F 0000 - IN.gov

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

08/25/2021PRINTED:

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

BOONVILLE, IN 47601

155801 07/19/2021

TRANSCENDENT HEALTHCARE OF BOONVILLE - NORTH

305 E NORTH ST

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey. This visit included the

Investigation of Complaint IN00357044 and

IN00355706.

Complaint IN00357044 - Substantiated.

Federal/State deficiencies related to the

allegations are cited at F602, F656, F657, F689,

F727, F728, F732, F744, and F880.

Complaint IN00355706 - Substantiated.

Federal/State deficiencies related to the

allegations are cited at F602, F656, F657, F689,

F727, F728, F732, F744, F812, and F880.

Survey dates: July 12, 13, 14, 15, and 19, 2021.

Facility number: 000450

Provider number: 155801

AIM number: 100273890

Census Bed Type:

SNF/NF: 40

Total: 40

Census Payor Type:

Medicare: 12

Medicaid: 26

Other: 2

Total: 40

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality review completed on July 29, 2021.

F 0000 By submitting the enclosed

materials, we are not admitting the

truth or accuracy of any specific

findings or allegations. We

reserve the right to contest the

findings or allegations as part of

any proceedings and submit these

responses pursuant to our

regulatory obligations. The facility

requests the plan of correction be

considered our allegation of

compliance effective August 18,

2021 to the state findings of the

Recertification and State

Licensure Survey and Complaint

Survey conducted on July 19,

2021.

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: QTNQ11 Facility ID: 000450

TITLE

If continuation sheet of 81

(X6) DATE




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483.12

Free from Misappropriation/Exploitation

§483.12

The resident has the right to be free from

abuse, neglect, misappropriation of resident

property, and exploitation as defined in this

subpart. This includes but is not limited to

freedom from corporal punishment,

involuntary seclusion and any physical or

chemical restraint not required to treat the

resident's medical symptoms.

F 0602

SS=E

Bldg. 00

Based on observation, interview, and record

review, the facility failed to ensure residents

were free from misappropriation of property for

5 of 7 residents reviewed for misappropriation

of personal items. The resident's personal items

were removed from their rooms and have not

been returned. (Resident B, Resident E,

Resident F, Resident G, Resident H)

Findings include:

1. On 7/12/21 at 11:12 a.m., Resident B

indicated approximately 2-3 months ago she was

removed from her room and placed in the lobby

during the day due to bed bugs. She indicated all

of her clothing, shoes, and personal items had

been placed in totes by the staff and removed

from her room. The resident indicated a pair of

"breast cancer" shoes, 3 pair of blue jeans, 3-4

pair of underwear, and a few "nice" blouses were

still missing. The resident indicated the facility

staff had requested the residents make a "list" of

the items they were still missing but she was

unable to remember everything.

The clinical record for Resident B was reviewed

on 7/15/21 at 9:53 a.m. Diagnoses included, but

were not limited to, anxiety disorder and major

F 0602 F - 602

1.) The corrective action taken

for those residents found to have

been affected by the deficient

practice is that the facility has

located most of the missing items

identified by the resident identified

as resident B and has returned

them to the resident. The items

that could not be located by the

facility have been replaced and

given to resident B. The

grievance/concern forms filed by

this resident have been reviewed

and all items have been found

and/or replaced and the grievance

forms have been updated to

reflect resolution to these

identified concerns.



08/18/2021 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QTNQ11 Facility ID: 000450 If continuation sheet of 81




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depressive disorder. A quarterly MDS

(Minimum Data Set) assessment, dated 5/4/21,

indicated the resident was cognitively intact.

The clinical record lacked documentation of an

personal effects inventory list of the resident's

personal items.

A "Grievance/Complaint Report," dated 6/7/21,

indicated the resident was missing 2 "little"

pillows, blue case over them, pictures, fire house

dog, 3 pair of slacks, pair of black jeans, an

orange and white cat, Christmas blouses, CD

player, and CD's. The report indicated all staff

were designated to take action on the concern

and the date to be resolved by was 6/14/21. The

report indicated the facility had looked through

the laundry room and searched the resident's

room. The facility found the 2 stuffed animals

and pictures on 7/1/21. The report lacked

documentation the resident's pillows, clothing,

CD player and CD's were located.


indicated the resident was missing a cassette

player and cassettes. The form indicated "all

staff would be designated to take action on the

concern and the date for the grievance to be

resolved by was 6/20/21. The report lacked

documentation of the cassette player and

cassettes being returned.


indicated the resident was missing red Christmas

shoes, white tennis shoes, black shoes, a pair of

new blue jeans, a black coat, several "breast

cancer" coats, and a throw. The report indicated

the Social Service Director and all staff would be

designated to take action on the concern and the

date for the grievance to be resolved was





as resident E and has returned



facility has been replaced and

given to resident E. Although the

resident did have a personal

effects inventory form in the

clinical record at the time of the

survey, an updated personal

effects inventory form has been

completed that accurately reflects

a list of the resident’s personal

effects. All of the


the resident have been reviewed

and all missing items have been

found and/or replaced and the

grievance forms have been

updated to reflect resolution to

these identified concerns.







as resident F and has returned




given to resident F. The










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7/14/21. The report indicated the facility would

search the resident's room, the laundry, and the

storage shed. The report indicated the facility

located the resident's coat and throw, but lacked

documentation of the other missing items being

located.

2. During an interview on 7/12/21 at 9:55 a.m.,

Resident E indicated in May, 2021, the

management staff at the facility had removed all

the resident's personal items from their room

one day in May, 2021. She indicated the facility

had told the residents they were "spraying for

ants" but actually the facility had bed bugs. She

indicated her personal items had been placed in

totes and taken to an outside laundry to be

laundered. Resident B indicated she was still

missing clothing and sandals. Resident B was

sharing a pair of sandals with her roommate.

The clinical record for Resident E was reviewed

on 7/13/20 at 2:20 p.m. Diagnosis included, but

were not limited to, major depressive disorder.

An annual MDS (Minimum Data Set) assessment,

dated 6/19/21. indicated the resident was

cognitively intact.

The clinical record lacked documentation of an

personal effects inventory form of the resident's

personal items.


indicated the resident was missing a long pillow

with "Grandma" written on it and a green shawl.

The form indicated the Social Service Director

and all staff was designated to take action on the

concern and the date to be resolved by was

6/20/21. The report lacked documentation of the

items being located or returned to the resident.









as resident G and has returned




given to resident G. A new

personal effects inventory form

has been completed that

accurately identifies all of the

resident’s current personal

belongings.







as resident H and has returned




given to resident H. A new

personal effects inventory form

has been completed that

accurately identifies all of the

resident’s current personal

belongings. The







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indicated the resident was missing 2 purses,

white shirt, green shirt, black sandals, a yellow

dress, and a sweater. The form indicated the

Social Service Director and all staff was


date to be resolved by was 6/20/21. The report

indicated the purses and yellow dress was found

on 6/14/21, but lacked documentation of the

other items being located or returned to the

resident.


indicated the resident was missing heavy gray

scarf, a scarf with a fringe, a white shirt with

flowers, different colored baseballs caps, and a

blue, white, and yellow scarf. The form indicated

the Social Service Director and all staff was


date to be resolved by was 6/20/21. The form

indicated the action taken to resolve the concern

was "search in laundry/resident room." The

report lacked documentation of the items being

located or returned to the resident.

3. During an interview on 7/12/21 at 2:19 p.m.,

Resident F indicated the facility had a "deep

clean" day approximately 4-6 weeks ago.

Resident F indicated she was informed the

facility had gotten "roaches" from a resident who

had recently been admitted to the facility, but the

facility had a "case of bed bugs." States she went

to physical therapy in her pajamas as the facility

staff had removed all her clothing and personal

items from her room, placing all the items into

totes. She indicated even her stuffed animals

were removed from her room. Resident F

indicated she was still missing 2 hair brushes and

a pair of red shorts.






The corrective action taken for

the other residents that have the

potential to be affected by the

same deficient practice is that all

residents have the potential to be

affected by this deficient

practice. A housewide audit has

been conducted of all residents’

personal effects to ensure no

items are currently missing. Any

missing items identified have been

located and returned to the

resident and/or replaced. A new

inventory of personal effects form

has been completed for each

resident to reflect an accurate

accounting of their personal

effects. In addition, all grievance

concerns for the past three

months have been reviewed and

have been completed to reflect

resolution to the identified

concern.

The measures that have been put

into place to ensure that the

deficient practice does not recur

is that a mandatory in-service has

been provided for all staff on the

facility’s policy related to ensuring





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On 7/13/21 at 8:49 a.m., Resident F indicated the

Administrator had spoke to her on 7/12/21 and

told her the facility did not know what they were

going to do about the missing items. She

indicated she was also missing 3 pairs of gripper

socks and a pair of mittens.

The clinical record for Resident F was reviewed

on 7/13/21 at 9:12 a.m. Diagnosis included, but

was not limited to, major depressive disorder. A

quarterly MDS (Minimum Data Set) assessment,

dated 6/22/21, indicated the resident was

cognitively intact.

A "Personal Effects" form, dated 8/5/20,

indicated the resident had "black framed glasses,

a medical alert necklace, and a gold wedding

band."


indicated the resident was missing "several items

of clothing, mostly bottoms." The form

indicated the individual(s) designated to take

action on this concern was the Social Service

Director and all staff will look in the area that is

being processed. The date to be resolved by was

6/10/21. The form indicated the action taken to

resolve the concern was "search in

laundry/resident room." The report lacked

documentation of the items being located or

returned to the resident.


indicated the resident was missing "several pairs

of shorts and tee shirts The form indicated the

individual(s) designated to take action on this

concern was the Social Service Director and all

staff "will look in the area that is being

processed." The date to be resolved by was

6/10/21. The form lacked a date the action

that the resident’s personal

property is free of

misappropriation. The in-service

also included instructions on the

completion of the personal effects

inventory form as well as the

importance of keeping the form

current and accurate. The

in-service also reviewed the

facility’s practices related to

ensuring that all

grievances/concerns are

appropriately addressed including

documentation of the resolution to

the expressed grievance/concern.

The corrective action taken to

monitor to ensure the deficient

practice will not recur is that a

Quality Assurance tool has been

developed and implemented to

monitor the handling of resident’s

personal property to ensure that

the resident’s belongings are

being secured and protected

against misappropriation. This

tool will be completed by the

Social Service Director and/or

their designee weekly for four

weeks, then monthly for three

months and then quarterly for

three quarters. The outcome of

this tool will be reviewed at the

facility’s Quality Assurance

meetings to determine if any

additional action is warranted.





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would be resolved by. The report indicated 2 pair

of pants were found in the laundry. The form

lacked documentation of the tee shirts being


4. On 7/12/21 at 9:39 a.m., Resident G indicated

in May, 2021, the facility moved all the residents

out of their rooms for the day. She indicated the

administrative staff had came into her room,

removed everything from her room, and placed

the items into a bag with the resident's name on

it. The items were taken out of the facility and

sent to an outside laundry or placed in the

outside shed. Resident H indicated the facility

staff had told her the facility was "spraying for

ants," but instead the facility had bed bugs. The

resident indicated she still had missing senior

citizens' medals, clothing and jewelry.

On 7/14/21 at 10:45 a.m., Resident G indicated

the facility had brought the items to the resident

in totes but a lot of the resident items were still

missing. She indicated the Social Service

Director had notified the residents to make a list

of all the items they still had missing. Resident

G indicated she was currently making her list to

give to the Social Service Director.

The clinical record for Resident G was reviewed

on 7/14/21 at 9:00 a.m. Diagnoses included, but

was not limited to, major depressive disorder and

anxiety disorder. A quarterly MDS (Minimum

Data Set) assessment, dated 6/8/21, indicated the

resident was cognitively intact.

The clinical record lacked documentation of a

personal effects inventory form.

On 7/14/21 at 2:45 p.m., CNA 1 and CNA 2

indicated in May, 2021, a resident was found to





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have bedbugs. The administrative staff had the

residents moved to the lobby or dining room

while they removed everything from the

resident's rooms, including jewelry clothing,

shoes, stuffed animals. "It was a fiasco." The

administrative staff placed all the resident's

items into bags with their names on the bags, but

when the items were sent to the outside laundry,

the items were all placed together. They

indicated residents were still missing items.

On 7/19/21 at 11:29 a.m., CNA 2 indicated

Resident H had jewelry and senior citizens'

medals which were removed from the resident's

room in May, 2021.

5. On 7/14/21 at 10:25 a.m., Resident H

indicated the facility had removed all the

resident's belongings in May, 2021, due to bed

bugs. Resident H indicated she was still missing

some three dresses.

The clinical record for Resident H was reviewed

on 7/19/21 at 8:14 a.m. Diagnosis included, but

was not limited to, depression. A quarterly MDS


indicated the resident was cognitively intact.


personal effects inventory form.


indicated the resident was missing "shorts and tee

three dresses." The form lacked documentation

of the "individual(s) designated to take action on

the concern, the date assigned, the dated to be

resolved by, or results of action taken." The

form lacked documentation of the dresses being






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During an interview on 7/14/21 at 10:19 a.m., the

Administrator in Training (AIT) indicated she had

been working at the facility the day of the bed

bug incident. She indicated the administrative

staff had removed the resident's clothing and

shoes but other personal items had been left in

the resident's rooms. The resident's items were

placed into bags and labeled with the resident's

names on them but they did not make out an

inventory list of the items that were removed.

The Social Service Director had a couple of totes

with clothing in them in her office.

During an interview on 7/14/21 at 5:04 p.m., the

Administrator indicated the facility had an

incident with bed bugs on May 11, 2021. The

Adm indicated the incident had not been handled

properly by the administrative staff that was at

the facility the day of the incident. The

administrative staff had placed all the resident's

clothing into bags with their names on them and

taken all the items that could be laundered to an

outside laundry where they placed everything

together to be laundered. Other items were place

into the storage shed outside of the facility. The

administrative staff had not made an inventory of

all the resident's items that had been removed.

During an interview on 7/15/21 at 9:59 a.m., the

Social Service Director indicated housekeeping

should have filled out and update the resident's

personal inventory forms in the past, but she

would be completing the task now. She indicated

if the resident had a personal effects form, it

would be in the clinical record. She had removed

the items from a "couple of resident's rooms:

when the facility had bed bugs in May, 2021. She

did not know why the administrative staff did not

fill out an inventory list of the items that were

removed from the resident's room.





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The current facility policy, "Personal Property,"

undated, provided by the Administrator on

7/19/21 at 2:14 p.m., included, but was not

limited to, "The resident's personal belongings

and clothing shall be inventoried and documented

upon admission and as such items are

replenished. The facility will promptly

investigate any complaints of misappropriation

or mistreatment of resident property."

This Federal tag relates to Complaints

IN00357044 and IN00355706.

3.1-28(a)

483.15(c)(3)-(6)(8)

Notice Requirements Before

Transfer/Discharge

§483.15(c)(3) Notice before transfer.

Before a facility transfers or discharges a

resident, the facility must-

(i) Notify the resident and the resident's

representative(s) of the transfer or discharge

and the reasons for the move in writing and

in a language and manner they understand.

The facility must send a copy of the notice to

a representative of the Office of the State

Long-Term Care Ombudsman.

(ii) Record the reasons for the transfer or

discharge in the resident's medical record in

accordance with paragraph (c)(2) of this

section; and

(iii) Include in the notice the items described

in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.

(i) Except as specified in paragraphs (c)(4)

(ii) and (c)(8) of this section, the notice of

transfer or discharge required under this

F 0623

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section must be made by the facility at least

30 days before the resident is transferred or

discharged.

(ii) Notice must be made as soon as

practicable before transfer or discharge

when-

(A) The safety of individuals in the facility

would be endangered under paragraph (c)

(1)(i)(C) of this section;

(B) The health of individuals in the facility

would be endangered, under paragraph (c)

(1)(i)(D) of this section;

(C) The resident's health improves

sufficiently to allow a more immediate

transfer or discharge, under paragraph (c)

(1)(i)(B) of this section;

(D) An immediate transfer or discharge is

required by the resident's urgent medical

needs, under paragraph (c)(1)(i)(A) of this

section; or

(E) A resident has not resided in the facility

for 30 days.

§483.15(c)(5) Contents of the notice. The

written notice specified in paragraph (c)(3)

of this section must include the following:

(i) The reason for transfer or discharge;

(ii) The effective date of transfer or

discharge;

(iii) The location to which the resident is

transferred or discharged;

(iv) A statement of the resident's appeal

rights, including the name, address (mailing

and email), and telephone number of the

entity which receives such requests; and

information on how to obtain an appeal form

and assistance in completing the form and

submitting the appeal hearing request;

(v) The name, address (mailing and email)

and telephone number of the Office of the





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State Long-Term Care Ombudsman;

(vi) For nursing facility residents with

intellectual and developmental disabilities or

related disabilities, the mailing and email

address and telephone number of the

agency responsible for the protection and

advocacy of individuals with developmental

disabilities established under Part C of the

Developmental Disabilities Assistance and

Bill of Rights Act of 2000 (Pub. L. 106-402,

codified at 42 U.S.C. 15001 et seq.); and

(vii) For nursing facility residents with a

mental disorder or related disabilities, the

mailing and email address and telephone

number of the agency responsible for the

protection and advocacy of individuals with a

mental disorder established under the

Protection and Advocacy for Mentally Ill

Individuals Act.

§483.15(c)(6) Changes to the notice.

If the information in the notice changes prior

to effecting the transfer or discharge, the

facility must update the recipients of the

notice as soon as practicable once the

updated information becomes available.

§483.15(c)(8) Notice in advance of facility

closure

In the case of facility closure, the individual

who is the administrator of the facility must

provide written notification prior to the

impending closure to the State Survey

Agency, the Office of the State Long-Term

Care Ombudsman, residents of the facility,

and the resident representatives, as well as

the plan for the transfer and adequate

relocation of the residents, as required at §

483.70(l).

F 0623 F - 623 08/18/2021 12:00:00AM





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Based on observation, interview and record

review, the facility failed to provide notice of

transfer or discharge to residents or resident

representatives as soon as was practicable for 1

of 1 residents reviewed for hospitalizations.

(Resident 39)

Finding includes:

On 7/12/21 at 2:52 p.m., Resident 39 was

observed lying in bed. The resident indicated she

had recently been transferred and admitted to the

hospital. She indicated she had not receive any

paperwork when she was transferred.

The clinical record for Resident 39 was reviewed

on 7/14/21 at 2:15 p.m. The record indicated

Resident 39 transferred to the hospital on

5/27/21 due to a change in condition. Diagnoses

included, but was not limited to, urinary tract

infection, hypertension, and hypokalemia. A


dated 6/15/21, indicated Resident 39 had

moderate cognitive impairment.

A nurse's note, dated 5/27/21 at 10:58 p.m.,

indicated an ambulance was at the facility to

transport the resident to the emergency room.

The notes lacked documentation the Notice of

Transfer/Discharge had been given to the

resident or sent to the resident's representative

as soon as practicable.


indicated the facility had reported a critical level

of potassium to the resident's physician. The

physician requested the resident be sent to the

emergency room to stabilize her electrolytes.

The note indicated the resident's sister had been

notified of the physician's order to send the


those residents found to have


practice is that the resident

identified as resident #39 who did

not receive a notice of

transfer/discharge form at the

time of their transfer to the

hospital on 05-27-21 has since

been readmitted to the facility and

has not suffered any negative

outcome from this action. If the

resident requires any future

transfers/discharges from the

facility, the appropriate notice of

transfer/discharge form will be

provided to the resident and/or

their representative. The nurse

who was responsible for the

completion of these forms at the

time of said transfer has been

re-educated on the facility policy

related to transfer/discharge

documentation. In addition, the

Notice of Transfer/Discharge form

has been corrected to reflect the

local ombudsman’s current

address and telephone number.





transferred/discharged residents

have the potential to be affected

by this deficient practice. A

housewide audit has been

completed on all

transfers/discharges within the

past thirty days to ensure that

each resident and/or their





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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(X5)

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resident to the emergency room.

The clinical record lacked documentation of the

notification in writing to Resident 39 or her

representative for the transfer.

On 7/14/21 at 3:10 p.m., the Administrator in

Training (AIT) indicated the Notice of

Transfer/Discharge had not been given to the

resident or resident's representative.

A copy of the "Notice of Transfer/Discharge"

form was provided by the Administrator on

7/14/21 at 4:22 p.m. The form had the local

Ombudsman, the Ombudsman's address and

telephone number listed incorrectly.

On 7/14/21 at 4:25 p.m., the Administrator

indicated the "Notice of Transfer/Discharge

should have been given to the resident when she

was discharged to the hospital. The

Administrator indicated the local Ombudsman's

name, the Ombudsman's address and telephone

number were incorrect on the form and the

facility had probably not notified the

Ombudsman of the transfer.

The current facility policy, "Notice of a Transfer

and/or Discharge." dated 3/28/19, provided by

the Administrator on 7/19/21 at 2:14 p.m.,

included, but was not limited to,

"The resident and/or representative (sponsor)

will be provided with the following information:

The reason for the transfer or discharge,

The effective date of the transfer or discharge.

The location to which the resident is being

transferred or discharged.

The name, address, and telephone number of the

state long-term care ombudsman,

representative has received a

copy of the Notice of

Transfer/Discharge Form with the

current ombudsman’s contact

information on the form.





been provided for all licensed

nurses, QMAs and Social

Services on the facility’s policy

related to transfer/discharge

documentation. The in-service

included a review of all the

required documents that must be

completed at the time of

transfer/discharge, including

those documents that must be

provided to the resident and/or

their representative.






monitor the transfer/discharge

documentation including the

documents that are to be provided

to the resident and/or their

representative at the time of

transfer/discharge. The tool will

also monitor to ensure that the

documentation provided is





08/25/2021PRINTED:

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OMB NO. 0938-0391




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state health department agency responsible for

the protection and advocacy of mentally ill or

developmentally disabled individuals (as applies);

and


state health department agency that has been

designated to handle appeals of transfers and

discharge notices.

The social service director will be responsible

for mailing the resident and/or the resident's

representative a copy of the Notice of

Transfer/Discharge form along with the facility

bed hold policy and document the mailing of this

information in the resident's clinical record."

3.1-12(a)(6)(A)

complete and accurate. This tool

will be completed by the Social

Service Director and/or their

designee weekly for four weeks,

then monthly for three months and

then quarterly for three quarters.

The outcome of this tool will be

reviewed at the facility’s Quality

Assurance meetings to determine

if any additional action is

warranted.

483.15(d)(1)(2)

Notice of Bed Hold Policy Before/Upon

Trnsfr

§483.15(d) Notice of bed-hold policy and

return-

§483.15(d)(1) Notice before transfer. Before

a nursing facility transfers a resident to a

hospital or the resident goes on therapeutic

leave, the nursing facility must provide written

information to the resident or resident

representative that specifies-

(i) The duration of the state bed-hold policy,

if any, during which the resident is permitted

to return and resume residence in the

nursing facility;

(ii) The reserve bed payment policy in the

state plan, under § 447.40 of this chapter, if

any;

(iii) The nursing facility's policies regarding

bed-hold periods, which must be consistent

with paragraph (e)(1) of this section,

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permitting a resident to return; and

(iv) The information specified in paragraph

(e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer.

At the time of transfer of a resident for

hospitalization or therapeutic leave, a nursing

facility must provide to the resident and the

resident representative written notice which

specifies the duration of the bed-hold policy

described in paragraph (d)(1) of this section.


review, the facility failed to provide a notice of

bed hold to residents or resident representatives

as soon as was practicable for 1 of 1 resident

reviewed. (Resident 39)

Finding includes:

On 7/12/21 at 2:52 p.m., Resident 39 was

observed lying in bed. The resident indicated she

had recently been transferred and admitted to the

hospital. She indicated she had not receive any

paperwork when she was transferred.

The clinical record for Resident 39 was reviewed

on 7/14/21 at 2:15 p.m. The record indicated

Resident 39 was transferred to the hospital on

5/27/21 due to a change in condition. Diagnoses

included, but was not limited to, urinary tract

infection, hypertension, and hypokalemia. A


dated 6/15/21, indicated Resident 39 had

moderate cognitive impairment.

A nurse's note, dated 5/28/21 at 4:23 a.m.,

indicated the resident had been admitted to the

hospital.

F 0625 F - 625





identified as resident # 39 who did

not receive a copy of the facility

bed hold policy at the time of their

transfer to the hospital on

05-27-21 has since been

readmitted to the facility and has

not suffered any negative

outcome from this action. If the

resident requires any future

transfers/discharges from the

facility, the resident and/or

representative will receive a copy

of the facility’s bed hold policy at

the time of the

transfer/discharge. The nurse

who was responsible for the

completion of the bed hold policy

and providing a copy to the

resident and/or representative has

been re-educated on the facility

policy related to the bed hold form

and the required documentation to

support that this information has

been provided to the resident

08/18/2021 12:00:00AM





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OMB NO. 0938-0391




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indicated an ambulance was at the facility to

transport the resident to the emergency room.

The notes lacked documentation the Bed Hold

policy had been given to the resident or sent to

the resident's representative.


indicated the facility had reported a critical level

of potassium to the resident's physician. The

physician requested the resident be sent to the

emergency room to stabilize her electrolytes.

The note indicated the resident's sister had been

notified of the physician's order to send the

resident to the emergency room.

The clinical record lacked documentation of the

notification in writing to Resident 39 or her

representative of the facility's bed hold policy.

On 7/14/21 at 3:10 p.m., the Administrator in

Training (AIT) indicated the Bed Hold policy had

not been given to resident or resident's

representative.

A copy of the "SNF Bed Hold/Re-Admission

information" policy" undated, was provided by the

Administrator on 7/14/21 at 10:30 a.m. The

form indicated "Residents leaving on an

emergency transfer to the hospital shall have the

notice of bed hold and readmission included with

the transfer papers to the hospital. As soon as it

is practical, the resident, family member, or legal

representative will be required to indicate

bed-hold preferences and acknowledge that

choice in writing."

3.1-12(a)(25)

3.1-12(a)(26)

and/or representative.









completed on all

transfers/discharges within the

past thirty days to ensure that

each resident and/or their

representative has received a

copy of the facility’s bed hold

policy at the time of the

transfer/discharge and that there

is documentation in the clinical

record to support this action.





been provided for all licensed

nurses and QMAs on the facility’s

policy related to providing the

resident and/or representative with

a copy of the facility’s bed hold

policy at the time of

transfer/discharge. The

in-service also re-educated the

staff on ensuring there is

documentation in the clinical

record to support that this

information (bed hold policy) has

been provided to the resident

and/or representative at the time

of transfer/discharge.





08/25/2021PRINTED:

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OMB NO. 0938-0391




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monitor the documentation to

support that at the time of

transfer/discharge the resident

and/or representative has been

provided a copy of the facility’s

bed hold policy. This tool will be

completed by the Social Service

Director and/or their designee

weekly for four weeks, then

monthly for three months and then

quarterly for three quarters. The

outcome of this tool will be




warranted.

483.20(f)(1)-(4)

Encoding/Transmitting Resident

Assessments

§483.20(f) Automated data processing

requirement-

§483.20(f)(1) Encoding data. Within 7 days

after a facility completes a resident's

assessment, a facility must encode the

following information for each resident in the

facility:

(i) Admission assessment.

(ii) Annual assessment updates.

(iii) Significant change in status

assessments.

(iv) Quarterly review assessments.

(v) A subset of items upon a resident's

transfer, reentry, discharge, and death.

(vi) Background (face-sheet) information, if

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there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7

days after a facility completes a resident's

assessment, a facility must be capable of

transmitting to the CMS System information

for each resident contained in the MDS in a

format that conforms to standard record

layouts and data dictionaries, and that

passes standardized edits defined by CMS

and the State.

§483.20(f)(3) Transmittal requirements.

Within 14 days after a facility completes a

resident's assessment, a facility must

electronically transmit encoded, accurate,

and complete MDS data to the CMS System,

including the following:

(i)Admission assessment.

(ii) Annual assessment.

(iii) Significant change in status assessment.

(iv) Significant correction of prior full

assessment.

(v) Significant correction of prior quarterly

assessment.

(vi) Quarterly review.

(vii) A subset of items upon a resident's

transfer, reentry, discharge, and death.

(viii) Background (face-sheet) information,

for an initial transmission of MDS data on

resident that does not have an admission

assessment.

§483.20(f)(4) Data format. The facility must

transmit data in the format specified by CMS

or, for a State which has an alternate RAI

approved by CMS, in the format specified by

the State and approved by CMS.

Based on record review and interview, the F 0640 F – 640

The corrective action taken for 08/18/2021 12:00:00AM





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facility failed to ensure a discharge assessment

was completed for 1 of 1 resident reviewed for

discharge MDS (Minimum Data Set) assessment.

(Resident 1)

Finding includes:

On 7/13/21 at 2:17 p.m., the clinical record for

Resident 1 was reviewed. The recorded indicated

Resident 1 entered the facility on 11/23/2020

with last census activity coded on 3/1/21. The

discharge form dated 3/1/21, indicated Resident

1 discharged home with his son.

The MDS (Minimum Data Set) discharge

tracking assessment was not listed in the MDS

information.

On 7/13/21 at 3:01 p.m., the MDS Coordinator

identified the discharge MDS record was missing

from the MDS schedule and indicated she had

"forgot about the MDS".


indicated the facility follows the RAI (Resident

Assessment Instrument) Manuel.


provided the current facility policy, MDS

Assessment Completion, revised date 3/20/21.

The Policy indicated, but was not limited to, "the

MDS coordinator will establish the schedule for

when an MDS is to be completed...the MDS

coordinator will be responsible for completing

any discharge MDSs [sic] within the required

14-day time frame."

3.1-31(g)



practice is that the MDS

discharge assessment for the

resident identified as resident # 1

has now been completed. The

missed discharged assessment

was merely an oversight and there

was no negative outcome for the

resident.









conducted of all discharges over

the past thirty days to ensure

there are no other missing

assessments. All discharges that

have occurred over the past thirty

days have been completed.





been conducted for the MDS

coordinator on the facility’s policy

related to completion of the

discharge MDS within the

required 14-day time frame.





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OMB NO. 0938-0391




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monitor the completion of the

MDS assessments in accordance

with facility policy. This includes

the discharge MDS assessment

completion within the 14-day time

frame. This tool will be completed

by the Director of Nursing and/or









483.21(b)(1)

Develop/Implement Comprehensive Care

Plan

§483.21(b) Comprehensive Care Plans

§483.21(b)(1) The facility must develop and

implement a comprehensive person-centered

care plan for each resident, consistent with

the resident rights set forth at §483.10(c)(2)

and §483.10(c)(3), that includes measurable

objectives and timeframes to meet a

resident's medical, nursing, and mental and

psychosocial needs that are identified in the

comprehensive assessment. The

comprehensive care plan must describe the

following -

(i) The services that are to be furnished to

attain or maintain the resident's highest

practicable physical, mental, and

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psychosocial well-being as required under

§483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be

required under §483.24, §483.25 or §483.40

but are not provided due to the resident's

exercise of rights under §483.10, including

the right to refuse treatment under

§483.10(c)(6).

(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with

the findings of the PASARR, it must indicate

its rationale in the resident's medical record.

(iv)In consultation with the resident and the

resident's representative(s)-

(A) The resident's goals for admission and

desired outcomes.

(B) The resident's preference and potential

for future discharge. Facilities must

document whether the resident's desire to

return to the community was assessed and

any referrals to local contact agencies

and/or other appropriate entities, for this

purpose.

(C) Discharge plans in the comprehensive

care plan, as appropriate, in accordance

with the requirements set forth in paragraph

(c) of this section.


review, the facility failed to implement a care

plan for 1 of 1 resident reviewed for ADLs

(Activities of Daily Living) and dementia, 1 of 2

residents reviewed for skin impairment, and 1 of

2 residents reviewed for receiving antipsychotic

medication. (Resident Q, Resident C, Resident J)

Findings include:

F 0656 F - 656





identified as resident Q has had

their care plan reviewed.

Resident Q’s care plan has now

been revised to address the

resident’s behaviors as well as

their current ADL needs and the

08/18/2021 12:00:00AM





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OMB NO. 0938-0391




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1. On 7/12/21 at 11:48 a.m., Resident Q was

observed to have facial stubble and indicated he

was not shaved very often. "No one has a razor

that does any good"

On 7/12/21 at 3:40 p.m., the family of Resident

Q was interviewed and indicated Resident 38 was

normally clean shaven, was particular about being

shaved, and wanted to be shaved.

On 7/13/21 at 9:26 a.m., Resident Q was

observed with facial stubble.

On 7/13/21 at 10:57 a.m., the clinical record of

Resident Q was reviewed. Diagnoses included,

but were not limited to unspecified dementia

with behavioral disturbance, hearing loss,

macular degeneration, and major depressive

disorder recurrent, mild.

An ADL care plan listed, "the resident has an

ADL self-care performance deficit related to

dementia, date initiated 2/19/21. Intervention

was side rails: bilateral half rails up as per Dr.s

[sic] order for safety during care provision, to

assist with bed mobility. Observe for injury or

entrapment related to side rail use. Reposition

approximately every 2 hours and as necessary to

avoid injury, dated 2/19/21."

Medication orders included, but were not limited

to, olanzapine 2.5 milligram, give 1 tablet by

mouth one time a day every other day for

dementia with behaviors related to unspecified

dementia with behavioral disturbance, order

dated 2/3/21.

Progress notes indicated:

3/24/21 at 8:55 a.m., resident wants to be alone,

"I'm dying".

level of assistance needed to

maintain good hygiene.





identified as resident C has had


Resident C’s care plan has now

been revised to address the

resident’s refusal of care, verbal

behaviors and bladder

incontinence. The care plan has

been updated to include

appropriate interventions to

address these identified needs.





identified as resident J has had


Resident J’s care plan has now

been revised to include a care

plan for the alteration in skin

integrity. The care plan now

includes appropriate interventions

to address the resident’s skin care

needs.










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OMB NO. 0938-0391




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3/4/21 at 11:41 a.m., ..."he also refused his a.m.

meds because he says he is dying..."

4/5/2021 11:30 a.m.,..."refuses to take his meds,

he refuses the water I offer, he refuses to take a

shower, he says he is dying, but he does go to

therapy because he believes if he exercises it

will speed up his death, resident states he wants

to die...."

4/7/2021 at 11:18 a.m., a social services note ...

"called [psychiatric services agency] and updated

about [Resident Q] current behaviors..."

4/7/2021 at 11:33 a.m., social services note

..."spoke to resident in an attempt to gain insight

regarding his behaviors. Resident reported that

he is "struggling to die"..."spoke with nursing

staff and they report that he has not ate or took

medications in five days".

4/30/2021 at 6:18 p.m., ..."declines supper

because his is dying..."

5/4/2021 at 3:00 p.m., ..."stating, "I don't need all

that because I am going to die soon". SS [social

services] notified."

The plan of care lacked identification of

behaviors and interventions to address or lessen

potential behaviors.

The plan of care also also lacked interventions to

address the level of ADL assistance needed to

maintain hygiene for Resident Q.

On 7/14/21 at 9:31 a.m., CNA 2 indicated during

interview, Resident Q was shaved when he

allowed it, he refused often. He washed himself,

but not as good as a shower would be, and


practice. A housewide audit of all

comprehensive care plans has

been completed. All resident’s

care plans have been reviewed

and updated as warranted to

address each of the resident’s

needs along with appropriate

individualized interventions to

meet those identified needs.





been provided for all members of

the interdisciplinary team on the

facility’s policy related to the

development and implementation

of a resident’s comprehensive

care plan. The in-service focused

on ensuring that all of each

resident’s needs were promptly

identified and appropriate

interventions put in place to

address those needs.






monitor the resident’s

comprehensive care plans to

ensure that all of the resident’s

needs are identified and

appropriate interventions put in

place to address the resident’s

individualized needs. This tool will

be completed by the MDS

coordinator and/or their designee






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accepted a shower at least once a week. Per the

facility West Assignment Sheet, Resident

shower days were Monday, Wednesday, and

Friday. He was up independently with walker of

wheelchair and was on a regular diet.

On 7/14/21 at 1:28 p.m., Resident Q indicated he

would be allow being shaved, if it could be done

while he was in bed. He only wanted shaved

around his mouth because that's all that bothers

him. When he was at his best, he shaved every

day, but not now.

On 7/14/21 at 1:33 p.m., CNA 3 indicated

Resident Q was shaved on shower days, but he

was "kinda funny about it" and doesn't always

allow it. Therapy 1 then indicated Resident 38

had been on caseload for ADLs recently, and

Resident Q would allow trimming of the

mustache area at times.

On 7/14/21 at 1:59 p.m., MDS Coordinator

indicated she does the care plans. When she

started not everyone had care plans and it was

very possible she hadn't gotten to Resident Q yet.

She would develop care plans by reviewing CNA

documentation and how they coded information,

then put in a care plan for his ADLs, example if

he was 1 or 2 assist for the categories.

On 7/19/21 at 2:29 p.m., the Social Services

Director (SSD) indicated Resident Q was

receiving psychiatric services and had spoken to

the MD (Medical Doctor) about his wishes. They

provide validation of Resident Q's feelings and

give reassurance..."he is strong on faith and likes

to talk to family"...he gets greeting cards and

staff have to read them to him..."give him

validation that he is safe" and it's just not on

paper.







warranted.





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2. On 7/12/21 at 4:10 p.m., family of Resident C

indicated resident had been incontinent during a

visit.


Resident C was reviewed. Diagnoses included,

but were not limited to, lyme disease, altered

mental status unspecified, disease of spinal cord,

unspecified, neuromuscular dysfunction of

bladder unspecified, and paraplegia.

The MDS Quarterly assessment dated 1/18/21,

indicated physical behaviors 1 to 3 days and

verbal behaviors 1 to 3 days, and refusal of care

for 1 to 3 days of assessment period. The MDS

Quarterly assessment dated 6/22/21, indicated

moderate cognitive impairment, and always

incontinent of bladder. The Annual MDS

assessment dated 7/2/21 indicated rejection of

care had occurred over 1-3 days of assessment

period and Resident C was dependent for

toileting and transfers with assist of 2 staff

members.

Care plans included, but were not limited to, non

pressure ulcer related to MASD (moisture

associated skin damage). Interventions included,

but were not limited to, cleanse with wound

cleanser...dated 6/30/21. Encourage [Resident C]

to drink fluids throughout the day..., dated

6/30/21. Provide peri-care after each

incontinence care...date initiated 7/7/21. Bowel

and bladder incontinence, dated 7/7/21.

The plan of care lacked refusal of care, physical

and/or verbal behaviors, and bladder

incontinence.

Review of CNA documentation for Resident C

for toileting indicated they required extensive





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

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TAG



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(X5)

COMPLETION


BOONVILLE, IN 47601

155801 07/19/2021


305 E NORTH ST

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assist during the day, limited assist at night, and

was always incontinent.

On 7/15/21 at 2:07 p.m., Resident C was

observed receiving peri care due to incontinence

of bladder. Resident was wanting to "get up and

out". Staff encouraging to Resident C to rest on

his side for a while, wait to apply cream to

buttocks, and allow new mechanical transfer

sling to be positioned. Resident remained

adamant to get up in the wheelchair and was

transferred to wheelchair per mechanical lift.

3. On 7/12/21 at 10:51 a.m., Resident J was

observed to be sitting in a recliner in his room.

Resident J had a dressing to his right forearm,

dated 7/11/21, and indicated he had received a

skin tear which the facility was treating daily and

also had itching to his shoulder area, on which

the facility had been applying an ointment to. He

indicated his physician had ordered him to see a

dermatologist but he had visited one in the past

for the itching and nothing was done. He

indicated he had recently had a scan for possible

liver disease. The resident indicated he received

an anticoagulant.

The clinical record for Resident J was reviewed

on 7/15/21 at 1:56 p.m. Diagnoses included, but

was not limited to, malignant neoplasm of the

prostate and urinary organ. A quarterly MDS


indicated Resident J was cognitively intact. The

MDS assessment indicated the resident was at

risk for pressure ulcer, had no skin tears, had a

pressure reducing device for the bed, and

received application of ointments/medications

other than to feet.


indicated the resident obtained a skin tear to his





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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BOONVILLE, IN 47601

155801 07/19/2021


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right forearm on 7/3/21, which was initially

covered with a Tegaderm (a waterproof, sterile

dressing) dressing. Upon assessment, the

periwound tissue was red and swollen granulation

tissue was present, the skin was not

approximated, the wound had a foul odor with

purulent drainage present. The area was

cleansed, a thin layer of Bactoban was applied to

the wound bed, and an oil emulsion dressing was

applied and secured with a dry dressing. The note

indicated the resident's physician would be

visiting the resident on 7/8/21 at the facility.

A physician's order, dated 7/7/21, indicated the

resident was to have "Bactroban (a topical

antibacterial medication) Ointment 2 %, apply to

right forearm skin tear topically one time a day

for wound care. Cleanse with wound cleanser,

pat dry, apply thin layer of bactroban to wound

bed, cover with oil emulsion dressing, and secure

with dry dressing." The dressing was to be

changed daily.


care plan for the alteration in skin integrity.


indicate both she and the Social Service Director

were responsible for completing the care plans.

She had just recently began employment with the

facility in December, 2020, and was still learning

the process. She indicated the resident needed a

skin integrity care plan.

The current facility policy, "Care Planning -

Interdisciplinary Team," dated 3/18/21, provided

by the Administrator on 7/19/21 at 2:14 p.m.,

included, but was not limited to, "The care plan is

based on the resident's comprehensive

assessment and is developed by a Care





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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BOONVILLE, IN 47601

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Planning/Interdisciplinary Team which includes,

but is not necessarily limited to the following

personnel:

The resident's Attending Physician;

The Registered Nurse who has responsibility for

the resident;

The Dietary Manager/Dietician;

The Social Services Worker responsible for the

resident;

The Activity Director/Coordinator;

Therapists (speech, occupational, recreational,

etc.), as applicable;

Consultants (as applicable);

The Charge Nurse responsible for resident care;

Nursing Assistants responsible for the resident's

care; and

Others as appropriate or necessary to meet the

needs of the resident.

Each discipline will be responsible for

identifying each of the resident's

problems/concerns and develop an appropriate

plan to meet the needs of each resident."


IN00357044 and IN00355706.

3.1-35(a)

483.21(b)(2)(i)-(iii)

Care Plan Timing and Revision

§483.21(b) Comprehensive Care Plans

§483.21(b)(2) A comprehensive care plan

must be-

(i) Developed within 7 days after completion

of the comprehensive assessment.

(ii) Prepared by an interdisciplinary team,

that includes but is not limited to--

(A) The attending physician.

F 0657

SS=D

Bldg. 00





08/25/2021PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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(B) A registered nurse with responsibility for

the resident.

(C) A nurse aide with responsibility for the

resident.

(D) A member of food and nutrition services

staff.

(E) To the extent practicable, the

participation of the resident and the

resident's representative(s). An explanation

must be included in a resident's medical

record if the participation of the resident and

their resident representative is determined

not practicable for the development of the

resident's care plan.

(F) Other appropriate staff or professionals

in disciplines as determined by the resident's

needs or as requested by the resident.

(iii)Reviewed and revised by the

interdisciplinary team after each assessment,

including both the comprehensive and

quarterly review assessments.


review, the facility failed to conduct care plan

conferences with the resident and/or resident

representative for 2 of 2 residents reviewed for

care plans conferences and failed to revise a care

plan for 1 of 4 resident reviewed for choices.

(Resident G, Resident L, Resident C)

Findings include:

1. On 7/12/21 at 9:40 a.m., Resident G was

observed lying in bed. Resident G indicated she

had been instructed to make a list of all her

missing personal items by the Social Service

Director. She indicated she had a lot of missing

personal items as she no longer had a home to go

to and would be staying indefinitely at the

facility.

F 0657 F - 657





identified as resident G has been

reviewed and revised. Resident

G’s care plan now reflects that the

resident plans for long-term

placement at the facility and

interventions are in place to meet

the resident’s personal choices.





identified as resident L no longer

resides at the facility.


08/18/2021 12:00:00AM





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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DEFICIENCY)

(X5)

COMPLETION


BOONVILLE, IN 47601

155801 07/19/2021


305 E NORTH ST

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On 7/14/21 at 10:20 a.m., Resident G indicated

her home had burnt down and she would be

staying long term at the facility.

The clinical record for Resident G was reviewed

on 9:00 a.m. Diagnoses included, but was not

limited to, major depressive disorder and anxiety

disorder. Thee quarterly MDS (Minimum Data

Set) assessment, dated 6/8/21, indicated the

resident was cognitively intact.

A care plan, dated 1/5/19, indicated the resident's

discharge plan was short term. The goal

indicated the resident planned to return home at

the time of discharge. Interventions, dated

1/5/19, included, but were not limited to:

"Honor my preferences, wants, and needs.

Periodic care conferences as scheduled.

When I discharge the facility will inform me of

any appointments I have.

Assist me with home health or any other services

if needed.

The facility will send all of my prescriptions to

the pharmacy of my choosing."

On 7/14/21 at 3:43 p.m., the Social Service

Director indicated she had been going through

the care plans and updating them recently, but had

not gotten to Resident G. She had just begun

employment with the facility in March, 2021.

The current facility policy, "Care Plans -

Comprehensive," dated 3/18/21, included, but

was not limited to, "Assessments of residents are

ongoing and care plans are revised as information

about the resident and the resident's condition

change. The Care Planning/Interdisciplinary

Team is responsible for the review and updating

of care plans:



practice is that upon review of the

clinical record of the resident

identified as resident C, there was

documentation of a care plan

conference being held on

05-05-21 at which time the

resident’s spouse was in

attendance. Resident C’s

representative will now be notified

of any changes in condition,

including skin tears as they occur.







practice. The MDS coordinator

has prepared a care plan

conference schedule in

conjunction with the MDS

schedule and each resident

and/or their representative is now

being invited to participate in a

care plan conference in

conjunction with the MDS

schedule.





been provided for the MDS

coordinator on the facility’s policy

related to the scheduling of care

plan conferences in conjunction

with the MDS schedule as well as





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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(X3) DATE SURVEY

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When there has been a significant change in the

resident's condition;

When the desired outcome is not met;

When the resident has been readmitted to the

facility from a hospital stay; and

At least quarterly."

2. On 7/12/21 at 5:37 p.m., during an

anonymous interview with Resident L's

representative, the representative indicated the

facility had not had a care conference with them

for over a year.

The clinical record for Resident L was reviewed

on 7/13/21 at 3:59 p.m. Diagnoses included, but

was not limited to, major depressive disorder,

dysphagia, heart failure, cerebral infarction

affecting the right side, and hypertension. An

annual MDS (Minimum Data Set) assessment,

dated 5/28/21, indicated Resident L had severe

cognitive impairment.


indicated the resident had a care conference on

that day.


care conference since 1/25/20.

3. On 7/12/21 at 4:20 p.m., the family of

Resident C indicated they had not had a care

conference, and hadn't had one since COVID-19

restrictions had occurred. The facility did not

call or inform them of anything.






bladder unspecified, and paraplegia. The MDS

upon the request of the resident

and/or their representative. Care

plan conferences are now being

scheduled in accordance with

facility policy.






ensure that care plan conferences

are being conducted in

accordance with facility policy.

The tool will monitor to ensure that

the resident and/or their

representatives are being invited

to participate in a care plan

conference at least quarterly and

more often if warranted. This tool

will be completed by the Director

of Nursing and/or their designee








warranted.





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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BOONVILLE, IN 47601

155801 07/19/2021


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physical behaviors 1 to 3 days and verbal

behaviors 1 to 3 days, and refusal of care for 1

to 3 days of assessment period. The MDS


moderate cognitive impairment. The Annual

MDS assessment dated 7/2/21 indicated

rejection of care had occurred over 1-3 days of

assessment period.

Care plans included, but were not limited to,

[Resident C] has tendencies to miss family and

become upset, initiated on 4/29/2019, revised on

12/15/2019. Interventions included, but were not

limited to, monitor behavior episodes and

attempt to determine underlying

cause...document behavior and potential

causes...offer resident conversation about family

or other topics of interest...dated 4/29/2019.

Progress notes indicated, but were not limited

to:

7/8/2021 at 7:23 p.m., per the SSD...resident was

sitting in the dining room and talking to another

resident. Writer could not hear what the

discussion was about. [Resident C] decided to go

in his wheelchair past the other resident and end

the conversation. The other resident stood up and

tapped his arm. [Resident C] kept rolling but

suffered a skin tear. The nurse, general manager

were notified. ...

7/7/2021 at 4:05 p.m., per the SSD ... has been

confused and having erratic behaviors...he was

difficult to redirect at times. He was resistive to

care but not on a daily basis...

5/25/2021 at 9:14 a.m., per the SSD...is

prescribed Zoloft (antidepressant





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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medication)...suggests mild depression...nursing

staff has noted he can be resistive to care...often

yells, kicks, and hits staff when they are trying to

provide care....gets upset easily and difficult to

redirect...

The medical record lacked documentation of

care plan meetings.

On 7/15/21 at 1:09 p.m., SSD indicated she

notified the other resident's family, not Resident

C's. The AIT (Administrator in Training) was to

call and let them know.

On 7/15/21 at 2:23 p.m., AIT indicated she did

the investigation through the facility, and she did

not notify any family.

On 7/15/21 at 9:14 a.m., SSD (social services

director) indicated during an interview, the care

conferences were supposed to be quarterly with

the MD'S (Minimum Data Set) assessments. She

had had informal conversations with Resident C's

family when they come for visitation. The last

time family was here they had concerns with his

change in behaviors, thinking he was not married,

and didn't know he was on an antidepressant

medication, and it was very informal.

On 7/14/21 at 3:43 p.m., the Social Service

Director indicated care conferences should be

done in coordination with the MDS assessments,

if needed for the resident, or requested by the

resident ore resident representative. She had

been trying to have care conferences as they

were needed, but had only started employment

with the facility in March, 2021. She had spoken

with Resident L's family member several times

but had not had a care conference. She indicated

at time some of the residents' families chose not





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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to attend the care conference and she would

attempt to document it.

The current facility policy, "Care Planning -

Interdisciplinary Team," dated 3/18/21, provided

by the Administrator on 7/19/21 at 2:14 p.m.,

included, but was not limited to, "The resident,

resident's family and/or the resident's legal

representative/guardian or surrogate are

encouraged to participate in the development of

and revisions to the resident's care plan. Every

effort will be made to schedule care plan

meetings at the best time of the day for the

resident and family. When a resident has no

family, the responsible party will be invited to

attend the care conference.


IN00357044 and IN00355706.

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

3.1-35(g)(2)

483.25(d)(1)(2)

Free of Accident

Hazards/Supervision/Devices

§483.25(d) Accidents.

The facility must ensure that -

§483.25(d)(1) The resident environment

remains as free of accident hazards as is

possible; and

§483.25(d)(2)Each resident receives

adequate supervision and assistance devices

to prevent accidents.

F 0689

SS=D

Bldg. 00


review, the facility failed to ensure the resident

environment remained as free of accident

hazards as possible for 1 of 2 residents reviewed

F 0689 F - 689





08/18/2021 12:00:00AM





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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(X4) ID

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BOONVILLE, IN 47601

155801 07/19/2021


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for smoking. (Resident C)

Finding includes:

On 7/12/21 at 10:57 a.m., Resident C was

observed during smoking time. A smoking apron

was applied per Laundry 1 to Resident C. The

smoking apron was noted to have fold creases

worn and frayed on the creases with holes down

the center of the apron with the appearance of

being very worn with brown/black discolorations

in areas of the chest of the apron.

On 7/12/21 at 11:14 a.m., Laundry 1 indicated

they only had one smoking apron. One had been

ordered and hadn't come in. Laundry 1 was

observed to cue and give reminder to Resident C

to pick up the cigarette higher due to having laid

it on his thigh area of the smoking apron while

lit.

On 7/13/21 at 11:04 a.m., the Administrator

indicated the new smoking apron had arrived at

the facility.






bladder unspecified, and paraplegia. The smoking

assessment dated 7/2/2020, indicated but was not

limited to, need for adaptive equipment smoking

apron, supervision...smoke during smoke breaks

if asks and supervise while smoking staff to light

cigarette...apron to be used for safety due to poor

muscle control.

The plan of care included, but was not limited to,

[Resident C] is a smoker, date initiated

identified as resident C is now

wearing a new smoking apron

during smoke breaks. The

resident’s cigarette is not being lit

until the smoking apron is in place

and is monitored during each

smoke break for resident safety.

The staff member identified as

Medical Records has been

re-educated on resident C’s

smoking needs which includes the

use of a smoking apron.





residents who smoke have the

potential to be affected by this

deficient practice. All residents

that smoke have been reassessed

related to their smoking safety

needs. Additional smoking aprons

have been purchased for use as

warranted by the resident’s

smoking assessments. All staff

that provide smoking supervision

have been re-educated on the

resident’s smoking safety needs

and interventions.






facility’s smoking safety policy.

The staff have been re-educated

on ensuring that smoking aprons

are in use when indicated and that

the aprons are immediately

replace when they are damaged





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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155801 07/19/2021


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4/22/2019, revision on 8/29/2019. Interventions

included, but were not limited to, ...non

compliant with wearing a smoking apron while

smoking, dated 4/1/21. Observe clothing and

skin for signs of cigarette burns, dated

2/14/2020. The resident requires a smoking

apron while smoking, dated 2/14/2020.


observed exiting for the smoking break.

Observation of new smoking apron folded in a

basket in Medical Records hand.


observed smoking with no smoking apron in use.

Medical Records was observed handing out

cigarettes and lighting them for the residents in

attendance.

On 7/14/21 at 1:15 p.m., Medical Records

indicated she had only "smoked the residents 3

times" and was unaware Resident C was to wear a

smoking apron.


provided the facilities current policy, Smoking

Policy - Residents, revised December 2007. The

Policy indicated, but was not limited to, "any

smoking- related privileges, restrictions, and

concerns ... shall be noted on the care plan, and

all personnel caring for the resident shall be

alerted to these issues."


IN00357044 and IN00355706.

3.1-45(a)(1)

or in poor condition.






monitor the smoking practices of

the residents during smoke

breaks. The tool will monitor to

ensure that all appropriate safety

interventions are in place and

being followed during resident

smoke breaks. This tool will be

completed by the Social Service









warranted.

483.35(b)(1)-(3)

RN 8 Hrs/7 days/Wk, Full Time DON

F 0727

SS=E





08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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§483.35(b) Registered nurse

§483.35(b)(1) Except when waived under

paragraph (e) or (f) of this section, the

facility must use the services of a registered

nurse for at least 8 consecutive hours a day,

7 days a week.

§483.35(b)(2) Except when waived under

paragraph (e) or (f) of this section, the

facility must designate a registered nurse to

serve as the director of nursing on a full time

basis.

§483.35(b)(3) The director of nursing may

serve as a charge nurse only when the

facility has an average daily occupancy of

60 or fewer residents.

Bldg. 00

Based on record review and interview, the

facility failed to provide a RN (Registered

Nurse) working at least 8 hours a day, 7 days a

week in the facility for 3 of 8 days reviewed.

(July 10, 2021, July 11, 2021, and July 12,

2021)

Findings include:


provided the "Daily Staffing" for July 5, 2021

through July 12, 2021. The schedule indicated a

RN was not scheduled or had worked on Friday,

July 10, Saturday, July 11, or Sunday, July 12,

2021.

On 7/19/21 at 9:12 a.m., the Director of Nursing

indicated he had not worked on July 10, July 11,

or July 12, 2021.


indicated the schedule lacked RN coverage on

F 0727 F - 727




practice is that although no

specific residents were identified

during the survey, all residents


by this deficient practice. The

facility has been actively

recruiting for additional RN

employees through multiple

employment resources. The

facility now has coverage that

provides 8 consecutive hours of

RN coverage seven days a week.







practice. The facility now has

08/18/2021 12:00:00AM





08/25/2021PRINTED:

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OMB NO. 0938-0391




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July 10, 11, and 12, 2021. He indicated the

facility had difficulty with RN coverage and it

was difficult finding RNs to hire.

The current facility policy, "Staffing Coverage &

Posting of Patterns," dated 11/5/19, provided by

the Administrator on 7/19/21, included, but was

not limited to, "Our facility maintains adequate

staffing on each shirt to ensure that our resident's

needs and services are met. Licensed registered

nursing and licensed nursing staff are available to

provide and monitor the delivery of resident care

services according to appropriate regulations.


IN00357044 and IN00355706.

3.1-17(b)(3)

coverage that provides 8

consecutive hours of RN coverage

seven days a week.





been provided for the Director of

Nursing on the facility’s practice

related to RN coverage, to ensure

their knowledge level of their

responsibility to secure 8 hours of

RN coverage seven days a week.

The facility’s staffing pattern

policy was reviewed with the

Director of Nursing which clearly

identifies the requirement of the 8


seven days a week.






monitor the nursing staff schedule

to ensure that there is 8


seven days a week. This tool will

be completed by the Executive













08/25/2021PRINTED:

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OMB NO. 0938-0391




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warranted.

483.35(d)(1)-(3)

Facility Hiring and Use of Nurse Aide

§483.35(d) Requirement for facility hiring

and use of nurse aides-

§483.35(d)(1) General rule.

A facility must not use any individual working

in the facility as a nurse aide for more than 4

months, on a full-time basis, unless-

(i) That individual is competent to provide

nursing and nursing related services; and

(ii)(A) That individual has completed a

training and competency evaluation program,

or a competency evaluation program

approved by the State as meeting the

requirements of §483.151 through §483.154;

or

(B) That individual has been deemed or

determined competent as provided in

§483.150(a) and (b).

§483.35(d)(2) Non-permanent employees.

A facility must not use on a temporary, per

diem, leased, or any basis other than a

permanent employee any individual who

does not meet the requirements in

paragraphs (d)(1)(i) and (ii) of this section.

§483.35(d)(3) Minimum Competency

A facility must not use any individual who has

worked less than 4 months as a nurse aide in

that facility unless the individual-

(i) Is a full-time employee in a

State-approved training and competency

evaluation program;

(ii) Has demonstrated competence through

satisfactory participation in a State-approved

nurse aide training and competency

evaluation program or competency evaluation

F 0728

SS=E

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08/25/2021PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

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DEFICIENCY)

(X5)

COMPLETION


BOONVILLE, IN 47601

155801 07/19/2021


305 E NORTH ST

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program; or

(iii) Has been deemed or determined

competent as provided in §483.150(a) and

(b).


facility failed to ensure an individual working as

a certified nursing assistance had a State

certification. A CNA's certification had expired .

(CNA 3)

Finding includes:

During review of the CNA certification on

7/15/21 at 12:40 p.m., CNA 3 was observed to

have begun employment at the facility on 6/1/12.

CNA 3's certification expired on 9/25/20.

Review of the CNA schedule from July 1, 2021

through July 19, 2021 indicated CNA 3 had

worked on 7/1/21, 7/2/21, 7/6/21, 7/8/21,

7/9/21, 7/13/21, and 7/15/21 providing showers

on the day shift.

The facility lacked documentation of CNA 3's

recertification from the Indiana Department of

Health.


indicated CNA 3 had been sent home and

removed from the schedule for Friday, July 16,

2021.


indicated the Business Office Manager had sent

the information to the State agency for CNA 3's

recertification.

The current facility policy, "Personnel Records,"

dated 3/12/21, provided by the Administrator on

F 0728 F - 728






during the survey, all residents


by this deficient practice. It

should be noted that no negative

outcomes have occurred related

to this deficient practice. The CNA

identified as CNA # 3 was

immediately removed from the

work schedule once their lapse in

certification was identified. CNA

# 3’s certification has been

renewed and the CNA has now

returned to their work schedule.






affected by this deficient practice

however no negative outcomes

have occurred. A housewide

audit of all CNA’s certifications

have been conducted and all

certifications are current.






08/18/2021 12:00:00AM





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FORM APPROVED

OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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BOONVILLE, IN 47601

155801 07/19/2021


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7/19/21 at 2:14 p.m., included, but was not

limited to, "Federal and state regulations require

that our facility maintain an individual personnel

record for each employee, However, it shall be

the employee's responsibility to provide the

Business Office manager and/or supervisor with

the required data. Personnel records contain, as

each may apply, the following data: ... Copy of

current licenses (as applicable)..."


IN00357044 and IN00355706.

3.1-14(b)

Nursing on their responsibility to

ensure that all certifications and

licensures are current at all times

in accordance with the

regulations.






monitor the CNA’s certifications to

ensure that each CNA’s

certification is current and

updated in a timely manner to

ensure continued compliance.

This tool will be completed by the

Business Office Manager and/or









483.35(g)(1)-(4)

Posted Nurse Staffing Information

§483.35(g) Nurse Staffing Information.

§483.35(g)(1) Data requirements. The

facility must post the following information on

a daily basis:

(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours

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08/25/2021PRINTED:

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OMB NO. 0938-0391




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worked by the following categories of

licensed and unlicensed nursing staff directly

responsible for resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed

vocational nurses (as defined under State

law).

(C) Certified nurse aides.

(iv) Resident census.

§483.35(g)(2) Posting requirements.

(i) The facility must post the nurse staffing

data specified in paragraph (g)(1) of this

section on a daily basis at the beginning of

each shift.

(ii) Data must be posted as follows:

(A) Clear and readable format.

(B) In a prominent place readily accessible

to residents and visitors.

§483.35(g)(3) Public access to posted nurse

staffing data. The facility must, upon oral or

written request, make nurse staffing data

available to the public for review at a cost not

to exceed the community standard.

§483.35(g)(4) Facility data retention

requirements. The facility must maintain the

posted daily nurse staffing data for a

minimum of 18 months, or as required by

State law, whichever is greater.


review, the facility failed to ensure the daily

staffing posted the number of nursing staff by

category (RN, LPN, and CNA) providing direct

care to residents during each shift and the actual

hours worked by the staff during each shift for 3

of 4 days of posted daily staffing was reviewed.

F 0732 F - 732






during the survey all residents


by the deficient practice. The

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Findings include:

On 7/12/21 at 9:20 a.m., the nursing staffing was

not posted in the facility.

On 713/21 at 9:01 a.m., the posted nursing

staffing listed the hours for Days: 1 LPN for 8

hours, 1 QMA for 8 hours, and 4 CNAs for 32

hours, Evening: 2 LPN for 8 hours, 1 QMA for 4

hours, and 4 CNAs for 16 hours, and Nights: 1

LPN for 8 hours and 2 CNAs for 16 hours. The

posted nursing staffing lacked documentation of

when the shifts/hours were occurring.

On 7/14/21 at 8:30 a.m., the posted nursing

staffing listed the hours for Days: 1 RN for 8

hours, 1 QMA for 8 hours, and 4 CNAs for 32

hours, Evening: 1 RN for 4 hours, 2 LPN for 8

hours, and 4 CNA/PCA for 16 hours, and Nights:

1 LPN for 8 hours and 2 CNA/PCA for 16 hours.

The posted nursing staffing lacked

documentation of when the shifts/hours were

occurring.

On 7/15/21 at 8:56 a.m., the posted nursing

staffing lacked documentation of the census.

On 7/19/21 at 8:00 a.m., the facility lacked

documentation of the posted nursing.


indicated the staffing was not properly posted.

The staff usually worked 12 hour shifts.

The current facility policy, "Staffing Coverage &

Posting of Patterns," dated 11/5/19, provided by

the Administrator on 4/19/21 at 2:14 p.m.,

included, but was not limited to, "Our facility

publicly posts the daily staffing patterns each day

to reflect the specific numbers of licensed and

facility has revised the format for

the daily staffing posting form.

The form now includes all required

components including the number

of nursing staff by category who

are providing direct care to the

residents during each shift, along

with the actual hours worked. The

hours for each shift are clearly

identified and the current daily

census is posted on the form as

well.







practice. The facility has revised

the format for the daily staffing

posting form. The form now

includes all required components

including the number of nursing

staff by category who are

providing direct care to the

residents during each shift, along

with the actual hours worked. The

hours for each shift are clearly

identified and the current daily

census is posted on the form as

well.





been provided for the Medical

Records clerk on the revised daily

staffing posting form, with specific

instructions on their responsibility

to ensure that this form is





08/25/2021PRINTED:

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OMB NO. 0938-0391




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unlicensed staff that are available to provide

direct patient care on each shift.


IN00357044 and IN00355706.

completed accurately daily and

posted in accordance with facility

policy.






monitor the daily staffing posting

form to ensure that the information

posted is complete, accurate and

posted daily in accordance with

facility policy. This tool will be

completed by the Director of

Nursing and/or their designee








warranted.

483.40(b)(3)

Treatment/Service for Dementia

§483.40(b)(3) A resident who displays or is

diagnosed with dementia, receives the

appropriate treatment and services to attain

or maintain his or her highest practicable

physical, mental, and psychosocial

well-being.

F 0744

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Based on observation, record review, and

interview the facility failed to provide an

environment that enhanced the quality of life for

1 of 2 residents review for dementia care. A

resident did not receive adequate stimulation to

reduce the decline of his cognitive status and

F 0744 F - 744





identified as resident Q has had

their plan of care reviewed.

08/18/2021 12:00:00AM





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maintain resident's well being.(Resident Q)

Finding includes:

On 7/12/21 at 11:48 a.m., Resident Q was

observed to have facial stubble and indicated he

was not shaved very often. "No one has a razor

that does any good"

On 7/13/21 at 10:57 a.m., the clinical record of

Resident Q was reviewed. Diagnoses included,

but were not limited to unspecified dementia

with behavioral disturbance, hearing loss,

macular degeneration, and major depressive

disorder recurrent, mild. Admission MDS

(Minimum Data Set) assessment dated

10/16/2020 indicated no cognitive impairment

and no behaviors. The Quarterly MDS dated

6/15/21 indicated moderate cognitive

impairment and no behaviors during the

assessment period.

A care plan, included but was not limited to, "the

depression has little or no activity involvement

r/t (related to) anxiety, depression, disinterest,

immobility, date initiated 10/9/2020, revised on

5/29/21. Interventions included, but were not

limited to, "Invite/encourage the resident's family

members to attend activities with resident in

order to support participation, date initiated

5/29/2021...the resident needs a variety of

activity types and locations to maintain interests,

dated 5/29/2021...resident needs

assistance/escort to activity functions, dated

5/29/2021."

The plan of care lacked interventions to address

or lessen potential behaviors related to dementia

and enhance Resident Q's daily life.

Resident Q’s plan of care has

been updated to address ways to

enhance the resident’s

environment in an effort to

improve their quality of life and

lessen their behaviors related to

their dementia. Psychiatric

services are also continuing to

monitor the resident closely as

well and will continue to make

recommendations related to their

psychosocial needs.





residents with dementia have the

potential to be affected by this

deficient practice. A housewide

audit of all residents with dementia

has been conducted and their

plans of care reviewed to ensure

that all of their needs related to

dementia have been identified and

addressed with appropriate

interventions to meet those needs.





been conducted for all staff on the

special needs of the dementia

resident. A review of the facility

policy related to dementia clinical

protocols was also reviewed with

the staff to ensure their

understanding of the special

needs of the dementia resident.






08/25/2021PRINTED:

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OMB NO. 0938-0391




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Medication orders included, but here not limited

to, olanzapine 2.5 milligram, give 1 tablet by

mouth one time a day every other day for

dementia with behaviors related to unspecified

dementia with behavioral disturbance, order

dated 2/3/21.

Progress notes indicated:

3/24/21 at 8:55 a.m., resident wants to be alone,

"I'm dying".

3/4/21 at 11:41 a.m., ..."he also refused his a.m.

meds because he says he is dying..."

4/5/2021 11:30 a.m.,..."refuses to take his meds,

he refuses the water I offer, he refuses to take a

shower, he says he is dying, but he does go to

therapy because he believes if he exercises it

will speed up hiss death, resident states he wants

to die...."

4/7/2021 at 11:18 a.m., a social services note ...

"called [psychiatric services agency] and updated

about [Resident Q] current behaviors..."

4/7/2021 at 11:33 a.m., social services note

..."spoke to resident in an attempt to gain insight

regarding his behaviors. Resident reported that

he is "struggling to die"..."spoke with nursing

staff and they report that he has not ate or took

medications in five days".

4/30/2021 at 6:18 p.m., ..."declines supper

because his is dying..."

5/4/2021 at 3:00 p.m., ..."stating, "I don't need all

that because I am going to die soon". SS [social

services] notified."

Psychiatry Progress note dated 5/24/21





monitor the plan of care for those

residents with dementia to ensure

that all of their needs have been

identified and address with

appropriate interventions in an

effort to improve/enhance their

overall quality of life. This tool will

be completed by the Social

Service Director and/or their








warranted.





08/25/2021PRINTED:

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OMB NO. 0938-0391




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indicated, but was not limited to, "resident is

positive for dementia related behavioral

disturbance (lability, attention seeking). He

receives individual and pharmacotherapy as

treatment."

On 7/19/21 at 2:29 p.m., Social Services

Director (SSD) indicated Resident Q was seen

per psychiatric services....the facility provided

validation of his feelings and reassurance...he

was strong on faith, likes to talk to his family,

and gets greeting cards which the staff read to

him. They were providing dementia care, it's just

not on paper. She had been hired in March of

2021.


provided the current facility policy, Dementia,

Caring for Residents, revision date June 2008.

The Policy indicated, but was not limited to, "the

staff and physician will evaluate individuals with

new of progressive cognitive impairment and

help identify symptoms and findings that

differentiate dementia from other causes...staff,

with the physician's input, will stage dementia

and identify prognosis...the staff and physician

will identify a plan to maximize remaining

function and quality of life."


IN00357044 and IN00355706.

3.1-37(a)

483.45(g)(h)(1)(2)

Label/Store Drugs and Biologicals

§483.45(g) Labeling of Drugs and Biologicals

Drugs and biologicals used in the facility

must be labeled in accordance with currently

accepted professional principles, and include

F 0761

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08/25/2021PRINTED:

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OMB NO. 0938-0391




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the appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) 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.

§483.45(h)(2) 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.


review, the facility failed to ensure medications

were labeled with open dates upon opening in 1

of 1 medication rooms and failed to secure

medications on medication carts. (Medication

Room, West Medication Cart, East Medication

Cart, Resident 30, Resident 2)

Finding includes:

1. On 7/13/21 between 8:52 a.m. and 9:07 a.m.,

DON (Director of Nursing) was observed to have

the East medication cart unlocked, with the key

engaged in the lock with multiple keys hanging

from the key ring, and leave the hallway with no

staff observing the medication cart, close the

F 0761 F - 761









East and West Hall medication

carts are now locked securely

when not directly being attended

by the licensed nurses or QMAs.





08/18/2021 12:00:00AM





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door of Resident 30's room to administer

medication to Resident 30. DON returned to the

hallway to prepare medication for Resident 2,

and locked the cart at 9:07 a.m.

On 7/14/21 at 9:23 a.m., DON indicated he was

supposed to "lock the medication cart every time

you leave the cart to go in a room or anything."

On 7/14/21 at 1:24 p.m., observation of the West

medication cart in the hallway with the key

engaged in the lock with multiple keys hanging

from the key ring, with the lock in the unlocked

position, and no staff were present. No residents

noted in vicinity.

2. On 7/14/21 at 9:18 a.m., QMA 1 opened the

medication refrigerator. 3 (Three) vials of the 6

(six) available vials of tuberculin (serum used to

detect tuberculosis) in the refrigerator were

opened and undated.

On 7/14/21 at 9:26 a.m., the Director of Nursing

(DON) indicated he was not sure how long the

vials were good for.

On 7/14/21 at 9:45 a.m., DON indicated the vials

of tuberculin were good till 12/2021, but once

opened were good for 30 days. He was

discarding the 3 opened vials.

On 7/19/21 at 2:14 p.m., Administrator provided

the current facility policy, Medication

Administration, revised date 3/14/2019. The

Policy indicated, but was not limited to, "the

nurse and/or QMA shall administer all

medications in accordance with acceptable

standards of medication administration practices

and manufacturer guidelines...the medication cart

is to be locked at all times when unattended by





three opened vials of tuberculin

serum were immediately

destroyed during the survey. All

tuberculin serum is now being

dated when initially opened and

discarded thirty days after the

opening date.







practice. All medication carts are

now being securely locked when

not directly attended by the

licensed nurse or QMA. In

accordance with the manufacturer

guidelines, all medications are

now being dated when opened

and promptly discarded upon the

manufacturer guidelines

recommended dates for usage.






Nursing, all licensed nurses and

QMAs on the facility’s policy

related to medication

administration and medication

storage. The licensed nurses,





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the nurse...medications are also to be dated when

opened in accordance with acceptable standards

of medication administration practices and

discarded in accordance with acceptable

standards of practice and the manufacturer

guidelines."

Additional policy, provided by the Administrator

on 7/19/21 at 2:14 p.m., Storage of Medications,

revised date 3/12/21. The Policy indicated, but

was not limited to, "the facility shall not use

discontinued, outdated, or deteriorated drugs or

biologicals. All such drugs shall be returned to

dispensing pharmacy or destroyed... only persons

authorized to prepare and administer medications

shall have access to the medication room,

including any keys."

3.1-25(j)

DNS and QMAs were reminded of

their responsibility to ensure that

all medications were properly

secured at all times and that when

required opened medications

were dated and discarded in

accordance with the individual

manufacturer guidelines.





developed and implemented for

the monitoring of medication

administration and storage. This

tool will monitor to ensure that

facility policies related to ensuring

that medications were secured at

all times and that the manufacturer

guidelines were being following

related to the dating of opened

medications and that medications

were discarded after opening in

accordance with their

manufacturer guidelines. This tool

will be completed by the Director

of Nursing and/or their designee








warranted.

483.60(d)(1)(2)

Nutritive Value/Appear, Palatable/Prefer

Temp

§483.60(d) Food and drink

F 0804

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Each resident receives and the facility

provides-

§483.60(d)(1) Food prepared by methods

that conserve nutritive value, flavor, and

appearance;

§483.60(d)(2) Food and drink that is

palatable, attractive, and at a safe and

appetizing temperature.


review, the facility failed to ensure food was

palatable and attractive to eat for 2 of 2 meals

observed and 1 of 1 Resident Council meeting.

Pureed foods were served repeatedly at meals

and residents receiving regular foods indicated

the foods were not cooked and they received the

same foods repeatedly.

Findings include:

On 7/12/21 at 10:12 a.m., the Cook 1 was

observed to be in the kitchen with his mask under

his nose. He indicated the facility had

pre-packaged puree foods for the residents who

required pureed foods. He indicated the facility

did not puree the foods on site. A pot of green

beans were observed cooking on the stove and

Cook 1 was observed to place frozen breaded

chicken patties into the deep fryer. No food

recipes were observed in the kitchen.

On 7/12/21 at 12:07 p.m., the lunch meal was

served in the dining room. The residents who

required pureed foods were served puree beef

and pureed peas along with pudding. Residents

who received regular foods received breaded

chicken patties, noodles, green beans, and fruit

or pudding.

F 0804 F – 804








by the deficient practices. The

residents are now receiving meals

that are palatable, attractive and in

accordance with the approved

menus to ensure that the meals

are nutritionally adequate to meet

the resident’s needs. The

residents are also now being

provided a variety of foods in

accordance with their individual

preferences/choices. The

dietician has reviewed and

approved the menus and is

continuing to work with the Food

Service Manager related to

additional training on the

preparation and serving of

nutritious meals. In addition, the

Cook identified as Cook # 1 is

now wearing their face mask in

accordance with acceptable

standards of infection control

08/18/2021 12:00:00AM





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The menu for 7/12/21 indicated residents were

to receive pollock almondine, parsley noodles,

sauteed mushrooms, choice of roll, and toffee

pecan bar for the noon meal.

On 7/13/21 at 12:15 p.m., during the serving of

the lunch meal, the residents who required

pureed foods were served pureed beef, mashed

potatoes, and pureed peas. The menu indicated

the residents were to receive country fried steak,

American fried potatoes, seasoned greens,

southern style biscuit and cherry fruit cobbler

for the lunch meal on 7/13/21. No food recipes

were observed.

During the Resident Council meeting on 7/14/21

at 10:10 a.m., the residents indicated the food

was terrible at the facility. The same foods were

served repeatedly, the portions sizes were small,

and the facility was provided a lot of fish and

chicken. The foods were not seasoned and were

either overcooked or undercooked. They

indicated the chili served for the evening meal on

7/11/21 had no meat in it or chili powder. The

residents indicated the food service manager

could not cook and one of the residents indicated

she had offered the food service manager some

recipes and the laundry lady had offered to teach

him to cook. The residents indicated they do not

have a food committee at the facility nor do they

do not have a selective menu. If they requested

extra helpings they were told they were out of

the foods, and the only alternates they were

offered were a hamburger or cheeseburger or a

salad which had nothing but lettuce in it.


Food Service Manager indicated the facility did

not offer a selective menu and offered a salad,

hamburgers or cheeseburgers, and peanut butter

practices.






affected by this deficient practice.

The residents are now receiving

meals that are palatable, attractive

and in accordance with the

approved menus to ensure that

the meals are nutritionally

adequate to meet the resident’s

needs. The residents are also

now being provided a variety of

foods in accordance with their

individual preferences/choices.

The dietician has reviewed and

approved the menus and is

continuing to work with the Food

Service Manager related to

additional training on the

preparation and serving of

nutritious meals. The Food

Service Director is also

interviewing residents to identified

their food preferences and solicit

any food concerns so that they

can be promptly addressed.





08/25/2021PRINTED:

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OMB NO. 0938-0391




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sandwiches for alternates. He indicated the

residents had to notify the kitchen 3 hours in

advance if they wanted an alternate for any of the

meals and the residents could have extra helpings

of foods if the kitchen had any left. The Food

Service Manager indicated the facility had

recipes and provided recipes for all the foods

including pureed foods for the week of 7/21/21

through 7/27/21.


Administrator indicated the Food Service

Manager had provided the wrong recipes and the

facility did not puree foods on site. The

Administrator indicated he had ate the noon meal

on 7/13/21 and thought the meat was a pork loin

and felt the residents should have been served

white gravy with their meat. He indicated it was

obvious the Food Service Manager did not follow

the recipes for the food cooked on 7/12/21 and

7/13/21. He indicated the Food Service Manager

had only been in the position for approximately 1

1/2 months and had just started the Safe-Serv

course.

The Resident Council meeting minutes were

reviewed on 7/14/21 at 3:30 p.m. The minutes

were as followed:

The July 7, 2021, minutes indicated the Food

Service Manager would put salt and pepper on the

resident's trays and would place burger garnishes

on the plate instead of leaving it up to the CNAs

to pass out the garnishes in bowls. The minutes

indicated the residents would like more snack

options and not just peanut butter crackers, they

would like more fresh fruits, vegetables,

homemade meals, and would like to have meat in

the vegetable soup and chili. One of the

residents indicated she would like to give the





been provided for all dietary staff

on the following of approved

menus. Additional training has

been provided on how to follow the

established food worksheets to

ensure the recipes are being

followed for each food item

prepared as well as additional

guidance on the weekly ordering

of food items to ensure an

adequate quantity of food items is

ordered. The dietician is also

reviewing the menus weekly and

approving any substitutes needed

and is also offering possible other

alternatives to provide the

residents with a larger variety of

food choices. The dietician will

also be continuing to provide

additional food preparation

training as the menus change and

to provide additional guidance in

food preparation as needed. The

Food Service Director is also

continuing with their Safe Serve

course to continue to enhance





08/25/2021PRINTED:

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Food Service Manager some recipes.

The June 9, 2021, minutes indicated the

residents felt as though the Food Service

Director could not cook.

The May 11, 2021, minutes indicated the food

selection was not appetizing, the residents

wanted more home made food, and the foods did

not taste good and had no flavor.

The April 14, 2021, minutes indicated the food

was still bad, getting frozen foods on their trays,

nothing was homemade, residents were unable to

obtain a "real" egg in the morning, the meat is too

tough and the residents were unable to chew it,

the food had no taste, as no salt/spices were

added, and the dessert portion sizes are small.


indicated the residents were being served the

same foods, especially the pureed foods

repeatedly. He indicated the facility needed a

food committee for the Food Service Manager

and the residents.

On 7/19/21 at 3:26 p.m., the Food Service

Manager indicated he ordered the foods for the

facility. He provided an "Order Details" dated

6/21/21, for the pureed foods he had ordered

from the facility food vendor and they were to

last for the week. He indicated the facility had 4

residents who received pureed foods. He

indicated he had bought a case of 24 servings of

puree garden broccoli, a case of 24 servings of

puree sausage link, a case of 14 servings of puree

beef, a case of 24 servings of puree turkey, and a

case of 24 puree pancakes. The Food Service

Manager also indicated he had ordered a case of

24 servings of a mixture of eggs, bacon/sausage,

their cooking skills.






monitor the quality of the food

being served to the residents.

The tool will also monitor to ensure

that the appropriate food items are

being ordered in accordance with

the approved menus and that the

food worksheet recipes are being

followed by the dietary staff in the

preparation and serving of each

food item. The tool will also

monitor the overall satisfaction of

the residents with the meal service

to ensure that the meals are

nutritious, palatable and

attractive. The tool will also

monitor to ensure that the portions

of food being served meet the

resident’s satisfaction, as their

prescribed diet permits. This tool

will be completed by the Executive









08/25/2021PRINTED:

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and pancakes which was mixed together that did

not show up on the order form. The Food

Service Manager indicated the food that was

ordered was pureed foods for the 4 residents

meals for a week. The Food Service Manager

indicated the residents would received the same

meal throughout the week. He also indicated the

Dietician had signed off on the menus when he

made substitutions but he did not substitute very

often.


indicated the "Order Details," dated 6/21/21, did

not cover enough meals for the week and the

residents were obviously receiving the same

foods. He indicated the Food Service Manager

was not following the menus.

The current facility policy, "Food

Palatability/Attractiveness", dated 10/22/19,

indicated "The Dietary Manager or designee, is to

assure that food is prepared appropriately in

accordance with the recipes. All diets served

(regular or mechanically altered) should be

seasoned appropriately to make food palatable

and appetizing to the residents. A food

committee consisting of facility residents is to

be in place that meets monthly to discuss any

areas of improvement from their prospective

related to food service/preparation. Any

recommendations from the food committee will

be taken under consideration by facility

management for possible changes when

appropriate."

1.3-21(a)(1)(2)





warranted.

483.60(d)(3)

Food in Form to Meet Individual Needs

§483.60(d) Food and drink

F 0805

SS=D

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Each resident receives and the facility

provides-

§483.60(d)(3) Food prepared in a form

designed to meet individual needs.


review the facility failed to provide foods to

meet the resident's needs for 2 of 2 meals

observed. Pureed foods were served repeatedly

at meals.

Finding includes:

On 7/12/21 at 10:12 a.m., the Cook 1 was

observed to be in the kitchen with his mask under

his nose. He indicated the facility had

pre-packaged puree foods for the residents who

required pureed foods. He indicated the facility

did not puree the foods on site. A pot of green

beans were observed cooking on the stove and

Cook 1 was observed to place frozen breaded

chicken patties into the deep fryer. No food

recipes were observed in the kitchen.

On 7/12/21 at 12:07 p.m., the lunch meal was

served in the dining room. The residents who

required pureed foods were served puree beef

and pureed peas along with pudding. Residents

who received regular foods received breaded

chicken patties, noodles, green beans, and fruit

or pudding.

The menu for 7/12/21 indicated residents were

to receive pollock almondine, parsley noodles,

sauteed mushrooms, choice of roll, and toffee

pecan bar for the noon meal.

On 7/13/21 at 12:15 p.m., during the serving of

the lunch meal, the residents who required

pureed foods were served pureed beef, mashed

F 0805 F - 805






during the survey all residents on

a pureed diet have the potential to

be affected by this deficient

practice. The facility has

reviewed the approved menus and

are now ordering the appropriate

quantity of food items for the

residents as listed on the

approved menus to ensure a

variety of food items are

provided. The facility is now

preparing and serving all food

items in accordance with facility

recipes and menus as approved

by the dietician. Food substitutes

will also be prepared by following

the food worksheet recipes in

accordance with the resident’s

personal preferences. In

addition, the cook identified as

cook # 1 is now wearing their face

mask in accordance with

acceptable standards of infection

control practices.





residents currently on a pureed

08/18/2021 12:00:00AM





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potatoes, and pureed peas. The menu indicated

the residents were to receive country fried steak,

American fried potatoes, seasoned greens,

southern style biscuit and cherry fruit cobbler

for the lunch meal on 7/13/21. No food recipes

were observed.


indicated the residents were being served the

same foods, especially the pureed foods

repeatedly.


Manager indicated he ordered the foods for the

facility. He provided an "Order Details" dated

6/21/21, for the pureed foods he had ordered

from the facility food vendor and they were to

last for the week. He indicated the facility had 4

residents who received pureed foods. He

indicated he had bought a case of 24 servings of

puree garden broccoli, a case of 24 servings of

puree sausage link, a case of 14 servings of puree

beef, a case of 24 servings of puree turkey, and a

case of 24 puree pancakes. The Food Service

Manager also indicated he had ordered a case of

24 servings of a mixture of eggs, bacon/sausage,

and pancakes which was mixed together that did

not show up on the order form. The Food

Service Manager indicated the food that was

ordered was pureed foods for the 4 residents

meals for a week. The Food Service Manager

indicated the residents would received the same

meal throughout the week. He also indicated the

Dietician had signed off on the menus when he

made substitutions but he did not substitute very

often.


indicated the "Order Details," dated 6/21/21, did

not cover enough meals for the week and the

diet have the potential to be


practice. The facility has

reviewed the approved menus and

are now ordering the appropriate

quantity of food items for the

residents as listed on the

approved menus to ensure a

variety of food items are

provided. The facility is now

preparing and serving all food

items in accordance with facility

recipes and menus as approved

by the dietician. Food substitutes

will also be prepared by following

the food worksheet recipes in

accordance with the resident’s

personal preferences.





been provided for the Food

Service Director and all dietary

staff on the ordering of food items

in the appropriate quantity and in


menus. The staff was also

in-serviced on how to follow the

food worksheet recipes for all

items listed on the approved

menus to ensure the residents

receive a variety of food items in


menus as well as their personal

food preferences.









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residents were obviously receiving the same

foods. He indicated the Food Service Manager

was not following the menus.

The current facility policy, "Food

Palatability/Attractiveness", dated 10/22/19,

indicated "The Dietary Manager or designee, is to

assure that food is prepared appropriately in

accordance with the recipes. All diets served

(regular or mechanically altered) should be

seasoned appropriately to make food palatable

and appetizing to the residents."

3.1-21(a)(3)


monitor the meal service delivery

to ensure that residents on a

pureed diet are being served a

variety of food items in

accordance with the facility’s

approved menus and the

resident’s personal preferences.

The tool will be completed by the

Executive Director and/or their








warranted.

483.60(i)(1)(2)

Food

Procurement,Store/Prepare/Serve-Sanitary

§483.60(i) Food safety requirements.

The facility must -

§483.60(i)(1) - Procure food from sources

approved or considered satisfactory by

federal, state or local authorities.

(i) This may include food items obtained

directly from local producers, subject to

applicable State and local laws or

regulations.

(ii) This provision does not prohibit or prevent

facilities from using produce grown in facility

gardens, subject to compliance with

applicable safe growing and food-handling

practices.

(iii) This provision does not preclude

residents from consuming foods not

procured by the facility.

F 0812

SS=E

Bldg. 00





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§483.60(i)(2) - Store, prepare, distribute and

serve food in accordance with professional

standards for food service safety.


review, the facility failed to ensure food was

prepared and served in a sanitary manner during 2

of 2 kitchen observations. Facial hair was not

covered, hand hygiene was not performed, face

masks were not worn properly, thermometers

were not in the refrigerators and freezers, and the

dishwasher was not reaching the proper

temperatures. (Kitchen, Food service Manager,

Cook 1, Dietary 1)

Findings include:

During the initial tour of the kitchen on 7/12/21

between 9:11 a.m. - 9:45 a.m., the following was

observed:

1. The stove had a brownish-yellow substance on

the back of it.

2. A soiled wet cloth was observed on the floor

in front of the 3-compartment sink.

3. Three countertops were soiled with dried

food particles on them.

4. A tray of 3 bowls of cereal were uncovered,

5. The middle table which had clean trays and

steam table pans stored on it had dirt and debris

on the top and the shelves.

6. A black substance was observed on the walls

under the dishwasher.

F 0812 F - 812









stove has now been cleaned and

is free of any brownish-yellow

substance. The stove is also

being cleaned promptly each time

any spills occur.









soiled wet cloth that was observed

on the floor in front of the

3-compartment sink has been

discarded.








by this deficient practice. All

three countertops have been

08/18/2021 12:00:00AM





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7. The black refrigerator lacked a thermometer in

the freezer and lacked a temperature log for

documentation of temperatures of the

refrigerator and freezer.

8. A plastic bag with Styrofoam cups was

observed lying on the floor between the food

delivery carts and the dry storage cans.

9. The walk-in freezer had ice build-up on the

right side hanging down onto a box, ice build-up

on the floor, and icicles hanging down from the

top vent.

10. The dishwasher wash cycle thermometer

gauge did not move from 150 degrees Fahrenheit

(F) from one cycle to the next and the the

dishwasher rinse cycle thermometer gauge

reached 168 degrees F after 3 complete cycles

were ran. The Food Service Manager indicated

the dishwasher was just repaired last week but he

would notify the Maintenance person. The Food

Service Manager indicated he would be using the

3-compartment sink and Styrofoam products

until the dishwasher was repaired. The Food

Service Manager indicated the dishwasher was a

high heat dishwasher.

11. The Food Service Manager and Cook 1 were

observed to have their masks under their noses.

During an observation on 7/13/21 between 10:45

a.m. and 12:17 p.m., the following was observed:

12. The ice build-up remained on the right side

of the walk-un freezer and the floor, and the top

vent continued to have icicles hanging from it.

13. The Food Service Manager was observed

with his mask under his chin and had uncovered

cleaned of any dried food

particles. All countertops are now

being cleaned after each usage to

ensure a clean work area is

readily available for use.









tray of three bowls of cereal that

were uncovered during the survey

have been discarded.









middle table which had clean trays

and steam table with pans stored

on it have been thoroughly

cleaned and are free of dirt and

debris. These tables are now

being cleaned after each use.









walls under the dishwasher have





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facial hair.

14. Dietary Aide 1 was observed without a face

mask. After donning the face mask, Dietary Aide

1 was observed to wear the mask under his nose.

15. Large and small Styrofoam bowls were

observed uncovered under a table in the kitchen

in a bin.

16. The black substance remained on the wall

under the dishwasher. The Food Service

Manager indicated the substance had been on the

wall since he became the manager.

17. The kitchen floor had dirt and debris on it.

18. On 7/14/21 at 9:54 a.m., the nourishment

room was observed. The room had 2

refrigerators in it and the Administrator in

Training indicated the refrigerator on the left was

for the employees and the refrigerator on the

right was for the resident's foods. A sign on the

left refrigerator indicated that refrigerator was

for resident snacks only. Both refrigerators

were observed to have employee foods in them.

Neither refrigerator had a thermometer in the

freezer sections. Both freezers had ice cream in

them as well as ice packs and a unknown black

plastic item. The nourishment refrigerator

temperature logs lacked documentation of a

freezer temperatures from January 1, 2021,

through July 14, 2021, and lacked documentation

of the refrigerator temperatures from January 1,

2021 through June 30, 2021. The Administrator

indicated the temperatures of both of the

refrigerators had not been obtained until July 1,

2021, and the freezer temperatures of either

refrigerator had been obtained.

now been cleaned and are free of

any black substance.









black refrigerator now has a

thermometer in the freezer and

has a temperature log where

temperatures of the refrigerator

and freezer are recorded daily.









plastic bag of Styrofoam cups that

was observed on the floor

between the food delivery carts

and the dry storage cans has

been discarded. No items are

currently being stored directly on

the floor.








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19. On 7/13/21 at 8:00 a.m., the dishwasher

temperature log dated July 1, 2021 through July

12, 2021, was provided by the Food Service

Manager. He indicated the dishwasher

temperature is checked 3 times a day. The log

was initialed with the Food Service Managers

initials each day and indicated the following

temperatures:

7/1/21 at 5:30 a.m.: wash temp 150 final rinse

temp: 180 and 7/1/21 at 12:00 p.m.: no

temperatures were documented


temp 180, 7/2/21 at 12:00 p.m.: wash temp 150

final rinse temp 180, and 7/2/21 at 6:00 p.m.:

wash temp 150 final rinse temp 180











final rinse temp 180 and 7/5/21 at 6:00 p.m.:













walk-in freezer has been cleaned

and is now free of any ice

build-up. The freezer has now

been placed on a routinely

cleaning schedule to ensure all

ice build-up is being removed.









dishwasher has now been

repaired and is functioning

properly. The dishwasher

temperatures are being monitored

on a temp log to ensure on-going

proper functioning in accordance

with the manufacturer guidelines.









Food Service Manager and Cook

1 are now wearing their face






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temp 180 - the final rinse temperature had been

altered to read 160, 7/8/21 at 12:00 p.m.: wash

temp 150 final rinse temp 180 - the final rinse

temperature had been altered to read 160, , and

7/8/21 at 6:00 p.m.: wash temp 150 final rinse


altered to read 160.



altered to read 160, 7/9/21 at 12:00 p.m.: wash

temp 150 final rinse temp 180 - the final rinse

temperature had been altered to read 160, , and

7/9/21 at 6:00 p.m.: wash temp 150 final rinse

temp 180. A notation to the side of the column

indicated the facility had used Styrofoam. The

Food Service Manager indicated it was the day

the dishwasher had been repaired also as it did

not get up to the proper temperatures.



altered to read 186, , 7/10/21 at 12:00 p.m.:

wash temp 150 final rinse temp 180, and 7/10/21

at 6:00 p.m.: wash temp 150 final rinse temp

180.




wash temp 150 final rinse temp 180.



altered to read 160. The time of 12:00 p.m. was

entered with the temperatures being wash temp


control practices.









walk-in freezer has been cleaned

and is now free of any ice

build-up. The freezer has now

been placed on a routinely

cleaning schedule to ensure all

ice build-up is being removed.









Food Service Manager is now

wearing their face mask in



practices and it complete covers

their nose and mouth. All facial

hair is now completely covered.









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150 and final rinse temperature of 165. The

column indicated Styrofoam was used .

On 7/14/21 at 8:15 a.m., the Food Service

Manager indicated the temperatures were

probably incorrect.


Manager indicated he did not have a cleaning

schedule for the kitchen.


Manager provided the temperature logs for the

large kitchen refrigerator and the walk-in freezer.

He indicated he did not obtain temperatures on

the milk cooler or the black refrigerator or

freezer. The Food Service Manager also

provided a cleaning schedule with different areas

to be cleaned throughout the days of the week for

4 different weeks. The schedules were divided

into the morning aide and evening aide and the

morning cook and the evening cook and were to

be initialed and dated when the jobs were

completed, but the schedules lacked any

documentation.

The current facility policy, "Food Receiving and

Storage." dated 3/11/21, provided by the

Administrator on 7/19/21 at 2:14 p.m., included,

but was not limited to, "Food Services, or other

designated staff, will maintain clean food storage

areas at all times. Refrigerated food must be

stored at or below 40 degrees Fahrenheit unless

otherwise specified by law. The freezer must

keep below 0 degrees to ensure frozen foods

frozen remain solid. Functioning of the

refrigeration and food temperatures will be

monitored at designated intervals throughout the

day by the Food Service Manager or designee and

documented according to state-specific





dietary aide identified as dietary

aide 1 is now wearing their face



control practices and it completely

covers their nose and mouth.









large and small Styrofoam bowls

that were uncovered under a table

in the kitchen in a bin have been

discarded. All Styrofoam bowls

are now properly covered when

stored.









walls under the dishwasher have

now been cleaned and are free of

any black substance.





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requirements. Dietary staff will wear hair

restraints (hair met, hat, beard restraint, etc.) so

that hair does not contact food."

The facility lacked documentation of a policy for

the dishwasher temperatures.


IN00355706.

3.1-21(a)(2)

3.1-21(i)(2)

3.1-21(i)(3)









kitchen floor has been cleaned

and is now free of dirt and

debris. The kitchen floor is on the

dietary routine cleaning schedule

and is cleaned at least daily.








by this deficient practice. The two

refrigerators in the nourishment

room have been deep cleaned.

Only resident food items are now

being stored in the refrigerator on

the right and all non-food items

have been removed (ice packs).

Thermometers have now been

placed in both freezer and

refrigerator sections of both

refrigerators and temperatures

are being recorded on the temp

logs of each refrigerator daily.











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dishwasher has now been

repaired and is functioning

properly. Dishwasher

temperatures are now being

recorded three times a day and

are in accordance with the

manufacturer guidelines. If at any

time the dishwasher is not in

proper working order, the

three-compartment sink will be

utilized as needed and Styrofoam

and paper products will be used

for meal delivery. A new dietary

cleaning schedule has been


ensure proper dietary sanitation is

maintained. A temperature log

has also been developed for the

milk cooler and the black

refrigerator/freezer and daily

temperatures are now being

recorded.







practice. The corrective action

taken is as previously outlined as

indicated in the above responses

numbered 1 through 19.





been provided for the Food

Service Manager and all dietary





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staff on the facility’s dietary

sanitation policies and procedures

as it related to the wearing of face

mask, facial hair coverage,

cleaning of all dietary equipment,

including stove,

refrigerator/freezers,

preparation/steam tables, storage

areas, recording of temperatures

related to refrigerators/freezers,

dishwashers, storage of dietary

supplies such as Styrofoam

products, proper storage of food

items to ensure they are properly

covered and dated/labeled.

On-going education will continue

to be provided in these areas by

the dietician during their regular

visits as well to ensure on-going

compliance.






monitor the dietary staff’s

compliance in following facility

policies and procedures related to

the procurement, storage,

preparation, and sanitation of

meal preparedness and delivery.












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warranted.

483.80(a)(1)(2)(4)(e)(f)

Infection Prevention & Control

§483.80 Infection Control

The facility must establish and maintain an

infection prevention and control program

designed to provide a safe, sanitary and

comfortable environment and to help prevent

the development and transmission of

communicable diseases and infections.

§483.80(a) Infection prevention and control

program.

The facility must establish an infection

prevention and control program (IPCP) that

must include, at a minimum, the following

elements:

§483.80(a)(1) A system for preventing,

identifying, reporting, investigating, and

controlling infections and communicable

diseases for all residents, staff, volunteers,

visitors, and other individuals providing

services under a contractual arrangement

based upon the facility assessment

conducted according to §483.70(e) and

following accepted national standards;

§483.80(a)(2) Written standards, policies,

and procedures for the program, which must

include, but are not limited to:

(i) A system of surveillance designed to

identify possible communicable diseases or

infections before they can spread to other

persons in the facility;

(ii) When and to whom possible incidents of

communicable disease or infections should

F 0880

SS=E

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be reported;

(iii) Standard and transmission-based

precautions to be followed to prevent spread

of infections;

(iv)When and how isolation should be used

for a resident; including but not limited to:

(A) The type and duration of the isolation,

depending upon the infectious agent or

organism involved, and

(B) A requirement that the isolation should be

the least restrictive possible for the resident

under the circumstances.

(v) The circumstances under which 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; and

(vi)The hand hygiene procedures to be

followed by staff involved in direct resident

contact.

§483.80(a)(4) A system for recording

incidents identified under the facility's IPCP

and the corrective actions taken by the

facility.

§483.80(e) Linens.

Personnel must handle, store, process, and

transport linens so as to prevent the spread

of infection.

§483.80(f) Annual review.

The facility will conduct an annual review of

its IPCP and update their program, as

necessary.


review, the facility failed to properly prevent

and/or contain COVID-19 and to ensure

F 0880 F - 880




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infection control practices were followed during

resident care for 1 of 2 observations of

glucometer cleaning, 1 of 2 observations

mechanical lift transfers, 2 of 2 observations of

staff entering transmission based precaution

rooms, 1 of 2 observations of resident care, 1 of

2 observations of dining, and 2 of 2 observations

of use of N95 masks were worn not worn or

worn incorrectly in TBP (transmission based

precaution) resident rooms, full PPE (personal

protective equipment) was not worn for

COVID-19 testing or hand hygiene performed

per guidelines. (Resident R, Resident S, Resident

N, Resident C, Resident O, Resident E, Resident

M, Resident P)

Findings include:

1. On 7/13/21 at 11:47 a.m., the Director of

Nursing (DON) was observed to wipe the used

glucometer with a hydrogen peroxide wipe front

and back, returned the glucometer to the drawer

of the medication cart, and performed hand

hygiene.

On 7/13/21 at 11:52 a.m., the DON indicated the

contact time should be 20 seconds or so. The

DON read the label of the hydrogen peroxide

wipes they indicated the glucometer should be

wet for approximately 30 seconds which was half

the contact time listed on the label for

disinfection, then they let it dry.

On 7/13/21 at 12:20 p.m., the DON indicated he

gave an inaccurate answer, the glucometer should

remain wet for the full contact time.

2. On 7/13/21 at 11:32 a.m., the DON was

observed in face shield, N95 mask over a

surgical mask, isolation gown and gloves






Director of Nursing is now

cleaning and disinfecting the

glucometers in accordance with

the manufacturer guidelines and

facility policy.





identified as resident C is now

receiving care and services by

nursing staff members who are

properly attired in personal

protective equipment in



practices. The Director of

Nursing is now wearing personal

protective equipment in



practices when entering a room of

a resident on transmission-based

precautions.





identified as resident S is now

receiving their medications in


standard of practice in the

administration of medications.

The Director of Nursing is now

administering medications to





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entering Resident R's transmission based

precaution room (due to new readmission from

the hospital) to administer antibiotics per

peripheral IV (intravenous access in arm).

3. On 7/14/21 at 8:24 a.m., the DON was

observed to dispense broprohin 300 mg from the

medication card into his fingers, for Resident S,

then deposit the pills into the pill cup.

On 7/14/21 at 8:30 a.m., the DON indicated he

"should have popped the pills into the medication

cup."

4. On 7/15/21 at 10:11 a.m., Medical Record

was observed to perform COVID-19 testing.

Medical Records had the vendors fill out consent

form for testing while wearing a face shield,

surgical mask. She set up the rapid COVID-19

testing supplies for Vendor 1's test, applied

gloves, obtained nasal swabs from Vendor 1, and

applied swab to the rapid test card. Medical

Records then set up changed gloves, set up the

second rapid test, obtained the nasal swab sample

from Vendor 2, applied the swab to the card,

removed her gloves, left the room without

performing hand hygiene and proceeded up the

hallway, coded through the door and entered the

bathroom in the therapy department to wash her

hands. Medical Records then took the rapid tests

to the Administrators office.

On 7/15/21 at 10:18 a.m., Medical Records

indicated a few of the nurses had trained her to

do the testing. She then indicated she was

supposed to wear a N95 mask, gown, and gloves

the way she was taught in Illinois. She was to

perform hand hygiene after the test and not just

change gloves between the tests.

residents in accordance with

acceptable standards of

medication administration

practices.









Medical Record clerk is now

performing COVID-19 rapid

testing in accordance with


control practices, including the

wearing of all appropriate

personal protective equipment and

performing hand hygiene promptly

upon removal of their gloves after

each test is completed.




practice is that the residents

identified as residents C, N, O

and E are now receiving care and

services by staff members who

are performing hand hygiene in

between contact with each

resident. The staff members

identified as PCA 1 and CNA 1

are now providing care and

services to the residents in



practices, including performing

hand hygiene in between contact





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On 7/15/21 at 10:32 a.m., Medical Records

indicated the Vendor rapid COVID-19 tests were

negative.

5. On 7/12/21 at 12:07 p.m., PCA 1 and CNA 1

were observed to be in the dining room. CNA 1

was observed to apply a clothing protector to

Resident C, pulled up the back of her scrub pants,

removed Resident N's face mask, obtained the

resident's food, and began feeding the resident.

No hand hygiene was observed. PCA 1 was

observed to place a clothing protector on

Resident O, touch her hair, opened the food cart,

closed the cart, went down the hall and returned.

She obtained Resident E's tray and served the

resident in her room. No hand hygiene was

observed.

6. On 7/13/21 at 9:32 a.m., CNA 2 and CNA 4

were observed to provide pericare to Resident

M. Both CNAs performed hand hygiene and

donned gloves. CNA 2 lowered the resident's

brief, obtained clean wipes and performed

perineal care to the resident. The resident was

incontinent of a large amount of loose stool.

While providing the care, CNA 4 got stool on her

hands. She wiped the stool off using a wipe,

assisted the resident to turn onto her left side,

and removed the soiled brief. CNA 4 obtained

clean wipes and wiped the resident buttocks and

rectal area getting stool on her right glove, which

she wiped on the soiled disposable incontinent

pad. She rolled the incontinent pad under the

resident, changed her gloves and performed hand

hygiene. CNA 4 placed a clean brief under the

resident and assisted the resident to turn to her

right side. CNA 2 obtained clean wipes and

wiped the resident's left buttock, removed the

resident's soiled disposable incontinent pad, and

assisted with applying the resident's clean brief.

with each resident.





identified as resident M is now

receiving incontinent care by staff

members who are performing

perineal care, hand hygiene and

glove usage in accordance with


control practices. The staff

members identified as CNA 2 and

CNA 4 are now providing the

residents with perineal care in



practices including proper glove

usage and hand hygiene.





identified as resident P is now

receiving care and services by

staff members who are utilizing

the proper personal protective

equipment including an N 95 face

mask, face shield, gown and

gloves when entering a resident’s

room who is on

transmission-based precautions.





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CNA 2 removed her gloves and both CNAs

repositioned the resident in her bed. CNA 4

elevated the resident's head, removed her gloves

and both CNAs exited the room and performed

hand hygiene.

On 7/19/21 at 9:52 a.m., CNA 4 indicated hand

hygiene should be performed prior to and after

providing care, if gloves become soiled, if you

touch any part of yourself, and when you remove

your gloves.

7. On 7/13/21 at 9:52 a.m., PCA 1 was observed

to don a disposable gown and enter Resident P's

room. PCA 1 had a surgical mask and face shield

on. The resident had a sign on the outside of his

entry door indicating the resident was on contact

and droplet precautions and required total body

protection. The door had a sign indicating a

disposable gown, gloves, N95 mask, and face

shield was required prior to entering the

resident's room. PCA 1 removed the gown in the

resident's room and exited the room with a

Styrofoam cup. PCA 1 indicated she did not

know she was to wear an N95 mask prior to

entering the resident's room. At 9:55 a.m., PCA

1 was observed to don a disposable gown and an

N95 mask and re-enter the resident's room with

the Styrofoam cup. No gloves were applied.

Upon exiting the resident's room, PCA 1

indicated she was unaware that gloves needed to

be donned and proceeded to read the procedure

on the resident's door of the necessary PPE

(personal protective equipment) required prior to

entering the room.

On 7/12/21 at 9:30 a.m., the facility provided the

current facility policy, Infection Control,

undated. The Policy indicated, but was not

limited to, infection control means preventing

No items, such as Styrofoam cups

are removed from any room

where transmission-based

precautions are in place but the

items are now being properly

discarded in the appropriate

hazardous waste container in the

resident’s room. The staff

member identified as PCA 1 is

now donning the appropriate

personal protective equipment

including a face shield, N95 mask,

gown and gloves when entering

any transmission-based

precautions room. PCA 1 is also

discarding any paper products

such as Styrofoam cups in the

appropriate receptacle in the

resident’s room.







practice. All staff members are

now utilizing acceptable standards

of infection control practices while

providing care and services to all

residents. This includes the

proper use of all personal

protective equipment including

face shields, N-95 face mask,

gowns, gloves and proper hand

hygiene in accordance with the


control practices when entering a

room where transmission-based

precautions are in place.





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the spread of microorganisms by following

certain practices, precautions, and

procedures...wearing gloves when indicated for

resident care. Wearing gown, apron, mask, and

protective eyewear in situations or during

procedures when indicated. Washing hands at

appropriate times...Wash your hands before and

after performing procedures, using the bathroom,

eating, serving food, or feeding a resident..use

isolation techniques when ordered and follow

directions on posted signs...consider all blood,

bodily fluids, and excrements contaminated."

The CDC (Center of Disease Control) guideline

indicate "During Specimen collection, facilities

must maintain proper infection control and use

the recommended personal protective equipment

(PPE), which includes an N95 or higher-level

respirator (or facemask if respirator is not

available), eye protection, gloves, and a gown,

when collecting specimen."


IN00357044 and IN00355706.

3.1-18(b)(1)

3.1-18(l)






proper donning and doffing of all


including face shield, face masks,

gowns, gloves and performing

hand hygiene. Each staff

member has successfully

completed a return demonstration

in the donning and doffing of all


including hand hygiene.

Successful hand hygiene return

demonstration has been

completed by all staff members

utilizing soap and water as well as

alcohol-based hand sanitizer. All

nursing personnel have also

successfully completed a return

demonstration on providing

perineal care of both male and

female residents to validate their





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knowledge level of the tasks. The

in-services also included that all

licensed nurses and QMAs

completed a successful return

demonstration of the cleaning and

disinfecting of glucometers in

accordance with the manufacturer

guidelines.






monitor staff compliance in

providing resident care and

services in accordance with


control practices. The tool will

monitor the following areas;

proper wearing of face masks,

proper donning and doffing of


including face shields, N-95 face

masks, gown and glove usage,

hand hygiene, perineal care,

cleaning and disinfecting of

glucometers. There will be visual

observations of these tasks daily

Monday through Friday by the





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Infection Preventionist and/or their

designee for the next six weeks.

Upon completion of these

observations the outcomes will be

reviewed by the Infection

Preventionist to determine the

frequency of continued monitoring

to be implemented at that time until

continued consistent compliance

is achieved for three months. At

the end of the three-month

monitoring period, the Infection

Control Preventionist will

determine the frequency of the

infection control monitoring to be

implemented. The Infection

Preventionist will also be

responsible for providing

continued education on infection

control practices.

F 9999

Bldg. 00

3.1-13 ADMINISTRATION AND

MANAGEMENT

(g) The administrator is responsible for the

overall management of the facility but shall not

function as a departmental supervisor, for

example, director of nursing or food service

supervisor, during the same hours.

The responsibilities of the administrator shall

include, but are not limited to, the following:

(1) Immediately informing the division by

telephone, followed by written notice within

twenty-four (24) hours, of unusual occurrences

that directly threaten the welfare, safety, or

health of the resident or residents,

F 9999 9999




practice is that all residents have

the potential to be affected by this

deficient practice. No residents

suffered any negative physical

outcomes from the event. All

reported missing personal items

have been either located and

returned to the residents or

replaced. The facility did follow

their policy in the treatment of the

infestation and no further

incidents have occurred. The

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This State Rule was not met as evidenced by:


facility failed to ensure an incident of bed bugs

was reported immediately to the State Survey

Agency that involved all residents in the facility

for 1 of 1 report of bed bugs reviewed.

Finding includes:

1. On 7/12/21 at 11:12 a.m., Resident B

indicated approximately 2-3 months ago she was

removed from her room and placed in the lobby

during the day due to bed bugs. She indicated all

of her clothing, shoes, and personal items had

been placed in totes by the staff and removed

from her room.

2. During an interview on 7/12/21 at 9:55 a.m.,

Resident E indicated in May, 2021, the

management staff at the facility had removed all

the resident's personal items from their room

one day in May, 2021. She indicated the facility

had told the residents they were "spraying for

ants" but actually the facility had bed bugs.

3. During an interview on 7/12/21 at 2:19 p.m.,

Resident F indicated the facility had a "deep

clean" day approximately 4-6 weeks ago. States

was informed the facility had gotten "roaches"

from a resident who had recently been admitted

to the facility, but the facility had a "case of bed

bugs."

4. On 7/12/21 at 9:39 a.m., Resident G indicated

in May, 2021, the facility moved all the residents

out of their rooms for the day. She indicated the

administrative staff had came into her room,

removed everything from her room, and placed

failure to report the event to the

appropriate State agency was

simply a miscommunication. In

the future all reportable events will

be the responsibility of the

Executive Director to report to the

appropriate agencies.







practice. No residents suffered

any negative physical outcomes

from the event. All reported

missing personal items have been

either located and returned to the

residents or replaced. The facility

did follow their policy in the

treatment of the infestation and no

further incidents have occurred.

The failure to report the event to

the appropriate State agency was

simply a miscommunication. In

the future all reportable events will

be the responsibility of the

Executive Director to report to the

appropriate agencies.




is that the facility has now

established a protocol whereby

the Executive Director and/or their

designee will be responsible for

the reporting of all unusual

occurrences to the appropriate





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the items into a bag with the resident's name on

them. The items were taken out of the facility

and sent to an outside laundry or placed in the

outside shed. Resident G indicated the facility

staff had told her the facility was "spraying for

ants," but instead the facility had bed bugs.

5. On 7/14/21 at 10:25 a.m., Resident H

indicated the facility had removed all the

resident's belongings in May, 2021, due to bed

bugs. Resident H indicated she was still missing

some three dresses.

On 7/15/21 at 8:00 a.m., the pest control report

was reviewed. The pest control report indicated

the facility had been treated for bed bugs on

5/11/21 and 5/12/21.

The State reportable incidents, were provided by

the Administrator on 7/12/21 at 9:25 a.m. The

facility lacked documentation of the bed bugs

reporting the bed bug incident to the State Survey

Agency.


Administrator in Training (AIT) indicated the

facility found 1 bed bug in lounge in May and had

facility the facility treated. All the residents

items were removed, placed in bags with the

resident's names on them and sent out to be

laundered. She indicated the outside laundry had

placed all the clothes together to launder them.

The laundered items had been returned to the

facility and the staff was still looking for

resident's clothing items.

During an interview on 7/14/21 at 8:45 a.m.,

CNA 2 indicated Resident J had bed bugs in his

room. When the bed bugs were found, the

management staff removed everything out of the

State agencies.






ensure that all reportable events

have been reported to the

appropriate State agencies in

accordance with the regulation.










warranted.





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resident's rooms, placed all the items into bags

with resident names on them, and sent everything

out to be laundered. The resident were placed in

the lobby or dining room for the day while there

rooms were treated.

During an interview on 7/14/21 at 3:50 p.m.,

CNA 1 and CNA 2 indicated the facility had an

incident of bed bugs in May, 2021. The bed bug

incident was a "fiasco." The management staff

removed everything in the resident's rooms,

placing the some of the items into the outside

storage shed. Other items were sent to an

outside laundry where they were all placed

together to be laundered. CNA 1 indicated

Resident J's recliner had been infested with the

bed bugs but none were found on the resident's

roommate side of the room. The resident was

relocated to another room at the facility and a

bed bug was found in that room also. CNA 1

indicated she had observed a bed bug in the

shower room on the wall, but did not know where

it had come from.


indicated the bed bug incident had not been

reported to the State Survey Agency. The

Administrator thought the Administrator in

Training (AIT) had reported the incident and the

AIT had thought the Administrator had reported

it.

The current facility policy, "Unusual Occurrence

Reporting," dated 1/20/19, provided by the

Administrator on 7/19/21 at 2:14 p.m., included,

but was not limited to, "Our facility will report

the following events to appropriate agencies: ...

Widespread rodent and/or insect infestations...

Unusual occurrences shall be reported via email

to appropriate agencies as required by current





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law and/or regulations within twenty-four (24)

hours of such incident or as otherwise required

by federal and state regulations."


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