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[Pages:19]DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

IDENTIFICATION NUMBER

155776

NAME OF PROVIDER OR SUPPLIER

SPRINGHILL VILLAGE

(X4) ID PREFIX

TAG

F 0000

SUMMARY STATEMENT OF DEFICIENCIE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION

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PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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Bldg. 00

This visit was for a Recertification and State Licensure Survey.

Survey dates: February 3, 4, 5, 6, and 9, 2020

Facility number: 012188 Provider number: 155776 AIM number: 200958030

Census Bed Type: SNF: 13 SNF/NF: 61 Total: 74

Census Payor Type: Medicare: 15 Medicaid: 37 Other: 22 Total: 74

F 0000

The creation and submission of this Plan of Correction does not constitute an admission by this provider of any conclusion set forth in the statement of deficiencies, or of any violation of regulation. This provider respectfully requests that the 2567 Plan of Correction be considered the Letter of Credible Allegation and requests a Post Survey Desk Review.

These deficiencies reflect State Findings cited in accordance with 410 IAC 16.2-3.1.

Quality review completed on 3/12/20.

F 0580 SS=D Bldg. 00

483.10(g)(14)(i)-(iv) Notify of Changes (Injury/Decline/Room, etc.) ?483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

_____________________________________________________________________________________________________

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: OX3H11 Facility ID: 012188

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

IDENTIFICATION NUMBER

155776

NAME OF PROVIDER OR SUPPLIER

SPRINGHILL VILLAGE

(X4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION

(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. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

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?483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in ?483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: OX3H11 Facility ID: 012188

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

IDENTIFICATION NUMBER

155776

NAME OF PROVIDER OR SUPPLIER

SPRINGHILL VILLAGE

(X4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION

under ?483.15(c)(9).

Based on record review and interview, the facility failed to ensure the physician had been notified of a resident's refusal of routine insulin injections, for 1 of 5 residents reviewed for unnecessary medications. (Resident 49)

Finding includes:

Resident 49's record was reviewed on 3/5/20 at 9:46 a.m. The resident had been admitted to the facility on 2/4/20. The resident discharged from the facility back to her home on 3/6/20.

The resident diagnoses included, but were not limited to, type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema (disease of the retina caused by diabetes that involves damage to the tiny blood vessels in the back of the eye), and type 2 diabetes mellitus with diabetic chronic kidney disease (gradual loss of kidney function caused by diabetes).

An admission Minimum Data Set (MDS) assessment, dated 2/10/20, indicated the resident had moderate cognitive impairment, had diagnoses which included, but were not limited to diabetes mellitus, and received medications which included, but were not limited to, insulin injections.

A care plan, dated 2/5/20, indicated the resident was at risk for adverse effects of hyperglycemia or hypoglycemia (low blood glucose) related to use of glucose lowering medication and/or diagnosis of diabetes mellitus. Interventions included, but were not limited to, monitor blood sugars as ordered, document abnormal findings and notify the physician, and medications as ordered.

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What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #49 returned home 3-6-2020 and will resume previous home insulin routine of sliding scale insulin. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All facility residents could be affected by alleged deficient practice. Nursing specific in-service to re-educate on Physician Notification of Refusal of Medication will be completed by April 8, 2020.

04/08/2020 12:00:00A

What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur? Daily during Clinical review the Medication Compliance report will be reviewed and MD notified per policy.

How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? Nursing Administration to complete QAPI tool 100% of Refusal of Medications, Treatments weekly for one month

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: OX3H11 Facility ID: 012188

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

IDENTIFICATION NUMBER

155776

NAME OF PROVIDER OR SUPPLIER

SPRINGHILL VILLAGE

(X4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION

A physician's order, dated 2/5/20, indicated Accu check (blood glucose testing) before meals and at bedtime. Notify the physician if the blood glucose reading was below 70 or greater than 400.

A physician's order, dated 2/5/20, indicated insulin lispro (a shorter acting insulin) insulin pen, 100 unit/milliliter (ml). Administer: 20 units, subcutaneous (applied under the skin), three times a day before meals for hyperglycemia (high blood glucose).

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and then monthly for four months. Following this time frame and review the QAPI team will re-evaluate the continued need for the audit tool. If 100% accuracy is not achieved an Action Plan will be developed. Executive Director to monitor for compliance.

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A physician's order, dated 2/6/20, indicated Lantus insulin (a long-acting insulin) solostar U-100 unit/ml. Administer 45 units subcutaneous every morning.

Review of the resident's February 2020 Medication Administration Record (MAR), indicated the resident had refused the insulin lispro injections on, 2/7/20 at 7:04 a.m., and 5:27 p.m., 2/8/20 at 6:56 a.m., 12:01 p.m., and 5:35 p.m., 2/9/20 at 7:14 a.m., and 5:04 p.m., 2/10/20 at 8:08 a.m., and 4:45 p.m., 2/11/20 at 8:03 a.m., 11:19 a.m., and 5:09 p.m., 2/12/20 at 6:52 a.m., and 11:39 a.m., 2/13/20 at 9:36 a.m., 11:27 a.m., and 5:24 p.m., 2/14/20 at 7:55 a.m., 10:06 a.m., and 4:02 p.m., 2/15/20 at 7:48 a.m., 12:55 p.m., and 5:22 p.m., 2/16/20 at 9:09 a.m., 12:57 p.m., and 4:32 p.m., 2/17/20 at 7:21 a.m., 11:26 a.m., and 4:44 p.m., 2/18/20 at 7:13 a.m., 11:45 a.m., and 4:38 p.m., 2/19/20 at 10:29 a.m., 1:22 p.m., and 5:31 p.m., 2/20/20 at 9:32 a.m., 11:38 a.m., and 5:29 p.m., 2/21/20 at 7:29 a.m., 11:25 a.m., and 5:12 p.m., 2/22/20 at 8:03 a.m., 11:17 a.m., and 5:23 p.m., 2/23/20 at 10:24 a.m., and 5:30 p.m., 2/24/20 at 7:46 a.m., 2/25/20 at 7:51 a.m., and 6:28 p.m., 2/26/20 at 7:11 a.m., 10:36 a.m., and 4:02 p.m., 2/27/20 at 6:53 a.m., 10:29 a.m., and 4:29 p.m., 2/28/20 at 8:56 a.m.,

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: OX3H11 Facility ID: 012188

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

IDENTIFICATION NUMBER

155776

NAME OF PROVIDER OR SUPPLIER

SPRINGHILL VILLAGE

(X4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION

and 5:14 p.m., and 2/29/20 at 4:58 p.m.

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A fax cover sheet, dated 2/8/20, indicated a fax had been sent to the resident's physician. The documented indicated, the resident had been refusing her insulin lispro, 20 units at mealtime and would like to determine if she takes or not. The physician written response indicated "OK."

Review of the resident's March 2020 Medication Administration Record (MAR), indicated the resident had refused the insulin lispro injections on, 3/1/20 at 11:49 a.m., 3/2/20 at 7:17 a.m., 11:24 a.m., and 5:20 p.m., 3/3/20 at 8:06 a.m., 10:35 a.m., and 4:15 p.m., 3/4/20 at 7:32 a.m., 11:46 a.m., and 5:35 p.m., and 3/5/20 at 8:06 a.m., and 11:42 a.m.

During an interview on 3/5/20 at 1:13 p.m., the resident indicated she knew when she was supposed to get her insulin. At home she was on a sliding scale (insulin amount determined by blood sugar levels) of her insulin before meals. She would only take as much as was based on her Accu check reading and what was indicated on the sliding scale. Since she had been at the facility, she had not been provided a sliding scale. The routine order for 20 units of lispro before meals, she believed, caused her blood glucose to drop too much.

During an interview, on 3/5/20 at 1:41 p.m., the Director of Nursing Services (DNS) indicated the physician had been notified, via fax, about the resident's refusal of her lispro insulin for the dates 2/5/20 through 2/8/20. She was not sure what the response of "ok" on the fax cover sheet sent to the resident's physician on 2/8/20 actually meant. To the best of her knowledge, the physician had never been asked about considering a sliding scale for the resident's lispro insulin.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: OX3H11 Facility ID: 012188

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

IDENTIFICATION NUMBER

155776

NAME OF PROVIDER OR SUPPLIER

SPRINGHILL VILLAGE

(X4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION

(X2) MULTIPLE CONSTRUCTION

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During an interview, on 3/5/20 at 1:20 p.m., Registered Nurse (RN) 7 indicated the resident refused her insulin lispro almost every time it was offered. The resident had Lantus administered every morning. She had received the insulin lispro a couple times, when first admitted, and her blood glucose level dropped really fast. RN 7 believed that was why she refused the insulin lispro. The RN was not able to state that the physician had ever been questioned about a sliding scale for the resident's insulin lispro.

On 3/5/20 at 2:00 p.m., the DNS provided a document, dated 2013 and titled, "2.0 Resident Medication Rights," and indicated it was the policy currently being used by the facility. The policy indicated, "...Procedure: ...4. Facility should notify Physician/Prescriber of a resident's refusal of medications/treatment for periods greater than twenty-four (24) hours...."

3.1-5(a)(3)

F 0657 SS=D Bldg. 00

483.21(b)(2)(i)-(iii) Care Plan Timing and Revision ?483.21(b) Comprehensive Care Plans ?483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: OX3H11 Facility ID: 012188

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

IDENTIFICATION NUMBER

155776

NAME OF PROVIDER OR SUPPLIER

SPRINGHILL VILLAGE

(X4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION

(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on record review and interview, the facility failed to revise a resident's care plan to accurately reflect their cognitive status for 1 of 16 residents' care plans reviewed. (Resident 40)

Finding includes:

Resident 40's record was reviewed on 3/4/20 at 12:49 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 11/7/19, indicated the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) assessment (a test used to get a snapshot of how a person is functioning cognitively) score of eight.

A Significant Change Minimum Data Set (MDS) assessment, dated 2/5/20, indicated the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) assessment (a test used to get a snapshot of how a person is functioning cognitively) score of fifteen.

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What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents #40's Care Plan has been corrected to accurately reflect the fluctuating cognition.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All facility residents could be affected by the alleged deficient practice. All Care Plans have been reviewed to ensure changes in resident care and assessment scores are documented accurately and needed interventions added to reflect person-centered care.

04/08/2020 12:00:00A

A care plan, started 12/16/19 and last reviewed 2/21/20, indicated the resident exhibited cognitive

What measures will be put into place or what systemic

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Event ID: OX3H11 Facility ID: 012188

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

IDENTIFICATION NUMBER

155776

NAME OF PROVIDER OR SUPPLIER

SPRINGHILL VILLAGE

(X4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION

impairment with a BIMS score of less than thirteen, moderate impairment.

During an interview on 3/4/20 at 2:33 p.m., the Social Services Director (SSD) indicated the resident was alert and oriented, but her cognition level fluctuated. The care plan should have been updated to indicate the resident was cognitively intact with the BIMS score of fifteen, or to show the resident had fluctuations in her cognition. The care plans should have been reviewed and revised with the MDS assessments.

On 3/4/20 at 3:12 p.m., the Director of Nursing Services (DNS) provided a document titled, "IDT Comprehensive Care Plan Policy," and indicated it was the policy currently being used by the facility. The policy indicated, "Policy: It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment...Procedure: ...Care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition...."

3.1-35(d)(2)(B)

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changes will you make to ensure that the deficient practice does not recur? The BIMS score charted, was done by therapy and this resident's Care Plan review had not yet been completed, so we have implemented that the BIMs score, post 5 days, is completed by SS and is documented, and Care Plans updated at the time of the assessment.

(X5) COMPLETION

DATE

How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place?

Care Plan QAPI tool will be utilized for review of 7 resident care plans weekly for one month and then monthly for four months. Following this time frame and review the QAPI team will re-evaluate the continued need for the audit tool. If 100% accuracy is not achieved an Action Plan will be developed. Executive Director to monitor for compliance

F 0740 SS=D Bldg. 00

483.40 Behavioral Health Services ?483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and

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