INDEPENDENCE MANOR CARE CENTER

Based on interview and record review, the facility failed to fully complete the Skilled
Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS- ) for two sampled
residents (Resident #25 and #167) who were discharged from Medicare part A services and
remained in the facility out of three sampled residents. The facility census was 68
residents.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification
memo (S&C-09-20), dated 1/9/09, showed the following:
-The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS- ) is issued when all
covered Medicare services end for coverage reasons;
-If the skilled nursing facility (SNF) believes on admission or during a resident’s stay
that Medicare will not pay for skilled nursing or specialized rehabilitative services and
the provider believes that an otherwise covered item or service may be denied as not
reasonable or necessary, the facility must inform the resident or his/her legal
representative in writing why these specific services may not be covered and the
beneficiary’s potential liability for payment for the non-covered services. The SNF’s
responsibility to provide notice to the resident can be fulfilled by the use of either the
SNFABN (form CMS- ) or one of the five uniform denial letters;
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to
pay for them him/herself or through other insurance they may have and
-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the
initiation, reduction, or termination of Medicare Part A benefits, the provider has met is
obligation to inform the beneficiary of his/her potential liability for payment and
related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys
notice to the beneficiary of his/her right to an expedited review of a service
termination.
1. Record review of the Beneficiary Notice-Resident discharged Within the Last Six Months
showed Resident #25 was discharged from Medicare Part A services on 5/22/18 and remained
in the facility.
Record review of the resident’s SNF/Beneficiary Protection Notification Review completed
by the facility staff showed:
-The resident’s Medicare part A skilled stay started on 4/28/18;
-The resident was discharged from Medicare Part A skilled services on 5/22/18 and
-The facility staff did not provide the resident the SNFABN form CMS- or an alternative
denial letter.
2. Record review of the Beneficiary Notice-Resident discharged Within the Last Six Months
showed Resident #167 was discharged from Medicare Part A services on 6/28/18 and stayed in
the facility.
Record review of the resident’s SNF/Beneficiary Protection Notification Review completed
by the facility staff showed:
-The resident’s Medicare part A skilled stay started on 5/30/18;
-The resident was discharged from Medicare Part A skilled services on 6/28/18 and
-The facility staff did not provide the resident the SNFABN form CMS- or an alternative
denial letter.
During an interview on 8/20/18 at 3:05 P.M., Social Services Designee (SSD) A said:
-He/she was responsible for delivering the Medicare Part A discharge notices;
-He/she was unaware the CMS- needed to be given to the resident upon discharge from

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure one
sampled resident’s (Resident #8) room out of 18 sampled residents,was free of strong urine
odor; and to ensure that all residents had a clean environment by maintaining the ceiling
fan blades in the dining room of the locked unit and a ceiling vent in the laundry area
free from a heavy build-up of dust; this practice potentially affected 20 residents who
reside in the locked unit and may use that dining room for meals and/or activities. The
facility census was 68 residents with a licensed capacity for 99.
1. Record review of Resident #8’s Face Sheet showed he/she was admitted to the facility on
[DATE] with the [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (a slowly progressive
disease of the brain that is characterized by impairment of memory and eventually by
disturbances in reasoning, planning, language, and perception);
-Generalized muscle weakness and
-Need for assistance with personal care.
Record review of the resident’s Potential for Skin Breakdown Care Plan, dated 7/27/17,
showed:
-The resident used a pressure-relieving mattress and chair cushion and
-The staff were to clean the resident following urination and bowel movements.
Record review of the resident’s Incontinence Care Plan, dated 8/10/17 showed:
-The staff were to change the resident’s soiled clothing after each incontinent episode
and
-The resident may wear briefs in bed according to family request.
Record review of the resident’s Activities of Daily Living (ADL’s – dressing, grooming,
bathing, eating, and toileting) Care Plan, dated 12/1/17, showed he/she required
one-person assistance with all ADL’s, with the exception of transfers in which he/she
required two-person assistance.
Record review of the resident’s Urinary Incontinence Evaluation, dated 5/11/17 showed:
-The resident was always incontinent of urine;
-The resident was in later stages of Dementia (a progressive organic mental disorder
characterized by chronic personality disintegration, confusion, disorientation, stupor,
deterioration of intellectual capacity and function, and impairment of control of memory,
judgment, and impulses);
-The resident was dependent upon staff for bed mobility, transfers, toileting and personal
hygiene;
-The resident was unable to change his/her own incontinence pad and sometimes soaked
his/her pad and
-The resident’s incontinence was due to cognitive (mental) and/or physical functioning.
Record review of the resident’s Annual Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning), dated 8/6/18, showed
he/she:
-Was severely cognitively impaired;

Based on interview and record review, the facility failed to check the State Certified
Nurse Aide (CNA) Registry to determine if newly hired individuals had a Federal Indicator
(shows abuse, neglect or misappropriation of property occurred while the individual was
employed as a CNA in a Medicaid and/or Medicare federally certified facility, which
prohibits the individual from working in a certified facility), Criminal Background Check
(CBC) and the Employee Disqualification List (EDL), a search to see if an applicant is not
eligible for hire, prior to hiring the staff member; and to ensure the facility policy
reflected the current guidelines for screening staff prior to hire for ten out of ten
sampled employees. The facility census was 68 residents.
Record review of the facility’s Abuse Prevention Policy updated 11/2017 showed:
-No later than two working dates of the date an applicant for a position to have contact
with residents is hired, a CBC will be completed,
–The policy did not outline the current required background checks that were required and
–The policy did not state the background checks were to be completed prior to hire.
1. Record review of Employee A’s personnel file showed:
-He/she was hired as a CNA on 1/17/18 and
-His/her CBC, EDL, and CNA registry check was completed on 7/19/18.
Record review of Employee B’s personnel file showed:
-He/she was hired as a CNA on 9/27/17;
-His/her CBC and EDL were completed on 1/11/18 and

-He/she was responsible for ensuring all background checks were completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative(s) in writing of a transfer or discharge to a hospital,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative(s) in writing of the facility bed hold policy for three sampled
residents (Resident #51, Resident #11 and Resident #50) out of 18 sampled residents. The
facility census was 68 residents.
Record review of an undated copy of the facility Bed Hold Policy showed when a resident
was hospitalized the facility would contact the resident’s responsible party(s) to ask if
he/she wishes to hold the room.
1. Record review of Resident #51’s face she showed he/she was admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].>-[DIAGNOSES REDACTED] (small sac like pouches that
protrude through the tube like intestinal wall) of the small intestine without perforation
or bleeding and
-Intestinal obstruction (a mechanical or functional obstruction of the intestines which
prevents the normal movement of the products of digestion).
Record review of the resident’s significant change Minimum Data Set (MDS- a federally
mandated assessment instrument to be completed by the facility staff for care planning)
dated 6/21/18 showed the resident was cognitively intact.
Record review of the resident’s Nurse Notes dated 5/22/18 at 9:49 A.M. showed physician’s
orders [REDACTED].
Record review of the resident’s Nurse Notes dated 6/1/18 at 4:17 P.M. showed the resident
was readmitted to the facility.
Record review of the resident’s medical records on 8/20/18 showed no written notice of the
facility bed hold policy had been provided to the resident or the resident’s
representatives.
During an interview on 08/20/18 at 10:15 A.M. the Social Services Designee (SSD) said:
-The resident and the resident’s representative(s) were given a copy of the facility bed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure one sampled resident
(Resident #11) taking Pro Re Nata (PRN – as needed) anti-anxiety medications had orders
limited to 14 days or to indicate a specific duration for the medication; and to
re-evaluate the continued need for a PRN medication after 14 days for one sampled resident
(Resident #35) out of 18 sampled residents. The facility census was 68 residents.
1. Record review of Resident #11’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnosis: [REDACTED].
-Restlessness and Agitation;
-[MEDICAL CONDITION] (a [MEDICAL CONDITION] characterized by loss of contact with the
environment, by noticeable deterioration in the level of functioning in everyday life) and
-Major [MEDICAL CONDITION] (a state of intense sadness or despair that has advanced to the
point of being disruptive to an individual’s social functioning and/or activities of daily
living).
Record review of the resident’s Physician order [REDACTED]. Give 0.25 ml every two hours
PRN for anxiety.
Record review of the resident’s nurses notes dated 7/14/18 through 7/16/18 showed:
-The resident was transferred to a local hospital on [DATE] and
-The resident returned to the facility on [DATE].
Record review of the resident’s POS, dated 8/2018 showed a physician’s orders [REDACTED].
Give 0.25 ml every two hours PRN for anxiety.
Record review of the resident’s Pharmacy Recommendation (date not indicated on form)
showed:
-Limit [MEDICAL CONDITION] medication to 14 days;
-The prescribing practitioner must document clinical rational and specify the duration of
use;
-There were no exceptions for Hospice (end of life care) residents and
-Add 14 day stop date to PRN [MEDICATION NAME] and re-evaluate for continuation at that
time.
Record review of the resident’s physician’s response to the Pharmacy’s recommendation,
signed 8/14/18, showed the following notes:
-No stop date;
-Continued behavior problems and
-Yells and aggressive.
During an interview on 8/21/18 at 10:30 A.M. the Director of Nursing (DON) said:
-The resident was the only facility resident receiving a PRN for anxiety and
-The resident’s physician had not limited the resident’s PRN antianxiety medication to 14
days or indicated a stop date of a different duration.
2. Record review of Resident #35’s admission face sheet shows he/she as admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Convulsions (an uncontrolled shaking of the body) and
-Anxiety disorder (a mental illness defined by feelings of uneasiness, worry and fear).
Record review of the residents quarterly Minimum Data Set (MDS-a federally mandated
assessment instrument to be completed by facility staff for care planning) dated 6/6/18
showed:

Based on observation, record review and interview, the facility failed to store
medications at a safe temperatures for effective administration at the front nurse’s
station medication room. This could affect all the residents who are on insulin who have
their insulin stored in the front nurse’s station medication room. The facility census was
68 residents.
Record review of the facility’s storage of medications policy dated (MONTH) 2007 states
medication requiring refrigeration must be stored in a refrigerator located in the drug
room at the Nurses station or other secured location. Medications must be stored
separately from food and must be labeled accordingly.
Record review of a Health and Human Services, Federal Drug Administration document on
Insulin (a hormone that helps lower the amount of sugar in the blood) storage states all
three U.S. pharmaceutical companies that manufacture insulin recommend that insulin be
stored in temperatures of 36 degrees to 46 degrees Fahrenheit. That insulin should not be
frozen, and that frozen insulin should not be used but should be discarded.
1. Observation on 8/17/18 at 9:04 A.M. with the Director of Nursing (DON) at front nurse’s
station medication storage refrigerator showed:
-The freezer compartment was heavily crusted with frozen condensate;
-The insulin injector pens (a device with a prefilled cylinder of insulin shaped like a
pen) were stored in a labeled plastic bags in a small plastic container beneath the
freezer compartment;