PRINTED: 101069017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF {x1} PROWDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (Te; DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING commoner) 165310 e. WING 101032017 NAME or PRcvaR OR SUPPLIER STREET ADDRESS. cm', STATE, ZIP cone HERITAGE SPECIALTY CARE OWE CEDAR IA 52404 (x4; SUMMARY STATEMENT or Io PRochR's PLAN OF ccnnecnon (x5, pREng (EACH DEFICIENCY MUST BE FRECEDED BY FULL PREFIX cossecrwencnon SHOULD BE TAG REGULATORY on Lee IDENTIFYING TAG CROSS-REFERENCE) TO THE APPROPRIATE BATE DEFICIENCY) 000 COMMENTS 000 Correction Date a? The foilowing information is related to the investigation of complaint #59490 and #69448 and facility reports #6868? and #69049. 68687?1, 690494 and 69448-6 are not substantiated and #69490-0 was substantiated. See code of Federal Regulations (45 CFR) Part 483, Subpart euc. 157 NOTIFY OF CHANGES 15? Noti?cation of Changes. A facility must immediateiy inform the resident; consuit 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 potentiai for requiring physician intervention; (B) A signi?cant change in the resident?s physical, mentai, or status (that is, deterioration in health, mental! or status in either ?fe-threatening conditions or clinical complications); (C) A need to after treatment signi?cantly {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 as speci?ed in LABORATORY DIRECT OR REPRESENTATIVES SIGNATURE TIA LE i3 ?anges Any de?ciency statement ending with an asterisk C) denotes a de?ciency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the ?ndings stated above are disclosebie Bi] days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above ?ndl and pisns of correction are disclosable 14 iays foilowing the date these documents are made aveiiabi to the faciliwaeneles are cited, an appro pier; of correction is requisite to continued program participation. {ii/l 7 FORM Previous Versions Obsolete Event I Fadiliy if): if continuation sheet Page 1 of3 Plan of correction for Prefix Tag F157: Please accept this as the credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth of the facts alleged or the 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/or state law. Professional standards of quality will be provided by: Resident ii 4 was discharged home on 7?28?2017 and staff notified the resident?s family of the accident at their routine daily arrival time as there was neither an injury nor a change in the resident?s condition warranting timely notification. will review physician orders and progress notes during clinical meeting to identify potential notification concerns and provide necessary follow upfnotification as indicated by review. The facility will provide education to all licensed nurses by 1043" 17 to?include timely notification of family for all accidents with injury or significant change in condition and morning notification for all accidents without injury that occur during hours of sleep. will present notification concerns to QA Committee for 3 months for review and recommendations. Compliance date of October 23, 2017. PRINTED: 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVE CENTERS FOR MEDICARE SERVICES OMB No. 0938?0391 STATEMENT OF DEFICIENCIES (Xi) MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: A BUILDWG COMPLETED 15531? 3- 1010312017 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE HERITAGE mas 2mm? mm CEDAR RAPIDS, IA 52404 9(4) In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION 0(5) PREFIX DEFICIENCY musr BE PRECEDED sY FULL PREFIX SHOULD BE catamaran TAG REGULATORY OR LSC IDENTIFYING TAG TO THE APPROPRIATE DATE DEFICIENCY) 157 Continued From page 1 157 (ii) When making noti?cation under paragraph of this section. the muet ensure that ail pertinent intormatien speci?ed in is available and provided upon request to the physician. The facititv must also premptiy notify the resident and the resident representative, if any, when there is? (A) A change in room or roommate assignment as speci?ed in ?483t10(e)(6); or A change in resident rights under Federal or State law or regulations as speci?ed in paragraph of this section. (iv) The facility must record and periodicaliv update the address {mailing and emaii) and phone number of the resident representative(s). This REQUIREMENT is not met as evidenced by: Based on staff interviews and clinicat record review the facility failed to notify family when one of four resident?s had a change in condition. (Resident The reported a census of 121 residents- Findings include: The MOS (Minimum Data Set) dated 5f18i2017 revealed Resident #4 had no cognitive impairment and diagnoses which included anemia, arthritis, failure to thrive and history of faiI. The Care Plan reported the resident is a fail risk and directed staff to provide therapy, a tow bed, FORM Previotrs Versions Obsoiete Eirth FacilIty IO: if continuaileh sheet Page 2 of 3 um.M DEPARTMENT OF HEALTH AND HUMAN PRINTED: FORM APPROVED CENTERS FOR MEDICARE 8: SERVICES OMB NO. 09380391 STATEMENT OF (x1) PROWDERJSUPPLIERICLIA {x2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A BUILDING COMPLETED 15531? 1010312017 NAME OF PROVIDER OR SUPPLIER STREET Aeneese. STATE. ZIP cone HERITAGE SPECIALTY CARE OWE CEDAR RAPIDS, 52404 {x4} SUMMARY STATEMENT oI= In PROVIDERS PLAN OF CCRRECTTON {x5} pREnx (EACH DEFICIENCY MUST BE PRECEDED BY FULL pREFix (EACH CORRECTIVE ACTION SHOULD BE TAG on Lee IDENTIFYING TAG TO THE APPROPRIATE DATE DEFICIENCY) 157 ContinUed From page 2 15? winged mattress and side rails for positioning and boundaries. Review an incident report dated reveaied Resident#4 rolled out of bed while Sleeping at 12:45 am. The nursing assessment revealed no apparent injuries. The resident denied pain and had he skirt issues. Staff noti?ed the on call physician at 1:40 am. with orders to monitor and report a Change in condition. The report documented staff noti?ed the resident's family on $532017 at 3 o'clock pm. The Nurse's Notes dated 614.1201? at 1:45 pm. revealed staff found Resident #4 on the ?oor beside the bed. The resident reported she felt out of bed. During an interview on 10/3/2017 at 11 o'clock SteffA, RN (Registered Nurse} and ADON (Assistant Director of Nursing), reported they read the incident reports every morning to make sure staff noti?ed physician and family. The incident Report revealed staff failed to notify family until 6i512017 at 3 o?ciock pm. During an interview on 9913:9017. Staff B, RN, Corporate Nurse revealed the facility did not have a policy regarding family noti?cation. FORM Previous Versions Obsolete Event ED: if continuation sheet Page 3 of 3