06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 OMB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 0000 Bldg. 00 This visit was for a Recertification and State Licensure Survey. This visit included the Investigation of Complaints IN00294042, IN00294151, and IN00294200. F 0000 Complaint IN00294042 - Substantiated. Federal/State deficiencies related to the allegations are cited at F580 and F677. Complaint IN00294151 - Substantiated. Federal/State deficiencies related to the allegations are cited a F677, F689, F725, and F921. Complaint IN00294200 - Substantiated. Federal/State deficiencies related to the allegations are cited a F695 and F880. Survey dates: May 13, 14, 15, 16, 17, and 20, 2019. The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Facility number: 000076 Provider number: 155156 AIM number: 100271060 Census Bed Type: SNF/NF: 121 SNF: 26 Total: 147 Census Payor Type: Medicare: 24 Medicaid: 96 Other: 27 Total: 147 These deficiencies reflect State Findings cited in accordance with 410 IAC 16.2-3.1. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 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 disclo 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. _____________________________________________________________________________________________________ Event ID: Facility ID: If continuation sheet KV9P11 000076 Page 1 of 111 FORM CMS-2567(02-99) Previous Versions Obsolete 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Quality review completed on 5/23/19. F 0550 SS=E Bldg. 00 483.10(a)(1)(2)(b)(1)(2) Resident Rights/Exercise of Rights §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 2 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. Based on observation, record review and interview, the facility failed to ensure each resident's dignity was maintained related to wearing hospital gowns in bed during the day for 4 of 4 residents reviewed for dignity. (Residents K, G, D, and C) F 0550 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) F550 – Resident’s Rights (Dignity) (X5) COMPLETION DATE 06/12/2019 12:00:00A The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Findings include: 1. On 5/13/19 at 11:20 a.m., Resident K was observed in her room in bed. The resident was awake and she was wearing a hospital gown. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. On 5/14/19 at 2:37 p.m., the resident was again observed in bed wearing a hospital gown. The resident was observed in bed wearing a hospital gown on 5/15/19 at 8:45 a.m., 10:32 a.m., 11:40 a.m., 1:47 p.m., and 3:30 p.m. On 5/16/19 at 9:34 a.m. and 10:15 a.m., the resident was again observed in bed wearing a hospital gown. 1) Immediate actions taken for those residents identified: The record for Resident K was reviewed on 5/16/19 at 9:45 a.m. Diagnoses included, but were not limited to,intracranial abscess and granuloma, vascular dementia with behavior disturbance, recurrent dislocation of left hip, dysphagia, schizophrenia, encephalopathy, type 2 diabetes, bipolar, cataract right eye, anxiety, hypertension, artificial opening of digestive tract, anemia, and cerebral infarct (stroke). Residents K, G, and C’s preferences were addressed regarding preferred clothing and care plan updated. Resident D was discharged. 2) How the facility identified other residents: The Quarterly Minimum Data Set (MDS) FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY All residents could be affected by Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 3 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) assessment, dated 3/8/19, indicated the resident was cognitively impaired for daily decision making and required extensive two person assistance with dressing. this deficient practice. Residents preferences audit completed to ensure all preferences are being followed. The current Plan of Care, indicated the resident did not have a care plan related to preferring to wear a hospital gown while in bed. 3) Measures put into place/ System changes: (X5) COMPLETION DATE Staff will be educated on Resident’s Rights as it pertains to dignity. Interview with the Director of Nursing on 5/17/19 at 2:30 p.m., indicated the resident did not have a care plan related to wearing a hospital gown in bed during the day. 2. On 5/13/19 at 12:00 p.m. and 2:50 p.m., Resident G was observed in bed. At those times he was wearing a hospital gown. 4) How the corrective actions will be monitored: Rounds will be completed at least 5x/week on various shifts and at various times to ensure dignity is maintained and residents are dressed based on their preference. On 5/14/19 10:25 a.m., and 10:52 a.m., the resident was observed in bed wearing a hospital gown. On 5/15/19 at 9:25 a.m., 11:01 a.m., and 3:25 p.m., the resident was observed in bed wearing a hospital gown. The Director of Nursing will be responsible for oversight of these audits. On 5/16/19 at 9:00 a.m., 11:20 a.m., 1:26 p.m., and 2:00 p.m., the resident was observed in bed wearing a hospital gown. The results of these audits will be reviewed in Quality Assurance Meeting monthly x 6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. On 5/17/19 at 10:45 a.m., and 10:58 a.m., the resident was observed in bed wearing a hospital gown. The record for Resident G was reviewed on 5/17/19 at 1:20 p.m. Diagnoses included, but were not limited to, cerebral ischemia, high blood pressure, alcohol abuse, polyosteoarthritis, dysphagia, peripheral vascular disease, stroke, glaucoma, legal blindness, chronic pain, and hemiparesis. 5) Date of compliance: 6/12/19 The Modification of the Quarterly Minimum Data FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 4 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Set (MDS) assessment, dated 2/27/19, indicated the resident was not alert and oriented and needed extensive assist with 2 person physical assist with bed mobility, transfers, dressing and toileting. The resident had range of motion impairments to both upper and lower extremities. His weight was 130 pounds, and he received an enteral feeding through the peg tube (a tube placed directly into the stomach to provide nutrition). There was no Care Plan indicating the resident wanted to be dressed in a hospital gown. A preference sheet, dated 12/28/18, indicated it was somewhat important for the resident to choose what clothes to wear, which were sweat pants. Interview with the 200 Unit Manager on 5/17/19 at 12:00 p.m., indicated there was no reason why the resident could not be dressed in street clothes every day. 3. On 5/13/19 at 11:13 a.m., Resident D was observed in bed wearing a hospital gown. On 5/14/19 at 9:10 a.m., the resident was observed in bed wearing a hospital gown. On 5/15/19 at 8:32 a.m., and 10:28 a.m., the resident was observed in bed wearing a hospital gown. On 5/16/19 at 9:00 a.m., 9:49 a.m., 11:15 a.m., and 1:15 p.m., the resident was observed in bed wearing a hospital gown. The record for Resident D was reviewed on 5/15/19 at 2:15 p.m. The resident was admitted to the facility on 1/5/19. Diagnoses included, but FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 5 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE were not limited to, fracture of the femur, stroke, history of falls, urinary tract infection, dementia, high blood pressure, major depressive disorder, and chronic obstructive pulmonary disease (COPD). The Significant Change Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was not alert and oriented and was severely impaired for decision making. The resident needed extensive assist with 2 person physical assist for transfers, bed mobility and dressing. A Care Plan, dated 4/3/19, indicated It was important for the resident to choose her own clothing along with care. The approaches were staff will assist the resident with daily preferences as needed. Interview with the 200 Unit Manager on 5/17/19 at 12:00 p.m., indicated there was no reason the resident could not be dressed in regular clothes, other than a hospital gown. 4. On 5/13/19 at 9:39 a.m., and 3:06 p.m., Resident C was observed in bed wearing a hospital gown. On 5/14/19 at 9:42 a.m., the resident was observed in bed wearing a hospital gown. On 5/15/19 at 9:00 a.m., 12:00 p.m., and 3:11 p.m., the resident was observed in bed wearing a hospital gown. On 5/16/19 at 9:10 a.m., 11:28 a.m., and 1:25 p.m., the resident was observed in bed wearing a hospital gown. On 5/17/19 at 10:13 a.m., the resident was observed in bed wearing a hospital gown. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 6 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE The record for Resident C was reviewed on 5/15/19 at 11:34 a.m., The resident was admitted to facility on 4/24/19. Diagnoses included, but were not limited to, pneumonia, lack of coordination, unsteadiness on feet, cognitive deficit, hemiplegia, stroke, chronic pulmonary disease, aphasia, urinary tract infection, high blood pressure, diabetes type 2, chronic kidney disease, respiratory failure, morbid obesity, tracheotomy, heart failure, and ventilator dependent. The Admission Minimum Data Set (MDS) assessment, dated 5/13/19, indicated the resident was rarely understood or understands. It was very important for the resident to choose what clothes to wear. The resident was totally dependent on staff with a 2 person physical assist for bed mobility and dressing. There was no Care Plan indicating the resident preferred to wear hospital gowns during the day. A preference interview, dated 4/27/19, indicated the interview was completed by the resident and it was very important for her to choose what clothes to wear. Interview with the resident's daughter on 5/15/19 at 8:20 a.m. indicated she would prefer her mom to be dressed in street clothes. She had brought clothes in and staff told her they could not get her dressed. Interview with the Director of Nursing on 5/20/19 at 9:09 a.m., indicated the resident could be dressed in street clothes, something other than a hospital gown. The activity preference sheet should be updated due to the resident was not able to respond to the questions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 7 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 3.1-3(t) F 0580 SS=D Bldg. 00 483.10(g)(14)(i)-(iv) Notify of Changes (Injury/Decline/Room, etc.) §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 8 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9). Based on record review and interview, the facility failed to ensure the resident's family member/ responsible party was promptly notified of a significant change in condition which lead to a hospital admission for 1 of 2 residents reviewed for notification of change. (Resident D) F 0580 F580 – Notification of Change 06/12/2019 12:00:00A This Plan of Correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Finding includes: The record for Resident D was reviewed on 5/15/19 at 2:15 p.m. The resident was admitted to the facility on 1/5/19. Diagnoses included, but were not limited to, fracture of the femur, stroke, history of falls, urinary tract infection, dementia, high blood pressure , major depressive disorder, and chronic obstructive pulmonary disease (copd). The Significant Change Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was not alert and oriented and was severely impaired for decision making. The resident needed extensive assist with 2 person physical assist for transfers, bed mobility and dressing. 1) Immediate actions taken for those residents identified: Resident D no longer resides at the facility. 2) How the facility identified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 9 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG Nurse's Notes, dated 4/6/2019 at 6:30 p.m., indicated the resident was received resting in bed on her back with barrel chest shallow respirations. Her eyes were sluggish and tactile and verbal responses were slow. The writer called the RN to observe and evaluate the resident. The Nurse Practitioner (NP) was notified and orders were received to send out resident 911 to the hospital. (X5) COMPLETION DATE An audit will be completed for residents with a change in condition and/or hospital transfer in the last 14 days to ensure appropriate parties notified. 3) Measures put into place/ System changes: Licensed nurses will be re-educated on notification of appropriate parties when a resident has a change of condition and/or is transferred to the hospital. Nurse's Notes, dated 4/7/2019 at 12:59 a.m., indicated the facility received a phone call from the emergency room needing information about the resident's medications and diagnoses. The nurse from the hospital indicated the resident had signs and symptoms of dehydration. 4) How the corrective actions will be monitored: There was no documentation the resident's responsible party was notified of resident being sent to the hospital. DON/designee will review documentation at least 5x/week to ensure appropriate parties are notified for residents with a change of condition and/or who are transferred to the hospital. The DON is responsible for compliance. A transfer form, dated 4/9/19 (completed 3 days later), indicated the resident was notified of her own transfer. Interview with the 200 Unit Manager on 5/17/19 at 12:10 p.m., indicated there was no information the resident's family was notified of the significant change in her condition and the transfer to the hospital. The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the This Federal tag relates to Complaint IN00294042. 3.1-5(a)(2) Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) other residents: Nurse's Notes, dated 4/7/19 at 12:24 a.m., indicated the resident was being admitted for bradycardia (low heart rate). FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY KV9P11 Facility ID: 000076 If continuation sheet Page 10 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE plan of correction as indicated. 5) Date of compliance: 6/12/19 F 0583 SS=D Bldg. 00 483.10(h)(1)-(3)(i)(ii) Personal Privacy/Confidentiality of Records §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 11 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. Based on observation, record review, and interview, the facility failed to ensure each resident was offered privacy during care related to not closing or knocking on the room door, pulling the privacy curtain around the resident and closing the blinds for 3 of 3 residents reviewed for privacy. (Residents B, L, and J) F 0583 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 06/12/2019 12:00:00A F583 - Privacy The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Findings include: Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1. On 5/14/19 at 9:01 a.m., Resident B was observed in bed, wearing a t-shirt and an incontinent brief and could be seen from the hallway. At that time, CNA 1 was in the room repositioning the resident for breakfast. The room door was open and the resident's privacy curtain was not completely pulled around her, as her roommate was observed in the first bed. The window blinds were also open. The CNA repositioned the resident without providing full privacy. 1) Immediate actions taken for those residents identified: The Record for Resident B was reviewed on 5/16/19 at 10:06 a.m. The resident was admitted to the facility on 4/25/19. Diagnoses included, but were not limited to, cardiomyopathy, edema, altered mental status change, transient ischemic attacks, hemiplegia. Resident B – Privacy curtain was pulled. Resident L - Privacy curtain was pulled. Resident J – New privacy curtain was hung. The Admission Minimum Data Set (MDS) assessment, dated 5/2/19, indicated the resident was not alert and oriented. The resident was an extensive assist with a 2 person physical assist for bed mobility, transfers, and locomotion on and off FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2) How the facility identified other residents: KV9P11 Facility ID: 000076 If continuation sheet Page 12 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY the unit. The resident received oxygen and a mechanically altered and therapeutic diet while at the facility. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE All residents have the potential to be affected by the deficient practice. Interview with the Corporate Nurse consultant on 5/14/19 at 9:25 a.m., indicated the CNA should have closed the door, pulled the privacy curtain around the resident and closed the blinds before providing care. 2. Interview with Resident L on 5/13/19 at 11:24 a.m., indicated the staff did not provide privacy during care. The facility staff did not pull the privacy curtain around her bed, leaving her exposed when the door was opened. 3) Measures put into place/ System changes: Staff will be re-educated regarding resident’s privacy while providing care and reporting of any curtains in need of replacement or repair. 4) How the corrective actions will be monitored: On 5/15/19 at 11:02 a.m., CNA 10 was observed in the room with Resident L, the door was slightly ajar. An unknown staff member knocked on the door, CNA 10 indicated "resident care", the unknown staff member proceeded to enter the room exposing the resident as the CNA was providing peri care. Interview at the time indicated she did not pull the privacy curtain around the resident's bed because she had pulled the door almost closed. The Director of Nursing or designee will complete rounds least 5 x per week on various shifts and times to ensure privacy is being maintained. An interview will be conducted on at least 3 residents per week to ensure staff are providing for privacy. The DON will be responsible for compliance. The record for Resident L was reviewed on 5/17/19 at 11:59 a.m. Diagnoses included, but were not limited to, multiple sclerosis, adult failure to thrive, malignant neoplasm of the digestive system, diabetes, chronic kidney disease, dementia, anxiety, and delusions. The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. The Quarterly Minimum Data Set (MDS) assessment, dated 3/12/19, indicated the resident was alert and oriented and required an extensive 2 person physical assist with transfers and personal hygiene. Interview with the Director of Nursing on 5/16/19 at 10:00 p.m., indicated staff should provide all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 13 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY residents with privacy during care. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 5) Date of compliance: 06/12/19 3. On 5/16/19 at 9:04 p.m., LPN 1 was observed preparing medications for Resident J at her medication cart parked at the end of the hallway from the resident's room. The LPN walked down the hallway with the resident's medications in her hand. She then entered the resident's room without knocking. CNA 4 indicated "you did not even knock". The CNA and an unknown staff member were providing incontinence care and the resident's body was exposed to the hallway. The record for Resident J was reviewed on 5/17/19 at 9:32 a.m. Diagnoses included, but were not limited to, cervical spinal bifida, paraplegia, lack of coordination, major depression, anxiety, insomnia, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 3/13/19, indicated the resident was alert and oriented and required an extensive 2 person physical assist with transfers and a 1 person physical assist with personal hygiene. Interview with the Director of Nursing on 5/16/19 at 10:00 p.m., indicated staff should provide all residents with privacy during care. 3.1-3(p)(4) F 0584 SS=D Bldg. 00 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 14 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. Based on record review and interview, the facility failed to protect a resident's personal property from loss or theft related to missing denim jeans for 1 of 4 residents reviewed for personal property. (Resident M) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0584 KV9P11 F584 – Safe/Clean/Comfortable/Homelike Environment Facility ID: 000076 If continuation sheet 06/12/2019 12:00:00A Page 15 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG Finding includes: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE The facility requests paper compliance for this citation. Interview with Resident M on 5/13/19 at 2:34 p.m., indicated he was missing a pair of black 505 Levi denim jeans from his closet. He reported the missing item to staff and was told he would have to talk with the Social Service Director (SSD). This Plan of Correction is the center's credible allegation of compliance. Interview with the SSD on 5/15/19 at 9:05 a.m., indicated the resident had reported the jeans missing and they were not found and had not been replaced. The Annual Minimum Data Set (MDS) assessment, dated 3/28/19, indicated the resident was alert and oriented for decision making. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. The Concern/Compliment Form, dated 4/11/19, indicated missing black Levis 32 x 36, not labeled, searching for missing item. No follow up was noted. 1.Immediate actions taken for those residents identified: The record for Resident M was reviewed on 5/15/19 at 3:07 p.m. Diagnoses included, but were not limited to, end stage renal disease, dialysis, major depression, hypertension, mood disorder, pacemaker, anxiety, and chronic pain. Interview with the Administrator on 5/17/19 2:00 p.m., indicated the resident's jeans will be replaced. The missing personal property for Resident M was replaced. 3.1-9(b) 1.How the facility identified other residents: All residents have the potential to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 16 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE be affected by this deficient practice. Grievance log for the past 30 days will be reviewed to ensure resolution and follow-up was completed. 1.Measures put into place/ System changes: Staff will be re-educated on the policy for reporting any mis-placed property and the process for marking clothing on and after admission. 1.How the corrective actions will be monitored: Grievances will be brought to morning meeting 5 days a week to review for resolutions between 3-5 business days. Any outstanding will be resolved immediately. The Administrator will be responsible for compliance. The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 17 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5) Date of compliance: 06/12/19 F 0623 SS=E Bldg. 00 483.15(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 section must be made by the facility at least 30 days before the resident is transferred or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 18 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 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 State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 19 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 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). Based on record review and interview, the facility failed to ensure a resident's Responsible Party was notified in writing related to a transfer to the hospital for 4 of 4 residents reviewed for hospitalization. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0623 F623 – Notice of Transfer 06/12/2019 12:00:00A The facility requests paper compliance for this citation. KV9P11 Facility ID: 000076 If continuation sheet Page 20 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG (Residents 58, G, D, and C) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE This Plan of Correction is the center's credible allegation of compliance. Findings include: 1. The record for Resident 58 was reviewed on 5/15/19 at 10:39 a.m. Diagnoses included, but were not limited to, pneumonia, hemiplegia/hemiparesis (weakness), traumatic brain injury, dysphagia (difficulty swallowing) history of falls, anxiety, delusional disorder, convulsions, and hypothyroidism. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. The Quarterly Minimum Data Set (MDS) assessment, dated 2/13/19, indicated the resident was moderately impaired for daily decision making. 1) Immediate actions taken for those residents identified: An entry in the Nursing Progress Notes, dated 2/1/19 at 11:34 p.m., indicated the resident was restless, could hardly get his breath and was coughing and gurgling. A nebulizer (breathing) treatment was given with no relief. The Nurse Practitioner (NP) was notified and orders were received to send the resident to the hospital. The resident's wife was notified at the time. Resident 58, G and C’s appropriate parties were notified of the transfer. Resident D no longer resides at the facility. The Transfer/Discharge form, dated 2/1/19, was scanned into the computer. There was no documentation indicating the resident's Responsible Party had received a written copy of the information. 2) How the facility identified other residents: All residents who transfer or are discharged are affected by this deficient practice. Interview with the Social Service Director on 5/14/19 at 2:45 p.m., indicated the resident's Responsible Party was notified via telephone about the transfer. She further indicated the information was being scanned into the computer but not mailed to the Responsible Party. 2. The record for Resident G was reviewed on 5/17/19 at 1:20 p.m. Diagnoses included, but were not FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY Event ID: 3) Measures put into place/ System changes: Nursing staff will be re-educated on the procedure for issuing the Notice of Transfer/Discharge to the KV9P11 Facility ID: 000076 If continuation sheet Page 21 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY limited to, cerebral ischemia, high blood pressure, alcohol abuse, polyosteoarthritis, dysphagia, peripheral vascular disease, stroke, glaucoma, legal blindness, chronic pain, and hemiparesis. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE resident/resident representative. An audit will be completed weekly on all transfer/discharges to ensure the notice was sent and receipt was documented. Social Services Director will be responsible for compliance. The Modification of the Quarterly Minimum Data Set (MDS) assessment dated 2/27/19, indicated the resident was not alert and oriented and needed extensive assist with 2 person physical assist with bed mobility, transfers, dressing and toileting. The resident had range of motion impairments to both upper and lower extremities. His weight was 130 pounds, and he received an enteral feeding through the peg tube (a tube placed directly into the stomach to provide nutrition). 4) How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. The resident was admitted to the hospital on 3/4/19 and 4/3/19. Nurse's Notes, dated 3/4/2019 at 9:18 a.m., indicated the resident had pulled out his gastric tube and was sent to the emergency room. The resident returned on 3/5/19. Nurse's Notes, dated 4/2/2019 at 10:31 a.m., indicated the resident had a temperature of 100.2 degrees and had finished antibiotics for a wound infection. The Physician gave orders to send the resident to the hospital. The resident was admitted and returned on 4/9/19 5) Date of compliance: 06/12/19 There was no documentation the resident's Responsible Party was notified in writing of the transfer. Interview with the Social Service Director (SSD) on 5/14/19 at 3:00 p.m., indicated she had not been sending the State approved transfer form to the resident's family member when there was an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 22 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE unplanned discharge. 3. The record for Resident D was reviewed on 5/15/19 at 2:15 p.m. The resident was admitted to the facility on 1/5/19. Diagnoses included, but were not limited to, fracture of the femur, stroke, history of falls, urinary tract infection, dementia, high blood pressure , major depressive disorder, and chronic obstructive pulmonary disease (copd). The significant Change Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was not alert and oriented and was severely impaired for decision making. The resident needed extensive assist with 2 person physical assist for transfers, bed mobility and dressing. Nurse's Notes, dated 4/6/2019 at 6:30 p.m., indicated the resident was received resting in bed on her back with barrel chest shallow respirations. Her eyes were sluggish and tactile and verbal responses were slow. The writer called a RN to observe and evaluate the resident. The Nurse Practitioner (NP) was notified and orders were received to send out resident 911 to the hospital. Nurse's Notes, dated 4/7/19 at 12:24 a.m., indicated the resident was being admitted for bradycardia (low heart rate). Nurse's Notes, dated 4/7/2019 at 12:59 a.m., indicated received a phone call from the emergency room needing information about the resident's medications and diagnoses. The nurse from the hospital indicated the resident had signs and symptoms of dehydration. There was no documentation the resident's Responsible Party was notified in writing of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 23 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE transfer. Interview with the Social Service Director (SSD) on 5/14/19 at 3:00 p.m., indicated she had not been sending the State approved transfer form to the resident's family member when there was an unplanned discharge. 4. The record for Resident C was reviewed on 5/15/19 at 11:34 a.m., The resident was admitted to facility on 4/24/19. Diagnoses included, but were not limited to, pneumonia, lack of coordination, unsteadiness on feet, cognitive deficit, hemiplegia, stroke, chronic pulmonary disease, aphasia, urinary tract infection, high blood pressure, diabetes type 2, chronic kidney disease, respiratory failure, morbid obesity, tracheotomy, heart failure, and ventilator dependent. The Admission Minimum Data Set (MDS) assessment, dated 5/13/19, indicated the resident was rarely understood or understands. It was very important for the resident to choose what clothes to wear. The resident was totally dependent on staff with a 2 person physical assist for bed mobility and dressing. Nurse's Notes, dated 5/5/2019 at 12:20 p.m., indicated the resident was moving her legs around and was having labored breathing with a small amount of blood in the foley catheter. Her vitals were taken and the resident looked to be in pain with facial grimacing and muscle tension. The intravenous site in the right arm was swollen. The Nurse Practitioner was notified and orders were given to send the resident to the hospital for evaluation. 911 was called and the resident was transferred to the hospital and admitted with the diagnosis of hypoxia. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 24 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE There was no documentation the resident's Responsible Party was notified in writing of the transfer. Interview with the Social Service Director (SSD) on 5/14/19 at 3:00 p.m., indicated she had not been sending the State approved transfer form to the resident's family member when there was an unplanned discharge. 3.1-12(a)(6)(ii) 3.1-12(a)(6)(iii) F 0641 SS=D Bldg. 00 483.20(g) Accuracy of Assessments §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. Based on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to restraints, fractures, and range of motion for 3 of 31 MDS assessments reviewed. (Residents G, 129, and L) F 0641 F641 – MDS Accuracy 06/12/2019 12:00:00A The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Findings include: Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1. The record for Resident G was reviewed on 5/17/19 at 1:20 p.m. Diagnoses included, but were not limited to, cerebral ischemia, high blood pressure, alcohol abuse, polyosteoarthritis, dysphagia, peripheral vascular disease, stroke, glaucoma, legal blindness, chronic pain, and hemiparesis. The Quarterly Minimum Data Set (MDS) assessment, dated 2/27/19, indicated the resident was not alert and oriented and needed extensive assist with 2 person physical assist with bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 25 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG mobility, transfers, dressing and toileting. The resident had range of motion impairments to both upper and lower extremities. His weight was 130 pounds, and he received an enteral feeding through the peg tube (a tube placed directly into the stomach to provide nutrition). An "other" restraint was checked as used less than daily. (X5) COMPLETION DATE The MDS for Resident G was corrected and resubmitted The MDS for Resident 129 was corrected and resubmitted The MDS for Resident L was corrected and resubmitted 2) How the facility identified other residents: Interview with the Corporate MDS Consultant on 5/14/19 at 2:58 p.m., indicated it was a mistaken entry on the MDS. The resident did not have any restraint.2. The record for Resident 129 was reviewed on 5/20/19 at 12:50 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypertension, atrial fibrillation, dementia, and heart failure. All residents who have the potential to be affected by the alleged deficient practice. MDS’s submitted since 5/20/19 will be reviewed for accuracy and resubmitted if appropriate. The Quarterly Minimum Data Set (MDS) assessment, dated 4/30/19, indicated the resident was moderately cognitively impaired, required an extensive 1 person physical assist with transfers. She had no upper and/or lower extremity impairments, and 1 fall with a major injury since her admission or prior assessment. 1.Measures put into place/ System changes: The MDS Coordinator/Designee will re-educate the IDT and licensed nurses on the importance of the accuracy of documentation. The MDS Coordinator/designee will review 2 MDS’s per week to ensure accurate coding and document on Accuracy of Assessments audit tool. The DON will be responsible for compliance. There was no documentation to indicate the resident had a fall with a major injury. Interview with the Corporate MDS Consultant on 5/14/19 at 2:58 p.m., indicated the fall with a major injury was documented in error and would be corrected. 4) How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or 3. On 5/15/19 at 9:14 a.m., Resident L was observed in bed, her right hand was resting flat on the bed and was in a fixed fist position. Interview at the time indicated she could not physically Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1.Immediate actions taken for those residents identified: Physician's Orders, dated 2/2019-5/2019, indicated there were no orders for any type of restraint. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY KV9P11 Facility ID: 000076 If continuation sheet Page 26 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY open her hand on her own and had not ever had a splinting device and/or therapy. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE until 100% compliance is achieved. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. The record for Resident L was reviewed on 5/17/19 at 11:59 a.m. Diagnoses included, but were not limited to, multiple sclerosis, adult failure to thrive, malignant neoplasm of the digestive system, diabetes, chronic kidney disease, dementia, anxiety, and delusions. 5) Date of compliance: 06/12/19 The Quarterly Minimum Data Set (MDS) assessment, dated 3/12/19, indicated the resident was alert and oriented and required an extensive 2 person physical assist with transfers and personal hygiene. She had no upper and/or lower extremity impairments. There was no documentation related to her limited range of motion to her right hand. Interview with the Director of Nursing on 5/17/19 at 12:45 p.m., indicated she was not aware the resident had limited range of motion to her right hand. The resident had not been assessed for limited range of motion in her right hand by nursing and/or the therapy department. Interview with the Director of Therapy on 5/20/19 at 12:22 p.m., indicated the resident had not been seen by therapy since her admission related to her right hand. An assessment was completed on 5/17/19, she had limited range of motion to her right had and was at risk for a possible flexion contracture in her right hand with 1st digit MP (metacarpophalangeal) flexion contracture. Interview with the 200 Unit Manager on 5/20/19 2:55 p.m., indicated the resident's right hand should have been properly assessed and documented in the MDS assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 27 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 3.1-31(d) F 0644 SS=D Bldg. 00 483.20(e)(1)(2) Coordination of PASARR and Assessments §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Based on record review and interview, the facility failed to ensure another Level I PASRR (Pre Admission Screening Resident Review) was completed due to a new diagnosis for 1 of 1 residents reviewed for PASRR. (Resident F) F 0644 06/12/2019 12:00:00A The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Finding includes: The record for Resident F was reviewed on 5/15/19 at 9:33 a.m. The resident was admitted to the facility on 1/14/19. Diagnoses included, but were not limited to, cirrhosis of liver, palliative care, asthma, heart failure, type 2 diabetes, kidney disorder, atrial fibrillation, high blood pressure, and bipolar disorder. FORM CMS-2567(02-99) Previous Versions Obsolete F644 – Coordination of PASARR Event ID: Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of KV9P11 Facility ID: 000076 If continuation sheet Page 28 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. The Admission Minimum Data Set (MDS) assessment, dated 1/25/19, indicated the resident was alert and oriented and was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability. The resident was coded as having the diagnosis of manic depression bipolar disease. 1) Immediate actions taken for those residents identified: The PASRR, dated 11/14/18, indicated the resident did not have a mental health diagnosis, a substance related diagnosis or dementia/neurocognitive disorder. A level II PASRR was not indicated based on the findings. Resident #53 annual PASARR review was completed. Interview with the Social Service Director on 5/14/19 at 2:30 p.m., indicated a new Level I PASRR needed to be completed due to the added diagnosis of manic bipolar disorder. She was aware a new one needed to be completed and had not yet arranged for it. All residents requiring yearly record review are affected by this deficient practice. 3.1-16(d)(1)(A) An audit was completed on all residents to ensure annual reviews were completed. 2) How the facility identified other residents: 3) Measures put into place/ System changes: 4) How the corrective actions will be monitored: Social Services Director will complete monthly audits to ensure compliance with PASARR requirements. The Administrator will be responsible for compliance. The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 29 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5) Date of compliance: 06/12/19 F 0656 SS=D Bldg. 00 483.21(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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 30 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG 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. Based on observation, record review and interview, the facility failed to ensure Care Plans related to limited range of motion were implemented for 3 of 31 Care Plans reviewed. (Residents 76, 107, and L) F 0656 F656 – Development of a Comprehensive Care Plan (X5) COMPLETION DATE 06/12/2019 12:00:00A This Plan of Correction is the center's credible allegation of compliance. 1. On 5/15/19 at 10:30 a.m., Resident 76 was observed in his room in bed. The resident's hands were closed in a fist and no splints were in use. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. The record for Resident 76 was reviewed on 5/16/19 at 11:31 a.m. Diagnoses included, but were not limited to, traumatic subdural hemorrhage, disorders of autonomic nervous system, respiratory failure with hypoxia, speech disturbance, occlusion and stenosis of basilar artery, tracheostomy status, gastrostomy status, vascular implants and grafts, history of pulmonary embolism, depressive episodes, anemia, and type 2 diabetes. Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) The facility requests paper compliance for this citation. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY KV9P11 Facility ID: 000076 If continuation sheet Page 31 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Resident L - Care plan was reviewed and updated for ROM and splints. Resident 107 - Care plan as reviewed and updated for ROM and splints. Resident 76 - Care plan was reviewed and updated for ROM and splints. The current Care Plans indicated there was no Care Plan in place related to a limitation in range of motion. Interview with the Director of Nursing on 5/20/19 at 5:30 p.m., indicated the resident's Care Plan needed to be updated. 2) How the facility identified other residents: 2. On 5/15/19 at 8:56 a.m., Resident 107 was observed in his room in bed. The resident's hands were closed in a fist and no splints were in use. All residents have the potential to be affected by the alleged deficient practice. The record for Resident 107 was reviewed on 5/16/19 at 1:45 p.m. Diagnoses included, but were not limited to, pneumonia, contracture of left and right shoulder and left and right hand, pain in left shoulder, neurogenic bladder, chronic respiratory failure with hypoxia, tracheostomy status, ventilator dependent, quadriplegia, hypertension and atrial fibrillation. 3) Measures put into place/ System changes: Education will be provided to the IDT and nursing staff regarding the updating of a resident’s care plan. The Medicare 30 day Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was cognitively intact for decision making and had a limitation in range of motion to both sides of his upper and lower extremities. 4) How the corrective actions will be monitored: The current Care Plan indicated there was no Care Plan in place related to a limitation in range of motion. An audit of the clinical dashboard will be completed 5 days/week during the clinical meeting to ensure the resident’s care plans are updated. The DON will be responsible for compliance. Interview with the Director of Nursing on 5/20/19 at 5:30 p.m., indicated the resident's Care Plan The results of these audits will Event ID: DATE 1) Immediate actions taken for those residents identified: The Quarterly Minimum Data Set (MDS) assessment, dated 4/9/19, indicated the resident was cognitively impaired for daily decision making and had a limitation in range of motion to both sides of his upper and lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete (X5) COMPLETION KV9P11 Facility ID: 000076 If continuation sheet Page 32 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY needed to be updated. 3. On 5/15/19 at 9:14 a.m., Resident L was observed in bed, her right hand was resting flat on the bed and was in a fixed fist position. Interview at the time indicated she could not physically open her hand on her own and had not ever had a splinting device and/or therapy. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. The record for Resident L was reviewed on 5/17/19 at 11:59 a.m. Diagnoses included, but were not limited to, multiple sclerosis, adult failure to thrive, malignant neoplasm of the digestive system, diabetes, chronic kidney disease, dementia, anxiety, and delusions. 5) Date of compliance: 06/12/19 The Quarterly Minimum Data Set (MDS) assessment, dated 3/12/19, indicated the resident was alert and oriented and required an extensive 2 person physical assist with transfers and personal hygiene. She had no upper and/or lower extremity impairments. There was no documentation related to her limited range of motion to her right hand. Interview with the Director of Nursing on 5/17/19 at 12:45 p.m., indicated she was not aware the resident had limited range of motion to her right hand. The resident had not been assessed for limited range of motion in her right hand by nursing and/or the therapy department. Interview with the Director of Therapy on 5/20/19 at 12:22 p.m., indicated the resident had not been seen by therapy since her admission related to her right hand. An assessment was completed on 5/17/19, she had limited range of motion to her right hand and was at risk for a possible flexion contracture in her right hand with 1st digit MP (metacarpophalangeal) flexion contracture. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 33 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Interview with the 200 Unit Manager on 5/20/19 2:55 p.m., indicated the resident's right hand should have been properly assessed and care planned. 3.1-35(a) F 0677 SS=E Bldg. 00 483.24(a)(2) ADL Care Provided for Dependent Residents §483.24(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; Based on observation, record review and interview, the facility failed to ensure the necessary treatment and services were provided for dependent residents related to being transferred out of bed, turned and repositioned every two hours, providing incontinence care and providing showers for 6 of 11 residents reviewed for activities of daily living (ADL's). (Residents K, E, G, F, B, and L) F 0677 This Plan of Correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1. On 5/13/19 at 11:20 a.m., Resident K was observed in her room in bed. The resident was awake and she was wearing a hospital gown. On 5/14/19 at 2:37 p.m., the resident was again observed in bed wearing a hospital gown. The resident was observed in bed wearing a hospital gown on 5/15/19 at 8:45 a.m., 10:32 a.m., 11:40 a.m., 1:47 p.m., and 3:30 p.m. 1.Immediate actions taken for those residents identified: On 5/16/19 at 9:34 a.m. and 10:15 a.m., the resident was again observed in bed wearing a hospital gown. Event ID: 06/12/2019 12:00:00A The facility requests paper compliance for this citation. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete F677 – ADL Dependent Resident Resident K was assisted out of KV9P11 Facility ID: 000076 If continuation sheet Page 34 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG The record for Resident K was reviewed on 5/16/19 at 9:45 a.m. Diagnoses included, but were not limited to, intracranial abscess and granuloma, vascular dementia with behavior disturbance, recurrent dislocation of left hip, dysphagia, schizophrenia, encephalopathy, type 2 diabetes, bipolar, cataract right eye, anxiety, hypertension, artificial opening of digestive tract, anemia, and cerebral infarct (stroke). The Quarterly Minimum Data Set (MDS) assessment, dated 3/8/19, indicated the resident was cognitively impaired for daily decision making and required extensive two person assistance with bed mobility and was totally dependent on staff for transfers with a two person assist. (X5) COMPLETION DATE 1.How the facility identified other residents: Residents requiring assistance with ADL’s have the potential to be affected. The current Care Plan indicated the resident had an ADL self care deficit or potential as evidenced by needing assistance or was dependent for bed mobility and transfers. Interventions included, but were not limited to, Broda chair as tolerated and dependent on 2 staff for transfers using a sliding technique. The hoyer lift was not to be used. 1.Measures put into place/ System changes: Staff will be re-educated on providing assistance with all ADL’s as needed, including showers, incontinence care along with turning and repositioning. The May 2019 Physician's Order Summary (POS) indicated the resident could be out of bed as tolerated. 1.How the corrective actions will be monitored: Interview with the Director of Nursing on 5/17/19 at 2:30 p.m., indicated the resident does get out of bed and she didn't know why she hadn't been assisted.2. On 5/14/19 at 8:55 a.m., Resident E was observed in her wheelchair. At that time, she was taken out of the dining room and placed in the 200 Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) bed. Resident E was checked for incontinence and changed appropriately. Resident G was turned and repositioned. Resident F was given a bed bath and changed per plan of care. Resident B was checked for incontinence, changed and repositioned per plan of care. Resident L received a shower and care plan update. On 5/17/19 at 8:40 a.m. and 12:26 p.m., the resident was observed in her room in bed. FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY The Director of Nursing or designee will complete care rounds on at least 5 residents per week at varied times/shifts to KV9P11 Facility ID: 000076 If continuation sheet Page 35 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY lounge. At 10:10 a.m. and 11:04 a.m., the resident remained in the lounge. At 12:00 p.m., the resident was taken to the main dining room for lunch. At 12:47 p.m., staff wheeled the resident down to the 200 unit and placed her by the Nurse's station. At 1:27 p.m., the resident was taken to the Activity room by Activity staff. At 3:01 p.m., she remained in the Activity room. The resident had not been repositioned during the above times in her wheelchair. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE ensure ADL assistance is provided per plan of care. Interviews will be conducted on 3 residents per week to ensure showers/baths are given per preference. The DON will be responsible for compliance. The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. On 5/16/19 at 8:53 a.m., the resident was observed sitting in her wheelchair in the main dining room eating breakfast. At 9:22 a.m., the resident was placed in the 200 lounge. At 10:45 a.m., the resident was in the Activity room. At 11:27 a.m., an Activity Aide pushed the resident to the main dining room. No staff had checked her for incontinence or repositioned her in the wheelchair. At 12:38 p.m., the resident was still eating her lunch and at 12:52 p.m., a CNA pushed the resident out of the dining room to the 200 unit. 5) Date of compliance: 6/12/19 On 5/16/19 1:15 p.m., CNA 2 and CNA 3 assisted the resident to bed and provided incontinence care. The resident's incontinent brief was heavily saturated with urine. The resident's buttocks were red. Interview with CNA 3 at that time, indicated she had taken the resident to the bathroom and provided incontinence care at 10:10 a.m. She did not provide incontinence care prior to lunch. The record for Resident E was reviewed on 5/15/19 at 10:03 a.m. Diagnoses included, but were not limited to, colon cancer, dementia, chronic obstructive pulmonary disease (COPD), type 2 diabetes, anemia, morbid obesity, osteoarthritis, hypothyroidism, breast cancer, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 36 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE high blood pressure, major depressive disorder, and history of falling. The Quarterly Minimum Data Set (MDS) assessment dated 5/5/19, indicated the resident was not alert and oriented, and was an extensive assist with 2 person physical assist for transfers, toileting and bed mobility. The resident was always incontinent of bladder. A Care Plan, updated 5/2019, indicated the resident was incontinent of bowel and bladder related to cognitive impairment. The approaches were to assist with incontinence care upon rising, around meal times, at bedtime and as needed. Interview with the Director of Nursing on 5/17/19 at 9:45 a.m., indicated residents were to be checked and changed at least every 2 hours. 3. On 5/13/19 at 12:00 p.m. and 2:50 p.m., Resident G was observed in bed. At those times he was wearing a hospital gown. On 5/14/19 10:25 a.m., and 10:52 a.m., the resident was observed in bed wearing a hospital gown. On 5/16/19 at 9:00 a.m., the resident was observed in bed. On 5/16/19 at 11:20 a.m., Resident G was observed in bed laying on his left side facing the door. At 1:26 p.m., the resident was observed in the same position in bed facing the door. At 2:00 p.m., CNA 1 was observed in the room. She indicated she was going to reposition him on his right side toward the window. Interview with CNA 1 at that time, indicated 2 other CNAs repositioned the resident for her at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 37 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 11:00 a.m., as she was unable to do it. She tried to reposition and change the residents at least every 2 hours if she was able to. On 5/17/19 at 10:45 a.m., and 10:58 a.m., the resident was observed in bed and wearing a hospital gown. The record for Resident G was reviewed on 5/17/19 at 1:20 p.m. Diagnoses included, but were not limited to, cerebral ischemia, high blood pressure, alcohol abuse, polyosteoarthritis, dysphagia, peripheral vascular disease, stroke, glaucoma, legal blindness, chronic pain, and hemiparesis. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 2/27/19, indicated the resident was not alert and oriented and needed extensive assist with 2 person physical assist with bed mobility, transfers, dressing and toileting. The resident had range of motion impairments to both upper and lower extremities. His weight was 130 pounds, and he received an enteral feeding through the peg tube (a tube placed directly into the stomach to provide nutrition). The Care Plan, updated on 10/17/18, indicated the resident had a self care deficit for bed mobility, transfers and toilet use. The approaches were extensive assist of 2 staff for bed mobility, and transfer with mechanical lift. The Care Plan, updated 5/10/19, indicated the resident had a wound to his coccyx. The approaches were to turn and reposition every 2 hours. Physician's Orders, dated 5/10/19, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 38 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE reposition resident every 2 hours. There was no Physician's Order for bed rest. Interview with the Director of Nursing on 5/17/19 at 9:45 a.m., indicated the resident was to be repositioned and turned at least every 2 hours. Interview with the 200 Unit Manager on 5/17/19 at 12:00 p.m., indicated there were no orders for bed rest for the resident. 4. During an interview with Resident F on 5/14/19 at 2:05 p.m., indicated she had preferred a bed bath versus a shower. She had not had at least 2 bed baths a week in the last month or so and does not recall when the last time her hair was washed. The record for Resident F was reviewed on 5/15/19 at 9:33 a.m. The resident was admitted to the facility on 1/14/19. Diagnoses included, but were not limited to, cirrhosis of liver, palliative care, asthma, heart failure, type 2 diabetes, kidney disorder, atrial fibrillation, high blood pressure, and bipolar disorder. The Admission Minimum Data Set (MDS) assessment, dated 1/25/19, indicated the resident was alert and oriented and was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability. The resident was coded as having the diagnosis of manic depression bipolar disease. It was somewhat important for the resident to choose between a bed bath or shower. The resident needed 1 person physical help with bathing. The Care Plan, dated 4/2/19, indicated the resident had an activities of daily living (ADL) self care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 39 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE deficit. The resident was scheduled for a shower on Wednesday and Saturday evenings. The resident received a bed bath on 4/17 and 5/8. She received a shower on 4/20/19. She refused a bed bath on 4/27 and 5/11/19. The resident's hair had been washed on 4/20/19 and 5/8/19. Interview with the 200 Unit Manager on 5/17/19 at 12:00 p.m., indicated the resident does refuse her baths sometimes, but she should still be offered 2 bed baths or showers a week. 5. On 5/14/19 at 9:01 a.m., Resident B was observed in bed, wearing a t-shirt and incontinent brief. At that time, CNA 1 was in the room repositioning the resident for breakfast. The resident's incontinent brief was observed to be wet with a blue line noted. The CNA did not change the resident at that time. She set the resident up for breakfast and proceeded to feed her. At 11:00 a.m., the resident was observed in bed laying on her back. CNA 1 indicated she had not gotten to her yet as far as providing morning care. At 11:45 a.m., CNA 1 had just finished giving Resident L a shower and proceeded to provide morning care for Resident B. She indicated she had checked and changed the resident when she started her shift at 6:00 a.m. this morning. The CNA did not provide incontinence care at 9:00 a.m., because she did not think it was appropriate to change her during breakfast. The CNA removed the resident's incontinent brief which was wet with urine. The resident's buttocks were red and her bandage was coming off of an open area on her coccyx. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 40 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE The Record for Resident B was reviewed on 5/16/19 at 10:06 a.m. The resident was admitted to the facility on 4/25/19. Diagnoses included, but were not limited to, cardiomyopathy, edema, altered mental status change, transient ischemic attacks, hemiplegia. The Admission Minimum Data Set (MDS) assessment, dated 5/2/19, indicated the resident was not alert and oriented. The resident was an extensive assist with a 2 person physical assist for bed mobility, transfers, and locomotion on and off the unit. She was frequently incontinent of urine. The resident received oxygen and a mechanically altered and therapeutic diet while at the facility. The Care Plan, dated 4/26/19, indicated the resident had a self care deficit with activities of daily living. The approaches were the resident required extensive assist by with 1 to 2 staff for toileting. A Bowel and bladder assessment, dated 4/26/19, indicated the resident was incontinent all or most of the time and used incontinent products. The current and revised 1/15/18, "Pressure Ulcer Prevention" policy, provided by the Corporate Nurse Consultant on 5/20/19 at 2:33 p.m., indicated "Turn dependent residents approximately every 2 hours or as needed and position resident with pillows or pads protecting bony prominences as indicated. The current and revised 1/16/18, "Incontinence Care" policy, provided by the Corporate Nurse Consultant on 5/20/19 at 2:33 p.m., indicated "Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 41 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE hours and provided perineal and genital care after each episode." Interview with the Director of Nursing on 5/17/19 at 9:45 a.m., indicated residents should be checked and changed for incontinence and repositioned at least every 2 hours.6. Interview with Resident L on 5/13/19 at 11:20 a.m., indicated it was her preference to have a shower, however, she had not had a shower in over a month. The record for Resident L was reviewed on 5/17/19 at 11:59 a.m. Diagnoses included, but were not limited to, multiple sclerosis, adult failure to thrive, malignant neoplasm of the digestive system, diabetes, chronic kidney disease, dementia, anxiety, and delusions. The Quarterly Minimum Data Set (MDS) assessment, dated 3/12/19, indicated the resident was alert and oriented and required an extensive 2 person physical assist with transfers, personal hygiene, and bathing. The 200 Unit Report Sheet indicated the resident was to have showers every Tuesday and Friday during the day. The CNA Point of Care documentation for the past 30 days indicated the resident had bed baths on 4/23, 4/26, 4/30, 5/1, 5/3, and showers on 5/7, 5/10, and 5/14. Interview with the 200 Unit Manager on 5/16/19 at 3:19 p.m., indicated the resident was receiving bed baths because she was refusing showers, however, it was not documented. This Federal tag relates to Complaints IN00294042 and IN00294151. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 42 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 3.1-38(a)(3) 3.1-38(b)(2) 3.1-38(b)(4) F 0679 SS=D Bldg. 00 483.24(c)(1) Activities Meet Interest/Needs Each Resident §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Based on observation, record review, and interview, the facility failed to ensure ongoing activities were provided to cognitively impaired and dependent residents for 1 of 4 residents reviewed for activities. (Resident D) F 0679 The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Finding includes: On 5/13/19 at 11:13 a.m., Resident D was observed awake in her room in bed. At that time, she had an enteral feeding through a peg tube (a tube directly in the stomach that provides nutrition) infusing at 60 cubic centimeters (cc) an hour. She was also wearing oxygen at 2 liters nasal cannula. There was no radio observed in her room and her television set was off. The lights were off in the room and blinds were closed. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. On 5/14/19 at 9:10 a.m. the resident was awake observed in bed. The enteral feeding was infusing at 60 cc/hour and she was wearing FORM CMS-2567(02-99) Previous Versions Obsolete 06/12/2019 12:00:00A F679 Activities Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 43 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG oxygen at 2 liters. She was dressed in a hospital gown. There was no radio in her room and the television was turned off. (X5) COMPLETION DATE Resident D has been discharged. 2) How the facility identified other residents: All residents who reside in the facility have the risk to be affected by the alleged deficient practice. The 1:1 activity participation logs will be reviewed to identify other residents at risk for the alleged deficient practice. On 5/16/19 at 9:00 a.m., 9:49 a.m., the resident was observed in bed. The resident's enteral feeding was infusing at 70 cc/hour and her oxygen was set at 1/2 liter per nasal cannula. There was no radio in the room and the television was turned off. 3) Measures put into place/ System changes: On 5/16/19 at 11:15 a.m., the resident was observed in bed. There was no radio in the room and the television was turned off. Activity staff will be re-educated on the facility activity programs by the Activity Director. The Activities Review tool will be completed at least 3 times a week for 4 weeks and weekly thereafter to ensure compliance. The Activity Director will be responsible for compliance. The record for Resident D was reviewed on 5/15/19 at 2:15 p.m. The resident was admitted to the facility on 1/5/19. Diagnoses included, but were not limited to, fracture of the femur, stroke, history of falls, urinary tract infection, dementia, high blood pressure , major depressive disorder, and chronic obstructive pulmonary disease (copd). 4) How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. The Significant Change Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was not alert and oriented and was severely impaired for decision making. The resident needed extensive assist with 2 person physical assist for transfers, bed mobility and dressing. The Care Plan, revised on 4/26/19, indicated the resident relied on staff for social, mental, and physical needs. The resident enjoyed group Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1) Immediate actions taken for those residents identified: On 5/15/19 at 8:32 a.m., and 10:28 a.m., the resident was observed awake and in bed. The resident's enteral feeding was infusing at 70 cc/hour and her oxygen was set at 1/2 liter per nasal cannula. There was no radio in the room and the television was turned off. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 5) Date of compliance: KV9P11 Facility ID: 000076 If continuation sheet Page 44 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY activities and her interests included, watching television and listening to music. The approaches were staff will provide 1:1 visits 3 times weekly for socialization, mental and physical stimulation. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 06/12/19 An Activity quarterly assessment, dated 4/28/19, indicated the resident enjoyed family visits, watching television, and going outside when the weather was nice. The resident had received 1 to 1 visits on 5/1, 5/3, 5/6, 5/8, 5/10, 5/13, and 5/15/19. Interview with the Activity Director on 5/20/19 at 11:45 a.m., indicated her staff does 1 to 1's with the resident three times a week. She could not find a radio for the resident and staff have been playing music on their cell phones for her. She indicated there was no radio in her room, nor was her television on. 3.1-33(a) F 0684 SS=E Bldg. 00 483.25 Quality of Care § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Based on observation, record review, and interview, the facility failed to ensure bruises and skin tears were assessed and monitored as well as signs and symptoms of constipation for 2 of 3 residents reviewed for medication side effects, 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0684 F684 – Quality of Care 06/12/2019 12:00:00A The facility requests paper compliance for this citation. KV9P11 Facility ID: 000076 If continuation sheet Page 45 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG of 5 residents reviewed for skin conditions (non-pressure related) and 1 of 1 residents reviewed for constipation. (Residents 107, 125, E, D, 38, and L) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1. On 5/15/19 at 8:56 a.m., Resident 107 was observed in his room in bed. The resident had multiple areas of reddish/purple discoloration to his right forearm. On 5/16/19 at 9:40 a.m., the reddish/purple discolorations remained to the resident's right forearm. A scab to the right forearm was also noted at that time. 1) Immediate actions taken for those residents identified: The record for Resident 107 was reviewed on 5/16/19 at 1:45 p.m. Diagnoses included, but were not limited to, pneumonia, contracture of left and right shoulder and left and right hand, pain in left shoulder, neurogenic bladder, chronic respiratory failure with hypoxia, tracheostomy status, ventilator dependent, quadriplegia, hypertension and atrial fibrillation. Resident 107 – A new skin assessment was completed, and all new areas were identified. Resident 125 – A new skin assessment was completed, and all new areas were identified. Resident E – Geri sleeves were applied, and new skin assessment completed. Resident D no longer resides at the facility. Resident 38 – A new skin assessment was completed, and all new areas were identified. Resident L had a bowel movement The Admission Minimum Data Set (MDS) assessment, dated 4/3/19, indicated the resident was cognitively intact for decision making and was totally dependent on staff for bed mobility. He was also receiving an anticoagulant (blood thinner). The Care Plan, dated 3/29/19, indicated the resident was on anticoagulant therapy. Interventions included, but were not limited to, daily skin inspection and report abnormalities to the Nurse. 2) How the facility identified other residents: A Physician's Order, dated 5/2/19, indicated the Event ID: (X5) COMPLETION This Plan of Correction is the center's credible allegation of compliance. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete COMPLETED 05/20/2019 B. WING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY All residents have the KV9P11 Facility ID: 000076 If continuation sheet Page 46 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) resident received Xarelto (a blood thinner) 15 milligrams (mg) at night. potential to be affected. The resident was also to receive weekly Skin Assessments on Wednesdays. 3) Measures put into place/ System changes: The Skin Assessment, dated 5/8/19, did not address the areas to the right arm. Staff will be re-educated regarding identification, reporting, documentation and weekly monitoring of skin conditions, interventions to protect skin from injury and bowel monitoring documentation and protocol There were no current Physician's Orders to monitor and assess the areas to the resident's right arm. Interview with the Director of Nursing on 5/17/19 at 2:30 p.m., indicated the areas to the resident's right arm should have been assessed when they were found and orders obtained to monitor. The Director of Nursing or designee will observe at least 3 residents per week to ensure all skin conditions are identified, documented and monitored. An audit of at least 5 residents per week will be completed to ensure bowel movements are documented and protocol initiated when appropriate. The DON will be responsible for compliance. On 5/17/19 at 8:43 a.m., an area of reddish/purple discoloration was observed on the resident's left forearm. The record for Resident 125 was reviewed on 5/15/19 at 9:13 a.m. Diagnoses included, but were not limited to, sepsis due to pneumonia, difficulty walking, chronic obstructive pulmonary disease, lung cancer, hypertension, peripheral vascular disease, absence of kidney, gout, abdominal aortic aneurysm without rupture, and atherosclerotic heart disease. The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the The Annual Minimum Data Set (MDS) assessment, dated 5/4/19, indicated the resident was cognitively intact for decision making and needed moderate one person assistance with bed mobility. Event ID: DATE 4) How the corrective actions will be monitored: 2. On 5/13/19 at 11:25 a.m., Resident 125 was observed with multiple areas of reddish/purple discoloration to both of his arms. FORM CMS-2567(02-99) Previous Versions Obsolete (X5) COMPLETION KV9P11 Facility ID: 000076 If continuation sheet Page 47 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE plan of correction as indicated. The current Care Plan indicated the resident was at risk for bleeding/bruising related to Aspirin use. Interventions included, but were not limited to, monitor and report any bruising related to lab draws and report to Physician any abnormal bleeding/bruising. 5) Date of compliance: 06/10/19 A Physician's Order, dated 5/7/19, indicated the resident was to have weekly Skin Assessments every Tuesday evening. The weekly Skin Assessment, dated 5/14/19, indicated the resident had a scab to his left upper quadrant. There was no documentation related to the discoloration to his arms. There were no current Physician's Orders to monitor and assess the areas to the resident's bilateral arms. Interview with the Director of Nursing on 5/17/19 at 2:30 p.m., indicated the areas to the resident's arms should have been assessed when they were found and orders obtained to monitor. 3. On 5/14/19 at 12:47 p.m., and 12:57 p.m., Resident E was observed sitting in a wheelchair by the Nurse's station. At that time, she was observed with her sweater sleeve rolled to the top of her shoulder. She had a dark red large scabbed area just above her elbow on her right arm. There was no bandage noted on it. A QMA and a LPN were observed next to the resident but neither one pulled the sleeve down or bandaged the sore. At 1:27 p.m., an Activity Aide took the resident down to the Activity room to watch a movie. The resident's scabbed area was still not covered. At 3:01 p.m., the resident remained in the Activity room with the area to her right arm still exposed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 48 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE On 5/15/19 at 1:45 p.m., the resident was observed sitting in her wheelchair in the 200 lounge. At that time she was wearing short sleeves. Her geri sleeves were off and her bandage was observed on the floor. At 2:59 p.m., the resident was in bed. She was dressed in a hospital gown and she had no geri sleeves to either arm. The record for Resident E was reviewed on 5/15/19 at 10:03 a.m. Diagnoses included, but were not limited to, colon cancer, dementia, chronic obstructive pulmonary disease (copd), type 2 diabetes, anemia, morbid obesity, osteoarthritis, hypothyroidism, breast cancer, high blood pressure, major depressive disorder, and history of falling. The Quarterly Minimum Data Set (MDS) assessment dated 5/5/19, indicated the resident was not alert and oriented, and was an extensive assist with 2 person physical assist for transfers, toileting and bed mobility. The resident was always incontinent of bladder. The Care Plan, dated 5/10/19, indicated skin tear to right forearm and left antecubital related to fragile skin. The approaches were treatments as ordered and use long sleeves or geri sleeves Physician's Orders, dated 5/10/19, indicated cleanse left antecubital areas and skin tear to right arm with normal saline, apply Xeroform and cover with dry dressing every Monday, Wednesday and Friday. Interview with the 200 Unit Manager on 5/15/19 at 1:50 p.m., indicated nursing staff should have covered the area if the bandage was off. The resident was to have geri sleeves to her arms to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 49 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE prevent skin tears. 4. On 5/13/19 at 11:13 a.m., Resident D was observed awake in her room in bed. At that time, she had an enteral feeding through a peg tube (a tube directly in the stomach that provides nutrition) infusing at 60 cubic centimeters (cc) an hour. She was also wearing oxygen at 2 liters nasal cannula. There were red and purple bruises noted to her left forearm. The left side rail was not padded. On 5/16/19 at 11:15 a.m., the 200 Unit Manager was asked to perform a skin assessment for the resident. At that time, she identified the bruises to her left arm. She was unaware of the bruises and indicated the side rail was to be padded. The record for Resident D was reviewed on 5/15/19 at 2:15 p.m. The resident was admitted to the facility on 1/5/19. Diagnoses included, but were not limited to, fracture of the femur, stroke, history of falls, urinary tract infection, dementia, high blood pressure , major depressive disorder, and chronic obstructive pulmonary disease (copd). The significant Change Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was not alert and oriented and was severely impaired for decision making. The resident needed extensive assist with 2 person physical assist for transfers, bed mobility and dressing. The Care Plan, updated on 4/26/19, indicated the resident had potential for further impaired skin. The approaches were to perform routine skin assessments and document findings. A weekly skin assessment, dated 5/13/19, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 50 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE indicated there were no bruises. Nurse's Notes, dated 5/11-5/16/19, indicated there was no documentation about any new bruising to her left forearm. Interview with the 200 Unit Manager on 5/16/19 at 11:15 a.m., indicated she was unaware the resident had any bruising to the left arm. The CNAs were to notify the nurse of any bruises noted during care and the nurse was to assess the area or areas and complete a skin assessment.5. On 5/13/19 at 9:38 a.m., Resident 38 was observed with multiple purple areas of discolorations to his bilateral upper extremities. The record for Resident 38 was reviewed on 5/17/19 at 11:10 a.m. Diagnoses included, but not limited to, atrial fibrillation, dementia, and prostate cancer. The Quarterly Minimum Data Set (MDS) assessment, dated 5/13/19, indicated the resident was severely cognitively impaired and required an extensive 2 person physical assist with transfers. The Weekly Skin Observation Sheet, dated 5/13/19, indicated skin intact no concern. The Skin - Other Skin Condition Report, dated 5/16/19, indicated the following: - left antecubital, purple red bruises, 1.8 cm (centimeters) x (by) 3.5 cm - right outer elbow, purple discoloration, 0.8 cm x 0.4 cm - left posterior forearm, reddish purple discoloration, 0.6 cm x 0.3 cm - left posterior forearm, fading discoloration, 1.5 cm x 0.8 cm FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 51 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE - several purplish and red discolorations present to the posterior forearm, small in size Interview with the 100 Unit Manager on 5/20/19 on 10:00 a.m., indicated the 5/13/19 Weekly Skin Observation Sheet was inaccurate, the resident's skin should have been properly assessed, documented, and monitored. The "Skin Condition Assessment and Monitoring - Pressure and Non-Pressure" policy, dated 6/8/18, provided by the Administrator on 5/17/19 at 1:00 p.m., indicated, "A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse." 6. Interview with Resident L on 5/13/19 at 11:29 a.m., indicated she had a concern related to constipation. She had not had a bowel movement for 5 days and had to go to the hospital ER last night for constipation. The record for Resident L was reviewed on 5/17/19 at 11:59 a.m. Diagnoses included, but were not limited to, multiple sclerosis, adult failure to thrive, malignant neoplasm of the digestive system, diabetes, chronic kidney disease, dementia, anxiety, and delusions. The Quarterly Minimum Data Set (MDS) assessment, dated 3/12/19, indicated the resident was alert and oriented and required an extensive 2 person physical assist with transfers, toileting, and personal hygiene. A Care Plan, dated 6/20/18, indicated the resident was at risk for constipation related to decreased mobility. The interventions included, but were not limited to, administer medications and bowel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 52 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE protocol as ordered. The CNA Point of Care documentation for the past 30 days indicated the resident did not have a bowel movement on 5/8 - 5/12/19. There was no documentation of interventions attempted related to the constipation. Nursing Progress Notes indicated the following: - 5/12/2019 at 8:12 p.m., "Resident states pain and no disdention (sp) to abdomen, discomfort verbalized and expressed as lower back pain. Being sent out 911...." - 5/12/2019 at 8:33 p.m., "Resident observed throwing her stuff at bedside, complaint verbalized expression of no BM (Bowel Movement) noted after offering medication resident refused, reapproach she took her Tramadol for back pain stated 4 (0-10), noted being sent out 911 all responsible parties notified." - 5/12/2019 11:50 p.m., "Resident is going to be returned here to home/facility and she passed a large BM. Diagnosis for her this shift was fecal impaction. Confirmed by and stated by resident's verbalized expression of lower back pain, pain medication wa (sp) given before she left. At this time she is stable and writer awaiting her return. noted." Interview with the 200 Unit Manager on 5/20/19 at 2:55 p.m., indicated the facility bowel protocol should have been initiated after 2 days of the resident not having a bowel movement. The current "Bowel Elimination Protocol" policy, provided by the Director of Operations on 2/20/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 53 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE at 2:00 p.m., indicated " Residents who have had no BM for 2 days (6 shifts) will be offered 4 oz. of prune juice at supper or at bedtime. (Check the diet order carefully for any diet restrictions, or food preferences) Residents who have had no BM for 3 days (9 shifts) will be assessed for the possibility of impaction...." 3.1-37(a) F 0685 SS=D Bldg. 00 483.25(a)(1)(2) Treatment/Devices to Maintain Hearing/Vision §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident§483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. Based on record review and interview, the facility failed to ensure residents received proper treatment and assistive devices related to hearing aides for 1 of 1 residents reviewed for hearing. (Resident 94) F 0685 This Plan of Correction is the center's credible allegation of compliance. Interview with Resident 94 on 5/13/19 at 10:22 a.m., indicated she had been waiting on the facility to order her hearing aids for 3 months. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the The record for Resident 94 was reviewed on 5/17/19 at 11:43 a.m. Diagnoses included Event ID: 06/12/2019 12:00:00A The facility requests paper compliance for this citation. Finding includes: FORM CMS-2567(02-99) Previous Versions Obsolete F685 – Treatment/Services to Maintain Vision/Hearing KV9P11 Facility ID: 000076 If continuation sheet Page 54 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY schizophrenia, hypertension, and anxiety. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. The Quarterly Minimum Data Set (MDS) assessment, dated 4/17/19, indicated the resident was alert and oriented and her hearing with an assistive device was minimally difficult in some environments. The 2/26/19 Auditory Visit indicated follow-up after 12 months unless the hearing aid was made then it will be fit once it was made. 1Immediate actions taken for those residents identified: Resident 94’s hearing aids were ordered. Interview with the Social Service Director (SSD) on 5/15/19 at 10:31 a.m., indicated there was a delay in the ordering process due to the resident's payor source. Further interview with the SSD indicated the resident did have medical insurance coverage at the time of her auditory visit, however, she was not made aware of the coverage and had not followed up on it. The resident's hearing aids should have been ordered. 2) How the facility identified other residents: All residents receiving ancillary services have the potential to be affected by this deficient practice. An audit will be completed on all residents to ensure ancillary services are arranged per request. 3.1-39(a) 3) Measures put into place/ System changes: Nursing staff will be educated to ensure residents are wearing their hearing aids. Social Service and Nursing managers will be re-educated regarding follow up of ancillary provider recommendations. 4) How the corrective actions will be monitored: All ancillary provider recommendations received after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 55 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE each visit will be reviewed by Social Service and DON or designee to ensure appropriate follow up is completed. The Administrtor will be responsible for compliance. The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5) Date of compliance: 06/12/19 F 0688 SS=E Bldg. 00 483.25(c)(1)-(3) Increase/Prevent Decrease in ROM/Mobility §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 56 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. Based on observation, record review and interview, the facility failed to ensure limitations in range of motion were assessed and anticontracture devices were applied for 4 of 7 residents reviewed for limited range of motion. (Residents 76, 107, G, and L) F 0688 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) F688 – Prevent Decrease in ROM/Mobility (X5) COMPLETION DATE 06/12/2019 12:00:00A The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Findings include: 1. On 5/15/19 at 10:30 a.m., 11:57 a.m. and 1:47 p.m., Resident 76 was observed in his room in bed. The resident's hands were closed in a fist and no splints were in use. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. On 5/16/19 at 9:43 a.m., the resident was observed in his room in bed. The resident's hands were closed in a fist and no splints were in use. On 5/17/19 at 8:40 a.m., the resident was observed in his room in bed. The resident's hands were closed in a fist and no splints were in use. The record for Resident 76 was reviewed on 5/16/19 at 11:31 a.m. Diagnoses included, but were not limited to, traumatic subdural hemorrhage, disorders of autonomic nervous system, respiratory failure with hypoxia, speech disturbance, occlusion and stenosis of basilar artery, tracheostomy status, gastrostomy status, vascular implants and grafts, history of pulmonary embolism, depressive episodes, anemia, and type 2 diabetes. FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY Event ID: 1) Immediate actions taken for those residents identified: Resident 76 – Splints were applied, ROM was added to the resident’s plan of care and task initiated. Resident 107 - Splints were applied, ROM was added to the resident’s plan of care and task initiated. KV9P11 Facility ID: 000076 If continuation sheet Page 57 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG The Quarterly Minimum Data Set (MDS) assessment, dated 4/9/19, indicated the resident was cognitively impaired for daily decision making and had a limitation in range of motion to both sides of his upper and lower extremities. The Occupational Therapy Discharge Summary, dated 4/19/19, indicated the staff were trained and educated on a wearing schedule for a hand brace to prevent deformity in the bilateral upper extremities. (X5) COMPLETION DATE 2) How the facility identified other residents: All residents who have contractures or at risk for contractures have the potential to be affected by the alleged deficient practice. An audit was completed on all resident that require the use of anti-contracture devices. Care plans were updated as needed. CNA 1 was educated on ADL care and ROM. The May 2019 Physician's Order Summary indicated the resident had no current orders related to splint use nor Restorative Nursing for splint application. Interview with Occupational Therapist 1 on 5/20/19 at 3:20 p.m., indicated the resident was discharged from therapy with splints and they should have been applied. 3) Measures put into place/ System changes: Nursing staff will be re-educated on Range of Motion related to Splints by the DON/designee. Splint placement will be checked during rounds by the Charge Nurses and Managers at least 5 days per week. Manager findings will be reviewed at the daily meetings. The DON will responsible for compliance. Interview with the Director of Nursing on 5/20/19 at 3:25 p.m., indicated that she would have to check with therapy about the splints. 2. On 5/15/19 at 8:56 a.m., 10:30 a.m., 11:57 a.m., and 1:50 p.m., Resident 107 was observed in his room in bed. The resident's hands were closed in a fist and no splints were in use. The resident indicated he could not open his hands. On 5/16/19 at 9:40 a.m., the resident was observed in his room in bed. The resident's hands were closed in a fist and no splints were in use. 4) How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or On 5/17/19 at 8:43 a.m., the resident was observed Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Resident G - Splints were applied, ROM was added to the resident’s plan of care and task initiated. Resident L – Therapy evaluated and recommendation splint for right hand and ROM were added to the resident’s care plan and task initiated. The current Care Plans indicated there was no Care Plan related to a limitation in range of motion. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY KV9P11 Facility ID: 000076 If continuation sheet Page 58 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY in his room in bed. The resident's hands were closed in a fist and no splints were in use. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE until 100% compliance is achieved. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. The record for Resident 107 was reviewed on 5/16/19 at 1:45 p.m. Diagnoses included, but were not limited to, pneumonia, contracture of left and right shoulder and left and right hand, pain in left shoulder, neurogenic bladder, chronic respiratory failure with hypoxia, tracheostomy status, ventilator dependent, quadriplegia, hypertension and atrial fibrillation. 5) Date of compliance: 6/12/19 The Medicare 30 day Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was cognitively intact for decision making and had a limitation in range of motion to both sides of his upper and lower extremities. The current Care Plans indicated there was no Care Plan related to a limitation in range of motion. The resident was discharged from Occupational Therapy on 4/24/19. Interview with Occupational Therapist 1 on 5/20/19 at 3:20 p.m., indicated the resident was discharged from therapy with palmar protectors and they should be in his room. Observation of the resident's room at the time with the Occupational Therapist, indicated the splints were not present. The Occupational Therapist brought a pair of splints with her and applied them to the resident's hands. The May 2019 Physician's Order Summary indicated the resident had no current orders related to splint use nor Restorative Nursing for splint application. Interview with the Director of Nursing on 5/20/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 59 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE at 3:25 p.m., indicated that she would have to check with therapy about the splints. 3. On 5/13/19 at 12:00 p.m. and 2:50 p.m., Resident G was observed in bed. At those times, there was no splint in either one of his hands. It was observed on the over bed table. On 5/14/19 10:25, and 10:52 a.m., the resident was observed in bed. At those times, there was no splint in either one of his hands. It was observed on the over bed table. On 5/15/19 at 9:25 a.m. and 11:01 a.m., 2:45 p.m., and 3:25 p.m., the resident was observed in bed. At those times, there was no splint in either one of his hands. It was observed on the over bed table. On 5/16/19 at 9:00 a.m., 11:20 a.m., 1:26 p.m., and 2:00 p.m., the resident was observed in bed. At those times, there was no splint in either one of his hands. It was observed on the over bed table. On 5/17/19 at 10:45 a.m.,10:58 a.m., and 3:07 p.m. the resident was observed in bed. At those times, there was no splint in either one of his hands. It was observed behind the television set. The record for Resident G was reviewed on 5/17/19 at 1:20 p.m. Diagnoses included, but were not limited to, cerebral ischemia, high blood pressure, alcohol abuse, polyosteoarthritis, dysphagia, peripheral vascular disease, stroke, glaucoma, legal blindness, chronic pain, and hemiparesis. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 2/27/19, indicated the resident was not alert and oriented and needed extensive assist with 2 person physical assist with bed mobility, transfers, dressing and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 60 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE toileting. The resident had range of motion impairments to both upper and lower extremities. A Care Plan, dated 2/2019, indicated the resident had an activities of daily living self care deficit. The approaches were bilateral hand splints as tolerated. Physician's Orders, on the current 5/2019 order summary, indicated left hand splint as tolerated. Nurse's Notes, dated 5/12-5/17/19 indicated there was no documentation the resident refused his splint or could not tolerate it. The Treatment Administration Record (TAR) indicated the hand splint was signed out as being applied on 5/13, 5/14, 5/16 and 5/17 for both days and evening shifts. There was no documentation the resident could not tolerate the hand splint or that he refused to wear it. Interview with the 200 Unit Manager on 5/20/19 at 10:44 a.m., indicated the splint was to be on the left hand only due to he was able to move the right hand freely. The Care Plan and CNA care card were updated to reflect the splint. Nursing staff were to document if the resident could not tolerate the splint or if he refused. There was no documentation the resident refused the splint or could not tolerate it. 4. On 5/15/19 at 9:14 a.m., Resident L was observed in bed, her right hand was resting flat on the bed, it was in a fixed fist position. Interview at the time indicated she could not physically open her hand on her own and had not ever had a splinting device and/or therapy. The record for Resident L was reviewed on 5/17/19 at 11:59 a.m. She was admitted on 6/12/18. Diagnoses included, but were not limited to, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 61 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE multiple sclerosis, adult failure to thrive, malignant neoplasm of the digestive system, diabetes, chronic kidney disease, dementia, anxiety, and delusions. The Quarterly Minimum Data Set (MDS) assessment, dated 3/12/19, indicated the resident was alert and oriented and required an extensive 2 person physical assist with transfers and personal hygiene. She had no upper and/or lower extremity impairments. There was no documentation related to her limited range of motion to her right hand. Interview with the Director of Nursing on 5/17/19 at 12:45 p.m., indicated she was not aware the resident had limited range of motion to her right hand. The resident had not been assessed for limited range of motion in her right hand by nursing and/or the therapy department. The facility did not currently have a restorative program. Interview with CNA 6 on 5/17/19 at 12:48 p.m., indicated she was familiar with the resident, she was admitted to the facility with limited range of motion to her right hand, she used to wear a blue palm protector and could open her hand just slightly with assist. Interview with LPN 3 on 5/17/19 at 12:51 indicated she was not aware of the resident having a blue palm protector. Interview with the 200 Unit Manager (UM) on 5/17/19 at 12:54 p.m., indicated the resident had a blue palm protector, however, it was used at her discretion. Therapy would complete an evaluation of the resident's right hand. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 62 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Interview with the Director of Therapy on 5/20/19 at 12:22 p.m., indicated the resident had not been seen by therapy since her admission related to her right hand. An assessment was completed on 5/17/19, she had limited range of motion and was at risk for a possible flexion contracture in her right hand with 1st digit MP (metacarpophalangeal) flexion contracture. He would not be able to determine at this time her course of therapy and or treatments until her therapy was completed. Interview with the UM on 5/20/19 at 2:55 p.m., indicated the resident's right hand should have been properly assessed, documented, and treated. 3.1-42(a)(2) F 0689 SS=D Bldg. 00 483.25(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. Based on observation, record review, and interview, the facility failed to ensure a resident remains free from accidents related positioning in a geri recliner chair and narcotic medication left at the bedside for 2 of 4 residents reviewed for accident hazards. (Residents B and M) F 0689 06/12/2019 12:00:00A The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete F689 – Free from Accidents/Hazards Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 63 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY 1. On 5/13/19 at 11:11 a.m., Resident B was observed reclined in a geri recliner chair. At that time, she was observed leaning all the way to the left side of the chair with her left arm hanging over the side of the geri chair touching the floor. CNA 5 stopped and looked at the resident and told RN 1 about the resident's position. RN 1 stated, "She always does that." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) At 11:51 a.m., Resident B was observed on the floor in the main dining room on her left side. The resident had fallen out of her geri recliner. CNA 5 ran down to the dining room and the 200 Unit Manager assisted the resident as well. 1) Immediate actions taken for those residents identified: Resident B was evaluated by therapy and placed in a Broda chair to prevent falls. Resident M was assessed for self-administration of medication. On 5/14/19 at 2:20 p.m. the resident was observed sitting up in a geri recliner chair. On 5/15/19 at 9:28 a.m., the resident was observed sitting in a geri recliner chair with a horn cushion noted between her legs and knees. At 10:05 a.m., the resident was observed leaning to the left side in the recliner chair. There were pillows noted to the left side. 2) How the facility identified other residents: At 11:02 a.m., the Therapy Director brought a padded broda chair to the unit. He indicated he had borrowed it from the another resident due to not having an extra chair for Resident B. He indicated sometimes the facility will rent or buy the chairs, however, at this time, he does not have an extra one for the resident. All residents have the potential to be affected by this deficient practice. An audit will be completed on all residents with falls since 5/20/19 to ensure appropriate interventions are in place. An audit will be conducted on all residents’ rooms to ensure medications are not left at the bedside. Interview with the Therapy Director at that time, indicated he was unaware the resident had an order for a broda chair. He indicated therapy just 3) Measures put into place/ System changes: Event ID: DATE Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. At 11:50 a.m., a dietary employee came down to the 200 unit and informed staff a resident had fallen and was on the floor. FORM CMS-2567(02-99) Previous Versions Obsolete (X5) COMPLETION KV9P11 Facility ID: 000076 If continuation sheet Page 64 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY picked up the resident due to her positioning in the recliner chair. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Staff will be re-educated on fall prevention/accidents and interventions and proper procedures regarding medication administration. The Record for Resident B was reviewed on 5/16/19 at 10:06 a.m. The resident was admitted to the facility on 4/25/19. Diagnoses included, but were not limited to, cardiomyopathy, edema, altered mental status change, transient ischemic attacks, hemiplegia. 4) How the corrective actions will be monitored: Director of Nursing or designee will review fall occurrences at least 5 days per week to ensure interventions are in place and care plan is updated. Care rounds will be completed at least 5 days per week on various shifts and times to ensure medications are not left at bedside. Any issues will be immediately addressed. The DON will be responsible for compliance. The Admission Minimum Data Set (MDS) assessment, dated 5/2/19, indicated the resident was not alert and oriented. The resident was an extensive assist with a 2 person physical assist for bed mobility, transfers, and locomotion on and off the unit. The Care Plan, revised on 5/3/19, indicated the resident was a high risk for falls. The approaches were to have therapy evaluate and treat for positioning in geri chair. The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. Nurse's Notes, dated 5/6/2019 and 5/9/19, indicated the resident had been found on the floor. Nurse's Notes, dated 5/13/2019 at 12:50 p.m., indicated summary of the fall: Resident in dining room and leaning to left side and fell out of geri chair. Resident lying on left side next to geri chair. Root cause of fall: Resident leaned to left side and fell out of the chair. Intervention and care plan updated, and therapy to evaluate for positioning in chair. 5) Date of compliance: 06/12/19 Physician's Orders, dated 4/26/19, indicated resident to be up in broda chair for positioning. Interview with the 200 Unit Manager on 5/15/19 at 1:00 p.m., indicated a broda chair has been ordered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 65 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE for the resident and therapy was now working on positioning for her. She was unaware of the Physician's Order for the resident to be up in a broda chair.2. On 5/13/19 at 2:08 p.m., there was a broken pill observed on Resident M's bedside table. Interview at the time with Resident M, indicated he was prescribed an as needed pain medication and he did not like to take the entire pill, so he would break it in half and take the other half when he was ready for it. He placed the remaining half of the broken pill on his bedside table He indicated the nursing staff were aware of this practice, they would often bring his medications into his room and set them on his bedside table and leave the room without ensuring the medications were properly administered. The record for Resident M was reviewed on 5/15/19 at 3:07 p.m. Diagnoses included, but were not limited to, end stage renal disease, dialysis, major depression, hypertension, mood disorder, pacemaker, anxiety, and chronic pain. The Annual Minimum Data Set (MDS) assessment, dated 3/28/19, indicated the resident was alert and oriented for decision making. A Physician's Order, dated 1/23/19, indicated Norco (a narcotic pain medication) 7.5/325 mg (milligrams) as needed every 8 hours. There was no order related to self administration of medications. The 5/2019 Medication Administration Record (MAR) indicated the resident was administered a Norco pill on 5/12/19 at 10:00 p.m. by LPN 1. Anonymous interview during the survey indicated the resident's medications were often FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 66 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE left at the bedside per his demand/request. Interview with LPN 1 on 5/16/19 at 9:37 p.m., indicated she had worked on 5/12/19 from 6:00 p.m., until 6:00 a.m. She did not recall administering an as needed pain medication to the resident. She stated, "However, it was possible that I did if my initials were on his MAR as administering the medication at 10:00 p.m. The resident was a special case and refused medications a lot." During her orientation she was told by other nursing staff on the unit to just leave the resident's medications at the bedside and he would take them when he wants, "everyone does it". She was not sure if there was an assessment and/or Physician's Order indicating the resident could self administer his own medications. She was aware narcotic medications should never be left at the resident's bedside. Interview with the Director of Nursing (DON) on 5/16/19 at 10:00 p.m., indicated the resident was alert and oriented, however, she was not aware if the resident had been assessed to self administer his medications. The nursing staff were not to leave narcotic pain medications at the bedside at any time. This Federal tag relates to Complaint IN00294151. 3.1-45(a)(1) 3.1-45(a)(2) F 0693 SS=E Bldg. 00 483.25(g)(4)(5) Tube Feeding Mgmt/Restore Eating Skills §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 67 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Based on observation, record review and interview, the facility failed to ensure tube feedings were infusing at the correct rate and time as well as having the head of the bed elevated while the feeding was infusing for 4 of 4 residents reviewed for tube feeding. (Residents K, 58, G, and D) F 0693 This Plan of Correction is the center's credible allegation of compliance. 1. On 5/14/19 at 2:30 p.m., Resident K was observed in bed. Her tube feeding was infusing at 85 cubic centimeters (cc's) via pump. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. On 5/16/19 at 9:34 a.m., the resident was observed in her room in bed. The tube feeding pump was turned off. At 10:15 a.m., the resident was in her room in bed. The head of the resident's bed was flat and the tube feeding was infusing at 85 cc/hour. Two CNAs were in the room at the time. CNA 8 left the room to get a Nurse to turn off the feeding pump. CNA 9 left the head of the Event ID: 06/12/2019 12:00:00A The facility requests paper compliance for this citation. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete F693 – Tube Feeding Management KV9P11 Facility ID: 000076 If continuation sheet Page 68 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) resident's bed flat while the feeding was infusing until she was asked to raise the head of the bed. 1.Immediate actions taken for those residents identified: The record for Resident K was reviewed on 5/16/19 at 9:45 a.m. Diagnoses included, but were not limited to, intracranial abscess and granuloma, vascular dementia with behavior disturbance, recurrent dislocation of left hip, dysphagia, schizophrenia, encephalopathy, type 2 diabetes, bipolar, cataract right eye, anxiety, hypertension, artificial opening of digestive tract, anemia, and cerebral infarct (stroke). Resident K - Head of bed was placed in semi-fowlers position. Resident 58 – Enteral feeding rate was adjusted to the correct rate per MD orders. Resident G – Enteral feeding rate was adjusted to the correct rate and times per MD orders. Resident D – No longer resides at the facility. The Quarterly Minimum Data Set (MDS) assessment, dated 3/8/19, indicated the resident was cognitively impaired for daily decision making and was receiving a tube feeding. All residents who receive tube feeding have the potential to be affected by the alleged deficient practice. 1.Measures put into place/ System changes: Interview with LPN 2 on 5/16/19 at 10:17 a.m., indicated the head of the resident's bed should not have been flat while the tube feeding was infusing. The nursing staff will be re-educated on proper settings of enteral feeding pumps as well as run times. Non-licensed nursing staff will be re-educated on proper positioning of residents with feeding tube and the procedure for placing the pump on hold for care. Interview with the Director of Nursing on 5/17/19 at 2:30 p.m., indicated the head of the resident's bed should not have been flat while the tube feeding was infusing and the feeding should have been infusing at the correct time. 2. On 5/14/19 at 8:55 a.m., Resident 58's tube feeding pump was infusing at 85 cubic centimeters (cc) an hour (hr). At 1:11 p.m. and 2:30 p.m., the tube feeding was turned off. The DON/designee will complete observation audits on at least 3 residents per week who receive enteral feeding to ensure proper positioning and the pump is set at the correct rate. DON is On 5/15/19 at 8:49 a.m. and 1:47 p.m., the resident's Event ID: DATE 1.How the facility identified other residents: A Physician's Order, dated 2/19/19, indicated the resident was to receive an enteral feeding of Glucerna 1.5 on for 16 hours at 85 cc/hour. Start at 7:00 p.m. and stop at 11:00 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete (X5) COMPLETION KV9P11 Facility ID: 000076 If continuation sheet Page 69 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) tube feeding was infusing at 85 cc/hr. responsible for compliance. On 5/16/19 at 9:37 a.m., the resident's tube feeding pump was turned off. 4) How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. On 5/17/19 at 8:40 a.m., the resident's tube feeding was infusing at 85 cc/hr. At 12:26 p.m., the resident's tube feeding pump was turned off. The record for Resident 58 was reviewed on 5/15/19 at 10:39 a.m. Diagnoses included, but were not limited to, pneumonia, hemiplegia/hemiparesis (weakness), traumatic brain injury, dysphagia (difficulty swallowing) history of falls, anxiety, delusional disorder, convulsions, and hypothyroidism. (X5) COMPLETION DATE 5) Date of compliance: 6/12/19 The Quarterly Minimum Data Set (MDS) assessment, dated 2/13/19, indicated the resident was moderately impaired for daily decision making and was receiving a tube feeding. A Physician's Order, dated 2/5/19, indicated the resident was to receive Jevity 1.2 at 95 cc/hr continuous x 20 hours. Ensure tube feeding was turned off from 10:00 a.m. to 12:00 p.m., and off from 10:00 p.m. to 12:00 a.m. due to administration of Dilantin (a seizure medication). A Care Plan, dated 2/28/19, indicated the resident received all of his nutrition by the way of a feeding tube due to having dysphagia (difficulty swallowing). Interventions included, but were not limited to, follow instructions for stopping/starting tube feeding as ordered with certain medication use and tube feeding as ordered. Interview with the Director of Nursing on 5/17/19 at 2:30 p.m., indicated the resident's tube feeding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 70 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE was running at the wrong rate and times.3. On 5/13/19 at 12:00 p.m. and 2:50 p.m., Resident G was observed in bed. At those times, his enteral feeding was infusing at 68 cubic centimeters (cc) through the peg tube (a tube inserted directly into the stomach to provide nutrition). The record for Resident G was reviewed on 5/17/19 at 1:20 p.m. Diagnoses included, but were not limited to, cerebral ischemia, high blood pressure, alcohol abuse, polyosteoarthritis, dysphagia, peripheral vascular disease, stroke, glaucoma, legal blindness, chronic pain, and hemiparesis. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 2/27/19, indicated the resident was not alert and oriented and needed extensive assist with 2 person physical assist with bed mobility, transfers, dressing and toileting. The resident had range of motion impairments to both upper and lower extremities. His weight was 130 pounds, and he received an enteral feeding through the peg tube. A Care Plan, updated 2/28/19, indicated the resident required a tube feeding. The approaches were to provide tube feeding formula and flushes per order. Physician's Orders, dated 4/10/19, indicated every shift provide Jevity 1.2 via pump continuously at 70 cc/hr times 22 hours. Interview with the 200 Unit Manager on 5/17/19 at 12:00 p.m., indicated the tube feeding should have been on at the ordered rate of 70 cc/hr. 4. On 5/15/19 at 8:32 a.m., and 10:28 a.m., Resident D was observed in bed. The resident's enteral FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 71 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE feeding was infusing at 70 cc/hour. On 5/16/19 at 9:00 a.m., 9:49 a.m., the resident was observed in bed. The resident's enteral feeding was infusing at 70 cc/hour. On 5/15/19 at 2:02 p.m., and 3:03 p.m., the resident was observed sitting up in a broda chair. The enteral feeding was infusing at 70 cc/hour. On 5/16/19 at 8:07 p.m., LPN 1 and 2 were observed in the resident's room. They had just finished lifting the resident up with the hoyer and placing bolsters on the bed. The LPN left the room when she was finished and the CNA stayed to remove the hoyer pad. The enteral feeding was turned off. At 8:58 p.m., the enteral feeding remained off. The record for Resident D was reviewed on 5/15/19 at 2:15 p.m. The resident was admitted to the facility on 1/5/19. Diagnoses included, but were not limited to, fracture of the femur, stroke, history of falls, urinary tract infection, dementia, high blood pressure , major depressive disorder, and chronic obstructive pulmonary disease (copd). The Significant Change Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was not alert and oriented and was severely impaired for decision making. The resident needed extensive assist with 2 person physical assist for transfers, bed mobility and dressing. Physician Orders, dated 4/12/19, indicated Glucerna 1.2 60 cc/hr continuous enteral feeding. The Care Plan, updated 2/28/19, indicated the resident received her nutrition through the peg FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 72 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE tube. The approaches were to provide tube feeding as ordered. Interview with the Hospice RN on 5/16/19 at 10:30 a.m., indicated she had not changed the Physician's Orders for the enteral feeding. Interview with the 200 Unit Manager on 5/16/19 at 10:00 a.m., indicated the tube feeding should be continuous at 60 cc/hour. 3.1-44(a) F 0695 SS=D Bldg. 00 483.25(i) Respiratory/Tracheostomy Care and Suctioning § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. Based on observation, record review and interview, the facility failed to ensure oxygen was set at the correct flow rate, orders were obtained for oxygen use and the oxygen was properly applied for 3 of 3 residents reviewed for oxygen. (Residents N, D, and B) F 0695 06/12/2019 12:00:00A The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Findings include: 1. On 5/14/19 at 10:10 a.m., Resident N was seated in his room in his wheelchair. The resident was wearing oxygen by the way of a nasal cannula. The resident's portable oxygen tank was set at 4 liters. FORM CMS-2567(02-99) Previous Versions Obsolete F695 – Respiratory/Trach Care and Suctioning Event ID: Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the KV9P11 Facility ID: 000076 If continuation sheet Page 73 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG (X5) COMPLETION DATE 1) Immediate actions taken for those residents identified: On 5/16/19 at 12:55 p.m., the resident was seated in his room in his wheelchair. The resident's oxygen was in use. The portable oxygen tank was set at 4 liters. Resident N – Oxygen was set to the correct flow rate. Resident D – No longer resides at the facility. Resident B – Oxygen was placed correctly in the resident’s nares. The record for Resident N was reviewed on 5/15/19 at 2:59 p.m. Diagnoses included, but were not limited to, pneumonia, edema, bladder cancer, atherosclerotic heart disease, rheumatoid arthritis, disorder of the bladder, osteoarthritis, hypertension, and chronic obstructive pulmonary disease. 2) How the facility identified other residents: The 5 day Medicare Minimum Data Set (MDS) assessment, dated 5/7/19, indicated the resident was cognitively intact for decision making and was receiving oxygen. All residents who receive oxygen affected by the alleged deficient practice. An audit was completed on all residents who receive oxygen therapy to ensure physician order is followed. A Physician's Order, dated 4/30/19, indicated the resident was to have oxygen at 3 liters per minute via nasal cannula continuously. 3) Measures put into place/ System changes: Interview with the Director of Nursing on 5/17/19 at 2:30 p.m., indicated the resident's oxygen should have been set at the correct rate. 2. On 5/13/19 at 11:13 a.m., Resident D was observed in her room in bed. At that time, she had an enteral feeding through a peg tube (a tube directly in the stomach that provides nutrition) infusing at 60 cubic centimeters (cc) an hour. She was also wearing oxygen at 2 liters nasal cannula. Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. On 5/15/19 at 9:05 a.m., the resident was seated in his wheelchair wearing his oxygen. The resident's portable oxygen tank was set at 2 liters. At 10:27 a.m., the portable oxygen tank was set at 4 liters. At 2:05 p.m., the resident was observed in his room in bed. The resident's oxygen was in use. The oxygen concentrator was set at 4 liters. FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY The nursing staff will be re-educated on oxygen use per physician orders and ensuring oxygen in placed properly when in use. The DON/designee will complete observations of at least 3 residents per week who are on KV9P11 Facility ID: 000076 If continuation sheet Page 74 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE oxygen to ensure it is properly positioned and at the correct rate. Concerns will be immediately addressed. The DON is responsible for compliance. On 5/14/19 at 9:10 a.m. the resident was observed in bed. The enteral feeding was infusing at 60 cc/hour and she was wearing oxygen at 2 liters. On 5/15/19 at 8:32 a.m., and 10:28 a.m., the resident was observed in bed. The resident's enteral feeding was infusing at 70 cc/hour and her oxygen was set at 1/2 liter per nasal cannula. 4) How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. On 5/15/19 at 2:02 p.m., and 3:03 p.m., the resident was observed sitting a broda chair by the Nurse's station. She was dressed in street clothes and was wearing oxygen at 2 liters nasal cannula. On 5/16/19 at 9:00 a.m., 9:49 a.m., the resident was observed in bed. The resident's enteral feeding was infusing at 70 cc/hour and her oxygen was set at 1/2 liter per nasal cannula. 5) Date of compliance: 6/12/19 The record for Resident D was reviewed on 5/15/19 at 2:15 p.m. The resident was admitted to the facility on 1/5/19. Diagnoses included, but were not limited to, fracture of the femur, stroke, history of falls, urinary tract infection, dementia, high blood pressure , major depressive disorder, and chronic obstructive pulmonary disease (copd). The significant Change Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was not alert and oriented and was severely impaired for decision making. The resident needed extensive assist with 2 person physical assist for transfers, bed mobility and dressing. There was no plan of care for the oxygen. There were no Physician's Orders for the oxygen. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 75 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Interview with the Hospice RN on 5/16/19 at 9:54 a.m. indicated there was no order for the oxygen, just for a nebulizer treatment. She indicated she had not adjusted the oxygen and was unsure why it was only at 1/2 liter. Interview with the 200 unit Manager 05/16/19 09:58 a.m., indicated she was unaware there was no order for the oxygen. 3. On 5/16/19 at 8:12 p.m., Resident B was observed laying in bed. The oxygen tubing was observed in her mouth and not in her nares. At 8:45 p.m., CNA 6 entered the resident's room, provided p.m. care and adjusted the oxygen and placed it back in her nose. The Record for Resident B was reviewed on 5/16/19 at 10:06 a.m. The resident was admitted to the facility on 4/25/19. Diagnoses included, but were not limited to, cardiomyopathy, edema, altered mental status change, transient ischemic attacks, hemiplegia. The Admission Minimum Data Set (MDS) assessment, dated 5/2/19, indicated the resident was not alert and oriented. The resident was an extensive assist with a 2 person physical assist for bed mobility, transfers, and locomotion on and off the unit. The resident received oxygen and a mechanically altered and therapeutic diet while at the facility. The Care Plan, updated 5/3/19, indicated the resident had copd and a history of smoking. The resident removed the oxygen tubing at times. The approaches were to remind and assist resident to keep oxygen in place. Interview with the 200 Unit Manager 05/17/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 76 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 12:00 PM indicated the resident removes her oxygen at times, but staff were to check on the resident and make sure the oxygen is in place. This Federal tag relates to Complaint IN00294200. 3.1-47(a)(6) F 0700 SS=D Bldg. 00 483.25(n)(1)-(4) Bedrails §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. Based on observation, record review, and interview, the facility failed to assess and provide the correct side rails for 2 of 4 residents reviewed for accident hazards. (Residents G and D) F 0700 Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 F700 Bed Rails The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Facility ID: 000076 If continuation sheet 06/12/2019 12:00:00A Page 77 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG On 5/14/19 10:25 a.m., Resident G was observed in bed laying on his right side with his nose in between the 1/4 rails and his mouth on the rail. The side rail was not padded. A nurse was immediately summoned to the room. The resident was repositioned on his back and the right side rail was padded. The record for Resident G was reviewed on 5/17/19 at 1:20 p.m. Diagnoses included, but were not limited to, cerebral ischemia, high blood pressure, alcohol abuse, polyosteoarthritis, dysphagia, peripheral vascular disease, stroke, glaucoma, legal blindness, chronic pain, and hemiparesis. (X5) COMPLETION DATE 2. How the facility identified other residents: All residents have the potential to be affected by this deficient practice. A facility wide audit will be completed to identify other residents. All residents with bed rails will be re-assessed for necessity and new assessment completed. The Modification of the Quarterly Minimum Data Set (MDS) assessment dated, 2/27/19, indicated the resident was not alert and oriented and needed extensive assist with 2 person physical assist with bed mobility, transfers, dressing and toileting. The resident had range of motion impairments to both upper and lower extremities. 3. Measures put into place/ System changes: Staff will be re-educated on the procedure for side rails evaluation and assessment. An observation and record review on at least 3 residents per week will be completed to ensure proper evolution for the use side rails has been completed, the proper device is in place per order and care plan There were no Physician's Orders for the side rails. A side rail assessment, dated 7/13/18, indicated the resident used the side rails to assist with positioning in bed. The resident was to have an assist bar to the right and left side. A side rail assessment, dated 4/10/19, indicated Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1. Immediate actions taken for those residents identified: Resident G – Side rail assessment completed. Resident D – No longer resides in the facility. Interview with the 200 Unit Manager at that time, indicated the resident was just repositioned and he moved himself over in the bed. She indicated the other pad for the rail was on the floor. They had tried other things beside the side rail and this was the best option for him. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY KV9P11 Facility ID: 000076 If continuation sheet Page 78 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY the assessment was not complete. The need for the rail indicated the resident jerks his upper right arm. There were no other interventions previously attempted. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE updated. DON will be responsible for compliance. 4. How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5. Date of compliance: 6/12/19 Interview with the 200 Unit Manager 05/20/19 10:44 a.m., indicated the side rail assessment was incomplete and she just finished it. The resident was to have an assist bar to the right and left sides which were to be padded to prevent him from leaning or laying on them. A side rail assessment was to be completed every quarter and there had not been one completed since July 2018. 2. On 5/13/19 at 11:13 a.m., Resident D was observed in her room in bed. At that time, she had an enteral feeding through a peg tube (a tube directly in the stomach that provides nutrition) infusing at 60 cubic centimeters (cc) an hour. She was also wearing oxygen at 2 liters nasal cannula. The resident had a full set of side rails attached to her bed which were in the up position. On 5/14/19 at 9:10 a.m. the resident was observed in bed. The enteral feeding was infusing at 60 cc/hour and she was wearing oxygen at 2 liters. She was dressed in a hospital gown. The resident had a full set of side rails attached to her bed which were in the up position. On 5/15/19 at 8:32 a.m., and 10:28 a.m., the resident was observed in bed. The resident's enteral feeding was infusing at 70 cc/hour and her oxygen was set at 1/2 liter per nasal cannula. The resident had a full set of side rails attached to her bed which were in the up position. The record for Resident D was reviewed on 5/15/19 at 2:15 p.m. The resident was admitted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 79 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE the facility on 1/5/19. Diagnoses included, but were not limited to, fracture of the femur, stroke, history of falls, urinary tract infection, dementia, high blood pressure , major depressive disorder, and chronic obstructive pulmonary disease (copd). The significant Change Minimum Data Set (MDS) assessment, dated 4/24/19, indicated the resident was not alert and oriented and was severely impaired for decision making. The resident needed extensive assist with 2 person physical assist for transfers, bed mobility and dressing. There was no Care Plan for a full set of side rails. A side rail assessment, dated 4/29/19, indicated the bed rail increased bed mobility use and the least restrictive rail was used. A half rail to the right and half rail to the left was to be in place. The resident was notified and agreed to the risks and benefits of bed rail utilization. Physician's Orders, dated 4/12/19, indicated Unity hospice. There was no order for side rails. Interview with the 200 Unit Manager on 5/16/19 at 9:06 a.m., indicated she was just made aware the resident had a full set of side rails. Hospice had sent the wrong side rails and attached them to the bed. 3.1-45(a)(1) F 0725 SS=E Bldg. 00 483.35(a)(1)(2) Sufficient Nursing Staff §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 80 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. Based on observation, record review and interview, the facility failed to ensure sufficient staffing was provided related to dependent residents not being transferred out of bed, not turned and repositioned every two hours, not providing timely incontinence care and not providing showers for 9 of 11 residents reviewed for activities of daily living (ADL's). The facility also failed to ensure call lights were answered in a timely manner on 1 of 4 units throughout the facility. (Residents K, Q, H, J, E, F, G, B, and L and the 200 Unit) F 0725 This Plan of Correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of 1. On 5/13/19 at 11:20 a.m., Resident K was Event ID: 06/12/2019 12:00:00A The facility requests paper compliance for this citation. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete F725- Sufficient Nurse Staffing KV9P11 Facility ID: 000076 If continuation sheet Page 81 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY observed in her room in bed. The resident was awake and she was wearing a hospital gown. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE correction is prepared and/or executed solely because it is required by the provisions of federal and state law. On 5/14/19 at 2:37 p.m., the resident was again observed in bed wearing a hospital gown. 1. Immediate actions taken for those residents identified: The resident was observed in bed wearing a hospital gown on 5/15/19 at 8:45 a.m., 10:32 a.m., 11:40 a.m., 1:47 p.m., and 3:30 p.m. Resident K – Dressed per preference. On 5/16/19 at 9:34 a.m. and 10:15 a.m., the resident was again observed in bed wearing a hospital gown. Resident F – Catheter bag was moved per request and the resident was given a bed bath. On 5/17/19 at 8:40 a.m. and 12:26 p.m., the resident was observed in her room in bed. Resident Q – Placed in bed. The record for Resident K was reviewed on 5/16/19 at 9:45 a.m. Diagnoses included, but were not limited to, intracranial abscess and granuloma, vascular dementia with behavior disturbance, recurrent dislocation of left hip, dysphagia, schizophrenia, encephalopathy, type 2 diabetes, bipolar, cataract right eye, anxiety, hypertension, artificial opening of digestive tract, anemia, and cerebral infarct (stroke). Resident H – Adult brief was changed, personal care provided. Resident J – Placed in bed. Resident E – Repositioned. The Quarterly Minimum Data Set (MDS) assessment, dated 3/8/19, indicated the resident was cognitively impaired for daily decision making and required extensive two person assistance with bed mobility and was totally dependent on staff for transfers with a two person assist. Resident G – Repositioned. Resident B – Adult brief was changed, personal care provided. The current Care Plan indicated the resident had an ADL self care deficit or potential as evidenced by needed assistance or was dependent in bed mobility and transfers. Interventions included, but were not limited to, Broda chair as tolerated and resident was dependent on 2 staff for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Resident L – Assisted with a shower. 2. How the facility identified KV9P11 Facility ID: 000076 If continuation sheet Page 82 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY transfers using a sliding technique. The hoyer lift was not to be used. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) All residents have the potential to be affected by this deficient practice. Staff will be re-educated on the importance of providing care to meet the residents needs and it is the responsibility of all staff to respond to the call lights. Staff will be re-educated on the policy for attendance and the company policy on providing 24-hour quality care. Interview with the Director of Nursing on 5/17/19 at 2:30 p.m., indicated the resident does get out of bed and she didn't know why she hadn't been. 2. During random observations on 5/16/19 from 8:03 p.m. to 9:06 p.m., on the 200 unit the following was observed: a. At 8:03 p.m., Resident F was screaming out loud for help with her "bag". Interview with the resident at that time, indicated she needed her foley catheter bag moved. There were 2 call lights on and no staff around. An audit of residents requiring the assistance of 2 staff will be completed and staffing will be adjusted on the units with high acuity residents to ensure the residents’ care needs are being addressed. b. At at 8:04 p.m., Resident Q was observed in her room with her head low and eyes closed sitting in her wheelchair waiting to go to bed. 3. Measures put into place/ System changes: c. At 8:14 p.m., CNA 4 helped Resident F with her foley bag. There were now 4 call lights on and 2 of them were the original ones from 8:03 p.m. e. At 8:20 p.m., a call light was turned on. LPN 1 was observed at the Nurse's station on the phone. CNA 4 walked down the hall towards the call light looking for other CNAs, but did not answer the light. The call light was answered at 8:31 p.m., by LPN 1 Executive Director/designee will review staffing sheets prior being posted to ensure coverage is on those units with residents requiring the assistance of 2 staff is adequate. Outside resources will be utilized if needed. Any identified issues will be immediately addressed. Executive Director/designee will be responsible for compliance. 4. How the corrective actions will be monitored: f. At 8:23 p.m., during an interview with Resident The results of these audits will be d. At 8:19 p.m., CNA 4 answered all 4 call lights one by one and left the residents's rooms without helping all of them. Event ID: DATE other residents: The May 2019 Physician's Order Summary (POS) indicated the resident could be out of bed as tolerated. FORM CMS-2567(02-99) Previous Versions Obsolete (X5) COMPLETION KV9P11 Facility ID: 000076 If continuation sheet Page 83 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY H regarding if he had been assisted when his call light was on at 8:03 p.m., he stated "I told the CNA I had to be changed and she has not been back yet." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. g. At 8:24 p.m., during an interview with Resident J regarding if she had been assisted when her call light was on at 8:03 p.m., she stated, "No, I asked to be put to bed and the Aide said she had to get help." 5. Date of compliance: 6/12/19 h. At 8:26 p.m. CNA 4 had asked LPN 1 for help in assisting Resident Q to bed. The LPN told the CNA she had to make a phone call and could not help her. CNA 4 asked QMA 1 if she could help her put Resident Q to bed and she indicated she had medications to pass. CNA 4 walked away towards the resident's room and waited. At 8:30 p.m. she put the mechanical lift into Resident Q's room and waited. Finally at 8:35 p.m., LPN 1 went down to assist CNA 4. i. At 8:49 p.m., during an interview with Resident H regarding if anyone had helped him with incontinence care yet, he indicated no one had come back. Resident J indicated no one had helped her go to bed, as she was still sitting in her wheelchair. She was supposed to be put to bed every night by 8:00 p.m. At 8:52 p.m., Resident J was placed in bed. j. At 9:03 p.m., Resident H put his call light back on. His complaint remained the same, he needed his incontinent brief changed. The Director of Nursing (DON) came down to the unit at 9:06 p.m. She was informed Resident H had been waiting over an hour to have his brief changed. k. There were 3 CNAs, 1 nurse and 1 QMA for the 200 unit. There were 43 residents who resided on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 84 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE the unit. Twenty three of those residents required a 2 person assist with the hoyer lift or sit to stand lift for transfers. The shower schedule was reviewed for the 200 unit as followed: Mondays and Thursdays: 6 showers on days and 5 on eves. Tuesdays and Fridays: 6 showers on days and 5 on eves. Wednesdays and Saturdays: 5 showers on days and 6 on eves. There were also 5 showers on Wednesday and Friday eves in an additional to the above. 1 resident received a bed bath daily. The staffing was as follows: Tuesday 5/14/19 there were 4 CNAs, 1 nurse and 1 QMA for day and evening shifts. Wednesday 5/15/19 there were 3 CNAs, 1 nurse, and 1 QMA for days and evening shifts. Thursday 5/16/19 there were 3 CNAs and 1 CNA in at 11 a.m. and 2 nurses for the day shift. Thursday 5/16/19 there were 3 CNAs, 1 nurse and 1 QMA for the evening shift. Interview with the Director of Nursing on 5/16/19 at 9:20 p.m. indicated she was aware there was a staffing problem and the residents should not have to wait that long for care to be rendered. Interview with the Administrator on 5/17/19 at 10:00 a.m., indicated they were continuing to hire more CNAs and Nurses. Interview with the 200 Unit Manager on 5/17/19 at 12:00 p.m., indicated Residents H and J were extensive assist with 2 person physical assist for transfers and incontinence care. Both residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 85 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE were mechanical lifts which required 2 staff for transfers. 3. A confidential staff interview during the survey indicated the entire facility was short staffed. "Some days there will be 7 plus showers to do plus taking care of all the other residents. Something falls short, either the residents get bathed or they get incontinence care every 2 hours, with the staff we have, it is nearly impossible." A confidential staff interview indicated "Sometimes only 2 CNAs were staffed on the unit. We have complained to Administration, but nothing had been done about it." A confidential staff interview indicated "I try my best to turn and reposition the residents every 2 hours but seems impossible when I have all of the hoyer lifts." A confidential staff interview indicated "There is no time to toilet the residents before and after meals, it was usually one or the other." A confidential resident interview indicated "There is not enough staff to take care of us. Staff were quitting and we do not know what is going to happen." A confidential interview indicated "The turnover in this place is crazy. There is not enough staff to take care of these people." A confidential interview indicated "These residents are not being turned and repositioned like they should. The Director of Nursing told me they were short staffed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 86 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 4. On 5/14/19 at 8:55 a.m., Resident E was observed in her wheelchair. At that time, she was taken out of the dining room and placed in the 200 lounge. At 10:10 a.m., and 11:04 a.m., the resident remained in the lounge. At 12:00 p.m., the resident was taken to the main dining room for lunch. At 12:47 p.m., staff wheeled the resident down to the 200 unit and placed her by the Nurse's station. At 1:27 p.m., the resident was taken to the Activity room by Activity staff. At 3:01 p.m., she remained in the Activity room. The resident had not been repositioned during the above times in her wheelchair. On 5/16/19 at 8:53 a.m., the resident was observed sitting in her wheelchair in the main dining room eating breakfast. At 9:22 a.m., the resident was placed in the 200 lounge. At 10:45 a.m., the resident was in the Activity room. At 11:27 a.m., an Activity Aide pushed the resident to the main dining room. No staff had checked her for incontinence or repositioned her in the wheelchair. At 12:38 p.m., the resident was still eating her lunch and at 12:52 p.m., a CNA pushed the resident out of the dining room to the 200 unit. On 5/16/19 1:15 p.m., CNA 2 and CNA 3 assisted the resident to bed and provided incontinence care. The resident's incontinent brief was heavily saturated with urine. The resident's buttocks were red. Interview with CNA 3 at that time, indicated she had taken the resident to the bathroom and provided incontinence care at 10:10 a.m. She did not provide incontinence care prior to lunch. The record for Resident E was reviewed on 5/15/19 at 10:03 a.m. Diagnoses included, but were not limited to, colon cancer, dementia, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 87 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE chronic obstructive pulmonary disease (copd), type 2 diabetes, anemia, morbid obesity, osteoarthritis, hypothyroidism, breast cancer, high blood pressure, major depressive disorder, and history of falling. The Quarterly Minimum Data Set (MDS) assessment dated 5/5/19, indicated the resident was not alert and oriented, and was an extensive assist with 2 person physical assist for transfers, toileting and bed mobility. The resident was always incontinent of bladder. A Care Plan, updated 5/2019, indicated the resident was incontinent of bowel and bladder related to cognitive impairment. The approaches were to assist with incontinence care upon rising, around meal times, and at bedtimes and as needed. Interview with the Director of Nursing on 5/17/19 at 9:45 a.m., indicated residents were to be checked and changed at least every 2 hours. 5. On 5/13/19 at 12:00 p.m. and 2:50 p.m., Resident G was observed in bed. At those times he was wearing a hospital gown. On 5/14/19 10:25 a.m., and 10:52 a.m., the resident was observed in bed wearing a hospital gown. On 5/16/19 at 9:00 a.m., the resident was observed in bed. On 5/16/19 at 11:20 a.m., Resident G was observed in bed laying on his left side facing the door. At 1:26 p.m., the resident was observed in the same position in bed facing the door. At 2:00 p.m., CNA 1 was observed in the room. She indicated she was going to reposition him on his right side FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 88 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE toward the window. Interview with CNA 1 at that time, indicated 2 other CNAS repositioned the resident for her at 11:00 a.m., as she was unable to do it. She tried to reposition and change the residents at least every 2 hours if she was able to. On 5/17/19 at 10:45 a.m., and 10:58 a.m., the resident was observed in bed wearing a hospital gown. The record for Resident G was reviewed on 5/17/19 at 1:20 p.m. Diagnoses included, but were not limited to, cerebral ischemia, high blood pressure, alcohol abuse, polyosteoarthritis, dysphagia, peripheral vascular disease, stroke, glaucoma, legal blindness, chronic pain, and hemiparesis. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 2/27/19, indicated the resident was not alert and oriented and needed extensive assist with 2 person physical assist with bed mobility, transfers, dressing and toileting. The resident had range of motion impairments to both upper and lower extremities. His weight was 130 pounds, and he received an enteral feeding through the peg tube (a tube placed directly into the stomach to provide nutrition). The Care Plan, updated on 10/17/18, indicated the resident had a self care deficit for bed mobility, transfers and toilet use. The approaches were extensive assist of 2 staff for bed mobility, and transfer with mechanical lift. The Care Plan, updated 5/10/19, indicated the resident had a wound to his coccyx. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 89 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE approaches were to turn and reposition every 2 hours. Physician's Orders, dated 5/10/19, indicated reposition resident every 2 hours. There was no Physician's Order for bed rest. Interview with the Director of Nursing on 5/17/19 at 9:45 a.m., indicated the resident was to be repositioned and turned at least every 2 hours. Interview with the 200 Unit Manager on 5/17/19 at 12:00 p.m., indicated there were no orders for bed rest for the resident. 6. During an interview with Resident F on 5/14/19 at 2:05 p.m., indicated she had preferred a bed bath versus a shower. She had not had at least 2 bed baths a week in the last month or so and does not recall when the last time her hair was washed. The record for Resident F was reviewed on 5/15/19 at 9:33 a.m. The resident was admitted to the facility on 1/14/19. Diagnoses included, but were not limited to, cirrhosis of liver, palliative care, asthma, heart failure, type 2 diabetes, kidney disorder, atrial fibrillation, high blood pressure, and bipolar disorder. The Admission Minimum Data Set (MDS) assessment, dated 1/25/19, indicated the resident was alert and oriented and was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability. The resident was coded as having the diagnosis of manic depression bipolar disease. It was somewhat important for the resident to choose between a bed bath or shower. The resident needed 1 person physical help with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 90 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE bathing. The Care Plan, dated 4/2/19, indicated the resident had an activities of daily living self care deficit. The resident was scheduled for a shower on Wednesdays and Saturdays evenings. The resident received a bed bath on 4/17 and 5/8. She received a shower on 4/20/19. She refused a bed bath on 4/27 and 5/11/19. The resident's hair had been washed on 4/20/19 and 5/8/19. Interview with the 200 Unit Manager on 5/17/19 at 12:00 p.m., indicated the resident does refuse her baths sometimes, but she should still be offered 2 bed baths or showers a week. 7. On 5/14/19 at 9:01 a.m., Resident B was observed in bed, wearing a t-shirt and incontinent brief. At that time, CNA 1 was in the room repositioning the resident for breakfast. The resident's incontinent brief was observed to be wet with a blue line noted. The CNA did not change the resident at that time. She set the resident up for breakfast and proceeded to feed her. At 11:00 a.m., the resident was observed in bed laying on her back. CNA 1 indicated she had not gotten to her yet as far as providing morning care. At 11:45 a.m., CNA 1 had just finished giving Resident L a shower and proceeded to provide morning care for Resident B. She indicated she had checked and changed the resident when she started her shift at 6:00 a.m. this morning. The CNA did not provide incontinence care at 9:00 a.m., because she did not think it was appropriate to change her during breakfast. The CNA removed the resident's incontinent brief which was wet with urine. The resident's buttocks were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 91 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE red and her bandage was coming off of an open area on her coccyx. The Record for Resident B was reviewed on 5/16/19 at 10:06 a.m. The resident was admitted to the facility on 4/25/19. Diagnoses included, but were not limited to, cardiomyopathy, edema, altered mental status change, transient ischemic attacks, hemiplegia. The Admission Minimum Data Set (MDS) assessment, dated 5/2/19, indicated the resident was not alert and oriented. The resident was an extensive assist with a 2 person physical assist for bed mobility, transfers, and locomotion on and off the unit. She was frequently incontinent of urine. The resident received oxygen and a mechanically altered and therapeutic diet while at the facility. The Care Plan, dated 4/26/19, indicated the resident had a self care deficit with activities of daily living. The approaches were the resident required extensive assist by with 1 to 2 staff for toileting. A Bowel and bladder assessment, dated 4/26/19, indicated the resident was incontinent all or most of the time and used incontinent products. The current and revised 1/15/18, "Pressure Ulcer Prevention" policy, provided by the Corporate Nurse Consultant on 5/20/19 at 2:33 p.m., indicated "Turn dependent residents approximately every 2 hours or as needed and position resident with pillows or pads protecting bony prominences as indicated. The current and revised 1/16/18, "Incontinence Care" policy, provided by the Corporate Nurse Consultant on 5/20/19 at 2:33 p.m., indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 92 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE "Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every 2 hours and provided perineal and genital care after each episode." Interview with the Director of Nursing on 5/17/19 at 9:45 a.m., indicated residents should be checked and changed for incontinence and repositioned at least every 2 hours. 8. Interview with Resident L on 5/13/19 at 11:20 a.m., indicated it was her preference to have a shower, however, she had not had a shower in over a month. The record for Resident L was reviewed on 5/17/19 at 11:59 a.m. Diagnoses included, but were not limited to, multiple sclerosis, adult failure to thrive, malignant neoplasm of the digestive system, diabetes, chronic kidney disease, dementia, anxiety, and delusions. The Quarterly Minimum Data Set (MDS) assessment, dated 3/12/19, indicated the resident was alert and oriented and required an extensive 2 person physical assist with transfers, personal hygiene, and bathing. The 200 Unit Report Sheet indicated the resident was to have showers every Tuesday and Friday during the day. The CNA Point of Care documentation for the past 30 days indicated the resident had bed baths on 4/23, 4/26, 4/30, 5/1, 5/3, and showers on 5/7, 5/10, and 5/14. Interview with the 200 Unit Manager on 5/16/19 at 3:19 p.m., indicated the resident was receiving bed baths because she was refusing showers, however, it was not documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 93 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE This Federal tag relates to Complaint IN00294151. 3.1-17(a) F 0732 SS=B Bldg. 00 483.35(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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 94 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY §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. Based on observation and interview, the facility failed to ensure the daily staffing pattern was posted for 1 of 6 days of the survey. F 0732 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) F732 – Post Nursing Staffing (X5) COMPLETION DATE 06/12/2019 12:00:00A The facility requests paper compliance for this citation. Finding includes: This Plan of Correction is the center's credible allegation of compliance. On 5/13/19 at 9:46 a.m. and 11:50 a.m., the daily staffing sheet posted at the 300 Unit was dated 5/10/19. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Interview with the Director of Nursing on 5/20/19 at 5:30 p.m., indicated the daily staffing sheet on the 300 Unit was outdated on 5/13/19. 1) Immediate actions taken for those residents identified: An updated staffing sheet was posted. 2) How the facility identified other residents: All residents have the potential to be affected by this deficient practice. 3) Measures put into place/ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 95 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE System changes: Posting information reviewed prior to posted and will be checked 5 x per week to ensure the information is present and accurate. The Administrator will be responsible for compliance. 4) How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5) Date of compliance: 6/12/19 F 0761 SS=D Bldg. 00 483.45(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 the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 96 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE §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. Based on observation, record review and interview, the facility failed to ensure medications were stored properly related to over the counter medications and inhalers kept at a resident's bedside for 1 of 5 residents reviewed for accident hazards. (Resident N) F 0761 Finding includes: On 5/14/19 at 10:16 a.m., two inhalers and a bottle of Aleve were observed on Resident N's over bed table. Interview with the resident on 5/15/19 at 10:27 a.m., indicated he was able to keep his inhalers and he kept them in the top drawer of his bed side stand. On 5/16/19 at 12:55 p.m., an inhaler was observed on the resident's over bed table. The record for Resident N was reviewed on 5/15/19 at 2:59 p.m. Diagnoses included, but were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 F761 Labels/Store Drugs & Biologicals The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1) Immediate actions taken for those residents identified: Resident N was assessed for self-administration of medications. Facility ID: 000076 If continuation sheet 06/12/2019 12:00:00A Page 97 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG not limited to, pneumonia, edema, bladder cancer, atherosclerotic heart disease, rheumatoid arthritis, disorder of the bladder, osteoarthritis, hypertension, and chronic obstructive pulmonary disease (COPD). A Physician's Order, dated 4/30/19, indicated the resident was to receive an Albuterol Sulfate HFA Aerosol Solution 108 (90 base), 2 puffs inhale orally every 6 hours as needed (prn) for COPD. There was no order to keep the medication at the resident's bedside. There was no Physician's Order for the Aleve. There was no Self Administration of Medication assessment available for review. Interview with the Director of Nursing on 5/17/19 at 2:30 p.m., indicated the resident should have had an order to keep his medications at the bedside and a self administer medication assessment completed. 3.1-25(j) 3.1-25(m) Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 2) How the facility identified other residents: Any resident can be affected by the deficient practice. 3) What measures will be put into place and what systemic changes will be made to ensure that the deficient practice does not recur? Nursing staff will be re-educated on the proper procedure on medication administration as it pertains to resident’s request to keep medication at bedside, including over-the-counter medications and the proper procedure for evaluating a resident for self-administration of medications. DON/Designee will complete an observation audit of at least 5 residents per week to ensure no over-the-counter or other medications are kept at the residents beside. Identified issues will be addressed immediately with. The Executive Director/Designee will be responsible for compliance. 4) How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5) Date of compliance: 6/12/19 The 5 day Medicare Minimum Data Set (MDS) assessment, dated 5/7/19, indicated the resident was cognitively intact for decision making and was receiving oxygen. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY KV9P11 Facility ID: 000076 If continuation sheet Page 98 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG F 0805 SS=D Bldg. 00 (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 483.60(d)(3) Food in Form to Meet Individual Needs §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(3) Food prepared in a form designed to meet individual needs. Based on observation, record review, and interview, the facility failed to ensure a resident received thickened liquids with a breakfast meal for 1 of 3 residents reviewed for nutrition. (Resident B) F 0805 On 5/14/19 at 9:01 a.m., Resident B was observed in bed, wearing a t-shirt and an incontinent brief and could be seen from the hallway. At that time, CNA 1 was in the room repositioning the resident for breakfast. The resident was served a mechanical soft diet of scrambled eggs, oatmeal, toast, coffee and orange juice. Both beverages were not thickened. CNA 1 assisted the resident with 3 sips of orange juice. The resident drank the juice. At that time, CNA 1 was asked to read the meal ticket, which indicated the resident's liquids were to be thickened to a nectar thick consistency. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1) Immediate actions taken for those residents identified: The Record for Resident B was reviewed on 5/16/19 at 10:06 a.m. The resident was admitted to the facility on 4/25/19. Diagnoses included, but were not limited to, cardiomyopathy, edema, altered mental status change, transient ischemic attacks, hemiplegia. Resident B – Provided with nectar thick liquids per order. 2) How the facility identified other residents: The Admission Minimum Data Set (MDS) assessment, dated 5/2/19, indicated the resident was not alert and oriented. The resident was an Event ID: 06/12/2019 12:00:00A This Plan of Correction is the center's credible allegation of compliance. Finding includes: FORM CMS-2567(02-99) Previous Versions Obsolete F805 Food in Form to Meet Individual Needs All residents on modified diets have the potential to be affected by this deficient practice. KV9P11 Facility ID: 000076 If continuation sheet Page 99 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY extensive assist with a 2 person physical assist for bed mobility, transfers, and locomotion on and off the unit. The resident received oxygen and a mechanically altered and therapeutic diet while at the facility. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 3) Measures put into place/ System changes: Staff will be re-educated on the proper preparation of thickened liquids and reminded to check the meal ticket for the proper dietary orders. A Care Plan, dated 4/26/19, indicated the resident was unable to consume regular consistency foods and required a pureed diet with honey thicken liquids. Physician's Orders, dated 5/9/19, indicated mechanical soft diet with nectar consistency for liquids. 4) How the corrective actions will be monitored: The DON/designee will complete observations of 4 meals per week on various days to ensure residents are being served the proper diet. Any concerns will be addressed immediately. The DON will be responsible for compliance. Interview with the Corporate Nurse Consultant on 5/14/19 at 10:00 a.m., indicated the dietary staff do not put thickener in the liquids and the CNAs were to thicken the juice. 3.1-21(a)(3) The results of these audits will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5) Date of compliance: 06/12/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 100 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING COMPLETED 05/20/2019 STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG 00 B. WING NAME OF PROVIDER OR SUPPLIER F 0880 SS=E Bldg. 00 (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 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 be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 101 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE (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. Based on observation, record review and interview, the facility failed to ensure hands were washed after glove removal, surfaces were sanitized before and after dressing changes and personal care equipment was stored properly for 3 of 3 wound care treatments observed and on 3 of 4 units throughout the facility. (Residents P, G, D and Units 100, 200, and 400) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0880 F880 – Infection Control 06/12/2019 12:00:00A This Plan of Correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not KV9P11 Facility ID: 000076 If continuation sheet Page 102 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG 1. On 5/17/19 at 11:38 a.m., the Wound Care Nurse was observed preparing supplies for Resident P's treatment to his left heel and chest. The Wound Care Nurse entered the resident's room and placed a bag on the resident's dining room table along with the wound care supplies. She did not move anything on the resident's table nor did she wipe down the table before setting up. (X5) COMPLETION DATE 1) Immediate actions taken for those residents identified: The Nurse removed the dressing to the resident's chest and then removed her gloves. She donned a clean pair of gloves. She did not wash her hands or use an alcohol based hand gel in between. After completing the treatment to the resident's chest, she removed her gloves and washed her hands. The Nurse then donned a clean pair of gloves and removed the dressing to the resident's left heel. She proceeded to cleanse the resident's heel with wound wash, applied Santyl ointment (a debriding agent) and a foam dressing all while wearing the same pair of gloves. Resident P – A new dressing was applied. Resident D – No longer resides at the facility. Resident G – A new dressing was applied. 100 Dining Room – The gown and sheet were placed in laundry. The wash basins observed in rooms 201 and 232 were properly stored. Room 433 – The toilet lid was repaired. Room 436 – The soiled washed cloth was place in laundry. The wound nurse was re-educated on proper procedure for dressing changes. After the treatment was completed, the Wound Nurse picked up the garbage bag off of the table and the medication wrappers. She did not wipe down the table when she was done. Interview with the Director of Nursing on 5/20/19 at 2:30 p.m., indicated hand hygiene was to be completed after glove removal. The over bed table was to be sanitized before and after use.2. On 5/17/19 at 10:58 a.m., Resident G was observed in bed. At that time, the Wound Nurse was preparing a dressing change to the resident's right foot and coccyx areas. The Wound Nurse washed her hands with soap and water and Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY 2) How the facility identified other residents: All residents have the potential to be affected by the alleged deficiency. KV9P11 Facility ID: 000076 If continuation sheet Page 103 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG donned clean gloves. She used the over bed table to lay all of her supplies on. She did not sanitize the over bed table before placing all of the wound supplies on top of it. The resident's incontinent brief was removed. She indicated the bandage had fallen off during incontinence care just prior to the treatment. She cleansed the coccyx wound with wound wash and patted dry. She removed her gloves and left the room to obtain a foam dressing. She did not use hand sanitizer or wash her hands with soap and water. She came back in the room and opened the foam package and laid it on the over bed table. She washed her hands with soap and water and donned clean gloves. She applied zinc oxide cream to the wound with a tongue blade and covered with the foam dressing. She used same gloves and cleansed the scrotal open area with wound wash and patted it dry. She applied zinc oxide cream with a tongue blade. She removed her gloves and left the room to obtain the gauze bandage. She did not wash her hands or use hand gel before she left. She came back into the room and washed her hands with soap and water and donned clean gloves. She applied the gauze bandage and removed the gloves. She did not wash her hands with soap and water or use hand gel. Clean gloves were donned to both hands. She picked up her scissors and cut off the kerlix gauze to the right foot. She did not clean or sanitize the scissors first or after she was finished. The gauze was removed and thrown away. She used her gloved hand and opened the bed side drawer and removed a wash cloth and placed it under his foot. Her gloves were removed and she donned another pair of clean gloves. She did not wash her hands or used gel. The wound was cleansed with wound wash and patted dry. Her gloves were removed and she opened the kerlix wrap. Clean gloves were donned to both hands. Again she FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 3) Measures put into place/ System changes: Staff will be re-educated regarding proper storage of wash basins and proper procedures on wound care. Education will also be provided to staff on reporting of repairs observed in the resident’s room. 4) How the corrective actions will be monitored: DON/designee will complete observation rounds on at least 5 resident rooms to ensure wash basins are stored, linen is disposed of properly and anything needing repaired is brought to the attention of the Maintenance Director. DON will be responsible for compliance. The DON/designee will observe 1 nurse per week complete a dressing change x 4 weeks then monthly to ensure proper procedures are followed. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the KV9P11 Facility ID: 000076 If continuation sheet Page 104 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY did not use hand gel or wash her hands. She used same scissors without cleaning them, and cut the Aquacel AG (a medicated bandage) into pieces to fit the wound. Using the same gloves, she applied medihoney to the entire wound and placed the Aquacel over all the necrotic areas. She covered with large ABD pads and wrapped with kerlix. She removed her gloves and left the room to obtain a roll of tape. She did not wash her hands or use hand gel. She entered the room with the tape and donned cleaned gloves and secured with tape. She removed her gloves and washed her hands with soap and water. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE plan of correction as indicated. 5) Date of compliance: 06/12/19 Interview with the Director of Nursing on 5/20/19 at 2:30 p.m., indicated hand hygiene was to be completed after glove removal. The over bed table and the scissors were to be sanitized before and after use. 3. On 5/15/19 at 10:28 a.m., Resident D was observed in bed. At that time, the Wound Nurse was preparing to change the resident's bandages to the pressure ulcer on her coccyx. The Wound Nurse washed her hands with soap and water donned clean gloves to both hands. She removed the old bandages to wound and took measurements. She removed her gloves and threw them away and donned a clean pair without washing her hands or using hand sanitizer. She placed all of the new bandages in the bed with the resident towards her feet. She removed her gloves and left the room to obtain tongue blades. She did not wash her hands after removing the gloves. She came back in the room and washed her hands with soap and water and donned another pair of clean gloves to both hands. She cleaned the wound with cleanser and patted it dry and used a tongue blade to administer the topical ointment. She reached in her pocket and pulled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 105 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE out a pair of scissors. She did not sanitize them and proceeded to cut the topical bandages in pieces to fit inside the wound. After applying the ointment and bandages she reached back into her pocket and pulled out a marker to sign and date the bandage. She did not change her gloves during that time. She removed her gloves and threw them away and picked up her camera hand tool and documented the measurements of the wound. She left the room and used hand sanitizing gel to her hands at the treatment cart. The current "Hand Hygiene" policy, provided by the Administrator on 5/20/19 at 9:26 a.m., indicated hand hygiene was to be performed before and after glove removal. Interview with the Director of Nursing on 5/20/19 at 2:45 p.m., indicated the Wound Nurse should have washed her hands after glove removal and sanitized her scissors before and after the treatment.4. On 5/13/19 at 9:22 a.m., the 100 unit dining room was observed. There was a hospital gown and sheet on the floor and hospital gown on one of the tables. Interview 5/20/19 at 1:53 p.m., indicated the gowns and linen should have been stored properly.5. During the Environmental Tour on 5/15/19 from 1:45 p.m.-2:20 p.m. the following was observed: 1. 200 Hallway: a. Room 201 had a wash basin stored on the back of the toilet lid, uncontained and unlabeled. There were three residents who shared the bathroom. b. Room 232 had a pink wash basin stored on the back of the toilet lid with wash cloths, uncontained and unlabeled. There were three FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 106 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE residents who shared the bathroom. 2. 400 Hallway: a. Room 433 had a toilet lift seat stored on the discolored floor, uncontained, next to the toilet. It was indicated the resident does use the toilet lift seat. There was one resident who used the bathroom. b. Room 436 had soiled wash cloths stored on the side of the sink. There was one resident who used the bathroom. Interview with the Director of Maintenance on 5/15/19 at 2:20 p.m., was unaware of storage for bedside equipment. A policy titled, "Cleaning-Sanitizing Bedside Equipment," was provided by the Nurse Consultant on 5/15/19 at 2:55 p.m. This current policy indicated, "...Note:...2. Bedside equipment such as bedpans, wash basins and urinals may be stored in separate plastic bags in shared bathrooms if items are appropriately labeled to indicate which resident they belong to...." This Federal Tag relates to Complaint IN00294200. 3.1-18(b) 3.1-18(l) 3.1-19(g)(1)(2)(3) F 0921 SS=E Bldg. 00 483.90(i) Safe/Functional/Sanitary/Comfortable Environ §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Based on observation and interview, the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0921 KV9P11 F921 - Enviornmental Facility ID: 000076 If continuation sheet 06/12/2019 12:00:00A Page 107 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY failed to keep the resident's environment clean and in good repair related to marred and chipped paint walls, doors, and closet doors, dirty fan blades, lime build up on faucets, rust stains in the toilet bowl and sink, and dirty tube feeding poles for 3 of 4 halls. (The 200, 300, and 400 hallways) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Findings include: Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1. During the Environmental tour with the Administrator and Director of Maintenance on 5/15/19 from 1:45 p.m.-2:20 p.m., the following was observed: 1. 200 Hallway: a. In Room 201 by bed 1, there was an extension cord wrapped around the privacy curtain with a phone charger plugged into the extension cord and the wall was gouged. There was one resident who resided in the room. 1) Immediate actions taken for those residents identified: Room 201 – Cords were removed and wall repaired. Room 210 – Marred closet door was repaired, brown substance removed from wall and wall repaired. Room 220 – Marred door frame and wall was repaired. Ceiling, vent and personal fan were cleaned. Room 222 – White spots on the floor were cleaned, lime and rust on faucet and rust marks on toilet removed. Room 228 – Gouges on wall and door were repaired, bathroom vent cleaned, lime removed around faucet, baseboard under sink b. In Room 210, the closet door was marred, had peeled paint and a dried brown substance on the doors, there were holes on the bedroom walls. There were two residents who resided in the room. c. Room 220 had a marred metal door frame, marred wall and a dirty ceiling vent in the bathroom. The resident's personal fan was on and had visible debris that came out of the fan cover. There were three residents who shared the bathroom and two residents who resided in the room. d. In Room 222's bathroom, there were white spots on the walls (soap residue), lime and rust on the faucet and rust marks in the toilet. There were four residents who shared the bathroom. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 108 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG e. In Room 228's bathroom, the walls were gouged, rust stains in the toilet, the ceiling vent had a build of dust and the door was gouged. There were two residents who shared the bathroom. 2. 300 Hallway: a. In Room 301, the resident's personal fan had a build up of visible dust. There were two residents who resided in the room. b. In Room 302's bathroom, the caulk around the sink had a yellow discolor. There were two residents who shared the bathroom. c. In Room 307, the walls were marred behind the head of the bed and the bathroom walls had chipped paint. There were two residents who resided in the room and shared the bathroom. d. In Room 308, the privacy curtain did not go all the way around bed 2, the baseboard had chipped paint, the wall in the bedroom was marred and there was not a toilet paper holder in the bathroom. There were two residents who resided in the room and shared the bathroom. e. Room 331's carpet was stained by the closet, the edge of the cove base was torn and jagged, the walls were marred, and the bathroom door frame was marred and had chipped paint. There Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE repaired. Room 232 – Door and closet gouges were repaired, bathroom vent cleaned, lime removed around faucet, baseboard under sink repaired. Room 301 – Personal fan cleaned. Room 302 – Caulk replaced around sink Room 307 – Wall behind bed and bathroom repaired. Room 308 – Privacy curtain repaired, baseboard re-painted, toilet paper holder replaced, marred wall repaired. Room 331 – Stained carpet edge and cove base repaired, marred walls and marred bathroom door frame repaired. Room 313 – Tube feeding pole cleaned, light bulb replaced in bathroom, rust stains removed from sink and toilet, transitional carpet strip replaced. Room 314 – Lime build up on faucet removed, caulking replaced around mirror. Room 318 – Toilet and sink stains removed. Room 415 – Door frame repaired, and bathroom door repaired Room 416 – Bathroom counter tops cleaned, and walls repaired. Room 433 – Walls repaired, bathroom walls repaired, bathroom floor repaired. Room 436 – Bathroom toilet white discoloration cleaned from base. f. In Room 232, the room door and closet door were gouged, the bathroom's ceiling vent had a build up of dust, lime around the facet, the baseboard under the sink was pushed in and had part of it missing. There were three residents who shared the bathroom, and two residents who resided in the room. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 2) How the facility identified KV9P11 Facility ID: 000076 If continuation sheet Page 109 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG were two residents who resided in the room and shared the bathroom. (X5) COMPLETION DATE 3) Measures put into place/ System changes: All staff will be educated on the use of the Maintenance Request Form by the DON/designee. Rounds will be completed at least 5 days per week by managers and they will complete a Maintenance Request Form as needed. Items needing repaired will be reviewed daily in the morning meeting. The Administrator will review the Maintenance Requests daily with the Maintenance Department to ensure repairs are completed. The Administrator/designee will complete the Environment Quality Assurance Worksheet on 5 rooms weekly x 8 weeks and monthly ongoing. The Maintenance Director will be responsible for compliance. g. In Room 314's bathroom, there was lime around the facet and the caulking was cracked around the mirror. There was one resident who resided in the room. h. Room 318's toilet and sink had rust stains. There was one resident who resided in the room. 3. 400 Hallway: a. Room 415's door frame had chipped paint and was marred, the bathroom door was marred. There was one resident who resided in the room. b. Room 416's bathroom had a dried white substance on the countertop and the walls had chipped paint. There was one resident who resided in the room. c. Room 433 had marred walls in the room and in the bathroom. The floor was discolored and had water damage around the toilet. There was one resident who resided in the room. 4) How the corrective actions will be monitored: The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated d. Room 436's bathroom toilet had a white discoloration around the base. There was one resident who resided in the room. Interview with Director of Maintenance at the end of the tour, indicated the above was in need of Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) other residents: All residents who reside in the facility have the potential to be affected by the alleged deficient practice. Audit of room repairs will be completed. f. In Room 313, the tube feeding pole had a dried substance on it, the light was burned out in the bathroom above the toilet, there were rust stains in the toilet and sink, and the transitional carpet strip was missing at the door's entrance. There was one resident who resided in the room. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY KV9P11 Facility ID: 000076 If continuation sheet Page 110 of 111 06/27/2019 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 155156 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 05/20/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 1101 E COOLSPRING AVE MICHIGAN CITY, IN 46360 APERION CARE ARBORS MICHIGAN CITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG (X3) DATE SURVEY repair or cleaning. The employees were to have written out work orders and placed them in the box in the "Employee Information Center". PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 1.Date of compliance: 6/12/19 This Federal Tag relates to Complaint IN00294151 3.1-19(f) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KV9P11 Facility ID: 000076 If continuation sheet Page 111 of 111