PRINTED: 05/01/2018 DEPARTMENT OF HEALTH AND HUMAN ... · revisions necessary. DON/designee will re-educate all licensed nurses on the Resident Rights-Notification of Changes policy

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

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NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

FORT WAYNE, IN 46816

155586 04/13/2018

LUTHERAN LIFE VILLAGES

6701 S ANTHONY BLVD

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey. This visit included a State

Residential Licensure Survey.

Survey dates: April 5, 6, 9, 10, 11 & 12, 2018

Facility number: 000283

Provider number: 155586

AIM number: 100275020

Census Bed Type:

SNF/NF: 120

SNF: 2

Total: 122

Census Payor Type:

Medicare: 11

Medicaid: 108

Other: 3

Total: 122

These deficiencies reflects State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality review completed April 16, 2018.

F 0000 Please accept this as our credible

allegation of compliance to our

recent ISDH annual survey.

Submission of this Plan of

Correction does not constitute an

admission or agreement by the

provider of the truth of facts

alleged or the corrections set forth

on the statement of deficiencies.

This Plan of Correction is prepared

and submitted because of

requirements under State &

Federal Law.

We are also scanning in several

attachments as supportive

documentation.

We respectfully request the

opportunity to have this POC

reviewed and accepted with paper

compliance.

Thank you.

James Schmidt, HFA

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;

F 0580

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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: WWB111 Facility ID: 000283

TITLE

If continuation sheet Page 1 of 33

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(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).

§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

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under §483.15(c)(9).

Based on observation, interview, and record

review, the facility failed to ensure the physician

in a timely manner for 1 of 1 resident reviewed

with a change in condition.

(Resident 105)

Findings include:

1. On 4/10/18 at 10:00 a.m., the clinical record of

Resident 105 was reviewed. Diagnoses included,

but were not limited to the following, enterocolitis

due to Clostridium difficile (germ which can cause

diarrhea), not specified as recurrent, congestive

heart failure, cardiomyopathy, acute kidney

failure, type 2 diabetes mellitus, and hypertension.

The admission Minimum Data Set (MDS)

Assessment, dated 3/21/18, indicated the

following: Resident 105 was independent

cognition; received antibiotics during the last 7

days.

On 4/6/18 at 2:00 p.m., the Administrator provided

a current copy of the policy and procedure for

"Infection Control" dated 4/3/17. The policy and

procedure included the following: "...The nurse is

responsible for alerting the attending physician of

resident's symptoms..."

On 4/10/18 at 4:04 p.m., the DON (Director of

Nursing) provided a current copy of the facility

policy and procedure for "...Clostridium Difficile (c

diff)" dated 2/12/18. The policy and procedure

included the following: "...Residents considered

at high risk for developing symptoms associated

with Clostridium difficile include those with

advancing age...previous gastrointestinal illness

caused by Clostridium difficile and

antibiotic...residents with these risks have

F 0580 F 580 NOTIFY OF CHANGES

(INJURY/DECLINE/ROOM, etc.)

1.The NP was notified on

4/10/18 of the continued loose

stool for resident #105. See

Attached F580A.

2.All other residents were

audited to determine if they had a

significant change of condition that

would require physician

notification. No other concerns

identified.

3.The facility has a policy, see

attached F580B, entitled

“Resident Rights-Notification of

Changes”, that was reviewed, no

revisions necessary.

DON/designee will re-educate all

licensed nurses on the Resident

Rights-Notification of Changes

policy.

4.Quality Monitoring: An audit

form was developed on 4/27/18 for

the DON/designee to audit 10

residents monthly for a total of 6

months to ensure physician

notification for significant changes

were completed. Results of these

audits will be reported to the QAA

committee monthly through

November 2018.

05/11/2018 12:00:00AM





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symptoms of diarrhea (i.e. three (3) loose stools in

a twenty-four (24) hour period), Clostridium

difficile should be considered as a

cause...Residents with previous infection who

develop diarrhea should be evaluated as soon as

practical..."

Current physician "Order Summary Report", dated

3/18, indicated to give the following: Vancomycin

25 mg/ml(milligrams/milliliter) give 5 ml d/c date

4/6/18..."

Review of the April 2018 MAR (medication

administration record) indicated the following:

"Vancomycin 25 mg/ml give 5 ml by mouth every

48 hours." The last documented dose was on

4/5/18 at 19:57 (7:57 p.m.).

A 4/6/18 progress note at 7:27 a.m., indicated

"...Stools formed w/slight foul odor..."

A 4/6/18 progress note at 12:48 p.m., indicated

"...Res continues with loose, foul smelling stools."

Documentation was lacking of the NP and/or

physician having been notified of the resident

having loose, foul smelling stools.

On 4/7/18, the BM report indicated the resident

was continent, had a medium loose/diarrhea stool

documented. Documentation was lacking in the

progress notes of characteristics (presence or

absence of odor) of resident's loose/diarrhea

stools. Documentation was lacking of the NP

and/or physician having been notified of the

resident having loose/diarrhea stools.


was continent, had a small, loose/diarrhea stool

documented. Documentation was lacking in the

progress notes of characteristics (presence or





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absence of odor) of resident's loose/diarrhea

stools. Documentation was lacking of the NP

and/or physician having been notified of the

resident having loose/diarrhea stools.


was continent, had a large and a medium

loose/diarrhea stool documented. Documentation

was lacking in the progress notes of

characteristics (presence or absence of odor) of

resident's loose/diarrhea stools. Documentation

was lacking of the NP and/or physician having

been notified of the resident having

loose/diarrhea stools.

Progress note, dated 4/10/18 at 11:16 a.m.,

indicated: "Res having diarrhea today, since he

woke up. Writer called and spoke with (name of

NP). Orders received for res (resident) to have prn

(as needed) Imodium (antidiarrheal medication)

started and collected another specimen for

C-Diff...specimen collected and sent to lab for

testing..."

A "Lab Results Report", collected 4/10/18 at 10:30

a.m., indicated the following: Clostridium difficile

4/10/18: "positive. "

On 4/11/18 at 3:08 p.m., the DON was interviewed.

She indicated the nurse caring for the resident

today, LPN 1, indicated the NP doesn't retest for a

week after Vancomycin was completed. The DON

indicated another C difficile sample was obtained

on 4/10/18, with a positive result. She indicated

LPN 1 indicated the reason the NP ordered the

Vancomycin to be restarted was because LPN 1

made the NP aware, on 4/10/18, the resident had

"complained" to her.

On 4/12/18 at 12:05 p.m., the NP was interviewed.





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She indicated she was called on Tuesday, 4/10/18,

and was made aware at that time, the resident was

having diarrhea, but should have been notified if

the resident continued with loose stools after the

medication had been discontinued on 4/6/18.

3.1-5(a)(3)

483.20(b)(2)(ii)

Comprehensive Assessment After Signifcant

Chg

§483.20(b)(2)(ii) Within 14 days after the

facility determines, or should have

determined, that there has been a significant

change in the resident's physical or mental

condition. (For purpose of this section, a

"significant change" means a major decline

or improvement in the resident's status that

will not normally resolve itself without further

intervention by staff or by implementing

standard disease-related clinical

interventions, that has an impact on more

than one area of the resident's health status,

and requires interdisciplinary review or

revision of the care plan, or both.)

F 0637

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Based on interview and record review, the facility

failed to ensure a significant change in status

assessment was completed for 1 of 1 residents

reviewed for significant change assessments

(Resident 128).

Findings include:

On 4/12/18 at 9:22 A.M., the record for Resident

128 was reviewed. Diagnoses included, but were

not limited to, cerebrovascular accident (stroke

8/17), history of falls, hypertension (high blood

pressure), chronic kidney disease, and insomnia.

The resident was admitted to the facility following

her stroke for rehabilitation.

F 0637 F 637 Comprehensive

Assessment after Significant

Change

1.Resident 128 no longer

resides in the facility.


reviewed regarding significant

change in medical status to

determine if a significant change

had occurred. No other residents

were identified.


attached F637A, entitled “Care

Plans”, that was reviewed, no

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An Admission MDS (Minimum Data Set)

assessment, dated 8/31/17, indicated the resident

had a BIMS (Brief Interview Mental Status) score

of 14 which signified she had no cognitive

impairment, required limited assistance of 1 staff

member with bed mobility, walking in her room,

and with dressing, required extensive assistance

of 2 staff members with transfers, required

supervision with eating and supervision with 2

staff members for toileting. The resident was

continent of bowel and bladder and the resident

had no mood issues.

A Nutrition/Dietary Note: 5 day Review, dated

8/31/17 at 6:52 A.M., indicated the resident's

weight on admission was 134.6. The note

indicated the resident was a "light eater" and on

average, her meal intakes were 75%. The resident

fed herself a regular diet and had no chewing or

swallowing problems.

A Nurse Note, dated 12/1/2017 at 8:47 A.M.,

indicated the resident's family had spoken with

the social worker at the facility and had requested

the resident be placed on palliative/comfort

measures care.

A Nurse Practitioner Progress Note, dated

12/1/2017 at 11:17 A.M., indicated the resident

was seen for review of medications and change to

comfort measures/palliative care. The NP (Nurse

Practitioner) discontinued several medications

including, but not limited to, Remeron (medication

for insomnia) and Lasix (water pill).

A Quarterly MDS assessment, dated 12/1/17,

indicated a BIMS score of 9 which signified

moderately impaired cognition. The MDS

indicated the resident had the following mood


DON/designee will re-educate the

MDS Coordinators on this policy,

as well as, educate licensed

nurses to inform MDS

Coordinators of significant

changes.



the DON/designee to audit all care

plans monthly for the next 6

months regarding significant

change criteria necessitating a

significant change MDS

assessment using the RAI

manual. Results of these audits

will be reported to the QAA


November 2018.





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issues: little interest or pleasure, feeling down,

depressed and hopeless, tired with little energy,

poor appetite, and feeling bad about and letting

self and family down. The residents weight was

111. The MDS indicated the resident needed

extensive assistance of 1 staff member with bed

mobility, transfers, walking in room, dressing, and

toilet use. The MDS indicated the resident was

occasionally incontinent of bowel and bladder.

On 4/12/18 at 11:09 A.M., the MDS Coordinator

was interviewed. During the interview, she

indicated she was unsure of why a significant

change MDS assessment had not been

completed. She indicated staff followed the RAI

(Resident Assessment Instrument) process for

determining a significant change in residents

condition and revision of the care plan.

On 4/12/18 at 11: 57 A.M., MDS Nurse 2 was

interviewed. During the interview, she indicated a

significant change in status MDS should have

been completed on 12/1/17.

3.1-31(d)(1)

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.

F 0657

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(D) A member of food and nutrition services

staff.

(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 interview and record review, the facility

failed to ensure care plans were updated for 1 of 1

residents reviewed with significant change in

condition (Resident 128).

Findings include:

On 4/12/18 at 9:22 A.M., the record for Resident

128 was reviewed. Diagnoses included, but were

not limited to, cerebrovascular accident (stroke

8/17), history of falls, hypertension (high blood

pressure), chronic kidney disease and insomnia.

The resident was admitted to the facility following

her stroke for rehabilitation. She had a significant

change in her condition and expired at the facility

on 1/7/18.

An Admission MDS (Minimum Data Set)

assessment, dated 8/31/17, indicated the resident

had a BIMS (Brief Interview Mental Status) score

of 14 which signified she had no cognitive

impairment, required limited assistance of 1 staff

member with bed mobility, walking in her room,

F 0657 F 657 Care Plan Timing and

Revision

1.Resident 128 no longer

resides in the facility.


reviewed regarding significant

change in medical status to

determine if a significant change

had occurred. No other residents

were identified.


attached F637A, entitled “Care

Plans”, that was reviewed, no


DON/designee will re-educate the

MDS Coordinators on this policy,

as well as, licensed nurses.

Dining Services was educated on

4-26-2018, see attached F657K.

SS staff were educated on

4-26-2018, see attached F842D.


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and with dressing, required extensive assistance

of 2 staff members with transfers and required

supervision with eating and supervision with 2

staff members for toileting. The resident was

continent of bowel and bladder. The MDS

indicated the resident had no mood issues.

1. A Quarterly MDS assessment, dated 12/1/17,

indicated a BIMS score of 9 which signified

moderately impaired cognition. The MDS

indicated the resident had the following mood

issues: little interest or pleasure, feeling down,

depressed and hopeless, tired with little energy,

poor appetite, and feeling bad about and letting

self and family down. The residents weight was

111. The MDS indicated the resident needed

extensive assistance of 1 staff member with bed

mobility, transfers, walking in room, dressing, and

toilet use and supervision of 1 staff member for

eating. The MDS indicated the resident was

occasionally incontinent of bowel and bladder.

A Care Plan with a focus on ADL's (Activities of

Daily Living) initiated on 8/28/17 and updated

1/9/18, indicated the resident had "an expected

decline in ADL self-care performance deficit r/t

(related to) Palliative Comfort Care. Palliative

Comfort Care for the resident was not started until

12/1/17. The care plan did not indicatethe reason

for Comfort Care, nor which ADL declines were

expected to occur and interventions to address

those declines. There was no care plan for bowel

and bladder incontinence identified on the MDS

dated 12/1/17.

2. A Nutrition/Dietary Note: Late Entry: 14 day

Review, dated 9/7/17 at 1:36 P.M., indicated the

resident's current weight was 122 (noted on

9/4/17) which showed a 9.4% weight loss since

admission on 8/24/17. The resident continued to


the DON/designee to audit all care

plans monthly for the next 6

months to ensure they thoroughly

and completely reflect the current

state of the residents. Results of

these audits will be reported to the

QAA committee monthly through

November 2018.





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feed herself a regular diet.

A Nutrition/Dietary Note, dated 9/21/17 at 11:43

A.M., indicated during a care plan meeting, the

residents family discussed her intakes and eating.

The family suggested to give more soft foods at

meals. "Staff to encourage softer foods, soft

sweets, etc."

A Care Plan with a focus on nutrition, initiated on

8/25/17 and updated 1/9/18, indicated the resident

was on a regular diet. Interventions included, but

were not limited to, monitor weights and

Fluid/Food intakes, provide diet as ordered, and

encourage me to drink plenty of fluids and eat

what I order. The care plan did not address the

residents weight loss identified on 9/7/17. The

care plan did not indicate staff were to encourage

softer foods and soft sweets.

3. A Social Service Note, dated 8/29/17 at 12:24

P.M., indicated Resident 128 had resided in

assisted living and was admitted to the facility

following hospitalization for rehabilitation. The

resident was cognitively intact with a BIMS score

of 14. She had a diagnosis of insomnia and was

taking Remeron (anti-depressant) to treat this.

The resident's discharge plans were to return to

her apartment in assisted living.

A Social Service Note, dated 9/21/17 at 9:38 A.M.,

indicated a BIMS had been completed and

indicated a score of 8 which signified moderately

impaired cognition. The note indicated the

residents previous BIMS score, completed on

9/5/17 had been 14 which signified no cognitive

impairment. The note indicated the resident

"voiced no concerns" and "did not exhibit any

moods" during the visit.





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A Social Service Note, dated 11/30/2017 at 11:55

A.M., indicated an assessment was completed.

The resident was "alert, smiled slightly" and did

not voice any concerns. She remained on

Remeron for insomnia. The residents BIMS score

was 9 which indicated moderately impaired

cognition. The resident was asked about her

mood and she expressed that she was

"tired-physically and emotionally"and indicated

family had requested "comfort measures/palliative

care per the resident's wishes. The note indicated

"Care plan reviewed and remains appropriate".

A Care Plan, initiated on 11/30/17, indicated the

resident had a mood problem related to insomnia

and anxiety. The goal was for the resident to have

improved sleep pattern and improved mood state

and decreased anxiety. The care plan did not

address the cause of anxiety identified on the

quarterly MDS dated 12/1/17. There was no care

plan to address the resident's decline in cognition

and end of life needs.

On 4/12/18 at 11:09 A.M., the MDS Coordinator

was interviewed. During the interview, she

indicated she was unsure of why care plans had

not been updated or initiated to reflect the

resident's significant change. She indicated staff

followed the RAI (Resident Assessment

Instrument) process for determining a significant

change in residents condition and revision of the

care plan.

3.1-35(a)

483.35(a)(3)(4)(c)

Competent Nursing Staff

§483.35 Nursing Services

The facility must have sufficient nursing staff

with the appropriate competencies and skills

F 0726

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sets to provide nursing and related services

to assure resident safety and attain or

maintain the highest practicable physical,

mental, and psychosocial well-being of each

resident, as determined by resident

assessments and individual plans of care and

considering the number, acuity and

diagnoses of the facility's resident population

in accordance with the facility assessment

required at §483.70(e).

§483.35(a)(3) The facility must ensure that

licensed nurses have the specific

competencies and skill sets necessary to

care for residents' needs, as identified

through resident assessments, and

described in the plan of care.

§483.35(a)(4) Providing care includes but is

not limited to assessing, evaluating, planning

and implementing resident care plans and

responding to resident's needs.

§483.35(c) Proficiency of nurse aides.

The facility must ensure that nurse aides are

able to demonstrate competency in skills and

techniques necessary to care for residents'

needs, as identified through resident

assessments, and described in the plan of

care.

Based on observation and interview, the facility

failed to ensure proper technique was used for

subcutaneous injections for 1 of 2 residents

observed during administration of subcutaneous

injections.

(Resident 21)

Findings included:

A review of Resident 21's clinical record on

F 0726 F726 Competent Nursing Staff

1.The RN was re-educated, see

attached F726B, on proper SQ

administration technique/policy,

see attached F726A, on 4/24/18.

2.Nurses were observed for

proper SQ administration

technique and no further problems

were identified

3.DON/or designee will

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4/10/2018 at 12:30 p.m., indicated a BIMS (Brief

Interview of Mental Status) score of 15 out of 15,

meaning cognitively intact. Diagnoses included ,

but were not limited to: diabetes.

On 4/10/2018 at 11:22 a.m., RN (Registered Nurse)

6 was observed administering 5 units of insulin by

subcutaneous (fatty layer of skin tissue) injection

to Resident 21's abdomen with one hand.

On 4/10/2018 at 11:35 a.m., RN 6 was observed

using only one hand to administer 4 units of

insulin by subcutaneous injection in Resident 9's

abdomen.

During an interview on 4/10/2018 at 12:30 p.m., the

DON (Director of Nursing) indicated the facility

had no skills check for subcutaneous injections.

During an interview on 4/12/18 at 12:04 p.m., LPN

(Licensed Practical Nurse) 9, indicated when

giving a subcutaneous injection you are to pinch

the skin up with a your first finger and thumb

before injecting the needle with the other hand.

During an observation on 04/12/18 at 12:54 p.m.,

LPN 5, demonstrated pinching up the fatty tissue

with one hand prior to insertng the needle into the

skin and injeecting with the other hand.

During an interview on 4/12/2018 at 1:04 p.m., RN

10, indicated fatty tissue is squeezed up prior to

injecting the insulin.

3.1-14(i)

re-educate all licensed nurses

regarding proper SQ

administration technique.



the DON/designee to randomly

audit 10 SQ injection

administrations monthly for the

next 6 months to ensure proper

SQ injection administration

technique is used. Results of



November 2018.

483.45(g)(h)(1)(2)

Label/Store Drugs and Biologicals

§483.45(g) Labeling of Drugs and Biologicals

Drugs and biologicals used in the facility

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must be labeled in accordance with currently

accepted professional principles, and include

the appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and

Federal laws, the facility must store all drugs

and biologicals in locked compartments

under proper temperature controls, and

permit only authorized personnel to have

access to the keys.

§483.45(h)(2) The facility must provide

separately locked, permanently affixed

compartments for storage of controlled drugs

listed in Schedule II of the Comprehensive

Drug Abuse Prevention and Control Act of

1976 and other drugs subject to abuse,

except when the facility uses single unit

package drug distribution systems in which

the quantity stored is minimal and a missing

dose can be readily detected.


review, the facility failed to ensure medications

were properly labeled, dated, and stored properly

for 3 out of 6 medication carts, and 1 out of 3

medication rooms reviewed for medication

storage.

Findings included:

On 4/10/18 at 10:52 a.m., the 300 Hall, cart 1 was

observed with LPN (Licensed Practical Nurse) 11

and the following items were found:

A Combivent Respimat inhaler with no date

opened.

F 0761 F761 Label/Store Drugs and

Biologicals

1.The Combivent Respimat

inhaler was properly labeled with a

date opened during the survey

period. ProStat Cherry was

properly labeled for the resident

that it is in use for during the

survey period. The expired apisol

was destroyed during the survey

period.

2.Reviewed all medication carts

and medication refrigerators to

identify additional storage issues,

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On 4/10/18 at 12:08 p.m., the 100 Hall, cart 2 was

observed for storage with LPN 12 and the

following items were found:

An opened bottle of Pro Stat Cherry, with no

resident name, no Physician's name, no date

opened, and no specific instructions for the

resident it was being used for.

During an interview on 4/10/2018 at 12:09 p.m.,

LPN 12 indicated the Pro Stat was not used for

multiple residents, and should have been labeled.

On 4/12/2018 at 12:24 p.m., the 500 Hall

Medication room was observed for med storage

with LPN 9. An opened bottle of Apisol was

found in the refrigerator with a date opened label

of 3/7/2018.

At this time, an interview with LPN 9 indicated the

Apisol was only good for 30 days once opened.

During an interview on 4/12/18 12:33 p.m., the Unit

Manager of the 500 Hall indicated the Apisol vials

were only good for 30 days after opened.

On 4/10/2018 at 12:30 p.m., a current facility policy,

dated 2/9/2018, "Medication Storage" provided by

the DON (Director of Nursing) indicated "...the

facility shall store all drugs and biologicals in a

safe, secure, and orderly manner. 3. Drug

containers that have missing, incomplete,

improper, or incorrect labels shall be returned to

the pharmacy for proper labeling before storing.

8. Drugs shall be stored in an orderly manner in

cabinets, drawers, carts or automatic dispensing

systems. Each resident's medications shall be

assigned to an individual cubicle, drawer, or other

holding area to prevent the possibility of mixing

none were noted.


attached F761A, entitled

“Medication Storage”, that was

reviewed, no revisions necessary.

DON/designee will re-educate

licensed nurses on medication

storage regarding labeling.

4.Quality Monitoring: The DON

/designee will utilize a medication

storage audit to audit medication

carts and med rooms monthly for

six months regarding medication

storage. Results of these audits

will be reported to the QAA


November 2018.





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medications of several residents..."

3.1-25(j)

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

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

F 0842

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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.

§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.


review, the facility failed to ensure documentation

was complete and accurate for 4 out of 8 resident

records reviewed.

(Resident 86, Resident 43, Resident 28, and

Resident 65)

F 0842 F 842 Resident

Records-Identifiable

Information

1.A) Residents #86, 43, 28,

charts were reviewed on 4/20/18

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1. A review of Resident 86's clinical record on

4/6/2018 at 11:05 a.m., indicated a BIMS (Brief

Interview of Mental Status) could not be

completed due to severe cognitive impairment.

Diagnoses included, but were not limited to:

dementia.

Progress Notes indicated the following

documented entries:

On 2/28/2018 at 4:47 p.m., a visit was documented

by the NP (Nurse Practitioner).

On 3/1/2018 at 7:46 a.m., a Nurse's Note was

documented, "...Res (resident) continues on F/U

(follow up) incident charting. All VS (vital signs)

and neuros (neurological assessment) WNL

(within normal limits). No c/o (complaints of) pain,

shows no s/s (signs or symptoms) of distress

thus far, no injuries noted. No s/s of AMS

(altered mental status), and shows no change in

LOC (level of consciousness). WCTM (will

continue to monitor) for change in cond

(condition)..."

A review Resident 86's Progress Notes indicated

documented entries for fall follow up through

3/4/2018 at 9:52 p.m.

On 4/10/18 at 12:55 p.m., Resident 86 was

observed sitting at a dining room table, on the

Memory Care Unit.

On 4/10/18 at 3:48 p.m., Resident 86 was observed

sitting at a dining room table, on the Memory Care

Unit.

On 4/12/18 at 11:50 a.m., Resident 86 was

observed walking in the hallway of the Memory

and missing documentation in the

progress notes were identified for

fall follow-up (#86, 43, 28). The

residents did not sustain any

measurable negative outcomes as

a result of this practice. B) The

information from the completed

concern/grievance form for

resident #65, with all

documentation and resolution,

were entered into resident #65’s

EMR on 4-23-2018. See attached

F842C.

2.Current risk management and

concern/grievance logs will be

reviewed and documentation will

be entered in the EMR, per

policies, see attached F842A and

F842B.

3.The facility has policies, see

attached F842A, entitled “Fall

Policy - Resident Safety AB”, no

revisions; and policy, see attached

F842B, “Concerns/Grievances”

revisions included adding

documentation in the EMR, #2 in

the policy. A) The DON/designee

will re-educate the Resident Care

Coordinators to ensure follow up

documentation for risk

management is completed in the

progress notes. B) The

SSD/designee will re-educate

Social Services staff on 4-26-2018,

see attached F842D, regarding the

Concerns/Grievance Policy on the

necessity to have documentation

in the EMR.

4.Quality Monitoring: A) An

audit form was developed on





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Care Unit.

There were no other entries on the record to

indicate the reason for the follow up or any facts

concerning Resident 86's fall.

During an interview on 4/6/2018 at 11:06 a.m., LPN

(Licensed Practical Nurse) 13 indicated Resident

86 had a fall on 3/1/2018 in his room. The fall

information was entered into the Risk

Management section of the electronic record and

therefore, could not be shared with the surveyor.


4/9/2018 at 5:22 p.m., indicated a BIMS of 3 out of

15, meaning severe cognitive impairment.

Diagnoses included, but were not limited to:

dementia.

On 4/9/18 at 3:23 p.m. Resident 43 was observed

propelling self in her wheelchair, in the hallway,

on the Memory Care Unit, while eating a cookie.

The resident was observed having a purple

discoloration around her right eye orbit with

swelling.

Progress Notes indicated the following

documented entries:

On 4/6/2018 at 10:56 a.m., a Social Service Note

was documented for a Care Plan.

On 4/7/2018 at 4:59 p.m., an Activity Visitation

was documented.

On 4/7/2018 at 8:23 p.m., a Nurse's Note was

documented "... No psychosocial harm noted res

(resident) pleasant and participating in activities

this am (morning) no concerns offered..."

Progress Notes indicated documented entries

4/26/18 for the DON /designee to

audit risk management EMR

documentation for 10 residents

monthly to ensure documentation

is completed in the progress notes

for a total of 6 months. B) The

SSD/designee will audit current

concern/grievance report logs, see

attached F842E, to ensure

follow-up documentation has also

been entered into the EMR for all

concerns/grievances, auditing for

the next 6 months. . Results of



November 2018.





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until 4/10/2018 at 8:48 p.m., referencing no pain, no

complaints about the bruise to her right eye.

There were no other notes to indicate how or any

facts surrounding how the resident received the

black eye.

During an interview on 4/9/2018 at 3:25 p.m., CNA

(Certified Nurse Aide) 8 indicated she did not

know how Resident 43 got a black eye.

During an interview on 4/9/2018 at 3:27 p.m., QMA

(Qualified Medication Aide) 7 indicated there was

an altercation with another resident, but she was

unsure of the details because she did not work the

weekend.


Memory Care Unit Manager indicated incidents

and altercations were documented in the Risk

Management section of the facility computer

program and was not sure if it was part of the

permanent record, and could not be shared with

the surveyor. She further indicated the follow ups

were documented in the Progress Notes.


4/9/2018 at 4:33 p.m., indicated a BIMS was unable

to be completed due to severe cognitive

impairment. Diagnoses included, but were not

limited to: dementia, spinal and back disease, and

osteoporosis (fragile, brittle bones) .

On 4/9/18 at 3:35 p.m., Resident 28 was observed

in her room, laying in her bed. The resident's right

eye orbit was discolored dark purple.

Progress Notes indicated the following:

On 4/5/2018 at 3:45 p.m., an Activity Visitation not

was documented and indicated Resident 28





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visited with her sister in the afternoon.

On 4/6/2018 at 6:51 a.m., an Administration Note

was documented that Resident 28 refused a

medication.

On 4/7/2018 at 8:14 p.m., a Nurse's Note was

documented and indicated "...Res (resident)

returned from the hospital with new diagnosis

maxillary sinus fracture, simple periorbital

laceration, and inferior & superior right pubic

ramus fracture. New orders for Keflex (antibiotic)

500 mg (milligrams) po (by mouth) q (every) 6

hours times 40 tabs (tablets), and hydrocodone

bitartate-acetaminophen (narcotic for pain) 5-325

mg 1 tab po..."

Progress Notes indicated documented entries

through 4/12/2018 at 12:40 p.m.


DON indicated incidents were documented in a

Risk Management note, not in the Progress Notes.

She looked up the incident on her lap top and

indicated the following: "...On 4/7/2018 at 7:30

a.m., Resident 28 stood from the table she was

sitting at, while holding her plate of food and

glass of juice. Resident 28 fell forward losing

control of the plate and glass, laying on the floor,

on her right side, she was tensed, moaning,

groaning, crying, she had facial grimacing, and

pain to her right hip and neck. Resident 28 had

impaired memory, ambulated without assistance a

predisposed situation. LPN 13 and RN Supervisor

witnessed the incident and called the Physician

and family member. Resident 28's right outer brow

was bleeding..."

The DON indicated incidents entered into the Risk

Management section were not part of the

permanent record, and could not be shared with





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the surveyor.

During an interview on 4/12/18 at 12:54 p.m., LPN

5 indicated she would document issues in the Risk

Management report and also documented in the

Progress Notes as to what had happened to a

resident. She would talk to the staff and resident

about what happened and the Unit Manager

would investigate any issues.4. The clinical

record review for Resident 65 began on 4/9/18 at

3:46 p.m. Diagnoses included, but were not

limited to, hemiplegia following a

CVA(cerebrovascular accident, a stroke), muscle

weakness, abnormalities of gait and mobility, PVD

(peripheral vascular disease), lymphedema

(swelling in extremity caused by lymph system

blockage), autonomic neuropathy (damage to

nerves that manage every day body functions),

major depressive disorder, and anxiety disorder,

urinary tract infection. Resident 65's current

Quarterly MDS (Minimum Data Set) dated 2/15/18

indicated a BIMS (Brief Interview of Mental

Status) score was 15/15 which indicated resident

was cognitively intact.

Review of Resident 65's Progress Notes for March

2018 and April 2018 were reviewed. A progress

note was lacking about missing ID cards.

An interview with Resident 65 on 04/06/18 at 11:51

a.m., indicated a couple of Saturday's ago, she got

her wallet from the top drawer of the dresser and

found all of her ID (identification) cards were

missing. Resident 65 indicated the her Social

Security Card, Health Insurance Card, Out of State

ID card and her birth certificate were missing.

Resident 65 also indicated none of her money was

missing, which was only a few coins. Resident 65

indicated she did not report the missing ID cards

until the following Monday and then reported the





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missing items to Social Service 3. Resident 65

further indicated the Administrator had even

reported the missing ID cards to the police.

On 4/10/18 at 11:35 a.m., a review of the incident

reported to ISDH provided by Social Service 3,

indicated, "...Incident Date 03/26/18...Involved:

Resident 65[Name]...Description...Resident

reported to SS (Social Service) around noon

today, that she was missing some items

from...wallet...noticed they were missing on

Saturday, but did not tell anyone until today.

Resident stated...missing the ID, SS (Social

Security) Card, and birth certificate from...wallet,

while money remained in...wallet...FWPD (City

Police) was notified of missing items (included

police report number). Other residents were

interview, nothing else was reported missing...."

An interview with Social Service 3 on 4/10/18 at

11:02 a.m., indicated Resident 65 had reported her

missing ID card, on 3/26/18 which included her

Social Security Card, Birth Certificate and ID Card,

which was from another State. Social Service 3

indicated she had reported the missing ID cards to

the Administrator. She also indicated the

Administrator had reported the missing ID cards

to the police and to ISDH (Indiana State

Department of Health). Social Service 3 indicated

they searched for the Resident's ID cards in their

room and in the facility laundry. Social Service 3

indicated Resident 65's Inventory Sheet listed a

brown wallet, but did not list the contents of the

wallet. Social Service further indicated she was

currently working on replacing Resident 65's ID

cards.

An interview with Social Service on 4/12/18 at

11:34 a.m., indicated she was ordering Resident

65's birth certificate and had applied for a Social





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Security Card. Social Service 3 indicated she was

the first staff Resident 65 had reported the ID

Cards were missing from her wallet. Social Service

3 indicated she documented the missing items in

Resident 65's electronic record and completed a

Concern/Grievance Report and reported to the

Administrator right away. Social Service 3

reviewed Resident 65's electronic progress notes

for her documentation about the missing items,

but reported she must not have documented in

Resident 65's progress notes. She provided a

copy of the Concern/Grievance Report and the

Missing Item/Concern Log. Social Service 3

further indicated she should have documented the

missing items in the resident's record and

indicated she would add a late entry to Resident

65's progress notes.

On 4/12/18 at 12:59 p.m., review Resident 65's

electronic progress notes, which indicated,

"...Late Entry...Social Service Note...Effective

Date: 3/26/2018 08:49...Created by: [Name, Social

Service 3]...Created Date: 4/12/2018 11:51...Note:

Resident told writer she had missing items from

wallet from the weekend. Resident is stating...is

missing her SS card, ID and birth cerf [sic]

(certificate). Resident stated all of her change was

still in wallet, she had no money. Writer did give

[Name of family member] a call to verify items.

Writer reported this to Admin. (Administrator).

Concern form filled out...."

An interview with the Social Service Director on

04/12/18 at 12:35 p.m., indicated if a resident was

missing personal items, Social Service Staff

should document the missing property on the

Concern/Grievance Form and enter the items on

the Missing Item/Concern log, search for the item,

and notify appropriate staff. She then indicated if

a resident's dentures were missing, a progress





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note should be enter into the resident's record,

but a resident's missing clothing may not be

documented in the resident's record but on a

Concern/Grievance Form should be completed

and the missing items listed on the Missing

Item/Grievance Log. She further indicated the

resident's missing ID cards should have been

documented in the resident's clinical record.

An interview with the Administrator on 04/12/18

at 1:25 p.m., indicated usually missing items such

as clothing would not be documented in the

resident's clinical record, but missing money,

hearing aids, dentures should be documented in

the resident's record to alert the other facility

department, such as the dietary department if a

resident's dentures were missing. The

Administrator further indicated Resident 65's

missing ID cards were reported to the city police

and ISDH, and an investigation was completed

which included interviewing other alert residents.

An interview with the DON (Director of Nursing)

on 04/12/18 at 1:28 p.m., indicated the facility did

not have a policy regarding documentation

required for missing items/concerns/grievances in

a resident's clinical record. She indicated Resident

65's missing ID cards should be documented on a

Concern/Grievance Form and further indicated

missing items were usually not part of the

resident's clinical record.

A current facility policy with a revision date of

3/1/18, titled, Concerns/Grievance Policy, was

provided by the DON on 4/12/18 at 1:40 p.m. The

policy indicated, "...The resident has the right to

voice grievances to the facility...Grievances

include those with respect to care and treatment

which has been furnished as well as that which

has not been furnished, the behavior of staff and





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of other residents, and other concerns regarding

their LTC (Long Term Care) facility stay. The

Administrator is identified as the Grievance

Officer....A resident may voice or file a written

concern/grievance with the charge nurse, social

worker or Grievance Officer...The assigned nurse

or social worker to the resident shall initially

address any concerns/grievances, problems, or

complaints. Every effort will be mad to correct

any concerns/grievance...If the reported

concern/grievance has to do with an allegation of

abuse, the Administrator should be notified

immediately, but not later than 2 hours after the

allegation is made. The Administrator will then

notify the appropriate agencies and initiate an

investigation. The investigation will be completed

within 5 days of the reported incident; follow up

will be provided to the respective party and

appropriate agencies...."

3.1-50(a)

483.80(a)(1)(2)(4)(e)(f)

Infection Prevention & Control

§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,

F 0880

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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;

(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.





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§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.


review, the facility failed to ensure infection

control and prevention intervention strategies

were implemented for 1 of 1 resident reviewed with

active Clostridium Difficile (C Difficile) infection.

This deficient practice had the potential to affect 5

residents residing in rooms adjacent to the

resident(Resident 105)

Findings include:

1. On initial tour of the facility on 4/5/18 at 2:38

p.m., Resident 105's room was observed. An

overlay, with 3 pockets was positioned on the

outside of the closed, entry door was observed.

The overlay was observed to have horizontal

pouches on the front. No sign was observed on

the door and/or the frame of door to the room to

instruct staff or visitors to see the nurse prior to

entering the room.

On 4/6/18 at 10:07 a.m., the overlay remained

hanging on the outside of Resident 105's entry

door. No sign was observed on the door and/or

the door frame.

F 0880 F 880 Infection Control

1.A) A sign was placed on

resident #105’s door during the

survey process. B) The adjacent

room was cleaned, correctly, per

policy, see attached F880A,

during the survey process that

day.

2.No other residents are

currently in isolation.

3.A) The facility has a policy,

see attached F880A, entitled

“IC-Isolation Policy” that was

reviewed, no revisions necessary.

The DON/designee will re-educate

licensed nursing staff regarding

placing a sign on the door of

residents in isolation. B)

Environmental services staff were

inserviced on 4-11-2018, attached

F880B, regarding the facility

“IC-Isolation Policy”, attached

F880A, on how to properly change

housekeeping equipment, mop

water, etc., after cleaning an

isolation room before moving onto

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On 4/9/18 at 8:38 a.m. the overlay remained

hanging on the outside of Resident 105's entry

door. No sign was observed on the door and/or

the door frame.

On 4/10/18 at 8:50 a.m., the door to Resident 105's

room was closed with the overlay on the outside

of the closed entry door. No sign was observed

on the door and/or door frame.

On 4/10/18 at 11:45 a.m., a female was observed to

leave the resident's room and was interviewed.

She indicated she was the Resident 105's family

member. She indicated the resident was not

feeling well today and still had diarrhea. She

indicated the Vancoymcin was stopped, she

thought "about a week ago."

On 4/11/18 at 1:48 p.m., Housekeeper 4 was

interviewed, She indicated she was made aware of

a resident being in isolation by the door to the

room having a sign on the door. She indicated the

sign would direct people to "see the nurse"

before entering the room. She indicated there was

no such sign on Resident 105's door and/or door

frame. She also indicated when she noticed the

overlay on the door with items in it, this may also

indicate the resident was in isolation.

On 4/11/18 at 1:51 p.m., the CNA 2 was

interviewed. She indicated she was aware the

room was an isolation room because of the

overlay on the door. She indicated no sign was

visible on Resident 105's door and/or door frame.

She indicated she normally works on the other hall

and wasn't really sure what was going on with this

resident .

On 4/11/18 at 2:00 p.m,. the Director of Nursing

(DON) was interviewed. She indicated isolation

the next room. Additionally, staff

received follow up/hands on

training from 4-13-2018 through

4-23-2018, attached F880C.

4.Quality Monitoring: A) An

audit form was developed on

4/27/18 for the DON /designee to

audit isolation room signage for

the next 6 months. Results of



November 2018. B) The EVS

Director/or designee will observe

and audit, see attached F880D,

environmental services cleaning of

isolation rooms, at least 3 times a

week, for the duration of the

isolation period for 6 months.

Results of these audits will be

reported to the QAA committee

monthly through November 2018





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rooms would have an overlay on the door. She

indicated they should also have a sign on the

door to indicated "See nurse before entering."

A current copy of the facility policy and

procedure "IC (Infection Control) Isolation

Policy" dated 11/2017, provided by the DON on

4/11/18 at 2:07 p.m., included the following:

"...Contact precautions: Signage at the entrance

to the resident room..."

On 4/11/18 at 3:05 p.m., the Unit Manager 15 was

interviewed. She indicated she had put the

isolation sign on the door previously. She

indicated the sign was not currently visible on the

door. She indicated she had just found the

isolation sign crumpled up in a pocket on the

overlay on the door. The Unit Manager indicated

a new sign would be put on the outside of the

door. The Unit Manager provided the crumpled

up sign which had printed on it "Please report to

nursing station BEFORE entering the room...."

2. On 4/11/18 at 1:40 p.m., Housekeeper 4 was

observed to have placed her housekeeping cart in

the hall outside Resident 105's room. She was

observed to put the wet floor sign in the doorway

to the room. The floor to Resident 105's room was

observed to be moist. Housekeeper 4 was then

observed to push her cart to the next room down

the hall. After Housekeeper 4 was observed to

clean the room beside the Isolation room, she was

observed to take the cotton strand mop from her

mop bucket on the cart and mop the room on the

other side to Resident 105. Housekeeper 4 was

not observed to change the cotton mop head

and/or mop water after mopping the isolation

room and before mopping the non isolation rooms

next to Resident 105's room. At 1:43 p.m., she was

observed to pull the housekeeping cart outside





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the room and put the wet floor sign in the door

way to the non isolation room.

On 4/11/18 at 1:48 p.m., Housekeeper 4 was

interviewed. She indicated she changed the mop

water after mopping every 4-5 rooms. She

indicated she had used the same cotton mop head

and mop water when she cleaned the isolation

room and when she cleaned the room next to it.

She indicated she did not change the mop head

and/or water after mopping the isolation room and

before mopping the next room.

On 4/11/18 at 2:53 p.m., the Director of

Environmental Services, was interviewed. He

indicated the Housekeeping staff should change

the mop head and mop water after cleaning an

isolation room and before cleaning another

resident room. He indicated to clean isolation

rooms, there were "micro mops" to be used,

which were separate mops entirely. The staff can

take off the rectangular mop head and discard it

so as to ensure the same mop head and water are

not used from an isolation room to another room.

3.1-18(a)

R 0000

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This visit was for a State Residential Licensure

Survey. This visit included a Recertification and

State Licensure Survey.

Survey dates: April 5, 6, 9, 10, 11 & 12, 2018

Facility number: 000283

Residential Census: 57

R 0000 Please accept this as our credible

allegation of compliance to our

recent ISDH annual survey.

Submission of this Plan of

Correction does not constitute an

admission or agreement by the

provider of the truth of facts

alleged or the corrections set forth

on the statement of deficiencies.

This Plan of Correction is prepared

State Form Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 32 of 33




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Lutheran Life Villages Assisted Living was found

to be in compliance with 410 IAC 16.2-5 in regard

to the State Residential Licensure Survey.

Quality review completed April 16, 2018.

and submitted because of

requirements under State &

Federal Law.

We are also scanning in several

attachments as supportive

documentation.

We respectfully request the

opportunity to have this POC

reviewed and accepted with paper

compliance.

Thank you.

James Schmidt, HFA

State Form Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 33 of 33

Documents

PRINTED: 05/01/2018 DEPARTMENT OF HEALTH AND HUMAN ... · revisions necessary. DON/designee will re-educate all licensed nurses on the Resident Rights-Notification of Changes policy