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(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
F 0000
Bldg. 00
This visit was for a Recertification and State
Licensure Survey. This visit included a State
Residential Licensure Survey. This visit included the
Investigation of Complaint IN00228805.
Complaint IN00228805- Substantiated. Federal
deficiencies related to the allegations were cited at
F157 and F309.
Survey Dates: August 15, 16, 17, 18 and 21, 2017.
Facility number: 000299
Provider number: 155676
AIM number: 100286940
Census Bed Type:
SNF/NF: 59
Residential: 13
Total: 72
Medicare: 9
Medicaid: 48
Other: 2
Total: 59
These deficiencies reflect State Findings cited in
accordance with 410 IAC 16.2-3.1.
Quality Review was completed on August 25, 2017.
F 0000 Submission of this Plan of Correction and Credible Allegation of Compliance does not constitute an admission by the certified and licensed provider at Milner Community Health Care, Inc., that the allegations contained in this survey report a true and accurate portrayal of the provisions of nursing care and services at this health care facility. Milner Community Health Care, Inc., as a licensed and certified provider, recognizes its obligation to provide legally and medically required care and services to our residents in an economical and efficient fashion. Please accept this Plan of Correction as the Credible Allegation of Compliance.
483.10(g)(14) NOTIFY OF CHANGES
F 0157
SS=D
FORM CMS-2567(02-99) Previous Versions Obsolete
Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: WV5511 Facility ID: 000299
TITLE
If continuation sheet Page 1 of 48
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
(INJURY/DECLINE/ROOM, ETC) (g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 2 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).
Based on interview and record review, the
facility failed to notify a resident's family
member of a discontinued medication, to
notify the physician when a medication
was not given as ordered and to notify the
physician when a referral for a speech
therapy screening was not completed for 3
of 3 resident's reviewed for notification.
(Residents D, B and C).
Findings include:
1. During an interview on 8/16/17 at
10:57 a.m., Resident D's family indicated
Buspar (an anxiolytic medication used to
treat anxiety) was decreased recently and
she was not notified. The family member
indicated she had asked about the
medications during a visit at the facility
and found out the Buspar was changed.
The record for Resident D was reviewed
on 8/17/17 at 1:07 p.m. Diagnoses
included, but were not limited to, anxiety
disorder, depressive episodes and
cognitive communication deficit.
A physician order dated 6/15/17,
indicated to discontinue buspirone
(Buspar) 5 mg daily.
F 0157 1. Resident D's Daughter/POA has been made aware of all changes.Resident B no longer resides in the facility.Resident C was admitted to hospice.2. All residents have the potential to be affected by this alleged deficient practice.3. All licensed staff will be in-serviced on notification policy to ensure compliance to facility protocol.4. DON/MDSC will audit new physician orders for 30 days to ensure notifications have been made. After 30 days they will audit 3 times weekly for 3months and there after QAA team recommended.
09/20/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 3 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
A nurse progress note dated 6/15/17 at
1:49 p.m., indicated the resident was
discussed in the Behavior Meeting due to
the use of Buspar. The resident had
tolerated a GDR (gradual dose reduction)
of the Buspar in the past and the MD
(medical doctor) ordered the Buspar to be
discontinued.
There was no documentation the
resident's daughter had been notified of
the discontinued Buspar.
During an interview on 8/18/17 at 1:32
p.m., the Director of Nursing (DON)
indicated the nurse taking the order for
any medication changes should also notify
the family. The DON indicated he could
not find any documentation of Resident
D's daughter being notified of the
discontinued Buspar.
2. The record for Resident B was
reviewed on 8/18/17 at 1:30 p.m.
Diagnoses included, but were not limited
to, unspecified convulsions, chronic atrial
fibrillation, type 2 diabetes mellitus with
hyperglycemia, and essential hypertension.
Medications included, but were not limited
to: Vimpat (lacosamide-an
anticonvulsants) 50 milligrams (mg) orally
daily at 10:00 a.m., also Vimpat 100 mg
daily at 10:00 p.m.
A review of the nurses notes for 4/22/17
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 4 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
at 10:56 p.m., indicated "... Resident
received 50 mg of this medication tonight
which is 1/2 dose. Resident and family
aware...." The physician was not notified
of the reduced dosage of the medication at
this time.
3. The record for Resident C was
reviewed on 8/16/2017 at 2:43 p.m.
Diagnoses included, but were not limited
to, unspecified dementia without
behavioral disturbance, insomnia,
hydrocephalus, anxiety disorder, adult
failure to thrive and heart failure.
A nursing note dated 7/5/2017 at 8:23
a.m., indicated the ADON had notified the
MD of the resident's poor appetite, refusal
of supplement and her pocketing
medications. The "...MD recommended
ST (speech therapy) to screen. Therapy
aware."
An email from the ADON to therapy
dated 7/5/2017 at 8:23 a.m., indicated the
resident needed a screen. "...Staff is
stating that she is pocketing medications
and has had wt [weight] loss and poor
appetite...."
An email from the ADON to the RD dated
7/5/2017 at 8:52 a.m., indicated the
resident "...is refusing Med Pass 2.0 at
times, cont [continue] with poor intake,
and noted to be pocketing meds
[medications]. I have contacted speech
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 5 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
for a screen and notified MD...."
No documentation was found the speech
therapy had screened the resident.
During an interview on 8/18/2017 at 11:09
a.m., PT 8 indicated Resident C did not
have a speech evaluation completed and a
doctor's order was not necessary to
complete the screen.
During an interview on 8/18/2017 at 11:37
a.m., the DON indicated a speech
evaluation was not completed.
During an interview on 8/18/2017 at 11:49
a.m., the RD indicated she was unaware a
speech evaluation was recommended.
During a phone interview on 8/18/2017 at
2:33 p.m., Resident C's doctor indicated
he was not made aware the speech
evaluation was not completed.
A facility policy dated 1/30/16 titled
"Change of Condition Notification"
received from the DON on 8/17/17 at
2:29 p.m., indicated "...It is the policy of
this facility to notify the Resident,
Resident's Physician, Resident's legal
representative of [sic] interested family
member when there is a change in the
Resident's condition...Areas that require
notification of the Physician, Resident,
Resident's legal representative and/or
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 6 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
interested family member:...Need to alter
treatment significantly...D/C [discontinue]
an existing form of treatment.... Notify if
medication is not available within 24
hours...The resident, resident's legal
representative and/or interested family
member must be kept informed of the
resident's status...."
This Federal tag relates to complaint
IN00228805.
3.1-5(a)(2)
3.1-5(a)(3)
483.10(a)(1) DIGNITY AND RESPECT OF INDIVIDUALITY (a)(1) A facility must treat 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.
F 0241
SS=D
Bldg. 00
Based on observation, interview and
record review, the facility failed to ensure
a cognitively impaired resident was
assisted to eat in an individualized manner
to preserve the resident's dignity while
dining in the assisted area of the main
F 0241 1. Resident C admitted to hospice services.2. All residents needing assistance with meals have the potential to be affected by this alleged deficient practice.3. All C.N.A. and licensed staff will
09/20/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 7 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
dining room for 1 of 14 residents observed
in the assisted area of the main dining
room. (Resident C)
Findings include:
During an observation in the main dining
room on 8/15/17 at 11:06 a.m., CNA
(Certified Nursing Assistant) 2 was
observed to feed Resident C. The CNA
gave Resident C a bite of spaghetti. The
resident had a long string of spaghetti
hanging out of her mouth and the CNA
did not assist the resident to remove the
spaghetti. The resident was able to use her
mouth and lips to maneuver the spaghetti
inside her mouth. CNA 2 gave the resident
a second bite of spaghetti and long strings
of spaghetti hung out of the residents
mouth again. The resident was able to tilt
her head down towards her clothing
protector and wipe the long strings of
spaghetti off her mouth and chin by
rubbing her chin on the clothing protector.
The CNA gave the resident a third bite of
spaghetti and there were long strings of
spaghetti which hung out of the resident's
mouth and all over the resident's clothing
protector. The CNA did not assist the
resident to get the spaghetti in her mouth
or to wipe it off of her mouth. The staff in
the assisted area of the main dining room
who were feeding other residents had cut
the spaghetti in small bite sized pieces. No
other residents in the assisted area of the
be in-services on dignity issues. 4. Different meal times will be observed 3 times a week for 4 weeks, 1 time a week for 3 months, then at the discretion of QAA.F241: Completion date 9-20-17 and ongoing.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 8 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
main dining room had long strings of
spaghetti hanging out of their mouths.
Resident C's record was reviewed on
8/16/17 at 2:43 p.m. Diagnoses included,
but were not limited to, dementia without
behavioral disturbance, generalized muscle
weakness and adult failure to thrive.
A care plan dated 6/28/17, indicated the
resident had dementia and was not feeding
herself. The goal was to maintain intakes
to prevent a further significant weight loss.
Interventions included, but were not
limited to, provide tray set up, cues and
full assistance with meals if needed.
During an interview on 8/18/17 at 1:35
p.m., CNA 3 indicated before feeding a
resident she would cut the food into
smaller pieces and cut up the spaghetti to
make it less messy for the resident's face
and clothes. CNA 3 indicated if a long
string of spaghetti was hanging out of a
resident's mouth, she would use the
silverware to catch the long noodle and
put in the resident's mouth or remove it.
During an interview on 8/18/17 at 2:08
p.m., LPN 4 indicated the staff should cut
up the spaghetti before assisting to feed a
resident. He indicated if he saw a resident
with a long string of spaghetti hanging out
of their mouth, he would ask the staff to
cut up the spaghetti or offer the resident
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 9 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
another food choice.
During an interview on 8/21/17 at 1:10
p.m., CNA 2 indicated Resident C was
difficult to get to eat and normally the
resident liked spaghetti. CNA 2 indicated
the food should be cut up in bite sized
pieces and spaghetti was difficult to feed
to a resident. CNA 2 indicated Resident C
did not like to be dirty and she had to wait
for Resident C to wipe off the spaghetti
noodles from her mouth before she could
give her another bite.
A current procedure titled "Procedure #59:
Assist To Eat", obtained from the Director
of Nursing on 8/21/17 at 12:48 p.m.,
indicated "...Offer assistance if resident
appears to be having difficulty during
meal...Residents may refrain from 'asking'
for assistance, thus staff should be
pro-active in observing the need for
assistance and offer the same...."
3.1-3(t)
483.20(d);483.21(b)(1) F 0279
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 10 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
DEVELOP COMPREHENSIVE CARE PLANS 483.20(d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan.
483.21(b) Comprehensive Care Plans
(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record.
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 11 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
(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 complete an
individualized plan of care related to
dental for 1 of 3 residents reviewed for
dental services, to monitor the signs and
symptoms of mood, depression and
insomnia and to monitor for a high risk
medication for 2 of 5 residents reviewed
for unnecessary medications. (Resident 6,
82 and 50).
Findings include:
1. On 08/16/17 at 10:50 a.m., Resident 6
was observed to be edentulous.
Resident 6's record was reviewed on
08/16/17 at 2:46 p.m. Diagnoses included,
but were not limited to, dementia without
behavioral disturbance, depressive
F 0279 1. Resident 6 has had dental care plan updated. Resident 82 has had care plan updated to observe for side effects. Resident 50 has had care plan updated to monitor signs and symptoms of insomnia, psychosis and mood.2. All residents with dentures, diuretics and a GDR have had their care plans reviewed and revised when appropriate. 3. Licensed staff will be in-serviced on the development and updating of care plans as needed.4. Orders will be audited to ensure proper care plans have been put in place or updated 2 times a week for 4 weeks and then weekly for 3 months, then at discretion of QAA.
09/20/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 12 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
episodes, muscle wasting and atrophy and
dysphagia.
An Annual Minimum Data Set (MDS)
Assessment dated 09/12/16, was marked
as "no natural teeth or tooth fragments" in
the Section L- Oral/Dental Status. The
Section V- Care Area Assessment (CAA)
Summary, indicated the dental care area
triggered and a care plan was needed.
No care plan related to Resident 6's dental
status was located.
During an interview on 08/18/17 at 9:41
a.m., the MDS coordinator indicated
Resident 6 did not have a dental care plan
and she should have been care planned.2.
The record for Resident 50 was reviewed
on 8/17/2017 at 9:42 a.m. Diagnoses
included, but were not limited to, other
specified mental disorders due to know
physiological condition, mixed
receptive-expressive language disorder,
anxiety disorder, sleep disorder,
unspecified dementia with behavioral
disturbance, unspecified psychosis not due
to a substance or known physiological
condition and vascular dementia with
behavioral disturbance.
On 12/16/2016, a physician's order
indicated Resident 50 was to receive one 5
mg (milligrams) tablet of celexa
(antidepressant) at bedtime for anxiety.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 13 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
On 11/20/2015, a physician's order
indicated Resident 50 was to receive one 3
mg capsule of melatonin (natural
supplement used to treat insomnia) every
day at 4:00 p.m. for vascular dementia
with behavioral disturbance. This order
was discontinued on 8/3/2017 and a new
order for melatonin 3 mg capsule every
day at 4:00 p.m. for sleep disorder was
placed on 8/3/2017.
On 6/28/2017, a physician's order
indicated Resident 50 was to receive 125
mg depakote sprinkles (mood stabilizer)
twice a day for unspecified dementia with
behavioral disturbance. This order was
discontinued on 8/2/2017 and a new order
for 125 mg depakote sprinkles twice a day
for unspecified psychosis not due to a
substance or known physiological
condition was placed on 8/2/2017.
On 6/20/2017, a physician's order
indicated the resident should have a
"...psyche eval and tx [psychiatry
evaluation and treatment]...."
A care plan dated 9/5/2013, with an
effective date of 6/12/2017, indicated the
resident was at risk for symptoms of
anxiety as evidenced by "...intrusive
wandering the facility and into my peers
rooms, exit seeking, pacing, trying to help
others even when they ask resident not
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 14 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
to..." The goal was the resident will show
no symptoms of anxiety through the next
review. Interventions included, and were
limited to, "...Offer redirection, 1 on 1,
activities, toileting, food, or fluids if
symptoms of anxiety are noted. Offer to
take me outside for a walk (weather
permitting), ask me to help you with a
task, ask me to help take care of the
babies. Speciality consult as needed.
Administer medications as ordered.
Observe me for side effects of
medications and notify my doctor if noted.
Review for reduction every 6 months and
prn [as needed]. Notify my doctor if
medications are ineffective...."
No care plans were found to monitor for
signs and symptoms of insomnia,
psychosis or mood.
The Nursing Facility Psychiatric Initial
Consult dated 8/2/2017, section titled
"Assessment/Treatment plan and
Recommendations, indicated
"...Depression-GDR [Gradual Dose
Reduction]-discontinue celexa 5 mg
daily...Recommend tracking for changes
in mood and document
accordingly...Refer to psychology for
evaluation. Will continue behavioral
health services to assure that the
psychotropic plan remains efficacious for
the resident's mental health needs...."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 15 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
During an interview on 8/17/2017 at 12:58
p.m., the DON indicated only physical
abuse, verbal abuse, wandering, or other
are charted in the electronic
documentation and the CNA's are
responsible for charting these behaviors.
Additionally, he indicated that nursing
staff does not regularly chart or track for
signs and symptoms of mood: including
depression, psychosis or insomnia, unless
the resident has had a recent GDR. He
also indicated Resident 50 has not had
monitoring for psychosis, depression or
insomnia.
During an interview on 8/17/2017 at 1:49
p.m., the DON indicated nurses should be
monitoring for signs and symptoms of
depression, psychosis and insomnia. 3.
The record for Resident 82 was reviewed
on 8/16/17 at 2:46 p.m. Diagnoses
included, but were not limited to, edema,
atrial fibrillation and hypertension.
Physician orders included, but were not
limited to, hydrochlorothiazide (a diuretic
used to treat high blood pressure and
swelling due to fluid build up and
promotes excretion of potassium) 25 mg
(milligram) daily ordered on 7/31/17 and
potassium chloride 20 meq
(milliequivalent) ordered on 7/31/17.
The care plan did not include the use of a
diuretic or the observation of side effects
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 16 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
of a diuretic.
During an interview on 8/21/17 at 9:40
a.m., the MDS(Minimum Data Set)
Coordinator indicated she does the
treatment plans for general medications.
She also indicated she usually does add a
treatment plan for the use of diuretics
including the risk for fluid volume excess
or fluid volume overload and did not add
this care plan for Resident 82.
During an interview on 8/21/17 at 1:49
p.m., the MDS Coordinator indicated the
facility did not have a Care Plan policy.
3.1-35(a)
483.24, 483.25(k)(l) PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING 483.24 Quality of lifeQuality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care.
483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to
F 0309
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 17 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
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, including but not limited to the following:
(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.
(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.Based on record review and interview, the facility
failed to provide an ordered anticonvulsant
medication at prescribed time and dosage and failed
to send correct medication with a the resident for a
leave for 1 of 1 resident reviewed for
anticonvulsant medications. (Resident B)
Findings include:
The record for Resident B was reviewed on 8/18/17
at 1:30 p.m. Diagnoses included, but were not
limited to, unspecified convulsions, chronic atrial
fibrillation, type 2 diabetes mellitus with
hyperglycemia, and essential hypertension.
Medications included, but were not limited to:
Vimpat (lacosamide-an anticonvulsants) 50
milligrams (mg) orally daily at 10:00 a.m., also
Vimpat 100 mg daily at 10:00 p.m.
F 0309 1. Resident B no longer resides in this facility.2. All residents have the potential to be affected by alleged deficient practice. No residents were found to be affected at this time.3. New policy has been developed for notification of physician for missing medications. All staff will be in-serviced on this new policy.4. DON/Designee will monitor all missing medications to make sure physician was notified and their commendation was followed. Monthly DON and pharmacists will report issues from missing medications.
09/20/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 18 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
A review of admission information indicated the
Resident admission time was 11:28 a.m. A review
of the nurse's notes dated 4/15/17 at 5:11 a.m.
indicated "...Resident has Vimpat ordered for 2200
(10:00 p.m.). Pharmacy was faxed and called
regarding this medication and assured (nurse on
duty) that the medication would be in no later than 4
hours. Medication has yet to arrive to facility,
spouse kept updated throughout the night, and
assured that writer would be in to give medications
as soon as it arrives...."
A nurses' notes written on 4/15/17 at 1:51 p.m.
indicated the pharmacy delivered Vimpat at 6:30
a.m.
A nurse's notes written on 4/22/17 at 10:56 p.m.
indicated the writer "... called (previous shift nurse)
regarding resident's Vimpat medication. She stated
that pharmacy (Name of pharmacy) was called
several hours ago ("early afternoon"). (Name of
pharmacy)
told her they may have to source out the order: 7
days (21 tablets). She stated that, "it should be taken
care of", resident received 50 mg of this medication
tonight, which is 1/2 dose. Resident and family
aware...."
The physician did not order the 1/2 dose of the
Vimpat and had not been notified only a 1/2 dose
had been given without the order to do so.
A nurse's note written on 4/23/17 at 12:50 .p.m.,
indicated "...(Name of pharmacy) returned call
regarding Vimpat medication. Stated it is in route
from secondary pharmacy; no ETA (estimated time
of arrival) offered. Resident and family aware."
During an interview with LPN 6 on 8/18/17 at 10:20
a.m.,she indicated Resident B left early with his
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 19 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
family for an leave, the medication was sent with
family, family did come back to get correct
medication since they noted the wrong medication
was sent with the resident. She was unable to
recall whether the medication was correct and in a
bag with his name on it when it was sent with him
on leave.
During an interview with the Director of Nursing
(DON) on 8/18/17 at 2:15 p.m., he indicated there
have been problems with medications being
available and staff were to contact him with
problems regarding medications. He also indicated
he was not aware of the problems with this resident.
A current policy titled "Medication Administration",
dated 2/10/16, received from the DON on 8/18/17 at
3:13 p.m. indicated "...12. If medication is given at a
time different from the scheduled time, note that in
the electronic MAR (Medication Administration
Record)...."
This Federal tag relates to complaint IN00228805
3.1-37(a)
483.25(g)(1)(3) MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE (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-
(1) Maintains acceptable parameters of nutritional status, such as usual body weight
F 0325
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 20 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
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;
(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Based on observation, record review and
interview, the facility failed to reassess
interventions, implement new
interventions and follow physician's
recommendations which resulted in a
significant weight loss for 1 of 1 resident
reviewed for nutrition. Resident C had a
15% weight loss in 49 days. Resident C
was not evaluated by speech therapy as
recommended by the doctor and new
interventions were not implemented to
prevent weight loss.
Finding includes:
During the initial dining observation on
8/15/2017 at 11:48 a.m., Resident C was
observed to be in the dining room, at a
table with three other residents being aided
to eat by a CNA. Her lunch consisted of
spaghetti. Resident C was observed to
only eat three bites of her spaghetti.
On 8/18/2017 at 11:30 a.m., Resident C
was observed to be in the dining room, at
a table with three other residents and a
staff member assisting her. The resident
was served a salmon steak, waffle fries, a
F 0325 1. Resident C was admitted to hospice.2. All residents have the potential to be affected by this deficient practice.3. Residents with significant weight loss will continue to be reviewed weekly by NAR team. NAR team will continue to reassess all the prior weeks interventions to insure follow ups occur according to facility protocol as well as determine if other dietary/nursing interventions are warranted at time of review. 4. RD/DON will audit NAR interventions weekly for 3 months, and then as QAA determines appropriate.
We as a facility are requesting an IDR on this tag based on the following facts:1. There was not a physicians order for a speech evaluation, it was a nursing measure requesting a speech screen. The assessment coordinator made the physician aware.2. The facility interventions were being implemented, reassessed and new interventions implemented as needed.3. The family was aware of the
09/20/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 21 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
small side salad and a small side of vanilla
ice cream. No supplement was observed
on her tray. The resident was observed to
eat 100 % of the ice cream and nothing
else.
On 8/21/2017 at 7:37 a.m., Resident C
was observed in the dining room during
breakfast service. The resident was
served a cheese omelette, a side of toast,
orange juice and chocolate milk. The
resident ate one bite of the omelette and
refused all other solid foods. She drank
one and a half servings of orange juice
and sips of her chocolate milk. During
this service, the staff assisting the resident
was observed to go into the kitchen and
get a small dish of strawberry ice cream.
The resident was observed to eat
approximately 50% of her strawberry ice
cream.
The record for Resident C was reviewed
on 8/16/2017 at 2:43 p.m. Diagnoses
included, but were not limited to,
6/21/2017- unspecified dementia without
behavioral disturbance, insomnia,
hydrocephalus, anxiety disorder, and heart
failure. On 7/20/2017 the diagnosis of
adult failure to thrive was added to the
resident's current diagnoses.
During Stage I of the survey on 8/16/2017
at 2:49 p.m., the Registered Dietitian
(RD) provided weights for Resident C.
residents deteriorating condition since admission to this facility on 6-21-17.4. On July 27, 2017 the diagnosis of Adult Failure to Thrive was added.The facility does not believe that this weight loss was avoidable.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 22 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
The weights for this resident were:
a. Weight at Admission: 134 pounds.
b. Weight on 7/07/2017: 126 pounds
(which was 8 pounds less than her
admission weight or a 6.0% weight loss
since her admission)
c. Weight on 7/17/2017: 120 pounds
(which was 14 pounds less than her
admission weight or a 10% weight loss
since her admission)
d. Weight on 8/09/2017: 114 pounds
(which was 20 pounds less than her
admission weight or a 15% weight loss
since her admission)
A nursing note dated 6/21/2017 at 10:33
p.m., indicated Resident C "...Wt# [weight
in pounds] 133.6...Assisted/supervised
with feeding self...."
A physician's order dated 6/21/2017,
indicated the resident was to receive a
regular diet.
An assessment note dated 6/30/2017 at
1:53 p.m., indicated "...Res [resident] wts
[weights] are being monitored in NAR
[Nutrition at Risk Team] and discussed
with IDT [Interdisciplinary Team] et [and]
RD. Res has had approx. [approximately]
3# [pound] loss since admission and has
had a poor appetite. Res has a hx
[history] of refusal of ... and meals before
this admission. MD [medical doctor]
notified of wt loss and N.O. [new order]
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 23 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
rec'd [received] to being [sic] Med Pass
2.0 po [by mouth] 90 mL's [milliliters]
TID [three times a day] as a dietary
supplement per RD recommendation.
Will continue to monitor wts weekly et
discuss in NAR. Res requires heavy
cueing and encouragement with total assist
at times and she is resistive to most
interventions...."
A physician's order dated 6/30/2017,
indicated the Resident was to receive Med
Pass 2.0 90 mL's TID for weight loss and
poor appetite.
From 6/30/2017 through 7/5/2017, the
resident received the supplement 8 out of
13 times and 2 of the 8 times the
supplement was given, it was consumed at
less than 90 mL's.
A nursing note dated 7/5/2017 at 8:23
a.m., indicated the ADON had notified the
MD of the resident's poor appetite, refusal
of supplement, and her pocketing
medications. The "...MD recommended
ST (speech therapy) to screen. Therapy
aware."
An email from the ADON to therapy
dated 7/5/2017 at 8:23 a.m., indicated the
resident needed a screen. "...Staff is
stating that she is pocketing medications
and has had wt loss and poor appetite...."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 24 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
An email from the ADON to the RD dated
7/5/2017 at 8:52 a.m., indicated the
resident "...is refusing Med Pass 2.0 at
times, cont [continue] with poor intake,
and noted to be pocketing meds
[medications]. I have contacted speech
for a screen and notified MD...."
No documentation was found that speech
therapy had screened the resident.
A nutritional status note dated 7/5/2017 at
4:35 p.m., indicated the RD had spoken to
Resident C's family about her food
preferences and the information was
shared with nutrition services.
Additionally, "...Weights monitored
closely with poor intakes. Supplements
are about 50% hit or miss. We will
continue the strawberry ice cream L&D
[lunch and dinner]. Will try some
different breakfast options, but (Resident)
has never been a brkfst [breakfast] eater.
She likes noodles and pasta. Enjoys
sweets and lemonade. Loves pizza. Will
update POC [plan of care] and follow
with NAR. UBW [usual body weight]
around 130-135#. PW [patient weight]
125.8#, down 4.8# (3.6%)/week [in one
week]...daughter is aware. She (daughter)
also voiced that she does not want a tube.
Any food she gets will be po. RD
supportive of wishes and will continue to
strive to find something she will eat...."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 25 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
From 7/5/2017 through 7/25/2017 the
supplement was given 63 out of 74 times,
or 75% of the time. Of the 64 times the
supplement was consumed, 9 times the
supplement consumed was less than
90mLs.
On 7/20/2017 at 11:33 a.m., a nursing
note indicated the MD was notified of the
resident's significant weight loss and a
diagnosis of "adult failure to thrive D/T
[due to] Dementia" was added as a
diagnosis for the resident.
On 7/26/2017 at 3:08 p.m., a nutritional
status note indicated dietary increased
Resident C's supplement from 90 mL's
TID to 120 mL's TID.
On 7/26/2017 at 3:11 p.m., a nutritional
status note indicated "...Per NAR review,
[Resident] is 117.8#, down 2.2# in a week
and down 15.8#(11.8%)/ 1 month. She
has dementia and despite continued
interventions, she won't eat or eats very
little and weight loss is insidious at this
point. Team discussed and since she
AFTT [adult failure to thrive], we note
she is taking her [supplement] 85% of the
time. Since she is accepting, we will
increase to 120 ml TID and orders are
received. Her family has indicated she
likes strawberry ice cream, so we plan to
offer a strawberry shake at noon and offer
strawberry ice cream at HS. If she
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 26 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
consumes the additional supplements, the
increase will be approx. [approximately]
1140 kcal [kilocalorie] and 3 gm [grams]
pro [protein]. DON planning to discuss
advance direction and feeding direction
with family. BMI is 20.2, down from
22.9 last month. RD remains available...."
A care plan initiated on 6/28/2107 and
updated 7/26/2017 indicated the resident
has "...dementia and am not feeding
myself. I will occasionally hold a cup. I
have a poor appetite and have had a
significant weight loss in the past month. I
am usually 130-135#. I have a diagnosis
of Adult Failure to Thrive...." The goal
was to maintain intakes to prevent a
further significant weight loss through the
next review. Interventions, included and
were limited to, "...[effective 6/28/2017]
Provide me tray set up, cues, and full
assistance if I need it. I lke [sic] rice
krispie treats. Notify my family and MD
of significant weight changes...[effective
7/5/2017] Supplement as ordered. I like
pasta and noodles. I am not a breakfast
eater, just toast or danish and juice. I will
occasionally eat eggs. I enjoy Sprite and
potato chips and may accept as a snack. I
like Lemonade. I like cheesecake...
[effective 7/26/2017] Offer me a
strawberry ice cream shake at Lunch and
offer me strawberry ice cream at
dinner...."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 27 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
On 7/26/2017, a physician's order
indicated the resident's Med Pass 2.0
should be increased from 90 mL's three
times a day to 120 mL's three times a day.
On 7/27/2017 at 4:08 a.m., an assessment
note indicated the resident "...Requires
total assist with meal intake with heavy
cueing and much encouragement to
consume meal...Res has no issues with
chewing or swallowing and has a very
limited list of foods that she likes per
family...."
On 7/27/2017, a physician's ordered
indicated the resident should have Med
Pass 2.0, strawberry ice cream at dinner
and a strawberry milkshake at lunch.
A nursing note dated 8/7/2017 at 9:07
a.m., indicated the resident was "...still
resisting care, difficult time getting resident
to take medications...."
An assessment note dated 8/16/2017 at
5:29 a.m., indicated "...Res current wt is
114.2 a loss of 9% in 1 month. Res has a
Regular diet with ice cream and shakes
and Med Pass 2.0 as a dietary supplement
d/t [due to] poor appetite and wt loss.
Res consumes Med Pass 2.0 approx.
[approximately] 50% of the time, res avg [
average] meal intake is 25% avg snack
intake is 70% avg fluid intake is 1000 cc
[cubic centimeter]...Res has dx of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 28 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
dementia with adult failure to thrive with
anticipated wt loss. Res requires assist
with meal intake with poor intake.
Family is aware of wt assessment. MD is
aware of wt assessment. Will monitor wts
weekly et discuss in NAR."
On 8/18/2017 during lunch service, the
tray card for Resident C was reviewed. A
strawberry milkshake supplement was not
listed on the tray card.
During an interview on 8/16/2017 at 2:49
p.m., the Registered Dietitian indicated
there was little documentation for the
resident.
During an interview on 8/18/2017 at 11:09
a.m., PT 8 indicated the Resident did not
have a speech evaluation completed.
During an interview on 8/18/2017 at 11:37
a.m., the DON indicated a speech
evaluation was not completed.
During an interview on 8/18/2017 at 11:49
a.m., the RD indicated she was unaware a
speech evaluation was recommended.
During an interview on 8/18/2017 at 12:14
a.m., the Dietary Services Director
indicated the Med Pass 2.0 strawberry
shake supplement should have been listed
on the resident's tray card.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 29 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
During a phone interview on 8/18/2017 at
2:33 p.m., the Resident's doctor indicated
he was not made aware the speech
evaluation was not completed and he
would have expected the facility to follow
his recommendation for a speech
evaluation before the Resident was
diagnosed with adult failure to thrive.
A current facility policy, dated 2/13/2016,
received from the DON on 8/16/2017 at
11:17 a.m., indicated it is "...the policy of
this facililty to review and address those
residents at risk for significant weight
change and skin breakdown. Those
residents will be monitored by the NAR
Team on a weekly basis involving all
applicable disciplines in an effort to
improve each resident's nutritional
status...Procedure: 1. NAR Team
members will meet weekly to monitor and
discuss the applicable resident(s), address
current interventions and determine if
other dietary or nursing interventions are
warranted at the time of review. A 2.5%
or more loss in one week will reuire a
written assessment and/or appropriate
intervention(s)...."
3.1-46(a)(1)
3.1-46(a)(2)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 30 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
483.45(d)(e)(1)-(2) 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--
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--
(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 documented in the clinical record;
(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;
F 0329
SS=D
Bldg. 00
Based on record review and interview, the
facility failed to monitor for signs and
F 0329 1. Resident 50 had care plan updated to include monitoring for
09/20/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 31 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
symptoms of psychosis, insomnia and
mood, failed to provide documentation
specific to behaviors resulting in a failed
gradual dose reduction (GDR), follow
through with a recommended GDR and
failed to monitor for a high risk medication
for 2 of 5 resident's reviewed for
unnecessary medications (Resident 50 and
82).
Findings include:
1. The record for Resident 50 was
reviewed on 8/17/2017 at 9:42 a.m.
Diagnoses included, but were not limited
to, other specified mental disorders due to
know physiological condition, mixed
receptive-expressive language disorder,
anxiety disorder, sleep disorder,
unspecified dementia with behavioral
disturbance, unspecified psychosis not due
to a substance or known physiological
condition and vascular dementia with
behavioral disturbance.
On 12/16/2016, a physician's order
indicated Resident 50 was to receive one 5
mg (milligrams) tablet of celexa
(antidepressant) at bedtime for anxiety.
On 11/20/2015, a physician's order
indicated Resident 50 was to receive one 3
mg capsule of melatonin (natural
supplement used to treat insomnia) every
day at 4:00 p.m. for vascular dementia
signs and symptoms of insomnia, psychosis and mood. Resident 82 had care plan updated for use of diuretics and to obtain labs are ordered by the physician. Facility will continue to follow physicians recommendations on labs to be drawn with certain medications. 2. All residents have the ability to be affected by this deficient practice.3. All licensed staff will be in-serviced on appropriate monitoring on change of resident's behavior following a GDR. 4. Social Service Director will monitor nursing documentation following GDR trials. DON will monitor and assure that residents receiving medications that require labs are being followed per physician instructions. Each will report monthly to QAA/Behavior committee.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 32 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
with behavioral disturbance. This order
was discontinued on 8/3/2017 and a new
order for melatonin 3 mg capsule every
day at 4:00 p.m. for sleep disorder was
placed on 8/3/2017.
On 6/28/2017, a physician's order
indicated Resident 50 was to receive 125
mg depakote sprinkles (mood stabilizer)
twice a day for unspecified dementia with
behavioral disturbance. This order was
discontinued on 8/2/2017 and a new order
for 125 mg depakote sprinkles twice a day
for unspecified psychosis not due to a
substance or known physiological
condition was placed on 8/2/2017.
On 6/20/2017, a physician's order
indicated the resident should have a
"...psyche eval and tx [psychiatry
evaluation and treatment]...."
A care plan dated 9/5/2013, with an
effective date of 6/12/2017, indicated the
resident was at risk for symptoms of
anxiety as evidenced by "...intrusive
wandering the facility and into my peers
rooms, exit seeking, pacing, trying to help
others even when they ask resident not
to..." The goal was the resident will show
no symptoms of anxiety through the next
review. Interventions included, and were
limited to: "...Offer redirection, 1 on 1,
activities, toileting, food, or fluids if
symptoms of anxiety are noted. Offer to
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 33 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
take me outside for a walk (weather
permitting), ask me to help you with a
task, ask me to help take care of the
babies. Speciality consult as needed.
Administer medications as ordered.
Observe me for side effects of
medications and notify my doctor if noted.
Review for reduction every 6 months and
prn [as needed]. Notify my doctor if
medications are ineffective...."
No care plans were found to monitor for
signs and symptoms of insomnia,
psychosis, or mood.
On 6/15/2017 at 1:08 p.m., a nursing note
indicated a new order was received to
"...decrease Depakote from BID [two
times a day] to daily at noon...."
The Behavior Detail Report from
6/15/2017 to 6/28/2017 indicated the
resident had one behavioral episode on
6/27/2017 at 3:00 p.m.
No behavioral episodes were documented
in the nursing notes from 6/15/2017 to
6/28/2017.
A nursing note dated 6/28/2017 at 3:55
p.m., indicated a new order was received
for depakote 125 mg by mouth twice a
day.
An assessment note dated 6/29/2017 at
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 34 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
10:08 a.m., indicated the resident "...had a
GDR of Depakote on 6-15-17. In last
few days resident has been exhibiting and
[sic] increase in behaviors AEB [as
evidenced by] refusal of ADL [activities
of daily living] care, verbally abusive
towards staff, general agitation with those
around her. MD was notified and
Depakote 125 mg was reinstated as a
FDR [failed dose reduction]...."
The Nursing Facility Psychiatric Initial
Consult dated 8/2/2017, section titled
"Assessment/Treatment plan and
Recommendations, indicated
"...Depression-GDR-discontinue celexa 5
mg daily...Recommend tracking for
changes in mood and document
accordingly...Refer to psychology for
evaluation. Will continue behavioral
health services to assure that the
psychotropic plan remains efficacious for
the resident's mental health needs...."
A social services note dated 8/9/2017 at
2:40 p.m., indicated "...Resident was seen
by [name of psychiatric service provider]
on 8/2/2017. Recommendations:
GDR-discontinue Celexa for Depression.
Continue Depakote for Psychosis.
Continue Melatonin for Sleep D/O
[disorder]. Will continue with psych
[psychiatric service provider] services.
The medication record from 8/1/2017
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 35 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
through 8/16/2017 indicated Resident 50
continued to receive celexa at 8:00 p.m.
after the recommended discontinue date
of 8/2/2017.
During an interview on 8/17/2017 at 12:58
p.m., the DON indicated only physical
abuse, verbal abuse, wandering, or other
are charted in the electronic
documentation and the CNA's are
responsible for charting these behaviors.
Additionally, he indicated that nursing
staff does not regularly chart or track for
signs and symptoms of mood: including
depression, psychosis or insomnia, unless
the resident has had a recent GDR. He
also indicated that Resident 50 has not had
monitoring for psychosis, depression or
insomnia.
During an interview on 8/17/2017 at 1:49
p.m., the DON indicated that the depakote
should not have been reinstated to twice a
day with only one behavior and the nurses
should be monitoring for signs and
symptoms of depression, psychosis and
insomnia. In addition, he indicated the
Celexa should have been discontinued
with the recommended GDR.
During an interview on 8/21/2017 at 2:15
p.m., the MDS Coordinator indicated
there was no psychotropic medication use
policy.
2. The record for Resident 82 was
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 36 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
reviewed on 8/16/17 at 2:46 p.m.
Diagnoses included, but were not limited
to, edema, hypertension and atrial
fibrillation.
Physician orders included, but were not
limited to, hydrochlorothiazide (a diuretic
used to treat high blood pressure and
swelling due to fluid build up) 25 mg
(milligram) daily ordered on 7/31/17 and
potassium chloride 20 meq
(milliequivalent) ordered on 7/31/17.
The care plan did not include the use of a
diuretic or the observation of side effects
of a diuretic.
The resident's chart did not have a
potassium level included and did not have
a physician order to complete a potassium
level.
A physician progress note dated 8/21/17 at
11:08 a.m. did not include an order for a
potassium level.
A pharmacy review completed on 8/1/17
indicated, "Resident's medication regimen
upon admission was reviewed, and no
major issues found concerning medication
therapy problems."
The Nursing 2016 Drug Handbook
indicated, the nursing considerations for
hydrochlorothiazide included, but were
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 37 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
not limited to, monitor fluid intake and
output, watch for signs of hypokalemia
(low potassium level) such as muscle
weakness and cramps and monitor elderly
patients who are especially susceptible to
excessive diuresis.
The Nursing 2016 Drug Handbook
indicated, the nursing considerations for
potassium chloride included, but were not
limited to, monitor electrolyte (potassium,
sodium and chloride) levels. The
handbook also indicated an adverse
reaction of the medication included
hyperkalemia (elevated potassium level).
During an interview on 8/21/17 at 11:07
a.m., the Director of Nursing (DON)
indicated he would expect the residents on
a diuretic to have a potassium level
completed. He also indicated it was the
consulting pharmacy's responsibility to
note if a potassium level was completed
and to make recommendations to the
facility if a potassium level needed
completed.
During an interview on 8/21/17 at 2:15
p.m., the Minimum Data Set Coordinator
indicated the facility does not have a
policy regarding high risk medications.
3.1-48(a)(3)
3.1-48(a)(2)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 38 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
483.35(g)(1)-(4) POSTED NURSE STAFFING INFORMATION 483.35(g) Nurse Staffing Information(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.
(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
F 0356
SS=C
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 39 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
(B) In a prominent place readily accessible to residents and visitors.
(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.
(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, record review and
interview, the facility failed to post the
correct number of RN's (Registered
Nurses), the total number of hours and the
facility census on the staff posting for 2 of
5 days during the annual survey. This has
the potential to affect 59 of 59 residents
residing in the facility.
Finding includes:
On 08/15/17, the staffing posted for the
6:00 a.m. to 2:00 p.m. shift did not
include the facility's census and listed two
RN's had worked for a total of 16 hours.
One RN was scheduled for a total of 8
hours. The 6:00 p.m. to 6:00 a.m. staffing
was not posted.
On 08/21/17, the staffing posted for the
6:00 a.m. to 2:00 p.m. shift did not
include the facility's census and listed 2
LPN's (Licensed Practicing Nurse) had
worked for a total of 8 hours and zero
F 0356 1. Report was completed and posted immediately.2. All residents have the potential to be affected by this deficient practice.3. All nursing staff will be in-serviced on posting daily hours.4. Administrator/Designee will audit posted hours daily for 4 weeks to ensure accuracy of information posted. Will report to QAA.
09/20/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 40 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
RN's. One LPN worked for a total of 8
hours and one RN worked for a total of 8
hours. The 6:00 p.m. to 6:00 a.m. staffing
was not posted.
During an interview on 08/21/17 at 9:53
a.m., the Director of Nursing (DON)
indicated the staff posting dated 8/15/2017
and 08/21/17 was inaccurate and
incomplete and the 6:00 a.m. to 6:00 p.m.
should have been posted.
483.45(b)(2)(3)(g)(h) DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.
(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.
(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who--
(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and
F 0431
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 41 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
(g) Labeling of Drugs and Biologicals.Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
(h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.
(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.Based on observation, interview and record review,
the facility failed to dispose of a scheduled II (a
controlled medication with a high potential for
abuse) medication according to guidelines
established in 1 of 4 medication carts reviewed (D
hall cart).
Findings include:
During the medication storage review on 8/17/17 at
9:22 a.m.,with Qualified Medications Aide (QMA) 5
the following was observed:
The D hall medication cart had a Controlled Drug
F 0431 1. Resident 2 controlled drug II was disposed of according to regulatory procedure.2. All residents have the potential to be affected by this deficient practice.3. All licensed staff will be in-serviced on the medication disposal policy.4. Controlled drug disposal records will be audited by the DON/Designee 3 times a week for 4 weeks, weekly for 3 months, then reported to QAA for
09/20/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 42 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
Administration Record which indicated one
Phenobarbital (a barbiturate used to treat seizures)
32.4 mg (milligrams) was destroyed for Resident 2
and the record had the signature of one Licensed
Practical Nurse (LPN) 6.
The record for resident 2 was reviewed on 8/12/17
at 12:59 p.m. Diagnoses included, but were not
limited to, spastic quadriplegic cerebral palsy and
unspecified convulsions (seizures).
During an interview on 8/17/17 at 10:01 a.m.,the
Director of Nursing (DON) indicated a drug
disposition form for the destroyed Phenobarbital
should have been in the resident's chart and the
form should have included the signatures of two
licensed staff. The DON was not able to locate the
drug disposition form in the resident's chart.
A current policy titled "Expired Medication
Disposal" dated 2/04/16, obtained from the DON on
8/17/17 at 10:01 a.m., indicated "....All medications
to be disposed of will have a drug disposition form
filled out...Medications require 2 licensed nurses to
sign for distruction [sic] of medication, if medication
is a narcotic then 1 nurse must be a RN [registered
nurse]...."
3.1-25(o)
recommendations.
R 0000
Bldg. 00
This visit was for a State Residential Licensure
Survey. This visit included a Recertification and
State Licensure Survey. This visit included the
Investigation of Complaint IN00228805.
R 0000 Submission of this Plan of Correction and Credible Allegation of Compliance does not constitute an admission by the certified and
State Form Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 43 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
Complaint IN00228805- Substantiated. Federal
deficiencies related to the allegations are cited at
F157 and F309.
Survey dates: August 15, 16, 17, 18, and 21, 2017
Facility number: 000299
Residential Census: 13
These State Residential Findings are cited in
accordance with 410 IAC 16.2-5.
Quality Review was completed on August 25, 2017.
licensed provider at Milner Community Health Care, Inc., that the allegations contained in this survey report a true and accurate portrayal of the provisions of nursing care and services at this health care facility. Milner Community Health Care, Inc., as a licensed and certified provider, recognizes its obligation to provide legally and medically required care and services to our residents in an economical and efficient fashion. Please accept this Plan of Correction as the Credible Allegation of Compliance.
410 IAC 16.2-5-2(c)(1-4)(d) Evaluation - Noncompliance (c) The scope and content of the evaluation shall be delineated in the facility policy manual, but at a minimum the needs assessment shall include an evaluation of the following:(1) The resident ' s physical, cognitive, and mental status.(2) The resident ' s independence in the activities of daily living.(3) The resident ' s weight taken on admission and semiannually thereafter.(4) If applicable, the resident ' s ability to self-administer medications.(d) The evaluation shall be documented in writing and kept in the facility.
R 0216
Bldg. 00
Based on interview and record review, the R 0216 1. Self Medication Assessment 09/20/2017 12:00:00AM
State Form Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 44 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
facility failed to ensure medication
self-administration evaluations were
completed for 2 of 2 residents reviewed
for self medication administration
(Residents 94 and 97).
Findings include:
1. The record for Resident 94 was
reviewed on 08/21/17 at 9:52 a.m.
Diagnoses included but were not limited
to, pain, rheumatoid arthritis and dry eye
syndrome.
A "Resident's Ability To Self Administer
Medications" evaluation was opened on
06/26/17 and was not completed. The
previous evaluation was completed
06/2016.
2. The record for Resident 97 was
reviewed on 08/21/17 at 10:42 a.m.
Diagnoses included but were not limited
to, mental disorders due to known
physiological condition, anxiety disorder
and osteoarthritis.
A "Resident's Ability To Self Administer
Medications" evaluation was opened on
03/13/17 and was not completed. The
previous evaluation was completed
03/2016.
During an interview on 08/21/17 at 12:34
p.m., the Director of Nursing (DON)
immediately completed for Residents 94 and 97.2. All residents have the ability to be affected by this deficient practice.3. All Assisted Living licensed staff will be re-educated on policy for Self Medication Assessments.4. Bi-annual Self Medication Assessments will be reviewed Monthly to ensure all residents schedule is followed. Reviews will be brought to QAA for to assure compliance followed.
State Form Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 45 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
indicated the facility should complete the
medication self-administration evaluations
yearly and the evaluations should have
been completed the day the assessments
were opened.
A current facility policy titled "Right to
Self Administer Medications" dated
revised on 02/17, received from the DON
on 08/21/17 at 1:15 p.m., indicated "...If
the resident chooses to self-administer
medications, it will be the responsibility of
the interdisciplinary team to assess the
resident's cognitive, physical and visual
ability to safely and adequately carry out
this function and determining if the
resident is clinically appropriate...A
'Residents ability to self -administer
medications' UDA [User Defined
Assessment] will be completed also...."
410 IAC 16.2-5-5.1(f) Food and Nutritional Services - Deficiency (f) All food preparation and serving areas (excluding areas in residents ' units) are maintained in accordance with state and local sanitation and safe food handling standards, including 410 IAC 7-24.
R 0273
Bldg. 00
Based on observation and interview, the
facility failed to ensure staff used proper
hand hygiene during a dining service for 8
of 14 residents being served food in the
assisted living dining room.
Finding includes:
During a dining observation on
R 0273 1. Staff member was educated on facility Glove Policy and proper hand washing procedure.2. All residents could be affected by this deficient practice.3. All Assisted Living Staff will be re educated on the facility Proper glove use Policy and hand washing procedure.4. Assisted Living meal service will be observed 2 times weekly for 4
09/20/2017 12:00:00AM
State Form Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 46 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
08/15/2017 at 11:25 a.m., LPN 7 took a
hairnet off of the second shelf of the food
cart and proceeded to use his gloved left
hand and his right hand with another glove
wrapped inside the hand to put on his hair
net. He then continued to put the right
glove on and served the food. LPN 7 was
observed to open drawers on the buffet
cart while he looked for something. He
moved from task to task and did not wash
his hands or change his gloves.
During an interview on 08/21/17 at 1:55
p.m., the Director of Dining Services
indicated the facility did not have a
specific glove policy and the facility
followed the federal/state regulations.
During an interview on 08/21/17 at 1:57
p.m., the Director of Nursing indicated
gloves would need to be changed after
touching anything foreign.
weeks to assure compliance. Results will be reported to monthly QAA meeting for recommendations.
410 IAC 16.2-5-12(d) Infection Control - Noncompliance (d) Prior to admission, each resident shall be required to have a health assessment, including history of significant past or present infectious diseases and a statement that the resident shows no evidence of tuberculosis in an infectious stage as verified upon admission and yearly thereafter.
R 0409
Bldg. 00
Based on interview and record review, the
facility failed to ensure a resident had an
annual health assessment which included a
statement to indicate the resident was free
of infectious disease completed yearly for
R 0409 1. Resident 101 began Hospice care on 8/31/17. Statement from Hospice indicates resident is free from infectious disease.2. All residents have the potential to be affected by this deficient
09/20/2017 12:00:00AM
State Form Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 47 of 48
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/02/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
ROSSVILLE, IN 46065
155676 08/21/2017
MILNER COMMUNITY HEALTH CARE
370 E MAIN ST
00
1 of 7 residents reviewed for an annual
health statement (Resident 101).
Finding includes:
The record for Resident 101 was
reviewed on 08/18/17 at 1:58 p.m.
Diagnoses included but were not limited
to, bacterial pneumonia, malignant
neoplasm of the left main bronchus, acute
upper respiratory infection and disease of
the blood and blood-forming organs.
An Annual health statement was not
located in Resident 101's record.
During an interview on 08/21/17 at 12:28
p.m., the Director of Nursing indicated he
could not locate an annual health
statement for Resident 101.
practice. All resident have a current Free from infectious disease statement.3. All Assisted Living staff will be in-serviced on completing monthly assessment forms.4. Director of Nursing will monitor EHR for completed assessments and to assure accuracy for 6 months. QAA will review report and evaluate compliance.
State Form Event ID: WV5511 Facility ID: 000299 If continuation sheet Page 48 of 48