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(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

CULVER, IN 46511

155589

00

11/05/2012

MILLER'S MERRY MANOR

730 SCHOOL ST

F0000

Miller’s Merry Manor of Culver,

Indiana does hereby request

consideration for Paper Compliance

for the Plan of Completion

submitted for our annual survey

dated November 5, 2012.

Attached with our plan of

correction, which we believe

responds to corrections and system

implementation are documents that

address the audit materials used in

attaining and maintaining

substantial compliance with the

findings.

If you should need any further

documentation or information

please do not hesitate to contact the

facility Administration at

574-842-3337 or through the

Gateways system e-mail.

F0000This visit was for a Recertification and

State Licensure Survey..

Survey dates: October 29, 30, and

31, 2012 and November 1, 2, and 5,

2012

Facility number: 000489

Provider number: 155589

AIM number: 100291210

Survey team:

Regina Sanders, RN-TC

Shannon Pietraszewski, RN

Janlyn Kulik, RN (October 29 and 30,

2012)

Census bed type:

SNF: 03

SNF/NF: 57

Total: 60

Census payor type:

Medicare: 05

Medicaid: 33

Other: 22

Total: 60

These deficiencies reflect state

findings cited in accordance with 410

IAC 16.2.

Quality review completed on

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: 1L0411 Facility ID: 000489

TITLE

If continuation sheet of 75

(X6) DATE




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CULVER, IN 46511

155589

00

11/05/2012


730 SCHOOL ST

November 13, 2012 by Bev Faulkner,

RN

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1L0411 Facility ID: 000489 If continuation sheet of 75




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CULVER, IN 46511

155589

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11/05/2012


730 SCHOOL ST

F0272

SS=D

483.20(b)(1)

COMPREHENSIVE ASSESSMENTS

The facility must conduct initially and

periodically a comprehensive, accurate,

standardized reproducible assessment of

each resident's functional capacity.

A facility must make a comprehensive

assessment of a resident's needs, using the

resident assessment instrument (RAI)

specified by the State. The assessment

must include at least the following:

Identification and demographic information;

Customary routine;

Cognitive patterns;

Communication;

Vision;

Mood and behavior patterns;

Psychosocial well-being;

Physical functioning and structural

problems;

Continence;

Disease diagnosis and health conditions;

Dental and nutritional status;

Skin conditions;

Activity pursuit;

Medications;

Special treatments and procedures;

Discharge potential;

Documentation of summary information

regarding the additional assessment

performed on the care areas triggered by

the completion of the Minimum Data Set

(MDS); and

Documentation of participation in

assessment.

1 F-272 Resident’s # 9 and # 50

have had their respective MDS

assessments and supplemental

assessments reviewed and

updated. Specific identified needs

have been addressed. No ill

12/05/2012 12:00:00AMF0272Based on observation, record review,

and interview, the facility failed to

ensure assessments were completed

timely and accurately for the Minimum

Data Set (MDS) Assessments,





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155589

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11/05/2012


730 SCHOOL ST

effects were suffered by either

resident. All residents in the

facility who have MDS

assessments have the potential

to be affected by this finding. To

ensure that this does not recur in

these specific areas, all residents

will have MDS assessments

completed at time of admission,

at least annually and with a

significant change for dental

services. Any resident who may

decline this initial and/or annual

exam if recommended will be

re-educated on the importance of

routine dental screening. To

ensure side rail assessments are

accurate, each resident will be

assessed for side rail needs on

admission, quarterly, annually

and with a significant change. To

ensure that significant changes in

resident condition i.e. skin tears,

changes in areas of ADL function

will be reviewed by the MDS

coordinator and the MDS

coordinator will make

modifications to the MDS

assessment at that time as

warranted. Auditing for the

effectiveness of these systems

will be done through the QA

program via the Social Services

assessment tool quarterly for

dental needs, monthly for

significant change needs for side

rails, weekly via review of the

nursing assessments done

weekly, the TAR and MAR’s will

be reviewed by the

DON/ADON/MDS coordinator. All

assessments will be audited by

related to dental status, a skin tear,

and side rail usage, for 2 of 24

residents reviewed for assessments.

(Residents #9 and #50)

Findings include:

1. During an observation on

10/29/2012 at 2:43 p.m., Resident #9

was observed to have missing teeth

on the left side of her mouth.

Resident #9's record was reviewed on

11/01/12 at 8:30 a.m. The resident's

diagnoses included, but were not

limited to, Alzheimer's disease and

dementia.

A Quarterly MDS, dated 9/10/12,

indicated the resident had no dental

problems.

A Social Service note, dated

09/10/12, indicated the resident's

teeth were in good condition. The

assessment lacked documentation to

indicate the resident had missing

teeth.

During an interview on 11/02/12 at

10:24 a.m., the Social Service

Director indicated there was not an

assessment to indicate the resident

had missing teeth.





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CULVER, IN 46511

155589

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11/05/2012


730 SCHOOL ST

the MDS coordinator prior to

locking and submitting. All audits

will be reviewed by the QA team

at least monthly. Any needed

corrections will be done at the

time of audits. (Attachment)

Completion date 12-5-12

F272

1. The MDS for the resident

with the skin tear and side rail

finding has been modified as of

11/26/12. The QA audit has been

updated to say, check for

accuracy prior to locking and

submitting and this is being done

with all MDS. All resident’s MDS

information has been audited, no

other issues were identified.

2. All resident’s receiving

Medicaid benefits have been

assessed for dental services

annual exams and there were no

other missed exams. Social

Services reviews completion and

accuracy of dental needs on a

quarterly basis using the QA Audit

tool “Social Services Needs

Review” to ensure that all

residents are receiving dental

exams at least yearly.

Documentation of resident

decline of services will be noted

in the medical record.

2. Resident #50's record was

reviewed on 11/02/12 at 9 a.m. The

resident's diagnoses included, but

were not limited to, congestive heart

failure and dementia.

The MDS Assessment, dated

10/21/12, indicated the resident had

no skin tears and did not use side

rails on his bed.

A) During an observation on

10/29/12 at 2:29 p.m., Resident #50's

had a half side rail up on the left

upper side of the bed. During an

interview at the time of the

observation, the resident indicated he

did not know why the side rail was

raised up on his bed.


2:56 p.m., LPN #2 indicated the

resident used half side rails on his

bed.


8:08 a.m., CNA #3 indicated the

resident used side rails on his bed to

assist him with bed mobility.

A care plan, dated 08/13/12, indicated

the resident required one half side rail

to be up on his bed to enable turning

and repositioning and to provide

tactile bed boundaries. The





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CULVER, IN 46511

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730 SCHOOL ST

interventions indicated to complete a

side rail screen initially, quarterly, and

as needed.

A side rail assessment, dated

10/18/12, indicated no side rails were

used.


8:54 a.m., the MDS Coordinator

indicated the side rail assessment

had not been filled out correctly. She

indicated the MDS Assessment was

not marked for the side rail because

she had been told if it is not used as a

restraint, not to mark it on the MDS

Assessment. She indicated the side

rail assessment had not been

completed correctly, so she did not

know if the side rail was a restraint or

not.

B) An Initial Occurrence Assessment,

dated 10/12/12 at 1:30 p.m., indicated

the resident had received a skin tear

to his left arm during a transfer from

the recliner to the the bedside

commode.

The Treatment Administration Record

(TAR), dated 10/12, indicated the

staff were monitoring the resident's

skin tear every shift from 10/12/12

through 10/26/12. The TAR indicated

the skin tear had healed on 10/26/12.





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730 SCHOOL ST

(The Annual MDS Assessment, dated

10/21/12, indicated the resident did

not have a skin tear)


8:54 a.m., the MDS Coordinator

indicated the skin tear should have

been marked on the MDS.

3.1-31(a)





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CULVER, IN 46511

155589

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11/05/2012


730 SCHOOL ST

F0279

SS=D

483.20(d), 483.20(k)(1)

DEVELOP COMPREHENSIVE CARE

PLANS

A facility must use the results of the

assessment to develop, review and revise

the resident's comprehensive plan of care.

The facility must develop a comprehensive

care plan for each resident that includes

measurable objectives and timetables to

meet a resident's medical, nursing, and

mental and psychosocial needs that are

identified in the comprehensive assessment.

The care plan must describe the services

that are to be furnished to attain or maintain

the resident's highest practicable physical,

mental, and psychosocial well-being as

required under §483.25; and any services

that would otherwise be required under

§483.25 but are not provided due to the

resident's exercise of rights under §483.10,

including the right to refuse treatment under

§483.10(b)(4).

F-279 Residents’ #’s 18 and 34

care plans have been updated to

reflect current health status and

plan of care and treatment. All

residents residing in the facility

have the potential to be affected

by this finding. To ensure that

this deficient practice does not

recur, care plan needs are

reviewed on a daily basis via the

24 hour- Condition report for

physician orders. Monitoring of

the effectiveness of the system is

done at least weekly through the

24 hour-Condition report audit,

which will continues to be done

weekly and through

comprehensive review of MDS

12/05/2012 12:00:00AMF0279Based on observation, interview and

record review, the facility failed to

develop care plans for isolation and

diabetes in 2 of 24 sampled residents

reviewed for care plans. (Residents

#18 and #34)

Findings included:

1. Resident #34's clinical record was

reviewed on 10/31/12 at 9:54 A.M.

Resident #34's diagnoses included

but were not limited to multiple

sclerosis, colostomy, abdominal

fistula, MRSA (Methicillin Resistant





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155589

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11/05/2012


730 SCHOOL ST

assessments for accurate

problem identification at time of

admission (within 14 days of),

quarterly, with significant change

and annually. Care plan review

will be completed monthly via the

QA audit tools and through the

QA program. (Attachments)


F279

1. All care plans were

reviewed and updated for each

resident, this was done by

12/5/2012

2. All the staff was in serviced

on updating and developing care

plans daily to match any new

orders and with any condition

change. Department Heads are

also updating and monitoring

changes with new orders.

3. The systematic changes

made to prevent any deficient

practice are being done through

weekly audits of pertinent

charting and new orders review.

This audit is completed by the

DON, MDS Coordinator,

In-service Director, S.S, and

Nursing Supervisor through the

24 hour condition report audit to

make sure the care plans reflect

any changes and will be reviewed

monthly by the QA committee.

Comprehensive review of MDS

assessments for accurate

problem identification at time of

admission (within 14 days of),

quarterly, with significant change

and annually will still be done as

per policy and QA program

audits.

Staphylococcus Aureus), and history

of necrotizing fasciitis (flesh eating

disease).

A routine culture of the abdominal

fistula collected on 10/18/12,

indicated on 10/20/12 the resident

had moderate MRSA.

A physician order, dated 10/20/12,

indicated the resident was to be

placed in transmission precautions.

A nursing note, dated 10/20/12 at

1:21 P.M., indicated the nurse

received preliminary report of wound

culture which had moderate MRSA.

The note also indicated the resident

was currently on contact based

transmission precautions.


indicated the resident to be placed on

"contact based transmission

precautions due to positive wound

culture for MRSA."

During the initial tour, on 10/30/12 at

11:00 A.M., the resident was

observed to be in isolation. Interview

with LPN #1 indicated the resident

was in isolation due to a positive

culture to her abscess.

An interview, on 11/2/12 at 12:35





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730 SCHOOL ST

P.M., with the Education/Infection

Control Coordinator, indicated care

plans could be initiated at anytime

with any staff nurse.

There was no care plan for Resident

#34 being in isolation for MRSA.


reviewed on 11/2/12 at 10:30 a.m.


but were not limited to HTN

(hypertension), DM (diabetes

mellitus), depression, anxiety,

Parkinson's disease.

During clinical record review, the

October 2012 Physician

Recapitulation Orders indicated the

following orders was initiated on

1/11/12:

Carbohydrate controlled diet.

Glipizide (oral hypoglycemic) 10 mg

(milligrams) one tab by mouth twice a

day.

Metformin (oral hypoglycemic) 1000

mg one tab by mouth twice a day.

HGBA1C (Hemoglobin A1C for blood

sugar assessment) and BMP (basic

metabolic profile) every three

months...

Blood sugar checks one time weekly.

Assess for signs/symptoms of

hypo/hyperglycemia (low or high

blood sugars) if blood sugar was less





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730 SCHOOL ST

was than 70 or greater than 200.

A care plan was initiated on 1/13/12

for the resident being a nutritional risk

related to but not limited to diabetes.

The October 2012 Physician

Recapitulation Orders indicated the

following orders was initiated on

1/19/12:

Blood sugar 70 or less give 4 oz

(ounces) of juice and repeat blood

sugar in 15 minutes.

Blood sugar check prn (as needed)

for signs/symptoms of

hypo/hyperglycemia.

Blood sugars less than 50 or greater

than 400, notify the physician.

Blood sugar recheck within 2 hours if

greater than 200 and resident was

symptomatic.

The October 2012 physician orders

indicated the following on 4/25/12:

Onglyza (oral hypoglycemic) 5 mg

(milligrams) 1 tab by mouth daily.


indicated the following:

Daily accu check (blood sugar check)

at 6:00 A.M. for 7 days.

Lantus 10 units at bedtime at 8:00

P.M. subcutaneously every three

days.

If accu check not below 120, increase





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Lantus at bedtime by 2 units. The

goal for blood sugars was 120-140 at

6:00 A.M. Call physician for blood

sugars less than 70 or greater than

200.


indicated to increase the bedtime

Lantus to 12 units subcutaneously.


indicated to increase the bedtime

Lantus to 14 units subcutaneously.


indicated the following:

Decrease Lantus (long acting insulin)

to 12 units at bedtime

subcutaneously.

Continue weekly accu checks (blood

sugar checks) at 6:00 A.M.

May do prn accu checks if the

resident has signs/symptoms of

hypo/hyperglycemia .

An interview on 11/2/12 at 12:35

P.M., with the Education/Infection

Control Coordinator, indicated care

plans could be initiated at anytime

with any staff nurse.

There was no care plan developed for

diabetes.

3.1-35(a)





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F0280

SS=E

483.20(d)(3), 483.10(k)(2)

RIGHT TO PARTICIPATE PLANNING

CARE-REVISE CP

The resident has the right, unless adjudged

incompetent or otherwise found to be

incapacitated under the laws of the State, to

participate in planning care and treatment or

changes in care and treatment.

A comprehensive care plan must be

developed within 7 days after the completion

of the comprehensive assessment; prepared

by an interdisciplinary team, that includes

the attending physician, a registered nurse

with responsibility for the resident, and other

appropriate staff in disciplines as determined

by the resident's needs, and, to the extent

practicable, the participation of the resident,

the resident's family or the resident's legal

representative; and periodically reviewed

and revised by a team of qualified persons

after each assessment.

F-280 Residents’ #’s

1-5-18-23-61 have had individual

care plans reviewed for accuracy,

corrections made and are

updated to reflect current status.

All residents within the facility

have the potential to be affected b

this finding. Therefore all

residents in house will have a

complete review of current care

plans completed by 12-5-12. To

ensure this finding does not recur,

any orders received on a daily

basis are updated to the care

plan by the receiving nurse at

time of order and reviewed by the

MDS coordinator on a daily basis

for compliance. All facility

personnel who have

documentation privileges into the

12/05/2012 12:00:00AMF0280

Based on record review and

interview, the facility failed to revise or

update care plans related to

medications for 5 of 24 residents

reviewed for care plans. (Residents

#1, #5, #18, #23, and #61)

Findings include:

1. Resident #1's record was reviewed

on 11/01/12 at 2:51 p.m. The


were not limited to, seizures and

dementia.

A microbiology culture screen, dated





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PCC/EMR may update the care

plan with significant changes and

have been re-inserviced on

11-20-12 of this policy and

procedure. Monitoring for the

effectiveness of this system is

done via the QA program utilizing

attached audit tools on a monthly

basis. Any findings are corrected

at time of discovery. Daily review

of the 24 hour-Condition report is

done daily by the DON/ADON or

designated nurse supervisor to

ensure that care plans are

updated on a daily basis.

(Attachments) Completion date

12-5-12

F280

All staff including Department

Heads received inservice training

on 11/20/2012 identifying policy

and procedure for updating care

plans daily to reflect any changes

in resident needs. All residents

care plans have been reviewed

and updated to reflect current

orders on GDR. All new orders

are being monitored by the MDS

Coordinator for compliance. The

DON completes daily audits using

the 24 hour condition report to

ensure care plan are updated

daily and a monthly review of all

Psychoactive medication needs is

done via the QA program review

audit tools. Findings are reported

to the QA committee on a

monthly basis


Vancomycin Resistant Enterococcus

(VRE) of the rectum.

A physician's order, dated 07/27/12,

indicated an order for Bactrim DS

(antibiotic) for seven days for a

urinary tract infection.

A care plan, reviewed in the computer

as current on 11/01/12, indicated the

resident had isolated VRE of the

rectum. The interventions indicated

to administer the antibiotic as

ordered.


3:11 p.m., the Infection Control Nurse

indicated the resident is no longer on

an antibiotic and has not been for a

long time. She indicated the

resident's physician did not want any

further treatment for the VRE.


reviewed on 10/31/12 at 3:00 P.M.

Resident's #5 diagnoses included, but





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were not limited to congestive heart

failure, bipolar disorder, anxiety

disorder, and depressive disorder.

A Psych NP (Nurse Practitioner) visit

note, dated 5/15/12, indicated the

resident was receiving Lexapro

(antidepressant) 20 mg (milligrams),

Ativan (antianxiety) 0.25 mg daily and

Seroquel (antipsychotic) 12.5 mg

daily.

A Psych NP visit note, dated 8/1/12,

indicated the resident was receiving

Lexapro 20 mg daily.

A care plan was initiated on 8/6/12 for

depression. The interventions

included but were not limited to, give

psych medications as ordered,

monitor medication side effects at

least daily on the medication record,

and notify the physician as needed.

Progress note, dated 9/8/12 at 10:37

A.M., indicated a new order for Ativan

0.25 mg once daily for increased

agitation.

A physician order, dated 9/8/12 at 12

P.M., indicated to restart Ativan 0.25

mg once a day prn for anxiety.

A care plan revised on 9/10/12 for prn

anxiolytic (antianxiety medication)





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


CULVER, IN 46511

155589

00

11/05/2012


730 SCHOOL ST

indicated the resident was taking prn

anxiolytic for restlessness. The

interventions included, administer

medication as ordered, monitor for

side effects, notify physician as

needed, address physical needs,

change environment, and redirect

thoughts.

An interview with the Social Service

Assistant on 11/2/12 at 11:00 A.M.,

indicated there was no meeting or

conference between the Pharmacy

Consultant, the Psych NP (Nurse

Practitioner) or facility staff regarding

gradual dose reductions.

On 11/5/12 at 10:50 A.M., an

interview with Medical Records and

the Education/Infection Control

Coordinator, indicated anyone could

initiate or update a careplan when

needed.

The care plan was not revised for

interventions of when gradual dose

reductions would be attempted

(unless it was contraindicated) and

the care plan did not indicate if the

physician or psych services would be

managing the psychotropic

medications.







12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


CULVER, IN 46511

155589

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11/05/2012


730 SCHOOL ST

Resident #23's diagnoses included,

but were not limited to, depressive

disorder, general anxiety disorder and

cerebral artery occlusion.


October 2012 physician orders

indicated the resident had been

receiving Zoloft 100 mg daily since

July 2, 2009.


for depression. The interventions

included, but were not limited to, give

psychotropic medications as ordered,

monitor medication side effects at

least daily on a psychotropic

medication record, and notify the

physician as needed.


Assistant, on 11/2/12 at 11:00 A.M.,



Consultant, the Psych NP (Nurse

Practitioner) or facility staff regarding


On 11/5/12 at 10:50 A.M., an





needed.





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



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(X5)

COMPLETION


CULVER, IN 46511

155589

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730 SCHOOL ST








medications.








Review of the physician orders

indicated the resident received the

following:

Clozepam (antianxiety) 0.25 mg three

times daily. This order began

1/11/12.

Prozac (antidepressant) 30 mg daily.

This order began on 1/11/12.

Risperdal (antipsychotic) 0.25 mg

twice a day. This order began on

3/20/12.

Ativan (antianxiety) 0.5 mg three

times a day as needed. This order

began on 3/27/12.

Review of the MAR for September

and October 2012 indicated the

resident was taking all the listed





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG




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TAG



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(X5)

COMPLETION


CULVER, IN 46511

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730 SCHOOL ST

medications in the dosages as

originally ordered.


related to depression. The

interventions included: Give psych

medications as ordered, monitor

medications side effects at least daily

on the psychotropic medication

record, notify physician prn, discuss

feeling about placement with resident,

encourage loved ones to keep in

contact/visit, encourage the resident

to attend activities and praise all

efforts, provide support and

encourage prn, listen attentively and

follow up on issues prn, assist

resident in expressing positive

thoughts and memories of her life,

encourage beauty shop visits.


and was revised on 8/29/12 related to

prn anxiolytic for nervousness. The

interventions included: resident

chooses to rearrange her belongings

in her room often, while she is looking

for items, administer medications prn,

monitor for side effects of anxiolytic

medications, notify physician prn,

address physical needs, change

environment, redirect thoughts, Social

Service to visit PRN providing

support.





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG




PREFIX

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(X5)

COMPLETION


CULVER, IN 46511

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11/05/2012


730 SCHOOL ST


and was revised on 9/17/12 related to

behaviors (moods and delusions).

The interventions included:

document mood behavior

(nervousness), administer psych

medications PRN, monitor

medications side effects at least daily,

notify physician PRN, listen to

concerns and follow up on these

promptly PRN, provide support and

encourage PRN, provide education

and support to family PRN.

Documentation on the

"Behavior/Psychotropic Medication

Quarterly," dated 8/22/12, indicated

that a tapering of the clozepam had

been attempted beginning 7/30/12,

but was unsuccessful.

Interview with the Social Service




Consultant, the Psych NP or the

facility staff regarding gradual dose

reductions.

On 11/5/12 at 10:50 A.M., an





needed.





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


CULVER, IN 46511

155589

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730 SCHOOL ST








medications.




but were not limited to dementia,

depressive disorder, Alzheimer

diseases and generalized anxiety

disorder.

Review of physician orders indicated

the resident received the following:

Geodon (antipsychotic) 20mg daily.

This order began 8/3/2011.

Citalopram (antidepressant) 10mg

daily. This order began 8/3/2011.


and October indicated the resident

was taking all the listed medications

in the dosages as originally ordered.

A Care plan for behaviors

(inappropriate physical behavioral

issues ex. hitting staff) was revised on

8/29/12. The interventions included:

administer psych medications as





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


CULVER, IN 46511

155589

00

11/05/2012


730 SCHOOL ST

ordered, monitor medication side

effects at least daily on the

psychotropic administration record,

notify physician as needed, provide

diversional activities, provide

education and support to family PRN

(as needed), psychiatrist/psychologist

to follow the resident PRN, Social

Service to visit as PRN, and

document physical behavior.

A Care plan for PRN anxiolytic

(restlessness, dx anxiety) was revised

on 8/29/12, The interventions

included: administer medications as

ordered, monitor for side effects,

notify physician PRN, address

physical needs, change environment,

redirect thoughts, psych services to

follow PRN.

A Care plan for behavior (displays

mood issues as exhibited by

restlessness dx anxiety) was revised

on 8/29/12. The interventions

included: administer psych

medications PRN, monitor

medications side effects at least daily

on psychotropic medication record,

notify physician PRN, listen to

concerns and follow up on these

promptly PRN, provide support and

encourage PRN, psych services to

follow resident PRN, and document

mood behavior.





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


CULVER, IN 46511

155589

00

11/05/2012


730 SCHOOL ST

A Care plan for depression was

revised on 8/29/12. The interventions

included: encourage loved ones to

keep in contact/visit, encourage

resident to attend activities and praise

all efforts, provide support and

encourage PRN, Social Service to

visit PRN, listen attentively and follow

up on issues PRN.



indicated the resident had went out

last year to a psych hospital and

came back with an order for Geodon.

She indicated there was no meeting

or conference between the Pharmacy



reductions.

On 11/5/12 at 10:50 A.M., an





needed.











12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG




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COMPLETION


CULVER, IN 46511

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730 SCHOOL ST


medications.

3.1-35(d)(2)(B)





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG




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DEFICIENCY)

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CULVER, IN 46511

155589

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730 SCHOOL ST

F0282

SS=D

483.20(k)(3)(ii)

SERVICES BY QUALIFIED PERSONS/PER

CARE PLAN

The services provided or arranged by the

facility must be provided by qualified

persons in accordance with each resident's

written plan of care.

F-282 It is the policy of this

facility that resident care plans

are updated with changes in

condition, quarterly, annually and

with significant change in order to

reflect the current resident

condition. The care plan for

resident # 50 was updated on

11-19-12 to reflect the current

intervention to help reduce skin

tear development. Resident # 1

no longer requires daily

documentation for isolation

needs, isolation has been

discontinued. All residents

residing in the facility have the

potential to be affected by this

finding. To ensure this does not

recur, the facility has a system in

place that identifies care plan

development and review. The

system requires care plans be

revised as changes in the

resident condition dictates. The

system ensures that care plans

are reviewed and revised as

changes occur daily, and a

complete review of care plans

and resident status is done at

least quarterly. All residents’ care

plans will be reviewed by 12-5-12

and then through the scheduled

care plan process. An inservice

for nursing staff was done on

11-7-12 to review the complete

12/05/2012 12:00:00AMF0282Based on observations, record

review, and interview, the facility

failed to follow physician's orders and

care plans related to geri sleeves

(skin protectors), padded arms of a

wheelchair, and daily documentation

for 2 of 24 residents reviewed for

following physician's orders and care

plans. (Residents #1 and #50)

Findings include:

1. Resident #1's record was reviewed

on 11/01/12 at 2:51 p.m. The


were not limited to, seizures and

dementia.

A microbiology culture screen, dated


Vancomycin Resistant Enterococcus

(VRE) of the rectum.

A care plan, reviewed in the computer

as current on 11/01/12, indicated the

resident had isolated VRE of the

rectum. The interventions indicated

to complete an assessment daily to

monitor symptoms.





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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CULVER, IN 46511

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730 SCHOOL ST

care plan process. Monitoring for

accuracy of care plans and

compliance with regulations will

be done quarterly by the MDS

Coordinator through the facility

QA program. (Attachments)


F282

1. All residents care plans

have been reviewed and all care

plans identified were updated to

reflect any changes. An In service

was held with all staff on the

importance of updating care

plans with any changes, including

resolving prior interventions and

making sure our staff was

following the plan of care for each

resident.

2. Individual resident care

plans are being revised daily as

changes occur and monitored

daily by reviewing new orders,

this review is done by the

DON/ADON/MDS coordinator

using the 24 hour condition report

review. On a monthly basis, the

In-service Director, MDS

Coordinator, S.S., Nursing

Supervisor and DON and monitor

for care plan accuracy using the

facility QA program audit tool.

The resident's assessment indicate a

daily assessment had not been

completed on July 24, 25, and 26,

2012; August 7, 8, 9, 10,11,12, 22,

23,24, 25, 26, 28, 29, and 30, 2012;

September 7, 8, 9, 10, 11, 12, 13, 14,

15, 16, 17, 18, 19, 29, and 30, 2012,

and October 18, 19, 20, 21, 22, 24,

25, 26, 27, 28, 29, 30, and 31, 2012.


3:11 p.m., the Infection Control Nurse

indicated the assessments were not

getting done daily.

2. During an observation on 11/01/12

at 8:30 a.m., Resident #50 had no

geri-sleeves on. He had short

sleeves on and he was sitting in his

wheelchair and the wheelchair's arms

were not padded.

During an observation on 11/01/12 at

4 p.m., the resident was sitting in his

wheelchair, had short sleeves on, and

the wheelchair's arms were not

padded and the resident did not have

on geri-sleeves.


4:21 p.m., CNA #4 indicated the

resident had no geri sleeves on. She

stated, "They must not have put them

on him today." She indicated the





12/12/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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CULVER, IN 46511

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arms of the wheelchair was not

padded.


8:10 a.m., the resident was sitting in

his recliner, had long sleeves on and

did not have geri-sleeves on.

During an interview at the time of the

observation, CNA #3 indicated the

resident did not have geri-sleeves on.

She indicated the geri-sleeves were

supposed to be on the resident.

Resident #50's record was reviewed

on 11/02/12 at 9 a.m. The resident's

diagnoses included, but were not

limited to, congestive heart failure and

dementia.

A care plan, dated 8/31/12, indicated

the resident will pick at his skin and

cause skin tears. The interventions

included, 6/26/12-encourage to

comply with preventative methods to

prevent skin tears; geri-sleeves, and

8/6/12-pad arms of wheelchair with

towels and wash clothes,

8/24/12-geri-sleeves apply daily after

bathing. The care plan had been

revised on 11/02/12 and an

intervention of long sleeves was

added.

The CNA assignment guide, received





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OMB NO. 0938-0391




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CULVER, IN 46511

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as current from the Infection Control

Nurse on 11/01/12 at 11 a.m.,

indicated, equipment-geri sleeves.

3.1-35(g)(2)





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OMB NO. 0938-0391




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F0323

SS=E

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-323 It is the intent of this

facility to safeguard all residents

from hazards or accidents.

Resident #65 did receive a skin

tear due to the nursing assistant

error on the assignment sheet.

All residents in the facility have

the potential to be affected by this


recur, and inservice was given on

11-20-12 regarding the

importance of adherence to care

plan interventions updated to the

Nursing assistant assignment

sheets. Weekly updates of the

assignment sheets will be done

by the DON/ADON/IED with any

changes reflective on the care

plan and with significant change.

Monitoring of effectiveness of the

system will be done weekly via

the nursing assistant assignment

sheet review for 30 days and then

monthly per the facility QA

program for the next 90 days and

then as indicted per QA program

but no less than quarterly.

(Attachments) When report of

water temperatures in resident

and common areas exceeded

120 degrees on 11-29-12, all staff

was alerted and the water within

the resident rooms and affected

common areas was shut off. No

12/05/2012 12:00:00AMF0323

A. Based on observation, record


failed to ensure a resident was free

from an accident related to not

padding a mechanical lift pad when it

was on the resident and not having

two assistance to help with bed

mobility,which caused a skin tear on a

resident. (Resident #65)

B. Based on observation, record


failed to insure residents were free

from potential hazards related to

water temperatures over 120 degrees

in 5 of 7 rooms checked for high

water temperatures (Rooms 304, 305,

308, 407, and 408), unlocked closet

which stored chemicals, which had

the potential to effect 4 of 20

residents who were identified by the

Director of Nursing as confused and

independent with mobility, who reside

on the Serenity Unit, and medication

being left unattended on top of a

medication cart on the Victory Unit.

(LPN #5)





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OMB NO. 0938-0391




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residents were harmed or injured

as a result of water temperature

issues. An investigation of the

cause of the water temperature

problem was completed and a

commercial plumbing contractor

was brought in for service.

During the time of repair the

facility staff received inservice

training on taking water

temperatures in the resident

rooms. This training included

proper calibration of

thermometers for accuracy of

temperatures. The water

remained off during the repair

time; water was delivered to the

resident rooms and common

areas that were at correct

temperature levels to provide

care and services. Logs of water

temperatures were maintained

throughout this time. At the time

it was determined that water

temperatures had stabilized for

more than an 8 hour period and

no fluctuations in temperatures

were noted, the system was

returned to normal status. At this

time, the system is working

properly and water temperatures

are being checked per facility

policy and procedure. Monitoring

of the facility water temperatures

will be done daily by the

Maintenance Supervisor per the

PM review on 10% of the resident

rooms or common areas over the

next 30 days and then per

scheduled PM program.

(Attachment) The door locking

mechanism on the soiled linen

Findings include:

A1) During an observation on

10/29/12 at 11:44 a.m., Resident #65

was sitting up in the wheelchair.

Bruising of the bilateral upper arms

was observed and the resident had

geri-sleeves (skin protectors) on both

arms.


observation, CNA's #6 and #7

indicated the resident bruises easily

and has very thin skin. They

indicated the bruising may be from

the mechanical lift pad, so they have

been instructed to use a blanket for

padding between the resident and the

mechanical lift pad.


8:45 a.m., CNA #3 indicated a blanket

was to be used between the resident

and the mechanical lift pad due to the

resident easily bruising and getting

skin tears.


8:35 a.m., CNA #8 entered Resident

#65's room and closed the door.

Resident #65 was heard yelling in her

room from the hallway. At 8:37 a.m.,

CNA #8 was observed to be applying

a clean incontinence brief to the





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closet has been repaired and is

functioning properly. All other

locking doors have been

inspected, no other issues have

been found. No residents

suffered any negative effects

from the finding. All other

mechanical door locking systems

of the same type as the defective

lock will be replaced by the

maintenance staff to ensure

compliance. This should be

completed by 1-5-12. Currently all

mechanical door locks are

operating correctly. All staff will

be reminded to notify

Maintenance services if a lock is

not working properly at the

inservice held 11-20-12.

Monitoring for effectiveness of the

system will be done by the

Maintenance Department per the

QA program schedule utilizing the

PM Audit tool no less than

monthly. (Attachment) None of

the residents residing in the

facility area where supplies were

left on top of the medication cart.

The staff member involved in this

finding has received disciplinary

action. To ensure this finding

does not recur, an inservice was

held on 11-7-12 to review the

policy and procedure for

medication administration and

proper storage of chemicals. The

DON/or designee will perform

weekly medication pass audits on

random nurses for the next 3

months then quarterly thereafter

and any disciplinary action or

corrections need will be done at

resident and turned the resident from

side to side in the bed. CNA #8 then

began to dress the resident in a clean

pair of pants. A mechanical lift pad

was underneath the resident on her

bed and there was no padding

between the resident and the

mechanical lift pad. CNA #8 was

providing care without assistance

from another staff member.

CNA #8 then turned the resident and

noticed blood from the resident's right

upper arm, and left the room to inform

the nurse of the injury.

RN #9 entered the resident's room at

8:42 a.m., and indicated the resident

had a "L" shape skin tear over the

bruise on the right upper arm. She

indicated the skin tear was three

centimeters long and 2 centimeters

long. RN #9 cleansed the area and

applied steri-strips.


8:50 a.m., CNA #8 indicated she had

not noticed the skin tear when she

first went in to care for the resident.

She indicated the resident had really,

"thin skin."


9:37 a.m., CNA #10 indicated she

assisted with transferring Resident





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that time. (Attachment) Any

findings will be reviewed monthly

through the QA program for

monitoring. Completion date for

all 12-5-12

F323

1. All residents care plans

have been reviewed and CNA

assignment sheets have been

updated. All assignment sheets

correlate with residents current

needs identified on the care plan

as relating to direct care needs

performed by CNA’s.

2. An in service was held on

11-20-12 on the importance of

following each resident’s plan of

care to prevent any accident from

occurring. All staff was made

aware that disciplinary action will

occur for not following the plan of

care at any time. The CNA did

receive disciplinary action for not

following the resident’s plan of

care. Weekly updates are being

done on the assignment sheets to

reflect significant changes and

will be monitor monthly per our

facility QA program.

#65 from the wheelchair to the bed

with the mechanical lift. She

indicated the resident had no skin

tear after the transfer was completed.

She indicated the resident sometimes

resists being turned when she is in

bed and the resident yells out with

care no matter how many staff are

assisting her.

Resident #65's record was reviewed

on 11/02/12 at 11:06 a.m. The


were not limited to, dementia and

anxiety.

The Annual Minimum Data Set (MDS)

Assessment, dated 09/12/12,

indicated the resident required

extensive total assistance of two or

more staff for bed mobility and had

skin tears.

The CNA care sheet, received as

current from the Infection Control

Nurse on 11/01/12 at 11 a.m.,

indicated to use geri-sleeves and

padding around the resident arms

when in the Hoyer (mechanical lift)

pad and to use two assistance for

transfers and mobility.

A care plan, revised on 09/13/12,

indicated the resident required total

assistance with activities of daily





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living. The interventions included,

one to two assistance for

bathing/dressing/grooming.

A care plan, revised on 07/06/11,

indicated the resident had a potential

for skin tears. The interventions

included, take extra care with

transfers, use palms of hands or arms

to support.

During an interview on 11/02/12 at 8

a.m., the Director of Nursing (DoN)

indicated the CNA should have used

a blanket between the resident and

the mechanical lift pad to help prevent

the skin tear due to the roughness of

the pad.

B1) During an observation on

10/29/12 at 2:40 p.m., the hot water in

Room #309 was hot to touch. The

Maintenance Director obtained the

water temperature with his

thermometer at 110 degrees.

During an observation of the water

temperatures on 10/29/12 at 3:30

p.m., with the Maintenance Director

present the following was observed:

Room# 308's bathroom faucet had a

hot water temperature of 125.4

degrees with the Surveyor's

thermometer and 122.7 with the





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


CULVER, IN 46511

155589

00

11/05/2012


730 SCHOOL ST

Maintenance Director's thermometer.

Room #305's bathroom faucet had a

hot water temperature of 130


thermometer and was 104 degrees

with the Maintenance Director's

thermometer.


observations, the Maintenance

Director indicated the water was,

"scalding". He indicated he will inform

the staff not to use the hot water until

the temperatures have been

regulated under 120 degrees. He

indicated the thermometer he was

using was a bought 6 months age.

He indicated he would call (plumbing

company). He indicated there had

been no complaints from the staff or

residents about the water being too

hot.

Room #304's bathroom faucet had a

hot water temperature of 122.7


thermometer (was not checked with

the Maintenance Director's

thermometer.

On 10/29/12 at 4:00 P.M., Room

#408's water temperature got up to

129.8 F with the Surveyor's

thermometer.





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


CULVER, IN 46511

155589

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11/05/2012


730 SCHOOL ST

On 10/29/12 at 4:05 P.M., Room

#407 water temperature got up to

122.9 F with the Surveyor's

thermometer.


observations, the Maintenance

Director indicated he checks random

water temperatures weekly and the

hot water has not been over 120

degrees. The Maintenance Director

provided a Preventative Maintenance

Log, which indicated the water

temperatures had been monitored

and were within the temperature

ranges of 100-120 degrees.


p.m., the Administrator indicated the

hot water had been turned off to all

the rooms. He indicated the

(plumbing company) was on their way

to the facility. He indicated there had

not been a spike in the water

temperatures before, and this was

something that just had to happen.

He indicated there had not been

burns to any of the residents. He

indicated the Maintenance Director

monitors the water temperatures for

Quality Assurance program. He

indicated he checks the water

temperatures monthly and calibrates

his thermometer every month, and





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




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TAG



DEFICIENCY)

(X5)

COMPLETION


CULVER, IN 46511

155589

00

11/05/2012


730 SCHOOL ST

the water temperatures have been

within range.


5:30 p.m., the Administrator indicated

the company was at the facility to

repair the hot water heater.


6:50 a.m., the Administrator indicated

the high hot water temperatures was

due to a mixing valve and the mixing

valve had been replaced.



they were checking the hot water

temperatures every half hour and the

temperatures were running 110

degrees.



the water temperatures were all in

range and the hot water was now

turned back on. He indicated the

staff have been inserviced on

checking hot water temperatures prior

to using the water for the residents

and the facility will continue to check

the water temperatures.

A Water Temperature Checks form,

provided by the Administrator on

11/01/12, indicated 15 rooms had





12/12/2012PRINTED:

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OMB NO. 0938-0391




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CULVER, IN 46511

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730 SCHOOL ST

been checked for hot water

temperatures, the temperatures

ranged from 100-112.9.

An undated, facility policy received

from the Administrator on 10/31/12 at

9:20 a.m. as current, indicated,

"...Acceptable temperature range is

100 degrees to 120 degrees..."

B2) During the initial tour on 10/29/12

at 8:45 a.m., the "Linen" closet on the

Serenity Unit was unlocked and there

were cleaning supplies stored in the

closet.


2:05 p.m.- Serenity hall "linen closet"

door was unlocked. The following

chemicals were stored in the closet:

Organic Carpet Cleaner

Neutral Floor Cleaner

Quat (disinfectant)

Tannit Stain Remover

Glass Cleaner

There were nine residents sitting in

the lounge outside of the closet,

watching a church service on the TV.


8:20 a.m., the "linen closet" on the

Serenity Unit was unlocked. There

were no residents in the area of the

closet.





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OMB NO. 0938-0391




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CULVER, IN 46511

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11/05/2012


730 SCHOOL ST


8:21 a.m., CNA #8 indicated

someone must not have closed the

door all the way.


8:30 a.m. , the Housekeeping

Supervisor indicated there were

confused residents on the Serenity

Unit. She indicated the lock was

broken and was being replaced and

she would take the chemicals out of

the closet until the lock was fixed.

The Material Safety Data Sheets

(MSDS) provided by the

Housekeeping Supervisor on

11/02/12 at 9 a.m., indicated:

Tannit Stain Remover, "...keep away

from children, may cause severe skin

and eye irritation...do not induce

vomiting. Get immediate medical

attention...."

Neutral Floor Cleaner, "...may cause

eye irritation...Keep out of reach of

children..."

Organic Carpet Spotter,

"...ingestion-may cause discomfort,

nausea, vomiting, and irritation to

mouth..."





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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COMPLETION


CULVER, IN 46511

155589

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11/05/2012


730 SCHOOL ST

Quaternary Neutral Disinfectant

(Quat)- "...irritation of skin, eyes, or

respiratory system. May cause

corneal injury...Get medical

attention..."

Glass Cleaner- "...use in

well-ventilated area. In case of

accident...Call physician..."

B3) During an observation on

10/30/12 at 4:45 p.m., LPN #5

prepared Resident #6's insulin after

the glucometer result was obtained.

LPN #5 drew up the insulin in the

syringe, then indicated he needed to

go find another nurse to verify the

correct amount of insulin and walked

away from the medication cart and off

of the Victory Unit, leaving the vial of

insulin and the container of bleach

wipes on the top of the medication

cart. LPN #5 was away from the

medication cart for one and a half

minutes.

LPN #5 then entered the resident's

room to give the resident the insulin

injection, with his back to the

medication cart in the hall. The insulin

vial, bleach wipes, and the keys to the

medication cart were left on top of the

cart.

LPN #5 came out of the room and





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CULVER, IN 46511

155589

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11/05/2012


730 SCHOOL ST

back to the medication cart, and

placed the insulin vial and bleach

wipes inside of the medication cart.


4:58 p.m., LPN #5 indicated he

shouldn't have left the insulin on top

of the medication cart and he thought

the keys to cart were in his pocket.

3.1-19(r)(1)(2)

3.1-45(a)(1)

3.1-45(a)(2)





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OMB NO. 0938-0391




A. BUILDING

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(X4) ID

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CULVER, IN 46511

155589

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11/05/2012


730 SCHOOL ST

F0328

SS=D

483.25(k)

TREATMENT/CARE FOR SPECIAL NEEDS

The facility must ensure that residents

receive proper treatment and care for the

following special services:

Injections;

Parenteral and enteral fluids;

Colostomy, ureterostomy, or ileostomy care;

Tracheostomy care;

Tracheal suctioning;

Respiratory care;

Foot care; and

Prostheses.

F-328 It is the intent of the facility

that care will be administered per

physician orders for any resident

with special needs. Resident #34

suffered no adverse effects from

improper sizing of colostomy

water. New orders were received

and updated for this resident. All

residents with special needs



finding. To ensure that this does

not recur, an inservice was held

on 11-7-12 to detail colostomy

care and special care needs per

physician orders. Monitoring of

the effectiveness of this system,

the DON or nurse designee will

complete weekly audits on

colostomy care over the next 3

months and then monthly for the

next 90 days. The DON will

present findings and compliance

to the QA committee on a

monthly basis. (Attachment)


F328

1. This resident is the only

special needs for colostomy care



ensure the colostomy appliance

(wafer) was cut and applied as

directed for 1 of 1 resident reviewed

for ostomies. (Resident #34)

Findings included:

Resident #34's clinical record was



but were not limited to multiple

sclerosis, colostomy, abdominal

fistula, MRSA (Methicillin Resistant

Staphylococcus Aureus), and history

of necrotizing fasciitis (flesh eating

disease).

A physician order, on 5/17/12,

indicated "make sure colostomy bag

[sic] is cut no bigger than the area

being covered, on both colostomy

opening and fistula opening."





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OMB NO. 0938-0391




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in the facility. A clarification was

received by the physician on

applying the colostomy wafer, and

this resident is receiving care per

plan of care and physician order.

2. There were no other

residents identified as in need of

special care services related to

colostomy care, and to ensure

any special care needs were and

will continue to be identified, an in

service was held on 11-20-12

regarding the importance of

accuracy of MD’s orders with any

special needs for individual

residents. On a weekly basis, the

DON will be auditing performance

audits for any special needs

residents. Monitoring is being

done through weekly audits by

the DON on colostomy care for

the next 3 months, then monthly

times 90 days any on compliance

will be presented to the QA

committee.

A physician order, on 10/25/12 at

2:30 P.M., indicated "please cut

wafer to the size of stoma and

fistula-no skin around area open."

On 10/31/12 at 10:00 A.M., observed

approximately .25 inch in diameter of

exposed skin between the draining

fistula site and the wafer on the

drainage bag to Resident #34's left

quadrant of her abdomen. Interview

with LPN #1 at this time indicated the

night shift placed the wafer over the

fistula site.

On 11/1/12 at 9:15 A.M., observed

approximately .25 inch in diameter of

exposed skin between the draining

fistula site and the wafer on the

drainage bag to Resident #34's left

quadrant of her abdomen. Interview

with LPN #1, at this time, indicated

she had not looked at the site and

would change the appliance so it

would fit as ordered.

3.1-47(a)(3)





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(X5)

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CULVER, IN 46511

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730 SCHOOL ST

F0329

SS=E

483.25(l)

DRUG REGIMEN IS FREE FROM

UNNECESSARY DRUGS

Each resident's drug regimen must be free

from unnecessary drugs. An unnecessary

drug is any drug when used in excessive

dose (including duplicate therapy); or for

excessive duration; or without adequate

monitoring; or without adequate indications

for its use; or in the presence of adverse

consequences which indicate the dose

should be reduced or discontinued; or any

combinations of the reasons above.

Based on a comprehensive assessment of a

resident, the facility must ensure that

residents who have not used antipsychotic

drugs are not given these drugs unless

antipsychotic drug therapy is necessary to

treat a specific condition as diagnosed and

documented in the clinical record; and

residents who use antipsychotic drugs

receive gradual dose reductions, and

behavioral interventions, unless clinically

contraindicated, in an effort to discontinue

these drugs.

F-329 The Social Services

Designee has reviewed all

monthly medication reviews for

accuracy and completed updates

as necessary for residents’ #’s

18-23-45-61. These residents

suffered no negative issues

related to lack of completed

assessments. All residents in the

facility who receive antipsychotics

have the potential to be affected

by this deficient finding. To

ensure that this does not recur, all

residents receiving antipsychotic

and/or psychoactive medication

will have a drug regimen review



assess, monitor effectiveness, and

review residents for unnecessary

medications and failed to provide a

clear rationale for continuing a

medication for 4 of 10 residents

reviewed for gradual dose reduction.

(Residents #18, #23, #45, and #61).

Findings included:






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CULVER, IN 46511

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and MAR review completed by

12-5-12. Any identified needs or

changes will be addressed at this

time. On a monthly basis going

forward, all residents receiving

psychoactive medications will

receive a monthly review and will

have a completed QA audit

review by the Social Services

Designee. Findings will be

reviewed with the QA committee

monthly. Completion date

12-5-12

F329

1. All residents who have

antipsychotics and or

psychoactive medication have

been reviewed and updated to

reflect any changes per our

policy. S.S. will meet monthly with

the Pharmacy Consultant to

review all residents on

antipsychotics and/or

psychoactive medication for

GDR. All reviews were completed

by 12-05-12.

2. An inservice was given to the

Nursing staff outlining the policy

for GDR requirements.

Systematically any GDR’s will be

completed timely following the

Behavior Antipsychotic

Medication Monthly Review,

Pharmacy Consultant

recommendations, Psych Service

recommendation, these reviews

are done monthly. Quarterly

review of any Psychoactive

medications will be completed

using the Antipsychotic

Medication Review QA tool.

Findings are reported to the QA


Resident #23's diagnoses included,





resident's Zoloft (antidepressant) was

initiated on 3/3/2009 for 50mg daily

and was increased to 100 mg daily on

July 2, 2009.

Review of the October 2012 MAR

(Medication Assessment Record),


100 mg of Zoloft daily.

Review of the Pharmacist Consultant

Drug regimen review notes from

8/20/09 to 10/12/12 indicated no

gradual dose reduction had been

recommended since the increase in

July in 2009.

A physician note on 9/27/12 indicated

he will consider changing

antidepressants if symptoms does not

change...having more flat affect. Not

as energetic or perky "as usual."


Assistant on 11/2/12 at 11:00 A.M.

regarding the social service role with

gradual dose reductions had






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Committee monthly and

summarized quarterly.conference between the Pharmacy

Consultant, Psych NP (Nurse

Practitioner) or herself at the same

time. She indicated when one

discipline orders or makes

recommendations, she will notify the

appropriate person of order or

recommendation. She also indicated

she thought that a diagnosis was

sufficient for a resident to have a

psychotropic medication and no

gradual dose reduction.

There was no collaboration between

the physician, the Social Service

Assistant, and the Pharmacy

Consultant for gradual dose

reductions.










following:



1/11/12.







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3/20/12.



began on 3/27/12.





originally ordered.

Review of notes by the Psych NP,

dated 2/27/12, 5/15/12, 7/3/12,

indicated there was no significant

changes, but the resident continued

to have paranoid behaviors with

recommendations to continue the

medications as ordered. A note of

8/7/12 indicated the resident was

stable and the family had requested

the clozepam be increased to the

original amount after a decrease two

weeks prior.


indicated the clozepam had been

reduced to twice daily on 7/30/12 and

then increased back to the original

three times daily on 8/4/12.








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that a tapering of the clozepam had

been attempted beginning 7/30/12 but

was unsuccessful.


records from 1/18/12 to 10/12/12

indicated no recommendations for

gradual dose reductions for the

Prozac or the Risperdal.







reductions.







disorder.



Geodon (antipsychotic) 20mg daily.


Citalopram (antidepressant) 10mg








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Review of notes by the Psych NP,

dated 5/15/12, 7/2/12, and 8/7/12,

indicated there was no significant

changes and the resident was stable.

The recommendations were to

continue medications as ordered and

to continue redirection.

A physician visit note, dated 2/23/12,

indicated the resident had not been

having hallucinations and agitation or

acting out. The medications were

reviewed and felt the Geodon

(antipsychotic) could be decreased in

dosage but will defer to psych.

A nursing note, dated 4/4/12 at 11:30

A.M., indicated the Geodon 20mg

was changed back to 8:00 A.M. daily

from 8:00 P.M. daily due to increased

aggression and behaviors.

A nursing note, dated 4/6/12 at 7:17

P.M., indicated the resident has had

increased behaviors. A urinalysis

was taken and the result came back

abnormal. Bactrim was ordered for 7

days.

A Quarterly MDS from 4/11/12 to

4/18/12 did not indicate the resident

had any behaviors in the last 7 days.





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indicated the resident was barely

arousable and the nurses reported

this was not the resident's normal

state.


indicated the resident had difficulty

responding to the physician.


indicated the resident was very

lethargic and the physician could not

get the resident to answer any

questions, other than the resident felt

tired. The nurses indicated this was

not the resident's usual state.




there were no behaviors for the

month of September, 2012.

An Activity note, dated 9/28/12,

indicated the resident was usually

asleep and will awaken at times.

The October 2012 MAR's (Medication

Administration Report) indicated no

behaviors the entire month.

On 10/30/12 at 10:15 A.M., the

resident was observed sleeping and





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did not participate or awaken for

morning exercise.

On 10/31/12 at 10:00 A.M., the



morning exercise.

On 11/1/12 at 10:45 A.M., the



morning exercise. The resident was

observed to be difficult to arouse,

drooling and his shirt damp.

On 11/2/12 at 10:15 A.M., the



morning exercise.

The antipsychotic side effects was

being monitored in the MAR's. The

last week of October 2012 indicated

the resident had no side effects.

Sedation was an option and it was not

checked off.






Assistant on 11/2/12 at 11:00 A.M.






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reductions.



The resident's diagnoses included,

but were not limited to, restless leg

syndrome and chronic pain.

A physician's order, dated 11/22/10,

indicated an order for diazepam

(antianxiety) 2 mg (milligram)

intramuscular every four hours as

needed for muscle spasms.

The Medication Administration

Record, dated 10/12, indicated the

diazepam was given on October 3,

11, 12, and 13, 2012. There was no

time listed when the medications was

given, no assessment and no

documentation of the effectiveness of

the medication.


a.m., the Infection Control Nurse

indicated there was no documentation

on the as needed sheet for the

diazepam.

3.1-48(a)(6)





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CULVER, IN 46511

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F0428

SS=D

483.60(c)

DRUG REGIMEN REVIEW, REPORT

IRREGULAR, ACT ON

The drug regimen of each resident must be

reviewed at least once a month by a

licensed pharmacist.

The pharmacist must report any

irregularities to the attending physician, and

the director of nursing, and these reports

must be acted upon.


facility that each resident’s drug

regimen is reviewed by a licensed

pharmacist or a monthly basis.

The drug regimen for residents’

#’s 18-23-61 were reviewed by

the licensed pharmacy consultant

on Recommendations were made

and neither resident suffered any

negative effects. All residents




recur, the pharmacy consultant

reviews each resident’s drug

regimen on a monthly basis. Any

recommendations made are

given to the DON who then

contacts the attending physician

for follow up. The attending

physician will approve or decline

recommendations, sign the

recommendation form, submit

rationale for decline if applicable.

Orders will then be updated as

necessary. Time frame for

completion of this process is 7-10

days. Monitoring of the monthly

drug regimen review is done

monthly via the QA program audit

toll and review of the resident

12/05/2012 12:00:00AMF0428Based on interview and record

review, the facility failed to ensure the

Pharmacy Consultant reviewed and

recommended residents for gradual

dose reductions for 3 of 10 residents

reviewed for gradual dose reduction.

(Residents #18, #23, and #61).

Findings included:








resident's Zoloft (antidepressant) was

initiated on 3/3/2009 for 50mg daily

and was increased to 100 mg daily in

July 2, 2009.

Review of the October 2012 MAR

(Medication Assessment Record),






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CULVER, IN 46511

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audit listing. This monitoring id

done by the DON/ADON.


F428

1. All residents who receive

antipsychotics and or

psychoactive medication have

been reviewed and dose

reductions were done as

appropriate. The Pharmacy

Consultant and Social Service

Director will be meeting on a

monthly basis to review pertinent

information for residents receiving

antipsychotics and/or

psychoactive medication, for

GDR needs per our policy.

2. Systematically using the

Behavior/Antipsychotic

Medication Monthly Review per

the QA program, and Consultant

pharmacist recommendations as

well as Psych. service

recommendations, all residents

who are receiving psychoactive

medications will be reviewed. Any

needs identified for GDR

attempts will be made at that

time, submitted to the attending

physician, and updated as per

orders. This review will be

initiated by Social Services, and

Nursing Services/DON/ADON.

On a quarterly basis updates of

and GDR’s for any psychoactive

medications will be presented to

the QA committee.

100 mg of Zoloft daily.


Drug regimen review notes from

8/20/09 to 10/12/12 indicated no

gradual dose reduction had been

recommended since the increase in

July in 2009.



regarding the social service role with

gradual dose reductions, indicated

there was no meeting or conference

between the Pharmacy Consultant,

Psych NP (Nurse Practitioner) or

herself at the same time.

There was no recommendation for

gradual dose reductions by the

Pharmacy Consultant.










following:







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OMB NO. 0938-0391




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CULVER, IN 46511

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1/11/12.





3/20/12.



began on 3/27/12.





originally ordered.




gradual dose reductions for the

Prozac or the Risperdal.







reductions.









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disorder.



Geodon (antipsychotic) 20 mg daily.


Citalopram (antidepressant) 10 mg



















reductions.





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A policy provided by Medical

Records, on 11/2/12 at 12:30 P.M.,

titled, "Psychotropic Drug Use Policy,"

dated 6/1/11, indicated "...Gradual

Dose Reduction (GDR) will be

attempted, unless clinically

contraindicated, in an effort to

discontinue these

drugs...Antipsychotics, GDR are

within the first year after admission or

after initiation: twice in two separate

quarters with at least one month

between attempts..." Antidepressants

and anxiolytics have the same

recommendations for GDR's.

3.1-25(i)





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CULVER, IN 46511

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F0431

SS=D

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

DRUG RECORDS, LABEL/STORE DRUGS

& BIOLOGICALS

The facility must employ or obtain the

services of a licensed pharmacist who

establishes a system of records of receipt

and disposition of all controlled drugs in

sufficient detail to enable an accurate

reconciliation; and determines that drug

records are in order and that an account of

all controlled drugs is maintained and

periodically reconciled.

Drugs and biologicals used in the facility

must be labeled in accordance with currently

accepted professional principles, and

include the appropriate accessory and

cautionary instructions, and the expiration

date when applicable.

In accordance with State and Federal laws,

the facility must store all drugs and

biologicals in locked compartments under

proper temperature controls, and permit only

authorized personnel to have access to the

keys.

The facility must provide separately locked,

permanently affixed compartments for

storage of controlled drugs listed in

Schedule II of the Comprehensive Drug

Abuse Prevention and Control Act of 1976

and other drugs subject to abuse, except

when the facility uses single unit package

drug distribution systems in which the

quantity stored is minimal and a missing

dose can be readily detected.

F-431 It is the policy of this

facility to destroy expired

medications and treatment

supplies and to date medication

vials when opened and disposed

12/05/2012 12:00:00AMF0431Based on observation, interview, and


ensure 1 of 1 vial of opened

Tuberculin testing antigen was





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of time when expired. The

Medication room, treatment carts,

and treatment supplies were

audited by the night shift nurses

and all expired medications and

supplies were disposed of. No

resident were negatively affected

by this finding. To ensure this

does not recur, the IED (Inservice

Education Director (will audit all

medication and treatment

supplies and mediation rooms

weekly for 6 weeks and then

monthly per the QA program. All

discrepancies and/or disposal will

be completed with this audit.

Monitoring will continue on a

monthly basis and reported to the

QA committee monthly for review.

(Attachment) Completion date

12-5-12

F431

1. An in service was held on

11-20-12 on the facility and

pharmacy policy and procedures

regarding medication labeling,

medication dating, disposal of

expired medications, medication

storage amongst other issues.

The medication room, treatment

cart, and med cart were all

audited; any expired meds or

treatment materials were

disposed of.

2. The in service director will

continue to audit all medication

and treatment carts and med

room weekly for 6 weeks then

monthly per the QA tool.

Threshold for compliance is

100%. All discrepancies and /or

disposal will be completed with

labeled with the date opened. In

addition, the facility failed to ensure

medical/nursing equipment was

discarded when expired from 1 of 1

medication rooms.

Findings included:

On 11/5/12 at 9:30 A.M., one vial of

Tuberculin Purified Protein Derivative,

Diluted Aplisol, was observed opened

with no label indicating when opened

in 1 of 2 refrigerators in the

medication room.

During observation of medication

room, two opened and partially used

calcium alginate was observed in two

separate opened packages, three

cleansing enema bags which expired

2009, five 20 French Y Port feeding

adapters and clamps which expired

06/2011, and one gastrostomy tube

which expired 12/2000.

Interview with the ADON during this

time, acknowledged the undated vial

and expired supplies.

Review of information retrieved from

the CDC (Center for Disease Control)

regarding Mantoux (Tuberculin

serum) indicated: "The label should

indicate the expiration date. If it's

been open more than 30 days or the





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this audit.expiration date has passed, the vial

should be thrown away and a new vial

used. When you open a new vial,

write the date and your initials on the

label to indicate when the vial was

opened and who opened it. "

(webwww.cdc.gov/tb/education/mant

oux/part1.htm)

3.1-25(j)





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F0441

SS=D

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

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.

F-441

It is the intent of this facility

12/05/2012 12:00:00AMF0441

Based on observation, record review,





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to follow infection control police and

procedures. Residents’ #’s 25-6-34

suffered no negative consequences

as a result of this finding.

All resident in the facility

have the potential to be affected by

this finding.

To ensure this does not

recur and inservice was held on

11-7-12 outlining proper glove use,

dressing changes, and treatments

among other procedural rules. Both

staff members involved in these

findings was disciplined per facility

policy.

The DON or designee will

complete weekly monitoring of

medication passes with random

nurse for the next 3 months, then

monthly x’s 3 months, then

quarterly. The DON will present any

compliance issues regarding

improper procedure steps to the QA

committee for review and/or

recommendations including

disciplinary action. (Attachment)


and interview, the facility failed to

provide a safe and sanitary

environment related to handwashing

and glove use with 1 of 1 glucometer

(blood sugar) check and 1 of 2 eye

drop instillation observations, and 1 of

1 dressing change observations, and

failed to ensure the dressing change

was completed to prevent the

potential for cross contamination of

the pressure areas, related to

cleansing the wounds. ( LPN #1, LPN

#2 and LPN #5 and Residents #6,

#25, and #34)

Findings include:


at 3:46 p.m., LPN #2 prepared

Resident #25's medication, which

included artificial tears eye drops.

LPN #2 washed her hands and

administered the eye drops to the

resident. LPN #2 did not have gloves

on while she administered the eye

drops.

A facility policy, dated 12/03/08, titled,

"Eye Drops and Eye Ointment

Procedure," received from the

Director of Nursing (DoN) as current,

indicated "...16. Perform hand

hygiene and put on gloves..."





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at 4:45 p.m., LPN #5 was completing

a glucometer check on Resident #6.

LPN #5 did not have gloves on while

completing the check, which included

placing blood on a test strip.

LPN #5 then brought the glucometer

out to the medication cart, put gloves

on and cleaned the glucometer with a

bleach towelette. LPN #5 then

removed the gloves. LPN #5 then

returned to the resident's room

obtained a pair of gloves and returned

to the medication cart. LPN #5 then

drew up the resident's insulin into the

syringe, took off the gloves, left the

unit to have the insulin double

checked by another nurse, returned

the resident's room applied gloves

and administered the insulin to the

resident and removed the gloves.

LPN #5 then returned to the

medication cart. LPN #5 then placed

the insulin and bleach towelettes in

the medication cart, and took the

medication cart back to the Nurses'

Station.

When LPN #5 got to the Nurses'

Station, LPN #5 then used alcohol gel

on his hands. LPN #5 did not wash

his hands through out the entire

procedure.





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4:58 p.m., LPN #5 indicated he

should have worn gloves with the

glucometer test. LPN #5 indicated he

did not think he washed his hands

after the glucometer check and after

he gave the resident the insulin.


"Use of Medical Gloves (application

and removal)", received from the DoN

as current, indicated, "...Gloves

should be used for hand

contaminating activities...when

touching blood...secretions...mucous

membranes..."

3. On 10/31/12 at 10:00 A.M.,

Resident #34 clinical record was

reviewed. Resident #34 diagnoses

included, but were not limited to

MRSA, Multiple Sclerosis.

Observation on 10/31/12 at 10:30

A.M., of a dressing change to

Resident #34's pressure ulcers on the

left and right buttocks indicated the

following: LPN #1 was observed to

remove an old dressing from

Resident #34's right and left buttocks.

LPN #1 did not wash hands or use

hand gel prior to reapplying a new

pair of gloves. LPN #1 was observed

to have used the same piece of

gauze to clean the right and left

buttock and used another gauze to





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pat dry the right buttock and used the

same piece of gauze to pat dry the

left buttock. Upon interviewing LPN

#1 on what she would do differently,

LPN #1 indicated she was following

her company's policy.


"Pressure Ulcer Treatment", received

from the Medical Records indicated,

"...Cleansing--Cleanse the wound and

surrounding tissue with each dressing

change... Cleanse the pressure ulcer

using enough pressure to cleanse the

wound without damaging tissue or

driving bacteria back into the

wound..."


"Hand Washing and Hand Asepsis",

received from the as current,

indicated, "...SPECIFIC TIMES

HANDS MUST BE

WASHED:...Before and after direct

resident contact..."

A request was made to the DoN on

10/31/12 for a policy on handwashing

and wound care/pressure ulcers.

The DON indicated she didn't have a

specific policy on hand washing

except for dining/kitchen and if hand

washing should be done, it would be

included in the policies for specific

treatments. There was no





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instructions on hand washing in the

pressure ulcer treatment policy.

3.1-18(l)





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F0465

SS=E

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-465

It is the intent of this facility

to provide a safe and sanitary

environment. Environmental issues

i.e. dust on exhaust fans; repair

issues and urine odor in one resident

room have been corrected.

Residents’ #’s 1-9-14-29-36-45-50

was not negatively affected by this

finding.

No other residents in the

facility were affected by this finding,

and an environmental walk through

audit was completed to address any

other areas that have the potential

to affect other residents.

To ensure this does not

recur an inservice was completed on

11-20-12 with all staff and

concentration to environmental

services employees on the

importance of a safe, sanitary and

comfortable environment be

maintained for all residents. All

exhaust fans have been cleaned and

will continue to be audited for

cleanliness monthly by the

housekeeping supervisor. The carpet

from resident room # 50 has been

removed and urine odor resolved.

Monitoring of the

effectiveness of this system will be

done monthly via the environmental

services audit tools in the facility QA

12/05/2012 12:00:00AMF0465

Based on observation and interview,

the facility failed to provide a safe,

sanitary, and comfortable

environment for residents, related to

dust accumulation on bathroom and

shower room exhaust fans which had

the potential to effect 60 residents

who receive showers in the facility,

stains on bathroom tile, gouges on

the walls, loose with sharp edges trim

on resident room doors, and urine

odor in a resident room for 7 resident

rooms observed. (Residents #1, #9,

#14, #29, #36, #45, and #50)

Findings include:

On 10/29/12 the following was

observed:

12:33 p.m.- There was an

accumulation of dust on Resident

#1's bathroom exhaust fan.

2:45 p.m.- There was an



3:01 p.m.- There was a scrape on the

wall by the bed and the door trim was

loose, ripped and had sharp edges in





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program and completed by the

designated environmental services

personnel. Corrections will be made

at time of discovery and findings

reported monthly to the Q”A

committee. (Attachment)


Resident #14's room.

3:22 p.m.- There were gouges in the

wall by the bed and by the recliner in

Resident #36's room.

On 10/30/12 the following was

observed:

10:36 a.m.- There was an



11:05 a.m.- The bathroom tile was

stained in resident #29's room.

There was a strong smell of urine in

Resident #50's room on 10/29/12 at

10 a.m., 10/29/12 at 2:30 p.m.,

10/31/12 at 8 a.m., 11/01/12 at 4

p.m., and 11/05/12 at 8:08 a.m.


8:08 a.m., CNA #3 indicated the urine

odor was coming from the resident's

carpeting.

During the environmental tour on

11/05/12 at 9:42 a.m., with the

Maintenance Director and the

Housekeeping Supervisor, there was

an accumulation of dust on the

exhaust fan in the shower room.


observation, the Maintenance

Director indicated the facility had only





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one shower room.

Resident #50's room continued to

have a strong urine odor.


observation, the Housekeeping

Supervisor indicated they clean the

resident's carpeting constantly. The

Maintenance Director indicated he

could smell the urine odor.

3.1-19(f)





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F0514

SS=D

483.75(l)(1)

RES

RECORDS-COMPLETE/ACCURATE/ACCE

SSIBLE

The facility must maintain clinical records on

each resident in accordance with accepted

professional standards and practices that

are complete; accurately documented;

readily accessible; and systematically

organized.

The clinical record must contain sufficient

information to identify the resident; a record

of the resident's assessments; the plan of

care and services provided; the results of

any preadmission screening conducted by

the State; and progress notes.


facility that records be complete

and accurate per physician

orders. A clarification order was

received for Resident # 9.

Resident #46 has received

appropriate dental services and

documentation has been

updated. Involved personnel have

received appropriate disciplinary

action related to transcription

issues. All residents residing in

the facility have the potential to be

affected by this deficient finding.

To ensure this does not recur, an

inservice was held on 11-7-12

regarding procedures related to

transcription and family decisions.

Pharmacy recommendations

follow through was addressed in

POC for F tag-428 response.

Monitoring of accuracy of resident

records will be done monthly per

the recapitulation reconciliation

process and medical records

12/05/2012 12:00:00AMF0514

Based on record review and

interview, the facility failed to ensure

resident's records were complete and

accurate related to physician's orders

and Social Service notes in regards to

family decisions for 2 of 24 resident

records reviewed. (Residents #9 and

#46)

Findings include:


reviewed on 11/01/12 at 2:05 p.m.

The resident's diagnoses included,

but were not limited to, insomnia and

dementia.

A Pharmacy recommendation, dated


an order for Ambien (sleeping





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open record review. Findings will

be corrected at the time of

discovery and reported to the QA

committee. (Attachment)


F514

1. All residents’ orders were

reviewed with record

reconciliation/recap review by

11-30-12. This review focused on

accuracy of all orders, any

transcription or general errors

were corrected and/or clarified at

that time. Completion of this

review and update was done by

the Nursing Supervisors,

Inservice Director and assigned

licensed nurses. An in service

was held on 11-20-12 with the

nursing staff regarding the policy

and procedure for order

transcription and clarification of a

new order. Disciplinary action for

the identified staff member

regarding transcription error has

been completed.

Social Service audit tool was

updated to say, dental exam at

least yearly or documentation

present reflecting decline of

service. Monitoring for accuracy

will be done through monthly

recaps and open record review

and reported to QA committee.

The QA committee will review the

audits and findings monthly for

the next 6 months or 95% for

compliance. If any of the audits in

place show any variance it will be

updated at time of discovery and

recommendations for disciplinary

medication) 10 mg (milligrams) at

bedtime and recommended the

Ambien be decreased to 5 mg at bed

time. The Physician's response

section indicated, "ok to decrease

dose to Ambien 5 mg...PRN (as

needed) sleep" and was signed and

dated on 10/24/12.

The Medication Administration

Record (MAR), dated 10/12, indicated

the Ambien was decreased to 5 mg

daily at 8 p.m. (not PRN as ordered).

The MAR indicated the resident

received the medication every night.


2:19 p.m., LPN #2 (the Nurse who

received the order) indicated she had

spoke with the physician on the

telephone and the physician did not

want to change the Ambien to as

needed. She indicated she did not

clarify the order.


12:45 p.m., the Director of Nursing

(DoN) indicated she had spoke with

the resident's physician and the order

should not have said PRN. She

indicated the nurse at the facility had

talked to him and he said to order it at

bedtime not PRN and the nurse

transcribed the order on the MAR but

did not write the order.





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action for individual(s) errors will

be done at that time per policy2. Resident #9's record was reviewed

on 11/01/12 at 8:30 a.m. The


were not limited to, Alzheimer's

disease and dementia. The resident

was admitted into the facility on

07/11/11.

The Consent record indicated the

resident's Guardian had consented to

dental services for the resident.

The record lacked documentation a

dental assessment had been

completed for the resident, since the

resident had been admitted into the

facility.


9:46 a.m., the Social Service Director

(SSD) indicated the resident has

been the list to be seen by the dentist

each time he comes. The SSD

indicated she has not documented

the refusals in the resident's record.

3.1-50(a)(1)

3.1-50(a)(2)





12/12/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


CULVER, IN 46511

155589

00

11/05/2012


730 SCHOOL ST


printed: 12/12/2012 department of health and human … · 2015-08-04 · street address, city,...

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