PRINTED: 05/05/2016 DEPARTMENT OF HEALTH AND HUMAN ... · conclusions set forth on the Statement of Deficiencies. The plan of correction is prepared and executed solely because it

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

VALPARAISO, IN 46383

155795 04/04/2016

AVALON SPRINGS HEALTH CAMPUS

2400 SILHAVY ROAD

00

F 0000

Bldg. 00

This visit was for a Recertification and

State Licensure Survey. This visit

included a State Residential Licensure

Survey.

Survey dates: March 28, 29, 30, 31, April

1, and 4, 2016

Facility number: 012766

Provider number: 155795

AIM number: 201051640

Census bed type:

SNF/NF: 18

SNF: 38

Residential: 65

Total: 121

Census payor type:

Medicare: 31

Medicaid: 12

Other: 13

Total: 56

These deficiencies reflect State findings

cited in accordance with 410 IAC

16.2-3.1.

Quality review completed by 32883 on

4/6/16.

F 0000 This plan of correction is

submitted by Avalon Springs

Health Campus in order to

respond to the alleged

deficiencies sited during the

Recertification and State survey

which was conducted on April 4,

2016.Preparation or execution of

this plan of correction does not

constitute admission or

agreement by provider of the truth

of the facts alleged or

conclusions set forth on the

Statement of Deficiencies. The

plan of correction is prepared and

executed solely because it is

required by the position of

Federal and State law.Please

accept this plan of correction as

the provider's credible allegation

of compliance effective May 4,

2016.Considering the volume,

scope, and severity of the alleged

deficient practice noted in the

CMS-2567, Avalon Springs

Health Campus respectfully

requests a desk review for this

survey. If approved, we would be

willing to provide all

documentation requested

including, but not limited to:

education records, policies and

procedures, checklists, and forms

that have been completed,

revised, or implemented as part

of this Plan of Correction.

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: 16VW11 Facility ID: 012766

TITLE

If continuation sheet Page 1 of 42

(X6) DATE




05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

483.10(e), 483.75(l)(4)

PERSONAL PRIVACY/CONFIDENTIALITY

OF RECORDS

The resident has the right to personal

privacy and confidentiality of his or her

personal and clinical records.

Personal privacy includes accommodations,

medical treatment, written and telephone

communications, personal care, visits, and

meetings of family and resident groups, but

this does not require the facility to provide a

private room for each resident.

Except as provided in paragraph (e)(3) of

this section, the resident may approve or

refuse the release of personal and clinical

records to any individual outside the facility.

The resident's right to refuse release of

personal and clinical records does not apply

when the resident is transferred to another

health care institution; or record release is

required by law.

The facility must keep confidential all

information contained in the resident's

records, regardless of the form or storage

methods, except when release is required by

transfer to another healthcare institution;

law; third party payment contract; or the

resident.

F 0164

SS=D

Bldg. 00

Based on observation, record review, and

interview, the facility failed to ensure

personal privacy was offered related to

F 0164 1. Resident #42 had no negative

outcome 2. Other residents

receiving insulin injections had no

issues. RN#1 received

05/04/2016 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 16VW11 Facility ID: 012766 If continuation sheet Page 2 of 42




05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

the administration of an insulin injection

for 1 of 1 residents observed for an

insulin injection during medication pass.

(Resident #42)

Finding includes:

On 3/30/16 at 11:00 a.m. RN #1 was

observed preparing to do an Accucheck

(a method used to obtain the resident's

blood to check their blood sugar) for

Resident #42. The RN placed the

resident in her room and positioned the

wheelchair on an angle so half of her

back was facing toward the room door.

The resident was approximately four feet

away from the open door. RN #1

obtained the resident's blood sugar and

walked out of the room. She indicated

the resident was to receive 10 units of

Novolog Insulin by the way of an Insulin

flex pen. The RN dialed the flex pen to

10 units and walked back into the room.

At that time, the resident's room door was

left open. The resident remained in the

same position as noted above. RN #1

attempted to get the resident to open her

eyes by tapping her arm. The resident

would not open her eyes. RN #1 was

speaking to the resident in a loud voice

and continued to tap her arm. At that

time, Resident #27, stood up from a

chair in the hallway (just outside the

resident's room), and walked into the

counseling regarding providing

privacy during insulin injection

administration. 3.

DHS/Designee will in-service

Licensed nurses regarding

providing privacy while

administering insulin injections.

DHS/Designee will observe/audit

insulin injections for privacy on 5

residents weekly, covering all

shifts, for 6 months or until QAA

states otherwise. 4. Audits to be

reviewed in QAA monthly for 6

months then quarterly thereafter

until 100% compliance is

achieved. QAA will make

recommendations and changes

as appropriate.5. Date of

Compliance 5.04.2016





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

room. Resident #27 started speaking to

Resident #42 indicating "(Resident's

name) can you open your eyes for me?"

RN #1 started talking to Resident #27

and then politely asked her to leave the

room and she would give her medications

in just a minute. Resident #27 walked

out of the room. At that time, the

resident's room door was still left open

and Resident #27 returned to the chair

she was sitting in and continued to watch

RN #1 and Resident #42. The nurse

raised up Resident #42's shirt and

administered the Insulin injection into her

abdomen. At that time, CNA #1 and

Dietary Cook #1 walked by the room and

they both looked into the room as RN #1

was administering the Insulin injection.

Interview with RN #1 at that time,

indicated the door to the resident's room

should have been closed during the

Accucheck as well the administration of

the Insulin.

The record for Resident #42 was

reviewed on 3/31/16 at 9:05 a.m. The

resident's diagnoses included, but were

not limited to, altered mental status,

anxiety disorder, major depressive

disorder, and cognitive communication

deficit.

The Quarterly Minimum Data Set (MDS)





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

assessment dated 3/26/16 indicated the

resident had a Brief Interview for Mental

Status (BIMS) score of 4, indicating she

was severely impaired for decision

making.

Interview with the Director of Nursing on

3/31/16 at 2:15 p.m., indicated the nurse

should have closed the resident's room

door during the Accucheck as well as the

administration of the Insulin injection.

3.1-3(p)(2)

483.15(a)

DIGNITY AND RESPECT OF

INDIVIDUALITY

The facility must promote care for residents

in a manner and in an environment that

maintains or enhances each resident's

dignity and respect in full recognition of his

or her individuality.

F 0241

SS=D

Bldg. 00

Based on observation, interview and

record review, the facility failed to ensure

a resident's dignity was maintained

related to an uncovered urinary catheter

bag for 1 of 1 resident's reviewed for

dignity. (Resident # 35)

Finding includes:

On 3/28/16 at 12:01 p.m., Resident #35

was observed being pushed down the 300

Hallway towards the 100 Hallway by a

F 0241 1. Urine was obtained for

resident #2Resident #10 received

second tylenol 500 mg tablet.

Resident had no negative

outcome.Resident #8 and #9 had

no negative outcome.2. Other

residents with orders for U/A were

audited with no concerns

identified. LPN #1 received

counseling regarding medication

administration. 3. DHS/Designee

will in-service Licensed nurses

on medication administration and

obtaining urine specimens as

ordered.DHS/Designee will

05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

private caregiver in his broda chair with

the urinary catheter bag uncovered and a

small amount of yellow urine present in

the bag. The broda chair had a dignity

bag near the resident's foot rest.

On 3/28/2016 at 12:13 p.m., the urinary

catheter bag was observed from the

resident's doorway, uncovered, hanging

on the bed frame, with a small amount of

yellow urine in the bag.

On 3/28/16 at 12:24 p.m., the resident

was observed being pushed in his broda

chair by the private caregiver down the

100 Hallway towards the 300 Hallway,

the urinary catheter bag was uncovered

with a small amount of visible yellow

urine in the bag. The resident was

pushed past two facility staff, LPN #3

and the MDS Coordinator, who both had

not noticed the urinary catheter bag was

uncovered.

On 4/04/2016 at 10:15 a.m., the resident

was in his broda chair with another

private caregiver in the 100 Hallway

lounge area watching TV with the urinary

catheter bag uncovered and a small

amount of yellow urine visible in bag.




complete medication

administration competencies on 2

nurses weekly covering all shifts

for 6 months or until QAA states

otherwiseDHS/Designee will audit

Orders for U/A 3x weekly for 6

months or until QAA states

otherwise 4. Audits to be












05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

not limited to, quadriplegic, traumatic

brain injury, aphasia (can not speak) and

seizures.

The resident's care plan dated 2/4/16

indicated the resident required an

external catheter related to urinary

incontinence. The nursing interventions

included, but were not limited to, store

the collection bag inside a protective

dignity pouch.

Review of the Physician Order Summary

for March 2016 indicated to measure the

urine volume and remove the Texas

catheter (a type of external catheter) once

a day.

Review of the Quarterly Minimum Data

Set assessment dated 3/28/16 indicated

the resident had an external catheter and

was totally dependent on all Activities of

Daily Living with a 2 person assist.

Interview with CNA #2 on 4/04/2016 at

10:17 a.m., indicated Resident #35's

urinary catheter bag should have been

covered and placed in the dignity bag on

his broada chair.

A facility policy titled, "Guidelines for

preserving dignity with indwelling

catheter," was provided by the Director of

Health Services on 4/4/16 at 10:55 a.m.





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

This current policy indicated, "...a) Keep

drainage bag covered with an appropriate

device...."

3.1-3(t)

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 0279

SS=D

Bldg. 00

Based on record review and interview,

the facility failed to ensure each resident

had a comprehensive care plan related to

a psychoactive medication for 1 of 15

residents whose plan of care was

reviewed. (Residents #98)

F 0279 1. Care Plan for resident #98

was updated to include

psychoactive medication. 2.

Other residents receiving

psychoactive medications were

audited for psychoactive

medication Care Plans with no

concerns identified. All care plans

for current health care center

05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

Finding includes:

Resident #98's record was reviewed on

3/30/15 at 9:45 a.m. The resident's

diagnoses included, but were not limited

to, Lewy body dementia, major

depressive disorder, and dementia with

delusions.

Review of the Quarterly Minimum Data

Set (MDS) assessment dated 1/27/16

indicated the resident had received an

antipsychotic medication on 7 of the 7

days in the reference period.

Review of 3/2016 Physician Order

Summary indicated an order for

quetiapine (Seroquel, an antipsychotic

medication) 12.5 milligrams every day.

Review of the 3/2016 Medication

Administration Record (MAR) indicated

the resident had received the quetiapine

medication daily as ordered.

Review of the resident's care plans lacked

a care plan for the use of the

antipsychotic medication.

Interview with the Minimum Data Set

(MDS) Coordinator on 4/1/16 at 1:36

p.m. indicated there was not a current

care plan for the antipsychotic

medication.

residents will be audited for

compliance. 3. DHS/Designee

will in-service MDS and Social

Services regarding having

required care plans for each

health care center resident as per

regulation, such as, psychoactive

medication care plans for

residents receiving psychoactive

medications. MDS/Designee will

audit 5 residents care plans

weekly including psychoactive

care plans for 6 months or until

QAA states otherwise. 4. Audits

to be reviewed in QAA monthly

for 6 months then quarterly

thereafter until 100% compliance

is achieved. QAA will make








05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

3.1-35(a)

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 0329

SS=D

Bldg. 00


the facility failed to ensure non

pharmacological interventions were tried

first and documented prior to the

administration of pain medication and

antidepressant medication used for

insomnia for 2 of 5 residents reviewed

for unnecessary medications. (Resident

#27 & #42)

F 0329 1. PRN Trazadone order for

resident #42 was updated to

include documentation of non

pharmacological interventions

prior to medication administration.

PRN Tylenol order for resident

#27 was updated to include

documentation of non


prior to medication administration

Neither resident had any negative

outcome. 2. Other residents'

05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

Findings include:

1. The record for Resident #42 was



not limited to, altered mental status,

anxiety disorder, major depressive

disorder, and cognitive communication

deficit.

The Quarterly Minimum Data Set (MDS)

assessment dated 3/26/16 indicated the

resident had a Brief Interview for Mental

Status (BIMS) score of 4, indicating she

was severely impaired for decision

making and not alert and oriented. The

resident received an antidepressant for 7

of the 7 days reviewed.

Physician Orders dated 1/15/16 indicated

Trazadone (an antidepressant medication)

50 milligrams (mg) at night time (hs) as

needed (prn).

The 2/2016 Medication Administration

Record (MAR) was reviewed. The prn

Trazadone was administered as follows:

2/4 at 10:12 p.m.: reason sleep



Continued review of the 2/20/16 MAR

indicated there were no interventions

PRN medication orders were

audited for prior intervention

documentation and updated as

needed 3. DHS/Designee will

in-service Licensed nurses on the

required documentation of non


attempted prior to administering

medications. DHS/Designee will

audit 5 PRN orders weekly for

documentation of non


prior to medication administration


otherwise. 4. Audits to be












05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

tried first before the administration of the

prn Trazadone for sleep.

Nursing Progress Notes dated 2/4, 2/12,

and 2/13/16 indicated there was no

documentation of any interventions tried

prior to the administration of the prn

Trazadone.


3/31/16 at 2:24 p.m., indicated there was

supposed to be a separate box on the

MAR for the documentation of prn

medications and what interventions were

tried first. She indicated nursing staff

were to document what interventions

were tried prior to the administration of

the prn medications on the MAR.

2. Record review for Resident #27 was

completed on 3/29/16 at 3:40 p.m. The


not limited to, hypertension, and

Alzheimer's Disease.

The Annual Minimum Data Set (MDS)

assessment completed on 2/2/16

indicated the resident had a BIMS (Brief

Interview of Mental Status) score of 4,

which indicated the resident was severely

cognitively impaired. The assessment

indicated the resident had received PRN

(when necessary) pain medication.

A Care Plan indicated the resident was at





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

risk for pain related to generalized aches

and pains. An approach included to

attempt non-medication interventions

first, for example: position for comfort,

one on one, or offer food or drink.

Review of the Physician Order Summary

indicated an order for acetaminophen

(Tylenol) 650 mg (milligrams) every 6

hours prn for pain.

Review of the February 2016 MAR

(Medication Administration Record)

indicated the resident received the

acetaminophen on the following dates

and times:

- 2/1/16 at 5:42 a.m.

- 2/5/16 at 9:11 a.m.

- 2/7/16 at 8:25 a.m.

- 2/8/16 at 1:29 p.m.

- 2/9/16 at 7:42 a.m..

- 2/10/16 at 1:27 p.m.

- 2/11/16 at 7:58 a.m.

- 2/12/16 at 8:31 a.m.

- 2/15/16 at 7:22 a.m.

- 2/17/16 at 7:12 a.m.

- 2/23/16 at 6:52 a.m.; 7:20 p.m.

- 2/24/16 at 6:15 p.m.

- 2/25/16 at 9:02 a.m.

- 2/29/16 at 7:14 a.m.

Review of the March 2016 MAR

indicated the resident received the





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

acetaminophen on the following dates

and times:

- 3/2/16 at 7:31 a.m.

- 3/4/16 at 7:32 a.m.,

- 3/5/16 at 9:27 a.m., 3:36 p.m.

- 3/6/16 at 8:49 a.m., 2:54 p.m.

- 3/7/16 at 7:16 a.m.

- 3/8/16 at 9:27 a.m.

- 3/9/16 at 6:47 a.m.

- 3/11/16 at 7:55 a.m.

- 3/13/16 at 9:08 a.m.

- 3/15/16 at 7:52 a.m.

- 3/16/16 at 8:27 a.m.

- 3/18/16 at 7:11 a.m.

- 3/24/16 at 9:23 a.m.

- 3/25/16 at 10:12 a.m.

- 3/28/16 at 6:58 a.m.

The record lacked indication that any

non-medication interventions had been

attempted prior to the administration of

the acetaminophen to the resident on the

above dates and times.

Interview with the DHS (Director of

Health Services) on 3/31/16 at 10:47

a.m., indicated the non-medication

interventions attempted were supposed to

be charted on the MAR. She further

indicated she was unable to find where

any non-medication interventions had

been attempted prior to the

administration of the acetaminophen to





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

the resident on the above dates and times.

3.1-48(a)(4)

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

F 0441

SS=D

Bldg. 00





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

accepted professional practice.

(c) Linens

Personnel must handle, store, process and

transport linens so as to prevent the spread

of infection.

Based on observation and interview, the

facility failed to ensure infection control

practices and standards were maintained

related to uncovered wash basins stored

in an unsanitary method for 2 of 30

rooms observed. (Room #106 and Room

#111)

Findings include:

1. During an observation on 3/28/16 at

11:43 a.m. in Room #106, there were two

wash basins uncovered on the bathroom

floor and one wash basin turned upside

down stored uncovered on the back of the

resident's toilet tank. One resident

resided in this room.

During further observation in Room #106

on 3/29/16 at 1:33 p.m., two wash basins

were stored on the bathroom floor

uncovered and one wash basin was

turned upside down, uncovered and

stored on the back of the toilet tank.

During the Environmental Tour on 4/1/16

at 9:34 a.m., with the Director of Plant

Operations and the Environmental

Service Director, in Room #106, two

F 0441 1. Wash basins in rooms 106

and 111 were discarded and

replaced. Neither resident was

had any negative outcome. 2.

Other rooms were audited for

sanitary storage of wash basins

with no concerns identified. 3.


Nursing staff on sanitary storage

of wash basins. DHS/Designee

will audit 5 rooms weekly,

covering all shifts, for sanitary

storage of wash basins for 6










05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

wash basins were observed, uncovered

and stored on the bathroom floor.

2. On 3/28/16 at 2:35 p.m. in Room #

111, a wash basin was observed to be

uncovered and stored on the bathroom

floor. One resident resided in this room.


at 9:34 a.m., with the Director of Plant

Operations and the Environmental

Services Director, in Room #111, a wash

basin was observed on the bathroom

floor, uncovered.

Interview with the DHS (Director of

Health Services) on 4/1/16 at 2:28 p.m.,

indicated there was not a policy for

infection control for the storage of wash

basins. The DHS further indicated that

she was unaware that the wash basins

were to be stored covered and off the

bathroom floor.

3.1-18(a)

483.70(h)

SAFE/FUNCTIONAL/SANITARY/COMFOR

TABLE ENVIRON

The facility must provide a safe, functional,

sanitary, and comfortable environment for

F 0465

SS=E

Bldg. 00





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

residents, staff and the public.


facility failed to maintain an environment

that was clean and in good repair related

to gouged walls and discolored bathroom

pull cords. (100 Hallway, 200 Hallway

and 300 Hallway)

Findings include:


from 9:34 a.m. until 9:50 a.m., with the

Director of Plant Operations and the

Environmental Service Director, the

following was observed:

1. 100 Hallway:

a. In Room #101, the bathroom pull cord

was discolored. There was one resident

who resided in this room.

b. In Room #111, the bathroom and

bedroom walls were marred. There was

one resident who resided in this room.

c. In Room #115, the inside of the

bathroom door near the corner was

marred. There was one resident who


2. 200 Hallway:

a. In Room #201, the bathroom wall was

F 0465 1. Bathroom pull cords will

be replaced in rooms 101, 207,

211 and 216 Walls will

be repaired in rooms 111, 201,

Doors will be repaired/replaced in

rooms 115, 211, 306 2. No

residents were affected. 3.


staff on completing maintenance

requests for marred, gouged, or

chipped walls/doors, as well

as, discolored pull cords.


maintenance regarding

maintaining an environment that

is clean and in good repair by not

having marred/gouged/chipped

walls or doors, or discolored pull

cords.ED/Designee will audit 3

rooms weekly for marred, gouged

or chipped doors/walls, and

discolored pull cords for 6 months

or until QAA states otherwise. 4.

Audits to be reviewed in QAA

monthly for 6 months then

quarterly thereafter until 100%

compliance is achieved. QAA will

make recommendations and

changes as appropriate.5. Date

of Compliance 5.04.2016

05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

marred. There was one resident who


b. In Room #207, the bathroom pull cord

had a brown discoloration. There were

two residents who shared this bathroom.

c. In Room #211, the outside of the

bathroom wooden door was chipped and

the bathroom pullcord had a brown

discoloration. There were two residents

who shared this bathroom.

d. In Room #216, the bathroom pull cord

had a brown discoloration. There were

two residents who shared this bathroom.

3. 300 Hallway:

a. In Room #306, the bathroom door was

gouged near the handle on the outside of

the door. There were two residents who

shared this bathroom.

Interview with the Director of Plant

Operations at the end of the tour,

indicated all the above were in need of

repair and or cleaning.

3.1-19(f)





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

R 0000

Bldg. 00

This visit was for a State Residential

Licensure Survey.

Residential Census: 65

Residential Sample: 7

Residential Supplemental Sample: 3

These deficiencies reflect state findings

cited in accordance with 410 IAC 16.2-5.

Quality review completed by 32882 on

4/6/16.

R 0000 This plan of correction is

submitted by Avalon Springs

Health Campus in order to

respond to the alleged

deficiencies sited during the

Recertification and State survey

which was conducted on April 4,

2016.Preparation or execution of

this plan of correction does not

constitute admission or

agreement by provider of the truth

of the facts alleged or

conclusions set forth on the

Statement of Deficiencies. The

plan of correction is prepared and

executed solely because it is

required by the position of

Federal and State law.Please

accept this plan of correction as

the provider's credible allegation

of compliance effective May 4,

2016.Considering the volume,

scope, and severity of the alleged

deficient practice noted in the

CMS-2567, Avalon Springs

Health Campus respectfully

requests a desk review for this

survey. If approved, we would be

willing to provide all

documentation requested

including, but not limited to:

education records, policies and

procedures, checklists, and forms

that have been completed,

revised, or implemented as part

of this Plan of Correction.

State Form Event ID: 16VW11 Facility ID: 012766 If continuation sheet Page 20 of 42




05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

410 IAC 16.2-5-1.4(e)(1-3)

Personnel - Noncompliance

(e) There shall be an organized inservice

education and training program planned in

advance for all personnel in all departments

at least annually. Training shall include, but

is not limited to, residents' rights, prevention

and control of infection, fire prevention,

safety, accident prevention, the needs of

specialized populations served, medication

administration, and nursing care, when

appropriate, as follows:

(1) The frequency and content of inservice

education and training programs shall be in

accordance with the skills and knowledge of

the facility personnel. For nursing personnel,

this shall include at least eight (8) hours of

inservice per calendar year and four (4)

hours of inservice per calendar year for

nonnursing personnel.

(2) In addition to the above required

inservice hours, staff who have contact with

residents shall have a minimum of six (6)

hours of dementia-specific training within six

(6) months and three (3) hours annually

thereafter to meet the needs or preferences,

or both, of cognitively impaired residents

effectively and to gain understanding of the

current standards of care for residents with

dementia.

(3) Inservice records shall be maintained

and shall indicate the following:

(A) The time, date, and location.

(B) The name of the instructor.

(C) The title of the instructor.

(D) The names of the participants.

(E) The program content of inservice.

The employee will acknowledge attendance

by written signature.

R 0120

Bldg. 00


the facility failed to ensure annual

R 0120 1. No residents had negative

outcomes2. LPN#2, #4, #5,

#6 will have documented

05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

medication administration inservices

were completed for 4 of 4 licensed staff

members reviewed. (LPN #2, LPN #4,

LPN #5, and LPN #6)

Finding includes:

Review of the facility inservices on

4/1/16 at 1:40 p.m. indicated LPN #2,

LPN #4, LPN #5, and LPN #6, who

worked in the facility during the 2015

calendar year, had not received annual

medication administration inservices for

the 2015 calendar year.

Interview with the Executive Director on

4/4/16 at 9:15 a.m. indicated the staff

completed inservices on the computer

and the nurses had separate ones they had

to do. She further indicated the facility

did not have access to the records and

could not provide documentation the staff

had completed the required inservice

hours.

in-serving on medication

administration per regulation. 3.


Licensed nurses on medication

administration and maintain

documentation of these

in-services.New licensed nurses

will receive medication

administration in-service within

first 30 days of

hire. DHS/Designee will audit

licensed nurses monthly for

annual medication administration

in-service for 6 months or until

QAA states otherwise.4. Audits








410 IAC 16.2-5-1.5(a)

Sanitation and Safety Standards - Deficiency

(a) The facility shall be clean, orderly, and in

a state of good repair, both inside and out,

and shall provide reasonable comfort for all

residents.

R 0144

Bldg. 00





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00


facility failed to maintain an environment

that was clean and in good repair related

to marred walls and dirty pull cords. (400

Hallway, 500 Hallway, 600 Hallway and

700 Hallway)

Findings include:

During the Assisted Living

Environmental Tour on 4/1/16 from

11:00 a.m. until 11:25 a.m. with the

Director of Plant Operations and the

Environmental Service Director, the

following was observed:

1. 400 Hallway:

a. In Room #405, the bedroom wall was

marred and the bathroom pullcord had a

yellow/brown discoloration. There was

one resident who resided in this room.

b. In Room #413, the bathroom pullcord

had a yellow/brown discoloration. There

was one resident who resided in this

room.

2. 500 Hallway:

a. In Room #502, the bathroom pullcord

had a yellow/brown discoloration. There

was one resident who resided in this

room.

R 0144 1. Bathroom pull cords will

be replaced in rooms 405, 413,

502 Walls will be repaired in

rooms 405, and 707. Doors will

be repaired/replaced in rooms

618 2. No residents were

affected. 3. DHS/Designee will

in-service staff on completing

maintenance requests for marred,

gouged, or chipped walls/doors,

as well as, discolored pull cords.


maintenance regarding

maintaining an environment that

is clean and in good repair by not

having marred/gouged/chipped

walls or doors, or discolored pull

cords.ED/Designee will audit 3

rooms weekly for marred, gouged

or chipped doors/walls, and

discolored pull cords for 6 months









05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

3. 600 Hallway:

a. In Room #618, the inside of the

wooden bathroom door was chipped in

the corner. There was one resident who


4. 700 Hallway:

a. In Room #707, the bathroom wall near

the shower was gouged. There was one

resident who resided in this room.

Interview with the Director of Plant

Operations at the end of the tour,

indicated all the above were in need of

repair and or cleaning.

410 IAC 16.2-5-2(e)(1-5)

Evaluation - Deficiency

(e) Following completion of an evaluation,

the facility, using appropriately trained staff

members, shall identify and document the

services to be provided by the facility, as

follows:

(1) The services offered to the individual

resident shall be appropriate to the:

(A) scope;

(B) frequency;

(C) need; and

(D) preference;

of the resident.

(2) The services offered shall be reviewed

R 0217

Bldg. 00





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

and revised as appropriate and discussed by

the resident and facility as needs or desires

change. Either the facility or the resident

may request a service plan review.

(3) The agreed upon service plan shall be

signed and dated by the resident, and a

copy of the service plan shall be given to the

resident upon request.

(4) No identification and documentation of

services provided is needed if evaluations

subsequent to the initial evaluation indicate

no need for a change in services.

(5) If administration of medications or the

provision of residential nursing services, or

both, is needed, a licensed nurse shall be

involved in identification and documentation

of the services to be provided.


the facility failed to have a Service Plan

signed by the resident and or the family

after a change in the resident's condition.

(Resident #6)

Finding includes:

The record for Resident #6 was reviewed

on 4/4/16 at 11:25 a.m. The resident's


to, severe dementia, atrial fibrillation

(abnormal heart rhythm) and chronic

kidney disease.

Review of the resident's Physician

Orders, indicated services of hospice that

began on 1/26/16 for uncontrolled atrial

fibrillation after a hospitalization.

Review of the resident's Service Plan

dated 2/1/16, indicated a lack of the

R 0217 1. Family has been notified of

change in condition for resident

#6 and asked to sign Service

Plan.2. Other residents will be

audited for signed Service Plan

with change in resident

condition.3. DHS/Designee will

in-service Licensed nurses,

Social Services and Legacy

Director on having family sign

Service Plan with change in

resident condition. DHS/Designee

will audit 3 Service Plans weekly

for residents with change in

condition for family

notification/signature for 6 months









05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

resident's or responsible party's signature

to indicate the change in condition noted

on the Service Plan was reviewed and

accepted.

Interview with the Assistant Director of

Health Services on 4/4/16 at 2:30 p.m.,

indicated neither the resident nor the

family signed the Service Plan to confirm

the needs of the resident had changed.

410 IAC 16.2-5-4(e)(1)

Health Services - Offense

(e) The administration of medications and

the provision of residential nursing care shall

be as ordered by the resident ' s physician

and shall be supervised by a licensed nurse

on the premises or on call as follows:

(1) Medication shall be administered by

licensed nursing personnel or qualified

medication aides.

R 0241

Bldg. 00

Based on observation, record review, and


Physicians Orders were followed as

written related to obtaining an Urinalysis

for 1 of 7 sampled residents, and the

administration of medications for 3 of 5

residents observed during medication

pass. (Residents #2, #8, #9 and #10)

Findings include:



resident was admitted to the facility on

R 0241 1. Urine was obtained for

resident #2Resident #10 received

second tylenol 500 mg tablet.

Resident had no negative

outcome.Resident #8 and #9 had

no negative outcome.2. Other

residents with orders for U/A were

audited with no concerns

identified. LPN #1 received

counseling regarding medication

administration. 3. DHS/Designee


on medication administration and

obtaining urine specimens as

ordered.DHS/Designee will

complete medication

administration competencies on 2

nurses weekly covering all shifts

05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

3/12/16 from a Long Term Care facility.

The resident's diagnoses included, but

were not limited to, dementia and stroke.

Nursing Progress Notes dated 3/31/16

indicated a fax was sent to the Physician

regarding the resident having increased

confusion and foul smelling cloudy urine.

Physician Orders dated 3/31/16 indicated

obtain a Urinalysis.

Nursing Progress Notes dated 3/31/16 at

4:29 p.m., indicated the urine had been

obtained and placed in the 200 hall

refrigerator for the lab to pick up.


10:34 p.m., indicated the resident had

increased confusion and refused care

several times.


1:59 p.m., indicated Nursing staff called

the lab to see if the results of the

urinalysis were available. At that time,

the lab indicated they had not received

the urine. The 200 unit was notified and

indicated the resident's urine was still in

the refrigerator at the facility.

On 4/3/16 another urine sample was

collected and delivered to the lab.


otherwiseDHS/Designee will audit

Orders for U/A 3x weekly for 6


otherwise 4. Audits to be












05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00


4/4/16 at 1:45 p.m., indicated she was

aware the urine had not been sent to the

lab in a timely manner.

2. On 4/4/16 at 8:10, LPN #1 was

observed pouring medication for

Resident #9. After preparing all of the

resident's medications, she walked over

to the dining room table and placed the

medication cup next to the resident. The

LPN wrote some information on a piece

of paper for the resident to read and then

left and walked back to her medication

cart. The LPN did not watch the resident

swallow her medications.

On 4/4/16 at 8:33 a.m., LPN #1 was


Resident #8. The LPN indicated she had

already prepared the resident's Miralax

powder (a medication used for

constipation) in a cup of water. She

indicated the resident did not want the

mixture to be gritty tasting. After

preparing all of the resident's

medications, she walked over to the

dining room table and handed the

resident the cup of the Miralax solution

as well as his medications. The resident

swallowed all of his medications but had

not finished drinking the Miralax water

solution. The LPN did not watch the

resident finish drinking the Miralax





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

mixed with water.

Interview with LPN #1 on 4/4/16 at 8:45

a.m., indicated she did not watch both of

the above mentioned residents take their

medication. She indicated she was

supposed to stay with the residents until

they had finished taking their meds.


4/4/16 at 1:45 p.m., indicated the LPN

should have stayed with each of the those

residents to ensure they had taken their

medications.

3. On 4/4/16 at 8:20 a.m., LPN #1 was


Resident #10. The LPN poured Tylenol

extra strength 500 milligrams (mg) 1

tablet into the medication cup. After

preparing the medications the LPN

indicated she had 10 pills in the

medication cup. She walked over to the

resident and administered the

medications to him.

After the pass, the LPN was asked to

remove the Tylenol medication from the

medication cart. The label on the

medication indicated Tylenol extra

strength 500 mg give 2 tablets to equal

1000 mg.






05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

reviewed on 4/4/16 at 8:50 a.m.

Physician Orders dated 6/6/15 and on the

current 4/2016 Physician Order Summary

indicated Tylenol 500 mg give 2 tabs to

equal 1000 mg daily.


a.m., indicated she should have

administered two Tylenol tablets to the

resident rather than only one.

410 IAC 16.2-5-4(e)(2)

Health Services - Offense

(2) The resident shall be observed for

effects of medications. Documentation of

any undesirable effects shall be contained in

the clinical record. The physician shall be

notified immediately if undesirable effects

occur, and such notification shall be

documented in the clinical record.

R 0242

Bldg. 00

Based on observation, record review and


each resident was observed for the effects

of medication related to not obtaining a

heart rate prior to the administration of

Digoxin (a medication used to control the

heart rate) for 2 of 5 residents observed

during medication pass. (Resident #9 &

#11)

Findings include:

R 0242 1. Residents #9 and #11 had no

negative outcome.2. LPN #1

received counseling regarding

medication administration

including assessing heart rate

prior to administration of

Digoxin.3. DHS/Designee will

in-service Licensed nurses on

medication

administration.DHS/Designee will

in-service Licensed nurses

regarding monitoring for adverse

effects of medications such as

Digoxin and notifying physician of

05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

1. On 4/4/16 at 8:10, LPN #1 was


Resident #9. At that time, the LPN

poured Digoxin 125 micrograms (mcg)

into a medication cup. After pouring all

the resident's medications, she walked

over to the dining room table and

administered the medications to her. The

LPN did not check the resident's heart

rate prior to the administration.


on 4/4/16 at 8:50 a.m.

Physician Orders on the current 4/2016

Physician Order Summary (POS)

indicated Digoxin 125 mcg 1 tablet daily.


a.m., indicated she did not check the

resident's heart rate prior to the

administration of the Digoxin. She

indicated there were no Physician ordered

parameters so there was no need to check

it.

2. On 4/4/16 at 8:40 a.m., LPN #1 was


Resident #11. At that time, the LPN

poured Digoxin 125 mcg into a

medication cup. After pouring all the

resident's medications, she walked over

to the dining room table and administered

any undesirable

effects.DHS/Designee will

complete med administration

competencies on 2 nurses

weekly,covering all shifts, for 6


otherwise.4. Audits to be












05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

the medications to her. The LPN did not

check the resident's heart rate prior to the

administration.


reviewed on 4/4/16 at 8:52 a.m.

Physician Orders on the current 4/2016

POS indicated Digoxin 125 mcg 1 tablet

daily.

The PDR (Physician Desk Reference)

2016 Edition located at the Nurse's

station, indicated Digoxin Nursing

considerations - monitor for signs and

symptoms of severe sinus bradycardia (a

very low heart rate). Patient counseling

indicated to monitor the heart rate and

blood pressure every day.


a.m., indicated she did not check the

resident's heart rate prior to the

administration of the Digoxin. She

indicated there were no Physician ordered

parameters so there was no need to check

it.

Interview with the Assistant Director of

Nursing on 4/4/16 at 9:45 a.m., indicated

the LPN should have obtained the

residents' heart rates before the

administration of the Digoxin.





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

410 IAC 16.2-5-8.1(a)(1-4)

Clinical Records - Noncompliance

(a) The facility must maintain clinical records

on each resident. These records must be

maintained under the supervision of an

employee of the facility designated with that

responsibility. The records must be as

follows:

(1) Complete.

(2) Accurately documented.

(3) Readily accessible.

(4) Systematically organized.

R 0349

Bldg. 00


the facility failed to ensure a skin

condition was measured weekly and the

treatment was documented as completed

as ordered by the Physician. (Resident

#6)

Finding includes:


on 4/4/16 at 11:25 a.m. The resident's


to, severe dementia, atrial fibrillation

(abnormal heart rhythm) and chronic

kidney disease.

Review of the resident's Physician's

Orders dated 3/21/16 indicated to cleanse

the right side of the cheek with normal

saline, allow to dry and apply to area with

triple antibiotic ointment daily and as

R 0349 1. Treatment orders for resident

#6 were updated to include

measurements. Skin impairment

for resident #6 is healed.2.

Orders for other residents with

skin impairment were audited for

documentation of treatments

including measurements.3.


Licensed nurses regarding

documenting treatments including

measurements.DHS/Designee

will audit 3 residents weekly for

documentation of treatments and

measurement of skin impairment










05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

needed. The 3/21/16 Physician's Order

further indicated weekly skin

measurements to right cheek.

Review of the resident's March

Treatment Administration Record lacked

an indication the treatment to the right

cheek was completed as ordered.

Review of the Nurse Notes from 3/21/16

through 4/3/16, lacked a weekly

measurement of the right cheek.

Interview with Assistant Director of

Health Services on 4/4/16 at 2:10 p.m.,

indicated the treatments to the right cheek

were completed and measured, but were

not documented in the resident's record.

410 IAC 16.2-5-8.1(g)(1-7)


(g) A transfer form shall include the

following:

(1) Identification data.

(2) Name of the transferring institution.

(3) Name of the receiving institution and

date of transfer.

(4) Resident ' s personal property when

transferred to an acute care facility.

(5) Nurses ' notes relating to the resident '

s:

(A) functional abilities and physical

limitations;

(B) nursing care;

(C) medications;

(D) treatment; and

(E) current diet and condition on transfer.

(6) Diagnosis.

R 0354

Bldg. 00





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

(7) Date of chest x-ray and skin test for

tuberculosis.


the facility failed to ensure a transfer

form was completed for 1 of 2 closed

records reviewed. (Resident #5)

Finding includes:

The closed record for Resident #5 was

reviewed on 4/1/16 at 3:14 p.m. The

resident was discharged to an assisted

living facility on 1/29/16.

Review of the Resident Transfer Form

dated 1/29/16 indicated the form was

incomplete. Review of the Discharge

Instructions form dated 1/29/16 indicated

the form was incomplete.

Interview with the Director of Health

Services (DHS) on 4/4/16 at 12:05 p.m.

indicated other information would have

been attached to the forms and sent with

the resident.

R 0354 1. Resident #5 is no longer in

facility.2. Transfer forms for the

last 30 days were audited for

completion.3. DHS/Designee will

in-service Licensed nurses on

completing transfer forms as per

regulation. DHS/Designee will

audit 3 transfer forms for

completion weekly for 6 months

or until QAA states otherwise.4.








05/04/2016 12:00:00AM

410 IAC 16.2-5-8.1(i)(1-8)


(i) A current emergency information file shall

be immediately accessible for each resident,

R 0356

Bldg. 00





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

in case of emergency, that contains the

following:

(1) The resident ' s name, sex, room or

apartment number, phone number, age, or

date of birth.

(2) The resident ' s hospital preference.

(3) The name and phone number of any

legally authorized representative.

(4) The name and phone number of the

resident ' s physician of record.

(5) The name and telephone number of the

family members or other persons to be

contacted in the event of an emergency or

death.

(6) Information on any known allergies.

(7) A photograph (for identification of the

resident).

(8) Copy of advance directives, if available.


the facility failed to ensure an emergency

file was immediately accessible and

complete for staff to review for 2 of 7

residents reviewed. (Resident #2 & #8)

Findings include:



resident was admitted to the facility on

3/12/16.

The emergency file was reviewed for the

resident. Hospital preference as well as

the telephone number, advance directive

information, and the resident's

emergency contacts were not completed

on the form in the emergency book

R 0356 1. Emergency file for resident #2

was updated.Emergency file for

resident #8 was completed and

added to binder.2. Emergency

files for Assisted Living residents

were audited with no other

concerns identified.3.


Licensed nurses, Social services

and Legacy Director regarding

emergency files.DHS/Designee

will audit emergency binder for

completed emergency files

weekly for 2 months, then

monthly for 4 months or until QAA

states otherwise.4. Audits to be








05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

located on the Legacy Unit.

Interview with the Legacy Director on

4/4/16 at 11:30 a.m., indicated the

resident's emergency file was not updated

to reflect her current status. 2. Record

review for Resident #8 was completed on

4/1/16 at 2:24 p.m. The resident's


to, diabetes mellitus, and hyperlipidemia.

The resident was admitted to the facility

on 8/22/14.

Review of the facility's resident's

emergency files indicated an emergency

information file had not been completed

for Resident #8.


p.m., indicated she was unable to locate

an information emergency file for

Resident #8 in the emergency

information residents' binder. She

indicated if an emergency had happened

she would just pull all the charts on the

cart to a safe place and wouldn't need a

separate emergency information file for

the residents.

410 IAC 16.2-5-12(c)

Infection Control - Noncompliance

R 0408





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

(c) Each resident shall have a diagnostic

chest x-ray completed no more than six (6)

months prior to admission.

Bldg. 00



had a chest X-ray completed no more

than six months prior to admission for 1

of 7 residents reviewed. (Resident #2)

Finding includes:


on 4/4/16 at 10:30 a.m. The resident was

admitted to the facility on 3/12/16 from a

Long Term Care facility.

The diagnostic lab information was

reviewed. There was no chest X-ray

completed for the resident prior to

admission to the facility.

Interview with the Medical Records

Coordinator on 4/4/16 at 1:00 p.m.,

indicated there was no chest X-ray

completed prior to the admission to the

facility.

R 0408 1. CXR was obtained for resident

#2.2. Other Assisted Living

residents were audited for CXR

prior to admission3.

ED/Designee will in-service

Admissions, Social services,

Nursing Administration regarding

having CXR completed within 6

months prior to

admissionDHS/Designee to audit

Assisted Living admissions for

CXR completed within 6 months

prior to admission weekly for 6


otherwise4. Audits to be








05/04/2016 12:00:00AM

410 IAC 16.2-5-12(e)(f)(g)

Infection Control - Noncompliance

(e) In addition, a tuberculin skin test shall be

completed within three (3) months prior to

R 0410

Bldg. 00





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

admission or upon admission and read at

forty-eight (48) to seventy-two (72) hours.

The result shall be recorded in millimeters of

induration with the date given, date read,

and by whom administered and read.

(f) For residents who have not had a

documented negative tuberculin skin test

result during the preceding twelve (12)

months, the baseline tuberculin skin testing

should employ the two-step method. If the

first step is negative, a second test should

be performed within one (1) to three (3)

weeks after the first test. The frequency of

repeat testing will depend on the risk of

infection with tuberculosis.

(g) All residents who have a positive reaction

to the tuberculin skin test shall be required

to have a chest x-ray and other physical and

laboratory examinations in order to complete

a diagnosis.



received a second step tuberculin skin

test two to three weeks after admission

for 1 of 7 residents reviewed. (Resident

#2)

Finding includes:


on 4/4/16 at 10:30 a.m. The resident was

admitted to the facility on 3/12/16 from a

Long Term Care facility.

A tuberculin skin test was documented as

being administered at the Long Term

Care facility on 2/8/16 and read on

2/11/16 prior to the resident's admission.

R 0410 1. TB skin test was administered

for resident #2.2. Other AL

residents were audited for 2 step

TB skin test. 3. DHS/Designee


regarding TB skin testing as per

regulation.DHS/Designee to audit

Assisted Living new admissions

for completion of 2 step TB skin

test weekly for 6 months or until

QAA states otherwise.4. Audits








05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

The health immunization form was

reviewed. There was no documentation

of a second step tuberculin skin test

completed after the resident was admitted

to the facility.

Interview with the Medical Records

Coordinator on 4/4/16 at 1:00 p.m.,

indicated they have not completed a

second step tuberculin skin test since the

resident was admitted to the facility.

410 IAC 16.2-5-12(k)

Infection Control - Deficiency

(k) The facility must require staff to wash

their hands after each direct resident contact

for which hand washing is indicated by

accepted professional practice.

R 0414

Bldg. 00

Based on observation, record review and


handwashing was completed after direct

resident contact related to obtaining a

blood pressure during medication pass

for 3 of 5 residents observed during

medication pass. (Residents #8, #10, &,

#11)

Finding includes:

On 4/4/16 at 8:20 a.m., LPN #1 was

observed preparing medication for

Resident #10. At that time, she indicated

she needed to obtain the resident's blood

R 0414 1. AL Residents #8,10, 11 had

no negative outcome2. LPN#1

received counseling regarding

handwashing after contact with

resident. 3. DHS/Designee will

in-service Licensed nurses

regarding proper handwashing as

per policy.DHS/Designee will

observe 2 nurses weekly for

proper handwashing during

medication administration,

covering all shifts, for 6 months or

until QAA states otherwise.4.







05/04/2016 12:00:00AM





05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00

pressure prior to the administration of his

medications. The LPN walked over to

the resident who was seated in the dining

room, eating his breakfast and obtained

his blood pressure with an automatic

cuff. The LPN was observed to make

physical contact with the resident. After

obtaining the blood pressure she walked

back to her medication cart and poured

the resident's medications and

administered them to him. The LPN was

not observed to wash her hands with soap

and water or use an alcohol based gel to

her hands.

At that time the LPN proceeded to

prepare and administer Resident #8's and

Resident #11's medications as well,

without washing her hands or using an

alcohol based gel.

The current 8/2014 Guideline for

Handwashing policy provided by the

Director of Nursing (DON) on 4/1/16 at

2:30 p.m., indicated health care workers

shall wash hands at times such as:

Before and after having direct physical

contact with residents.

Interview with the DON on 4/4/16 at

11:00 a.m., indicated LPN #1 should

have washed her hands after obtaining

the resident's blood pressure.






05/05/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155795 04/04/2016


2400 SILHAVY ROAD

00


Documents

PRINTED: 05/05/2016 DEPARTMENT OF HEALTH AND HUMAN ... · conclusions set forth on the Statement of Deficiencies. The plan of correction is prepared and executed solely because it