07/25/2019 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 155064 OMB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 Complaint IN00296899. F 0000 Complaint IN00296899 -Unsubstantiated due to lack of evidence. Survey dates: June 11, 12, 13, 14, 17, 18, 19, 20 and 21, 2019. Facility number: 000025 Provider number: 155064 AIM number: 100274850 Census Bed Type: SNF/NF: 64 SNF: 9 Total: 73 Census Payor Type: Medicare: 8 Medicaid: 60 Other: 5 Total: 73 These deficiencies reflect State Findings cited in accordance with 410 IAC 16.2-3.1. Quality Review was completed on July 2, 2019. 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, 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 7SCR11 000025 Page 1 of 129 FORM CMS-2567(02-99) Previous Versions Obsolete 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 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 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, interview and record review, the facility failed to ensure a smoke-free campus for 2 of 2 resident's reviewed for smoking (Resident 3 and 45), failed to ensure a cognitively FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0550 07/21/2019 12:00:00A F 550 The facility requests paper compliance for this citation. 7SCR11 Facility ID: 000025 If continuation sheet Page 2 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG impaired resident was properly clothed during a dancing activity with members of the opposite sex (Resident 4, 19, 28 & 65 ) for 4 of 6 residents reviewed for activities and failed to ensure a resident was free of food stained clothing (Resident 16) for 1 of 20 residents who resided on the Harmony Unit. The facility also failed to provide a dignified clean and odor free rooms for 6 of 20 residents who resided on the Harmony Behavior Unit (Residents 10, 33, 53, 54, 57 and 59). (X5) COMPLETION 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. Upon entrance to the facility, on 6/11/19 at 10:15 a.m., Resident 45 was observed standing in a parking lot off the facility grounds with a walker and smoking a cigarette. A sign by the main entrance indicated the facility was a smoke-free campus. 1.Immediate actions taken for those residents identified: On 6/12/19 at 9:52 a.m., the Minimum Data Set (MDS) Coordinator was observed standing outside the south end 300 hallway smoking a cigarette. She was approximately 6 feet from the door, a faint smell of smoke could be smelled just inside the door by Room 301. Issue 1) The facility has transitioned to a smoking facility. Resident # 3 and # 45 were provided a designated smoking area. Issue2) Resident #4 was provided appropriate support garments. Behavior monitoring, and plan of care reviewed. Resident currently resides outside facility Psychiatrist, Primary care physician and psychologist notified. Resident # 19, #65, and #28 were interviewed by social services with no noted recollection of the event. Issue 3) Resident #16 clothes were changed. Residents clothing was inspected for stains and returned to laundry for washing. On 6/12/19 at 9:55 a.m., a "No Smoking within 15 feet of the Facility" sign was observed by the employee entrance, across from the time clock. On 6/12/19 at 10:01 a.m., cigarette butts were observed on the ground outside the back door and a "Smokers Outpost" (an ashtray with a long neck and a small hole at the top to deposit cigarette butts) was at the end of the sidewalk by the bushes. On 6/13/19 at 10:01 p.m., QMA 3 and LPN 4 were observed sitting on a parking cement block in the Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This Plan of Correction is the center's credible allegation of compliance. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 3 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG front of the building smoking cigarettes. During an interview, on 6/12/19 at 9:54 a.m., the Executive Director indicated indicated residents leave with family or walk off the property to smoke if deemed safe, the campus is considered smoke-free and there are no designated areas for smoking on the premises. During an interview, on 6/12/19 at 10:00 a.m., the MDS Coordinator indicated as long as staff was 8 feet from the doors, they were permitted to smoke behind the building; however, resident's were not able to smoke on the property and had to sign out and leave the facility grounds. Resident's were made aware of the smoking policy upon admission (X5) COMPLETION DATE 1.How the facility identified other residents: Any resident that wanted to smoke had the potential to be affected. Any resident present in the Activity Room on the Harmony Unit on 6/11/19 at 10:47am had the potential to be affected, however no adverse outcome was identified. Any resident with stained clothing had the potential to be affected, however no negative outcome identified. Any resident utilizing the Harmony Quiet Room had the potential to be affected however none were identified to have had a negative outcome. Any resident that resided in room 129 had the potential to be affected, however no negative During an interview, on 6/13/19 at 11:14 a.m., Resident 45 indicated she was required to sign out of the building, leave the property and go across the drive way to a parking lot where two orange lines were painted on the ground and to be in compliance with the facility policy she could only smoke behind those lines. During an interview, on 6/13/19 at 10:57 p.m., QMA 3 indicated the facility was a smoke-free campus, there was not to be any smoking on the property and he should not have been smoking in front of the building. During an interview, on 6/18/19 at 4:05 p.m., the Executive Director indicated all residents, upon admission, were educated regarding the smoking policy and all staff, upon hire, were educated regarding the smoking policy. No staff or Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Family was notified of clothing need. Issue 4) The Harmony Quiet Room floor was stripped and waxed. Two love seats were discarded. The bathroom in the Quiet Room was stripped and waxed. The identified light was repaired and remains functional. Issue #5) Harmony room 129. Resident #54 was moved to another room. Room 129 bathroom and room were stripped and waxed. On 6/18/19 at 1:05 p.m., Resident 3 was observed standing in the front yard by a tree, smoking a cigarette. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 4 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG residents should be smoking on the facility grounds and the facility was in the process of re-educating all the staff regarding the smoking policy. (X5) COMPLETION DATE 1.Measures put into place/ System changes: Staff and residents were educated on Facility Smoking Policy. Housekeeping staff/Floor Tech will monitor Harmony Unit at least twice daily for needed sanitation. Education provided to facility staff on behavior management techniques. Those residents identified to have behaviors will be reviewed weekly in Comprehensive Clinical review, weekly Behavior Management meetings, and daily during regular scheduled department meeting. Residents will be observed daily for appropriate, dignified clean clothing during routine facility rounding. Identified issues will be addressed timely. 2. On 6/11/19 at 10:47 a.m., Residents 4, 19, 28 and 65 were observed in the Activity room on the Harmony Unit. Resident 4 was dancing next to Resident 19, and they were touching each other. Resident 4 did not appear to be wearing female support garments, specifically a bra, while she was dancing as indicated by her large breasts dangling and moving, unencumbered under her t-shirt, while she was dancing with a male resident, Resident 19. Resident 65 indicated to Resident 28 she was "hot" and Resident 65 wanted Resident 28 to give him a lap dance. 1.How the corrective actions will be monitored The record for Resident 4 was reviewed on 6/18/19 at 3:09 p.m. Diagnoses included, but were not limited to, Diabetes Mellitus without complications type 2, major depressive disorder, Alzheimer's disease, cognitive communication deficit, delusional disorders and anxiety disorder. Dignity rounds will be completed by Activities Director with Administrative oversight at least 3x/week at varied times to include all three shifts to ensure dignity is maintained, including but not limited to sanitation/cleanliness, appropriate dignified dress; smoking privileges provided. The record for Resident 19 was reviewed on 6/17/19 at 4:41 p.m. Diagnoses included, but were not limited to, dementia with behavioral Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) outcome was identified. A current facility policy, titled "Smoking Safety," revised on 1/22/19, received from the Assistant Director of Nursing on 6/19/19 at 1:51 p.m., indicated "...If smoking is allowed at this facility, the facility will designate areas approved for smoking by residents, visitors and staff. Smoking includes the use of electronic cigarettes. The designated area(s) will be outside in accordance with state/local standards. Designated Smoking Areas for this facility are as follows: Residents: [this area is blank] Staff: [this area is blank]...." FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 5 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 disturbance, diabetes mellitus, major depressive disorder and gastro-esophageal reflux disease (GERD). PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Behaviors monitored daily during stand-up meeting, weekly during Comprehensive Clinical Review and Behavioral Management meeting. . The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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. A care plan, dated 1/17/19, indicated the resident made gestures towards other females such as trying to hold hands or patting them on the knee with a goal of being easily redirected if tried to make a romantic gesture towards a female. The interventions included, but were not limited to, staff to move away from females when trying to hold hands or pat their knees. 3. During an observation, on 6/11/19 at 10:42 a.m., Resident 16 was sitting up in his wheelchair in the activity room and his shirt and pants had stains all over them. During an observation, on 06/11/19 at 12:31 p.m., the resident was sitting up in his wheelchair in the hallway and his shirt and pants had stains all over them. 1.Date of compliance: 7-21-19 During an observation, on 6/17/19 at 10:18 a.m., the resident was sitting up in his wheelchair and had on long gray pants with multiple stains all over them. During an observation, on 6/18/19 at 1:33 p.m., the resident was sitting up in his wheelchair in his room, he had on green sweat pants with food pieces on the upper left side of his pants. During an observation, on 6/19/19 at 2:04 p.m., with the Assistant Director of Nursing (ADON), the resident was sitting up in his wheelchair in the television/quiet room and had food pieces on his shirt and pants. The ADON indicated the resident would be taken care of right away. The record for Resident 16 was reviewed on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 6 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 6/13/19 at 1:43 p.m. Diagnoses included, but were not limited to, cerebral infarction, paralytic syndrome affecting the left non dominant side and lack of coordination. A care plan, dated 1/19/19, indicated the resident had an ADL (activities of daily living) self care deficit related to paralysis. The interventions included, but were not limited to, the resident required extensive assistance by one staff to dress, the resident required extensive assistance by one staff to eat and the resident required extensive assistance by one staff with bathing/showering. 4. Harmony Quite Room: Before entering the room, there was a pungent urine odor. There were 5 residents siting in the room (Resident 10, 53, 33, 57, and 59). There were 2 love seats that were worn and stained and residents were sitting on them. The floor was sticky and shoes stuck to the floor. When the bathroom door was opened a foul, strong urine odor was present. The light in the bathroom did not work. On 6/11/19 at 1:45 p.m., an environmental tour was conducted with the Administrator, the Regional Executive Director, the Regional Nurse Consultant and the Director of Nursing. The Regional Executive director indicated the Harmony quite room did have a strong/foul urine odor and residents were present in the room. 5. Harmony Room 129: There was a pungent smell of urine outside the entry door and upon entering the room. The floor by the entry and bathroom was sticky, and reeked of urine. Resident 54 was in bed B. An admission packet, received from the Executive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 7 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 Director during the entrance conference, updated in 2018 indicated the Resident Rights included the right to be treated with respect and dignity and the right to receive services in the facility with reasonable accommodation of the resident's needs and the right to a safe, clean, comfortable and homelike, environment. 3.1-3(t) F 0561 SS=D Bldg. 00 483.10(f)(1)-(3)(8) Self-Determination §483.10(f) Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. §483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. §483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. §483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility. §483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 8 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 not interfere with the rights of other residents in the facility. Based on observation, interview and record review, the facility failed to honor a resident's request for a preferred food and failed to provide a resident with alternate food for 2 of 6 residents observed for dining in the Harmony unit male dining room. (Residents 23 and 57) F 0561 07/21/2019 12:00:00A F 561 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. During an observation of the Harmony Unit dining room for males, on 6/11/19 at 12:55 p.m. , Resident 57 was eating the food from Resident 23's plate. CNA 9 removed the plate from Resident 23 while he was still eating and did not offer him any more food. Then Resident 23 requested a peanut butter sandwich and CNA 9 indicated she would get the sandwich. CNA 9 left the male dining room, went to the female dining room and did not get Resident 23 a peanut butter sandwich and did not provide Resident 57 with more food. 1.Immediate actions taken for those residents identified: During an interview, on 6/11/19 at 1:18 p.m., CNA 9 indicated she didn't have time to get the peanut butter sandwich and indicated Resident 57 had also requested a sandwich but it would be like getting them seconds and she was serving the other residents. Resident #23 was provided with a peanut butter sandwich. Resident #57 was provided with a sandwich. The record for Resident 23 was reviewed on 6/21/19 at 10:30 a.m. Diagnoses included, but were not limited to, depression and hypertension. 1.How the facility identified other residents: An MDS (minimum data set) assessment completed on 4/18/19, indicated the resident had no swallowing disorder and needed supervision of oversight, encouragement and cueing during meals. Any resident requesting a preferred food or alternate choice had the potential to be affected however no other resident was identified to have a concern. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 9 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 57 was reviewed on 6/13/19 at 1:07 p.m. Diagnoses included, but were not limited to, type 2 diabetes, cerebral infarct due to embolism of the left middle cerebral artery and cognitive communication deficit. 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 was re educated on Self-Determination. Facility will monitor for alternate food choices being offered and resident satisfaction of receiving preferred food choice when requested. At least one resident meal will be observed daily for observation to include all three meals on weekly basis. An MDS assessment, completed on 5/20/19, indicated the resident had no swallowing disorder and needed supervision of oversight, encouragement and cueing during meals. An admission packet, received from the Executive Director during the entrance conference and updated in 2018, indicated the Resident Rights included the right to self determination and the facility must promote and facilitate self determination through support of the residents' choices including the right to make choices about aspects of life in the facility which are significant to the resident. 4) How the corrective actions will be monitored The responsible party for this corrective action is the Executive Director/Director of Nursing/Designee. Self Determination rounds will be made at least 3 times weekly to ensure food choices and alternate choices are being offered. 3.1-3(u)(3) The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 10 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 5) Date of compliance: 7-21-19 F 0580 SS=E 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 11 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 or State law or regulations as specified in paragraph (e)(10) of this section. (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 interview and record review, the facility failed to notify the physician of significant weight changes for 4 of 5 residents reviewed for nutrition (Residents 16, 19, 59 and 62). F 0580 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. The record for Resident 16 was reviewed on 6/13/19 at 1:43 p.m. Diagnoses included, but were not limited to, cerebral infarction, paralytic syndrome affecting the left non dominant side and vitamin deficiency. A physician order, dated 1/18/19, indicated a diet of NAS (no added salt), mechanical soft texture, may have double portions and nectar consistency for fluids. The resident had the following weights: a. 1/17/19 144.2 pounds b. 2/20/19 135. 2 pounds- a significant weight loss of 6.24% weight loss in one month. Event ID: 07/21/2019 12:00:00A The facility requests paper compliance for this citation. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete F580 Notify of Changes 1) Immediate actions taken for those residents identified: 7SCR11 Facility ID: 000025 If continuation sheet Page 12 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 2) How the facility identified other residents: Any resident residing in the facility had the potential to be affected. Weight audit was conducted of current residents. 24-hour summary was reviewed for the previous 7 days to determine any resident change of condition. Any identified issues were reported to primary physician and resident representative. During an interview, on 6/18/19 at 4:04 p.m., the ADON (Assistant Director of Nursing) indicated there was no documentation of the physician being notified of the resident's significant weight loss. 2. The record for Resident 19 was reviewed on 6/17/19 at 4:41 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, diabetes mellitus, major depressive disorder and gastro-esophageal reflux disease (GERD). 3) Measures put into place/ System changes: Nursing staff were re-educated on the component of F-tag 580 and the need of timely notification of a resident’s representative and primary care physician regarding changes of condition. Nursing staff will utilize the 24-hour Summary to identify residents that have experienced a change of condition. Weights will be reviewed during scheduled morning meeting Any identified issues of concern will be immediately addressed A physician's order, dated 2/15/19, indicated a diet of NAS, mechanical soft texture, thin consistency, regular consistency snacks and large portions. The resident had the following weights: a. 1/5/19 169 pounds. b. 2/6/19 159.2 pounds- a significant weight loss of 5.8 % in one month. c. 3/9/19 168.8 pounds-a significant weight gain of 6.0 % in one month. d. 5/4/19 164.8 pounds e. 6/1/19 181.4 pounds a significant weight gain of 10.0 % in one month. A care plan, dated 4/4/18, indicated the resident had GERD. The interventions included, but were not limited to, monitor vital signs and notify physician of significant abnormalities. Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Resident # 16, #19,#59,and #62 were assessed, orders reviewed and primary physician was notified and updated as well as the residents representative. A care plan, dated 1/19/19 and revised on 3/6/19, indicated the resident was unable to consume regular consistency foods and fluids and required a mechanically altered diet. The interventions included, but were not limited to, monitor weight as indicated. FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY 4) How the corrective actions will be monitored: The responsible party for this plan of correction will be the Director of 7SCR11 Facility ID: 000025 If continuation sheet Page 13 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 During an interview, on 6/20/19 at 10:51 a.m. the DON indicated she was not able to locate any documentation of the physician being notified of any of the significant weight changes. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Nursing/designee, who will audit 3 resident records weekly to determine prompt notification of change is occurring Issues identified will be immediately addressed. The results of these audits will be reviewed in Quality Assurance Performance Improvement Meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. 3. The record for Resident 59 was reviewed on 6/18/19 at 3:13 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, major depressive disorder, dysphagia and ulcerative colitis. A physician's order, dated 5/14/19, indicated a mechanical soft diet with thin liquids. 5) Date of compliance: 7-21-19 The resident had the following weights: a. 10/21/18 167.6 pounds b. 11/7/18 155 pounds-a significant weight loss of 7.52% in one month. A care plan, dated 11/14/18, indicated the resident received a regular diet with mechanical texture thin consistency. The interventions included, but were not limited to, monitor weights when available. During an interview, on 6/20/19 at 2:07 p.m., the DON indicated the nurse on duty should notify the physician of the weight loss and document the information in the progress notes. The DON could not find documentation the physician was notified of the significant weight loss for the resident. 4. The record for Resident 62 was reviewed on 06/20/19 at 1:16 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, dementia with behavioral disturbance, muscle weakness, difficulty in walking, need for assistance with personal care, restlessness and agitation, mood affective disorder, traumatic subdural hemorrhage without loss of consciousness. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 14 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 A care plan, dated as revised on 06/11/19, addressed the problem the resident was not able to consume regular consistency foods and required a mechanically altered diet. He was at risk for weight loss due to his recent decline in health and refusal to eat at times. Interventions, initiated on 03/06/19 indicated to monitor and record intake every shift and provide diet as ordered. Interventions, initiated on 06/11/19, indicated to monitor weight as ordered, notify physician of significant weight changes, position for eating and drinking safely and refer to speech therapy for evaluation and treatment as indicated. No other interventions related to weight loss or nutrition were located. A review of Resident 62's weights, indicated the following: a. On 03/06/19 at 1:43 p.m., he weighed 195.6 pounds. b. On 03/25/19 at 7:58 p.m., he weighed 190.4 pounds. c. On 04/30/19 at 5:14 p.m., he weighed 174.8 pounds. d. On 05/04/19 at 10:50 a.m., he weighed 174.6 pounds. e. On 05/21/19 at 8:50 p.m., he weighed 146.0 pounds. f. On 06/08/19 at 2:40 p.m., he weighed 164.6 pounds. No other weights were located in the record. A dietary progress note, dated 05/07/19 at 2:20 p.m., indicated the resident had a weight of 174.6 pounds which was a loss of 8.3% x 30 days. The resident's weight loss might have been related to recently being at the hospital and returning a few days ago. The resident was on Remeron with possible side effect of an increased appetite. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 15 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 was started on a house supplement three times a day on 04/08/19, at times would refuse it and to continue with the supplement at this time. The resident was noted to have behaviors and was looking for new placement. A dietary progress note, dated 06/13/19 at 11:07 a.m., indicted the resident had a weight of 164.6 pounds which was a loss of 15.8 % x 90 days and was a significant weight loss. The weight loss might be contributed to a recent hospitalization. He was started on Remeron on 05/20/19 to help increase his appetite and started on a house supplement three times a day on 05/23/19. The resident fell on 05/09/19, 05/19/19 and 05/23/19. A diagnosis of Alzheimer's was noted, may see a decline with the disease progression and to clarify house supplement at 90 ml (milliliters) and to increase to four times a day. No documentation the resident's physician was notify of the weight loss or rapid weight gain was located. During an interview, on 06/20/19 at 1:15 p.m., the DON indicated according to the facility policy, residents were to be weighed weekly x 4 weeks upon admission and it was not clear on why this did not happen for Resident 62. If a large weight difference was noticed, the resident should have been reweighed. The nurse who worked when the weight was obtained should have notified the physician and should have documented the notification in the progress notes. Weight gains should also be reweighed and the physician notified. A current policy, titled "Physician-Family Notification-Change in Condition", revised 11/13/18 and received from the DON on 6/20/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 16 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 4:00 p.m., indicated, "To ensure that medical care problems are communicated to the attending physician or authorized designee...in a timely, efficient and effective manner...The facility will inform the resident; consult with the resident's physician or authorized designee...when there is...A significant change in the resident's physical, mental, or psychosocial status...." 3.1-5(a)(2) F 0602 SS=D Bldg. 00 483.12 Free from Misappropriation/Exploitation §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Based on interview and record review, the facility failed to ensure resident's were protected from misappropriate of medications for 2 of 2 resident's reviewed for misappropriation of medications (Residents 10 and 9). F 0602 07/21/2019 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. A Facility Reported Incident (FRI), dated 3/25/19, indicated the facility was contacted by the local police department to report LPN 1 was taken into custody for an unrelated matter and during routine procedures, was found to be in possession of a medication (Haldol) belonging to Resident 10. 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 A "[Name of police department] Supplemental Report," dated 3/25/19, indicated LPN was found FORM CMS-2567(02-99) Previous Versions Obsolete F 602 Misappropriation Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 17 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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) to be in possession of a bottle of liquid Haldol in the name of Resident 10. required by the provisions of federal and state law. The record for Resident 10 was reviewed on 06/13/19 at 2:32 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, major depressive disorder, psychotic disorder with delusions due to known physiological condition, restlessness and agitation, anxiety disorder and unspecified dementia without behavioral disturbance. 1.Immediate actions taken for those residents identified: 2) How the facility identified other resident: The "Follow-Up" section of the FRI, dated 3/25/19. indicated the facility had conducted an interview with LPN 1 on 3/28/19. During that interview, she had indicated she took the medication belonging to Resident 10. Any resident had the potential to be affected but there were no other residents identified. 3) Measures put into place/ System changes: 2. A Facility Reported Incident (FRI), dated 3/25/19, indicated the facility was contacted the local police department to report LPN 1 was taken into custody for an unrelated matter and during routine procedures, was found to be in possession of a medication Lotrisone cream, later identified to belong to Resident 9. All staff in service was conducted on abuse prevention and reporting. Nursing staff was provided reeducation on the handling of discontinued medications per facility policy. Nursing staff was provided reeducation on the the facility policy for returning medications to the pharmacy. The record for Resident 9 was reviewed on 6/19/19 at 9:30 a.m. Diagnoses included, but were not limited to, major depressive disorder, rheumatoid arthritis, unspecified dementia without behavioral disturbance and Diabetes Mellitus type II. A Physician's order, dated 2/6/19, indicated Lotrisone (steroid and antifungal) cream 1-0.05% Event ID: DATE Investigation was completed on both of these residents and reported to the appropriate state agencies. Medications were reviewed for both residents. A Physician's order, dated 3/2/19, indicated 5 mg (milligrams) of Haldol every 8 hours as needed for agitation. The order was discontinued on 3/6/19. None of the medication was administered to the resident. FORM CMS-2567(02-99) Previous Versions Obsolete (X5) COMPLETION 7SCR11 Facility ID: 000025 If continuation sheet Page 18 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 behind left ear every shift for a rash for 7 days until finished. 4) How the corrective actions will be monitored: The "Follow-Up" section of the FRI, dated 3/25/19. indicated the facility had conducted an interview with LPN 1 on 3/28/19. During that interview, she had indicated she was unaware of how the medication belonging to Resident 9 had gotten into the purse. Responsible party for this POC will be DON/Designee who will 3 times weekly monitor drug disposition records for appropriate drug disposition. The results of these audits will be reviewed in QAPI monthly for 6 months or until 100% compliance is achieved for 3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated During an interview, on 6/18/19 at 4:13 p.m., the Director of Nursing (DON) indicated the discontinued medications and empty medication cards were supposed to be removed from the medication cart, placed into the medication room to be sent back to the pharmacy and a disposition sheet completed with one being sent to the pharmacy and the facility to keep a carbon copy. During an interview, on 6/19/19 9:50 a.m., the Regional Nurse Consultant indicated the nurse was terminated, the policies were reviewed and no changes were made. A current facility policy, titled "Discontinued Medications Policy," undated, received from the DON on 6/17/19 at 3:30 p.m., indicated "When medications are discontinued by a prescriber...the medications are marked as 'discontinued' and destroyed, or, if the packages are unopened, returned to [Pharmacy] within 48 hours...B. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by [name of Pharmacy]. Medications are removed from the medication cart immediately upon receipt of an order to discontinue (to avoid inadvertent administration). C. Discontinued medications that are unopened (such as unit-dose packages or sealed containers) may be returned to [Pharmacy] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5) Date of compliance: 7/21/19 7SCR11 Facility ID: 000025 If continuation sheet Page 19 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 in accordance with the Medication Return policy. Discontinued medications not returned to the pharmacy are destroyed in accordance with the Medication Destruction policy...." A current facility policy, titled "Returning Medications to [Name of Pharmacy] Policy," undated, received from the Regional Nurse Consultant on 6/19/19 at 9:49 a.m., indicated "...B. For each medication returned, an entry is made on the (medication disposition) form. The entry includes the date, medication name and strength, quantity, and prescription number. C. Completed (medication disposition) forms are kept by the facility...." A current facility policy, titled "Abuse Prevention and Reporting-Indiana," revised last 1/22/19, received from the Executive Director on 6/18/19 3:35 p.m., indicated "Guidelines: The resident has the right to be free from abuse, neglect, misappropriate of resident property, and exploitation...Orientation and Training of Employees...During orientation of new employees, the facility will cover at least the following topics:...What constitutes abuse, neglect, exploitation, mistreatment and misappropriation of resident property...." 3.1-28(a) F 0606 SS=D Bldg. 00 483.12((a)(3)(4) Not Employ/Engage Staff w/ Adverse Actions §483.12(a) The facility must§483.12(a)(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 20 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. Based on record review and interview, the facility failed to ensure staff were not hired when previous findings of resident abuse/misappropriation were identified in the employee screening process for 1 of 9 staff hired in 2019 (LPN 10). F 0606 07/21/2019 12:00:00A F 606 The facility requests paper compliance for this citation. This Plan of Correction is the center's credible allegation of compliance. Finding includes; 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. During the employee records review, on 6/14/19 at 1:50 p.m., LPN 10 did not have a current nursing license in the facility staff license book. During an interview on 6/14/19 at 2:16 p.m., the Human Resource (HR) staff indicated LPN 10's license expired on 10/31/18 and she had a status of being valid to practice while she was on probation due to being reviewed for fraud or material deception. The HR staff indicated she found out the same day of this interview the LPN's license was suspended on June 3 and was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1) Immediate actions taken for 7SCR11 Facility ID: 000025 If continuation sheet Page 21 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 no longer valid to practice and LPN 10 had worked on June 3, 4, 5, 6, 9 and 10 without a valid nursing license. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE those residents identified: No residents were identified A time card report from Sunday June 2, 2019 through Saturday June 15, 2019, verified LPN 10 had clocked in and worked the following dates: a. 6/3/19 from 10:01 p.m. through 8:31 a.m. b. 6/4/19 10:01 p.m. through 9:26 a.m. c. 6/5/19 at 10:38 p.m. through 7:05 a.m. d. 6/6/19 at 10:22 p.m. through 6:41 a.m. e. 6/8/19 at 10:01 p.m. through 3:26 p.m. f. 6/9/19 at 10:37 p.m. through 7:55 p.m. 2) How the facility identified other resident: Any resident had the potential to be affected on the days the nurse worked. However, none were identified. An Indiana State Board of Nursing finding, filed March 4, 2019, and received from the facility's employee record, indicated LPN 10 was not to work in an unsupervised setting in a nursing capacity, her current employer was to sign and return a copy of her Probation order within 10 days and the employer was to submit quarterly reports to the Board. The finding indicated LPN 10 had misappropriated a resident's property. 3) Measures put into place/ System changes: Nurse is no longer employed with the facility. A complete audit of all employee files was conducted and no other employees were identified to have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by court of law. No other employees were identified to have any disciplinary action against them in regard to abuse, neglect, exploitation, misappropriation of property or mistreatment of a resident. Facility will continue to complete background checks and licensing verification upon hire. Facility will audit employee licenses and During an interview on 6/19/19 at 10:26 a.m., with HR staff, the Executive Director(ED) and the Regional Nurse Consultant present, the ED indicated LPN 10 was fired from the facility for smoking an electronic cigarette (vaping) in the facility and then was hired back with the assumption she would be monitored for vaping by a collaborative effort from the ED and DON. The HR staff indicated LPN 10 was first hired on 11/1/16, had resigned on 10/30/18 for vaping in the facility, then was rehired on 12/3/18. The ED indicated she was not aware of the reason the LPN's license was on probation and then suspended until she read from the employee file during the interview. The LPN was on probation for writing a medication order without FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 22 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG authorization from a medical professional, obtained the medication from another resident and gave it to the resident who she wrote the medication order for without authorization. The incident took place at a different facility on 6/13/16. The ED indicated she would need to review the abuse policy and the employee file to determine if LPN 10 should have been hired by the facility. (X5) COMPLETION DATE 4) How the corrective actions will be monitored: The responsible party for auditing employee licenses and certifications will be DON/Designee. Audits will be performed twice monthly. The results of these audits will be reviewed in QAPI monthly for 6 months or until 100% compliance is achieved for 3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated A current policy, titled " Abuse Prevention and Reporting-Indiana" dated 11/28/16 and received from the ED on 6/18/19 at 3:35 p.m., indicated, "...The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation...Pre-Employment Screening of Potential Employees...This facility will not knowingly employ any individual convicted of resident abuse, neglect, exploitation, mistreatment, or misappropriation of resident property...This facility will not knowingly hire any staff with a disciplinary action in effect against their license by a state licensing body results from a finding of abuse, neglect, exploitation, mistreatment or misappropriation of resident property...all potential employees will be screened for a history of abuse, neglect or mistreatment of patients during the hiring process. It will consist of, but is not limited to the following...State licensing authorities...Reference checks from previous/current employees...criminal background checks of all professional staff...." Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) certifications monthly x2. During an interview, on 6/19/19 at 11:39 a.m., the ED indicated LPN 10 should not have been hired by the facility due to the action under the LPN's license which constitutes misappropriation of a resident's property which is considered abuse and is prohibited by the facility's abuse policy and compliance program. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 5) Date of compliance: 7/21/19 7SCR11 Facility ID: 000025 If continuation sheet Page 23 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 3.1-28(b)(1)(B) 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 interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed regarding antipsychotic and anticoagulant medications for 2 of 28 resident's reviewed for resident assessment (Resident 18 and 13). F 0641 This Plan of Correction is the center's credible allegation of compliance. 1. The record for Resident 18 was reviewed on 06/14/19 at 11:06 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia in other diseases elsewhere without behavioral disturbance and dementia in other diseases classified elsewhere with behavioral disturbance. 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. A Quarterly MDS assessment, dated 4/10/19, indicated the resident had received an antipsychotic medication for 7 out of 7 days during the look-back period. A review of the Physician's orders for Resident 18 did not indicate the resident had received an antipsychotic medication. 1.Immediate actions taken for those residents identified: Resident #18 and #14 was assessed and an MDS modification was completed. During an interview, on 6/18/19 at 3:12 p.m., the MDS Coordinator indicated the resident did not receive an antipsychotic medication. 2. The record for Resident 13 was reviewed on 06/14/19 at 9:25 a.m. Diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, anxiety disorder, depressive Event ID: 07/21/2019 12:00:00A The facility requests paper compliance for this citation. Finding includes: FORM CMS-2567(02-99) Previous Versions Obsolete F 641 Accuracy of Assessments 1.How the facility identified other residents: Any resident who had an MDS completed had the 7SCR11 Facility ID: 000025 If continuation sheet Page 24 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 disorder and schizoaffective disorder. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE potential to be affected, however no others were identified. A review of assessments completed over the last quarter was completed to determine Psychotropic and Anticoagulant medications were properly coded. Any identified areas were corrected. A MDS assessment, dated 03/27/19, indicated the resident received an anticoagulant medication 7 of the 7 days during the look back period. A review of the physician's orders did not indicate the resident received an anticoagulant. During an interview, on 06/18/19 at 3:12 p.m., the MDS Coordinator indicated the resident did not receive an anticoagulant during the look back period and her MDS was not accurate. 1.Measures put into place/ System changes: An in-service was given to the interdisciplinary team on coding the RAI’s correctly which included Psychotropic and Anticoagulant medications A current facility policy, titled "Resident MDS Assessment And Care Planning Standard" dated 06/05/16 and received from the MDS Coordinator on 06/18/19 at 4:01 p.m., indicated "...Quality Measure are reviewed for accuracy of MDS answers and reviewed at QA&A meetings for quality improvement areas. Printed and reviewed at a minimum monthly for review with IDT members and QA Committee...." 1.How the corrective actions will be monitored: The Director of Nursing/designee will review/audit two resident records each week to ensure compliance with psychotropic, and anticoagulant submissions. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. 3.1-31(c)(13) 3.1-31(d) 5) Date of compliance: 7-21-19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 25 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER F 0644 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 483.20(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 interview and record review, the facility failed to ensure mental health diagnoses were indicated on the Preadmission Screening and Resident Review (PASARR) Level I (Resident 10, 56 & 70) and failed to follow PASARR Level II recommendations for a dementia work-up (Resident 50) for 4 of 4 residents reviewed for PASARR. F 0644 F 644 Coordination of PASARR and Assessments. The facility requests paper compliance for this citation. Findings include: This Plan of Correction is the center's credible allegation of compliance. 1. The record for Resident 10 was reviewed on 06/13/19 at 2:32 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, major depressive disorder, psychotic disorder with delusions due to known physiological condition, restlessness and agitation, anxiety disorder and unspecified 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 07/21/2019 12:00:00A 7SCR11 Facility ID: 000025 If continuation sheet Page 26 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG dementia without behavioral disturbance. (X5) COMPLETION DATE 1.Immediate actions taken for those residents identified: A new PASSAR for resident #10, # 56 and# 70 was submitted by Social Services. 1.How the facility identified other residents: Residents residing in the facility have the potential to be affected. An audit for appropriate PASRRs has been completed of current residents in the facility by the SSD. Any issues identified related to PASSAR were corrected by social services. 2. The record for Resident 50 was reviewed on 6/13/19 at 3:04 p.m. Diagnoses included, but were not limited to, personality disorder, panic disorder, anxiety disorder, schizoaffective disorder and social phobia. A PASARR ( preadmission screening and resident review) Level II, dated 5/24/19, indicated the recommendations were for the resident to have a psychiatric evaluation and dementia work up. 1.Measures put into place/ System changes: The Administrator, DON, Social Services and Admissions were educated on the Components of F644- Coordination of PASSAR and Assessments During an interview, on 6/20/19 at 9:38 a.m., the Social Services Director (SSD), indicated there was no information in the electronic record of a psychiatric evaluation or a dementia work up being completed for the resident. The SSD did not know if the psychiatric evaluation or the dementia work up had been scheduled. 3. The record for Resident 56 was reviewed on 06/13/19 at 11:21 a.m. Diagnoses included, but were not limited to, major depressive disorder, a mood disorder due to a known physiological condition with depressive features and delusional disorder. Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) correction is prepared and/or executed solely because it is required by the provisions of federal and state law. The "Indiana Level I Form Preadmission Screen and Resident Review," dated 1/18/19, did not indicated Resident 10 had any "mental health diagnosis" known or suspected and no Level II would be required because the resident did not have any serious mental illnesses. The rational listed on the form indicated, "...The Level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted...." FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 1.How the corrective actions will be monitored: New residents’ history will be reviewed weekly x 6 months by the Director of Nursing or designee to ensure PASRR accuracy level. If a discrepancy is found a new 7SCR11 Facility ID: 000025 If continuation sheet Page 27 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 level 1 PASRR with corrected information will be completed and submitted by Social Service or designee. New orders for psychotropic medications and/or mental status changes will be reviewed \audited weekly in the morning clinical /stand up meeting to identify any psychotropic medication changes and/or mental status changes that would require a new level 1 PASARR to be submitted. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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. A PASARR level I, dated 12/27/18, indicated the resident did not have a serious mental illness. A physician's order, dated 05/07/19, indicated to take 5 mg (milligrams) of fluphenazine (an antipsychotic medication) daily for delusional disorder. An Admission MDS assessment, dated 05/13/19, indicated the resident did not have a serious mental illness which required a PASARR level II. During an interview, on 06/13/19 at 2:40 p.m., the SSD indicated a level II should have been completed due to the resident did have mental health diagnoses. 4. The record for Resident 70 was reviewed on 06/13/19 at 1:17 p.m. Diagnoses included, but were not limited to, anxiety disorder, major depressive disorder and unspecified psychosis not due to a substance or known physiological condition. A PASARR level I, dated 11/14/18, indicated the resident's Level I showed low-level behavioral health symptoms which appeared to be situational. The nursing facility should watch her symptoms/behaviors to see if they were improved or resolved within 30-60 days of the screen. If they did not, the nursing facility must submit another Level I which was called a status change. The status change would would decide if a PASARR Level II evaluation for serious mental illness was needed. 5) Date of compliance: 7-21-19 A physician's order, dated 03/06/19, indicated to take Seroquel (an antipsychotic medication) 75 mg three times a day for dementia with behavioral disturbance and unspecified psychosis not due to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 28 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 a substance or known physiological condition. A Quarterly MDS assessment, dated 05/25/19, indicated the resident did not have a serious mental illness which required a PASARR level II. During an interview, on 06/13/19 at 2:40 p.m., the SSD indicated Resident 70's situation did not improve and a new Level I should have been completed. A current policy, titled "Preadmission Screening and Annual Resident Review [PASARR] ", reviewed on 11/17/17 and received from the SSD on 6/19/19 at 4:40 p.m., indicated, "...The facility will care plan and provide the specialized services as indicated in the level II determination. The services will be provided under the direction of the qualified personnel indicated...." A current facility policy, titled "Preadmission Screening and Annual Resident Review" dated 11/28/12 and received from the SSD on 06/13/19 at 3:04 p.m., indicated "...Annually and with any significant change of status, the facility will complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly...." 3.1-16(d)(1)(A) 3.1-16(d)(1)(B) F 0645 SS=D Bldg. 00 483.20(k)(1)-(3) PASARR Screening for MD & ID §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 29 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 §483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k) (3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. §483.20(k)(2) Exceptions. For purposes of this section(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 30 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. §483.20(k)(3) Definition. For purposes of this section(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter. Based on record review and interview, the facility failed to ensure a resident had a PASARR (Preadmission screening and resident review) Level II completed according to the Level I recommendations and to have a Level I completed prior to admission to the facility for 2 of 6 residents reviewed for PASARR (Resident 16 and 59). F 0645 F 645 PASSAR Screening for MD & ID 07/21/2019 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 1. The record for Resident 16 was reviewed on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 31 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG 6/13/19 at 1:43 p.m. Diagnoses included, but were not limited to, cerebral infarction, paralytic syndrome affecting the left non dominant side, psychoactive substance-induced mood disorder, delusional disorder, and hallucinations. During an interview on 6/18/19 at 11:17 a.m., the Social Services Director (SSD) indicated Resident 16's PASARR level II was missed and was not completed. (X5) COMPLETION DATE 1.Immediate actions taken for those residents identified: A new PASSAR for resident #16 and #59 was submitted by Social Services. 2. The Record for Resident 59 was reviewed on 6/18/19 at 3:13 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, major depressive disorder, psychosis not due to known physiological cause and anxiety disorder. 1.How the facility identified other residents: Residents residing in the facility with MD & ID have the potential to be affected. An audit for appropriate PASSARs was completed of current residents in the facility by the SSD. Any issues identified related to PASSAR were corrected by social services. A PASSAR Level I was not located in the electronic record. During an interview, on 6/18/19 at 3:45 p.m., the SSD indicated the resident had left the facility for an inpatient psychiatric facility stay, and he should have had a Level I PASARR complete prior to returning to the facility. A current policy, titled " Preadmission Screening and Annual Resident Review (PASARR) revised on 11/17/17 and received from the SSD on 6/19/19 at 4:40 p.m., indicated, "...It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASARR) screening process (Level I) of all new and readmissions per requirement to determine if the individual meets 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. A PASSAR level I dated 12/17/18 indicated a PASARR Level II must be conducted. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 1.Measures put into place/ System changes: The Administrator, DON, Social Services and Admissions were educated on the Components of F645-PASSAR Screening for MD & ID 1.How the corrective actions 7SCR11 Facility ID: 000025 If continuation sheet Page 32 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Based upon the Level I screen , the facility will not admit and individual with a mental disorder or intellectual disability until the Level II screening process has been competed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. If a provisional admission to the facility is approved via the Level II screen process, the facility will coordinate with the State PASARR representative related to the individual needs of the resident as indicated...The objective of the PASARR process is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified...." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE will be monitored: New residents’ history will be reviewed weekly x 6 months by the Director of Nursing or designee to ensure PASRR accuracy level. If a discrepancy is found a new level 1 PASRR with corrected information will be completed and submitted by Social Service or designee. Any resident that receives new mental illness diagnosis or intellectual disability will have a PASSAR completed. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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. 3.1-16(d)(1) 3.1-16(d)(1)(A) 5) Date of compliance: 7-21-19 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 33 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c) (6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the 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 develop a care plan for a midline Intravenous (IV) catheter and for nutrition for a resident with diabetes mellitus and chronic pancreatitis for 1 of 28 residents reviewed for care plans (Resident 57). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0656 F656 Develop/Implement Comprehensive Care Plan 07/21/2019 12:00:00A The facility request paper compliance for this citation This Plan of Correction is the center's credible allegation of 7SCR11 Facility ID: 000025 If continuation sheet Page 34 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG Finding includes: The record for Resident 57 was reviewed on 6/13/19 at 1:07 p.m. Diagnoses included, but were not limited to, type 2 diabetes, chronic pancreatitis and chronic kidney disease stage 3. The electronic record did not have a care plan for the midline IV, the administration of IV fluids or for diabetes. (X5) COMPLETION DATE 1) Immediate actions taken for those residents identified: Resident #57 no longer has a midline IV catheter. During an interview, on 6/12/19 at 11:02 a.m., RN 11 indicated Resident 57 had a midline catheter in for IV fluid administration. 2) How the facility identified other residents: The facility has determined that any resident presenting with an IV midline catheter has the potential to be affected however no other resident was identified. Audit was conducted to identify those residents with IV midline catheters. Care Plans were reviewed and revised to reflect current plan of care. During an interview, on 6/17/19 at 2:45 p.m., the ADON indicated she could not locate any plan of care for the midline IV catheter. During an interview, on 6/17/19 at 3:45 p.m., the ADON indicated the resident had pertinent diagnoses listed as diabetes and chronic pancreatitis and did not have a care plan for nutrition and usually the care plan would be in place due to the diagnoses. 3) Measures put into place/ System changes: The Regional Nurse Consultant conducted an in-service for the interdisciplinary team to review procedures for development of a comprehensive care plan. New admissions will be reviewed within 24-48 hours of admission to A current policy, titled "Comprehensive Care Plan", revised on 11/17/17 and received from the Regional Nurse Consultant on 6/18/19 at 3:55 p.m., indicated, "...To develop a comprehensive care plan that directs the care team and incorporates the resident's goal, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 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. During an observation, on 6/17/19 at 11:05 a.m., the Resident 57 ambulated to the nurse's desk and showed his IV in his upper right arm and stated he had asked if the IV could be taken out and it was bothering him. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 35 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 and psychosocial well-being...The facility will develop and implement an comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment...A comprehensive care plan must be...prepared by and interdisciplinary team, that includes but is not limited to...A member of food and nutrition services staff...." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE ensure diagnosis are reflective of resident condition and person-centered care plans are initiated. Additionally, all new admissions are reviewed in weekly Comprehensive Clinical Review meeting to ensure the development of person care plans are reflective of resident condition. 4) How the corrective actions will be monitored: The Director of Nursing or designee will randomly review three residents’ records weekly ensure that care plans have been developed that accurately reflect resident condition MDS coordinator will review during scheduled care plan meetings that care plans are current. Any issues will be immediately addressed. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. 3.1-35(a) 3.1-35(b)(1) 5) Date of compliance: 7-21-19 F 0657 SS=D Bldg. 00 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 36 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Based on observation, interview and record review, the facility failed to update care plans for a resident who no longer had an indwelling urinary catheter or an active infection (Resident 20) and who no longer received a medication for insomnia and had a wander guard on her right ankle (Resident 25) for 2 of 28 residents reviewed for care plans. F 0657 F657 Care Plan Timing and Revision (X5) COMPLETION DATE 07/21/2019 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 1. During an interview, on 6/12/19 at 2:12 p.m., Resident 20 was not observed to be in isolation or have an indwelling urinary catheter. The record for Resident 20 was reviewed on Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This 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 7SCR11 Facility ID: 000025 If continuation sheet Page 37 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG 6/13/19 at 2:09 p.m. Diagnoses included, but were not limited to, vascular dementia with behavioral disturbance, spastic hemiplegia affecting left non-dominant side, Diabetes Mellitus type 2, major depressive disorder, anxiety disorder, impulse disorder and pseudobulbar affect disorder. (X5) COMPLETION DATE 1) Immediate actions taken for those residents identified: Resident #20 care plan for urinary catheter was resolved. Resident #25 were assessed and comprehensive person care plans were revised to reflect resolution of wander guard and insomnia medication. 2) How the facility identified other residents: Audit was conducted to determine that those residents that have catheters, wander guards, or receive medication for diagnosis of insomnia have current and updated care plans. Any issue identified was immediately addressed A care plan, dated 11/16/18 and revised on 11/21/18, indicated the resident had an alteration in urinary elimination as evidenced by an indwelling catheter. During an interview, on 6/21/19 at 9:54 a.m., the Director of Nursing indicated the resident did not have a urinary catheter or an infection and the care plan should have been updated. 2. During an observation on 06/13/19 at 11:13 a.m., Resident 25 was sitting in the Main Dining Room, reading a book and talking with a group of other residents who were playing cards. She had a wander guard on her right ankle. Activity staff invited the resident to have her nails painted. 3) Measures put into place/ System changes: The Regional Nurse Consultant conducted an in-service for the interdisciplinary team to review procedures for development of a comprehensive care plan. The MDS coordinator \Director of Nursing will review care plans within 24-48 hours of admission, quarterly, annually and with significant changes.to ensure timely revisions have occurred. Identified areas of concern will be The record for Resident 25 was reviewed on 06/13/19 at 10:59 a.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, generalized anxiety disorder and other specified depressive episodes. A care plan, dated 3/6/19, indicated the resident Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) correction is prepared and/or executed solely because it is required by the provisions of federal and state law. A care plan, dated 12/10/18, indicated the resident had an infection (clostridium difficile colitis, also known as C. diff, is an inflammation of the colon caused by a bacterial infection) and was on antibiotics. Interventions included, but were not limited to, Contact Isolation: wear gowns and masks when changing contaminated linens. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 38 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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) was receiving melatonin (a hormone) related to insomnia. Interventions included, administer sedative/hypnotic medications as ordered by physician. Monitor/document side effects, effectiveness every shift and adverse effects. addressed immediately. During weekly Comprehensive Clinical Review, MDS Coord/Director of nursing director will ensure timely care plan revisions. A "Note to Attending Physician/Prescriber," dated 7/26/18, indicated the melatonin was discontinued. 4) How the corrective actions will be monitored: The Director of Nursing or designee will randomly review five residents’ records weekly to ensure that care plans have been revised to reflect current status. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. A care plan, dated 5/20/19, addressed the resident being an elopement risk/wanderer. Interventions included, assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, monitor for fatigue and weight loss, provide structured activities and Wander guard placed on left ankle. During an interview, on 6/18/19 at 3:48 p.m., the Assistant Director of Nursing indicated the care plan should have been updated once the melatonin was removed. (X5) COMPLETION DATE 5) Date of compliance: 7-21-19 During an interview, on 6/20/19 at 9:00 a.m., the Director of Nursing indicated the wander guard care plan should have been updated. A current facility policy, titled "Comprehensive Care Plan," revised on 11/17/17, received from the Regional Nurse Consultant on 6/18/19 at 3:55 p.m., indicated the care plans are "...Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments...The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving...." 3.1-35(d)(2)(B) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 39 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG F 0660 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 483.21(c)(1)(i)-(ix) Discharge Planning Process §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 40 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 41 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG Based on interview and record review, the facility failed to develop and implement a resident's discharge goals for 1 of 2 residents reviewed for discharge planning (Resident 50). F 0660 F 660D Discharge Planning (X5) COMPLETION DATE 07/21/2019 12:00:00A This Plan of Correction is the center's credible allegation of compliance. During an interview on 6/12/19 at 11:09 a.m., Resident 50 indicated she wanted to live someplace else beside the facility and was from another city. 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. During an interview, on 6/14/19 at 1:06 p.m., the resident indicated she would rather be at a nursing facility in the city she came from or a city close to it. The record was reviewed on 6/13/19 at 3:04 p.m. Diagnoses included, but were not limited to, schizoaffective disorder, mild cognitive impairment, anxiety disorder and social phobia. 1.Immediate actions taken for those residents identified: Care plan was developed that included discharge plan goals for resident # 50. The care plan did not include discharge plans. A social services note, dated 5/2/19, indicated the resident would need time to adjust to the new facility and the staff would continue to encourage the resident to participate with activities of choice. 1.How the facility identified other residents: Facility audit was conducted to determine active residents had discharge plans developed. Any issue identified was addressed. During an interview on 6/18/19 at 3:33 p.m., the Social Services Director (SSD), indicated the resident's daughter would like her to stay long term although the resident would like to live in a less restrictive environment. She indicated when the resident stabilized she could try to get her back to a regular unit at the facility and then to an assisted living facility. She indicated she did not document this information or develop a care plan for the resident to include this information. 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. Finding includes: FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 1.Measures put into place/ System changes Education provided to the IDT on the components of F660, Discharge planning process . 7SCR11 Facility ID: 000025 If continuation sheet Page 42 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG A current policy, titled "Comprehensive Care Plan", revised on 11/17/17 and received from the Regional Nurse Consultant on 6/18/19 at 3:55 p.m., indicated, "...To develop a comprehensive care plan that directs the care team and incorporates the resident's goal, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being...The facility will develop and implement an comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment... Discharge plans in the comprehensive care plan, as appropriate...." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 1.How the corrective actions will be monitored: Responsible party for this plan of correction is the Executive Director/designee who will oversee the audit of 3 residents weekly for the ongoing process of discharge planning. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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. 3.1-35(a) 3.1-35(b)(1) 5) Date of compliance: 7-21-19 483.25 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, interview and record review the facility failed to identify non pressure skin issues for 1 of 1 resident reviewed for skin issues (Resident 13). F 0684 F 684 Quality of Care 07/21/2019 12:00:00A The facility requests paper compliance for this citation. Finding includes: FORM CMS-2567(02-99) Previous Versions Obsolete COMPLETED 06/21/2019 B. WING APERION CARE KOKOMO F 0684 SS=D Bldg. 00 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY This Plan of Correction is the Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 43 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 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. During an observation, on 06/18/19 at 9:14 a.m., the resident was observed with two small scabbed sores on her right upper arm. The record for Resident 13 was reviewed on 06/14/19 at 9:25 a.m. Diagnoses included, but were not limited to, mild intellectual disabilities, generalized anxiety disorder, major depressive disorder and schizoaffective disorder, bipolar type. 1.Immediate actions taken for those residents identified: Resident 13's weekly skin assessments, did not indicate the resident had any open sores on her upper body. Resident # 13’s Plan of Care & Interventions were reviewed and revised related to non-pressure areas. Resident 13's care plans did not indicate a care plan related to open sores on her upper body related to picking at her skin. 1.How the facility identified other residents: During an interview, on 06/18/19 at 10:43 a.m., the Social Service Director (SSD) indicated the resident picked at her skin and it was anxiety related. The resident had stopped for a while and then recently had started back up again due to increased anxiety related to improved mobility and recent talk of being discharged. Current Residents with non-pressure related areas have the potential to be affected by this practice. Center will complete an audit of current Residents with non-pressure areas and update to ensure assessments are current& care plan interventions are in place.    During an interview, on 06/18/19 at 11:14 a.m., the SSD indicated the resident did previously have a care plan related to her picking at her skin; however, it was resolved and should have been opened back up when the resident began picking her skin again. Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) center's credible allegation of compliance. During an interview, on 06/12/19 at 10:27 a.m., Resident 13 indicated she had a habit of picking at her skin. She was observed to have 3 open sores on her upper right chest and multiple small open sores along her right lower arm. FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY 1.Measures put into place/ System changes: 7SCR11 Facility ID: 000025 If continuation sheet Page 44 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 Nursing Staff will be Re-educated on Skin Condition Assessment & Monitoring- Pressure and Non-Pressure Policy & Procedureand care plan revision   During an interview, on 06/18/19 at 1:12 p.m., the Regional Nurse Consultant indicated if a new skin area was observed the nurses should have documented them on the weekly skin assessments. A current facility policy, titled "Skin Condition Assessment & Monitoring-Pressure and Non-Pressure" dated 06/08/18 and received from the Regional Nurse Consultant on 06/18/19 at 3:55 p.m., indicated "...Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications or infection weekly...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. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment...The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care...." 1.How the corrective actions will be monitored: Director of Nursing is the responsible party for this Plan of Correction. Director of Nursing/designee will Audit 3 residents non-pressure related areas weekly to ensure assessments are current and care planned interventions are in place. Audit findings will be presented to the QAA Committee monthly x 6 months. The QAA Committee will review findings and determine the need for further monitoring and/or education per the QAA process. Compliance will be determined based on results of audits. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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. 3.1-37(a) 5)Date of compliance: 7-21-19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 45 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG F 0689 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 483.25(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 did not wander into other resident rooms, implement new interventions for residents after a fall and to ensure potentially harmful metal and pointed edged items were removed from residents who resided on the locked behavior unit for 5 of 5 residents reviewed for accidents (Residents 19, 171, 53, 38 and 62). F 0689 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. During an observation on 6/12/19 at 4:29 p.m., Resident 19 was wandering into other residents' room. During an observation, on 6/13/19 at 2:48 p.m., the resident was lying in bed in another resident's room with his eyes closed. The CNA 12 indicated the resident was in the wrong room and CNA 12 left the resident to sleep in the wrong room. 1.Immediate actions taken for those residents identified: During an observation, on 6/13/19 at 10:03 p.m., the resident was ambulating in the hallway with another male resident and LPN 14 was sitting at the nurse desk. Event ID: 07/21/2019 12:00:00A The facility requests paper compliance for this citation. Finding includes: FORM CMS-2567(02-99) Previous Versions Obsolete F 689E Accidents Hazards Resident # 19 was assessed for wandering. Care plan and interventions revised and updated. Removed bottle openers, knife, 7SCR11 Facility ID: 000025 If continuation sheet Page 46 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG During an observation, on 6/13/19 at 10:28 p.m., the Activity Director walked the resident into the quiet room, left the resident in the room and she walked back out. During an observation, on 6/13/19 at 10:36 p.m., the resident wandered into Resident 4 and 10's shared room, then walked back out. (X5) COMPLETION DATE 2)How the facility identified other residents: Residents identified using the wandering assessment. Those identified to wander will have their care plans reviewed and revised as appropriate. Audit was completed of current residents with falls within last 30 days to ensure care plans and interventions were updated and current. Harmony unit sweep was completed to ensure potentially harmful objects were not kept in resident possession. Residents will be identified thru admission, process, quarterly, annually and with significant change. During an observation, on 6/14/19 at 1:08 p.m., the resident was standing in the hallway with a bandage on his right lower arm which was loose and gauze was dangling down his arm. The record for Resident 19 was reviewed on 6/17/19 at 4:41 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, diabetes mellitus, major depressive disorder and gastro-esophageal reflux disease (GERD). A care plan, dated 9/11/18, indicated the resident had an intrusive wandering problem and poor safety awareness along with standing over others without understanding personal space. The interventions, included, but were not limited to, encourage participation in simple activities, monitor quarterly for least restrictive measures and to observe the resident for thirst, hunger, pain, or need for toileting, provide a safe structured daily routine and environment and observe resident's whereabouts frequently. 1.Measures put into place/ System changes: Education provided on managing behaviors with Dementia residents, and Intrusive Wandering. Staff provided with possible activities to manage difficult resident behaviors and wandering. A progress note, dated 6/13/19 at 5:52 a.m., indicated the resident had intrusive wandering in other clients' rooms and attempted to lay in bed Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) key chain, and any sharp objects were removed from Resident #171. Care Plan reviewed and revised Removed foreign identified in the Earlobe of resident#53 and provided with L earring. Care Plan reviewed and revised. Resident #38and #62 had fall care plans reviewed and revised with updated interventions. During an observation, on 6/13/19 at 10:29 p.m., the resident walked out of the quiet room and back to the nurses station. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 47 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG with other residents. Resident assisted up and encouraged to go to bed with assistance of two staff and the resident got out of bed and continued to intrusive wander. A progress note, dated 6/6/19 at 9:32 a.m., indicated the resident had an unwitnessed fall in another resident's room and was found on the mat beside another resident's bed. A progress note, dated 5/28/19 at 3:19 a.m., indicated the resident had been intrusively wandering into other clients' rooms. A progress note, dated 5/2/19 at 2:44 a.m., indicated the resident was intrusively wandering into other clients' rooms. A progress note, dated 5/2/19 at 11:06 a.m., indicated the resident was in search of his wife and attempts to redirect not successful. The psychiatrist was called and an order for Haldol 5 mg (milligram) one time only was obtained and given to the resident. (X5) COMPLETION DATE 1.How the corrective actions will be monitored: To ensure continued compliance the Director of Nursing/designee will through direct observation, 3 times weekly, ensure the provision of appropriate diversions/re-directions/activities for those residents identified to intrusively wander. Observations will include all three shifts. Audit completed 3 times weekly on accidents/hazards to determine compliance with care plan revision and intervention implementation. A progress note, dated 4/26/19 at 2:11 a.m., indicated the resident observed wandering into other clients' rooms and pacing. A progress note, dated 4/11/19 at 10:32 p.m., indicated the resident wandered over to room mates side of the bed and the room mate became verbally aggressive to the resident. A progress note, dated 3/31/19 at 1:45 p.m., Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Education provided on prohibition of potentially harmful possessions. Intervention folder updated to assist staff when dealing with residents with dementia and wandering behaviors. Education provided on care plan revision and intervention updates for those residents with falls. Accidents/Incidents will be reviewed daily during regularly scheduled department meetings for care plan updates and implementation of interventions. Behavior Management Meetings are held weekly that include facility Psychologist, Director of Nursing, ADON, Activities Manager, and Social Services. Weekly Comprehensive Clinical Review meeting which consist of Admin. DON, ADON, MDS, SS, and Activities Director A progress note, dated 6/12/19 at 2:04 p.m., indicated the resident had a witnessed fall in the hallway and fell out of a chair, struck his head and was and sent to the ER for CT scan of head. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 48 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 indicated the resident had a witnessed fall in the quiet room and was attempting to sit on the couch and lost balance and fell onto the floor. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Audit weekly all new admissions to determine no prohibited items are kept in resident possession. Any identified areas of concern will be addressed immediately. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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. A progress note, dated 3/27/19 at 4:48 p.m., indicated the resident had an unwitnessed fall in the quiet room and was found laying on his left side. A progress note, dated 1/15/19 at 11:45 p.m. indicated the resident had a witnessed fall in the hallway and was attempting to sit in an unlocked wheelchair and fell on his left side. During an interview, on 6/20/19 at 10:51 a.m., the DON indicated the wandering interventions had not been updated on the care plan since 9/2018 and the fall care plan interventions had not been updated since 1/16/19. 1.Date of compliance: 2. During an observation of the Harmony Unit on 6/19/19 at 2:32 p.m., with the ADON present, Resident 171 had two metal bottle openers and one pocket knife hanging from the sides of his belt on his pants. The ADON asked the resident if she could have the knife and the bottle openers. The resident willingly gave the items to the ADON. The resident still had multiple keys, key chains and some unidentified metal objects hanging from the sides of his pants and the ADON indicated she would only be able to address a little at a time to keep the resident from becoming upset. The ADON indicated the resident had not had any behaviors since admission. The record for resident 171 was reviewed on 6/19/19 at 3:00 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, insomnia, delirium due to known FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 49 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 physiological condition, recurrent major depressive disorder, post traumatic stress disorder and cognitive communication deficit. The Admission/Re-Admission Observation dated 6/12/19 at 12:00 p.m., indicated the resident did not have any valuables with him A care plan, dated 6/12/19, indicated the resident had a potential for aggressive behavior related to the dementia. The interventions included, but were not limited to, encourage participation in activities, provide diversion when in common areas and remove from the area when the resident shows increased aggression. The care plan did not include the monitoring of the metal devices the resident had on his belt. 3. During an observation, on 6/11/19 at 3:23 p.m., Resident 53 had a tan pointed edged foreign object in his left ear lobe which was about 1 and 1/2 inches long and the diameter of a toothpick. The resident indicated his earring for the left ear had been missing for about a week and he had the foreign object in his ear since the earring was lost. The record for Resident 53 was reviewed on 6/14/19 at 3:08 p.m. Diagnoses included, but were not limited to, paranoid schizophrenia, cognitive communication deficit and acute recurrent sinusitis. A weekly skin observation, dated 6/11/19 at 10:35 a.m., indicated the resident had no skin concerns. During an interview on 6/11/19 at 3:37 p.m., the Unit Manager (UM)/Wound nurse indicated she was not aware the resident had something in his ear lobe. The resident removed the object when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 50 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 asked to by the UM and indicated it was a piece of grapevine he had obtained from the courtyard. The UM indicated she had worked on the unit but had not been close enough to the resident to see the foreign object in his ear. A current policy, titled "Contraband Items" not dated and received from the ADON on 6/19/19 at 1:51 p.m., indicated "...Residents are prohibited from having the following items at any time in their possession...Weapons including knives, razors, letter openers, box cutter...Sharp objects including metal items, hard plastic or items that cut or puncture...." A current policy, titled "Harmony Behavioral Health Unit" revised on 3/2019 and received from the Executive Director on 6/14/19 at 1:48 p.m., indicated "...Residents who meet the following criteria will be considered for placement on the Behavioral Health Unit...Presence of severe and persistent mental illness...Active or history of aggressive, harmful, inappropriate behavior or maladaptive behavior...The goals of the BHU[Behavior Health Unit] program include...Decreased psychotic, self-injurious, antisocial and aggressive behaviors..."4. The record for Resident 38 was reviewed on 06/14/19 at 1:28 p.m. Diagnoses included, but were not limited to, unspecified atrial fibrillation, difficulty in walking, lack of coordination, dementia with behavioral disturbance, delusional disorder and psychotic disorder with delusions. A review of Resident 38's record indicated he had falls on 02/06/19, 05/24/19, 06/3/19 and 06/10/19. A care plan, dated as revised on 06/12/18, addressed the problem the resident was at risk for fall or injury from weakness and tiredness related FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 51 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 hypertension and dementia. Interventions included, but were not limited to, assist the resident to sit in a chair in the dining room, initiated on 02/08/19. No other updated interventions were located in the resident's care plan. During an interview, on 06/18/19 at 3:02 p.m., the DON indicated after the resident fell on 6/10/19 a new intervention was not implemented and documented. After the May 24th and June 3rd fall, the interventions of removing the wheelchair pedals and to start therapy were added; however, the care plan was not updated. After every fall, a new intervention should be documented and the care plan should be updated to reflect the new intervention. 5. The record for Resident 62 was reviewed on 06/14/19 at 1:16 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, dementia with behavioral disturbance, muscle weakness, difficulty in walking and traumatic subdural hemorrhage without loss of consciousness. A review of Resident 62's record indicated he had falls on 05/09/19, 05/19/19, 05/21/19 and 05/23/19. A care plan, dated as revised on 06/11/19, addressed the problem the resident was at a high risk for falls related to a poor safety awareness and Alzheimer's dementia. He had a subdural hematoma from a fall which resulted in hospitalization. Interventions included, but were not limited, send to the ER for evaluation and non-skid footwear, initiated on 05/10/19, send to the ER for evaluation, initiated on 05/19/19 and place bed against the wall and place a mattress on the floor at bedside, initiated on 05/23/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 52 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 During an interview, on 06/20/19 at 1:15 p.m., the DON indicated Resident 62 had a fall on 05/21/19 and she could not locate where a new intervention was put into place or updated on the care plan. A current facility policy, titled "Fall Prevention Program," dated as revised 11/21/17, received from the Regional Nurse Consultant on 06/18/19 at 3:55 p.m., indicated "...The Fall Prevention Program includes the following components...immediate change in interventions that were successful...Care plan incorporates: Identification of all risk/issue, Addresses each fall, Interventions are changed with each fall, as appropriate, preventative measures...." 3.1-45(a)(1) 3.1-45(a)(2) F 0690 SS=D Bldg. 00 483.25(e)(1)-(3) Bowel/Bladder Incontinence, Catheter, UTI §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 53 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. Based on interview and record review, the facility failed to ensure a resident admitted with an indwelling urinary catheter was assessed for the on-going need for the use of the catheter for 1 of 2 residents reviewed for catheter use (Resident 13). F 0690 F 690D Bowel/Bladder Incontinence,Catheter The facility requests paper compliance for this citation. Finding includes: This Plan of Correction is the center's credible allegation of compliance. During an interview, on 06/12/19 at 10:24 a.m., Resident 13 indicated she has had a catheter for over a year and had not seen a specialist about the catheter. She would like to get rid of the catheter because "it is embarrassing to have" and "it really hurts in that area." 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 13 was reviewed on 06/14/19 at 9:25 a.m. Diagnoses included, but were not limited to, muscle wasting and atrophy, neuromuscular dysfunction of the bladder, anxiety disorder and major depressive disorder. A physician's order, dated 09/27/18, indicated the facility may place a Foley catheter for urinary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 07/21/2019 12:00:00A 1.Immediate actions taken for 7SCR11 Facility ID: 000025 If continuation sheet Page 54 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG retention. (X5) COMPLETION DATE 1.How the facility identified other residents: Any resident identified to have a catheter had the potential to be affected. Audit was conducted to identify those residents that currently utilized a catheter. Orders clarified with primary care physician and care plans updated as needed. During an interview, on 06/14/19 at 1:47 p.m., the Director of Nursing (DON) indicated the resident was admitted to the facility, with the indwelling catheter, after surgery for her back in January of 2018. The resident had not seen a urologist since admission and the facility had not tried to remove the catheter. During an interview, on 06/18/19 at 9:43 a.m., the Physical Therapist (PT) indicated the resident arrived to the facility around 1 and a half years ago. She had back surgery due to compression of the spinal cord and was a total assist and paralyzed after the surgery. Over the last year and a half, she had regained movement and has been walking for over 3 weeks now. She has no limited range of motion and has "pretty good bed mobility." 1.Measures put into place/ System changes: Licensed nursing staff will be educated on bowel/bladder/Foley assessments. Residents will be assessed upon admission quarterly, annually and with significant change. A review of the "Foley Catheter Evaluation" for Resident 13 indicated the evaluations were completed on 09/27/18 which was signed on 11/02/18 and another evaluation completed on 06/05/19. 1.How the corrective actions will be monitored: The Director of Nursing / designee will be the responsible party for this plan of correction. Audits will be conducted upon admission and weekly to determine Foley assessments have been completed accurately. Diagnosis are supportive, orders are current and care plans are updated. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or During an interview, on 06/18/19 at 1:12 p.m., the Regional Nurse Consultant indicated a Foley catheter evaluation should have been completed every 6 months for the resident. During an interview, on 06/18/19 at 4:01 p.m., the Regional Nurse Consultant indicated she could not locate a specific policy for the use of a Foley Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) those residents identified: Resident #13 was reassessed, care plan reviewed and updated. Appointment scheduled for urologist. A care plan, dated as revised on 09/28/18, addressed the problem the resident had an indwelling urinary catheter related to neurogenic bladder. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 55 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 catheter 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 x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 3.1-41(a)(2) 5) Date of compliance: 7-21-19 F 0692 SS=D Bldg. 00 483.25(g)(1)-(3) Nutrition/Hydration Status Maintenance §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. Based on observation, interview and record review, the facility failed to complete nutrition assessments after significant weight changes and failed to obtain weekly weights after admission for 3 of 5 residents reviewed for nutrition (Resident 62, 16 and 59). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0692 F 692 Nutrition Hydration 07/21/2019 12:00:00A The facility requests paper compliance for this citation. This Plan of Correction is the 7SCR11 Facility ID: 000025 If continuation sheet Page 56 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 center's credible allegation of compliance. Findings include: 1. On 06/13/19 at 11:14 a.m., Resident 62 was in his room, in bed, asleep. 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 06/14/19 at 12:57 p.m., Resident 62 was in his bed, asleep, his lunch tray was on his bed side table at the end of the bed. On 06/18/19 at 11:32 a.m., Resident 62 was in his bed asleep. The record for Resident 62 was reviewed on 06/20/19 at 1:16 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, dementia with behavioral disturbance, muscle weakness, difficulty in walking, need for assistance with personal care, restlessness and agitation, mood affective disorder, and traumatic subdural hemorrhage without loss of consciousness. 1.Immediate actions taken for those residents identified: Residents # 62,#16,and #59 weights were reviewed with primary care physician and documented in progress notes. 2.Immediate actions taken for those residents identified: How the facility identified other residents: Active residents’ records were reviewed for current weight loss. Orders were reviewed and revised as needed. Notification of physician regarding any identified weight loss. Dietary orders were reviewed, care plans were reviewed and updated. RD reassessed residents who have had recent weight loss, progress notes were completed, and recommendations made as appropriate. A review of Resident 62's weights, indicated the following: a. On 03/06/19 at 1:43 p.m., he weighed 195.6 pounds. b. On 03/25/19 at 7:58 p.m., he weighed 190.4 pounds. c. On 04/30/19 at 5:14 p.m., he weighed 174.8 pounds. d. On 05/04/19 at 10:50 a.m., he weighed 174.6 pounds. e. On 05/21/19 at 8:50 p.m., he weighed 146.0 pounds. f. On 06/08/19 at 2:40 p.m., he weighed 164.6 pounds. No other weights were located in the record. 1.Measures put into place/ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 57 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG Resident 62 had the following discharges: a. On 03/15/19, he had a psychiatric inpatient stay and returned to the facility on 03/25/19. b. On 04/19/19, he had a psychiatric inpatient stay and returned to the facility on 04/30/19. c. On 5/19/19, hospital stay after a fall and returned on 5/21/19. A readmission dietary evaluation, dated 04/30/19, indicated the resident required limited assistance with eating and to continue the current plan of care. A dietary progress note, dated 05/07/19 at 2:20 p.m., indicated the resident had a weight of 174.6 pounds which was a loss of 8.3% x 30 days. The resident's weight loss might have been related to recently being at the hospital and returning a few days ago. The resident was on Remeron with possible side effect of an increased appetite. The resident was started on a house supplement three times a day on 04/08/19, at times would refuse it and to continue with the supplement at this time. The resident was noted to have behaviors and was looking for new placement. (X5) COMPLETION DATE 1.How the corrective actions will be monitored: The responsible party for this plan of correction is the Director of Nursing and Dietary Manager. Audits will be conducted three times weekly per the dietary manager/Director of Nursing to determine weights have been obtained and documented timely. Weights will be reviewed daily during clinical review meeting and weekly during Comprehensive Clinical Review Meeting. The results of these audits will be reviewed in Quality Assurance A physician's order, dated 05/23/19, indicated to give a house supplement three times a day. A dietary progress note, dated 06/13/19 at 11:07 a.m., indicted the resident had a weight of 164.6 pounds which was a loss of 15.8 % x 90 days and was a significant weight loss. The weight loss might be contributed to a recent hospitalization. He was started on Remeron on 05/20/19 to help increase his appetite and started on a house Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) System changes: Licensed Nursing staff were educated on weighing residents and documentation requirements. The Registered Dietitian will meet with the DNS/designee at the end of each facility visit to review nutritional recommendations with specific attention made to significant weight loss. Routine orders consist of weekly weights times 4 weeks upon admission, then monthly thereafter unless otherwise indicated. Identification of significant weight changes will be reported timely to the physician and the registered dietician. Care plans will be updated. Communication slips will be completed and forward to dietary department with any diet changes or recommendations . A physician's order, dated 04/30/19, indicated the resident was to receive a mechanical soft textured diet with thin liquids. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 58 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 supplement three times a day on 05/23/19. The resident fell on 05/09/19, 05/19/19 and 05/23/19. A diagnosis of Alzheimer's was noted, may see a decline with the disease progression and to clarify house supplement at 90 ml and to increase to four times a day. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Meeting monthly for 6 months or until 100% compliance 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 . A physician's order, dated 06/14/19, indicated to give a house supplement four times a day. A care plan, dated as revised on 06/11/19, addressed the problem the resident was not able to consume regular consistency foods and require a mechanically altered diet. He was at risk for weight loss due to his recent decline in health and refusal to eat at times. Interventions, initiated on 03/06/19 indicated to monitor and record intake every shift and provide diet as ordered. Interventions, initiated on 06/11/19, indicated to monitor weight as ordered, notify physician of significant weight changes, position for eating and drinking safely and refer to speech therapy for evaluation and treatment as indicated. No other interventions related to weight loss or nutrition were located. 5) Date of compliance: 7-21-19 No other dietary progress notes were located. No Interdisciplinary Team (IDT) notes related to the resident's weight loss were located. No documentation the resident's physician was notify of the weight loss or rapid weight gain was located. During an interview, on 06/20/19 at 1:15 p.m., the DON indicated on 05/19/19 the resident had an unwitnessed fall in his room, was sent to hospital and was admitted. He returned to the facility on 05/21/19. The resident had a psychiatric inpatient FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 59 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 stay and returned to the facility with a weight loss. The IDT reviewed falls, behaviors, medication concerns or errors or refusals, and also recommendations from psych or therapy or dietician. The IDT meets weekly. The resident received a house supplement four times a day which the dietician increased on 06/13/19 and he received an appetite stimulate. According to the facility policy, residents were to be weighed weekly x 4 weeks upon admission and it was not clear on why this did not happen for Resident 62. If a large weigh difference was noticed, the resident should have been reweighed. The IDT track the weights and have monthly weight meetings. The nurse who worked when the weight was obtained should have notified the physician and should have documented the notification in the progress notes. Weigh gains should also be reweighed and the physician notified. A current facility policy, titled "Weight Measurement" not dated and received from the Executive Director on 06/19/19 at 9:05 a.m., indicated "Policy: Resident's weights are taken upon admission, upon readmission and as indicated. Procedure: A baseline weight will be established upon admission. The resident will be weighed weekly for four (4) weeks after admission and monthly thereafter. Weekly weighing may be resumed if there is a significant change in condition, food intakes declined over time or there is evidence of altered nutrition status. Consistent weighing process and technique is used to determine accurate body weight measurement. This includes weighing the resident: At approximately the same time of day, using the same scale." 2. The record for Resident 16 was reviewed on 6/13/19 at 1:43 p.m. Diagnoses included, but were not limited to, cerebral infarction, paralytic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 60 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 syndrome affecting the left non dominant side and vitamin deficiency. A physician order, dated 1/18/19, indicated a diet of NAS (no added salt), mechanical soft texture, may have double portions and nectar consistency for fluids. The resident had the following weights: a. 1/17/19 144.2 pounds b. 2/20/19 135. 2 pounds- a significant weight loss of 6.24% weight loss in one month. c. 4/2/19 133.2 pounds. 7.63 % in 3 months. There was no nutrition assessment in the electronic record after the significant weight loss and no new interventions. A care plan, dated 1/19/19 and revised on 3/6/19, indicated the resident was unable to consume regular consistency foods and fluids and required a mechanically altered diet. The interventions included, but were not limited to, monitor weight as indicated. During an interview, on 6/18/19 at 4:04 p.m., the ADON indicated there was no nutrition note in the electronic record in the assessment section and no progress notes about the weight loss. She indicated the dietician should have been notified for a nutritional assessment and usually the resident would have more frequent weights and a care plan for nutrition would be initiated. 3. The Record for Resident 59 was reviewed on 6/18/19 at 3:13 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, major depressive disorder, dysphagia and ulcerative colitis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 61 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 A physician's order, dated 5/14/19, indicated a mechanical soft diet with thin liquids. The resident had the following weights: a. 10/21/18 167.6 pounds b. 11/7/18 155 pounds-a significant weight loss of 7.52% in one month. c. 6/1/19 157.8 A care plan, dated 11/14/18, indicated the resident received a regular diet with mechanical texture thin consistency. The interventions included, but were not limited to, monitor weights when available. During an interview, on 6/20/19 at 2:07 p.m., the DON indicated there was no nutrition note and no progress notes about the weight after the resident had a significant weight loss on 11/7/19. She indicated the resident should have been re-weighed and the resident's significant weight loss should have been discussed during the IDT (interdisciplinary team) meeting. A current facility policy, titled "Weight Measurement" not dated and received from the Executive Director on 06/19/19 at 9:05 a.m., indicated "Policy: Resident's weights are taken upon admission, upon readmission and as indicated. Procedure: A baseline weight will be established upon admission. The resident will be weighed weekly for four (4) weeks after admission and monthly thereafter. Weekly weighing may be resumed if there is a significant change in condition, food intakes declined over time or there is evidence of altered nutrition status. Consistent weighing process and technique is used to determine accurate body weight measurement. This includes weighing the resident: At approximately the same time of day, using the same scale." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 62 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 A current policy, titled "Nutritional Assessment" not dated and received from the ED on 6/19/19 at 4:05 p.m., indicated, "...The resident's nutritional status will be evaluated in order to identify any nutrition-related problems and degree of nutrition risks. A nutritional plan of care and interventions will be documented...." 3.1-46(a)(1) F 0694 SS=D Bldg. 00 483.25(h) Parenteral/IV Fluids § 483.25(h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. Based on interview and record review, the facility failed to provide care for a resident with a midline catheter for 1 of 1 residents reviewed for Intravenous (IV) fluids (Resident 57). F 0694 07/21/2019 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 57 was reviewed on 6/13/19 at 1:07 p.m. Diagnoses included, but were not limited to, type 2 diabetes, chronic pancreatitis and chronic kidney disease stage 3. 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 A progress note, dated 6/7/19 at 4:55 a.m., indicated the resident pulled out the midline IV. A progress note, dated 6/7/19 indicated Vascular access was called at 6:00 a.m. and stated they would be in to place another midline. FORM CMS-2567(02-99) Previous Versions Obsolete F 694 Parenteral Fluids Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 63 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG The electronic record did not have any physician's orders for the care of a midline IV. (X5) COMPLETION DATE 1.How the facility identified other residents: Facility wide audit was conducted to identify those residents that currently utilize a Midline catheter for IV fluids Residents identified had physician orders for care and maintenance reviewed and care Plan developed. Any resident that utilized IV midline for fluids had the potential to be affected however noted to be affected. During an interview, on 6/17/19 at 11:05 a.m., the resident indicated he had an IV and had asked the staff if it could be taken out and they had not taken it out yet and it was bothering him. The resident was not receiving IV fluids. During an interview, on 6/17/19 at 2:45 p.m., the ADON indicated the dressing on the midline IV should be changed every 7 days, the arm circumference measured and a cap change completed with every blood draw. She indicated there were no physician's orders for the care of the midline IV and no documentation in the electronic record of care being completed for the IV. 1.Measures put into place/ System changes: Nursing staff were educated on Midline/IV policy, Care and Maintenance. Documentation will be reflected on the Medication Administration Record. A current policy, titled "Midline and Central Catheter Flush Protocol" dated 8/12/14 and received from the Corporate Clinical Nurse on 6/17/19 at 3:40 p.m., indicated , "...Vascular access devices shall be flushed at established intervals to promote and maintain patency and prevent the mixing of incompatible medications and solutions...Outcomes...Provide continuous patient IV access for intermittent delivery of fluids...Alternate flushing/locking protocols may be administered based on individual facility policy and/or physician order...Flushing is indicated every 24 hours when no infusion of medications or fluids has occurred...." 1.How the corrective actions will be monitored: The monitoring of this will plan of correction will be the Director of Nursing/Designee. Observational audits will occur on 3 residents weekly that have IV’s present to determine that care and maintenance has been provided as ordered. The results of these audits will be 3.1-47(a)(2) 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: Resident # 57 no longer resides in facility During an interview, on 6/12/19 at 11:02 a.m., RN 11 indicated Resident 57 had a midline catheter for IV fluid administration and was not receiving IV fluids currently. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 64 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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: 7-21-19 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 interview and record review, the facility failed to ensure a side rail assessment including the risk and benefits of the side rails were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0700 07/21/2019 12:00:00A F700 Bedrails The facility is requesting paper 7SCR11 Facility ID: 000025 If continuation sheet Page 65 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG complete and a physician's order was obtained for 2 of 3 residents reviewed for side rails (Resident 38 and 62). (X5) COMPLETION DATE 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 06/12/19 at 9:32 a.m., Resident 38 was observed to be in his bed, a side rail on the resident's right side was in the up position. The record for Resident 38 was reviewed on 06/14/19 at 1:28 p.m. Diagnoses included, but were not limited to, unspecified atrial fibrillation, difficulty in walking, lack of coordination, dementia with behavioral disturbance, delusional disorder and psychotic disorder with delusions. A physician's order for the use of side rails was not located in the resident's record. 1) Immediate actions taken for those residents identified: Residents #38 and #62 were assessed for bedrail need. Per results of assessment, physician orders were obtained, consents signed as required, education provided on the risk and benefits and care plans reviewed and revised. A care plan for the use of side rails was not located in the resident's record. A side rail evaluation which included the risks and benefits for the use of side rails was not located in the resident's record. Informed consent or the alternatives tried prior were not located. During an interview, on 06/18/19 at 1:49 p.m., the Director of Nursing (DON) indicated before side rails were placed a side rail assessment should have been completed, a physician's order should have been obtains, then the rails should be put on and a care plan initiated. 2) How the facility identified other residents. Audit was conducted to identify those residents currently using side rails. Those residents were re-assessed, if bed rails were not indicated the bed rails were removed, if bed rails were indicated, orders were obtained, consents were signed and education was provide on the risk 2. On 06/14/19 at 12:57 p.m., Resident 62 was in his bed, asleep. He had two quarter rails in the up position and his bed was against the wall. The record for Resident 62 was reviewed on Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 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 7SCR11 Facility ID: 000025 If continuation sheet Page 66 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG 06/14/19 at 1:16 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, dementia with behavioral disturbance, muscle weakness, difficulty in walking and traumatic subdural hemorrhage without loss of consciousness. (X5) COMPLETION DATE 3) Measures put into place/ System changes: Education provided to Nursing, Therapy, and Maintenance on the components of F700. Residents will be assessed upon admission, re-admission, quarterly, annually with significant change, and as needed for the use of bed rails Bed rail utilization will be reviewed during scheduled care plan meetings. Residents will be identified through admission, quarterly, annual, and significant change assessment process. New Admissions will be reviewed weekly in Comprehensive Clinical Reviews with focus on bed rail usage if indicated. A care plan for the use of side rails was not located in the resident's record. A "Side Rail Assessment" dated 05/21/19, indicated the resident did not have side rails attached to his bed frame. Informed consent or the alternatives tried prior were not located. During an interview, on 06/20/19 at 1:15 p.m., the DON indicated the side rail assessment dated 5/21/19, on readmission, indicated he did not have side rails. After looking at the residents bed, she indicated he did have side rails, his assessment should reflect he had side rails and a physician's order should have been obtained and a care plan initiated. 4) How the corrective actions will be monitor The Director of Nursing/Designee will audit new admissions for the completion of assessments, orders, consents, and education relative to bedrail usage and care plan initiation. Random weekly observational audits will be conducted by Director of Nursing/designee and Maintenance Director/designee to ensure correct installation, use, and maintenance of bed rails. A current facility policy, titled "Side Rails/Bed Rails" dated 04/10/18 and received from the Regional Nurse Consultant on 06/18/19 at 2:10 p.m., indicated "...After alternatives to bed rails have been attempted and determined that these alternatives do not meet the resident's needs, the facility shall assess the resident for the risks of entrapment and possible benefits of bed rails...In addition, the resident assessment should include an evaluation of the alternatives to the use of a bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs...After alternatives have been attempted Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) and benefits. Care plans were reviewed and or revised to identify assessed need. A physician's order for the use of side rails was not located in the resident's record. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 67 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 and prior to installation, the facility shall obtain informed consent from the resident or if applicable, the resident representative for the use of bed rails...The care plan shall be developed on an individual basis...." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Maintenance Director will keep a current log of those residents currently utilizing rails for preventative maintenance. Any identified issues will be immediately addressed through ongoing/ 1-1 education. The results of these reviews and or concerns will be discussed in scheduled daily departmental meetings as well as Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved times 3 consecutive months. 3.1-45(2) 5) Date of compliance: 7-21-19 F 0732 SS=C 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 68 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. Based on observation, interview and record review, the facility failed to post the nursing staff daily for 1 of 9 days reviewed. F 0732 F 732C Posted Staffing 07/21/2019 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. During an observation, on 6/14/19 at 11:15 a.m., the facility nursing staff posting was for 6/12/19. During an interview, on 6/14/19 at 11:15 a.m., the Executive Director indicated the staff posting was not updated and should be updated each day. 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. A policy on staff posting was not provided by the time of the Exit Conference on 6/22/19. 3.1-17(a) 3.1-17(b) 1.Immediate actions taken for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 69 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 those residents identified: Nurse staff hours were posted on 6/14/19. No residents were identified as affected. 1.How the facility identified other residents: No residents were identified as affected. 1.Measures put into place/ System changes: The DON or designee will audit nurse staff posting at least 5 times per week to ensure that the hours are posted. The weekend managers will ensure that the nurse staff postings are updated and posted on weekends. 1.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 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: 7-21-19 F 0740 SS=D Bldg. 00 483.40 Behavioral Health Services §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 70 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. Based on observation, interview and record review, the facility failed to have documentation in the electronic record timely and to show the coordination of care with the behavioral health services staff which included the psychiatrist, psychologist and behavioral health clinician, for residents placed on the Behavioral Health Unit (Harmony Unit) for 2 of 3 residents reviewed for behavioral health services (Residents 8 and 4). F 0740 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. The record for Resident 8 was reviewed on 6/14/19 at 10:22 a.m. Diagnoses included, but were not limited to schizoaffective disorder, bipolar type, Parkinson's disease, cerebrovascular disease, chronic pancreatitis, dementia with behavioral disturbance, anxiety disorder, and type 2 Diabetes Mellitus. A care plan, dated 12/14/18, indicated the resident was resistive to care and refused to take medications related to delusion she was a registered nurse and knew what was best. The interventions included, but were not limited to, allow the resident to make decisions about treatment, encourage as much participation by the resident as possible during care and provide consistency in care. Event ID: 07/21/2019 12:00:00A The facility requests paper compliance for this citation. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete F 740 D Behavioral Health Services 1.Immediate actions taken for those residents identified: Resident #4 is currently out of the facility. Resident will be assessed upon return with review of plan of care. Resident #8 was assessed, care plans reviewed and revised, requested review by psychiatrist, 7SCR11 Facility ID: 000025 If continuation sheet Page 71 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG The Initial Psychiatric Evaluation, dated 12/23/18, was a check off sheet and did not include the resident specific history of present illness, current symptoms, current behaviors and duration of current symptoms. The treatment plan was a check off list which included to continue the current treatment plan, encourage ADL's, support and reassure. (X5) COMPLETION DATE 1.How the facility identified other residents: Any resident had the potential to be affected, none were identified to hav ha a negative outcome 1.Measures put into place/ System changes: Behavior Management Meetings are held weekly that include facility Psychologist, Director of Nursing, ADON, Activities Manager, Behavioral Clinician and Social Services. Weekly Comprehensive Clinical Review meetings are held to review those residents with behaviors which consist of Admin. DON, ADON, MDS, SS, and Activities Director. Attendance in meetings will be documented. Any recommendations made will be sent to the appropriate practioneer for review with noted documentation Monthly Psychiatrist progress notes will be scanned into electronic medical record for review by psychologist and primary care physician. Psychologist will provide timely A psychiatric progress note, dated 4/27/19, indicated the history of present illness/interval history since last date of service/staff reports was cognitive decline with the impression the resident was deteriorating. The resident's behaviors were not addressed in the note. A psychiatric progress note, dated 5/28/19, indicated the history of present illness/interval history since last date of service/staff reports was dementia progress with the impression the resident was deteriorating. A late entry psychologist progress note, dated 3/7/19, indicated the Behavioral Treatment Team reviewed the resident's incidents since her last review of physical aggression and screaming, no recommendations were made regarding her medications and the psychiatrist would be interviewing the resident soon. The resident may well be a strong candidate for a Lewy-Body dementia given her diagnosis of Parkinson's Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) psychologist and primary care physician related to medications, diagnosis and behaviors. Resident reviewed at behavior management meeting with documented attendance. A psychiatric progress note, dated 3/29/19, indicated the history of present illness/interval since the last date of service/staff reports was dementia progression with an impression the resident was deteriorating. The treatment plan included to observe for mood and behavior changes. The resident's behaviors were not addressed in the note. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 72 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG disease. (X5) COMPLETION DATE 1.How the corrective actions will be monitored: Timeliness of physician progress notes will be audited by social services with direct oversight of the Administrator and Director of Nursing. Three resident records will be reviewed weekly to ensure recommendations addressed, coordination of care between physicians,and progress notes scanned into electronic medical record. Any identified issues will be addressed immediately. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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 psychiatrist notes did not include the recommendation by the psychologist to review the possibility of a Lewy-Body dementia diagnosis. A Behavior Management Team Review, signed by the SSD (Social Services Director) dated 4/4/19, indicated the summary of the behavioral occurrences included there were behaviors related to mental illness and refusing psychotropic medications, with one occurrence of false accusations and one occurrence of threatening behaviors. The medical considerations of the behaviors was schizoaffective disorder-bipolar type and Parkinson's disease and the team recommendations were medications reviewed and no recommendations necessary at this time and will review at the next behavior meeting. The Behavior Management Team review did not include the team members present for the review. The Behavior Management Team review did not include the recommendation from the psychologist on 3/7/19 to consider the diagnosis of Lewy-Body dementia or the psychiatrist Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) progress notes timely for those residents seen. Recommendations will be made to Social Services/Director of Nursing to ensure coordination of care is ongoing. Facility Psychologist and Psychiatrist notified/educated of required timeliness of submission of progress notes. A late entry psychologist progress note, dated 5/6/19. indicated the resident's behavioral incidents and symptoms were reviewed with the Behavioral Treatment Team. The resident had 3 behaviors and 17 incidents which included biting, generally inappropriate social behaviors, refused medications, cursing, threatening behavior, sadness. There had been no changes in the psychotropic medications but may want to review the possibility of a Lewy-Body dementia diagnosis. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 5) Date of compliance: 7-21-19 7SCR11 Facility ID: 000025 If continuation sheet Page 73 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 progress note indicating the dementia and cognitive decline were the present history of illness. A Behavior Management Team Review, signed by the SSD and dated 5/3/19, indicated the resident's behaviors were related to mental illness and refusing psychiatric medications, the medical consideration of behaviors was schizoaffective disorder-bipolar type and Parkinson's disease. The precipitating and contributing factors were internal agitation and new admission to the facility. The review did not include the recommendation of the psychologist to consider the diagnosis of Lewy-Body dementia and did not include the members of the behavior management team present. The resident was not a new admission and had been at the facility for several months. A Behavior Management Team review, signed by the SSD and dated 6/5/19, indicated the resident's behaviors were related to mental illness and refusing psychiatric medication, the medical considerations of behaviors was schizoaffective disorder-bipolar type and Parkinson's disease. The precipitating and contributing factors were internal agitation and new admission to the facility. The review did not include the recommendations of the psychologist to consider the diagnosis of Lewy-Body dementia and did not include the members of the behavior management team present. During an interview, on 6/14/19 at 1:27 p.m., RN 2 indicated the resident did not attend activities on the unit, would come out of her room to get her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 74 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 meal tray and then return back to her room and would attend special activities like Mother's Day on the healthcare unit. During an interview, on 6/21/19 at 1:44 p.m., the Executive Director (ED) indicated the psychologist did not enter his notes into the facility computer system and the facility staff had to ask for his notes and then scan the into their computer system and this was the reason for the late note entries. She indicated it would be the nursing management team who would be responsible to read his notes and take the information to the behavior meeting. The facility did not have a policy on who attended the behavior meetings. Resident 8 was not being seen by the Behavioral Clinicians as they only see residents who were seen had to qualify for MRO (Medicaid Rehabilitation Option) and resident 8 did not qualify. The Medicaid Rehabilitation Option-an Indiana Health Coverage Program for individual with serious mental illness provides clinical behavioral health services to members who live in the community who need aid intermittently for mental illness. The resident had been in the facility for over 6 months and was not included in the behavioral health clinician services and remained on the locked behavior unit of the facility. 2. The record for Resident 4 was reviewed on 6/18/19 at 3:09 p.m. Diagnoses included, but were not limited to, major depressive disorder, Alzheimer's disease, cognitive communication deficit, delusional disorders, attention and concentration deficit, unspecified dementia with behavioral disturbance and anxiety disorder. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 75 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 A Physician's orders, dated 1/16/19, indicated the resident may attend group or 1 to 1 psychological services and for a psychological evaluation and treatment as indicated. The "Behavior Management Team Review," dated 1/23/19, 1/30/19, 2/27/19, 3/7/19, 3/27/19, 4/10/19, 4/24/19, 5/22/19 and 6/5/19, signed by the social services director, did not reflect who was in attendance, indicated the behaviors were related to dementia, she had poor impulse control, and the medical considerations of behaviors were delusional disorder, anxiety disorder, dementia and communication deficit. The "Initial Psychiatric Evaluation," dated 1/31/19, indicated the resident was being seen for dementia progression. The evaluation was a check-off form. A section titled, "Impact of Medical Conditions/Treatments on Mental Health Status," indicated the "Patient's Deteriorating physical health is a principal source of his/her mental health distress...Side effects of patient's treatments for physical illness/disease (e.g. [for example] Pain, reduced energy, sleep disorder, NVD [nausea/vomiting/diarrhea], wasting [losing weight], etc. exacerbate mental health distress...Medications for physical illness/disease influence medical decision making re [for example] psychoactive agents/doses/freq [frequency]..." Her diagnosis was marked as "Unspecified dementia with behavioral disturbance" and the "Though Content: Delusions...Hallucinations..." was not marked. The resident was "uncooperative" "has poverty of thought" and "nonverbal." The Psychiatrist "Progress Note," dated March 2019, 4/26/19 and 5/27/19, indicated the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 76 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 dementia had progressed, she had cognitive decline and the "impression" was the resident was deteriorating. A late entry psychologist progress note, dated 1/23/19, was not entered into the medical record until 2/27/19. The examination indicated the resident presented as calm, friendly flat, inattentive, communicative, casually groomed and relaxed. "She exhibited poor self-awareness during the time with the interviewer and this behavior raises the question regarding how good her judgment and insight are. It is unclear if her short-term memory issues are a result of poor attention and/or her ability to concentrate on what is going on around her...She exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate...[Resident name]'s condition today does not allow cognition to be formally tested. Vocabulary and fund of knowledge indicate cognitive functioning in the normal range. Insight into problems appears to be poor. There are no signs of anxiety. A short attention span is evident. She appeared to have little awareness and/or caring about personal boundaries wanting to sit very close to the male interviewer and touching others on the Unit, especially males when observed. Her answers never answered a question and always seemed to be part of her 'story' of what is happening. Otherwise, her speech was tangential with each question...Diagnoses: The following Diagnoses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 77 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 are based on currently available information and may change as additional information becomes available. Vascular dementia with behavioral disturbance...Therapy Content/Clinical Summary:...the target of the session was to make an initial positive contact/interaction with her along with starting to gather historical information including history of symptoms, etc..."and "...as a therapeutic focus on assessing the type and severity of the problem and gather information regarding attempting to stabilize her given her recent hx [history] at [Name of Facility]. This session the therapeutic focus was on the exploration of patterns of behavior. The patient was also encouraged to explore the sources of maladaptive behaviors. Therapeutic efforts also included aiding the patient in identifying the precipitants of unproductive feelings and behaviors...Return 2-3 weeks, or earlier if needed...." At the time of entrance to the facility, on 6/11/19, there were no other psychologist progress notes in the medical record. A "Treatment Plan" by the Behavioral Health Clinician, dated 3/26/19, indicated the resident would receive case management for skill training, medication training, psychiatric evaluation and outside services. The case management frequency and duration was 3 hours per week. The skill training frequency and duration was 7 hours per week. The medication training frequency and duration was 1 hour per week. The psychiatric evaluation frequency and duration was 1 time yearly for 1 hour. Diagnoses listed included, but were not limited to, schizophrenia (which was marked as diagnoses prior to admission), disorientation, dementia in other diseases classified elsewhere with behavioral FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 78 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 disturbance and personal history of other mental and behavioral disorders. The "Patient Goal(s)...in her own words: Patient was not able to provide an intelligible response. When writer asked if she wanted to learn how to ask for what she needs, she nodded yes....Problem 1:Psychosis (includes hallucinations and delusions) Problem Descriptor 1: Patient is prescribed anti-psychotic medication and exhibits hallucinations. Throughout the assessment she would lift her hands and start wiggling her fingers, as if playing piano. She also lifted her feet and was pedaling with them. When asked if she sees and hears things others cannot, patient said yes. She denied that it was upsetting or disturbing to her. Patient has a concurrent diagnosis of delusional disorder. Patient had limited verbal responses to questions, though her responses...and comments were unrelated to what was being discussed. She required some physical prompting to move i.e.: writer had to gesture to chair for patient to sit after patient indicated she wanted to sit. Patient would not stand until writer put out hand. Staff had to hold patient's hand while walking from her room to meet with writer. Note: When music was played, patient sang along clearly enough to identify lyrics and danced independently. Goal 1: Patient will learn to manage symptoms of psychosis such that behaviors do not interfere with her placement of participation in daily activities. Objective 1: With verbal prompts and modeling as needed, Patient will ask (either verbally or with sign/gesture) for permission to touch another person 1 of 5 trials over the next 90 days...Objective 2: With staff assistance as needed, given a choice of 2 activities, patient will select 1 and participate with staff and/or peers for 5 minutes 1 of 5 trials over the next 90 days...Objective 3: With staff assistance as needed, Patient will explore relaxation strategies (i.e.: calming music, easy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 79 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 exercises, coloring, etc.), with staff helping develop a list of 2 or 3 activities that appear to aid Patient in relaxing 1 of 5 trials over the next 90 days...Objective 4: With input from nursing home staff and assistance from [Behavioral Health Clinician] staff, Patient will learn to say or sign "help" 1 of 5 trials over the next 90 days...Objective 6: With staff assistance, and offered the facility menu options and information about which foods are better choices for managing diabetes, Patient will make the better choice 1 of 5 trials over the next 90 days...Problem 2: Cognitive Disorders...Strategies to address the conditions are captured in Problem 1 about...Problem 3: Mood Disorders...Patient has diagnosis of personal history of other mental disorders including depression and anxiety. Patient denied feeling anxious or depressed. Psychologist reported patient struggles with personal boundaries and wanting physical contact, not necessarily aggression and was hospitalized for this behavior. Strategies for addressing these behaviors are capture in Problem 1 as well...." The diagnoses of schizophrenia is not located in the resident's record. A facility policy, titled "Behavior Management Program" revised 10/30/17 and received from the DON on 6/20/19 at 4:00 p.m., indicated, "...To establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being... consistent implementation during the resident's daily routine and across settings, of systemic plans which are designed to change inappropriate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 80 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 behaviors...individual, group and family psychotherapy...Formal behavior modification programs...Monitoring of Behaviors and Effectiveness of Interventions...Review of behaviors and interventions implemented during daily or weekly clinical review meetings...Review of behaviors and psychotropic medications during Behavior Management/Psychotropic Medication Review meetings...The facility will attempt to identify, to the extent possible, any previous history of mental illness, comorbidities, pattern of behaviors, preferences, interests, daily routines, medication use and effective behavior management interventions in developing an individualized plan of care...Staff should determine, in collaboration with the practitioner, resident and family/resident representative if and why behaviors should be addressed...." 3.1-37(a) 3.1-43(a)(1) F 0744 SS=D Bldg. 00 483.40(b)(3) Treatment/Service for Dementia §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Based on observation, interview and record review, the facility failed to provide person centered dementia care, plan and interventions, to prevent and relieve the residents wandering and intrusive wandering for 1 of 3 residents reviewed for dementia care. (Resident 19) F 0744 During an observation on 6/12/19 at 4:29 p.m., Event ID: 07/21/2019 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 Finding include: FORM CMS-2567(02-99) Previous Versions Obsolete F744 Treatment and Services for Dementia 7SCR11 Facility ID: 000025 If continuation sheet Page 81 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG Resident 19 was wandering into other residents' room then would stand at the exit doors and push on the handles. (X5) COMPLETION DATE 1) Immediate actions taken for those residents identified: Resident #19 care plans were reviewed and revised as appropriate. Nursing Staff and Activity staff were educated on managing behaviors and intrusive wandering. Intervention book was updated to reflect strategies to deescalate intrusive wandering. Requested review per psychologist and psychiatrist. Primary care physician was updated on Resident #19 behaviors. Stop signs were offered to Resident #10 and #4 and others that resident#19 frequented. During an observation, on 6/13/19 at 10:03 p.m., the resident was ambulating in the hallway with another male resident and LPN 14 was sitting at the nurse desk. During an observation, on 6/13/19 at 10:13 p.m., the resident continued to wander the halls of the unit. During an observation, on 6/13/19 at 10:16 p.m., the resident tried to open the door on the 100 hall. During an observation, on 6/13/19 at 10:20 p.m., the resident wandered into the dining area on the unit. During an observation, on 6/13/19 at 10:24 p.m., the resident was trying to open the door near the 100 hall exit, ambulated back to the nurses station and asked LPN 14 if she put the groceries in the truck, ambulated back to the kitchen and then started pulling on the door at the 100 hall. 2) How the facility identified other residents: Residents were identified that had dementia with intrusive wandering behaviors. Those residents identified were re-assessed care plans reviewed and revised as needed. Residents will be identified upon admission, quarterly, annually and with significant changes. During an observation, on 6/13/19 at 10:28 p.m., the Activity Director walked the resident into the quiet room, left the resident in the room and she walked back out. During an observation, on 6/13/19 at 10:29 p.m., the resident walked out of the quiet room and 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. During an observation, on 6/13/19 at 2:48 p.m., the resident was lying in bed in another resident's room with his eyes closed. The CNA 12 indicated the resident was in the wrong room and CNA 12 left the resident to sleep in the wrong room. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 3) Measures put into place/ 7SCR11 Facility ID: 000025 If continuation sheet Page 82 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG back to the nurses station. During an observation, on 6/14/19 at 1:08 p.m., the resident was standing in the hallway with a bandage on his right lower arm which was loose and gauze was dangling down his arm. During an observation, on 6/14/19 at 1:30 p.m., the resident was wandering the hallway with a female resident. The record for Resident 19 was reviewed on 6/17/19 at 4:41 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, diabetes mellitus, major depressive disorder and gastro-esophageal reflux disease (GERD). A care plan, dated 9/11/18, indicated the resident had an intrusive wandering problem and poor safety awareness along with standing over others without understanding personal space. The interventions, included, but were not limited to, encourage participation in simple activities, monitor quarterly for least restrictive measures and to observe the resident for thirst, hunger, pain, or need for toileting, provide a safe structured daily routine and environment and observe resident's whereabouts frequently. (X5) COMPLETION DATE 4) How the corrective actions will be monitored: To ensure continued compliance the Director of Nursing /designee will audit 3 times weekly through direct observation the provision of appropriate activities and group sessions for those residents diagnosed with dementia and intrusive wandering. Weekend managers with through direct observation ensure that appropriate activities are being A care plan, dated 4/5/18, indicated the resident was an elopement risk and wanderer related to exit seeking. The interventions included, but were not limited to, assess for fall risk, distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation and Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) System changes: Education was provided on managing behaviors for residents with Dementia, and Intrusive Wandering. Staff educated to encourage residents to attend group sessions and activities provided by facility psychologist. Facility staff in serviced on activities for residents with dementia and wandering. Intervention folder updated to provide strategies to deescalate intrusive wandering behaviors. Behavior Management Meetings are held weekly that include facility Psychologist, Director of Nursing, ADON, Activities Manager, and Social Services. Weekly Comprehensive Clinical Review meetings are held to review those residents with behaviors which consist of Admin. DON, ADON, MDS, SS, and Activities Director. During an observation, on 6/13/19 at 10:36 p.m., the resident wandered into Resident 4 and 10's shared room, then walked back out. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 83 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 monitor for fatigue. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE provided. Any identified areas of concern will be addressed immediately. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. A progress note, dated 6/13/19 at 5:52 a.m., indicated the resident had intrusive wandering in other clients' rooms and attempted to lay in bed with other residents. Resident assisted up and encouraged to go to bed with assistance of two staff and the resident got out of bed and continued to intrusive wander. 5) Date of compliance: 7-21-19 A progress note, dated 6/6/19 at 9:32 a.m., indicated the resident had an unwitnessed fall in another resident's room and was found on the mat beside another resident's bed. A progress note, dated 5/28/19 at 3:19 a.m., indicated the resident had been intrusively wandering into other clients' rooms. A progress note, dated 5/2/19 at 2:44 a.m. indicted the resident was intrusively wandering into other clients' rooms. A progress note, dated 5/2/19 at 11:06 a.m., indicated the resident was in search of his wife and attempts to redirect not successful. The psychiatrist was called and an order for Haldol 5 mg (milligram) one time only was obtained and given to the resident. A progress note, dated 4/26/19 at 2:11 a.m., indicated the resident observed wandering into other clients' rooms and pacing. A progress note, dated 4/11/19 at 10:32 p.m., indicated the resident wandered over to room mates side of the bed and the room mate became verbally aggressive to the resident. During an interview, on 6/20/19 at 10:51 a.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 84 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 DON indicated the wandering interventions had not been updated on the care plan since 9/2018. 3.1-37(a) F 0745 SS=E Bldg. 00 483.40(d) Provision of Medically Related Social Service §483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Based on interview and record review, the facility failed to provide social services to ensure the residents were assessed for mental health and intellectual disability needs through the PASARR (Pre-admission screening and annual resident review), to ensure discharge planning was initiated for a resident who did not want to remain at the facility long term and for dental care for 5 of 6 residents reviewed for Social Service intervention. (Resident 50, 16, 70, 16, and 1) F 0745 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. The record for Resident 50 was reviewed on 6/13/19 at 3:04 p.m. Diagnoses included, but were not limited to, personality disorder, panic disorder, anxiety disorder, schizoaffective disorder and social phobia. A PASARR ( preadmission screening and resident review) Level II, dated 5/24/19, indicated the recommendations were for the resident to have a psychiatric evaluation and dementia work up. 1.Immediate actions taken for those residents identified: 1.A new PASSAR for resident #50 was submitted by Social Services. Care plan was updated for resident #50 to reflect During an interview, on 6/20/19 at 9:38 a.m., the Social Services Director (SSD), indicated there was no information in the electronic record of a psychiatric evaluation or a dementia work up Event ID: 07/21/2019 12:00:00A The facility requests paper compliance for this citation. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete F 745E Provision of Social Services 7SCR11 Facility ID: 000025 If continuation sheet Page 85 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 being completed for the resident. The SSD did not know if the psychiatric evaluation or the dementia work up had been scheduled. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE discharge planning. 2.A new PASSAR for resident#16 was submitted 3.A new PASSAR for resident#70 was submitted 4.A new PASSAR for resident #10 was submitted 5.Resident #1 has a scheduled dental appointment. Dietary orders were reviewed and requested RD follow up to ensure residents ability to eat and drink was not compromised. Care plans reviewed and revised as needed. During an interview on 6/12/19 at 11:09 a.m., Resident 50 indicated she wanted to live someplace else beside the facility and was from another city. During an interview, on 6/14/19 at 1:06 p.m., the resident indicated she would rather be at a nursing facility in the city she came from or a city close to it. The care plan did not include discharge plans. 1. How the facility identified other residents: Any resident residing in the facility had the potential to be affected. Audit completed to identify those current residents that have dentures. Care plans were reviewed and revised Any issues identified were addressed timely. Residents residing in the facility with MD & ID have the potential to be affected. An PASSARs audit was completed of current residents in the facility by the SSD. Any issues identified related to PASSAR were corrected. During an interview on 6/18/19 at 3:33 p.m., the Social Services Director (SSD), indicated the resident's daughter would like her to stay long term although the resident would like to live in a less restrictive environment. She indicated when the resident stabilized she could try to get her back to a regular unit at the facility and then to an assisted living facility. She indicated she did not document this information or develop a care plan for the resident to include this information. 2. The record for Resident 16 was reviewed on 6/13/19 at 1:43 p.m. Diagnoses included, but were not limited to, cerebral infarction, paralytic syndrome affecting the left non dominant side, psychoactive substance-induced mood disorder, delusional disorder, hallucinations. A PASSAR level I dated 12/17/19 indicated a PASARR Level II must be conducted. 1.Measures put into place/ System changes: Facility staff were educated to notify Social Services immediately should issues arise with dentures. Education provided on the During an interview on 6/18/19 at 11:17 a.m., the Social Services Director (SSD) indicated Resident 16's PASARR level II was missed and was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 86 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG completed. A PASRR level I, dated 11/14/18, indicated the resident's Level I showed low-level behavioral health symptoms which appeared to be situational. The nursing facility should watch her symptoms/behaviors to see if they were improved or resolved within 30-60 days of the screen. If they did not, the nursing facility must submit another Level I which is called a status change. The status change would would decide if you need a PASRR Level II evaluation for serious mental illness. (X5) COMPLETION DATE 2.How the corrective actions will be monitored: New residents’ history will be reviewed weekly x 6 months by the Social Service Director with Administrative oversight to ensure PASRR accuracy level. If a discrepancy is found a new level 1 PASRR with corrected information will be completed and submitted by Social Service or designee. Any resident that receives new mental illness diagnosis or intellectual disability will have a PASSAR completed. Audits will be completed weekly to identify any resident with lost or damaged dentures. Issues addressed promptly.The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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. During an interview, on 06/13/19 at 2:40 p.m., the SSD indicated Resident 70's situation did not improve and a new Level I should have been completed. 4. The record for Resident 10 was reviewed on 06/13/19 at 2:32 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, major depressive disorder, psychotic disorder with delusions due to known physiological condition, restlessness and agitation, anxiety disorder and unspecified dementia without behavioral disturbance. The "Indiana Level I Form Preadmission Screen and Resident Review," dated 1/18/19, did not indicated Resident 10 had any "mental health diagnosis" known or suspected and no Level II would be required because the resident did not Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) components of F791 related to dental services Residents were educated through resident council meetings to promptly notify staff of missing or broken dentures. The Administrator, DON, Social Services and Admissions were educated on the Components of F645-PASSAR Screening for MD & ID 3. The record for Resident 70 was reviewed on 06/13/19 at 1:17 p.m. Diagnoses included, but were not limited to, anxiety disorder, major depressive disorder and unspecified psychosis not due to a substance or known physiological condition. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 87 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 have any serious mental illnesses. The rational listed on the form indicated, "...The Level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted...." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 5) Date of compliance: 7-21-19 5. During an interview, on 6/13/19 at 9:34 a.m., Resident 1 indicated her bottom dentures where missing. The record for Resident 1 was reviewed on 06/14/19 at 1:52 p.m. Diagnoses included, but were not limited to, schizoaffective disorder-bipolar type, major depressive disorder and generalized anxiety disorder. During an interview, on 6/17/19 at 11:42 a.m., the Social Services Director indicated the nursing staff had not reported to her the resident was missing her bottom teeth, and it should have been reported. The resident also misplaced her dentures a lot, which was not care planned. A current job description, titled "Social Services Director", dated 7/18/14 and received from the HR Director on 6/19/19 at :38 p.m., indicated Primary Job Function...The primary purpose of this position is the direction and operation of the facility's Social Services Department to ensure that the medically related, emotional and social needs of the residents are met in accordance with current federal, state and local standards...This includes...Assisting in the development of a written plan of care...Arranging psychological care and evaluation services as needed...Working with family and resident to identify needs for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 88 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 adaptive equipment, clothing, personal items, transportation, advocacy assistance and referrals to community services...Assuring that all progress notes charted are informative and descriptive of the services provided...." 3.1-34(a) F 0757 SS=D Bldg. 00 483.45(d)(1)-(6) Drug Regimen is Free from Unnecessary Drugs §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. Based on interview and record review, the facility failed to ensure lab work was completed for a resident who received an oral hypoglycemic medication for 1 of 4 resident reviewed for unnecessary medications (Resident 19). F 0757 F 757 Unnecessary Drug 07/21/2019 12:00:00A The facility requests paper compliance for this citation. This Plan of Correction is the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 89 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX 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 center's credible allegation of compliance. The record for Resident 19 was reviewed on 6/17/19 at 4:41 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, diabetes mellitus, major depressive disorder and gastro-esophageal reflux disease (GERD). 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. A physician's order, dated 4/4/18, indicated a lab of Hgb A1C (a lab which evaluates the amount of glucose in the blood over the last 2 to 3 months and helps to evaluate if the measures taken are controlling the diabetes) every 3 months. A physician's order, dated 4/3/18, indicate metformin (an oral hypoglycemic) 500 mg (milligrams) three times a day. 1.Immediate actions taken for those residents identified: HGBA1C drawn on 6-12-19 for resident #19. Results reported to physician. No order changes noted A pharmacy review, dated 6/8/19, indicated the resident had an order for a HgbA1C every three months, the last one in the electronic record was dated July 2018 and please make sure this lab had been drawn and the results scanned into the electronic record. 1.How the facility identified other residents: Audit completed for those residents receiving oral hypoglycemics. Orders reviewed for scheduled labs to determine completion, any issues identified were immediately addressed. A care plan, dated 4/4/18, indicated the resident had Diabetes Mellitus with a goal of minimal complications related to the diabetes. The interventions included, but were not limited to, observe for signs and symptoms of hyperglycemia. 1.Measures put into place/ System changes: Labs will be audited at least 3 times weekly to verify draw, resultant and notification. Nursing will be educated on lab ordering. Labs will be scanned into electronic medical record. During an interview, on 6/20/19 at 2:16 p.m., the DON indicated the resident only had one HgbA1C completed since the physician wrote the order on 4/4/2018. 3.1-48(a)(3) FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 90 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 1.How the corrective actions will be monitored: The DON/Designee will audit 24 hour summary for physician notification of lab results 3 X a week. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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: 7-21-19 F 0758 SS=E Bldg. 00 483.45(c)(3)(e)(1)-(5) Free from Unnec Psychotropic Meds/PRN Use §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 91 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Based on interview and record review, the facility failed to ensure appropriate indications for the use of an antipsychotic medication, failed to monitor for specific behaviors and failed to complete an AIMS (Abnormal Involuntary Movement Scale) test prior to the administration of an antipsychotic medication for 5 of 8 residents reviewed for unnecessary medications (Residents 10, 25, 44, 19 and 38). F 0758 07/21/2019 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 F 758 Free from Unnecessary Psychotropic Meds Preparation and/or execution of Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 92 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG The physician's orders included, but were not limited to, 250 mg (milligrams) Depakote ( a mood stabilizer) tablet Delayed Release (started 6/3/19) two times a day related to unspecified dementia without behavioral disturbance and monitor for physical aggression, abusive language and resistive to care and 150 mg Seroquel (an antipsychotic medication) tablet (started 5/10/19) two times a day related to unspecified dementia with behavioral disturbance and psychotic disorder due to known physiological condition and monitor for resistive to care, verbal aggression, disorganized thinking, physical aggression, yelling, pacing and wandering. (X5) COMPLETION DATE 1.Immediate actions taken for those residents identified: Resident assessment was completed using AIMS Scale for residents #10, #25, #44,#19,and#38. Additionally, antipsychotic medications reviewed behavior monitoring revised and care plans updated. Pharmacy was requested to review those residents receiving antipsychotics to ensure appropriate diagnosis/ indication for use with recommendations as appropriate. Primary Physicians and Psychiatrist notified of recommendations. During an interview, on 6/18/19 at 3:27 p.m., the Assistant Director of Nursing (ADON) indicated unspecified dementia without behavioral disturbance was not an appropriate diagnoses for the administration of Depakote. 1.How the facility identified other residents: Audit was conducted to identify those residents that receive anti-psychotic meds to determine appropriate indication for use. Residents will be identified through the admission process, quarterly, annual and significant change assessments. Audit was completed to ensure 2. The record for Resident 25 was reviewed on 06/13/19 at 10:59 a.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, generalized anxiety disorder and other specified depressive episodes. The Physician's orders included, but were not limited to, 25 mg of Seroquel at bedtime for unspecified dementia with behavioral disturbance Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 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 10 was reviewed on 06/13/19 at 2:32 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, major depressive disorder, psychotic disorder with delusions due to known physiological condition, restlessness and agitation, anxiety disorder and unspecified dementia without behavioral disturbance. FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 93 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG and monitor for repetitive speech, continuous pacing, paranoia and disorganized thinking, 0.5 mg of Ativan (an antianxiety medication) three times a day related to generalized anxiety disorder and 15 mg of Remeron (an antidepressant medication) once a day. (X5) COMPLETION DATE 3.) Measures put into place/ System changes: Residents will be identified and reviewed upon admission, quarterly, annually and with significant change. New Admissions will be reviewed weekly in Comprehensive Clinical Review for 4 weeks. Review Order Listing report daily to identify any new medications (antipsychotics)ordered to ensure appropriate diagnosis and monitoring initiated. Residents will be reviewed weekly per DNS, ADNS, Social Services, Activities and facility Psychologist during behavior management meeting to determine appropriate indication for use and to monitor the behaviors associated with psychotropic medication. Gradual dose reductions will be reviewed weekly during Behavior Management meeting. Psychotropic medications are additionally reviewed monthly per Pharmacy which includes Gradual Dose Reduction. Facility Psychiatrist reviews residents receiving psychotropic medications monthly and as needed. Identified issues will be addressed timely. Social Services to review and update psychotropic care plans. A "Consultant Pharmacist's Medication Regimen Review," dated 2/19/19, indicated the Seroquel was given for a diagnosis of unspecified dementia with behavioral disturbance. A care plan, dated 5/20/19, indicated the resident used psychotropic medications of Seroquel for dementia with behavioral disturbance. During an interview, on 6/20/19 at 9:38 a.m., the ADON indicated the resident should not receive an antipsychotic for dementia with behaviors. 3. The record for Resident 44 was reviewed on 06/14/19 at 10:53 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, systolic and diastolic heart failure, unspecified dementia with behavioral disturbances, down syndrome and major depressive disorder without psychotic features. The Physician's orders included, but were not limited to, an order for clonazepam tablet 0.5 mg (milligrams) by mouth at bedtime every Tuesday, Thursday, Saturday and Sunday related to other Alzheimer's disease which was started on 3/7/19 and clonazepam tablet 0.5 mg by mouth two times a day every Monday, Wednesday and Friday Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) those residents that receive antipsychotic medications has received an AIMS assessment The Nursing staff were to monitor for repetitive speech, continuous pacing, paranoia, disorganized thinking, irritability, restlessness, yelling/screaming and anxiousness. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 94 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 related to unspecified dementia with behavioral disturbance, and monitor the resident for agitation, restlessness, hitting, and pinching. On 3/8/19, the resident was ordered 100 mg of Haloperiodol Decanoate Solution (an antipsychotic) injected every 21 days related to Alzheimer's disease and unspecified dementia with behavioral disturbance, and monitor the resident for agitation, yelling and physical aggression. On 1/30/19, the resident was ordered 500 mg of Divalproex Sodium (a mood stabilizer) tablet delayed release twice a day for behaviors related to unspecified dementia with behavioral disturbance, and monitor the resident for agitation, yelling and physical aggression. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Results will be reported to primary physician. 4) How the corrective actions will be monitored: The Director of Nursing/Designee is the responsible person for this plan of correction. The Director of Nursing/Designee will audit 3 resident records weekly to determine appropriate indications for use and behavior monitoring. AIMS audit weekly of 5 residents, to determine timeliness of assessment. New admissions audits will be completed within 24-48 hours to ensure indications, monitoring, and care plans are current. Identified issues will be addressed immediately. Results of auditing will be reviewed during Quality Assurance Meeting monthly for 6 months or until 100%compliance is achieved x3 consecutive months. A care plan, dated 5/20/19, indicated the resident used psychotropic medications, Haldol, related to behavior management. The intervention was to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. An order for 1 mg Haloperidol tablet one time a day, started on 11/15/18, was ordered for impulse control. 5) Date of compliance: 7-21-19 A "Consultant Pharmacist's Medication Regimen Review," dated 12/9/19, indicated the resident needed an AIMS evaluation completed because had an order for Haldol. An AIMS was not completed until 12/20/18, after the medication was started. During an interview, on 6/18/19 at 3:49 p.m., the ADON the Resident did not have correct diagnoses for those medications and the facility should monitor for psychotic issues if the resident received an antipsychotic. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 95 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 During an interview, on 6/19/19 at 10:59 a.m., the Director of Nursing indicated an AIMS test should have been completed prior to the administration of an antipsychotic 4. The record for Resident 19 was reviewed on 6/17/19 at 4:41 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, diabetes mellitus, major depressive disorder and gastro-esophageal reflux disease (GERD). A physician's order, dated 4/318, indicated Risperdal M tab disintegrating 0.5 mg at bedtime related to vascular dementia. A care plan, dated 4/4/18, indicated the resident used the psychotropic medication Risperdal related to vascular dementia with behavior disturbance. A care plan, dated 4/4/18, indicated the resident had a behavior problem of placing himself on the floor. The interventions included, but were not limited to, administer medications as ordered. A care plan, dated 4/4/18, indicated the resident had a behavior problem of bumping his hips and buttocks against the handrails on the wall. The interventions included, but were not limited to, administer medications as ordered. During an interview, on 6/20/19 at 2:25 p.m., the DON indicated Risperdal was an antipsychotic and not indicated for the use of dementia with behaviors. The Nursing Drug Handbook 2019, indicated the nursing considerations for Risperdal included but FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 96 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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, a black box warning for elderly patients with dementia related psychosis who were treated with antipsychotics were at an increased risk for death. The drug is not approved to treat elderly patients with dementia related psychosis. 5. The record for Resident 38 was reviewed on 06/14/19 at 1:28 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, delusional disorder and psychotic disorder with delusions. A physician's order, dated 05/29/19, indicated to give Depakote Sprinkles (a mood stabilizer) 500 mg (milligrams) twice a day for dementia with behavioral disturbance and to monitor for being resistive to care, pacing, aggression, striking out secondary to paranoia, intrusive wandering and urinating in inappropriate places. A physician's order, dated 05/29/19, indicated to give Zyprexa (an antipsychotic) 7.5 mg twice a day for psychotic disorder with delusions and to monitor for being resistive to care, pacing, aggression, striking out secondary to paranoia, intrusive wandering and urinating in inappropriate places. A physician's order, dated 05/29/19, indicated to give Lexapro (an antidepressant) 5 mg once a day for major depressive disorder and to monitor for pacing, wandering, insomnia and being resistive to care. A care plan, dated as revised on 06/02/19, addressed the problem the resident received Depakote for dementia with behavioral disturbance. A care plan, dated as revised on 06/02/19, addressed the problem the resident had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 97 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 diagnosis and history of severe mental illness related to psychotic disorder with delusions and delusional disorder. The delusions to monitor for were not located. During an interview, on 06/18/19 at 3:26 p.m., the Assistant Director of Nursing (ADON) indicated the use of the mood stabilizer should not be linked to dementia with behaviors, it should be used for a mood disorder or seizures. Currently, he was not being monitored for delusions only his behaviors and his delusions were they were not listed in his record. Behavior monitoring should be specific as to what his delusions were. A current facility policy, titled "Psychotropic Medication-Gradual Dosage Reduction," dated a revised 02/01/18, received from the Executive Director on 06/19/19 at 9:05 p.m., indicated "...To ensure that residents are not given psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions...Staff will monitor residents for side effects, withdrawal symptoms and /or changes in behavior and report to physician and/or psychiatrist. Documentation of observed side effects by nursing staff will occur as indicated in the Nurses Notes and/or on the EMAR...." 3.1-48(a)(3) 3.1-48(a)(4) F 0759 SS=D Bldg. 00 483.45(f)(1) Free of Medication Error Rts 5 Prcnt or More §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 98 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 percent or greater; Based on observation, interview and record review, the facility failed to ensure medications were administered without a 5 % or greater error rate for 2 of 25 opportunities for error, resulting in a medication error rate of 8 %. (Resident 28 and 60) F 0759 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) F 759 Medication error rate >5% 07/21/2019 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. The record for Resident 28 was reviewed on 6/20/19 at 2:34 p.m. Diagnoses included, but were not limited to, vascular dementia with behavioral disturbance, unspecified convulsions and dysphagia following cerebral infarction. 1.Immediate actions taken for those residents identified: Resident # 28 and # 60 had no adverse effects from medication administered During an interview, on 6/17/19 at 3:02 p.m., the ADON indicated Depakote ER delayed release is not okay to crush and the pharmacy indicated they would need to send Depakote sprinkles or Depakote liquid. The Nursing 2019 Drug Handbook indicated for the administration of Depakote: don't crush delayed or extended release tablets. 1.How the facility identified other residents: Any resident that received medications from RN 11 and RN 2 had the potential to be affected, however none were identified. 2. During an observation of medication administration for Resident 60, on 06/20/19 at 3:27 p.m., RN 2 removed one Sinemet (a medication for Parkinson's disease) CR 50/200 mg (milligram) ER (extended release) tab from the pharmacy card. RN 1.Measures put into place/ System changes: Physicians were notified. Education provided on administration of enteric coated Event ID: DATE The facility requests paper compliance for this citation. 1. During a medication administration observation on 6/17/19 at 12:30 p.m., RN 11 crushed the Depakote ER tablets (extended release) for Resident 28 and mixed the medication in pudding. During an interview, before RN 11 administered the medication she indicated the resident had a order to crush pharmaceutically acceptable medications and she did not know if the order included enteric coated, extended release medications. FORM CMS-2567(02-99) Previous Versions Obsolete (X5) COMPLETION 7SCR11 Facility ID: 000025 If continuation sheet Page 99 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 2 proceeded to crush the medication and mix it into pudding. When RN 2 was stopped before she administered the medication, she indicated she did not believe the medication was an ER medication and would have to check the pharmacy card. After checking the card, she indicated the medication was ER and should not have been crushed. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE medications and administration guidelines. The Director of Nursing or designee will observe at least 2 nurses or QMA’s per week perform medication administration on at least one resident on varied shifts to ensure medications are administered as ordered. A current policy, titled "Medication Administration Policy", revised on 1/1/2015 and received from the DON on 6/20/19 at 4:00 p.m., indicated, "... Medications must be administered in accordance with a physician's order...the right resident, right medication, right dosage, right route, and right time...." 1.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 x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 3.1-48(c)(1) 5) Date of compliance: 7-21-19 F 0760 SS=D Bldg. 00 483.45(f)(2) Residents are Free of Significant Med Errors The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. Based on observation, interview and record review, the facility failed to ensure discharge orders from a hospital discharge were followed 2 of 4 residents reviewed for significant medication errors. (Residents 11 and 38) F 0760 This Plan of Correction is the center's credible allegation of compliance. 1. The record for Resident 11 was reviewed on Event ID: 07/21/2019 12:00:00A The facility respectfully requests a desk review for this citation. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete F760 Free of Significant Medication Errors: 7SCR11 Facility ID: 000025 If continuation sheet Page 100 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG 6/14/19 at 3:19 p.m., Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, dementia, hypertension, diabetes mellitus with diabetic neuropathy and congestive heart failure. The hospital discharge instructions dated 6/11/19 indicated to stop the Aldactone, drink fluids and keep hydrated. The resident was diagnosed with acute kidney injury which had improved since the admission and was probably secondary to dehydration from poor oral intake and being on Aldactone and other nephrotoxic medications. The resident had a fall which was probably secondary to generalized weakness from dehydration and acute kidney injury. (X5) COMPLETION DATE 1) Immediate actions taken for those residents identified: Resident # 11 and #38 was assessed, no negative outcomes identified. Medication orders and care plans reviewed and updated as required. Medication variance report completed for #11. Notification was made to family and physician. The facility Medication Administration Record indicated the resident received the spironolactone (Aldactone) through 6/19/19. 2) How the facility identified other residents Any resident residing in the facility had the potential to be affected. Audit conducted of new admission orders for 6-2019 completed to determine orders had been taken off correctly. Any identified issues were addressed. During an interview, on 6/20/19 at 10: 40 a.m., the DON (Director of Nursing) indicated the order to stop the resident's Aldactone was not noted until June 19, 2019 and should have been stopped on June 11, 2019. She indicated the resident's physician was notified. 2. The record for Resident 38 was reviewed on 06/14/19 at 1:28 p.m. Diagnoses included, but were not limited to, unspecified atrial fibrillation, difficulty in walking, lack of coordination, dementia with behavioral disturbance, delusional disorder and psychotic disorder with delusions. 3) Measures put into place/ System changes: Directed education presented regarding prevention of medication errors, hospital discharge orders and documentation per the A progress note, dated 05/24/19 at 8:40 p.m., indicated on 05/24/19 at 4:45 p.m., the resident had 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. A physician's order, dated 7/31/18, indicated spironolactone (Aldactone a diuretic) 25 mg (milligram) one time a day for hypertension. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 101 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 an unwitnessed fall and was noted on his floor face down. The resident was sent to the hospital and was admitted with atrial fibrillation with rapid ventricular response. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Regional Nurse Consultant. New Admission order audits completed within 24 hours and verified per 2 licensed staff. A hospital discharge note, dated 05/28/19, indicated the resident's discharge diagnosis and active problem was atrial fibrillation, unspecified type. 4) How the corrective actions will be monitored: The Director of Nursing and Assistant Director of Nursing will review all new admission orders for accuracy and documentation. Any identified issues will be immediately addressed through 1-1 education, and or disciplinary action. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. A care plan related to atrial fibrillation was not located in the resident's record. The hospital current discharge medication list, dated 05/28/19, indicated to start flecainide (a medication to treat abnormal heart rhythm) 50 mg (milligrams) every 12 hours. A review of Resident 38's May and June medication administration record (MAR) indicated the flecainide was not started upon return from the hospital. 5) Date of compliance: 7-21-19 A review of Resident 38's record did not indicate the resident's physician was contacted regarding the resident's discharge instructions from the hospital. A physician's progress note, dated 06/04/19, indicated to continue toprol (an antihypertensive medication) and to stop taking flecainide. A review of Resident 38's record did not indicate the physician was notified the flecainide was not given between 05/28/19 and 06/04/19. During an interview, on 06/14/19 at 1:45 p.m., the DON indicated the physician could have given a verbal order to discontinue the flecainide and if so, it would be documented in the progress notes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 102 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 During an interview, on 06/18/19 at 3:02 p.m., the DON indicated she could not locate any documentation on where the medication was started or documentation of where the medication was discussed with the doctor. A current facility policy, titled "Physician OrdersEntering and Processing," dated as revised 01/31/18, received from the Executive Director on 06/19/19, indicated "...To provide general guidelines when receiving, entering and confirming physician or prescriber's orders. (a prescriber is noted as physician, nurse practitioner, and a physician's assistant.)...Notify the resident's physician (if not prescribing physician), for verification if applicable...Verbal and Telephone orders will be documented as such in the Electronic Medical Record...." 3.1-48(c)(1) 3.1-48(c)(2) F 0791 SS=D Bldg. 00 483.55(b)(1)-(5) Routine/Emergency Dental Srvcs in NFs §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 103 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 §483.55(b)(2) Must, if necessary or if requested, assist the resident(i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. Based on interview and record review, the facility failed to ensure dental services were provided for residents with dentures for 2 of 4 resident's reviewed for dental services (Resident 1 and 50). F 0791 F 791 D routine emergency Dental Services 07/21/2019 12:00:00A The facility requests paper compliance for this citation. Findings include: This Plan of Correction is the center's credible allegation of compliance. 1. During an interview, on 6/13/19 at 9:34 a.m., Resident 1 indicated her bottom dentures where missing. Preparation and/or execution of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 104 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG The record for Resident 1 was reviewed on 06/14/19 at 1:52 p.m. Diagnoses included, but were not limited to, schizoaffective disorder-bipolar type, major depressive disorder and generalized anxiety disorder. A care plan, dated 12/6/18, indicated the resident required assistance of one person with denture care. Interventions included, but were not limited to, assist the resident to gather supplies and provide denture care with supervision or set-up limited assistance by staff of one, 6-7 times a week. (X5) COMPLETION DATE 1.Immediate actions taken for those residents identified: Resident #1 and #50 have scheduled dental appointments. Dietary orders were reviewed and requested RD follow up to ensure residents ability to eat and drink was not compromised. Care plans reviewed and revised as needed. A care plan which addressed the resident's dental needs was not located in the record. A review of the Activities of Daily Living log for May 2019 and June 2019 indicated the resident was supervision to total dependence for personal hygiene, which included brushing teeth. 1.How the facility identified other residents: Any resident residing in the facility had the potential to be affected. Audit completed to identify those current residents that have dentures. Care plans were reviewed and revised Any issues identified were addressed timely. During an interview, on 6/17/19 at 11:42 a.m., the Social Services Director indicated the nursing staff had not reported to her the resident was missing her bottom teeth, and it should have been reported. The resident also misplaced her dentures a lot, which was not care planned. During an interview, on 06/19/19 at 11:07 a.m., the Director of Nursing (DON) indicated she was not made aware the resident had missing lower dentures. Once nursing staff had identified the dentures were missing, they should have notified the DON so the facility could begin looking for them. The resident should have been care planned for denture care, including misplaced Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 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. A physician's order for dental services was dated 12/6/17. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 1.Measures put into place/ System changes: Facility staff were educated to notify Social Services immediately should issues arise with dentures. 7SCR11 Facility ID: 000025 If continuation sheet Page 105 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG dentures. 2. During an interview, on 6/12/19 at 11:11 a.m., Resident 50 indicate she had top dentures and not lower dentures and she had not seen a dentist. (X5) COMPLETION DATE 1.How the corrective actions will be monitored: The responsible party for this plan of correction is the Administrator. Audits will be completed weekly to identify any resident with lost or damaged dentures was promptly referred. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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 50 was reviewed on 6/13/19 at 3:04 p.m. Diagnoses included, but were not limited to, mild cognitive impairment, gastro-esophageal reflux disease and panic disorder. An Admission/Re-Admission Observation, dated 5/2/19 did not indicate the resident had upper or lower dentures. The section for dentures was not completed and the observation indicated the resident had no broken or carious teeth. A care plan, dated 5/2/19, indicated the resident was able to consume regular consistency food and did not require a mechanically altered diet. 5) Date of compliance: 7-21-19 A current policy, titled "Dental Services and Loss or Damage of Dentures", dated 11/28/17 and received from the Executive Director (ED) on 6/17/19 at 3:35 p.m., indicated, "...The facility will, if necessary or requested by the resident, assist with scheduling appointments for dental services, arranging for transportation to and from the dental services location and promptly refer residents with lost or damaged dentures for dental services. 'Prompt referral' means, within reason, as soon as the dentures are lost or damaged. Referral does not mean that the resident must see the dentist at that time, but does mean that an appointment Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Education provided on the components of F791 Residents were educated through resident council meetings to promptly notify staff of missing or broken dentures. During an observation, on 6/19/19 at 2:01 p.m. with the ADON, the resident did not have lower dentures and the ADON indicated the admission documentation should have included the resident did not have lower dentures. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 106 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 [referral] is made, or that the facility is aggressively working at replacing the dentures...." 3.1-24(a)(1) 3.1-24(a)(3) F 0802 SS=E Bldg. 00 483.60(a)(3)(b) Sufficient Dietary Support Personnel §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). Based on observation, interview and record review, the facility failed to ensure there was enough staff for the resident's to receive their meal within a reasonable time for 26 residents out of 73 who received their food in the Main Dining Room. F 0802 F 802 E Dietary Staffing The facility requests paper compliance for this citation. Finding includes: This Plan of Correction is the center's credible allegation of compliance. During the dining observation, on 6/11/19 at 12:33 p.m., 26 residents were in the dining room waiting to receive lunch, some resident's had drinks but Preparation and/or execution of this plan of correction does not constitute admission or agreement FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 07/21/2019 12:00:00A 7SCR11 Facility ID: 000025 If continuation sheet Page 107 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 there was no utensils available to eat with. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 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 first meal in the dining room was served on 6/11/19 at 1:04 p.m., resident's still did not have utensils. On 6/11/19 at 1:31 p.m., all residents had received utensils. During an interview, on 6/11/19 at 1:23 p.m., the Executive Director indicated the meals times were at 7:30 a.m. for breakfast, 12:30 p.m. for lunch and 5:30 p.m. for dinner. Due to being short staffed in the kitchen and the dining services director resigning, the facility was not able to get the dishes done after breakfast and prior to the lunch service. 1.Immediate actions taken for those residents identified: Residents eating in the main dining received their meals within a reasonable time, 1.How the facility identified other residents: Any resident had the potential to be affective that ate in the main dining room, however no negative outcomes were identified During an observation, on 6/13/19 at 12:56 p.m., the first lunch tray was served in the dining room. On 6/13/19 at 1:25 p.m., the last tray in the dining room was served. During an interview on 6/21/19 at 2:37 p.m., the Executive Director indicated the delay in meal times was directly related to staffing issues. 1.Measures put into place/ System changes: Dietary manager hired. Support staff hired. Education was provided on the components of F 802 regarding dietary support personnel. Meal observations daily per management staff to include all three meals. Identified concerns will be immediately addressed. A policy on staffing the dining room was not provided prior to the Exit Conference on 6/22/19. 3.1-20(h) 1.How the corrective actions will be monitored: Responsible party for oversight of this Plan of Correction will be Dietary manager/designee. Audits conducted during meal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 108 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 observations per Facility Management staff, to include meals served within reasonable time and the provision of fluids and utensils. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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: 7-21-19 F 0806 SS=E Bldg. 00 483.60(d)(4)(5) Resident Allergies, Preferences, Substitutes §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; Based on observation, interview and record review, the facility failed to ensure resident's received an appropriate substitution for mixed vegetables for 9 of 26 resident's who received mashed potatoes instead of mix vegetables in the Main Dining Room (MDR). (Resident 10, 12, 26, and 6 unidentified residents) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F 0806 F 806E Resident Allergies,Preferences,Substituti ons 07/21/2019 12:00:00A The facility requests paper compliance for this citation. 7SCR11 Facility ID: 000025 If continuation sheet Page 109 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 Plan of Correction is the center's credible allegation of compliance. Finding includes: 1. During an observation on 6/13/19 at 12:30 p.m., the menu for lunch that day was "Tasty Meatsauce...Mostaccioli...Italian Blend Vegetables..." the room trays were being prepared and served on the behavioral unit. At 12:56 p.m., the MDR began being served lunch trays which consisted on spaghetti and meatsauce and mixed vegetables. At 1:25 p.m., Residents in the MDR were served spaghetti and meatsauce with mashed potatoes. 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. During an interview on 6/13/19 at 1:27 p.m., a Cook from a sister facility indicated the facility did not have enough vegetables and had to serve mashed potatoes instead. 1.Immediate actions taken for those residents identified: Resident #10 resides on the harmony unit and did not receive mashed potatoes. Resident #12 is unidentifiable and not on the Sample List Provided to the facility. Resident #26 was offered an alternative to the mashed potatoes, however alternate was refused. During an interview on 6/13/19 at 1:36 p.m., the Executive Director indicated she was unaware the facility had run out of vegetables and should have served something comparable. A current facility policy, titled "Menu Substitutions," undated, received from the Director of Nursing on 6/13/19 at 2:14 p.m., indicated "...Substitutions shall provide equal nutritive value. See Reference-List of Nutritive Value Substitutions...List of Nutritive Value Substitutions...Vegetables....Broccoli...Carrots...." Mashed potatoes were not listed as a replacement vegetable. 1.How the facility identified other residents: Any resident eating in the Main Dining room on 6-13-19 at 12:56 pm had the potential to be affected, however no negative outcome was identified. 3.1-21(a)(4) 1.Measures put into place/ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 110 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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: Education provided to dietary staff on the provision of appropriate substitutes. 1.How the corrective actions will be monitored: The responsible party for this plan of correction is the Dietary Manager/designee Meal observations/audits will occur daily per management team to include all meals where appropriate substitutions will be observed. Issues identified will be addressed timely. .The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance 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: 7-21-19 F 0835 SS=F Bldg. 00 483.70 Administration §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 111 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG Based on interview and record review, the administrator failed to ensure the staff employed at the facility were free of abuse allegations, to ensure environmental concerns had been addressed, to ensure the kitchen had adequate and qualified staff and to ensure the facility smoking policy was enforced. This deficient practice had the potential to affect 73 of 73 residents who resided in the facility. F 0835 F835 F Administration (X5) COMPLETION DATE 07/21/2019 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. 1. During an interview, on 6/19/19 at 11:39 a.m., the ED indicated LPN 10 should not have been hired by the facility due to the action under the LPN's license which falls under misappropriation of a resident's property which is considered abuse and is prohibited by the facility's abuse policy and compliance program. Cross reference F580. 2. During an interview on 6/21/19 at 3:03 p.m., the Administrator indicated there were no specific action plan in place regarding the environment. Cross reference F921. 1.Immediate actions taken for those residents identified: 1.LPN #10 is not employed by facility. 2.Action Plan was developed for environmental issues. 3.Certified Dietary manager hired; ancillary dietary staff in place. 4.New policy initiated for smoking. No resident was identified to have had a negative outcome. Staff identified smoking Received disciplinary action. 3. During an interview on 6/21/19 at 2:37 p.m., the Executive Director indicated the delay in meal times was directly related to staffing issues. Cross reference F 802. 4. During an interview, on 6/18/19 at 4:05 p.m., the Executive Director indicated all residents, upon admission, were educated regarding the smoking policy and all staff, upon hire, are educated regarding the smoking policy. No staff or residents should be smoking on the facility grounds and the facility was in the process of re-educating all the staff regarding the smoking policy. Cross reference F 550. Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This facility respectively requests desk review for this citation. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY 1.How the facility identified 7SCR11 Facility ID: 000025 If continuation sheet Page 112 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 other residents: 1.A facility audit was completed to ensure employees were free of abuse allegations. 2.Any resident that resides within the facility had the potential to be affected, however none were identified. A facility wide review was completed by management staff to identify areas other that those identified on the 2567. 3.No resident was identified to have been affected. 4.A facility audit was completed to identify those residents that smoke, assessments were completed, and care plans were developed. 3.1-13(q) 1.Measures put into place/ System changes: 1.HR will review background checks and license review bi-monthly. Facility will prohibit the hiring of any applicant that has a history of abuse(misappropriation). 2.Action plan was developed for identifying, planning and implementing processes to ensure environmental concerns are addressed timely. 3.Monitoring meal times per management staff daily to determine continued timely service. Education provided on meal time requirements 4.New policy initiated for smoking. Staff, residents and families educated on new policy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 113 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 . 4) How the corrective actions will be monitored: The monitoring of this will be a joint effort between the facility Director of Nursing/ designee. Human resources will audit every employment background check prior to hire to ensure no applicant has a history of abuse. Maintenance director will complete environmental QA audit 2x weekly and review with Director of Nursing/designee those areas identified throughout the facility that require attention. Repairs will be logged when completed. Log book will be reviewed during QA to identify trends, Dietary Manager will review audits of meal service times 3 times weekly to identify trends related to staffing. Action Plan developed. Random observational audits conducted by Activity Director 3 times weekly to determine adherence/compliance to the Smoking policy. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. 5) Date of compliance: 7-21-19 F 0867 SS=F 483.75(g)(2)(ii) QAPI/QAA Improvement Activities FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 114 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG TAG 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER Bldg. 00 (X3) DATE SURVEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; Based on observation, interview and record review the facility failed to ensure the Quality Assurance and Quality Improvement committe identified and corrected repeated concerns in the facility. This deficient practice had the potential to affect 73 of 73 residents who resided in the facility. F 0867 F867 Quality Assurance 07/21/2019 12:00:00A Facility respectively request a desk review 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. Finding include: The facility's Quality Assurance Committee did not identify issues, develop and implement appropriate measures to correct identified issues as follows: The facility had a pattern of repeat concerns from prior surveys and did not maintain correction of the identified repeat deficiencies and did not identify and develop actions for the prevention of deficient practice identified on the standard annual survey as listed below. 1.Immediate actions taken for those residents identified: 1. Environment: Item identified were repaired, care plans revised, behavior training provided, and physician notified. Issue 1) Action Plans developed for individual repair/maintenance areas. Maintenance director will ensure identified areas are placed on his preventative maintenance F465: 2/8/16, 3/17/17 F 921: 8/13/18 Cross reference: F 921 During an interview on 6/21/19 at 3:03 p.m., the Administrator indicated there were no specific action plan in place regarding the environment. She indicated rounds were completed to identify FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 115 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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) concerns. Angel rounds were also completed by each manager. If there were concerns, they should be place on a maintenance slip for review and completion. The list "gets heavy" sometimes. The entire team was to monitor. program Action plan was developed for cleaning, and the Housekeeping director will place specific projects on a cleaning schedule. 2. Accident Hazards and Supervision: Issue 2) Action plans were developed to address the following: residents with wandering behaviors. resident do not have in their possession prohibited items. implementing new interventions and care plan revisions. F689: 8/13/18, 1/23/19, 3/1/19 Cross reference: F689 3. Dementia Care F744: 3/1/19 Crosss Reference: F744 4. Notification of Changes (X5) COMPLETION DATE Issue 3) Action plans were developed to address interventions/plan to prevent or relieve behaviors for residents that wander or intrusively wander. F 580: 1/23/19, 3/1/19 Cross referecne: F580 3.1-52(b)(2) Issue 4) Action plan developed to address Notification of Changes and documentation of such to include the resident, the resident representative and physician. 1.How the facility identified other residents: Any current resident had the potential to be affected however no adverse effects were identified. . 2.Measures put into place/ System changes: The Maintenance Director and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 116 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 Department Heads through Guardian Angel rounds will make rounds (5 times weekly) of all rooms and common areas and report any needed repairs. Staff was re-educated on the maintenance request forms, to be checked by the Maintenance Director/designee and prioritized with the Executive Director during daily stand up meeting. Repairs are made based on this prioritization. The Maintenance Director will record/ log when repairs are completed. Housekeeping Director will provide staff with individual cleaning assignments and complete a facility round daily to determine satisfaction. Staff educated to encourage residents to attend group sessions and activities provided by facility psychologist. Education provided on managing behaviors with Dementia residents, and Intrusive Wandering. Staff provided with additional strategies to deescalate wandering. Education provided on prohibition of potentially harmful possession. Intervention folder updated to assist staff when dealing with residents with dementia and wandering behaviors. Behavior management Meeting held weekly with participation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 117 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 DON, ADON,SS,ACTIVITIES, and PSYCHOLOGIST. Education provided on care plan revision and intervention updates for those residents with falls Accidents/Incidents will be reviewed daily during regularly scheduled department meetings for care plan updates and implementation of intervention. Nursing staff were re-educated on the component of F-tag 580 and the need of timely notification of a resident’s representative and primary care physician regarding changes of condition. Weights will be reviewed during scheduled morning meeting Any identified issues of concern will be immediately addressed 1. How the corrective actions will be monitored: Oversight of this plan of Correction will be the Director of nursing or designee Housekeeping Director will audit 3 times weekly to determine the environment is clean and odor free. Maintenance Director will audit 3 times weekly to determine facility needed repairs are being identified, addressed timely and placed on a preventative maintenance program as necessary, who will during the routine facility rounds visually check/audit for areas that need to be addressed or repaired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 118 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 DON/designee will audit 3 residents, on behavior monitoring, 3 times weekly, identified to wander DON/designee will audit 3 residents related to Accidents/Hazards 3 times weekly. Identified issues will be immediately addressed The DON/Designee will audit 3 resident records weekly to determine prompt notification of change is occurring. Issues identified will be immediately addressed. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. 5) Date of compliance: 7-21- F 0880 SS=D Bldg. 00 483.80(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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 119 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 00 COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 §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; (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 120 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 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, interview and record review, the facility failed to ensure glucometers were cleaned per facility policy for 1 of 1 observation during medication pass. This deficient practice had the potential to affect 3 of 3 residents utilizing the glucometer. (Resident 54, 57 and 8) F 0880 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. A current policy, titled "Glucometer Cleaning" revised on 11/17/17 and received from the Corporate Clinical Support Nurse on 6/17/19 at 3:40 p.m., indicated, "...To prevent the growth and spread of microorganisms and bloodborne Event ID: 07/21/2019 12:00:00A This facility request paper compliance for this citation. During a medication pass observation, on 6/17/19 at 11:25 a.m., RN 11 indicated the glucometer was used for multiple residents and was cleaned during the night shift, then she used alcohol swabs to wipe down the glucometer. RN 11 indicated she did not know if alcohol swabs were approved to clean the glucometer. The ADON was present and indicated bleach wipes were to be used to clean the glucometers and Resident 54, 57 and 8 utilized this glucometer. FORM CMS-2567(02-99) Previous Versions Obsolete F880 Infection Prevention and Control 1.) Immediate actions taken for those residents identified: Resident #53and#8 were 7SCR11 Facility ID: 000025 If continuation sheet Page 121 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG pathogens...The blood glucose monitor should be cleaned and disinfected between each resident test...To clean and disinfect the meter, use pre-moistened wipe/towel of 1 ml (milliliter) of 5-6% sodium hypochlorite solution(household bleach)...Wipe meter with 1:10 bleach wipe/towel until all surfaces of the glucometer are visibly wet...Place glucometer on a clean surface such as paper towel and allow to air dry for no less than 3 minutes.... Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE assessed. Resident #57 no longer resides in facility. No negative outcomes identified. RN #11 was educated on facility policy on glucometer cleaning. 2) How the facility identified other residents: Any resident who received glucometer/accuc heck testing by RN#11 had the potential to be affected however no one was identified. 3) Measures put into place/ System changes: In-service provided on infection control with a specific focus on glucometer cleaning to licensed nursing staff and Qualified medication aides. The Director of Nursing Services/designee will conduct observational audits of glucometer usage 3 times weekly to assure adherence to infection control procedure. Identified areas of concern will be addressed with 1-1 in servicing, 4) How the corrective actions will be monitored: The Director of Nursing Services/designee will conduct observational audits of glucometer usage 3 times a week to assure adherence to the facilities infection control standard. Any variations will be immediately corrected with 1-1 education. The results of these audits will be reviewed in Quality Assurance Meeting monthly for 6 months or 3.1-18(b)(1) FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 122 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 until 100% compliance is achieved x3 consecutive months. 5) Date of compliance: 7-21-19 F 0921 SS=F 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, interview and record review, the facility failed ensure the environment was clean and in good repair for 4 of 4 units observed in the facility. F 0921 The facility requests paper compliance for this citation. Findings include: This Plan of Correction is the center's credible allegation of compliance. During an observation of the facility on 6/11/19 at 10:20-11:20 a.m. and 12:58-1:30 p.m., the following was observed: 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. A. Room observations: 1. Harmony Room 129: pungent smell of urine outside the entry door and upon entering the room. The floor by the entry and bathroom was sticky, and reeked of urine. There were holes in the wall above the sink, with 2 screws sticking out of the wall above the sink. There was missing trim on the base of the sink and the dresser. The cove board was tearing loose under sink. There was a large break and piece of the marble windowsill on right side missing with sharp edges. The privacy curtain had spills and stains on the lower edges. There was gouges in the wall beside the bed and there was a build up of dust and debris around the cove board in the entire room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 07/21/2019 12:00:00A F 921 1.Immediate actions taken for those residents identified: No resident was identified to be affected 7SCR11 Facility ID: 000025 If continuation sheet Page 123 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG 2. Harmony Room 127: the bathroom had an approximate (approx) 12 inch (in) x 12 in area of patched dry wall not painted behind toilet above tile, the sink had a green/blue leak stain around and under hot and cold water handles, and the water was dripping. The trim was coming off around sink, and there was brown staining on the wall above the trash can. The air conditioning unit was loose and pulling away from wall 1-2 inches. There were gouges on wall behind both beds and the entry door had gouges and chipped paint. (X5) COMPLETION DATE 3) Measures put into place/ System changes: Harmony Room #129 both living area and bathroom floors were stripped and waxed. Holes in the wall above sink were repaired and the two screws were removed. Trim was replaced on sink and dresser. Cove base under sink was repaired. Marble on windowsill was replaced. Privacy curtain was replaced with a new curtain. Walls beside bed were repaired. Cove board was cleaned around the entire room. 4. Harmony Dining Room: The floor was dirty with black marks all over. The heat/air unit under the window had wood with missing paint and was scuffed with black marks. The wall at the back of the room had scuff marks. The thermostat on wall was missing the cover. The window in the dining room was open and there was no screen in the window and the other screens that were present were torn and shredded. Harmony Room #127 patched drywall was painted behind toilet. Sink handles were replaced and water leak was repaired. Trim around sink was repaired. Walls were washed to down remove any staining. Air conditioning unit was secured. Wall behind both beds was repaired. Entry door was sanded and painted. 5. Harmony Activity Room: The walls were scuffed and marred. The wall under the had sink had unfinished. The floor had scattered debris. Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1.How the facility identified other resident: Any resident had the potential to be affected but no resident was identified to have been affected 3. Harmony Quite Room: Before entering the room, there was a pungent urine odor. There were 7 residents siting in the room. 5 residents were identified as Residents 10, 53, 33, 57, and 59). There were 2 love seats that were worn and stained. The floor was sticky, and had a build up of dirt and debris around the cove board. The marble window seal was loose on the right side. The had sink in the room had no soap or paper towels. When the bathroom door was opened a foul, strong urine odor was present. The light in the bathroom did not work. The floor was soiled around the toilet and the room. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 124 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG 6. Harmony Unit Medication door: The medication room door was scuffed and marred. 06/11/19 11:17 AM sofa in quiet room next to door is stained all over cushions, sofa across from the TV has food crumbs all over, the upholstery is faded, very dirty all over. The ceiling lights have cord across the ceiling and plugged into wall outlet, there is softball sized hole in wall where door knob hits the wall, doors to med room and clean utility, have scuff marks over lower doors, and wall next to med room is all scuffed with missing paint. The hand rail next to the nurses station has worn off varnish (X5) COMPLETION DATE Harmony Dining Room floor was thoroughly cleaned. Wood was painted under the window at the heating/air unit. The walls were thoroughly cleaned, and scuff marks were removed. The thermostat cover was replaced. New screens were put in the windows. 8. Room 108: floor of the room had debris. The bathroom had a hole in drywall to the right of the sink above the cove board, approx. 4 in x 3 in,. The call light in the bathroom was long enough to reach outside the doorway and was laying on the floor. The hot water handle was rusted, and the cold water handle was cracked. There was a torques bed pan on the floor behind the toilet. Harmony Activity Room floors were stripped and waxed. The walls were thoroughly cleaned and scuff marks, any marred areas were repaired. Harmony Unit Medication door was sanded and repainted. Sofa was removed, and other seating has been provided. Ceiling light cords have been rerouted as not to be exposed. Hole in the wall behind door has been repaired. Door to clean utility room has been 9. Room 111: The bathroom had patched drywall to the right of the entrance door, not painted. The toilet was soiled with splattered bowel movement on the seat, base and bowel. There was a hole in the drywall by metal water fixture. The metal water and flush fixture was soiled and had the blue/green hue. Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Harmony Quite Room living area and bathroom was stripped and waxed. The loveseats were discarded, and different seating was provided. Cove board was cleaned around the entire room. Paper towel and soap were provided at the sink. The light in the bathroom was replaced. The marble windowsill was replaced. 7. Harmony Unit Room 202: The counter top on the dresser next to sink was pulled apart, the tiles on the floor were separated and didn't cover the flooring underneath the tiles and the baseboard trim was peeling off. The toilet bowl was dirty and stained, the toilet paper holder was missing and the toilet paper was sitting on a bucket out of reach from the toilet. FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 125 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 Harmony Room #202 countertop next to dresser has been repaired. Tiling on floor was repaired. Baseboard trim was repaired. Toilet bowl was cleaned. Toilet paper holder was replaced and toilet paper was placed on holder. 11. Room 119: There were no doors on the closet. There scuffed paint beside the bed, cove board was pulling away form the wall at the closet doors, and the doors were scuffed and marred. The bathroom floor had laminate wood flooring that was torn away with exposed tile underneath. Room #108 floor was cleaned. The wall to the right of the sink was repaired. Call light cord was replaced in the bathroom. The sink handles were placed in the bathroom. The bed pan was removed from behind the toilet. 12. Room 315: The bathroom sink was pulling away from the wall, 1-2 inches, there was a urine odor, 2 screws were laying on the tub, with a tub drain out and laying in base of tub. There was moisture damage above the air conditioner unit. The cloth love seat in room had soiling and a quarter size tear in the seat. Room #111 bathroom drywall was repaired and painted. Toilet base, bowl and seat was disinfected and cleaned. The sink fixtures were replaced. 13. Room 313: The cove board was pulling away from wall around room. The cloth love seat had scattered areas of staining. The wall paper was pealing off the wall above the air conditioning unit. The bathroom had a toilet riser on floor, the sink was pulling away from the wall, and there was chipped marred paint on the wall and the doors. Room #117 the wallpaper was repaired above light socket and by bathroom door. Privacy curtain hooks were reattached. Closet door was replaced. Wall behind bed B was repaired. Bathroom was thoroughly cleaned and disinfected. Bath basin was removed from under the sink. 14. Room 306: The bathroom floor entrance had trim that was pulling up off the floor, the door was Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) cleaned and painted. Wall beside next to med room has been repainted. Handrail next to nurses’ station has been retained. 10. Room 117: There was torn wall paper by the light socket above Bed A. The privacy curtain had 3 hooks that were not attached. The left side closet door was missing. The wall behind Bed B had scratches and mars. The bathroom had a urine odor. There was a bath basin on the floor under the sink. The water was dripping and would not shut off. The trash can had trash in it with no liner. The door had mars and scratches and the wall paper was pulling away form the wall at the bathroom door. The ceiling vent outside room 117 was surrounded by a build up of dust on the ceiling tiles. FORM CMS-2567(02-99) Previous Versions Obsolete (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 126 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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) scuffed and marred and the call light cord had a rubber glove tied to end. There was a bath basin on the floor under the sink. Sink was repaired. Trash can liner was placed in trash can. Ceiling vent was cleaned. 15. Room 301: The curtain rod was pulling off wall on right side and the wall paper was coming off the wall around air conditioning unit. There was a bath basin under sink and no liner in trash can. There were spills and debris on the floor by the nightstand. The wallpaper was pulling away from wall by the light above Bed B. The bathroom toilet was soiled around the outer rim and the toilet seat riser had a broken lid . The walls were scuffed and marred. Room#119 closet doors were replaced. Walls were cleaned and scuffed marks were removed. Cove board was repaired by the closet doors. Bathroom floor laminate was repaired. 17. Dining room: There was torn tile entering dining area next to Activity room door. The exit door to the courtyard had a build up of debris at the egress and torn flooring. The glass window above the door had multiple cracks in the glass. The wall paper around the dining room had mars and scuffing. The second exit door to the court yard had dirt and debris in the egress. The walls outside the kitchen doors were soiled soiled with splatters,scuffed and marred. The Floor exiting the dining area to Redbud lane had a build up of dirt and debris at the cove board and an approx 8-10 foot area of cove board was missing. The wall paper on the right side was dirty and pulling away in many area. Room #306 bathroom floor entrance trim was replaced. Door was painted. Rubber glove was removed from call light cord. Bath basin was removed. Room #301 Curtain rod was reattached. Wall paper around air conditioning unit and light above bed b was repaired. Bath basin was removed from under sink. Trash can liner was placed in can. Floor was thoroughly mopped. Bathroom was cleaned and disinfected. Broken toilet riser was removed and replaced. Walls were cleaned and repaired of On 6/11/19 at 1:45 p.m., an environmental tour was conducted with the Administrator, the Regional Executive Director, the Regional Nurse Consultant Event ID: DATE Room #315 bathroom sink was replaced. Bathroom was cleaned and disinfected. Screws laying on tub were removed. Loveseat was removed and other seating was provided. Wall around air conditioning unit was repaired. 16. Activity Room: Above the cove board across from the activity room had dry wall patches that were not painted. The Activity room floor had debris and there was a build up of debris and dirt around the cove board. FORM CMS-2567(02-99) Previous Versions Obsolete (X5) COMPLETION 7SCR11 Facility ID: 000025 If continuation sheet Page 127 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION TAG and the Director of Nursing. All the above concerns were discussed. The Regional Executive director confirmed these were areas of concern. She indicate the Harmony quite room did have a strong urine odor and residents were present in the room. (X5) COMPLETION DATE Activity Room – drywall above the cove board base across from activity room was repaired and painted. Activity room was cleaned and mopped thoroughly. Cove board was thoroughly cleaned. Dining room torn flooring was repaired. Both exit door egresses were cleaned. The glass window above the exit door was replaced. The wallpaper in dining room was cleaned thoroughly and repaired. Dining room floor was stripped and waxed including area leading out to redbud lane. Missing cove board was replaced. B. A. Brown, greenish, blackened ceiling tiles: 1. Harmony Unit: a. 4 tiles at first light fixture outside room 213. b. 7 tiles between rooms 211 - 209 c. 2 tiles between rooms 204 202 d. 1 tile outside room 205, with orange hue e. 9 tiles between room 200 and the nurses station f. 5 tiles between the nurses station and the dogwood room Shower on 200 hall was repaired. Missing or loose tiles were replaced. 2. 300 hall a. 3 ceiling tiles outside private dining room b. 4 tiles outside room 302 c. 7 ceiling tiles outside the Harmony Unit doors All indicated ceiling tiles have been replaced. Facility doors and trim will be painted at 10 doors per week until painting has been completed throughout the facility. C. The entry door trim and door ways throughout the building had marring and scuffed paint, including resident rooms, fire doors, activity room, clean and soiled utility, and exit doors. Environmental concerns will be reviewed and addressed daily. All staff has been provided with additional education on On 6/11/19 at 1:45 p.m., an environmental tour was conducted with the Administrator, the Regional Event ID: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) scuffs and marring. 18. Shower room in the 200 hall: On 6/14/19 at 1:45 p.m., there was water all over the entire floor of the room due to the shower to the left wound not shut off. At this time during interview, a confidential interviewee indicated the shower had continuously run for a long time and had been reported and it was not fixed. The shower had missing tiles on the walls close to the floor and other tiles were loose from the wall. FORM CMS-2567(02-99) Previous Versions Obsolete 00 A. BUILDING NAME OF PROVIDER OR SUPPLIER TAG (X3) DATE SURVEY 7SCR11 Facility ID: 000025 If continuation sheet Page 128 of 129 07/25/2019 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 155064 (X2) MULTIPLE CONSTRUCTION 00 A. BUILDING COMPLETED 06/21/2019 B. WING STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3518 S LAFOUNTAIN ST KOKOMO, IN 46902 APERION CARE KOKOMO (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 Executive Director, the Regional Nurse Consultant and the Director of Nursing. All the above concerns were discussed. The Administrator indicated the tiles had been replaced on the Harmony unit multiple times. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE the process of completing work orders. Any issues Environmental rounds will be completed weekly x2 by maintenance director/housekeeping supervisor/ED/designee. Any concerns identified will be addressed immediately. 3.1-19(f) 4) How the corrective actions will be monitored: The results of these audits will be reviewed in QAPI monthly for 6 months or until 100% compliance is achieved for 3 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: 7-21-19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7SCR11 Facility ID: 000025 If continuation sheet Page 129 of 129