PRINTED: 02/08/2018 DEPARTMENT OF HEALTH AND HUMAN … · (x1) provider/supplier/clia department of...
Transcript of PRINTED: 02/08/2018 DEPARTMENT OF HEALTH AND HUMAN … · (x1) provider/supplier/clia department of...
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
F 0000
Bldg. 00
This visit was for the Investigation of
Complaints IN00246573, IN00247919,
IN00249592, IN00250153, and
IN00250908.
Complaint IN00246573 - Substantiated.
No deficiencies related to the allegations are
cited.
Complaint IN00247919 - Substantiated.
Federal/State deficiencies related to the
allegations are cited at F584.
Complaint IN00249592 - Substantiated.
Federal/State deficiencies related to the
allegations are cited at F803, F804, and
F842.
Complaint IN00250153 - Substantiated.
Federal/State deficiencies related to the
allegations are cited at F689.
Complaint IN00250908 - Substantiated.
Federal/State deficiencies related to the
allegations are cited at F689.
Survey dates: January 17, 18 & 19, 2018
Facility number: 000125
Provider number: 155220
F 0000 The facility is submitting plan of
correction in accordance with the
regulatory requirement and is
submitting supporting
documentation and evidence for
your review.
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 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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: 2FUG11 Facility ID: 000125
TITLE
If continuation sheet Page 1 of 22
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
AIM number: 100266740
Census bed type:
SNF/NF: 139
Residential: 44
Total: 183
Census payor type:
Medicare: 26
Medicaid: 82
Other: 31
Total: 139
These deficiencies reflect State Findings
cited in accordance with 410 IAC 16.2-3.1.
Quality review completed on 1/22/18.
483.10(i)(1)-(7)
Safe/Clean/Comfortable/Homelike
Environment
§483.10(i) Safe Environment.
The resident has a right to a safe, clean,
comfortable and homelike environment,
including but not limited to receiving
treatment and supports for daily living safely.
The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and
homelike environment, allowing the resident
to use his or her personal belongings to the
extent possible.
F 0584
SS=E
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 2 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
(i) This includes ensuring that the resident
can receive care and services safely and that
the physical layout of the facility maximizes
resident independence and does not pose a
safety risk.
(ii) The facility shall exercise reasonable care
for the protection of the resident's property
from loss or theft.
§483.10(i)(2) Housekeeping and maintenance
services necessary to maintain a sanitary,
orderly, and comfortable interior;
§483.10(i)(3) Clean bed and bath linens that
are in good condition;
§483.10(i)(4) Private closet space in each
resident room, as specified in §483.90 (e)(2)
(iv);
§483.10(i)(5) Adequate and comfortable
lighting levels in all areas;
§483.10(i)(6) Comfortable and safe
temperature levels. Facilities initially certified
after October 1, 1990 must maintain a
temperature range of 71 to 81°F; and
§483.10(i)(7) For the maintenance of
comfortable sound levels.
Based on observation and interview, the
facility failed to ensure Housekeeping
services were provided to maintain a clean
and sanitary environment related to unclean
floors, walls, furniture, and equipment in
resident rooms and dining rooms on 2 of 3
resident halls and 2 of 4 Dining Rooms.
(East Hall, West Hall, Main Dining Room &
F 0584 DYER NURSING &
REHABILITATION CENTER
PLAN OF CORRECTION
Complaint Survey January 2018
F584
Please accept the following as the
facility’s credible allegation of
compliance. This plan of
correction does not constitute an
01/29/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 3 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
West Unit Dining Room)
During the Environmental Tour, with the
Housekeeping Supervisor, on 1/19/18 at
10:50 a.m., the following was observed:
1. East Hall
a. Room 105: There was an accumulation of
tan spillage on the wall near the head of Bed
1. There was dust and debris on the floor
tacks of the closet door. The floor and the
base of the toilet in the bathroom were dirty.
Two residents resided in the room.
b. Room 108: The base of the toilet was
dirty. Two residents resided in the room.
c. Room 127: There was spillage on the
floor and the floor mat near Bed 2. One
resident resided in the room.
2. West Hall
a. Room 150: Floor tile around the toilet
was missing. The caulking around the toilet
was discolored. Two residents resided in the
room.
b. Room 161: There was dried debris on the
floor mat, dried tube feeding on the tube
feeding pole, and the oxygen canister for
Bed 2. The base of the toilet was dirty.
Two residents resided in the room.
admission of guilt or liability by the
facility and is submitted only in
response to the regulatory
requirement.
What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient
practice;
The Facility removed and cleaned
the area with the tan spillage on
the wall near the head of the bed
in room 105. The facility removed
the dust and debris on the floor
and the tracks of the closet doors.
The facility cleaned the the base
of the toilet and the floor in the
bathroom. In room 108 the facility
cleaned the base of the toilet in
108. The facility cleaned the
spillage on the floor and the floor
mat in room 127 near bed 2.
The facility replaced the tile and
caulking around the toilet in room
150. The facility removed the dried
debris on the floor mat and the
dried feeding off the feeding pole
and the oxygen canister room
161-2. The facility also cleaned
the base of the toilet for room 161.
The facility removed the spillage
on the dresser in room 185
nearest to bed 1. The facility
removed the dried spillage on the
wall in the West Unit dinning area.
Resident G’s Broda chair was
cleaned and the two small
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 4 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
c. Room 185: There was spillage on the
dresser near Bed 1. One resident resided in
the room.
d. Unit Dining Room: There was dried
spillage on the wall.
e. Resident G was seated in a Broda chair in
the hallway by the Nurses Station. There
was an accumulation of spillage and debris
on the bars of the chair.
3. Main Dining Room:
a. There were stains in the two small
couches near each of the entrances.
During the Environmental Tour, the
Housekeeping Supervisor confirmed the
above area were in need in cleaning.
This Federal tag relates to Complaint
IN00247919.
3.1-19(f)
couches in the Main dinning area
were cleaned.
How the facility will identify
other residents having the
potential to be affected by the
same deficient practice and
what corrective action will be
taken;
All residents have the potential to
be affected by the same deficient
practice. The facility staff
completed rounding of all resident
rooms and resident common
areas to identify any areas
affected by the same deficient
practice. If an area was identified it
was corrected immediately.
What measures will be put
into place or what systemic
changes will be made to
ensure that the deficient
practice does not recur
The housekeeping manager will
meet with facility staff daily to
identify areas of concern and
correct identified concerns
immediately.
How the corrective action(s)
will be monitored to ensure the
deficient practice will not
recur, i.e., what quality
assurance programs will be put
into place;
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 5 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
Administrator/designee will audit 5
resident rooms and 1 common
area five days a week to ensure
that resident have a safe and
clean comfortable homelike
environment . A summary of the
audits will be presented to the
Quality Assurance committee
monthly by
Administrator/designee for 6
months. Thereafter, if determined
by the Quality Assurance
committee, auditing and
monitoring will be done quarterly
and present quarterly at the QA
meeting. Monitoring will be on
going.
Date Certain: 1/29/2018
483.25(d)(1)(2)
Free of Accident
Hazards/Supervision/Devices
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment
remains as free of accident hazards as is
possible; and
§483.25(d)(2)Each resident receives
adequate supervision and assistance devices
to prevent accidents.
F 0689
SS=D
Bldg. 00
Based on observation, record review, and
interview, the facility failed to ensure fall
prevention interventions were in place
related to devices not functioning or in place
correctly, residents left unsupervised in the
Dining room, and interventions not
F 0689 The facility is submitting plan of
correction in accordance with the
regulatory requirement and is
submitting supporting
documentation and evidence for
your review.
DYER NURSING &
01/29/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 6 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
implemented for resident positioning for 2 of
3 residents reviewed for falls. (Residents D
and G). The facility also failed to utilize
appropriate, hazard-free assistive devices
related to dining for 1 randomly observed
resident. (Resident J)
Findings include:
1. On 1/17/18 at 6:40 p.m., Resident G was
observed in a Broda chair in the hallway
across from the Nursing Station. Bruising
was present on the resident's left forehead
and temporal areas.
On 1/18/18 at 7:36 a.m., Resident G was
observed in a Broda chair at table in the
Main Dining Room. The resident was
seated near the Kitchen doors which were
located in the back of dining room. The
entrance doors to the Main Dining Room
were at the opposite end of the room. No
staff members were in the room. At 7:37
a.m., a staff member brought another
resident into the Main Dining Room, sat the
resident at table, and left. No staff members
were observed in the Main Dining Room at
7:43 a.m. or 7:48 a.m.
On 1/18/18 at 11:40 a.m., the Hospice
Nurse transferred the resident in the Broda
chair to her room from the hallway The
REHABILITATION CENTER
PLAN OF CORRECTION
Complaint Survey January 2018
F689
Please accept the following as the
facility’s credible allegation of
compliance. This plan of
correction does not constitute an
admission of guilt or liability by the
facility and is submitted only in
response to the regulatory
requirement.
What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient
practice;
The chair alarm for RG is in place
and staff are completing random
checks to ensure this alarm is in
place and that the resident is not
left unsupervised in the dining
room.
RJ is currently in the hospital and
will be evaluated by the Speech
Therapist upon readmission
The floor mattress for RD was
immediately corrected.
How the facility will identify
other residents having the
potential to be affected by the
same deficient practice and
what corrective action will be
taken;
All residents have the potential to
be affected by the same deficient
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 7 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
Hospice Nurse observed the chair alarm
had been in the off position. The Hospice
Nurse indicated he had previously observed
the alarm off on the day after the resident's
most recent fall on 1/8/18.
On 1/18/18 at 1:10 a.m., CNA 1 and CNA
2 were observed transferring the resident
from the Broda chair into bed. The CNA's
lifted the resident from the chair into her
bed. A blue Dycem pad was in place on
top of the white chair alarm pad.
The record for Resident G was reviewed on
1/18/18 at 9:11 a.m. Diagnoses included,
but were not limited to, cerebral
infarction(stroke), dementia, repeated falls,
palliative care, and sleep disorder.
A Care Plan, initiated on 11/21/16 and last
revised on 1/9/18, identified Resident G as
being at risk for falling related to a history of
falls, cerebral infarction, and dementia.
Care Plan interventions included, but were
not limited to, dycem (a pad to prevent
sliding) below chair cushion, bed and chair
alarms, and resident to be on the morning
get up list.
The 1/8/18 Accident/Incident Investigation,
completed by Nursing staff, was reviewed.
The resident resident was seated in the hall
practice. The facility staff
completed rounding of all resident
rooms and residents with fall and
swallowing interventions to ensure
placement and effectiveness.
Deficient areas were corrected
immediately.
What measures will be put into
place or what systemic
changes will be made to
ensure that the deficient
practice does not recur
All staff were re-in serviced on
interventions for falls, following the
meal cards and safe practices.
How the corrective action(s)
will be monitored to ensure the
deficient practice will not
recur, i.e., what quality
assurance programs will be put
into place;
DON/designee will observe 10
random meals weekly and will
observe 5 residents at each meal
to ensure that any interventions
listed on the dietary card are
followed.
DON/designee will observe 10
residents with a history of falls 5
days each week to ensure fall
interventions are in place and to
ensure residents are not leave in
the dining room unattended.
A summary of the audits will be
presented to the Quality
Assurance committee monthly by
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 8 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
by the Nursing Station and fell. The alarm
was not sounding at the time of the fall. A
Fall Event Note, completed on 1/8/18 at
3:00 p.m., was reviewed. The resident was
in the Broda chair and fell forward out of the
chair. A hematoma was observed the left
forehead area. A Fall Root Cause Analysis
form, completed on 1/9/18, was reviewed
for the 1/8/18. The resident was in front of
the Nursing Station seated in a Broda chair.
The alarm was not on and the resident fell
from the chair.
During an interview with the facility
Administrator and Director of Nursing on
1/18/18 at 3:40 p.m., the Director of
Nursing indicated the fall interventions
should have been in place.
2. The evening meal service in the East Unit
Dining Room was observed on 1/17/18 at
5:20 p.m. Resident J received a plate of
ground meat, mashed potatoes cream corn,
and a bowl of fruit pieces. The dietary tray
card was on the table next to her plate. The
tray card indicated no straws were to be
used. At 5:40 p.m., LPN 1 sat down next
the resident and assisted her with her meal.
The LPN gave the resident her liquid shake
using a straw. The resident took several
sips using the straw.
DON/designee for 6 months.
Thereafter, if determined by the
Quality Assurance committee,
auditing and monitoring will be
done quarterly and present
quarterly at the QA meeting.
Monitoring will be on going.
Date Certain: 1/29/2018
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 9 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
The record for Resident J was reviewed on
1/19/18 at 9:15 a.m. Diagnoses included,
but were not limited to, dysphagia (difficulty
swallowing), malnutrition and chronic kidney
disease.
A Care Plan, initiated on 3/24/14 and last
revised on 10/19/17 indicated the resident
had impaired swallowing due to dysphagia.
Interventions included, but were not limited
to, observe for swallowing difficulties, diet
as ordered, observe closely for signs of
choking or aspiration, and safe swallow
strategies.
3. During an observation on 01/18/18 at
11:20 a.m., Resident D was in bed, the bed
was in low position, and a mattress was
leaning up against the hutch stand on the wall
across from the foot of the bed.
Resident D's record was reviewed on
01/18/18 at 3:16 p.m. Diagnoses included,
but were not limited to, amputation of right
foot and dementia
A Quarterly Minimum Data Set assessment,
date 10/20/17, indicated the resident's
cognition was intact, required limited
assistance for transfers, was unsteady with
transfers, and had no falls.
A care plan, dated 10/28/16 and revised on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 10 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
1/17/18, indicated he was at risk for falls.
Interventions included, 01/17/18 - 15 minute
checks for 72 hours, 01/15/18 - rearrange
room, 01/08/18 - encourage to lay down
after meals and offer assistance, floor
mattress next to bed, and safety checks.
A Physician's Order, dated 01/09/18,
indicated nursing intervention - mattress next
to bed.
A Fall Event, dated 1/13/18 at 12:40 a.m.,
indicated the resident was sitting in a
wheelchair at the Nurses' Station, fell
forward out of the locked wheelchair onto
the the floor, and received a skin tear above
the right eye.
An Investigation of the fall, dated 01/13/18
at 12:40 a.m., indicated, "...Was the cause
of the fall known? Resident has habit of
leaning forward in Wheelchair...Activity at
time of the fall -fell forward out of chair..."
During an observation on 01/19/18 at 8:20
a.m., Resident D was sitting in his
wheelchair, in his room eating breakfast.
During an observation on 01/19/18 at 10:20
a.m., the resident was sitting in a wheelchair
at the Nurses' Station, a footboard was on
the legs of the chair and the foot pedals
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 11 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
were lowered. He was leaned forward in the
chair, with his head close to lying on his lap.
The Director of Nursing (DON) was at the
Nurses' Station. The DON indicated at the
time of the observation, the resident and
indicated the intervention for the leaning was
therapy. The DON indicated the resident
would be assisted into bed after his room
was cleaned. The DON approached the
resident and asked him if he was "ok" with
leaning forward, the resident raised his head
up, eyes were closed and stated, "yes". The
DON then asked the resident, "you're not
going to fall forward are you?", then walked
down the hall to check if the room had been
cleaned.
During an observation on 01/19/18 at 10:25
a.m., the resident remained in the wheelchair
at the Nurses' Station, he was leaned
forward in the wheelchair with his head
close to his lap, he reached out and touched
the pad on the foot pedal, then sat up and
leaned forward again.
During an observation on 01/19/18 at 10:30
a.m., the resident was assisted to bed by the
CNA's.
During an interview on 01/19/18 at 10:30
a.m., the Corporate RN Consultant
indicated the mattress was to be on the floor
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 12 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
next to the bed.
During an interview on 1/19/18 at 11:22
a.m., the DON indicated there were no
interventions initiated for the leaning forward
in the wheelchair.
This Federal tag relates to Complaints
IN00250153 and IN00250908.
3.1-45(a)(2)
483.60(c)(1)-(7)
Menus Meet Resident Nds/Prep in
Adv/Followed
§483.60(c) Menus and nutritional adequacy.
Menus must-
§483.60(c)(1) Meet the nutritional needs of
residents in accordance with established
national guidelines.;
§483.60(c)(2) Be prepared in advance;
§483.60(c)(3) Be followed;
§483.60(c)(4) Reflect, based on a facility's
reasonable efforts, the religious, cultural and
ethnic needs of the resident population, as
well as input received from residents and
resident groups;
F 0803
SS=E
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 13 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
§483.60(c)(5) Be updated periodically;
§483.60(c)(6) Be reviewed by the facility's
dietitian or other clinically qualified nutrition
professional for nutritional adequacy; and
§483.60(c)(7) Nothing in this paragraph
should be construed to limit the resident's
right to make personal dietary choices.
Based on observation, review of dietary
menus and serving instructions, and
interview, the facility failed to ensure food
was served in the appropriate portions
related to not using the required size utensils
to provide correct portions as per the
Dietary Spread Sheets for meal service for 1
of 1 Kitchen. (Main Kitchen)
Finding includes:
The Evening Meal service in the Main Dining
Room was observed on 1/17/18 at 5:50
p.m. Dietary staff were serving food from
the steam table in the Dining Room. Dietary
staff 1 was using tongs to pick up a serving
of the pork meat entree. A four ounce ladle
was used to served the corn. A number (16)
blue scoop was used to serve portions of
the mashed potatoes and the pureed meat.
No menu or spread sheet was present when
staff were serving.
Dietary staff 1 indicated she did not have a
spread sheet in place when they were
F 0803 DYER NURSING &
REHABILITATION CENTER
PLAN OF CORRECTION
Complaint Survey January 2018
F803
Please accept the following as the
facility’s credible allegation of
compliance. This plan of
correction does not constitute an
admission of guilt or liability by the
facility and is submitted only in
response to the regulatory
requirement.
What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient
practice;
All residents have the potential to
be affected by this deficient
practice.
How the facility will identify
other residents having the
potential to be affected by the
same deficient practice and
what corrective action will be
taken;
The facility administrator and
01/29/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 14 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
serving. She indicated they normally use the
blue scoop for meats, potatoes, pureed
foods and mechanically altered diets.
The Daily Spread Sheet for 1/17/18 was
reviewed. The Spread Sheet indicated a
#12 scoop was to used for the pork
shoulder meat to provide a 2 ounce serving.
A #8 scoop was to be used for buttered
mashed potatoes. The Spread Sheet was
signed by the Registered Dietitian.
During an interview on 1/17/18 at 6:56 p.m.,
the facility Administrator indicated the
Dietary staff should have followed the
spread sheets to provide the required
portions.
This Federal tag relates to Complaint
IN00249592.
3.1-20(i)(4)
kitchen supervisor reviewed the
utensils for portion sizes and the
menu spread sheet to ensure
facility staff have the proper tools
and information for meal service.
What measures will be put
into place or what systemic
changes will be made to
ensure that the deficient
practice does not recur
All serving kitchen staff were re-in
serviced portion sizes and
appropriate utensils for serving
food. The staff was also in
serviced on the menu spread
sheet and how to use it during
meal prep and serving sizes.
How the corrective action(s)
will be monitored to ensure the
deficient practice will not
recur, i.e., what quality
assurance programs will be put
into place;
Administrator/designee will audit
10 random meals each week to
ensure that residents are receiving
the appropriate portion size. A
summary of the audits will be
presented to the Quality
Assurance committee monthly by
DON/designee for 6 months.
Thereafter, if determined by the
Quality Assurance committee,
auditing and monitoring will be
done quarterly and present
quarterly at the QA meeting.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 15 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
Monitoring will be on going.
Date Certain: 1/29/2018
The facility is submitting plan of
correction in accordance with the
regulatory requirement and is
submitting supporting
documentation and evidence for
your review.
483.60(d)(1)(2)
Nutritive Value/Appear, Palatable/Prefer
Temp
§483.60(d) Food and drink
Each resident receives and the facility
provides-
§483.60(d)(1) Food prepared by methods that
conserve nutritive value, flavor, and
appearance;
§483.60(d)(2) Food and drink that is
palatable, attractive, and at a safe and
appetizing temperature.
F 0804
SS=D
Bldg. 00
Based on observation, record review, and
interview, the facility failed to ensure food
was served at palatable temperatures for
foods tested during 1 of 3 meal services
observed. (The Evening meal)
Finding includes:
A test tray was requested to be sent from
Dietary to the East wing at the time room
F 0804 The facility is submitting plan of
correction in accordance with the
regulatory requirement and is
submitting supporting
documentation and evidence for
your review.
DYER NURSING &
REHABILITATION CENTER
PLAN OF CORRECTION
Complaint Survey January 2018
F804
Please accept the following as the
01/29/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 16 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
trays were sent for the evening meal on
1/17/18. Temperatures on test tray were
completed and noted as follows:
Meat: 108. 5 F
Potatoes: 113.7
Corn: 108. 0 F
The food on the tray was luke warm to
touch.
The Corporate Nurse Consultant was
present when the food temperatures were
taken and was informed the food was luke
warm to touch.
Random interviews, with two different family
members present during the meal service,
indicated the food was always served cold
to their family members.
This Federal tag related to Complaint
IN00249592.
3.1-21(a)(2)
facility’s credible allegation of
compliance. This plan of
correction does not constitute an
admission of guilt or liability by the
facility and is submitted only in
response to the regulatory
requirement.
What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient
practice;
All residents have the potential to
be affected by this deficient
practice.
How the facility will identify
other residents having the
potential to be affected by the
same deficient practice and
what corrective action will be
taken;
The facility administrator and
kitchen supervisor reviewed the
meal service to observe
temperatures of food coming out of
the oven and again observing
temperature at the steam
table.Room tray pass was
observed to identify deficient food
temperature.
What measures will be put
into place or what systemic
changes will be made to
ensure that the deficient
practice does not recur
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 17 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
All serving kitchen staff were re-in
serviced on temperature guidelines
for serving food to facility
residents. All staff was re-in
serviced on passing trays to the
units.
How the corrective action(s)
will be monitored to ensure the
deficient practice will not
recur, i.e., what quality
assurance programs will be put
into place;
Administrator/designee will audit
all meals 5 days a week to ensure
that residents are receiving the
meals at appropriate
temperatures. A summary of the
audits will be presented to the
Quality Assurance committee
monthly by DON/designee for 6
months. Thereafter, if determined
by the Quality Assurance
committee, auditing and
monitoring will be done quarterly
and present quarterly at the QA
meeting. Monitoring will be on
going.
Date Certain: 1/29/2018
483.20(f)(5); 483.70(i)(1)-(5)
Resident Records - Identifiable Information
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that
F 0842
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 18 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
is resident-identifiable to the public.
(ii) The facility may release information that is
resident-identifiable to an agent only in
accordance with a contract under which the
agent agrees not to use or disclose the
information except to the extent the facility
itself is permitted to do so.
§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted
professional standards and practices, the
facility must maintain medical records on
each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
§483.70(i)(2) The facility must keep
confidential all information contained in the
resident's records,
regardless of the form or storage method of
the records, except when release is-
(i) To the individual, or their resident
representative where permitted by applicable
law;
(ii) Required by Law;
(iii) For treatment, payment, or health care
operations, as permitted by and in
compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of
abuse, neglect, or domestic violence, health
oversight activities, judicial and administrative
proceedings, law enforcement purposes,
organ donation purposes, research purposes,
or to coroners, medical examiners, funeral
directors, and to avert a serious threat to
health or safety as permitted by and in
compliance with 45 CFR 164.512.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 19 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
§483.70(i)(3) The facility must safeguard
medical record information against loss,
destruction, or unauthorized use.
§483.70(i)(4) Medical records must be
retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge
when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident
reaches legal age under State law.
§483.70(i)(5) The medical record must
contain-
(i) Sufficient information to identify the
resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and
services provided;
(iv) The results of any preadmission
screening and resident review evaluations and
determinations conducted by the State;
(v) Physician's, nurse's, and other licensed
professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic
services reports as required under §483.50.
Based on record review and interview, the
facility failed to ensure medical records were
complete related to lack of ongoing
documentation following admission for 1 of
3 residents reviewed for documentation.
(Resident F)
Finding includes:
The closed record for Resident F was
reviewed on 1/18/18 at 12:54 p.m. The
F 0842 DYER NURSING &
REHABILITATION CENTER
PLAN OF CORRECTION
Complaint Survey January 2018
F842
Please accept the following as the
facility’s credible allegation of
compliance. This plan of
correction does not constitute an
admission of guilt or liability by the
facility and is submitted only in
response to the regulatory
requirement.
01/29/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 20 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
resident was admitted on 12/22/17.
Diagnoses included, but were not limited to,
dementia and high blood pressure.
Nursing Progress notes were completed as
follows:
12/22/17 at 2:59 p.m. The resident was
transported to the facility by family from the
hospital. The resident was alert and
responsive with some confusion. A head to
toe assessment was completed. The
Physician was notified of the admission.
12/23/17 at 12:40 a.m. The Daughter can
be reached at (phone number).
12/24/17 at 6:10 p.m. The resident was
hard to arouse, skin warm and dry, lungs
clear, did not wake up for dinner.
12/24/17 at 6:30 p.m. The resident is alert
and talking to family. Family requests blood
work be done.
12/24/17 at 6:54 p.m. Lab called for stat lab
tests.
12/24/17 at 7:02 p.m. The family states they
have decided to send the resident to the
hospital for an evaluation.
12/24/17 at 7:57 p.m. The resident left the
facility on a stretcher to the hospital.
The only set of Vital Signs was completed
on 12/22/17 at 2:45 p.m. No other resident
What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient
practice;
Resident F discharged from the
facility
How the facility will identify
other residents having the
potential to be affected by the
same deficient practice and
what corrective action will be
taken;
All residents have the potential to
be affected by the same deficient
practice.
What measures will be put
into place or what systemic
changes will be made to
ensure that the deficient
practice does not recur
All nursing staff were in serviced
on the following:
Monitoring vital signs for 72 hours
after admission
Monitoring and assessing
residents 72 hours after admission
Documenting vitals and resident
assessments in the clinical
record.
How the corrective action(s)
will be monitored to ensure the
deficient practice will not
recur, i.e., what quality
assurance programs will be put
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 21 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
02/08/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
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 COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(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
DYER, IN 46311
155220 01/19/2018
DYER NURSING AND REHABILITATION CENTER
601 SHEFFIELD AVE
00
assessments were noted.
During an interview on 1/18/18 at 2:43 p.m.,
the Director of Nursing indicated Nursing
staff are to completed an assessment of the
resident every shift for 72 hours following
new admission.
This Federal tag relates to Complaint
IN00249592.
3.1-50(a)(1)
into place;
DON/designee will audit all new
admissions and re admissions
daily for 72 hours to ensure
appropriate medical record
documentation is completed. A
summary of the audits will be
presented to the Quality
Assurance committee monthly by
DON/designee for 6 months.
Thereafter, if determined by the
Quality Assurance committee,
auditing and monitoring will be
done quarterly and present
quarterly at the QA meeting.
Monitoring will be on going.
Date Certain: 1/28/2018
The facility is submitting plan of
correction in accordance with the
regulatory requirement and is
submitting supporting
documentation and evidence for
your review.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet Page 22 of 22