Substantiated. Federal/S

PRINTED: 01/11/2018 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 00 COMPLETED 155400 B. WING 12/21/2017

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 4600 E JACKSON ST LIBERTY VILLAGE MUNCIE, IN 47303

Bldg. 00 This visit was for the Investigation of F 0000 Submission of this Plan of Complaints IN00247307 and Correction does not constitute an admission to or an agreement with IN00248344. facts alleged on the survey report.

Complaint IN00247307 - Substantiated. Submission of this Plan of Federal/State deficiency related to the Correction does not constitute an admission or an agreement by the allegation is cited at F880. provider of the truth of facts alleged or corrections set forth on Complaint IN00248344 - Unsubstantiated the statement of deficiencies. due to lack of evidence. The Plan of Correction is prepared and submitted because of Survey dates: December 20 and 21, 2017 requirements under State and Federal law. Facility number: 000269 Please accept this Plan of Provider number: 155400 Correction as our credible AIM number: 100267720 allegation of compliance.

Census bed type: SNF: 61 Total: 61

Census payor type: Medicare: 3 Medicaid: 53 Other: 5 Total: 61

This deficiency reflects State findings cited in accordance with 410 IAC 16.2-3.1.

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: 5I0U11 Facility ID: 000269 If continuation sheet Page 1 of 7 PRINTED: 01/11/2018 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 00 COMPLETED 155400 B. WING 12/21/2017

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 4600 E JACKSON ST LIBERTY VILLAGE MUNCIE, IN 47303

Quality Review completed on December 27, 2017.

F 0880 483.80(a)(1)(2)(4)(e)(f) SS=F Infection Prevention & Control Bldg. 00 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5I0U11 Facility ID: 000269 If continuation sheet Page 2 of 7 PRINTED: 01/11/2018 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 00 COMPLETED 155400 B. WING 12/21/2017

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 4600 E JACKSON ST LIBERTY VILLAGE MUNCIE, IN 47303

(X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG DEFICIENCY) DATE (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. Based on observation and interview the F 0880 The Residents in rooms 106, 114, 01/02/2018 12:00:00AM facility failed to ensure the propeer storage 116, 117, 120, 121, 122, 204, 205,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5I0U11 Facility ID: 000269 If continuation sheet Page 3 of 7 PRINTED: 01/11/2018 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 00 COMPLETED 155400 B. WING 12/21/2017

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 4600 E JACKSON ST LIBERTY VILLAGE MUNCIE, IN 47303

Findings include: All residents have the potential to be affected. All urinals, bedpans, During an observation on 12/20/2017 at wash basins, and other personal 11:25 a.m., acompanied by the care equipment are being properly Administrator, Clinical Consultant and the cleaned and stored,

Director of Nursing, the resident bathrooms were inspected and the following concerns were noted: The facility’s policies have been reviewed with no changes indicated Room 106 Visibly soiled bedside commode at this time. The nursing staff have cover on bathroom floor. been re-educated on proper Room 114 Wash basin on bathroom floor, cleaning/sanitation/storage of bedpans, urinals, wash basins, and not bagged. other personal care equipment. A Room 116 One soiled urinal in bag and one monitoring tool has been wash basin stored on the floor under the implemented.

sink.

Room 117 One unclean bedpan and one unclean wash basin on the bathroom floor The DON or designee will be unbagged. responsible for checking rooms to ensure personal care equipment, Room 120 Wash basin on bathroom floor including bedpans, urinals, and unbagged. washbasins are clean and stored Room 121 Soiled urinal on back of the appropriately. These observations will occur on scheduled work days toilet. Soiled unbagged urine collection hat as follows: Daily on an ongoing on floor next to toilet basis. Should a concern be found, Room 122 Wash basin in bathroom not immediate corrective action will occur. Results of these reviews and bagged. any corrective action will be Room 204 Bagged urinal hanging from trash reviewed during the facility’s QA

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5I0U11 Facility ID: 000269 If continuation sheet Page 4 of 7 PRINTED: 01/11/2018 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 00 COMPLETED 155400 B. WING 12/21/2017

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 4600 E JACKSON ST LIBERTY VILLAGE MUNCIE, IN 47303

floor. Room 209 Bedside commode in shower with dark yellow/brown stains on seat. Room 215 Wash basin located on the back of he toiled unbagged. Urinal soiled and unbagged located behind sink. Room 216 One urinal not bagged with yellow liquid, hanging from the trash can in the bathroom.

During an interview on 12/20/2017 at 11:13 a.m., CNA 4 indicated urinals, bed pans and wash basins were sometimes marked with the resident's name, but not always. The CNA indicated the items needed to be cleaned and sanitized after each use, bagged in a plastic bag and placed in the resident's room or bathroom.

During an interview on 12/20/2017 at 10:20 a.m., CNA 8 indicated soiled bedpans, urinals and wash basins should be rinsed out and cleaned in the soiled hold room, sanitized and placed in a plastic bag and placed in the clean hold for future use. The CNA indicated the personal care items are stored in the resident's bathroom.

During an interview on 12/21/2017 at 12:21 p.m., QMA 6 indicated used urinals,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5I0U11 Facility ID: 000269 If continuation sheet Page 5 of 7 PRINTED: 01/11/2018 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 00 COMPLETED 155400 B. WING 12/21/2017

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 4600 E JACKSON ST LIBERTY VILLAGE MUNCIE, IN 47303

During an interview no 12/20/2017 at 11:25 a.m., the Clinical Consultant indicated bedpans, wash basins and urinals could be used by multiple residents if they were cleaned and sanitized properly between uses. She also indicated urinals, bedpans and wash basins did not need to be labled with the resident's name and should never be stored on the floor.

Review of a current policy dated 10/2014, titled "Bedpan/Urinal Sanitation", indicated the following: "Purpose: Sanitization of bedpans and urinals is completed in an effort to prevent the spread of healthcare associated infections. Policy: All bedpans/urinals currently in use will be sanitized according to current facility practice/frequency. ... Procedure: ... 1. Collect all soiled bedpans/urinals on the unit. 2. Fill sinks with appropriate amounts of

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5I0U11 Facility ID: 000269 If continuation sheet Page 6 of 7 PRINTED: 01/11/2018 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 00 COMPLETED 155400 B. WING 12/21/2017

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 4600 E JACKSON ST LIBERTY VILLAGE MUNCIE, IN 47303

This Federal tag relates to Complaint IN00247307.

3.1-18(a)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5I0U11 Facility ID: 000269 If continuation sheet Page 7 of 7