printed: 10/14/2016 department of health and human ... · printed: 10/14/2016 form approved omb no....

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

10/14/2016PRINTED:

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

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED 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

NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

F 0000

Bldg. 00

This visit was for a Recertification and

State Licensure Survey.

This visit was done in conjunction with

the Investigation of Complaint

IN00207154.

Complaint IN00207154 - Substantiated.

Federal/State deficiencies related to the

allegations are cited at F353 and F465.

Survey dates: August 17, 18, 19, 22, 23,

24, & 25, 2016

Facility number: 000114

Provider number: 155207

AIM number: 100266640

Census bed type:

SNF/NF: 92

Total: 92

Census payor type:

Medicare: 3

Medicaid: 60

Other: 29

Total: 92

These deficiencies reflect State findings

cited in accordance with 410 IAC

16.2-3.1.

F 0000 September 14, 2016 Randy Fry

Public Health Nurse Supervisor

Division of Long Term Care 2

North Meridian Street

Indianapolis, Indiana 46204 Mr.

Fry, REQUEST FOR DESK

REVIEW OF THE FOLLOWING

2567 F323, F353, F371, F441,

F465, F541, F520 Dear Randy,

Thank you for taking the time to

review our recentlysubmitted

2567, from New Haven Care and

Rehabilitation Center, New

Haven,Indiana. I am requesting

desk reviewcompliance as I feel

the citations were isolated events,

with correctionsimmediately taken

to correct those deficiencies. I do

not believe that any residents’

wereaffected by the deficiencies,

validating my request for a desk

review. Staff were in-serviced

and re-educated by the

nursepractice educator in regards

to documentation and

administration of PRN

painmedications and the

effectiveness of the meds given,

the facility hand-washingpolicy

regarding inanimate objects,

infection control processes

related to thedelivery of meals

served on the hallways, infection

control related to theproper

placement of catheter tubing –

new lateral bags were ordered to

assistwith this process, and

housekeeping staff was

re-educated regarding the 5 and

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: PCUS11 Facility ID: 000114

TITLE

If continuation sheet of 64

(X6) DATE




10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

QR completed on August 29, 2016 by

17934.

7step cleaning process. Auditing

tools were put in to place for

review of thedeficiencies in the

2567 as detailed in our Plan of

Correction. Please also accept

my Informal Dispute Resolution

for thefollowing deficiencies:

F323, F353, F520 cited by the

Indiana State Departmentof

Health Survey team. I appreciate

theopportunity to respond to the

survey via this process. As a

friendly reminder to you, the

provider was offeredan extension

of this document and all

documents related to our POC

and IDR,based on the late arrival

of our letter detailing the specifics

ofcompliance. This extension

was grantedvia email received on

September 7th at 3:34 p.m.

Respectfully Submitted, Shauna

Shafer MAE, HFA Center

Executive Director New Haven

Care and Rehabilitation

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

SS=D

Bldg. 00

Based on observation, interview and

record review, the facility failed to ensure

adequate supervision for the safety of 1

of 1 resident reviewed for frequent falls.

(Resident #K)

F 0323 This Plan of Correction is

prepared and executed

because it is required by the

provisions of the state and

federal law and not because

Genesis Healthcare New Haven

Center agrees with the

allegations and citations listed

09/12/2016 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PCUS11 Facility ID: 000114 If continuation sheet of 64




10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

Findings include:

An observation of Resident #K on

8-17-2016 at 2:55 p.m., indicated he was

in his wheelchair at the 100/200 hall

nurse station area. Resident I was

observed to take 2 small cans of shaving

cream from the supply cart that was part

way in and part way out of the supply

room across from the nurse station. A

staff member happened to be nearby and

removed the shaving cream cans from the

resident.


8-22-2016 at 4:18 p.m., indicated the

resident was sitting in his wheelchair and

tried to stand up. The wheelchair was not

locked and the wheelchair had to be

steadied prior to staff getting to the

resident so he would not fall. Resident

#K's nurse was down the hall, another

staff member had her back to the resident

and the other staff were behind the nurse

station at the time the resident stood up

from his wheelchair with the alarm

sounding.



resident was in his wheelchair propelling

himself into room 114. At this time,

there were no staff in the hall, and a nurse

was at the nurse's station around the

on pages 1-50 of this statement

of deficiencies. Genesis

Healthcare New Haven Center

maintains that the alleged

deficiencies do not jeopardize

the health and safety of the

residents, nor are they of such

character so as to constitute

substandard quality of care or

limit our capability to render

adequate care. Please accept

this plan of correction as our

credible allegation of

compliance. F-323 SS = D;

483.25(h) FREE OF

ACCIDENTHAZARDS/SUPERVI

SION/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.

1.What corrective action(s) will

be accomplished for those

residents found to have been

affected by the deficient practice?

Resident K was placed on 1:1

supervision on 08/25/2016. The

Social Service Director is

working with the responsible

person for Resident #K, for

alternate placement in a

secured unit

2.How will other residents

having the potential to be affected

by the same deficient practice be

identified and what corrective

action(s) will be taken? The

residents residing at the facility





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

corner. Nurse #12 was observed to come

out of the isolation room across from

room 114. The nurse was not aware that

Resident #K had entered room 114 and

had to be prompted to see the resident.

An interview with Nurse #12 at this time

indicated Resident #K should not be in

that room. Nurse #9 was observed to

wheel the resident down the 200 hall and

sat him by Nurse #9 who was passing

medications. Nurse #9 indicated

Resident #K will be trying to go in other

residents rooms while she was passing

the medications.

An interview with CNA #2 on 8-25-2016

at 9:35 a.m., indicated for Resident #K

had to be kept in sight at all times while

he is up in the hall in his wheelchair.

CNA #2 indicated Resident #K will go

into other residents' room and all staff

were aware and had to keep him in sight.

An interview with Nurse #9 on

8-25-2016 at 9:37 a.m., indicated for

Resident #K, it takes all staff to keep an

eye on him when he was up. Nurse #9

indicated the other day in the early

morning, the resident was in his

wheelchair and she had to get a nebulizer.

Nurse #9 indicated she observed the

resident almost fall as he had taken his

shoes and socks off. She indicated she

stopped and put his shoes and socks on

were reviewed by the Center

Executive Director and the

Clinical Interdisciplinary Team

on 08/25/2016 with no other

residents noted to be affected.

3.What measures will be put

into place or what systematic

changes will be made to ensure

that the deficient practice does

not recur? The Licensed Nurses

were re-educated by the Nurse

Practice Educator on08/26/2016

through 09/06/2016 on

reporting concerns of need for

increased supervision to the

CNE/CED

4.How will the corrective

action(s) be monitored to ensure

the deficient practice will not

recur, i.e. what quality assurance

program will be put into place;

and by what date the systemic

changes will be completed?

Audits for new admissions and

residing residents with falls or

wandering behaviors will be

conducted 5 times a week

times two weeks, twice weekly

times two weeks then weekly

times 5 months to ensure

compliance with

documentation of resident

review to ensure that resident

is properly placed. The Center

Nurse Executive will review the

audits monthly at the QAA

Meeting for any further

recommendations should

concerns be verbalized The

CED/CNE/NPE or designee to





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

and made sure he was seated in his

wheelchair. Nurse #9 indicated the other

nurse was passing medications to her

residents, the aides were getting other

residents up and by the time she got back

from getting the nebulizer, Resident #K

was on the floor in the hallway. Nurse #9

indicated it was a challenge to complete

her nursing tasks and medication pass

while trying to keep an eye on the

resident.

An interview with the Center Nurse

Executive (CNE) on 8-25-2016 at 10:50

a.m., indicated Resident #K had an alarm,

a low bed, mat for the floor next to the

bed and the resident will follow the

nurses around especially at night. The

CNE indicated Resident K required

redirection, and did not feel he needed

one on one care. She indicated the

resident attends activities and eats in the

assisted dining room. She indicated the

staff on the100/200 hall (South Unit)

were to help watch him as well as the

Unit Manager (who was off this week),

the wound nurse (who was off this week)

and an aide that was on light duty. The

CNE indicated the nurse educator was

filling in the for the unit manager this

week and was there to help. The CNE

indicated all the staff were responsible

for watching the resident. She indicated

the resident sometimes sits in her office

Monitor monthly for

compliance of alleged

deficiencies in the 2567 to be

forwarded to the QAA

committee for additional

interventions as a need is

identified. e)By what date will

the systemic changes be

completed? Date of compliance

09/12/2016

IDR INFORMATION: F-323

The Provider disputes the citation

of F323. The included

documents will demonstrate

thefacility did care plan for the

stated and observed behaviors

exhibited byResident #K and

provide appropriate interventions

to address the behaviors

ofResident #K. With respect, the

Provider requests that due

consideration be given by the

State Agency in removing

thealleged deficiency F323.

Deficiency:F – 323 483.25(h)

FREE OF ACCIDENT

HAZARDS/SUPERVISION/DEVI

CES states thefacility must

ensure that the resident

environment remains as free of

accidenthazards as is possible;

and each resident receives

adequate supervision

andassistance devices to

prevent accidents. The Indiana

State Department of Health

survey team alleges that

thisrequirement is not met as

evidenced based on the

observation, interview,

andrecord review, the facility





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

and she has been walking him with a gait

belt and an assist of 2 each evening.

Some of the nurse notes were reviewed

with the CNE about the resident needing

1:1 care during their shift and the resident

going in other resident rooms. The CNE

was informed Resident #K was observed

on 8-24-2016 going into another

resident's room and there was no staff

around to see this. The CNE indicated

she was not made aware of this

information and staff had not indicated to

her that they need help with this resident.

An observation of the 100/200 hall

nurses' station on 8-25-2016 at 9:38 a.m.,

indicated there were no staff at the station

at this time.

The record review for Resident #K began

on 8-22-2016 at 3:48 p.m. Diagnoses

included but were not limited to,

Alzheimer's Disease, acute upper

respiratory infection, muscle weakness,

cognitive communication deficit;

dysphagia, psychosis, anxiety,

hypertension, abnormal involuntary

movements, insomnia, diabetes, atrial

fibrillation, long term use of

anticoagulants and history of falling.

A review of the current physician orders

for safety measures as provided by the

Center Executive Director on 8-25-2016

failed to ensure adequate

supervision for thesafety of 1

of 1 resident reviewed for

frequent falls (Resident #K).

R#Kwas admitted on June 16,

2016 with diagnoses of

Alzheimer’s Disease,Unspecified,

Acute Upper Respiratory

Infection, Muscle Weakness,

CognitiveCommunication Deficit,

Dysphagia,Unspecified psychosis

not due to substance or known

psychological condition,Other

specified anxiety disorders,

essential hypertension.

SEEATTACHMENT: Admission

Record Resident #K The

Survey Team referenced an

observation of theresident which

occurred on 8/17/2016 at 2:55

p.m. which indicated that

Resident#K was in his wheelchair

at the 100/200 hall nurse station

area. Resident was observed to

take 2 small cans ofshaving

cream from the supply cart that

was part way in and part way out

of thesupply room across the

nurse station. Astaff member

happened to be nearby and

removed the shaving cream cans

from theresident. In the

resident’s care plan, dated

6/24/16, poor impulsecontrol of

the resident is

documented. Redirection is

included as an intervention along

with providingalternative objects

or activities. Basedon the

observation by the survey team,

the shaving cream cans were

promptly removedby a staff





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

at 11:18 a.m., indicated the following:

An order "do not put resident to bed until

after 11 pm to help keep him on routine

from home and prevent falls" was dated

6-27-2016

An order for a low bed with mat to floor

and check placement every shift was

dated 6-27-2016.

An order to toilet resident with assist x 1

and use of gait belt before and/or after

meals and at bedtime every shift was

dated 6-16-2016.

An order for a wheelchair alarm check

placement and function every shift dated

8-22-2016. A previous order for the

wheelchair alarm was dated 6-22-2106

and discontinued on 8-18-2016.

An order for Resident #K "may ambulate

with walker and assist x 1 using gait belt.

Resident may use wheelchair as needed

every shift' was dated 6-16-2016.

An order for a Wander Guard/Wander

Elopement device due to poor safety

awareness with an expiration date of Nov

2018 placed on left ankle was dated

6-22-2016.

An order for an ASRSB (alarming self

releasing seat belt) to wheelchair and

check placement, functioning and

resident ability to release every shift was

dated 7-18-2016 and discontinued on

8-17-2016.

An order for a bed sensor alarm check

member without direction from

the surveyor, thus following the

careplan. In addition, the

responsible party, the Health

InformationCoordinator/Central

Supply Coordinator was

positioned at the cart,

unloadingthe cart. At no time,

was the cart leftunattended or not

directly being supervised by the

employee. This

employeeimmediately re-directed

the resident which was successful

in retrieving theshaving cream

can and placed in the locked

central supply room without

incident. See attachment #1 and

#2. An observation of Resident

#K on 8/24, indicated theresident

was self-propelling himself into

room 114. Based on the

interview with a nurse, Nurse#12,

the resident should not be in that

room. In the resident’s care

plan,dated 6/24, wandering is

addressed. The Licensed Nurse

did re-direct theresident promptly

and it was done timely as the

residents in that room thatRes. K

attempted to enter did not have

call light on to alert staff of

anyconcerns. The center

followed the planof care of

re-directing the resident and was

successful. Resident was not

displaying any type ofbehaviors or

considered to be a danger to self

or others. This behavior was only

observed once by theSurvey

team over 7 full business days at

the center. Resident #K does

attend activities as well toassist





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

placement and function every shift was

dated 6-22-2016 and discontinued on

8-18-2016.

A medication order for Xarelto

(anti-coagulation) tablet 15 mg by mouth

1 time a day was dated 6-24-2016. (This

medication had a risk for increased

bleeding and bruising.)

A care plan for "Resident is at risk for

falls: impaired mobility, confusion

related to Alzheimer's Disease,

impulsivity related to Alzheimer's

Disease, frequent falls at home" was

initiated on 6-20-2016 and revised on

8-22-2016. The following interventions

were in place:

On 8-21-2016, replace wheelchair alarm

due to failed alarm reduction was added.

Check and change was dated 8-15-2016.

An revision on 8-4-2016 indicated "do

not place resident in bed until after 1

a.m."

Floor mat and low bed were dated

6-20-2016.

On 8-22-2016, a Physical Therapy screen

as resident was added as resident was

showing an increased desire to ambulate.

Remind resident to sit upright when in

wheelchair every shift was dated

8-21-2016.

The following interventions were dated

with reduction of wandering. See

attachment #3 There are no

documents supporting

anyresident ever having to call to

have resident removed and no

grievance filed

byresidents/visitors regarding his

wandering. Residents and family

were oftensupportive of resident

due to his diagnosis. The facility

grievance log wasreviewed by the

Center Executive Director and no

concerns or grievances

wereidentified on Resident #K.

See attachment #4, #5, and #6.

On 6/20, aWanderguard was

placed on Resident #K to address

the risk of the elopementrelated

to resident’s desire to leave

facility prematurely and to ensure

thesafety of the resident. The

resident isnoted with zero

elopements since admission to

the center and indicates thestaff’s

supervision along with device to

attempt to avoid this type

ofincident/accident. The Survey

Team interviewed the Center

NurseExecutive on 8/25. Nursing

notes werereviewed which stated

on 8/25, 8/17, and 8/10 resident

received 1:1 care. Staffutilized 1:1

at times per nursing judgement

for increased supervision to

ensurethe resident’s supervision

needs were met. At no time, 1:1

supervision wasordered by an MD

nor requested by staff caring for

Resident #K. Resident #K

current plan of care was

deemedeffective and responsible

party was in agreement with plan





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

6-20-2016:

Assist resident getting in and out of bed

with 1 person and use of gait belt.

Assist resident with ambulation

providing wheelchair.

Provide verbal cues for safety and

sequencing when needed.

Provide verbal cues for proper pacing and

energy conservation techniques

Provide resident/caregiver education for

safe techniques

Place call light within reach at all times

Maintain a clutter free environment in the

resident room and consistent furniture

arrangement

When resident is in bed, place all

necessary personal items within reach.

A review of the Kardex printed 7-7-2016

indicated Resident #K had fallen since

admission with no injury. The assistive

devices in place were a chair alarm;

"RFA 6-29 change chair pad

alarm...and...7-12 dysum to w/c

(wheelchair)...." On 7-8-2016 "...have

him when in w/c alone up front around

South nurses station area...."

A review of the Kardex printed

8-17-2016 indicated in the Accidents fall

risk category - falls since admission or

prior assessment with no injury was

marked, chair alarm and bed alarm were

marked and yellowed out with d/c on

of care. See attachment #7.

On8/25, 15 minute checks were

added per nursing judgement.

See attachment #8. A review of

falls to date indicated Resident

#K hadnine falls while in the

facility. Based on a history of

falls the facility hadinitiated a bed

alarm, clear pathways, bed in low

position, and a mat atbedside,

upon admittance. Resident

#Kreceived PT/OT/ST from 6/16

– 7/15. On 6/19 a fall occurred

while wife was in theroom.

Resident fell to the floor

fromwheelchair. Resident was

assisted upfrom the floor with a

gait belt and 2 person assist. A

root cause analysis determined

residentfrequently gets up and

down from wheelchair, he does

not self-lock wheelchair.Resident

was trying to get up from the

wheelchair, but he tripped over

hispedal. Interventions included:

pedalswere removed from

wheelchair and resident was

placed on hourly checks. A

resident wheelchair alarm was

added. Care plan was updated,

and the physician wasnotified.

On 6/27 Resident #K was found

on the buttocks infront of bed. He

was wearing grip socksat the

time, however he had knocked

his water jug to the floor. A root

causeanalysis determined the

cause of the fall was the resident

had been attemptingto drink

water. He dropped the water to

the floor, and he slipped on

thespilled water. The time was





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

8-18-2016, wander alarm marked, low

bed and mat on floor written in, a date of

8-3 non skid socks when shoes off was

written, on 7-17 dysum to w/c yellowed

out with a date of 8-18 written next to it,

up until at least 11 p.m. (11 p.m.

yellowed out and 1 a.m. written in) dated

8-4-2016, 8-21 referral therapy and

8-21-2016 w/c sensor alarm were all

recorded on the form.

A review of the nurses' notes indicated

the following:

On 6-18-2016 at 1:39 p.m., the note

indicated "Res <sic> requiring one on

one care this shift...trying to transfers

<sic> self with unsteady gait...res <sic>

with confusion..."

On 6-21-2016 at 2:40 a.m., the note

indicated the "resident had been trying to

put shoes on his feet to go mow the

lawn...was redirected 5 or 6

times...pleasantly confused...multiple

attempts to get out of w/c while at nurses

station...staff taking turns providing 1:1

care...was returned to bed with alarms in

place...hourly checks...."

On 6-22-2016 at 12:32 a.m., the note

indicated "...remains confused and needs

constant one to one during night time, at

nurses station in wheelchair, wanting to

get up and not following direction...."

On 6-22-2016 at 9:43 a.m., the note

10:30 p.m.and resident’s home

routine was to stay up till 11 p.m.

Interventions included: a note

was added tothe resident’s chart

indicating assisting resident to

bed after 11 p.m. wouldbe optimal

to maintain resident’s prior

routine. Personal items to be

kept within reach,especially the

water pitcher. Care planwas

updated, physician and wife were

notified. On 6/29 Resident #K

was in wheelchair, and his

wifewas visiting. Wife went to

step outsideof room and resident

wanted to follow her, so he got up

from wheelchair to walkbeside

her. When she redirected him

backto the wheelchair he lost his

footing and went to the floor.

Wife got staff to assist. A root

causeanalysis determined

Resident #K wanted to be with his

wife. The resident wheelchair

alarm did not go off,as it had not

stayed attached to shirt.

Intervention:Resident’s alarm was

changed from an RFA alarm to a

chair pad alarm. Care planwas

updated. Physician was notified.

On 7/8 Resident #K was in

hallway trying to stand upfrom

wheelchair. Resident tripped

overthe wheel of the chair. A root

cause analysis determined

resident was trying toget up from

the wheelchair in order to push it

and ambulate. Intervention:

Ensure brakes are on

whenresident is attempting to

stand up from chair and

encourage the resident to sitby





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

indicated the resident "...requiring one on

one care...keep res <sic> at nursing

station...res <sic> requiring

supervision...if res <sic> in bed check

every hour...."

On 6-23-2016 at 6:57 p.m., the note

indicated the resident "...continues with

impulsive behaviors...."

On 6-28-2016 at 9:57 p.m., the note

indicated the "...resident continuously

getting up from his w/c self transferring

gait unsteady...."

A review of the nurses' notes for July

2016 indicated the following:

On 7-3-2016 at 1:12 a.m., Resident #K

"...had attempted to remove all cups,

straws and spoons from med

cart...attempting to pick up objects off

floor unseen by staff...attempts to get in

garbage cans multiple times...brought

resident to sit with writer while charting

and resident removed papers from

desk...has been one on one with staff

since the beginning of 3rd shift...."

Additional nurses' notes indicated to

"...keep resident near staff/nursing station

for close monitoring &

observation...wanders in hallway in

wheelchair...gets out of wheelchair

frequently...needs frequent

redirection...getting out of bed setting off

alarms...banging his w/c into med

the nurse’s station. Care plan

wasupdated. Physician and wife

werenotified. On 7/12 Resident

#K was in main dining room. He

slid from his wheelchair to the

floor.Intervention: non-skid

material was added to seat of

wheelchair. Care plan was

updated and physician and

wifewere notified. On 8/3

Resident #K was found on the

floor mat on hishands and knees.

His alarm was sounding. The

resident was found without

properfootwear at the time of the

fall. Intervention included

non-skid socks to be worn at all

times when notwearing shoes.

Care plan updated andphysician

and wife were notified. On 8/4

Resident #K was found sitting

upright next tobed on floor mat.

The bed alarm wassounding and

bed was found in lowest position.

Since the fall occurred at 5:15,it

was determined that resident #K

required at later bedtime. Care

plan wasupdated and physician


Resident #K was found in hallway

on all 4extremities, and the

wheelchair was still connected via

alarming belt. A root cause

analysis was performed, and

itwas determined the resident

forgot to release seatbelt,

however resident wasable to do

so on command after the fall. The

self-releasing belt

wasdiscontinued as a result of

this fall. Care plan was updated

and physician was notified. On





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

cart...unaware of his surroundings

A review of nurses' notes on 8-1,4, 6, 7,

10, 11,15, 16, 17, 18, 20 21, 22-2016,

indicated Resident #K was strolling in

and out of resident rooms and nurses

station. On 8-18-2016 at 7:38 p.m., the

resident was on 15 minute checks. On

8-17-2016 at 1:14 a.m., the resident

required one on one care for safety

awareness due to numerous attempts to

stand up in w/c with redirection lasting

only seconds. On 8-10-2016 at 3:43 a.m.,

the note indicated the "...resident very

busy and up all noc (night)...attempted to

put to bed but was on mat on floor 5

times in one hours <sic> time...requires

one on one assist...."

A note on 8-4-2016 at 2:30 a.m.,

indicated "...resident up in hallway

wandering in wheelchair...resident going

in and out of resident room...exit

seeking...confused and unable to be

reoriented...."

A review of nurses' notes on 8-25-2016 at

4:02 a.m., indicated the "...resident was a

1:1 care until 2:30 a.m. until he went to

bed...standing up and setting off w/c

alarm's numerous times...toileted and

fluid and snacks given without

success...picking at floor, desks and med

carts...easily redirected with short

memory span and restarts behaviors....."

8/21 Resident #K removed his

shoes and socks inthe hall and

fell forward out of his wheelchair.

A root cause analysisindicated

that the resident had been

intrigued with his shoes and

socks, wasleaning over to work

with them and fell. A therapy eval

was ordered and a wheelchair

alarm was reinitiated. Resident

#K was screened after fall, but

itwas determined the resident had

met his maximum potential.

Upon review of all the fall

incidents it is apparentthe facility

did follow policies and procedures

surrounding

fallprevention/interventions – care

plans were updated, new

interventions werenoted after

each fall, notifications were made

to MD/responsible person with

nofurther concerns, and the

Interdisciplinary team reviewed

each fall duringclinical morning

meeting after each fall to ensure

review was completed

andinterventions were in place.

See Attachment #9. Theincident

and accident reports/logs are

reviewed monthly in Quality

AssuranceMeeting for any further

recommendations. Inthe case of

6 out of the 9 falls, a staff

member or family member

witnessed thefall demonstrating

the increase supervision that the

center provided to theresident as

well as avoiding major injuries

and keeping resident safe. The

care plan dated 6/20/2016

indicated that Resident #K would





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

Additional notes indicated Resident #K

had to be redirected from others rooms

on 8-24-2015 and 8-23-2015.

A social service assessment note dated

July 15, 2016 indicated Resident #K had

a BIMS (Brief Inventory of Mental

Status) of 2/2, which indicated the

resident had severe impairment in his

cognitive abilities.

A Fall Risk assessment was completed

on 6-23-2016 with a score of 11, which

indicated the resident was a high risk for

falls.

A review of the initial fall reports

provided by the CNE on 8-24-2016 at

8:45 a.m., indicated the resident had had

9 falls since admission on 6-16-2016.

A review of each each initial report

indicated the following:

On 6-22-2016, Resident #K had a fall

from his wheelchair, in his room, with his

family present. The resident tripped on

the pedals of the wheelchair and the

pedals were removed.

On 6-27-2016, Resident #K was found on

the floor in his room. The resident

slipped out of bed due to spilling water

on the floor and having socks on. The

have “no falls with injury.” Due to

the successful interventions the

resident had only 1 fall

whichresulted in bruising to his

left buttocks and left hip. In

summary, the Provider attests

that it has beendiligent and took

appropriate actions to provide

adequate supervision of Resident

#K to mitigate the risk of an

incidents andaccidents. In the

FederalRegulation

supervision/adequate supervision

refers to an intervention and

meansof mitigating and/or reduce

the risk of an accident.

Additionally, the Provider attests

thatResident #Ks interventions

were monitored and modified as

necessary inaccordance with

current standards of practice. The

surveyors observed the care plan

interventions for Res #K to be in

compliance for 7 business days.

The ResponsiblePerson, wife, of

Res. #K also did not share any

concerns or recommendations

forthe IDT in regards to plan of

care when attending Care

Conferences or beingnotified

during incidents. See attachment

#10. With respect, the Provider

requests that dueconsideration be

given by the State Agency in

removing the alleged

deficiencyF323.





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

resident's bed alarm sounded. The

facility changed the time to 11:00 p.m. to

put resident to bed and the staff were to

make sure personal items were in reach.

On 6-29-2016, Resident #K's family was

visiting in the resident's room and the

family stepped outside the room. The

resident wanted to follow the family so

he got up. The resident's family

re-directed the resident back to his room

and he lost his footing and fell. The

alarm type on his wheelchair was

changed to a sensor alarm.

On 7-8-2016, Resident #K was in his

wheelchair in the hall. He got up out of

the wheelchair and tripped over the wheel

of the wheelchair. Staff observed the fall

and tried to get to him. Staff were to

ensure the brake on wheelchair was

secure when transferring and staff were

to try to have resident sit by the nurses'

station.

On 7-12-2016, Resident #K was in dining

room and slid out of his wheelchair. A

non-skid material was placed on the seat

of his wheelchair.

On 8-3-2016, Resident #K was found in

his room on his hands and knees on the

mat that was on the floor next to his bed.

Staff were to ensure the resident had non

skid socks on when he was not wearing





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

shoes.


his room on a mat sitting upright with the

alarm sounding and his bed in the lowest

position. The resident's bedtime changed

to 1:00 a.m.


the hallway on all 4 extremities with the

wheelchair still connected via the

alarming belt. The resident had large

amount of urine and soiled pants and the

resident forgot to undo the seatbelt. The

seatbelt was discontinued.

On 8-21-2016, Resident #K was in his

wheelchair in the hallway. He was

removing his shoes and socks and the

resident fell forward out of chair (staff

had just replaced his shoes and socks

prior to the fall). A physical therapy

evaluation was completed and a

wheelchair alarm was placed.

None of falls resulted in any injuries

except for bruising on his left buttock and

left hip on 8-3-2016.

A current facility policy, "Falls

Management" with a revision date of

3-15-2016 and provided by the CNE on

8-25-2016 at 10:50 a.m. indicated

"...those determined to be at risk will

receive appropriate interventions to





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

reduce risk and minimize injury...patients

experiencing a fall will receive

appropriate care and investigation of the

cause..."

3.1-45(a)(2)

483.30(a)

SUFFICIENT 24-HR NURSING STAFF PER

CARE PLANS

The facility must have sufficient nursing staff

to provide nursing and related services to

attain or maintain the highest practicable

physical, mental, and psychosocial

well-being of each resident, as determined

by resident assessments and individual

plans of care.

The facility must provide services by

sufficient numbers of each of the following

types of personnel on a 24-hour basis to

provide nursing care to all residents in

accordance with resident care plans:

Except when waived under paragraph (c) of

this section, licensed nurses and other

nursing personnel.

Except when waived under paragraph (c) of

this section, the facility must designate a

licensed nurse to serve as a charge nurse

on each tour of duty.

F 0353

SS=E

Bldg. 00



F 0353 F 353 483.30 (a) SUFFICIENT

24-HR NURSING STAFF

PERCARE PLANS

09/12/2016 12:00:00AM





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

sufficient nursing staff provided the

necessary care, supervision and services

in a timely manner to meet the needs of

the residents on 1 of 2 units in the

facility. This deficient practice has the

potential to affect 44 of 44 residents who

resided on the 100 and 200 halls (South

Unit) in the facility.

(Resident #D, Resident #K, Resident #S,

Resident #T, Resident #U, Resident #V)

Findings include:

On 8/17/16, no specified time, the facility

provided the completed "Resident Census

and Conditions of Residents" form. This

form was dated 8/17/16 and was

completed by the CNE "Clinical Nurse

Executive." This form included, but was

not limited to, the following: "...Of the

92 total residents, the follow numbers of

residents required assist of 1 or 2 staff for

the following activities of daily living

tasks: 66 residents for transferring; 75

residents for dressing; 67 residents for

toilet use and 40 residents for eating. Of

the 92 residents, the following were

identified to be dependent for the

following tasks: 43 for bathing; 10 for

transferring; 12 for toilet use and 6 for

eating.

On 8/23/16 at 3:40 p.m., LPN #22 was

observed to be working the evening shift


beaccomplished for those


affected by the deficientpractice?

Resident D, K, S, T, U and V

did not have any adverse

outcomes relatedto

medications or treatments or

omissions noted in the vital

signs. Resident S and V’s

medical record was reviewed

with the MD and vitalsign

orders were changed to have

completed monthly as these

residents arestable by

08/25/2016. The licensed Nurse

will notify the manager or

supervisor ifanticipating a

delay in medication pass or

treatments to seek assistance

fromresiding nurses to

complete within the timeframe.

Resident K was placed on 1:1

observation with staff on

08/25/2016

2.How will you identify

otherresidents having the

potential to be affected by the

same deficient practiceand what

corrective action will be taken?

The residing residents did not

have adverse outcomes related

toResident #K and there were

no grievances filed by the

residing residents inregards to

Resident #K’s wandering

behavior by 08/26/20116. The

residing residents did not

express concerns and there

were nonegative outcomes

with one (1) incident of





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

on the 100 hall as a staff nurse. At this

time, LPN #21 was observed to be

administering treatments to residents in

the 100 hall. LPN #21 was observed to

have worked the day shift on 8/23/16 on

the 100 hall.

On 8/24/16 at 9:38 a.m., LPN #21 was

observed to be passing medications in the

100 hall. The CNE was observed at the

nurses station. The CNE asked LPN #21

how many more medications she had to

administer. LPN #21 indicated "Oh, I

don't know." The CNE indicated to LPN

#21 the facility was going to call the

Nurse Practitioner to inform her the nurse

on the 200 hall (other hall of the unit) had

given her medications late.

On 8/24/16 at 9:48 a.m., LPN #21 was

observed to be passing medications to the

Resident #S.

On 8/24/16 at 10:14 a.m., LPN #21 was

observed to be passing medications to

Resident #T.

On 8/24/16 at 10:17 a.m., LPN #21 was


Resident #U.

On 8/24/16 at 10:23 a.m., LPN #21 was


Resident #V.

medications and

treatmentsadministered late on

08/23 and 08/24/2016. The

Licensed Nurses

administeredmedications and

treatments as ordered on those

dates. c) What measures will

be put into place or whatsystemic

changes you will make to ensure

that the deficient practice does

notrecur? TheLicensed Nurses

will report to a supervisor,

manager, or another charge

nurseif anticipated not be able

to complete an assigned task

on time withmedications and

treatments to obtain further

assistance by 08/26/2016.

TheLicensed Nurses will

continue to follow clinical

protocols in the

circumstancethat a medication

or treatment is completed past

the parameters. The

LicensedNurses were

re-educated by the (NPE) Nurse

Practice Educator 08/26/2016

through09/06/2016

1.How the corrective actions

willbe monitored to ensure the

deficient practice will not recur?

The CNE or designee will

complete audits toensure the

Licensed Nurses are

completing medication pass

and treatments in

theappropriate time frame.

These audits will be conducted

5 times weekly times

twoweeks, twice weekly times

two weeks, weekly times 5





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

On 8/24/16 10:11 a.m. LPN #22 was

interviewed. She indicated she was

working today as the wound nurse,

completing skin and wound treatments.

She indicated the facility had a wound

nurse but the wound nurse has been off

for a few weeks. She also indicated the

day shift nurses work from 6:00 a.m. -

2:30 p.m. She indicated she work last

evening (8/23/16) on the 100 hall as a

floor nurse.

On 8/24/16 at 10:37 a.m., LPN #21 was


room 101 at 10:10 a.m.; room 103 at

10:13 a.m. and room 103 at 10:17 a.m.

On 8/24/16 at 2:30 p.m., the Medication

Administration (MAR) of Resident #S

was reviewed. The MAR indicated the

resident's day shift medications were

scheduled to be given at 8:00 a.m. The

MAR also indicated the resident was to

have vital signs taken every Monday,

Wednesday and Friday. Documentation

for the month of August 2016 indicated

to date, of the 11 days the resident was to

have had vitals signs taken, a complete

set of vital signs was documented on only

4 of the 11 days.

On 8/24/16 at 2:35 p.m., the MAR of

Resident #T was reviewed. The MAR

months and to

ensurecompliance. Falls will be

monitored 5 x per week in

theclinical morning meeting by

the CNE or designee to identify

root cause andinterventions

which are appropriate for the

resident. This monitoring will

occur 5 times per weekfor six

months. The CED/CNE/NPE or

designee to Monitor monthly

for 6 months for complianceof

alleged deficiencies in the 2567

to be forwarded to the QAA

committee foradditional

interventions as a need is

identified.

1.By what date will the systemic

changes be completed? Date of

Compliance: September 12,

2016

F-353 The Provider

disputes the citation of F- 323.

Theincluded documentation will

demonstrate the facility did

ensure there wassufficient

nursing staff to provide nursing

and related services to attain

ormaintain the highest physical,

mental, and psychological

well-being of eachresident, as

determined by resident

assessments and individual plans

of care. With respect, the

Provider requests that

dueconsideration be given by the

State Agency in removing the

alleged deficiencyF353.

Deficiency:F-353 483.30(a)

Sufficient 24 Hour Nursing

Staff Per Care Plans states





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

indicated for the day shift, the resident

had medications scheduled to be given at

8:00 a.m., 12:00 p.m. and 2:00 p.m.


Resident #U was reviewed. The MAR

indicated the resident was to have her

blood pressure (BP) checked prior to

administration of a blood pressure

medication. Of the 24 days to date, the

resident's blood pressure was not taken

16 days of the 24 days prior to

administration of the blood pressure

medication.


Resident #V was reviewed. The MAR

indicated the only day shift medications

the resident was ordered to receive, were

scheduled at 8:00 a.m.

On 8/24/16 at 10:15 a.m., LPN #21 was

interviewed. She indicated the CNE

notified the Nurse Practitioner this

morning of some of her resident's

medications being passed late. She

indicated one of her residents, received

her scheduled 8:00 a.m. medications at

10:15 a.m. LPN #21 indicated she had

stayed after her scheduled shift yesterday

to complete her skin treatments that

didn't get completed during the day shift.

She indicated they had a wound nurse but

she had been off for a few weeks.

thefacility must have sufficient

nursing staff to provide

nursing and relatedservices to

attain and maintain the highest

practicable physical, mental

andpsychological well-being of

each resident, as determined

by residentassessments and

individual plans of care. The

facility must provide services

bysufficient numbers of each

of the following types of

personnel on a 24 hourbasis to

provide nursing care to all

residents in accordance with

resident careplans: Except

when waived under paragraph

(c) of this section, licensed

nursesand other nursing

personnel. Except when

waived under paragraph (c) of

thissection the facility must

designate a licensed nurse to

serve as charge nurseon each

tour of duty. The Indiana State

Department of Health survey

teamalleges that this

requirement is not met as

evidenced based on the

observation,interview and

record review. The Surveyteam

alleges the provider failed to

ensure sufficient nursing staff

provided thenecessary care,

supervision, and services in a

timely manner to meet the

needsof the residents of 1 of 2

units in the facility. On 8/25, a

member of the Survey Team had

anextensive conversation with the

Clinical Quality Specialist and the

CenterNurse Executive. This





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

On 8/25/16 at 8:25 a.m., LPN #9 was was

observed in the dining room documenting

meal intakes for the residents. At this

time, she was interviewed and indicated

one of the nurses from the south unit had

to be in the main dining room from 7:30

a.m. to 8:00 a.m. She indicated at 8:00

a.m., the other nurse from the south unit

was to come to the dining room from

8:00 a.m. to 8:30 a.m. She also indicated

at lunch, one nurse from the south unit

went to the dining room from 11:30 a.m.

- 12:00 p.m. and then she switched with

the other nurse, who was in the dining

room from 12:00 p.m. to 12:30 p.m.

On 8/25/16 at 10:55 a.m., the CNE

provided a current copy of the facility

"Staffing Center Plan." This plan was

dated 9/1/13, and included but was not

limited to, the following: "(Name of

facility)"... will provide...appropriate

staffing levels to meet the needs of the

patient population...Purpose: To

assure...appropriate staffing levels are

scheduled and maintained...Staffing

levels are reviewed on an ongoing basis

by Center staff to evaluate compliance

and provide appropriate levels of are by

qualified employees. A written staffing

plan is prepared for each department...."

On 8/25/16 at 11:10 a.m., the Clinical

conversationdetailed coverage

which was based on the building’s

census. During the week of

survey, the census ranfrom 94 to

88 residents. During thattime,

each day and evening shift had 4

nurses and 8 CNAs. Thisallows

for a less than 1:24 LPN/RN ratio.

See attachment: #8. For the

weekending August 27, the

center posted an LPN .88 hppd,

which is greater than thestate

expectation of .5. For the

weekending August 20, the

center posted a .75 hppd, and for

the month of August,the MTD

LPN hppd equaled .76, which

again, is greater than the

stateexpectation. In addition to

our directcare nurses, the

provider staffs a full-time DON,

two unit managers,supervisors,

and full-time MDS

coordinator. The hppd for nursing

admin – without any direct care

nursing staff –equaled .25 hppd

for the week ending 8/20 and .30

hppd for the week ending8/27.

The staffing requirement was

metas evidence by the staffing

sheets posted daily to indicate

appropriate levelsof staffing as

well as no concerns/grievances

filed from the residents orvisitors.

See attachment #5, #11, and #12.

While Nurse #9 indicated she

was not usually able toadminister

medications within the allotted

timeframe, the Survey Team was

inthe center 7 full business days

during the 8 am, noon, and 4 p.m.

medicationpass along with





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

Quality Specialist (CQS) and the Center

Nurse Executive (CNE) were

interviewed. They indicated the

following:

On 8/17/16 the census was 92; on

8/24/16 the census was 90 and on

8/25/16, the census was 89. The CQS

indicated with the census ranging from

89-92 residents, they would have the

same staffing pattern. The CQS also

indicated the desired staffing pattern as

the following for the North unit: day

shift, typically had 2 nurses staffed and

up to 4 CNAs (certified nursing

assistants) staffed; evening shift typically

had 2 nurses staffed and would have "up

to 4 CNAS depending whether the

facility was up to budget or not." The

CQS and the CNE indicated the evening

shift had a "free floating nurse" that

helped as needed with admissions and

wherever she was needed. They further

indicated the night shift typically staffed

1 nurse and 2 CNAs. They indicated for

the South Unit, day shift had 2 nurses

and typically 4 CNAs. They also

indicated the evening shift had 2 nurses

and 4 CNAs and night shift typically had

1 nurse and 2 CNAs. The CQS and CNE

indicated the staffing pattern was

dependent on census. They indicated the

facility also had a wound nurse who

performed the skin treatments on

residents in the facility.

treatment observations with only

one incident of a nurserunning

behind in both areas. The

centerfollowed proper procedure

with Nurse Practitioner notified of

the latemedication pass and no

errors in the process were noted.

The nurse needed an additional

30 minutes tocomplete the full

medication pass. Theresidents

whom received the medication

late did not express concerns and

no adverseoutcomes noted to the

residents. It wasalso noted that

the surveyor was interviewing

nurses during their shifts

whichcontributed them running

behind with duties that shift. The

survey team was able to

observemedication pass and

treatment observation to ensure

MD orders were completed bythe

Licensed Nurses. The survey

team wasalso able to observe call

lights being answered promptly by

staff, turning andre-positioning

rounds being completed per

schedule, toileting/incontinence

careprovided as within every 2

hours and as needed,

hydrationpass being completed

timely, and adequate assistance

in the dining rooms whichindicate

the resident’s needs were being

met on a consistent basis.

Thefacility grievance log was

reviewed by the Center Executive

Director and noconcerns or

grievances were filed related to

late treatments/medications

orstaffing concerns.

Medications/treatments





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

On 8/25/16 at 11:16 a.m., the CNE

indicated the facility had a wound nurse

who was scheduled Monday through

Friday and provided wound/skin

treatments for both units. The CNE

indicated if a staff nurse called off, the

wound nurse would work a cart (have a

resident assignment) and there would be

no wound nurse for that shift, which

resulted in the nurses having to complete

wound and skin treatments for their

residents. The CNE indicated LPN #22

was covering for the wound nurse this

week. The CNE indicated the wound

nurse was on vacation this week but was

also not at the facility last week. The

CNE indicated the floor nurses did have

to perform the wound care because the

wound nurse was on LOA (leave of

absence) for two weeks but they "had

nurses pick up."

On 8/25/16 at 11:30 a.m., the CQS was

interviewed. She indicated the "written

staffing plan" referenced in the "Staffing

Center Plan" was the nursing schedule.

She indicated the CNE, Center Executive

Director (CED) and the scheduler

reviewed the staffing in the "stand up"

meeting. She indicated every manager,

Social Service and the IDT

(Interdisciplinary Team) attended the

stand up meetings at 9:00 a.m. She

wereadministered to the residents

as identified in the 2567. See

attachment #5, #12, and #13 The

surveyors provided the Center

Executive Directorwith a list of

residents with numbers only. The

2567 utilizes letters to refer to the

residents in 2567 – so theyare not

easily identifiable for the Center

Executive Director to provide

thespecific documentation to

debate each resident letter

utilized in the citation. The

identified residents did receive

themedication and treatment

orders per the MD order as

observed by thesurveyors. The

surveyors were notifiedand it is

noted that the center followed

policy in notifying the MD that

theseorders would be completed

minimally late and that no

treatments or medicationswere

held related to timeliness of

completion. See attachment #14.

The Survey Team referenced an

observation of theresident which

occurred on 8/17/2016 at 2:55

p.m. which indicated that

Resident#K was in his wheelchair

at the 100/200 hall nurse station

area. Resident was observed to

take 2 small cans ofshaving

cream from the supply cart that

was part way in and part way out

of thesupply room across the

nurse station. Astaff member

happened to be nearby and

removed the shaving cream cans

from theresident. In the resident’s

care plan, dated 6/24/16,

poorimpulse control of the





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

indicated the facility had an on call

manager and the nurse managers had a

call rotation.

On 8/25/16 at 2:20 p.m., the CNE was

interviewed. She indicated the facility

had a "free floating" evening shift and

weekend supervisor. She indicated these

supervisors were free to float to wherever

they were needed in the facility. She also

indicated sometimes this supervisor

would have to take an assignment, for

example, if a staff member called off

work. She indicated on the night shift,

there was not a "free floating" supervisor

and the night shift supervisor had

residents assigned to care for.

Confidential direct care nursing staff

interviews were conducted. The staff

indicated they were unable to complete

their work in a timely manner.

2. An interview on 8-23-2016 at 9:36

a.m. with Resident #D, who had a BIMS

(Brief Interview for Mental Status) of

15/15 (which indicated the resident was

cognitively intact) on the quarterly MDS

(Minimum Data Set) assessment dated

7-8-2016, indicated her shoulders ached

and she had not gotten any pain

medication for her pain today. Resident

#D indicated if they would give me some

Tylenol, it would take care of it.

resident is

documented. Redirection is

included as an intervention along

with providingalternative objects

or activities. Basedon the

observation by the survey team,

the shaving cream cans were

promptlyremoved by a staff

member without direction from

the surveyor, thus followingthe

care plan. In addition, the

responsible party, the Health

InformationCoordinator/Central

Supply Coordinator was

positioned at the cart,

unloadingthe cart. At no time,

was the cart leftunattended or not

directly being supervised by the

employee. This

employeeimmediately re-directed

the resident which was successful

in retrieving theshaving cream

can and placed in the locked

central supply room without

incident. See attachment #1 and

#2. An observation of Resident

#K on 8/24, indicated theresident

was self-propelling himself into

room 114. Based on the

interview with a nurse, Nurse#12,

the resident should not be in that

room. In the resident’s care

plan,dated 6/24, wandering is

addressed. The Licensed Nurse

did re-direct theresident promptly

and it was done timely as the

residents in that room thatRes. K

attempted to enter did not have

call light on to alert staff of

anyconcerns. The center

followed the planof care of

re-directing the resident and was





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

An interview with Staff #12 on

8:23-2016 at 9:36 a.m., indicated she was

preparing medications for another

resident and Resident #D's medications

were next. A review of the MAR

(Medication Administration Record) at

this time for the "Tylenol Extra Strength

tablet 500 mg (milligrams) by mouth 2

times a day for pain," indicated the

Tylenol had not been marked as given.

The MAR indicated the administration

times were 8 a.m. and 8 p.m.

An interview with Resident #D on

8-24-2016 at 9:30 a.m., indicated she had

not received her morning medications,

including her pain medication. The

MAR was reviewed at this time and the 8

a.m. medications were not initialed by the

nurse which included the pain

medication.

During an observation on 8-24-2016 at

9:32 a.m., Nurse #12 was observed to

prepare and administer to Resident #D,

her 8:00 a.m. medications.


8-24-2016 at 9:35 a.m., indicated there

was an hour before and an hour after the

time on the MAR that the nurses should

have had the residents' medications

passed. Nurse #9 indicated she was not

usually able to administer the

successful. Resident was not

displaying any type ofbehaviors or

considered to be a danger to self

or others. This behavior was only

observed once by the

Surveyteam over 7 full business

days at the center. Resident #K

does attend activities as well to

assist with reduction ofwandering.

See attachment #3and #4. There

are no documents supporting any

resident ever having tocall to

have resident removed and no

grievance filed by

residents/visitorsregarding his

wandering. Residents and family

were often supportive of

residentdue to his diagnosis. The

facility grievance log was

reviewed by the CenterExecutive

Director and no concerns or

grievances were identified on

Resident#K. See attachment #5

and #6. On 6/20, aWanderguard

was placed on Resident #K to

address the risk of the

elopementrelated to resident’s

desire to leave facility prematurely

and to ensure thesafety of the

resident. The resident isnoted

with zero elopements since

admission to the center and

indicates thestaff’s supervision

along with device to attempt to

avoid this type

ofincident/accident. The Survey

Team interviewed the Center

NurseExecutive on 8/25. Nursing

notes werereviewed which stated

on 8/25, 8/17, and 8/10 resident

received 1:1 care. Staffutilized 1:1

at times per nursing judgement





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

medications within that timeframe.

An interview with Resident #D on

8-25-2016 at 10:03 a.m., indicated the

resident had not received her 8 a.m.

medications, which included her pain

medication. A review of Resident #D's

MAR indicated the 8 a.m. medications

had not been initialed by the nurse.


8-17-2016 at 2:55 p.m., indicated he was

in his wheelchair at the 100/200 hall

nurse station area. Resident # K was

observed to take 2 small cans of shaving

cream from the supply cart that was part

way in and part way out of the supply

room across from the nurse station. A

staff member happened to be nearby and

removed the shaving cream cans from the

resident.



resident was sitting in his wheelchair and

tried to stand up. The wheelchair was not

locked and the wheelchair had to be

steadied prior to staff getting to the

resident so he would not fall. Resident

#K's nurse was down the hall, another

staff member had her back to the resident

and the other staff were behind the nurse

station at the time the resident stood up

from his wheelchair with the alarm

for increased supervision to

ensurethe resident’s supervision

needs were met. At no time, 1:1

supervision wasordered by an MD

nor requested by staff caring for

Resident #K. Resident #K

current plan of care was

deemedeffective and responsible

party was in agreement with plan

of care. A review of falls to date

indicated Resident #K hadnine

falls while in the facility. Based

on a history of falls the facility

hadinitiated a bed alarm, clear

pathways, bed in low position,

and a mat atbedside, upon

admittance. Resident #Kreceived

PT/OT/ST from 6/16 – 7/15. On

6/19 a fall occurred while wife

was in theroom. Resident fell to

the floor fromwheelchair.

Resident was assisted upfrom the

floor with a gait belt and 2 person

assist. A root cause analysis

determined residentfrequently

gets up and down from

wheelchair, he does not self-lock

wheelchair.Resident was trying to

get up from the wheelchair, but

he tripped over hispedal.

Interventions included:

pedalswere removed from

wheelchair and resident was

placed on hourly checks. A

resident wheelchair alarm was

added. Care plan was updated,

and the physician wasnotified. On

6/27 Resident #K was found on

the buttocks infront of bed. He

was wearing grip socksat the

time, however he had knocked

his water jug to the floor. A root





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

sounding.



resident was in his wheelchair propelling

himself into room 114. At this time,

there were no staff in the hall, and a nurse

was at the nurse's station around the

corner. Nurse #12 was observed to come

out of the isolation room across from

room 114. The nurse was not aware that

Resident #K had entered room 114 and

had to be prompted to see the resident.

An interview with Nurse #12 at this time

indicated Resident #K should not be in

that room. Nurse #9 was observed to

wheel the resident down the 200 hall and

sat him by Nurse #9 who was passing

medications. Nurse #9 indicated

Resident #K will be trying to go in other

residents rooms while she was passing

the medications.

An interview with CNA #2 on 8-25-2016

at 9:35 a.m., indicated for Resident #K

had to be kept in sight at all times while

he is up in the hall in his wheelchair.

CNA #2 indicated Resident #K will go

into other residents' room and all staff

were aware and had to keep him in sight.


8-25-2016 at 9:37 a.m., indicated for

causeanalysis determined the

cause of the fall was the resident

had been attemptingto drink

water. He dropped the water to

the floor, and he slipped on

thespilled water. The time was

10:30 p.m.and resident’s home

routine was to stay up till 11 p.m.

Interventions included: a note

was added tothe resident’s chart

indicating assisting resident to

bed after 11 p.m. wouldbe optimal

to maintain resident’s prior

routine. Personal items to be

kept within reach,especially the

water pitcher. Care planwas

updated, physician and wife were

notified. On 6/29 Resident #K

was in wheelchair, and his

wifewas visiting. Wife went to

step outsideof room and resident

wanted to follow her, so he got up

from wheelchair to walkbeside

her. When she redirected him

backto the wheelchair he lost his

footing and went to the floor.

Wife got staff to assist. A root

cause analysisdetermined

Resident #K wanted to be with his

wife. The resident wheelchair

alarm did not go off,as it had not

stayed attached to

shirt. Intervention: Resident’s

alarm was changed from an RFA

alarm to a chairpad alarm. Care

plan was updated. Physician was

notified. On 7/8 Resident #K was

in hallway trying to stand upfrom

wheelchair. Resident tripped

overthe wheel of the chair. A root

cause analysis determined

resident was trying toget up from





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

Resident #K, it takes all staff to keep an

eye on him when he was up. Nurse #9

indicated the other day in the early

morning, the resident was in his

wheelchair and she had to get a nebulizer.

Nurse #9 indicated she observed the

resident almost fall as he had taken his

shoes and socks off. She indicated she

stopped and put his shoes and socks on

and made sure he was seated in his

wheelchair. Nurse #9 indicated the other

nurse was passing medications to her

residents, the aides were getting other

residents up and by the time she got back

from getting the nebulizer, Resident #K

was on the floor in the hallway. Nurse #9

indicated it was a challenge to complete

her nursing tasks and medication pass

while trying to keep an eye on the

resident.

An observation of the 100/200 hall

nurses' station on 8-25-2016 at 9:38 a.m.,

indicated there were no staff at the station

at this time.

A social service assessment note dated

July 15, 2016 indicated Resident #K had

a BIMS of 2/2, which indicated the

resident had severe impairment in his

cognitive abilities.

This Federal tag relates to complaint IN00207154.

the wheelchair in order to push it

and ambulate. Intervention:

Ensure brakes are on

whenresident is attempting to

stand up from chair and

encourage the resident to sitby

the nurse’s station. Care plan

wasupdated. Physician and wife

werenotified. On 7/12 Resident

#K was in main dining room. He

slid from his wheelchair to the

floor.Intervention: non-skid

material was added to seat of

wheelchair. Care plan was

updated and physician and

wifewere notified. On 8/3

Resident #K was found on the

floor mat on hishands and knees.

His alarm wassounding. The

resident was found withoutproper

footwear at the time of the

fall. Intervention included

non-skid socks to be worn at all

times when notwearing shoes.

Care plan updated and

physicianand wife were notified.

On 8/4 Resident #K was found

sitting upright next tobed on floor

mat. The bed alarm

wassounding and bed was found

in lowest position. Since the fall

occurred at 5:15,it was

determined that resident #K

required at later bedtime. Care

plan wasupdated and physician


Resident #K was found in hallway

on all 4extremities, and the

wheelchair was still connected via

alarming belt. A root cause

analysis was performed, and

itwas determined the resident





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

3.1-17(a)

forgot to release seatbelt,

however resident wasable to do

so on command after the fall. The

self-releasing belt

wasdiscontinued as a result of

this fall. Care plan was updated

and physician was notified. On

8/21 Resident #K removed his

shoes and socks inthe hall and

fell forward out of his wheelchair.

A root cause analysisindicated

that the resident had been

intrigued with his shoes and

socks, wasleaning over to work

with them and fell. A therapy eval

was ordered and a wheelchair

alarm was reinitiated. Resident

#K was screened after fall, but

itwas determined the resident had

met his maximum potential. Upon

review of all the fall incidents it is

apparentthe facility did follow

policies and procedures

surrounding

fallprevention/interventions – care

plans were updated, new

interventions werenoted after

each fall, notifications were made

to MD/responsible person with

nofurther concerns, and the

Interdisciplinary team reviewed

each fall duringclinical morning

meeting after each fall to ensure

review was completed

andinterventions were in place.

See attachment #7. Theincident

and accident reports/logs are

reviewed monthly in Quality

AssuranceMeeting for any further

recommendations. Inthe case of

6 out of the 9 falls, a staff

member or family member





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

witnessed thefall demonstrating

the increase supervision that the

center provided to theresident as

well as avoiding major injuries

and keeping resident safe. The

care plan dated 6/20/2016

indicated thatResident #K would

have “no falls with injury.” Due to

the successful interventions the

resident had only 1 fall

whichresulted in bruising to his

left buttocks and left hip. In

summary, the Provider attests

that it has beendiligent and took

appropriate actions to provide

adequate supervision ofResident

#K to mitigate the risk of an

incidents andaccidents. In the

FederalRegulation

supervision/adequate supervision

refers to an intervention and

meansof mitigating and/or reduce

the risk of an accident.

Additionally, the Provider attests

thatResident #Ks interventions

were monitored and modified as

necessary in accordancewith

current standards of practice.

Thesurveyors observed the care

plan interventions for Res #K to

be in place for 7business days.

The Responsible Person,wife, of

Res. #K also did not share any

concerns or recommendations for

the IDTin regards to plan of care

when attending Care

Conferences or being

notifiedduring incidents. See

attachment #10. In summary, the

Provider attests that it has

beendiligent to provide

appropriate staffing as defined by





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

the state department’sguidelines.

The center did not receive

concerns/grievances filed from

theresidents or visitors pertaining

to the staffing levels at the

center. There were no care

deficits which could belinked

directly to staffing and it is unclear

what threat is imposed upon

ourresidents based on the current

staffing levels. The resident’s

needs at the center were met by

the staff. With respect, the

Provider requests that

dueconsideration be given by the

State Agency in removing the

alleged deficiency F353.

483.35(i)

FOOD PROCURE,

STORE/PREPARE/SERVE - SANITARY

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

F 0371

SS=E

Bldg. 00


record review the facility failed to ensure

beverages on room trays and cups of ice

were covered when transported through

common hallways and a dome cover

which had fallen on the floor was not

placed back on a resident's plate during

meal service. The facility also failed to

ensure staff washed their hands after

touching soiled items and before feeding

a resident her meal. This deficient

practice had the potential to affect 45 of

F 0371 F-371 SS=EE

483.35(i)FOODPROCURE,

STORE/PREPARE/SERVE –

SANITARY a)What corrective

action(s) will be accomplished

forthose residents found to have

been affected by the deficient

practice? C N A’s # 6, 2, 7, 3, 8,

1, 4, and 5 were re-educated by

the NPE08/26/2016 through

09/06/2016 on applying lids

when transferring meals

andbeverages as well as

handwashing during dining

services. b)How will other

09/12/2016 12:00:00AM





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

45 residents who ate their meals in their

rooms and 10 of 10 residents who ate

their meals in the Assist Dining Room.

Findings include:

1. An observation of the lunch meal tray

delivery in the 100 hall on 8-17-2016


At 11:33 a.m., Certified Nursing

Assistant (CNA) #6 was observed to hold

a cup with his thumb on the rim of the

cup and pour hot water into the cup.

CNA #6 was observed to deliver the cup

to the resident in room 103 while holding

his thumb on the rim of the cup.

At 11:34 a.m., the meal cart was parked

outside room 106 and CNA #6 was

observed to carry a cup of hot water

uncovered, down the hall to room 102.

At 11:41 a.m., CNA #2 was observed to

move the 100 hall meal tray cart down

the hall with 2 trays with dome covers

that did not completely cover the plates

of food.

At 11:42 a.m., one tray remained on the

cart unattended with the dome cover not

completely covering the plate of food.

CNA #2 moved the tray down the hall

and delivered the tray with the dome

cover not completely covering the plate

residents having the potential to

beaffected by the same deficient

practice be identified and what

correctiveaction(s) will be taken?

There were no adverse

outcomes noted to the residing

residents in thefacility.

c)What measures will be put into

place or what systematicchanges

will be made to ensure that the

deficient practice does not recur?

The Nursing Staff will be

re-educated by the NPE on

application of lidsto the meals

and beverages as well as

handwashing during dining

services by 08-26-2016.

d)How will the corrective action(s)

be monitored toensure the

deficient practice will not recur,

i.e. what quality

assuranceprogram will be put into

place; and by what date the

systemic changes will

becompleted? The CNE or

Designee will complete an

audit ofapplication of lids when

transferring meals or

beverages in the hallway as

wellas handwashing during

dining services 5 times a week

times for two weeks,

twiceweekly times two weeks

then weekly times 5 months to

ensure proper procedure is

being followed. This

monitoring will occur during all

threemeal times. The

CED/CNE/NPE or designee to

Monitor monthly for

compliance of





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

to a resident in room 112.

2. An observation of the lunch meal tray

delivery in the 200 hall on 8-17-2016



move a tray to the bottom rung of the

food cart and the dome cover slipped off

part of the plate and was not completely

covering the plate of food. CNA #6

pushed the meal tray cart further down

the hall with the food on the plate not

completely covered.

At 11:48 a.m., CNA #7 pushed the 200

hall meal tray cart down the hall and the

dome cover fell off of the plate of food

from the tray that was on the bottom rung

of the cart and landed on the floor. CNA

#7 was observed to pick up the dome

cover from the floor, replaced the dome

cover over the food on the plate and

delivered the meal tray to room 214.


carry and uncovered cup of a hot drink

from the meal tray cart which was parked

by room 212 down to the resident in

room 214.

3. An observation in the 200 hall on

8-18-2016 at 8:51 a.m., indicated CNA

#3 obtained a cup of coffee from the meal

allegeddeficiencies in the 2567


committee for

additionalinterventions as a

need is identified. e) By

what date will the systemic

changes becompleted? Date

ofcompliance 09/12/2016





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

tray cart that was parked outside room

211. CNA #3 carried the cup of coffee

down the hall uncovered to a resident in

room 214.

4. An observation in the 200 hall of the

meal tray cart on 8-22-2016 at 11:34

a.m., indicated no lids were on the open

cart for the coffee cups.

An observation on 8-22-2016 at 11:35

a.m., indicated CNA #6 carried an

uncovered cup of ice from the

"employees only". The room was located

across from the 100/200 hall nurse

station and down the hall and around the

corner to room 108.

An observation on 8-22-2016 at 11:37

a.m., indicated CNA #8 poured a cup of

coffee from a coffee pot on the meal tray

cart parked outside room 201. CNA #8

was observed to carry the cup of coffee

uncovered down the hall approximately

20 feet to room 202.

5. During an observation of the lunch

meal on 8/23/16 in the 300 Hall,


At 11:25 a.m., the food cart was parked

in the beginning of the 300 Hall.

Certified Nursing Assistant (CNA) #1

was observed to pour a cup of coffee at





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

the food cart and place the cup on a meal

tray. She was then observed to carry the

meal tray from the food cart through the

300 Hall to a resident's room, not in close

proximity to the food cart. The cup of

coffee was not covered.


put ice in a disposable glass at the ice

machine close to the nurses station in the

400 Hall. She was then observed to carry

the disposable glass of ice through the

hallway to a resident's room. The

disposable glass of ice was not covered.


pour a cup of coffee at the food cart and

place the cup on a meal tray. She was

then observed to carry the meal tray from

the food cart through the 300 Hall to a

resident's room, not in close proximity to

the food cart. The cup of coffee was not

covered.





the food cart through the 300 Hall, not in

close proximity to the food cart. The cup

of coffee was not covered.


meal on 8/23/16 in the 400 Hall,





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00


At 12:20 p.m., CNA #4 was observed to




the food cart through the 400 Hall to a

resident's room, not in close proximity to

the food cart. The cup of coffee was not

covered.


meal on 8/23/16 in the Assist Dining

room, the following was observed:


wash her hands appropriately for the

recommended amount of time. She was

then observed to sit down on a dining

room chair next to a resident seated at a

dining room table. She was observed to

place her clean hands on the arms of the

chair and move the chair up closer to the

table. She began feeding the resident her

lunch meal. She was not observed to

re-wash her hands.

At 12:31 p.m., Social Service was

observed to carry a glass of milk into the

Assist Dining Room from the hallway.

The glass of milk was not covered.


stand up from the dining room chair





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

where she was seated and accept 3

disposable spoons from the Unit

Manager. She was then observed to sit

back down on the dining room chair and

used her hands to scoot the chair up

closer to the table. She was observed to

continue feeding the resident her lunch

meal. She was not observed to re-wash

her hands.

The Dietary Manager was interviewed on

8/25/16 at 10:15 a.m. During the

interview she indicated the hall carts

were to be moved from room to room

when delivering food and beverages. She

also indicated if meal trays were carried

through the hall, everything needed to be

covered and the dome cover that fell on

the floor should never have been placed

back on the resident's plate. She further

indicated staff were to wash their hands

after touching anything soiled and before

feeding a resident their meal.

A current facility policy "Meal Service",

with a revision dated of 6/15/16 and

provided the Administrator on 8/25/16 at

10:29 a.m., indicated "...Room trays are

served by nursing or other designated

staff. Food and beverage carts are moved

down the hallway when distributing trays.

Uncovered trays are not carried down the

hall...."





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

A current facility policy "Hand

Washing", with a revision date of 10//15

and provided by the Administrator on

8/25/16 at 10:29 a.m., indicated "...Hand

washing is performed frequently and

using correct hand washing technique...to

minimize the spread of disease...Hand

washing is performed after:... After

contacting any soiled utensils...Before

touching any clean utensils, plates,

cups...."

3.1-21(i)(1)

483.65

INFECTION CONTROL, PREVENT

SPREAD, LINENS

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

F 0441

SS=E

Bldg. 00





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

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.

A. Based on observation, interview and


2 of 4 nursing staff (Nurse #14, Nurse

#15) washed their hands for the

recommended amount of time during 2 of

3 observation of wound care treatments.

(Resident #53, Resident #9)

B. Based on observation, interview and


catheter tubing for 2 residents (Resident

#42 and Resident #53) of 8 residents with

urinary catheters were kept off the floor.

C. Based on observation, interview and


glasses of milk were covered when

F 0441 F-441 483.65 INFECTION

CONTROL,PREVENT SPREAD,

LINENS


be accomplished forthose



Licensed Nurses 14 and 15

were re-educated and

treatment

competencycompleted by the

NPE 08/26/2016 on adequate

length of time for

handwashingduring

treatments. Residents’ #42 and

#53 catheter tubing was

repositioned bythe nurses on

08/24/2016 to ensure it does

09/12/2016 12:00:00AM





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

transported through common hallways

during medication pass.

Findings include:

A1. During an observation of wound care

treatment on 8/23/16 from 9:36 a.m.

through 9:55 a.m., Nurse #14 prepared

supplies for wound care treatment for

Resident # 53's MASD (moisture

associated skin damage) on the coccyx

area. Nurse #14 and CNA (Certified

Nursing Assistant) #4 were observed to

wash their hands with soap and water.

They both lathered their hands for more

than 20 seconds before rinsing their

hands with water, dried their hands with

clean paper towels and turned the water

off with a clean paper towel. The nurse

and CNA donned disposable gloves

before providing care to Resident #53.

The CNA turned and positioned the

resident on her right side and held the

resident there while the nurse provided

wound care. The nurse touched the

resident while she assessed the wound.

The nurse indicated the dressing

(bandage) had come off and she needed

to replace the dressing. The nurse

removed the disposable gloves, discarded

the gloves in the plastic trash bag,

washed her hands with soap and water,

lathered her hands for only 10 seconds

before rinsing her hands with water,

not touch the floor when

resident isup in the wheelchair.

There were no adverse

outcomes to the residing

residentsfrom the lids that

were not applied to the milk on

the observed date.


having the potential to beaffected


identified and what


The residing residents were

not noted with any adverse

outcomes fromthe observed

concerns.


into place or what

systematicchanges will be made

to ensure that the deficient

practice does not recur?

The Licensed Nurses were

re-educated on

handwashingprocedures

during treatments by the NPE

on 08/26/2016. The nursing

staff werere-educated on

proper positioning of Foley

catheter tubing by the NPE

on08/26/2016. The nursing staff

were re-educated on

application of lids

whencarrying beverages or

meals in the hallways by the

NPE on 08/26/2016





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

drying her hands with clean paper towel

and turned off the water with clean paper

toweling. The nurse donned disposable

gloves and cleaned the wound and

surrounding skin with wound cleanser

spray and with a gloved hand patted the

skin dry with a clean 4x4 (size in inches)

gauze square. The nurse applied a 2x2

(size in inches) hydrocolloid dressing (an

adhesive bandage that forms a gel and

promotes healing) to the coccyx wound

and gently pressed down the edges of the

dressing. The nurse removed the

disposable gloves, washed her hands with

soap and water, lathered her hands for

only 10 seconds before she rinsed her

hands with water, dried her hands with a

clean paper towel and turned the water

off with a clean paper towel. The nurse

donned disposable gloves and applied

Silvadene zinc oxide (an antimicrobial

skin protectant) to skin of perineal area

and the coccyx area around the dressing.

The nurse and CNA removed the

disposable gloves and washed their hands

with soap and water, lathered their hands

for more then 20 seconds before rinsing

their hands with water, dried their hands

with clean paper towel and turned off the

water with a clean paper towel.

2. During an observation of wound care

treatment on 8/23/16 at 10:05 a.m., Nurse

#13 prepared wound care supplies for

through09/06/2016.


action(s) be monitored toensure


recur, i.e. what quality




becompleted?

The CNE or designee will

complete an audit oftreatment

observation to include

handwashing, application of

lids tomeals/beverages when

serving in hallways, and to

ensure proper positioning

ofFoley catheters

5 times a week times two

weeks, twice weeklytimes two

weeks then weekly times 5

months toensure proper

procedure is being followed.

The CED/CNE/NPEor designee

to

Monitor monthly for

compliance of



committee for


need is identified.

This monitoring will occur on

all shifts.





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

Resident #9's unstagable pressure ulcer.

Nurse #13 washed her hands with soap

and water, lathered her hands for 45

seconds before rinsing with water, dried

her hands with paper towel, turned water

off with a clean paper towel and donned

disposable gloves. Nurse #15 was

present to assist Nurse #13 during the

wound care treatment. Nurse #15


lathered her hands for 20 seconds before

rinsing with water, dried her hands with

clean paper towels and turned the water

off with a clean paper towel and donned

disposable gloves. Nurse #15 assisted to

position Resident #9 onto her left side

and held resident in position while Nurse

#13 preformed wound care. Nurse #13

performed wound care and when she

tried to apply the transparent dressing

over the foam dressing, the transparent

dressing failed to adhere to the residents

skin. While Nurse #13 held the resident's

dressing in place with her clean gloved

hand, Nurse #15 removed her disposable

gloves, washed her hands with soap and

water, lathered her hands for only 10


with a clean paper towel, turned the water

off with a clean paper towel, retrieved

treatment cart keys from Nurse #13's

uniform pocket and left the room to

retrieve a new transparent dressing from

the treatment cart. Upon retuning to the


changes becompleted?

Date of compliance 09/12/2016





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

room, Nurse #15 placed the packaged

transparent dressing on the top of the

clean paper towel on the over-bed table

and washed her hands with soap and

water, only lathering her hands for 10


her hands with clean paper towels, turned

the water off with clean paper towels and

donned disposable gloves. Nurse #15

then opened the transparent dressing

package and applied the transparent

dressing over the foam dressing that

Nurse #13 had held in place. Nurse #15

removed the disposable gloves and


lathering her hands for only 10 seconds

while she moved her hands in and out of

water during lathering her hands before

rinsing her hands with water. She dried

her hands with clean paper towels and

turned the water off with a clean paper

towel and left the room. Nurse #13

gathered trash and placed it in a plastic

trash bag, removed the disposable gloves

and washed her hands with with soap and

water and lathered her hands more than

20 seconds before rinsing with water. She

dried her hands with clean paper towels

and turn off the water with a clean paper

towel.

During an interview with Nurse #15 on

8/24/16 at 11:5 a.m., she indicated during

handwashing, the hands should be





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

lathered for 20 seconds before rinsing

with water. She also indicated all staff

were educated on proper handwashing

procedure during orientation and

indicated all facility staff were educated

last month (July 2016) during the

facility's annual competency testing. She

further indicated handwashing with soap

and water should be done before donning

and after removing disposable gloves.

During an interview with CNE (Center

Nurse Executive [Director of Nursing])

on 8/25/16 at 12:30 p.m.,she indicated

during proper handwashing with soap

and water, the hands should will be

lathered for at least 20 seconds before

rinsing with water. The CNE indicated

hands should be dried with clean paper

towels and the water should be turned off

with clean paper towels. She also

indicated handwashing should be done

before and after disposable glove use.

She further indicated hands should be

lathered for at least 20 seconds before

rinsing with water in-between glove

changes. The CNE indicated there was

not a specific facility policy regarding

handwashing during wound care and/or

treatments.

A current facility policy, titled, Hand

Washing, with revision date of 10/16/15,

was provided by the CED (Center





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

Executive Director) on 8/25/16 at 1:25

p.m., indicated, "...Policy...Hand washing

is performed frequently and using correct

hand washing technique....Purpose...to

minimize the spread of

disease....Process...2. Hand washing

technique includes the following....2.2.

Procedure for wetting, lathering and

rinsing hand is followed...2.2.1 Wash

hands for minimum of 15-20 seconds...."

A current facility police, titled, Wound

Dressings: Aseptic, with revision date of

11/30/15, provided by the CED on

8/25/16 at 1:25 p.m., indicated, "...2.

Gather supplies... 3. use personal

protective equipment as indicated...4.

Clean over-bed-table...11. Cleanse

hands....13. If a break in aseptic

technique occurs, stop the procedure,

remove gloves, cleanse hands, and apply

clean gloves...After remove the soiled

dressing...17. Cleanse hands...18. Apply

gloves...21.1 if gloves become

contaminated, remove gloves, cleanse

hands and apply clean gloves...."

B1. Review of the clinical record for

Resident #42 on 8/24/16 at 12:07 p.m.,

indicated the following: diagnoses

included, but were not limited to,

neuromuscular dysfunction of bladder.

A physician's order for Resident #42,





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

dated 10/26/15, indicated a Foley catheter

for neuromuscular dysfunction of

bladder.

During an observation on 8/18/16 at 1:32

p.m., Resident #42 was observed being

pushed in her wheelchair into the activity

room by a visitor. Her catheter tubing

was observed on the floor.


p.m., Resident #42 was observed being

pushed in her wheelchair outside of the

facility by a visitor. Her catheter tubing

was observed on the ground.


p.m., Resident #42 was observed seated

in her wheelchair in her room. Her

catheter tubing was observed on the

floor. She stated she and her volunteer

had just come back into the building after

taking a walk outside.


p.m., Resident #42 remained seated in

her wheelchair in her room. The catheter

tubing remained on the floor.

A facility care plan for Resident #42,

with a review date of 7/8/16, indicated

the focus area of resident exhibits or is at

risk for impaired renal function and is at

risk for complications related to





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

indwelling Foley catheter. Interventions

to the focus included, but were not

limited to, record output,

observe/monitor for signs and symptoms

of infection and report to physician,

monitor/observe output for odor, color,

consistency, and amount, catheter care

twice a day and PRN, provide privacy

bag, and keep catheter off floor.



the focus are of resident exhibits or is at

risk for complications of infection related

to chronic UTI's. Interventions to the

focus included, but were not limited to,

assess characteristics of urine, color, odor

sediment and monitor for urinary

frequency and urgency and report to

physician as indicated, assist resident

with handwashing throughout the day as

needed, educate resident/health care

decision maker on good hand-washing

and prevention of spread of infection, and

monitor for signs and symptoms of

infections and report to physician as

indicated.

B2. Review of the clinical record for

Resident #53 indicated the following:

diagnoses included, but were not limited

to, Type II diabetes mellitus, morbid

obesity, HTN, heart failure, and venous

insufficiency.





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

A Progress Note for Resident #53, dated

5/26/16 at 3:28 p.m., indicated the Nurse

Practitioner ordered a Foley catheter due

to diagnosis of urinary retention.


p.m., Resident #53 was observed seated

in her wheelchair in the activity room.

Her catheter tubing was observed on the

floor.


a.m., Resident #53 was observed seated

in her wheelchair in the assist dining

room. Her catheter tubing was observed

on the floor. She was then pushed in her

wheelchair through the hallway to her

room by Certified Nursing Assistant #4.

Her catheter tubing remained on the

floor.



the focus area of resident requires

indwelling catheter due to urinary

retention. Interventions included, but

were not limited to, change Foley

monthly and as needed, catheter care

every shift and/or PRN, monitor for signs

and symptoms of infection and report to

physician, and monitor output for odor,

color, consistency, and amount. The care

plan did not indicate to the keep the





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

catheter tubing off the floor.



the focus area of resident has history of

urinary tract infections. Interventions to

the focus included, but were not limited

to, monitor labs as ordered, monitor

output for odor, color, consistency and

amount, and observe/monitor for signs

and symptoms of infection and report to

physician.

The Center Nurse Executive and the

Clinical Quality Specialist were

interviewed on 8/25/16 at 9:43 a.m.

During the interview they indicated

catheter tubing should not be on the floor.

A facility policy on catheter care was

requested on 8/25/16 at 9:53 p.m.

The Clinical Quality Specialist was

interviewed on 8/25/16 at 1:50 p.m.

During the interview she indicated the

facility did not have a policy on catheter

care.

C. During an observation on 8-22-2016

at 4:15 p.m., Nurse #9 was observed to

carry two uncovered 4 ounce cups of

milk down the 200 hall from the 100//200

hall nurses' station and placed them on a

treatment cart outside room 204. Nurse

#9 asked for help from another staff to





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

re-position a resident in his wheelchair

while leaving the 2 cups of milk

unattended on the treatment cart. When

Nurse #9 was finished assisting the

resident, the nurse was observed to pick

up the 2 cups of milk without washing

her hands or performing hand hygiene

and she carried them down the hall to the

medication cart which was parked

between rooms 215 and 217. Nurse #9

was observed to wash her hands and then

put protein powder in one of the cups of

milk for a resident in room 215. Nurse

#9 carried the cup of milk with the

protein powder into room 215 and gave

the cup of milk to the resident to drink.

An interview with the Nurse #9 at this

time indicated the other cup of milk

would have the protein powder added to

it and given to the resident in room 217.

3.1-18(j)

3.1-18(l)

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

SS=D

Bldg. 00





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00



the bathroom cleaning was completed for

1 of 3 bathrooms observed. (Room 112)

Findings include:

An interview with Resident D on

8-22-2016 at 8:47 a.m., indicated the

housekeeper came in and sprayed the

floor and emptied the trash, but had not

mopped the floor.

An interview with Resident D's family

member on 8-22-2016 at 10:50 a.m.,

indicated on the weekend when visiting,

the bathroom trash was full and odorous

and the floor was not clean.

An observation of the bathroom in room

112 on 8-22-2016 at 1:51 p.m., indicated

the bathroom floor edges had a brown

colored gritty substance which was

sticky. A paper towel was rubbed along

the edge and the brown residue came up

on the toweling. The floor did not appear

clean, the trash was full and a dead spider

was between the wall and the toilet.

An interview with Housekeeper #10 on

8-23-2016 at 11:31 a.m., indicated when

a room was cleaned, it is dusted, swept

and the bathroom sink, toilet and floor

was to be mopped. Housekeeper #10 was

F 0465 F-465 483.70

SAFE/FUNCTIONAL/SANITARY/

COMFORTABLEENVIRONMENT

1.What corrective action(s)

will be accomplished forthose



Room 112 was immediately

cleaned.

Housekeeper #11 was

reeducated on the 5 and 7 Step

cleaning process by

housekeepingmanager on

8/29/2016.




identified and what


Other residents residing at

Genesis New Haven Center

have the potentialto be affected

by the alleged deficient

practice

Housekeeping staff were

re-educated on the 5 and 7 step

housekeepingprocess. They

were also re-educated on

accurate completion of the

routine jobform housekeeping

manager on 8/29/2016.


09/12/2016 12:00:00AM





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

observed to empty the trash from the

resident's room. After the meal tray was

delivered, Housekeeper #10 indicated to

the resident she would come back and

finish.



the same dead spider remained between

the toilet and the wall as was observed

the day before. The edges of floor had a

brown sticky residue that could be

removed with a paper towel.



the dead spider remained between the

toilet and the wall, the floor had a black

mark on it along with the sticky residue

around the edges of the floor and the

trash can was full. An interview with

Resident D at this time indicated the

housekeeper had not been in to clean the

room or the bathroom.

An interview with the Housekeeping

Manager on 8-24-2016 at 2:36 p.m.,

indicated each resident's room and

bathroom was cleaned daily. The

Housekeeping Manager indicated he had

housekeeping start at 6 a.m. and they had

staggered shifts so there was a

housekeeper in the facility at least until

9:30 p.m. daily. He indicated the

into place or what



practice does not recur?

The CED or designee will

conduct audits whichmonitor

the cleanliness of resident

rooms. These will be

conducted 5 times aweek times

two weeks, twice weekly times

two weeks then weekly times

5months to ensure proper

procedure is being followed.

Immediate follow-up by the

housekeepingmanager or

designee regarding any

concerns brought forward by

staff orresidents will occur.








becompleted?

The CED/CNE/NPE or designee

to

Monitor monthly for

compliance of







10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

housekeeper would write their initials

next to the room number after cleaning

and then would sign and date their sheet

prior to ending their shift.


Manager on 8-24-2016 at 3:10 p.m.,

indicated room 112 was cleaned by the

Housekeeper #11 for the past 3 days on

the day shift. An "H1 Housekeeper"

instruction and check off sheet was

provided by the Housekeeping Manager

for the past 3 days (8-22, 23 and 24,

2016) and the Housekeeper #11's initials

were written next to room 112 on each

form. The Housekeeping Manager

indicated the housekeeper should follow

the 5 step and 7 step procedure for

cleaning resident rooms and bathrooms.

He indicated the "7 step Procedure" for

bathrooms included the following:

"Check/refill supplies, pull trash/replace

liner, dust mop/sweep, clean sink

area/tub, clean commode/base, clean

walls/partitions, damp mop...."

At the bottom of the form, the following

was written "...check off resident room

immediately after it has been

cleaned...turn in completed routine to

HSKP Manager at end of shift...." The

Housekeeping Manager indicated there

should not be a dead spider between the

toilet and the wall in the bathroom for 3

days. He indicated he did not know what

committee for


need is identified.

5.By what date will the

systemic changes

becompleted?

Date completed: 09/12/2016





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

the sticky residue was along the

baseboard in the bathroom.


Manager on 8-24-2016 at 3:30 p.m.,

indicated a housekeeper was sent to clean

the bathroom in room 112.


Manager on 8-24-2016 at 3:44 p.m.,

indicated he contacted Housekeeper #11

who signed off on cleaning room 112

today and asked her if she cleaned the

bathroom. He indicated Housekeeper

#11 told him the residents in room 112

were always in the bathroom, so she

didn't clean the bathroom. The

Housekeeping Manager indicated

Housekeeper #11 should not have

initialed that the room and bathroom

were cleaned when it was not cleaned.

A current policy, "7-Step Daily

Washroom Cleaning" dated 1-1-2000 and

provided by the Housekeeping Manager

on 8-24-2016 at 3:30 p.m., indicated the

purpose was "...to show Housekeeping

employees the proper method to sanitize

a washroom or bathroom in a long-term

care facility...always dust mop the floor

before you bring any water into a

room...2...Empty Trash...always empty

trash before you use any water...reline

receptacles and sanitize as





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

needed...3...Dust Mop Floor...be sure to

move any items in bathroom when dust

mopping...7...Damp Mop Floor...Use

proper mop and germicide solution to

disinfect the floor...Be sure to run mop

along edges and never push dirt into

corners...."

This federal tag relates to Complaint

IN00207154.

3.1-19(f)

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

F 0514

SS=D

Bldg. 00





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

any preadmission screening conducted by

the State; and progress notes.

Based on interview and record review,

the facility failed to ensure residents who

received as needed pain medication had

documentation they were monitored for

the effectiveness of the medication for 2

of 3 residents reviewed for pain.

(Resident #C and Resident # D)

Findings include:

1. The record review for Resident C

began on 8-23-2016 at 11:30 a.m.

The diagnoses for Resident C included

but were not limited to anxiety,

dysphagia (difficulty swallowing),

encephalopathy, enterocolitis due to

Clostridium difficile, heart failure,

muscle weakness and depression.

An admission MDS (Minimum Data Set)

assessment dated 7-26-2016 indicated a

BIMS (Brief Interview for Mental Status)

of 12/15, which indicated moderate

impairment. Additional information

from the MDS indicated Resident #C was

receiving prn (as needed) pain medication

and non-medication measures for pain

management.

A review of the physician's orders

indicated "...acetaminophen ER

(extended release) tablet extended release

F 0514 F514 RES

RECORDSCOMPLETE/ACCURA

TE/ACCESSIBLE


be accomplished forthose



Monitoring tools of the

residents requiring PRN pain

management wereimmediately

placed on the resident’s MAR

on 8/26 by NPE. Licensed

Nurses were re-educated on

proper documentation

surroundingthe distribution of

pain medication and the

effectiveness by 8/26 by NPE




identified and what


Residing residents at the

centerdid not have an adverse

outcome related to the

documentation concern on

8/25/16 Other residents

residing at Genesis New Haven

Center who utilizemedications

for pain management have the

potential to be affected by

thealleged deficient practice

The Licensed Nurses will

ensure residents utilizing pain

meds have a PRNpain

medication sheet placed on the

MAR to follow-up on the

resident’s responseto the pain

medication administered

09/12/2016 12:00:00AM





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

650 mg (milligrams), give 650 mg by

mouth every 8 hours as needed for pain

or fever...." (order date was 7-19-2016

and was active).

An additional pain medication, tramadol

HCl table 50 mg, give 1 tablet by mouth

every 12 hours as needed for pain was

dated 7-19-2016 and was active.

A review of the July 2016 MAR

(Medication Administration Record),

indicated the prn acetaminophen was

administered 5 times and the prn

tramadol was administered one time.

There was not a PRN Pain Management

Flow Sheet found in Resident C's records

for July 2016.

A review of the August 2016 MAR

through 8-24-2016, indicated the prn

acetaminophen was administered 5 times

and the prn tramadol was administered 6

times.

A review of the PRN Pain Management

Flow Sheet indicated 3 of the 5

acetaminophen administrations were

entered on the sheet and 3 of the 6

tramadol administrations were entered on

the sheet. The PRN Pain Management

Flow Sheet was a pain evaluation and

treatment record for the effectiveness of

the treatment. Additional discrepancies


into place or what



practice does not recur? The

Licensed Nurses will be

re-educated by the NPE or

designee by 8/26to ensure

residents utilizing pain meds

have a PRN pain medication

sheet placedon the MAR to

follow-up on the resident’s

response to the pain

medicationadministered During

the monthly changeover, a

PRN painmedication sheet will

be placed on the resident’s

MAR to monitor

theeffectiveness and response

of pain medications given.








becompleted? The CED/NPE/UM

or designee will audit

properdocumentation of the

pain medication and the

resident’s response. These will

beconducted 5 times a week

times two weeks, twice weekly

times two weeksthen weekly

times 5 months to ensure

proper procedureis being

followed. The CED/CNE/NPE

or designee to Monitor monthly

for compliance of






10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

for the tramadol indicated the following:

An entry for tramadol on the Flow Sheet

on 8-14-2016 at 9:00 p.m. and on

8-23-2016 at 10:45 p.m. did not match

the MAR as there was not tramadol

initialed as given on the 14th or the 23rd.

A review of the nurses' notes for July and

August through 8-13-2016, which were

provided by the Center Nurse Executive

(CNE) on 8-24-2016 at 4:21 p.m.,

indicated an entry on 7-29-2016 and

8-13-2016 that reflected prn pain

medication given.

A care plan for risk for alterations in

comfort for Resident #C was dated

7-25-2016 and indicated the interventions

to "...evaluate pain characteristics:

quality, severity, location,

precipitating/relieving factors...utilize

pain scale...evaluate resident's past

coping mechanisms to determine what

measures work best...advise resident to

request pain medication before pain

becomes severe...."

An interview with the Clinical Quality

Specialist on 8-25-2016 at 10:00 a.m.,

indicated there was not a PRN Pain

Management Flow Sheet for the Resident

C for July 2016.

2. The record review for Resident D


committee for


need is identified.


changes becompleted? Date of

compliance 09/12/2016





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

began on 8-22-2016 at 2:00 p.m. The

diagnoses included but were not limited

to, atherosclerotic heart disease of native

coronary artery with unspecified angina

pectoris, hypertension, pain, muscle

weakness, seizures, anxiety and shortness

of breath.

A review of the Admission MDS

assessment dated 4-7-2016 indicated a

BIMS of 14/15, which indicated Resident

#D was cognitively intact. The section of

the MDS for pain assessment indicated

pain was rated a "5" frequently, was

unable to answer if it affected her sleep

or day to day activities, was not on

routine pain medications, received prn

pain medications and

non-pharmacological pain treatments.

The quarterly MDS dated 7-8-2016

indicated a BIMS score of 15/15, had

mild pain, not on routine pain

medications, received prn pain

medications and no numeric description

of pain but described pain as mild. The

pain did affect sleep and day to day

activities.

A review of the current physician orders

indicated "...morphine sulfate solution 20

mg/ml (milligrams per milliliter) give 5

mg by mouth every 4 hours as needed for

pain/sob (shortness of breath)...." The

order was 4-1-2016 and active.





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

"...Morphine sulfate solution 20 mg/ml

give 7.5 mg by mouth every 24 hours as

needed for pain every hs (at bedtime) prn

with an order date of 4-1-2016 and

marked as active. An order for

"...Tylenol Extra Strength tablet 500 mg

give 2 tablets by mouth every 6 hours as

needed for pain or fever...." was dated

4-1-2016 and was discontinued on

8-18-2016. Routine Tylenol Extra

Strength was started on 8-18-2016 with 2

tablets by mouth 2 times a day.

A review of the April 2016 MAR


The prn morphine sulfate 20 mg/ml 5 mg

was administered 13 times, the prn

morphine sulfate 20 mg/ml 7.5 mg was

administered 5 times and the prn Tylenol

extra strength 500 mg 2 tablets was

administered 22 times. There was not a

PRN Pain Management Flow Sheet

found for April 2016 for Resident #D that

reflected the pain assessment and

evaluation of the effectiveness of the pain

medication in the resident's record.

A review of the May 2016 MAR


The prn administration of the Tylenol


documented in May 20 times. The prn

morphine sulfate 20 mg/ml 5 mg was

administered 5 times per the





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

documentation. No morphine sulfate 20

mg/ml 7.5 mg was documented as

administered. The PRN Pain

Management Flow sheet was only

completed for 6 of times for the Tylenol

and the morphine sulfate prn

administration was not documented at all

on the flow sheet.

A review of the June 2016 MAR




documented in June 45 times with only 3

entries recorded on the PRN Pain

Management Flow Sheet. No prn

morphine sulfate was documented as

administered on the June 2016 MAR.

A review of the July 2016 MAR




documented in July 52 times with only

14 entries recorded on the PRN Pain

Management Flow Sheet. No prn

morphine sulfate was documented as

administered on the July 2016 MAR.

A review of the August 2016 MAR




documented in August 28 times through





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

8-17-2016 with only 2 entries recorded

on the PRN Pain Management Flow

Sheet. No prn morphine sulfate was

documented as administered on the

August 2016 MAR.

A care plan for risk for alterations in

comfort for Resident #D was dated

4-1-2016 and indicated the interventions

which included but were not limited to

the following , "...evaluate pain

characteristics: quality, severity, location,

precipitating/relieving factors...utilize

pain scale...medicate resident as ordered

for pain and monitor for effectiveness

and monitor for side effects...."

During an interview with Resident #D's

family member on 8-22-2016 at 10:50

a.m., the family member expressed a

concern about staff checking on the

resident after a pain medication was

administered to see if it worked to relieve

the pain.

An interview with the RN Nurse

Educator on 8-24-2016 at 9:00 a.m.,

indicated for a resident with pain, the

nurse should assess where the pain is,

have the resident rate the level of the

pain, try a non-pharmacological method

of pain control, check the orders for the

pain medication, document any PRN pain

medication on the PRN Medication Flow





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

sheet and recheck after the pain

medication was given to evaluate the

effectiveness.


8-24-2016 at 9:35 a.m., indicated for a

resident with PRN pain medications, the

nurse was to assess the location of the

pain and record the time the pain

medication was given on the MAR.

Nurse #9 indicated she forgets to

document on the "yellow sheet" (PRN

pain management flow sheet) which the

nurse indicated was where the pain level

and the effectiveness of the pain

medication were documented.

An interview with the Clinical Quality

Specialist on 8-25-2016 at 10:00 a.m.,

indicated there was not a PRN Pain

Management Flow Sheet for Resident D

for April 2016.

A current facility policy, "Pain

Management" with a revision date of

3-15-2016 and provided by the Corporate

Nurse on 8-25-2016 at 10:00 a.m.,

indicated "...at a minimum of daily,

patients will be evaluated for the

presence of pain by asking an inquiry of

the patient or by observing for signs of

pain...if PRN medications are given,

document...on the PRN Pain

Management Flow Sheet....patients





10/14/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


NEW HAVEN, IN 46774

155207 08/25/2016

NEW HAVEN CENTER

1201 DALY DR

00

receiving interventions for pain will be

monitored for the effectiveness and side

effects in providing pain

relief...document...effectiveness of PRN

medications...."

3.1-50(a)(2)


printed: 10/14/2016 department of health and human ... · printed: 10/14/2016 form approved omb no....

Documents