printed: 07/06/2017 department of health … · except for nursing homes, ... her paranoia and...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

07/06/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

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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

HUNTINGTON, IN 46750

155531 06/05/2017

OAKBROOK VILLAGE

850 ASH ST

00

F 0000

Bldg. 00

This visit was for a Recertification and

State Licensure Survey.

Survey dates: May 30, 31 and June 1, 2,

and 5, 2017.

Facility number: 000569

Provider number: 155531

AIM number: 100267660

Census bed type:

SNF/NF: 39

Total: 39

Census payor type:

Medicare: 3

Medicaid: 30

Other: 6

Total: 39

These deficiencies reflect State findings

cited in accordance with 410 IAC

16.2-3.1.

Quality review completed on June 7,

2017.

F 0000 Submission of this Plan of

Correction does not constitute an

admission or agreement by the

provider of the truth of facts

alleged or corrections set forth on

the statement of deficiencies.

This plan of correction is

prepared and submitted due to

requirements under State and

Federal law. Please accept this

plan of correction as our credible

allegation of compliance.

483.20(d);483.21(b)(1)

DEVELOP COMPREHENSIVE CARE

PLANS

483.20

(d) Use. A facility must maintain all resident

assessments completed within the previous

F 0279

SS=D

Bldg. 00

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: SMM411 Facility ID: 000569

TITLE

If continuation sheet of 28

(X6) DATE




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15 months in the resident’s active record

and use the results of the assessments to

develop, review and revise the resident’s

comprehensive care plan.

483.21

(b) Comprehensive Care Plans

(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

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SMM411 Facility ID: 000569 If continuation sheet of 28




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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.

Based on observation, interview, and

record review, the facility failed to

identify and develop a care plan to

manage a resident's psychiatric condition

for 1 of 5 residents reviewed for

unnecessary medications (Resident 35).

Findings include:

On 6/1/17 at 10:25 a.m., Resident 35 was

in her room.

On 6/2/17 at 9:45 a.m., she was sitting

outside in the gazebo with two other

residents and a staff member.

On 6/2/17 at 10:47 a.m., she was sleeping

in bed, and did not wake when spoken to.

Review of the clinical record began on

F 0279 The targeted resident did not

experience any negative outcome

associated with this alleged deficient

practice. The care plan has been

reviewed and revised to reflect all

diagnoses including the resident’s

psychiatric conditions.

All residents have the potential to be

affected. The care plans have been

reviewed and/or revised to reflect all

diagnoses including psychiatric

conditions.

The facility’s policy for care plan

development has been reviewed

with no changes at this time. The

SSD has been re-educated on the

policy with a special focus on care

planning psychiatric conditions. A

06/23/2017 12:00:00AM





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155531 06/05/2017

OAKBROOK VILLAGE

850 ASH ST

00

5/30/17 at 3:20 p.m. Diagnoses included,

but were not limited to, hypertension,

psychosis, paranoia, and delusions,

depression, chronic obstructive

pulmonary disease (COPD), and anxiety.

A 5/5/17, annual Minimum Data Set

(MDS) assessment indicated she was

cognitively intact and had demonstrated

no behaviors, delusions or hallucinations

during the assessment period.

Medications included, but were not

limited to, Cymbalta 60 mg

(antidepressant) daily at bedtime,

venlafaxine 75 mg (antidepressant) daily,

trazodone 150 mg (antidepressant) at

bedtime, Buspar 10 mg (antianxiety)

three times daily, and quetiapine

fumarate 25 mg (antipsychotic) three

times daily, Namenda XR 14 mg

(dementia medication) and Exelon 4.6

mg/24 hr patch (dementia medication)

one patch every 24 hours.

The clinical record indicated she had

admitted to the facility from home on

5/1/17.

A Social Services Assessment, dated

5/5/17, indicated, but not limited to, the

following diagnoses: psychosis, paranoia,

delusions, depression, anxiety, insomnia,

and dementia, although she was

monitoring tool has been developed.

The DON or designee will be

responsible to review care plans on

a weekly basis to ensure care plan

problems are present for diagnoses

including psychiatric conditions.

These reviews will be conducted

weekly based on the MDS schedule

on an ongoing basis for a minimum

of six months. Should a concern be

found, immediate corrective action

will occur. These reviews and any

corrective actions will be discussed

during the facility’s quarterly QA

meetings and the plan adjusted if

indicated.





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155531 06/05/2017

OAKBROOK VILLAGE

850 ASH ST

00

cognitively intact. There was no

indication in the assessment of the

resident's psychosis, or the definition of

her paranoia and delusions.

She had current care plan problems, last

reviewed on 5/18/17, of receiving

Seroquel (quetipine fumarate) for

psychosis, paranoia, and delusions.

Interventions included to receive her

medications, monitor for side effects and

change in mood or behavior, and

psychiatric evaluation as indicated. The

care plan did not address or define her

psychosis, paranoia, and delusions.

Review of Mood and Behavior Records

for May and June 2017 indicated the only

behaviors she had exhibited were

declining a shower on two occasions,

once because she had already showered

that morning, and once because she was

tired.

During an interview on 6/2/17 at 1:41

p.m., the Social Services Director (SSD)

indicated Resident 35 wanted to see the

mental health provider, but could not

afford to at that time. She indicated she

was not aware of what the resident's

delusions were, other than possibly

talking to a family member that had died.

She indicated the resident had told her

she sees the family member and talks to





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850 ASH ST

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them, but is aware that they are deceased

and not really there. She indicated there

was no other information regarding her

delusions, or what she was paranoid

about.

During an interview, on 6/2/17 at 2:41

p.m., with the SSD and DON, the SSD

indicated the facility did not have a

careplan accessible to staff for her

delusions and paranoia. They indicated

they believed her delusions involved her

talking to her deceased family member,

although she will tell you he is dead

when she is talking to him and it was not

distressing to her.

3.1-35(a)

3.1-35(b)(1)

483.24(a)(2)

ADL CARE PROVIDED FOR DEPENDENT

RESIDENTS

(a)(2) A resident who is unable to carry out

activities of daily living receives the

necessary services to maintain good

nutrition, grooming, and personal and oral

hygiene.

F 0312

SS=D

Bldg. 00

Based on, interview and record review,

the facility failed to ensure residents who

were dependent on staff for showering,

received those services for 1 of 2

residents reviewed for Activities of Daily

Living (ADL). (Resident 8)



associated with this alleged deficient

practice. Showers are being given

and documented based on the

resident’s preference. Shower

schedule has been updated to

reflect the resident’s preference.

06/23/2017 12:00:00AM





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OAKBROOK VILLAGE

850 ASH ST

00

Findings include:

1. The clinical record for Resident 8 was

reviewed on 6/2/17 at 8:09 a.m.

Diagnoses for the resident included, but

were not limited to, Alzheimer's disease,

Parkinson's disease, heart failure and

diabetes mellitus. A 4/6/17, Quarterly,

Minimum Data Set assessment, indicated

Resident 8 required extensive assistance

with one person assistance for hygiene.


p.m., a family member stated she did not

think the facility kept him clean enough.

She indicated he was often "wet" when

she came to visit.


a.m., CNA 10 indicated staff could often

get him to the toilet, depending on how

his day was going.

A current Daily Preference sheet, dated

3/10/17 and revised 4/27/17, indicated

Resident 8 preferred two showers per

week in the evening.

A current Care Plan, dated 1/20/17 and

revised 4/27/17, indicated Resident 8

required assistance in performing

Activities of Daily Living (ADL) related

to Alzheimer's disease, decreased range

of motion, fall risk and impaired balance.

All other residents have the

potential to be affected. Their

shower/bathing preferences and

documentation have been reviewed

to ensure they are getting showers

per their preference. Shower

schedules have been updated to

reflect their preferences.

The facility’s policy for showers has

been reviewed with no changes

indicated. The nursing staff have

been re-educated on the policy with

a special focus on providing and

documenting showers/bathing. A

monitoring tool has been

implemented.

The DON or designee will interview

residents and review shower

documentation to ensure

showers/baths are being provided.

Three residents will be interviewed

and documentation checked on

scheduled work days as follows:

daily for two weeks, twice weekly

for two weeks, one time weekly for

two weeks, monthly for two months,

then quarterly thereafter on an

ongoing basis for a minimum of six

months. Should a concern be found,

immediate corrective action will

occur. Results of these reviews and





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155531 06/05/2017

OAKBROOK VILLAGE

850 ASH ST

00

Interventions included, but were not

limited to, showers/baths per schedule,

bathing per choice and provided assist

with ADL's as resident requires.

Review of the shower sheet, Resident 8

was scheduled to have a shower during

the evening shift on Monday and

Thursday.

Review of the 2017 ADL record,

Resident 8 did not receive a shower on

the following days:

March 2 (Thursday), March 16

(Thursday), March 23 (Thursday), April

3 (Monday), April 6 (Thursday), April 10

(Monday), April 13 (Thursday), April 20

(Thursday), May 11 (Thursday), May 15

(Monday), May 18 (Thursday), May 22

(Monday) and May 29 (Monday).

On 6/5/17 at 10:53 a.m., the Director of

Nursing (DON) indicated Resident 8 was

to receive at least two showers per week

unless he asked for more.

Review of a current facility policy, dated

10/2014, titled "SHOWERING A

RESIDENT," which

was provided by the DON on 6/5/17 at

11:17 a.m., indicated the following:

"PURPOSE:

A shower will clean, refresh, and soothe

any corrective action will be

discussed during the facility’s

quarterly QA meetings and the plan

adjusted if indicated.





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155531 06/05/2017

OAKBROOK VILLAGE

850 ASH ST

00

the resident; stimulate circulation, and

provide an opportunity for resident to

exercise arms and legs.

POLICY:

Resident will receive a shower at least

twice weekly unless condition warrants

otherwise or resident refuses."

3.1-38(a)(2)(A)

483.45(d)

DRUG REGIMEN IS FREE FROM

UNNECESSARY DRUGS

(d) Unnecessary Drugs-General. Each

resident’s drug regimen must be free from

unnecessary drugs. An unnecessary drug is

any drug when used--

(1) In excessive dose (including duplicate

drug therapy); or

(2) For excessive duration; or

(3) Without adequate monitoring; or

(4) Without adequate indications for its use;

or

(5) In the presence of adverse

consequences which indicate the dose

should be reduced or discontinued; or

(6) Any combinations of the reasons stated

in paragraphs (d)(1) through (5) of this

section.

F 0329

SS=D

Bldg. 00


record review, the facility failed to ensure

residents were free from psychoactive

F 0329 The targeted resident has had his

psychotropic/mood stabilizer

medications reviewed by the

MD/NP. The facility is following new

06/23/2017 12:00:00AM





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155531 06/05/2017

OAKBROOK VILLAGE

850 ASH ST

00

medications without indication for use

for 1 of 5 residents reviewed for

unnecessary medications (Resident 40).

Findings include:

On 6/1/17 at 9:09 a.m., Resident 40 was

in his room.

On 6/1/17 at 10:26 a.m., he remained in

his room.

On 6/1/17 at 1:14 p.m., he remained in

his room.

On 6/2/17 at 8:36 a.m., he was in his

room, eating breakfast.

Review of the clinical record began on

5/31/17 at 8:48 a.m. Diagnoses included,

but were not limited to, anxiety, cardiac

arrhythmia, edema, major depression,

muscle wasting and atrophy, atrial

fibrillation, restless leg syndrome, CVA

with left hemiparesis (stroke with

left-sided weakness), congestive heart

failure, and mood disorder.

He had current medication orders for, but

not limited to, Cymbalta 90 mg

(antidepressant) daily and Depakote

Sprinkle 250 mg (mood stabilizer) twice

daily.

orders provided by the physician to

taper and discontinue the Depakote.

All other residents receiving

psychotropic medications have been

reviewed to ensure appropriate

behavioral indicators are being

documented to support prescribed

psychotropic medications. If it was

found that behavior indicators were

not present to support the

medication/s, the MD/NP was

contacted to request GDR or

statement of contraindication.

The facility’s policies for

psychotropic medication use have

been reviewed and no changes are

indicated at this time. The

Behavioral Review Team, including

the SSD and DON, have been

re-educated on the policies including

behavioral indicators and gradual

dose reductions. A monitoring tool

has been implemented.


responsible for reviewing

psychoactive medications to ensure

behavioral indicators are

documented to support the use of

the psychotropic medication, GDRs

are completed as indicated, or

contraindication statements are





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155531 06/05/2017

OAKBROOK VILLAGE

850 ASH ST

00

A 3/21/17, quarterly Minimum Data Set

assessment indicated he was cognitively

intact, had no behaviors, and a PHQ-9

(depression assessment) score of one

(indicating either loss of appetite or

overeating).

A Behavioral health progress note, dated

1/10/17, indicated he admitted to feeling

"short or snappy" especially when he was

in pain. The note indicated he reported

he cursed at a staff member and had been

rude all night, but had apologized in the

morning. The note indicated he had

difficulty sleeping due to waking up

approximately 4 times a night due to

taking water pills, which made him tired

during the day.

Review of a psychiatric progress note,

dated 2/15/17, indicated Resident 40 had

been socially inappropriate and had

"nearly hostile behavior typical of a

paranoid personality", such as leaving

cell phone on to record staff comments,

low mood, and feels events conspire

against him, the "government states I

can't have any more therapy". The note

indicated he refused care at times and had

behaviors "just short of being hostile".

An order was written to add Depakote

125 mg twice daily for mood disorder.

A 3/8/17 nurses note indicated an order

obtained from the MD. These

reviews will be done on residents

receiving psychotropic/mood

stabilizer medications on a monthly

basis. Should a concern be found,

immediate corrective action will

occur. Results of these reviews and

any corrective actions will be


quarterly QA meetings on an


months and the plan adjusted if

indicated.





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155531 06/05/2017

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850 ASH ST

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was received to start physical and

occupational therapy due to him requiring

more assistance with ADLs and transfers.

A 3/14/17 nurses note indicated he had

five teeth extracted.


dated 3/15/17, indicated that on the

previous visit he was having socially

inappropriate behaviors typical of a

paranoid personality and he had done

well on the Depakote.

A 4/15/17 nurses notes indicated he was

not feeling well and began an antibiotic

and nebulizer treatments for an upper

respiratory infection.


dated 4/19/17, indicated at the previous

visit on 3/15/17, the resident was noted to

continue to have inappropriate and

hostile behaviors that were mildly

improved with Depakote. The staff

reported he had a chronically negative

outlook, but his behavior had smoothed

out.


dated 5/17/17, indicated at the 4/19/17

visit he continued to have behaviors and

still had a chronically negative outlook.

The note indicated to discontinue





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155531 06/05/2017

OAKBROOK VILLAGE

850 ASH ST

00

Trazodone (an antidepressant) and to

increase the Depakote to 250 mg twice

daily.

Review of "MOOD AND BEHAVIOR

COMMUNICATION MEMO"

documents for February 2017 through

May 2017, indicated the following

behaviors:

2/2/17- he was upset there was no gravy

on his food, and he should be able to get

a decent hamburger; he demanded

ketchup and mayo, then yelled because

there was not enough whipped cream on

his dessert and demanded more.

2/3/17- his call light was answered, and

he had his blanket pulled up in the

middle, exposing himself and told the

CNA she smelled good. When she went

back in later and the blanket was still

pulled up, he asked for the comforter.

2/4/17- he was assisted to his recliner,

and about a half hour later, he wanted his

cell phone and remote and indicated they

should know by now he wanted them

when he was in his chair.

2/10/17- he wanted to take his shower

later.

2/12/17- he wanted to go to bed, and said





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850 ASH ST

00

he had his call light on for 20 minutes

and was complaining about the nurse.

2/18/17- he "refused to go to bed" and

wanted to stay in his recliner to watch a

movie.

2/19/17- he wanted to sleep in his T-shirt,

because he didn't like any of the facility's

gowns, indicating they were too big.

2/26/17- he refused to get up for

breakfast because his leg had shook all

night and was sore.

3/2/17- he was upset that he had missed a

milkshake activity. The memo indicated

he had arrived at 5:30 p.m., and the

activity had begun at 5 p.m.

3/3/17- he refused to get out of bed and

get washed up for breakfast.

3/4/17- he refused to get in bed, wanted

to stay in his recliner and watch TV.

3/12/17- he was using the bathroom, put

on his call light, and transferred himself

into his wheelchair before staff got there.

3/24/17- he wanted to wait until after

breakfast to shower.

3/29/17- he refused to get out of bed at





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850 ASH ST

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7:25 a.m.

3/31/17- he wanted to shower later in the

day.

4/1/17- staff was "doing H.S. [bedtime]

care" and was almost done. He called a

friend on the phone while staff was

finishing, and they told him he didn't

need to be on the phone during care.

4/7/17- he was "not participating in full

therapy treatment" due to being upset

about not getting a shower that morning.

He then complained about not getting a

left ankle brace at admission. He was

reminded he needed to work on strength

and range of motion before being fitted.

4/11/17- he wanted to wait until his pain

pill kicked in for his shower.

4/21/17- wanted to wait for a shower.

4/25/17- he was still in his nightgown in

bed, "making excuses" about why he

wasn't up yet. He continued to make

excuses when staff attempted therapy.

He ate breakfast and lunch lying down,

although it was explained to him he

needed to sit at side of bed.

5/2/17- he wanted to wait until later for

his shower.





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850 ASH ST

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5/5/17- he wanted to wait until later for

his shower.

5/16/17 he wanted to wait until later for

his shower.

5/19/17 he "refused" his shower, stating

he was sore, and refused to get out of bed

for breakfast.

On 6/1/17 at 2:37 p.m., the SSD

indicated she had not received any

behavior memos for Resident 40 in

January 2017.

Review of a Social Service progress note,

dated 1/20/17, indicated the Social

Services Director (SSD) met with

resident regarding his refusal of showers,

as he had requested his showers at 6 a.m.

The note indicated if he didn't want to get

up, his shower would be offered after

breakfast.


dated 3/1/17, indicated he had refused

showers a few times in February and

refused to get out of bed and get washed

up. He declined a time change for his

showers.


dated 5/1/17, indicated he still refused his





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showers at 6 a.m., but would take one

after breakfast most of the time.


a.m., Resident 40 was in his room, sitting

in his recliner watching TV. He

indicated he gets frustrated with staff at

times, but didn't feel he was depressed or

had any mood changes. He indicated he

had transferred to the facility in order to

receive more physical therapy in hopes of

returning home and living independently,

but the therapy had stopped when he

didn't make anymore progress.


p.m., the SSD indicated the facility

monitored behaviors of verbal

aggression, physical aggression and

crying. She indicated rejection of care is

not considered when evaluating or

starting psychoactive medications for

residents.


p.m., the SSD and DON indicated

Resident 40 could be very manipulative.

The DON indicated the Depakote had

been started due to the resident making

paranoid statements about the

government saying he couldn't have more

physical therapy. She indicated the

resident did receive Medicaid, which paid

for the physical therapy.





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Review of a policy, titled "USE AND

TAPERING OF

PSYCHOPHARMACOLOGICAL

MEDICATIONS...", dated 12/2015 and

provided by the DON on 6/5/17 at 10:28

a.m., indicated the following: "...Each

resident's medication regimen must be

free from unnecessary medications. An

unnecessary medication is any

medication when used: ...Without

adequate indications for its use...."

3.1-48(a)(4)

483.55(b)(1)(2)(5)

ROUTINE/EMERGENCY DENTAL

SERVICES IN NFS

(b) Nursing Facilities

The facility-

(b)(1) Must provide or obtain from an outside

resource, in accordance with §483.70(g) of

this part, the following dental services to

meet the needs of each resident:

(i) Routine dental services (to the extent

covered under the State plan); and

(ii) Emergency dental services;

(b)(2) Must, if necessary or if requested,

assist the resident-

(i) In making appointments; and

(ii) By arranging for transportation to and

from the dental services locations;

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(b)(5) Must assist residents who are eligible

and wish to participate to apply for

reimbursement of dental services as an

incurred medical expense under the State

plan.

Based on record review and interview,

the facility failed to ensure routine dental

services were provided for 1 of 3

residents reviewed for dental status and

services (Resident 31).

Findings include:

Review of Resident 31's clinical record

began on 6/1/17 at 9:00 a.m. Diagnoses

included, but were not limited to,

diabetes mellitus (DM), hypothyroidism,

history of cancer (neck glands),

hypokalemia, and dementia.

She had current medication orders for,

but not limited to, the following: Lasix

40 mg (anti-edema) once daily for edema,

Synthroid 125 mcg (thyroid replacement)

once daily every morning before

breakfast for hypothyroidism, and

Potassium Chloride ER 20 meq

(Potassium replacement) once daily for

hypokalemia.

A quarterly, 4/6/17, Minimum Data Set

assessment (MDS) indicated she was

severely cognitively impaired. The

assessment indicated she had no natural


experience any negative outcomes

related to the alleged deficient

practice. A dental appointment has

been set up for this resident.

All residents have the potential to be

affected. Their dental records have

been reviewed and appointments

made for them to see the dentist if

indicated.

The facility’s policy for dental

services has been reviewed and no

changes are indicated at this time.

The SSD has been re-educated on

the need to follow

recommendations related to future

dental appointments/referrals. A


implemented.

The SSD or designee will be

responsible for reviewing dental

progress notes after each dental visit

to ensure follow up appointments

are being scheduled and attended.

These reviews will be done after

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teeth or tooth fragments (edentulous).

She had a current care plan, initiated on

10/12/16 and last revised 4/20/17, for the

problem of resident requires special

attention to oral care due to has no

natural teeth and does not wear her

dentures, and receiving medications that

could cause a dry mouth.

She had a dental exam, dated 5/27/16,

which indicated that she should be

reevaluated in 6 months (180 days). On

6/5/17 at 9:14 a.m., no further dental

exams were presented by the facility.

On 6/2/17 at 10:47 a.m., the Director of

Nursing (DON) indicated that the facility

switched to [name of new dental

provider] from [previous dental provider]

in January because [name of previous

dental provider] just stopped showing up

when scheduled. The November

appointment was missed related to [name

of previous dental provider] not showing

up.

On 6/2/17 at 2:57 p.m., the Social

Service Director (SSD) indicated that she

did not notify [name of previous dental

provider] about their lack of services.

The SSD and DON indicated that a

notice was provided to[name of previous

dental provider] that the building would

each dental visit monthly. Should a

concern be found, immediate

corrective action will occur. Results

of these reviews and any corrective

action will be discussed during the

facility’s quarterly QA meetings on

an ongoing basis for a minimum of

six months and the plan adjusted if

indicated.





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terminate the written contract with them

effective December 31, 2016. The SSD

indicated that no services were provided

to the residents until March 2017 when

the new company began services and that

Resident 31 was on the list on 3/23/17

but was not able to be seen.

No further information was received

prior to exit from the facility.

3.1-24(a)(1)

483.45(b)(2)(3)(g)(h)

DRUG RECORDS, LABEL/STORE DRUGS

& BIOLOGICALS

The facility must provide routine and

emergency drugs and biologicals to its

residents, or obtain them under an

agreement described in §483.70(g) of this

part. The facility may permit unlicensed

personnel to administer drugs if State law

permits, but only under the general

supervision of a licensed nurse.

(a) Procedures. A facility must provide

pharmaceutical services (including

procedures that assure the accurate

acquiring, receiving, dispensing, and

administering of all drugs and biologicals) to

meet the needs of each resident.

(b) Service Consultation. The facility must

employ or obtain the services of a licensed

pharmacist who--

(2) Establishes a system of records of

receipt and disposition of all controlled drugs

in sufficient detail to enable an accurate

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reconciliation; and

(3) Determines that drug records are in

order and that an account of all controlled

drugs is maintained and periodically

reconciled.

(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 the appropriate accessory and

cautionary instructions, and the expiration

date when applicable.

(h) Storage of Drugs and Biologicals.

(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.

(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.

Based on observation, interview and

record review, the facility failed to ensure

1 of 2 medication carts were maintained

in a secure manner to prevent potential

access at all times by unauthorized users

for the 100 Hall medication cart for 1 of

1 observations. The facility also failed to

F 0431 No residents were affected by this

alleged deficient practice. The 100

hall medication cart is being locked

when unattended and the narcotic

box has been securely fastened to

the medication cart.

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ensure the narcotic drawer was securely

fastened to the inside of the medication

carts for 1 of 2 carts observed during

medication storage (100 Hall Cart).

Findings include:

1. During an observation on 6/2/17 at

10:00 a.m., the 100 Hall medication cart

was observed unlocked and unattended.

No staff was observed in the area. At

10:09 a.m., a nurse returned and locked

the medication cart.

2. During medication storage

observation on 6/5/17 at 8:58 a.m., while

attempting to ensure the narcotic box was

secured to the narcotic drawer, the entire

narcotic box was removed from the

drawer and the entire contents of the

narcotic box was able to be taken out

from the bottom of the box.

On 6/5/17 at 9:00 a.m., the Maintenance

Director was called to secure the narcotic

box to the drawer. The contents of the

box were removed and stored until the

box was reattached.


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

indicated it was a total "fluke" and she

could not believe the entire box was able

to be removed.

All other medication carts and

treatment carts have been checked

and are being kept locked when

unattended. All medication carts

with narcotic boxes have them

securely fastened to the medication

cart.

The facility’s policy for drug storage

has been reviewed and no changes

are indicated at this time. The

Nurses and QMAs have been

re-educated on the policy with a

special focus on securing medication

carts and narcotic boxes. A


implemented.


responsible for completing the

monitoring tool to ensure the

medication carts are kept secured

and narcotic boxes are secured to

the medication carts. These reviews

will be done on scheduled work days

as follows: daily for two weeks, two

times weekly for two weeks, weekly

for two weeks, then monthly

thereafter. Should a concern be


will occur. Results of these reviews

and any corrective actions will be









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Review of a current, undated policy,

titled "STORING DRUGS", which was

provided by the DON on 6/5/17 at 11:17

a.m., indicated the following:

"POLICY

Drugs and biologicals will be stored in a

safe, secured, and orderly manner at

proper temperatures and accessible only

to licensed nursing and pharmacy

personnel or staff members lawfully

authorized to administer medications.

PROCEDURES

...8. Controlled drugs in Schedule II

(C-II) are subject to special storage....

C-II drugs must be stored under

double-lock in a separate drawer or

compartment reserved specifically for

that purpose. No other drugs should be

included in the C-II locker except those

other controlled drugs that due to special

circumstances may need additional

storage security."

3.1-25(m)

3.1-25(n)

indicated.

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

INFECTION CONTROL, PREVENT

SPREAD, LINENS

(a) Infection prevention and control program.

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The facility must establish an infection

prevention and control program (IPCP) that

must include, at a minimum, the following

elements:

(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 (facility assessment

implementation is Phase 2);

(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

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





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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.

(4) A system for recording incidents

identified under the facility’s IPCP and the

corrective actions taken by the facility.

(e) Linens. Personnel must handle, store,

process, and transport linens so as to

prevent the spread of infection.

(f) Annual review. The facility will conduct

an annual review of its IPCP and update

their program, as necessary.


record review, the facility failed to follow

standard handwashing procedures for 1 of

1 G-tube medication administration

observations (Resident 9).

Findings include:

During a medication administration

observation, beginning on 6/2/17 at 11:51

a.m., LPN 31 completed a handwash,

leaving the water running in the sink, and

filled a graduated cup with water.

Holding the cup in her left hand, she

turned the faucet off with her right hand,



related to the alleged deficient

practice. LPN #31 has been

re-educated on hand hygiene with a

special focus on hand hygiene during

G-Tube care.

All residents with G-tubes have the

potential to be affected. Nurses and

QMAs have been re-educated on

hand hygiene with a special focus on

hand hygiene during G-Tube care.

06/23/2017 12:00:00AM





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touching both faucet knobs. She carried

the cup to Resident 9's bedside table,

assisted her with repositioning using her

bed pad, and returned to the bathroom

sink. LPN 31 washed her hands, turned

the faucet knobs off with paper towel,

and dried her hands again with the same

paper towel. While preparing to

administer the medications, she spilled

the liquid medication and returned to the

medication cart in the hallway to prepare

another dose. She did not wash her

hands when she returned to the room.

After completing the medication

administration via the resident's G-tube,

she again washed her hands at the same

bathroom sink. While drying her hands,

she dropped a paper towel into the sink,

which had not fully drained and was

partially filled with bubbles and water.

She picked up the wet paper towel, threw

it in the trash, and continued to dry her

hands. She did not wash her hands again

before turning off the sink with dry paper

towel.

LPN 31 indicated at the time of the

observation she should not have touched

the faucet after drying her hands.

Review of a policy, titled

"HANDWASHING/HAND HYGIENE",

dated 10/2014 and provided by the DON

on 6/2/17 at 12:11 p.m., indicated the

The facility’s policy for hand hygiene

has been reviewed and no changes

are indicated at this time. The

nurses and QMAs have been

re-educated on hand hygiene with a

special focus on hand hygiene during

G-tube care. A monitoring tool has

been implemented.


responsible for completing the

monitoring tool and ensuring proper

hand hygiene is being completed.

The monitoring will occur on

scheduled work days reviewing

three staff members as follows:

daily for two weeks, two times

weekly for two weeks, one time

weekly for two weeks, monthly for

two months, then quarterly

thereafter. Should a concern be


will occur. Results of these reviews

will be discussed during the facility’s




indicated.





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following: "...Hand hygiene is the single

most important measure for preventing

the spread of

infection...HANDWASHING

PROCEDURE...12. Dry hands

thoroughly with a single use paper towel.

13. Use towel to turn off faucet and

discard towel...."

3.1-18(l)


printed: 07/06/2017 department of health … · except for nursing homes, ... her paranoia and...

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