on 4/28/11 at 3:30 P.M.,

indicated that sliding scale

coverage is not verified by another

nurse prior to administration.

Interview with DON on 4/28/11 at

3:40 P.M., she indicated the ADON

(Assistant Director of Nursing)

checks the sliding scale coverage's

at the end of the month to monitor

accuracy.

On 4/28/11 at 3:55 P.M., the DON

indicated that she did not have any

documentation that Accu Check

sliding scale coverage was checked

from the first of the year through

the current date.

A facility policy titled, "Blood

Glucose Monitoring", dated


insulin coverage as

ordered...Document findings on the

appropriate Blood Glucose

Monitoring form...."

3.1-48(c)(2)





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F0371 The facility must -

(1) Procure food from sources approved or

considered satisfactory by Federal, State or

local authorities; and

(2) Store, prepare, distribute and serve food

under sanitary conditions

SS=F

Based on observation, interview,

and record review, the facility

failed to ensure food preparation

areas were clean and sanitary

related to a dust and particle

buildup, and that food preparation

and serving dishes and cups were

clean and sanitary and that dishes

were stored correctly. This

deficient practice had the potential

to effect 91 of 92 residents who

receive meals prepared in 1 of 1

facility kitchen.

Findings include:

During a tour of the facility's

kitchen conducted with the Dietary

Manager on 4/25/11 at 2:30 P.M.,

the following observations were

made:

There was a dust buildup on the eye

wash station located above the hand


Manor Walkerton to procure food

from sources approved or

considered satisfactory by

Federal, State, or local

authorities, and store, prepare,

distribute and serve food under

sanitary conditions.

On 4/25/11, the eye wash station,

the red fire extinguisher by the

sink, the red fire extinguisher by

the kitchen office door and the

silver fire extinguisher were all

dusted and cleaned. The eye

wash station and the fire

extinguishers were added to the

AM and PM daily checklist on

4/26/11. (See Attachment I).

On 4/25/11, the stained

condiment bowls and fruit bowls

were discarded. The stainless

steel bowl was removed,

re-washed and re-sanitized. The

sanitation checklist for Dinner

Ware Cleaning and Storage was

updated so that the AM and PM

supervisors are checking for food

particles and stains. The

sanitation checklist for Pot and

Pan Storage, small wares and

utensils was updated to include

that the AM and PM supervisors

will maintain that all pots, pans,

05/28/2011 12:00:00AM





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washing sink, the red fire

extinguisher by the sink, the silver

fire extinguisher on the post by the

sink, and the red fire extinguisher

by the kitchen office door. A dust

and particle buildup on the ledge

below the steam table and on the

cabinet shelf located to the right of

the steam table.

Dry, gritty particles were noted on

the following dishes and serving

items:

One square, stainless steel serving

bowl; one 10 quart, square serving

bowl; one 4 ounce scoop; one white

# 6 scoop; 3 of 6 dinner plates; 5 of

6 coffee mugs; 2 of 2 plastic

carafe's; 1 of 1 glass carafe; 2 of 2

small saucers; 5 of 10 condiment

bowls and 3 of 3 cereal bowls.

Brown stains were noted on the

following dishes:

2 of 3 small fruit bowls and 5 of 10

condiment bowls.

small wares and utensils are

clean and dry before storage.

(See Attachment J)

Regarding the particles on the

dishes and as indicated on the

2567: On 4/25/11 the dishwasher

was shut down and beginning the

afternoon of 4/25/11, all dishes

were being hand washed.

On 4/25/11 Gordon’s Food

Service was consulted and the

dishwasher was “shocked” per

their instructions.

On 4/25 and 4/26/11, numerous

leaks resulted from the

“shocking” and were repaired.

After all the leaks were repaired

the dishwasher was cleaned,

scraped, de-scaled, de-limed,

vacuumed, scrubbed, etc.

On 4/27/11 GCS, a vendor who

repairs dishwashers came in and

fixed a gasket that could not be

fixed by our maintenance man.

The machine was checked out

completely. We went back to

regular china and discontinued

the use of disposables.

On 5/3/11, the dietary manager

noticed some black and white

specs on the drinking glasses.

We discontinued the use of china

and went back to supplementing

with paper. Administrator and

Dietary Manager went from table

to table in the dining room





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One wet stainless steel bowl was

stacked in the cabinet between two

other stainless steel bowls.

During interview on 4/25/11 at 3:00

P.M., with the Dietary Manager,

she indicated (Name) Food Service

was in last week and checked the

dishwasher and it is serviced

monthly. She further indicated

dietary staff is responsible for spot

checking dishes prior to putting

them away.

Resident Group meeting on 4/26/11

at 1:30 P.M., 4 of 22 residents (#

334, # 371, # 386, # 389) all voiced

concerns about blacks specks and

grit in the drinking cups and

glasses.

On 4/29/11 at 1:10 P.M., the

Dietary Manager indicated the

dishwasher was shut down Monday

(4/25/11) evening and it remained

down until Wednesday (4/27/11)

evening. During this time the

dishes were being handwashed and

supplemented with Styrofoam

explaining to the residents why

we were using paper products

again. All residents and the

family member present voiced

that they understood.

On 5/5/11, maintenance cleaned

the bottom of the holding tank,

pulled the intake and pressure

hoses and the pump and cleaned

all of those. Re-assembled

everything and “shocked” the

machine again.

On 5/9/11 Gordon’s Food Service

was here all morning tested the

dish machine. The water, soap,

and rinse agent were all checked

and the temperatures were

adjusted. Tested the spots on the

glasses for proteins and starch

and all tested negative, however

we were still having the specs.

Took glasses with him and

re-tested the specs and called

back later and said the specs

tested positive for “starch”.

On 5/10/11 Gordon’s called and

had us reset the dispenser to run

more soap through the dish

machine. Ran two racks of

glasses through the machine nine

(9) times, changing the water in

the holding tank every third time.

After nine (9) times we did not

see a big improvement.

On 5/10/11 in the afternoon, the

maintenance man “shocked” the

system again. Also ran one

gallon of vinegar through the





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products.

A "Dietary Food Safety Sanitation

Checklist", undated, received on

4/26/11, indicated, "...Pans stored

clean and dry...Steamtable...Unit is

clean-including well,

shelves...Smallwares,

utensils...dishes, cups,

silverware...Pitchers...Stored clean

& dry with no food residue...Has

no...stains...General Kitchen...Fire

extinguishers clean...Diet

Kitchens...Cupboards and drawers

free of debris...Dishmachine in

good working order...Dishes are air

dried thoroughly prior to being put

away..."

A "Sanitation Checklist for Pot and

Pan Storage, Smallwares, and

Utensils", undated, received on

4/26/11, indicated, "...AM and PM

supervisor will maintain that all

pats (sic), pans, smallwares, and

utensils are clean and dry before

storage."

A "A.M. Daily Cleaning Check

machine four (4) times. Ran and

rinsed machine 3-4 times before

using. Ran a rack of glasses

through two (2) times with no

noticeable improvement.

On 5/10/11 a new pressure

regulator was installed on the

machine per Gordon’s Food

Service. Ran some test glasses

and no improvement.

5/11/11 Residents voiced

concerns over using disposable

dishes, so at lunch we went back

to using china and hand washing

dishes.

5/12/11 Gordon’s Food Service

and a representative from US

Chemical was here to look at

machine. Ran “Laundry Break”

through the machine. Ran racks

and racks of glasses through

machine. Slight improvement

noted however there were still

specs. Both Gordon’s and US

Chemical stated that it was

probably a build up of starch that

happened over several years.

On 5/13/11 a new dishwasher

was ordered. It should be

installed within two weeks. The

dishes are being hand washed

and monitored for specs per our

policy.

All residents are a risk to be






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List", undated, received 4/26/11,

indicated, "...Dust Eye Wash

Station...Dust All Fire

Extinguishers..."

A "P.M. Daily Cleaning Check

List", undated, received 4/26/11,

indicated, "...Dust Eye Wash

Station...Dust All Fire

Extinguishers..."

A "Sanitation Checklist for

Dinnerware Cleaning and Storeage

(sic)", undated, received 4/26/11,

indicated, "...AM and PM

supervisor will check for food

particles, stains, etc. Any stained

dishes will be discarded."

3.1-21(i)(2)

An in-service with all dietary staff

was provided on 5/14/11 on

washing dishes, kitchen

sanitation, cleaning, pot and pan

storage, small wares and utensil

storage.

Daily AM and PM cleaning

checklist (Attachment I) will be

completed two times per day for

60 days by Dietary manager or

designee. Quality assurance tool

“Dietary Food Safety and

Sanitation Checklist” (See

Attachment K) will be completed

by Dietary manager or designee

two times per week for four

weeks, weekly for the four

following weeks, and then per the

quality assurance schedule. If

any issues are found during

audits, a repeat audit will be

done. Any issues, trends will be

logged on a facility QA tracking

tool and reviewed during the

monthly facility QA meeting to

ensure ongoing compliance.





05/20/2011PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


500 WALKERTON TRAIL

WALKERTON, IN46574

155574 04/29/2011


00

F0441 The facility must establish and maintain an

Infection Control Program designed to provide

a safe, sanitary and comfortable environment

and to help prevent the development and

transmission of disease and infection.

(a) Infection Control Program

The facility must establish an Infection Control

Program under which it -

(1) Investigates, controls, and prevents

infections in the facility;

(2) Decides what procedures, such as

isolation, should be applied to an individual

resident; and

(3) Maintains a record of incidents and

corrective actions related to infections.

(b) Preventing Spread of Infection

(1) When the Infection Control Program

determines that a resident needs isolation to

prevent the spread of infection, the facility

must isolate the resident.

(2) 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.

(3) The facility must require staff to wash their

hands after each direct resident contact for

which hand washing is indicated by accepted

professional practice.

(c) Linens

Personnel must handle, store, process and

transport linens so as to prevent the spread of

infection.

SS=D

Based on observation, record

review and interview, the

facility failed to ensure staff


has an established and

maintained Infection Control

program designed to provide a

safe, sanitary and comfortable

environment and to help prevent

05/28/2011 12:00:00AM





05/20/2011PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG



DEFICIENCY)

(X5)

COMPLETION


500 WALKERTON TRAIL

WALKERTON, IN46574

155574 04/29/2011


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washed their hands after

administering medications

through a resident's gastric tube

and then passing medications

to another resident. (Resident #

60)

Findings include:

During an observation of a

medication pass on 4/26/11 at

12:00 p.m., accompanied by

LPN # 2. An observation was

made of LPN # 2 administering

Resident #60's medications

through his gastric tube.

After LPN # 2 had completed

administering the medications,

she removed her gloves and

exited the resident's room

without washing her hands or

using any type of hand

sanitizer.

the development and

transmission of disease and

infection.

Resident #60 was not affected by

this finding as his medication

administrator via G-Tube had

been completed.

All residents who receive

medications can be affected by

this deficient practice.

To ensure the system is effective,

hand washing checks will be

done weekly on 10 employees for

four (4) weeks then 10 employees

monthly thereafter utilizing the

Quality Assurance tool Infection

Control Review (See Attachment

L). Also, the Medication Pass

Procedure Quality Assurance

Check Off Sheet (See Attachment

M) will be used for three (3)

employees weekly for four weeks

and then for three (3) employees

monthly thereafter. Hand

washing education and skills

check off was done for every staff

member of facility and was

completed on May 10th, 2011.

Professional staff will be

inserviced on specifics related to

med pass and hand washing on


2011.







05/20/2011PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


500 WALKERTON TRAIL

WALKERTON, IN46574

155574 04/29/2011


00

LPN # 2 was observed to

immediately prepare and

administer another resident's

oral medications without

washing her hands or using a

hand sanitizer prior to

administering them.



at 12:15 p.m. regarding LPN #2

failing to wash her hands after

passing medications through a

resident's gastric tube and

walking out without washing

her hands, the Director of

Nursing inquired about the

LPN using any hand sanitizer.

No hand sanitizer was observed

to be used.

The facility's policy and

procedure titled "Hand

Washing and Hand Asepsis,

dated 6/9/10, indicated "Policy:





05/20/2011PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


500 WALKERTON TRAIL

WALKERTON, IN46574

155574 04/29/2011


00

To provide protection for

resident and staff when

performing direct care

procedure. To ensure that hands

remain clean so as to assist in

maintenance of a clean

environment and assist in the

prevention and the transmission

of disease and infection...A.

Specific times hands must be

washed:...before and after

direct resident contact...."

3.1-18(l)


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