F 0000 F 0558 06/14/2018 12:00:00Am

PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

Bldg. 00 This visit was for a Recertification and State F 0000 This plan of correction constitutes Licensure Survey. the facility's written allegation of compliance for the deficiencies Survey dates: May 9, 10, 11, 14, and 15, 2018 cited. The submission of this plan of correction is not an admission Facility number: 000188 of or agreement with deficiencies Provider number: 155291 or conclusions contained in the AIM number: 100266310 Indiana Department of Health's inspection Report. Census Bed Type: SNF/NF: 101 Eagle Valley Meadows is Total: 101 respectfully requesting consideration for a desk review of Census Payor Type: this plan of correction in lieu of Medicare: 6 post survey revisit Medicaid: 78 Other: 17 Total: 101

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

Quality review completed on May 23, 2018.

F 0558 483.10(e)(3) SS=D Reasonable Accommodations Bldg. 00 Needs/Preferences §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Based on observation, interview, and record F 0558 What corrective action(s) will 06/14/2018 12:00:00AM review, the facility failed to provide foot stools for be accomplished for those 2 of 2 residents reviewed with lower extremity residents found to have been edema (Residents 123 and 32). affected by the deficient

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: LK8R11 Facility ID: 000188 If continuation sheet Page 1 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 practice? Findings include: · Residents 95 and 123 were given pillowed foot stools to utilize 1. On 5/10/18 at 10:52 a.m., during an interview for elevation of feet while up in and observation, Resident 123 indicated the chairs. doctors wanted her to elevate her feet, due to edema, and a diagnosis of CHF (Congestive Heart How will you identify other Failure). The facility did not have a foot stool residents having the potential available and she had to use a milk crate with a to be affected by the same pillow on it to elevate her legs. She lifted the deficient practice and what pillow and a scuffed, dirty, blue industrial milk corrective action will be taken? crate was observed. · All residents with orders to elevate feet have the potential to Resident 123's medical record was reviewed on be affected. 5/14/18 at 11:00 a.m. Diagnoses included but were · A thorough review of all not limited to heart failure, and peripheral venous residents with orders to elevate insufficiency. A Physician's Order, dated 4/13/18, feet was completed by the IDT indicated, a foot stool to elevate legs QD (every team to ensure proper devices day). where in place for elevation. Care plans and resident profiles were On 5/14/18 at 11:20 a.m., during an interview, the updated to reflect any changes. Regional Vice President of Operations, indicated if What measures will be put into a resident did not have a recliner, with a built in place or what systemic footrest, they should have provided an ottoman changes you will make to to them. ensure that the deficient 2. On 5/10/18 at 10:08 a.m., during an initial practice does not recur? interview with Resident 95, he indicated his only · All staff will be re-educated concern was regarding new physician orders for regarding ensuring proper the swelling in his feet and legs. He indicated he interventions are in place per the had received new orders for him to have his feet resident profile by June 11, 2018. up and elevated at least three times a day, but it · All new physician orders will had been too hard to do because of the limited be reviewed in the daily Clinical availability of the stand up lift, which he required Meeting. Appropriate device to be to use in order to get in and out of bed. Resident utilized will be determined by the 95 indicated, as an alternative to getting in and IDT team for any resident receiving out of bed several times a day, staff had brought new orders to elevate feet. Care him a milk crate from the kitchen, so that he could plans and resident profiles will be stay in his wheelchair and rest his feet on the milk updated at that time. crate. Resident 95 pointed to a black milk crate beside his bedside table. He indicated, he did not How the corrective action (s)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 2 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

A most recent comprehensive assessment was a quarterly Minimum Data Set (MDS) assessment, dated 4/18/18. The MDS indicated, the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score 15 of 15, and required extensive assistance for transfers from surface to surface with the help of two staff members and a stand up mechanical lift. Active diagnosis included, but were not limited to, edema in bilateral lower extremities.

On 5/15/18 at 12:30 p.m., during an interview the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 3 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

3.1- 3(v)(1)

F 0582 483.10(g)(17)(18)(i)-(v) SS=D Medicaid/Medicare Coverage/Liability Notice Bldg. 00 §483.10(g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 4 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations. Based on interview and record review, the facility F 0582 What corrective action(s) will 06/14/2018 12:00:00AM failed to provide a written notice to a resident's be accomplished for those guardian of the effective end date for Medicare residents found to have been coverage related to skilled nursing services for 1 affected by the deficient of 3 residents reviewed for notification of ending practice? coverage (Resident 30). · A written notice of noncoverage of services under Findings include: Medicare was sent to Resident 30’s responsible party On 5/11/18 at 10:58 a.m., a record review was conducted for residents who received notices of How will you identify other Medicare Non-Coverage for Services (NOMNC). residents having the potential Three notices, of random selection, were provided to be affected by the same by the Business Office Manager, and included deficient practice and what Resident 30. corrective action will be taken? · All residents receiving A document titled, "SNF (Skilled Nursing Facility) Medicare services have the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 5 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 Determination on Continued Stay", was provided potential to be affected. for Resident 30. This document indicated, the · A thorough audit of all effective date coverage of skilled nursing services residents who have received would end was on 3/3/18. The notification was not Medicare benefits in the past 90 signed by the resident or guardian/ family days was completed to ensure member. The document indicated, "This is to proper notifications of noncoverage confirm that you were advised of the were completed. non-coverage of the services under Medicare by What measures will be put into telephone on 2/28/18." It was signed by the Social place or what systemic Service Director (SSD). The file did not contain a changes you will make to mailed notification. ensure that the deficient practice does not recur? During an interview with the SSD, on 5/11/18 at · Social Service Staff will be 11:42 a.m., she indicated, she spoke to the reeducated on the CMS guidelines guardian, of Resident 30, on the telephone for for notice of noncoverage for notification of non-coverage of services under Medicare benefits by June 11, Medicare. She did not send notification in the 2018 mail, or provide a copy of the document to the · All residents being cut from Guardian. Medicare services will be reviewed in the facility’s weekly Medicare On 5/11/18 at 3:25 p.m., during an interview, the Meeting and status of notification Clinical Consultant indicated, there was not a of noncoverage will be discussed facility policy for non-coverage of services under at that time. Medicare, the NOMNC form regulations are followed. How the corrective action (s) On 5 /11/18 at 3:29 p.m., the Clinical Consultant will be monitored to ensure the provided a document titled, "Form Instructions for deficient practice will not the Notice of Medicare Non-Coverage (NOMNC) recur, i.e., what quality CMS-10095". This form indicated, providers were assurance program will be put required to develop procedures to use when the into place? beneficiary/enrollee was incapable or The Social Service Director or incompetent, and the provider cannot obtain the designee will be responsible for signature the enrollee's representative through the completion of the Notice of direct personal contact. If the provider was Medicare Noncoverage Letter personally unable to deliver a NOMNC to a QAPI Tool weekly times 4 weeks, person acting on behalf of an enrollee, then the bi-monthly times 2 months, provider should telephone the representative to monthly times 4 and then advise him or her when the enrollee's services quarterly until continued were no longer covered. The date of the compliance is maintained for 2

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 6 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

3.1-4(f)(3)

F 0583 483.10(h)(1)-(3)(i)(ii) SS=D Personal Privacy/Confidentiality of Records Bldg. 00 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 7 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. Based on observation, interview, and record F 0583 What corrective action(s) will 06/14/2018 12:00:00AM review, the facility failed to provide a privacy be accomplished for those curtain to maintain the privacy of a double residents found to have been occupancy room for 1 of 5 residents reviewed affected by the deficient (Resident 62). practice? · A privacy curtain was hung Findings include: in room 150 to ensure resident 62’s privacy On 5/10/18 at 9:40 a.m., Room 150 was observed as a double occupancy room and there was no How will you identify other privacy curtain for Resident 150A's area or a residents having the potential privacy curtain for Resident 150B's area. to be affected by the same deficient practice and what During an interview on 5/10/18 at 9:44 a.m., corrective action will be taken? Resident 62 indicated she had no privacy curtain, · All residents with shared and her roommate, Resident 44, moved out accommodations have the yesterday. potential to be affected · A room by room audit was During an interview on 5/11/18 at 1:52 p.m., completed to ensure all rooms Resident 62 indicated she had been in her current have appropriate privacy curtains room about 6 months and never had a privacy installed. Corrective action was curtain. When she had a roommate, she had to get taken as needed. dressed quickly, when a staff member would have What measures will be put into taken her roommate to the bathroom. She would place or what systemic have liked to have a privacy curtain, especially changes you will make to when she would have slept and she was ensure that the deficient frustrated and upset. She had an outside track practice does not recur? (type of privacy curtain track) and her roommate's · All staff will be reeducated on area had an inside track (type of privacy curtain resident’s rights to privacy by June

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 8 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

During an interview on 5/15/18 at 8:49 a.m., the How the corrective action (s) Social Services Director indicated all residents had will be monitored to ensure the the right to privacy. deficient practice will not recur, i.e., what quality During an interview on 5/15/18 at 11:50 a.m., the assurance program will be put Regional Vice President of Operations indicated into place? the curtain hooks for an outside privacy curtain The Housekeeping Supervisor track had been ordered for Resident 62's room, so or designee will be responsible for she could have had a privacy curtain. A purchase the completion of the Environment order was provided. QAPI Tool weekly times 4 weeks, bi-monthly times 2 months, During an interview on 5/14/18 at 9:27 a.m., the monthly times 4 and then Regional Vice President of Operations indicated if quarterly until continued there was a roommate in the room with Resident compliance is maintained for 2 62, there should have been a privacy curtain. consecutive quarters. The results of these audits will be reviewed by During an interview on 5/15/18 at 8:15 a.m., the the QAPI committee overseen by Regional Vice President of Operations indicated the ED. If threshold of 95% is not all residents that came into the building would achieved, an action plan will be have received a copy of the Resident Handbook, developed. Residents' Rights & Advanced Directives.

A document was provided, on 5/11/18 at 3:20 p.m.,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 9 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

3.1-3(o)

F 0636 483.20(b)(1)(2)(i)(iii) SS=D Comprehensive Assessments & Timing Bldg. 00 §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

§483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 10 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months. F 0636 What corrective action(s) will 06/14/2018 12:00:00AM Based on observation, interview, and record be accomplished for those review, the facility failed to accurately assess residents found to have been residents regarding, Dialysis (Resident 301), affected by the deficient Hospice (Resident 8), and emotional-behavioral practice: status (Resident 57) for 3 of 25 residents reviewed All MDS assessments for for comprehensive assessments. Resident 301 reviewed, and modified as indicated, to include Findings include: Dialysis coding. All MDS assessments for 1. On 5/10/18 at 11:17 a.m., during an initial Resident 8 reviewed, and modified

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 11 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

On 5/11/18 10:37 a medical chart review was How other residents having the completed for Resident 301. A copy of Resident potential to be affected by the 301's hospital discharge report/summary was same deficient practice will be provided by the Clinical Consultant. The identified and what corrective discharge summary indicated Resident 301 had a action(s) will be taken: Dialysis catheter placed on 4/3/18, and would Residents receiving dialysis have resume Dialysis treatments on 4/21/18. the potential to be affected by this finding. A facility audit of MDS Physician orders for Resident 301 included but assessments will be conducted by were not limited: an admission order regarding his the MDS Coordinator or designee Dialysis access site, a permacath to his right for all dialysis residents to ensure chest, special instructions to monitor the site; an coding accuracy. admission order for Resident 301 to receive Residents receiving hospice Dialysis 3 times a week on Tuesday, Thursday, services have the potential to be and Saturday at 2:00 p.m. affected by this finding. A facility audit of MDS assessments will be A nursing progress note on 4/21/18 indicated, conducted by the MDS "...resident alert and oriented, dialyzed today..." Coordinator or designee for all and a nursing progress note on 4/24/18 indicated, hospice residents to ensure "...site care done at the dialysis center..." inclusion of hospice admitting diagnosis. A most recent comprehensive assessment was an Residents with missing and/or admission Minimum Data Set (MDS) assessment, artificial limbs have the potential to dated 4/27/18. The MDS assessment did not be affected by this finding. A indicate the resident had received Dialysis since facility audit of MDS assessments his admission to the facility. will be conducted by the MDS Coordinator or designee for all On 5/11/18 at 2:21 p.m., in and interview with the residents with missing and/or Director of Nursing (DON) indicated Resident 301 artificial limbs to ensure inclusion refused a lot of his care, but had been to Dialysis of active diagnosis of amputation a few times which should have been coded in the status.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 12 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 MDS. What measures will be put into place or what systemic 2. On 5/14/18 at 10:07 a.m., a complete medical changes will be made to record review was completed for Resident 8. A ensure that the deficient most recent comprehensive assessment was a practice does not recur: Significant Change MDS assessment, dated The MDS Coordinator will be 4/30/18. The MDS indicated the resident was in-serviced on or before -----June moderately cognitively impaired with a Brief 11, 2018 to review the facility Interview for Mental Status (BIMS) score 6 out of policy related to accurate coding 15. Active diagnoses for Resident 8 did not of active diagnoses. Active include her diagnosis of caner. The MDS diagnoses include any conditions indicated Resident 8 had a condition or chronic that have a direct relationship to illness that may result in a life expectancy of less the resident’s current functional than 6 months, and was receiving Hospice care. status, cognitive status, mood or behavior status, medical Physician orders for Resident 301 indicated but treatments, nursing monitoring, or was not limited to an order to admit the resident to risk of death. Hospice care. The MDS coordinator will re-review all MDSs completed each week to A care plan for Resident 301 indicated, "...resident ensure accuracy of assessments requires hospice related to lung cancer...." in regards to dialysis , hospice, and emotional behavioral status. In an interview with the MDS Coordinator on How the corrective action(s) 5/15/18 at 11:50 a.m., he indicated he double will be monitored to ensure the checked and Resident 8 did have an admitting deficient practice will not diagnosis of lung caner for her Hospice care. He recur, i.e., what quality indicated it should have been reflected in her most assurance program will be put recent significant change MDS. 3. Record review into place: for Resident 57 was completed on 5/14/18 at 10:12 Ongoing compliance with this a.m. The record indicated, Resident 57 was corrective action will be monitored admitted to the facility on 12/28/11, with current through the facility Quality diagnosis to include but not limited to: acquired Assurance and Performance absence of right leg above knee, vascular Improvement Program (QAPI). dementia with behavioral disturbance, venous The MDS Coordinator or designee insufficiency (chronic peripheral), and dementia in will be responsible for completing other diseases classified elsewhere with the “MDS Coding and Care Plan behavioral disturbance. Accuracy” QAPI tool weekly for 4 weeks; then monthly for at least 3 On 5/09/18 at 2:27 p.m., Resident 57 was observed, months. If threshold of 90% is not propelling himself with his hands, in a wheel chair met for either QA tool, an action

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 13 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

Review of the Quarterly Minimum Data Set (MDS), dated 3/20/18, indicated, the Brief Interview for Mental Status (BIMS) was documented as 00, indicated Resident 57 was unable to complete the assessment. He was extensive assistance of 2 or more for bed mobility, transfers, and toilet use. Extensive assist of 1 for dressing, eating, and personal hygiene. Limited assist of 1 for locomotion on and off the unit. He did not walk in the room or corridor. Total dependence of 2 or more staff for bathing. Mobility devices included a wheelchair. There was no diagnosis indicating the right AKA.

On 5/14/18 at 1:30 p.m., the Regional Vice President of Operations provided documents, titled, "Care Plan", dated 3/2/13 through. The care plan problems indicated, "1. Self-care deficit related to cognitive impairment ...Resident has right AKA ...2. Pain related to history of ankle/foot pain, hand injury, history of fracture and osteoporosis and right AKA, and area to right upper medial leg ...3. Resident is at risk for skin breakdown related to impaired cognition, refusal of care, and decreased mobility, incontinence at times. Resident will refuse showers and skin assessments. Resident has right AKA ...4. Resident is at risk for falls due to history of falling, decreased mobility ...Resident has AKA."

On 5/14/18 at 2:48 p.m., the MDS Coordinator indicted, he had spoken with his assistant who had completed the Quarterly MDS's for Resident

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 14 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

On 5/15/18 at 1:48 p.m., the Director of Nursing Services (DNS) indicated, the MDS Coordinator was responsible for assuring MDS's were completed correctly.

On 5/15/18 at 10:19 a.m., the Regional Consultant provided a policy, titled, "Resident Assessment [RAI] Omnibus Budget Reconciliation Act [OBRA] Required Assessments", dated 1/2016. The policy indicated, "It is the policy of American Senior Communities to conduct an initial and periodic comprehensive as well as no less than quarterly, accurate, standardized reproducible assessment of each resident's functional capacity to develop a care plan, to provide appropriate care and services to each resident ...5. The Interdisciplinary Team [IDT] will utilize resident observation and communication as the primary source of information when completing the RAI ..."

3.1-31(a) 3.1-31(c)(1)

F 0655 483.21(a)(1)-(3) SS=D Baseline Care Plan Bldg. 00 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 15 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 16 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 details of the comprehensive care plan, as necessary. F 0655 What corrective action(s) will 06/14/2018 12:00:00AM Based on observation, interview, and record be accomplished for those review, the facility failed to develop and residents found to have been implement a baseline care plan regarding Dialysis affected by the deficient for 1 of 1 resident reviewed for Dialysis (Resident practice: 301). Resident 301 has care plan in place, which includes dialysis. Findings include: How other residents having the On 5/10/18 at 11:17 a.m., during an initial interview potential to be affected by the with Resident 301, he indicated he had come to same deficient practice will be the facility after a serious infection in his left identified and what corrective forearm Dialysis graft. He indicated he was in the action(s) will be taken: hospital for a while for survey and got a new All new admissions have the Dialysis access site placed in his chest. He potential to be affected by this indicated that since he had been in the facility as a finding. A facility audit will be new admission he had been to at least three conducted by the Nurse Dialysis sessions. Management Team of all recent admissions for the month of May On 5/11/18 10:37 a medical chart review was to ensure care plan is in place. completed for Resident 301. A copy of Resident What measures will be put into 301's hospital discharge report/summary was place or what systemic provided by the Clinical Consultant. The changes will be made to discharge summary indicated Resident 301 had a ensure that the deficient Dialysis catheter placed on 4/3/18, and would practice does not recur: resume Dialysis treatments on 4/21/18 after his The Interdisciplinary Care Plan return to the facility. team will be in-serviced on or before June 11, 2018 to review the Physician orders for Resident 301 included but facility policy related to were not limited: an admission order regarding his development and implementation Dialysis access site, a permacath to his right of baseline person-centered care chest, special instructions to monitor the site; an plans for each new admission. admission order for Resident 301 to receive Care plans will be initiated within Dialysis 3 times a week on Tuesday, Thursday, 48 hours of admission, and will be and Saturday at 2:00 p.m. based on information from the admission assessment, No baseline care plan was developed for Resident observations, interviews, and 301 regarding his Dialysis. resident preferences.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 17 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

On 5/15/18 at 10:31 a.m., the DON indicated the 48 The MDS coordinator or designee hour/baseline care plan should include the most will re-review all new admission pertinent nursing care items which would be baseline care plans weekly for things that would help staff take care of the accuracy and to ensure that the resident right then, until more comprehensive care care plan is resident specific and plans could be put in place. She indicated Dialysis covers all immediate health and should have been baseline care planned for safety needs. Resident 301. How the corrective action(s) On 5/15/18 at 10:52 a.m., in an interview with the will be monitored to ensure the Regional Consultant, she indicated yes, Dialysis deficient practice will not and the services provided in conjunction with it, recur, i.e., what quality should be baseline care planned. assurance program will be put into place: On 5/15/18 at 12:30 p.m., the Clinical Consultant Ongoing compliance with this provided a copy of a current facility policy titled, corrective action will be monitored "IDT [interdisciplinary team] Baseline Care Plan" through the facility Quality dated, 10/2017. The policy indicated, "...it is the Assurance and Performance policy of this facility that each resident will have Improvement Program (QAPI). an interdisciplinary baseline care plan developed The MDS Coordinator or designee within 48 hours of admission...the baseline care will be responsible for completing plan will include, but not be limited to:... the the “Baseline Care Plan” QAPI resident's immediate health and safety needs...." tool weekly for 4 weeks; then monthly for at least 3 months. If 3.1-30(a) threshold of 90% is not met for either QA tool, an action plan will be developed. Findings will be submitted to the QAPI Committee for review and follow up.

F 0656 483.21(b)(1) SS=D Develop/Implement Comprehensive Care Plan Bldg. 00 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 18 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 19 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 residents, regarding Dialysis (Resident 301) and comprehensive person-centered dental status (Resident 30). care plan for each resident, consistent with the resident rights Findings include: set forth that includes measurable objectives and timeframes to meet 1. On 5/10/18 at 11:17 a.m., during an initial a resident’s medical, nursing, interview with Resident 301, he indicated he had mental and psychological needs come to the facility after a serious infection in his that are identified in the left forearm Dialysis graft. He indicated he was in comprehensive assessment. the hospital for a while for survey and got a new What corrective action(s) will Dialysis access site placed in his chest. He be accomplished for those indicated that since he had been in the facility as a residents found to have been new admission he had been to at least three affected by the deficient Dialysis sessions, but did not like the Dialysis practice: center and was waiting to be switched to a new Resident 30 has Dental care plan center. in place Resident 301 has Dialysis care On 5/11/18 10:37 a medical chart review was plan in place completed for Resident 301. A copy of Resident 301's hospital discharge report/summary was How other residents having the provided by the Clinical Consultant. The potential to be affected by the discharge summary indicated Resident 301 had a same deficient practice will be Dialysis catheter placed on 4/3/18, and would identified and what corrective resume Dialysis treatments on 4/21/18 after his action(s) will be taken: return to the facility. All residents have the potential to be affected by this finding. A Physician orders for Resident 301 included but facility audit will be conducted by were not limited: an admission order regarding his the Nurse Management Team of Dialysis access site, a permacath to his right all residents to ensure a dental chest, special instructions to monitor the site; an care plan is in place. admission order for Resident 301 to receive All residents receiving dialysis Dialysis 3 times a week on Tuesday, Thursday, have the potential to be affected and Saturday at 2:00 p.m. by this finding. A facility audit will be conducted by the Nurse A complete copy of Resident 301's care plans Management Team of all residents were provided by the Clinical Consultant on receiving dialysis to ensure a 5/15/18 at 10:50 a.m. The care plans included but dialysis care plan is in place were not limited to a care plan initiated on 5/9/18, What measures will be put into 19 days after the resident's admission. The care place or what systemic plan indicated, "...Resident is receiving changes will be made to

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 20 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 hemodialysis and is at risk for complications such ensure that the deficient as fluid imbalance, bleeding or infections. Right practice does not recur: chest permacath Dialysis on Tuesday, Thursday, The Interdisciplinary Care Plan Saturday..." team will be in-serviced on or before June 11, 2018 to review the On 5/15/18 at 10:52 a.m., in an interview with the facility policy related to Clinical Consultant, she indicated the facility development and implementation followed the RAI guideline for implementation of of person centered care plans for care plans and comprehensive care plans should each resident. Care plans will be be in by day 14 after a resident's admission. 2. initiated if indicated, reviewed and During an observation and interview on 5/10/18 at updated to reflect each resident’s 10:58 a.m. Resident 30 was observed to have status as indicated in the several broken and missing natural teeth. He comprehensive assessment. Care indicated he wanted to get them all "cut off" and plans are reviewed/initiated and get dentures. He saw a dentist once, but the updated by the IDT at admission, dentist had not been back. quarterly, annually, and with any change of condition. The medical record for Resident 30 was reviewed The MDS coordinator or designee on 5/14/18 at 11:10 a.m., a "Dental Exam" record, will re-review weekly all resident dated 4/26/18, indicated, "... patient would like a care plans for those residents with new complete upper denture, and lower partial a admission, quarterly, annual or made. Root tips #20, #21, #22, #26 needs change of condition MDS smoothed before impressions are taken." The assessment for the week to record diagram indicated upper teeth were all ensure comprehensive care plans missing and the lower arch teeth numbered 18, 19, were developed for residents 23, 24, 25, 28, 29, 30, 31, and 32 were missing. dental status and dialysis if There was not a care plan for missing or broken applicable. teeth, in the resident's medical record. How the corrective action(s) will be monitored to ensure the On 5/14/18 at 8:48 a.m., the Minimum Data Set deficient practice will not (MDS) Coordinator provided a list of residents recur, i.e., what quality who had missing or broken teeth, Resident 30 was assurance program will be put listed. into place: Ongoing compliance with this On 5/15/18 at 8:41 a.m., during an interview with corrective action will be monitored the Director of Nursing Services (DNS), she through the facility Quality indicated, Resident 30 should have a care plan for Assurance and Performance missing, broken teeth. Improvement Program (QAPI). The MDSC/designee will be On 5/15/18 at 9:11 a.m., during an interview with responsible for completing the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 21 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

3.1-35(a)

F 0684 483.25 SS=D Quality of Care Bldg. 00 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Based in observation, interview, and record F 0684 What corrective action(s) will 06/14/2018 12:00:00AM review, the facility failed to identify, assess, and be accomplished for those obtain treatment orders for a surgical wound for 1 residents found to have been of 1 residents reviewed for surgical wounds affected by the deficient (Resident 68). practice? · Orders for care and Findings include: treatment of Resident 68’s surgical site and abdominal drain On 5/9/18 at 11:23 a.m., Resident 68 was observed were received and followed. lying in bed with her eyes closed. She appeared to Resident 68 has returned home.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 22 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 be sleeping. She was observed to have a tracheostomy and a tube feeding. An ostomy (a How will you identify other surgical opening in the abdomen to circumvent residents having the potential the bowel) and urinary drainage bags were to be affected by the same secured on the bed frame. She also had a drainage deficient practice and what bag for her peritoneal drain (a tube placed into an corrective action will be taken? abcess for drainage). · All new admissions have the potential be affected. On 5/11/18 at 12:22 p.m., Resident 68 was · A thorough audit of all new observed sitting in front the Nurses's Station in admission within the last 30 days her wheelchair (w/c). Her urinary catheter bag and was completed to ensure all ostomy drainage bag, were observed hanging appropriate orders and treatment under the w/c. The resident was dressed in 2 plans were in place. Care plans hospital gowns, one forward, one backwards. Her and resident profiles were updated peritoneal drainage bag was observed beside her, as appropriate. on the w/c seat., she was wearing oxygen by trach What measures will be put into mask. The portable oxygen tank was set on 2 liters place or what systemic (a measure of oxygen flow). changes you will make to ensure that the deficient On 5/11/18 at 2:21p.m., Resident 68 was observed practice does not recur? as she continued to sit in front of the Nurse's · All nursing staff will be Station in her w/c. reeducated regarding the Nursing Admission/Return Admission On 5/11/18 at 3:20 p.m., Resident 68 was observed process including thorough still sitting in front of the Nurse's Station in her admission assessment and w/c. ensuring appropriate orders and treatment plans are in place by On 5/11/18 at 12:28 p.m., Resident 68 was June 11, 2018 observed in the Main Dining Room, wheeling · All new admissions will be herself around. Her peritoneal drainage bag was reviewed the following business visable on the w/c seat beside her. day by the Nurse Management team during the New Admission On 5/11/18 at 11:28 a.m., Resident 68's medical Review meeting to ensure record was reviewed. Diagnoses included, but appropriate orders have been were not limited to, peritoneal abcess. No obtained and treatment plans are physician's orders were found for the care of the in place. Care plans and resident drainage device (tube), which was surgically profiles will be created/updated as placed into Resident 68's peritoneal abcess. There appropriate was not a care plan that related to the care of the drain, or that refered to the device. The MDS How the corrective action (s)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 23 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

On 5/15/18 at 10:51 a.m., the Regional Consultant indicated, during an interview, Resident 68 should have had a base line care plan in place for the care of the perotoneal abcess and drainage device.

On 5/15/18 at 2:18 p.m.., during an interview, the MDS Coordinator indicated, Resident 68's MDS assessment was not coded as having a wound because nursing says a peritoneal abcess was not a wound. It should have been coded as a surgical wound but the record did not reflect it's presence, therefore the MDS assessment can not enter a code for something not on the medical record. The

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 24 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

A current policy, dated as revised on 11/2017, provided by the DNS on 5/15/18 at 10:19 a.m., titled, "IDT (Interdisciplinary Team) Comprehensive Care Plan Review", indicated, "...It is the policy of this facility that every resident will have a comprehensive person-centered care plan developed based on comprehensive assessment... Care Plan problems, goals and interventions will be updated based on changes in resident assessment/condition, resident preferences or family input."

3.1-37(a)

F 0689 483.25(d)(1)(2) SS=D Free of Accident

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 25 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. F 0689 What corrective action(s) will 06/14/2018 12:00:00AM Based on observation, interview, and record be accomplished for those review, the facility failed to properly follow facility residents found to have been policy and procedure to prevent the possibility for affected by the deficient accidents for 2 of 8 residents reviewed for practice? accidents (Residents 3 and 7). · Resident 3 no longer resides at facility. Findings include: · Fall interventions and care 1. On 5/09/18 at 10:36 a.m., Resident 3 was plans were updated on 5/10 for observed lying in bed, eyes closed and breathing Resident 7. Resident 7 has deeply. The bed was against the wall, and she experienced no further falls since was positioned lying near the back side of the that date. bed, with a body positioning pillow under the covers down the length of the front side of the How will you identify other bed. A fall mat was observed on the floor in front residents having the potential of the bed. to be affected by the same deficient practice and what Record review was completed for Resident 3 on corrective action will be taken? 5/11/18 at 09:01 a.m. The record indicated the · All residents who are at risk resident was re-admitted from the hospital on for falls potential to be affected. 4/16/18 and had current diagnosis, to include but · A thorough review of all were not limited to: dementia without behavioral residents identified as being at disturbance, hemiplegia (paralysis) affecting left risk with falls was conducted to non dominant side, cognitive communication ensure interventions and care deficit, abnormal posture, and age-related physical plans were up to date and disability. accurate. Review was also conducted to ensure all identified Review of a Significant Change Minimum Data Set interventions were in place. (MDS), dated 4/23/18, indicated the Brief What measures will be put into Interview for Mental Status (BIMS) score was 00 place or what systemic

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 26 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 and indicated the resident was unable to changes you will make to complete. She required extensive assistance of 2 ensure that the deficient or more for bed mobility, transfers, and toileting. practice does not recur? Extensive assistance of 1 for locomotion on and · All nursing staff will be off the unit, dressing, eating, and personal reeducated on the facility’s Fall hygiene, and she did not walk in the room or Management Policy by June 11, corridor. There was no fall history since the prior 2018 assessment or re-admission. · All falls will be reviewed by the IDT team the following business On 5/9/18 at 11:02 a.m., the Memory Care day as part of the daily Clinical Facilitator provided a report, titled, "Facility Event Meeting, to determine root cause, Report", dated 4/8/18 - 5/9/18. The report and other possible interventions to indicated, Resident 3 had an unwitnessed fall over prevent future falls. Care plans and her body pillow on 5/5/18 at 4:53 a.m., new fall resident profiles will be updated as interventions were hospice was called for appropriate. Residents restlessness and will evaluate medications. experiencing falls will also be reviewed on GEMBA rounds. On 5/14/18 at 12:54 p.m., the Regional Consultant provided reports titled, "ASC [American Senior How the corrective action (s) Communities] Fall Event Report", dated 2/5/18 will be monitored to ensure the through 4/4/18. The fall reports indicated, deficient practice will not Resident 3 had 7 falls during that time period. recur, i.e., what quality Documentation included the following fall details: assurance program will be put a. On 2/5/18 the resident had a witnessed fall into place? when she fell out of her chair while reaching for The Director of Nursing or something on the floor in the dining room. New designee will be responsible for intervention: one-one during dining. the completion of the Fall b. On 2/20/18 the resident has a witnessed fall. Management QAPI Tool weekly She was observed getting out of the wheel chair times 4 weeks, bi-monthly times 2 and slowly going to the floor while holding onto months, monthly times 4 and then the dining table. New intervention: keep in eye quarterly until continued sight of staff at all times. compliance is maintained for 2 c. On 3/11/18 the resident had an unwitnessed fall consecutive quarters. The results from her wheel chair in the hallway. New of these audits will be reviewed by intervention: offer to walk resident at least once a the QAPI committee overseen by shift. the ED. If threshold of 95% is not d. On 3/16/18 the resident had an unwitnessed fall, achieved, an action plan will be she was found on the floor in the activity room. developed. New intervention: resident was taken to a common area.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 27 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

On 5/11/18 at 12:25 p.m., the Director of Nursing Services (DNS) provided documents for Resident 3, titled, "Care Plan", dated 6/6/16. The care plan indicated, "Problem: Resident is at risk for fall due to: weakness, gait disturbance, history of falls prior to admission with history of pelvic fracture, history of transient ischemic attack (TIA) and cardiovascular accident (CVA) with left hemiplegia, dementia, depression, COPD ...Resident takes anti-depressants daily ...Goal: Resident fall risk will be reduced in an attempt to avoid significant fall related injury. Approach: 5/10/18 low air loss mattress, 5/6/18 body pillow in bed, check resident every hour during hours of sleep, mat at bedside on the floor, 3/22/18 resident is to be offered to lay down after each meal, 2/22/18 dycem (non-slip material) to wheel chair, 6/6/16 call light in reach, non-skid footwear, personal items in reach."

On 5/11/18 at 2:39 p.m., Licensed Practical Nurse (LPN) 26 indicated, Resident 3 had previously lived on the secured memory care unit, and more recently returned after a hospitalization. She thought the resident had fallen during the period

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 28 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

2. On 5/09/18 at 11:05 a.m., Resident 7 was observed sitting at a table in the dining/activity room with a peer, quietly watching television. The Memory Care Facilitator indicated, the resident had fallen earlier that morning.

On 5/11/18 at 2:27 p.m., Resident 7 was observed sitting in her wheel chair, in the doorway of her room, leaning forward peeking down the hallway towards the nurse's station.

5/14/18 at 9:12 a.m.,, Resident 7 was observed in her wheel chair by her bed, indicated she was going to pee and needed no help.

Record review was completed for Resident 7 on 5/15/18 at 10:05 a.m. The record indicated the resident was admitted on 6/22/15, and currently had diagnosis that included but were not limited to: dementia without behavioral disturbance, and repeated falls.

Review of a Quarterly MDS, dated 4/18/18, indicated, "Resident 7 had a BIMS score of 5, indicated severely impaired. There were signs and symptoms of delirium present but fluctuate to include inattention, and disorganized thinking. No

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 29 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

On 5/9/18 at 11:02 a.m., the Memory Care Facilitator provided a copy, titled, "Facility Event Summary Report", dated 4/8/18 to 5/9/18. The report indicated, Resident 7 had an unwitnessed fell on 5/9/18 at 1:10 a.m., the physician was notified and the care plan updated, the family was not notified.

Review of the Fall Event form, dated 5/9/18 at 11:25 a.m., indicated the family was notified at 1:27 a.m.

On 5/10/18 at 11:13 a.m., review of Resident 7's progress notes, dated 5/9/18 - 5/10/18, indicated, "On 5/9/18 at 1:28 a.m., the resident was yelling out for help, upon entering room the resident was found sitting on floor in front of bed...[I was trying to take myself to the BR]...will pass on in report to notify family ..."

On 5/15/18 at 2:04 p.m., the DNS indicated, after a fall occurs the nurse completes and assessment, neurological checks and vital signs were also checked if the fall was unwitnessed. Whether witnessed or unwitnessed a fall event form was initiated and hot charting on the event followed. The resident chart would be reviewed and using the information gathered on the fall event form, both were used to help determine the root cause of the fall. If the resident was injured in the fall, the physician, family and DNS were notified

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 30 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

On 5/15/18 at 10:19 a.m., the DNS Specialist provided a policy titled, "IDT Comprehensive Care Plan Review", dated 11/2017. The policy indicated, "It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning ...Care Plan problems, goals, and interventions will be updated based on changes in resident assessment/condition, resident preferences or family input."

On 5/15/18 at 10:53 a.m., the DNS Specialist provided a policy, titled, "Fall Management Program", dated 11/2017. The policy indicated, "It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls...Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls...3. A care plan will be developed at the time of admission with specific care plan interventions to address each resident's fall risk factors. Care plan including interventions

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 31 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

3.1-45(a)

F 0690 483.25(e)(1)-(3) SS=D Bowel/Bladder Incontinence, Catheter, UTI Bldg. 00 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 32 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. F 0690 06/14/2018 12:00:00AM Based on observation, interview, and record What corrective action(s) will review, the facility failed to ensure adequate hand be accomplished for those washing and proper medications were applied residents found to have been during a disposable brief change for 1 of 1 affected by the deficient resident reviewed for disposable brief change practice? (Resident 44). · New orders were obtained for oral and topical antifungal for Findings include: resident 44. Resident continues to receive topical cream. During an observation on 5/14/18 at 1:24 p.m., Licensed Practical Nurse (LPN) 17 cleaned How will you identify other Resident 44's perineal (surface region between residents having the potential pubic bone and the anus (lower opening of the to be affected by the same digestive tract) area after a bowel movement (BM). deficient practice and what She used multiple soapy wash cloths, the resident corrective action will be taken? continued to indicate it hurt, and did not change · All residents who receive her gloves before applying (name of skin assistance with peri-care have the protectant, zinc oxide paste) to the resident's very potential to be affected. dark red, excoriated (damage or removal of part of · A skin assessment of all the surface of the skin) perineal area and applying residents within the facility was

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 33 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 the new disposable brief. completed to ensure all skin areas were identified and proper During an interview on 5/14/18 at 1:35 p.m., LPN treatment plans in place. New 17 indicated she should have changed gloves treatment orders were obtained as after cleaning the resident, after a BM, and before appropriate. she applied (name of skin protectant with zinc What measures will be put into oxide) and placed the clean disposable brief on place or what systemic Resident 44. Before she left the room, she washed changes you will make to her hands for 14 seconds. ensure that the deficient practice does not recur? During an interview on 5/14/18 at 1:40 p.m., the · All nursing staff will be Regional Consultant indicated LPN 17 should re-educated regarding proper have removed the dirty gloves, and washed her peri-care and handwashing hands before applying the (name of skin procedures by June 11, 2018 protectant with zinc oxide) and the new · All nurses will be re-educated disposable briefs. on the proper utilization of anti-fungal treatments by June 11, During an interview on 5/14/18 at 1:48 p.m., 2018 Registered Nurse (RN) 10 indicated Resident 44 · Skills validations (return had a history of urinary tract infections (UTI), and demonstration) for per-care and poor glove changing and lack of proper hand handwashing will be completed for washing could have been a factor in the repeated all nursing staff by June 14, 2018 UTIs. · Nurse manager or designee will round daily monitoring for Documents were provided on 5/14/18 at 2:54 p.m., proper handwashing and peri care from the Regional Consultant, of the recent UTI techniques history of Resident 44. They were as follows: a. Lab results, dated 1/21/18, indicated UA (urine How the corrective action (s) analysis) results: Proteus mirabilis (bacteria). will be monitored to ensure the b. Physician's orders, dated 1/22/18, indicated deficient practice will not discontinue (name of antibiotic), begin (name of recur, i.e., what quality different antibiotic). assurance program will be put c. Physician's orders, dated 4/5/18, indicated begin into place? (name of antibiotic). The Director of Nursing d. Lab results, dated 4/8/18, indicated UA results: Services or designee will be Klebsiella Pneumoniae (bacteria) responsible for the completion of e. Lab results, dated 4/25/18, indicated UA results: the Infection Control QAPI Tool Proteus mirabilis (bacteria). weekly times 4 weeks, bi-monthly f. Physician's orders, dated 4/25/18, indicated times 2 months, monthly times 4 discontinue (name of antibiotic), begin (name of and then quarterly until continued

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 34 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

During a record review on 5/14/18 at 4:15 p.m., the physician's orders were as follows: a. Started 9/16/15 to open ended (ongoing): House anti-fungal cream. Special instruction: Indications: Apply to bilateral groin/peri-area (external female genitals) and bilateral buttocks after incontinent episodes, PRN (as needed). b. Started 5/1/18, ended date 5/13/18: Nystatin (anti-fungal) powder.

During an interview on 5/14/18 at 4:15 p.m., the Regional Nurse Consultant indicated if the resident's perineal area was very dark red and excoriated, LPN 17 should have used nystatin powder during the disposable brief change.

During an interview on 5/15/18 at 12:16 p.m., the Regional Nurse Consultant indicated the physician gave new orders: a. 5/14/18 and 5/17/18: fluconazole (anti-fungal) 150 mg, oral, once a day b. Nystatin cream, three times a day until resolved. Discontinue the House anti-fungal cream.

A document, titled, " Medications Administration History, dated 4/15/18 - 5/15/18, indicated

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 35 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

During an interview on 5/10/18 at 9:11 a.m., the Interim Administrator (IA) indicated hand washing should have been 30-40 second lather, the rinse.

A policy, titled, "Hand Hygiene," revised date, 2/2018, was provided by the Regional Consultant on 5/10/18 at 9:15 a.m. It indicated, " ...Duration of the entire procedure: 40-60 seconds - Scrub/Friction for 20 seconds ..." and " ...before clean/aseptic procedure."

During an interview on 5/14/18 at 4:15 p.m., the Regional Nurse Consultant indicated there was no policy for changing resident's disposable brief.

3.1-41(a)(2)

F 0695 483.25(i) SS=D Respiratory/Tracheostomy Care and Bldg. 00 Suctioning § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. Based on observation, interview, and record F 0695 What corrective action(s) will 06/14/2018 12:00:00AM review, the facility failed to ensure adequate be accomplished for those tracheal catheter (a tube inserted into the residents found to have been respiratory airway (trachea) for the purpose of an affected by the deficient established and maintained open airway and practice?

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 36 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 ensured exchange of oxygen and carbon dioxide) · Resident 68 has returned cleaning and suctioning was completed for 1 of 1 home. There are currently no resident reviewed for tracheal catheter care other residents requiring (Resident 62). Tracheostomy care residing in the facility. Findings include: How will you identify other During an observation on 5/10/18 at 12:27 p.m., residents having the potential Licensed Practical Nurse (LPN) 7 was providing to be affected by the same tracheal catheter care for Resident 68. She did not deficient practice and what clear the resident's over-the-bed table of the corrective action will be taken? resident's items (open plastic bag of cookies, open · Any resident requiring tracheal cup of orange juice, TV remote control, salt and catheter care has the potential to pepper shakers, box of tissues, toilet paper roll, be affected. and a small plant in dirt), or clean the over-the-bed · There are no other residents table. She put on disposable unsterile gloves and requiring tracheal care residing in opened the sterile Trach Care Kit (package of the facility. fluids and supplies to clean a tracheal catheter). What measures will be put into She removed the unsterile gloves, and did not place or what systemic wash her hands, before putting on the sterile changes you will make to gloves from the Trach Care Kit. She contaminated ensure that the deficient the sterile gloves as she picked up the unsterile practice does not recur? tracheotomy oxygen mask and wiped it. Using the · All nurses will be re-educated tracheotomy brush, she moved it in and out the regarding the facility’s tracheotomy catheter in the resident's neck Tracheostomy Care Policy by causing the resident to cough. LPN 7 indicated to June 11, 2018 the resident that she should have coughed. She · Skills validations (return provided no other words to indicate to the demonstrations) will be completed resident what she was doing. LPN 7 put the for all nurses regarding proper tracheal oxygen mask back over the tracheal tracheostomy care by June 14, catheter and asked the resident if she was ok. 2018. Resident 62 indicated, "No." The nurse did not ask any follow up questions to the resident. Using How the corrective action (s) the same contaminated gloves, LPN 7 removed the will be monitored to ensure the tracheal oxygen mask, and used the sterile suction deficient practice will not catheter to suction the tracheal catheter. She recur, i.e., what quality pushed the suction catheter in the tracheal assurance program will be put catheter about one inch. She placed the into place? tracheotomy dressing, then wiped inside the The Director of Nursing tracheal oxygen mask again, and placed it in front Service or designee will be

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 37 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

During an interview on 5/11/18 at 3:46 p.m., the Regional Consultant indicated the staff should have been following the physician's orders and an ambu-bag and one-size smaller tracheal catheter should have been at the resident's bedside and not in the resident's closet.

During a record review on 5/14/18 at 11:03 a.m., the nursing progress notes indicated on 4/15/18 at 5:43 a.m., Resident 68 was sent to (name of nearby hospital), was somewhat confused and pulled out trach (tracheal catheter), and at 12:02 p.m., resident returned from hospital with 6 mm uncuffed (did not have an inflatable encircled balloon) trach put back in. On 5/7/18, at 1:21 a.m., Resident 68 pulled out trach and at 12:09 p.m., resident returned from the hospital with trach replaced.

During an interview on 5/14/18 at 4:34 p.m., the Regional Consultant indicated when Resident 68

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 38 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

During an interview on 5/11/18 at 3:48 p.m., Registered Nurse (RN) 10 indicated RN's can put a one-size smaller tracheal catheter back in the resident's tracheotomy site, but Licensed Practical Nurses (LPN) cannot.

During a record review on 5/11/18 at 11:04 a.m., Resident 62's diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, acute respiratory failure with hypoxia, pneumonia, shortness of breath, altered mental status, encephalopathy, malnutrition, peritoneal abscess, chronic pancreatitis, and weakness.

During a record review on 5/14/18 at 11:03 a.m., Resident 62's care plans indicated Resident required a tracheotomy with potential for complications, observe for congestion and suction trach as needed, and resident had a deficit with impaired decision making ability due to diagnosis of encephalopathy.

During an interview on 5/10/18 at 9:11 a.m., the Interim Administrator (IA) indicated hand washing should have been 30-40 second lather, the rinse.

A policy, titled, "Tracheotomy - Routine Care,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 39 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

3.1-47(a)(4) 3.1-47(a)(5)

F 0744 483.40(b)(3) SS=D Treatment/Service for Dementia Bldg. 00 §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Based on observation, interview, and record F 0744 06/14/2018 12:00:00AM review the facility failed to follow a physician What corrective action(s) will order for a resident to reside on a secured unit for be accomplished for those 1 of 5 residents reviewed for dementia care residents found to have been (Resident 84). affected by the deficient practice? Findings include: · Resident 84 was assessed for proper placement within the On 5/09/18 at 2:13 p.m., Resident 84 was observed facility and the physician order to asleep in a chair in his room, on the B Hall reside on a secured unit has been (non-secured unit). discontinued.

On 5/10/18 at 12:10 p.m., Resident 84 was How will you identify other observed in the Main Dining Room, where he was residents having the potential

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 40 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 eating lunch. to be affected by the same deficient practice and what On 5/15/18 at 9:38 a.m., a record review was corrective action will be taken? conducted for Resident 84. A current physician's · All residents with physician order dated 12/7/17, with an end date of "open orders to reside on a secured unit ended", indicated, "It is clinically indicated that have the potential to be affected. the resident reside on a secured unit." Diagnoses · An audit of all residents who included, but were not limited to dementia, and have transitioned off of the Alzheimer's disease. facility’s secured unit was completed to ensure that all have On 5/14/18 at 4:12 p.m., the Regional Consultant appropriate physician orders in indicated they should have discontinued the place. order when the resident was moved out of the What measures will be put into secured unit, she did not know when that place or what systemic occurred. changes you will make to ensure that the deficient On 5/15/18 at 10:22 a.m., after further practice does not recur? investigation, the Regional Consultant indicated, · IDT team will review all Resident 84 was placed in a room on the B Hall potential room moves during the after he returned from the hospital on 3/17/18. It Facility Morning Meeting to ensure was easier to maintain contact isolation outside of all proper physician orders are in the secured unit due to the wandering population. place. An order to move the resident had not been · IDT will review all new/return obtained from the physician. The resident no admissions as part of the daily longer required contact isolation and not been new admission review process and returned to the secured unit. will confirm all appropriate physician orders in place. On 5/15/18 at 10:31 a.m., the DNS (Director of How the corrective action (s) Nursing Services) indicated, Resident 84's will be monitored to ensure the physician orders had not been changed to reflect deficient practice will not his move off the Cottage (secured unit). The recur, i.e., what quality physician had not been notified but she thought assurance program will be put the physician should have been aware of where into place? he was residing, because she visited him in his The Director of Nursing or new room. There were not any open beds in the designee will be responsible for secured unit, after he was cleared from isolation. the completion of the The order should have been changed. Admission/Readmission QAPI Tool weekly times 4 weeks, On 5/15/18 at 12:30 p.m., the Regional Consultant bi-monthly times 2 months, indicated, the facility did not have a policy on monthly times 4 and then

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 41 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

3.1-37(a)

F 0812 483.60(i)(1)(2) SS=E Food Bldg. 00 Procurement,Store/Prepare/Serve-Sanitary §483.60(i) Food safety requirements. The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Based on observation, interview and record F 0812 06/14/2018 12:00:00AM review, the facility failed to store, distribute and What corrective action(s) will serve food under sanitary conditions, by properly be accomplished for those

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 42 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 handling drinking cups and glasses, open dating residents found to have been and labeling condiments, and performing proper affected by the deficient handwashing in the dining room. This practice practice? had the potential to effect 31 of 31 residents who · All opened and undated consumed meals in the Main Dining Room. condiment bottles were discarded. Findings include: · Customer care representative was immediately 1. During a dining observation on 5/09/18 at 12:18 reeducated on proper handling of p.m., individual bottles of mayonnaise, ketchup drinkware and mustard were observed on the dining tables. · Identified CNA was There were 5 of 7 bottles of mayonnaise did not reeducated on proper hand have an opened date marked on the bottles. There hygiene were 14 undated ketchup, and 7 undated mustard bottles observed on the tables. How will you identify other residents having the potential On 5/11/18 at 2:40 p.m., during an observation, all to be affected by the same of the bottled condiments remained on the tables, deficient practice and what 5 of 7 mayonnaise bottles were unmarked, 14 corrective action will be taken? ketchup and 7 mustard bottles were unmarked. · All residents have the potential to be affected During an interview on 5/11/18 at 3:25 p.m., the · An audit was completed by Clinical Consultant indicated, all opened the Dietary Services Manager of condiments, on the dining room tables should all food storage areas to ensure have had an opened date marked on them. proper labeling and dating. Corrective actions were taken as During an interview with the Dietary Manager on appropriate 5/11/18 at 3:41 p.m., he indicated, all opened What measures will be put into condiments should have been dated. He checked place or what systemic bottles at the end of each meal to date any bottles changes you will make to that were opened during meal service. ensure that the deficient practice does not recur? A second observation of condiments, on the · All staff will be inserviced on dining tables, was made, during the interview. One the food safety policy including additional bottle of mayonnaise was present and proper hand hygiene in dated. Two additional bottles of mayonnaise and accordance with professional one of ketchup (undated), had been placed on the standards for food safety service tables, they had not been opened, and were still by June 11, 2018 sealed. The other bottles of ketchup and mustard · All Dietary staff will be remained opened and undated. reeducated on the facility Food

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 43 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 Storage policy including proper A current policy, dated 11/17, titled, "Food labeling and dating of open items. Storage", was provided by the interim · Meal observation checklist will Administrator on 5/9/18 at 2:45 p.m. This policy be completed during meal times indicated, "Items with a ph (a measure of acidity) by the assigned meal manager to less than 4.6 are not potentially hazardous foods ensure proper handling of dishware and do not need to be disposed of within 7 days and utensils as well as proper of opening. These items include mayonnaise, hand hygiene is being performed salad dressings, mustard, ketchup, BBQ per facility policy (barbeque) sauce, pickles and pickle relish. Label these items when opened and use or dispose of How the corrective action (s) within 30 days of opening to ensure quality." will be monitored to ensure the deficient practice will not 2. On 5/9/18 at 12:18 p.m., during a dining recur, i.e., what quality observation in the Main Dining Room, the assurance program will be put Customer Care Representative was observed as into place? she passed drinks to residents. The Dietary Services Manager or designee will be responsible for She used a rolling cart with a clear plastic tub of the completion of the Food ice and scoop on the top of the cart. There were Storage and Meal Observation glasses in racks on the 2nd and 3rd shelves of the QAPI Tools weekly times 4 cart. weeks, bi-monthly times 2 months, monthly times 4 and then Pitchers on the top of the cart contained water, quarterly until continued fruit punch, grape and orange drinks. The compliance is maintained for 2 Customer Care Representative was filling glasses consecutive quarters. The results with ice, 2 glasses at a time. She held both of of these audits will be reviewed by them, together, in her left hand, then she placed the QAPI committee overseen by the glasses back on the cart, with her right hand, the ED. If threshold of 95% is not placing her open hand over the top of glasses, achieved, an action plan will be with her fingers touching the rims. She served developed. drinks to 26 unidentified residents in the Main Dining Room.

The Customer Care Representative obtained a plastic cup with a lid from the kitchen. She carried the cup and lid to Resident 201. She held the lid gripped in her hand with four fingers touching the inside surface of the lid. She poured coffee into the cup and placed the lid on it.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 44 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

On 05/14/18 at 11:20 a.m., Regional Vice Present provided a current policy, revised 11/2017, titled, "General Food Preparation and Handling". This policy indicated, "Handle utensils, cups, glasses, and dishes in such a way to avoid touching surfaces with which food or drink will come in contact."

During an interview on 5/11/18 at 3:25 p.m., the Clinical Consultant indicated employees serving meals to residents should not touch the glassware in a manner that would contaminate them. 3. During an observation, on 5/9/18 at 12:23 p.m., Certified Nursing Aide (CNA) 16 washed his hands for 8 seconds before serving lunch to Resident 61.

During an observation, on 5/9/18 at 12:30 p.m., CNA 16 appropriately washed his hand, and then, touched his watch two times, before he served lunch to Resident 200.

During an observation, on 5/9/18 at 12:36 p.m., CNA 15 washed her hands for 6 seconds before she served lunch to Resident 9.

During an observation, on 5/9/18 at 12:42 p.m., CNA 15 washed her hands for 14 seconds before she served lunch to Resident 151.

During an observation, on 5/9/18 at 12:45 p.m., CNA 16 washed him hands for 7 seconds before she served lunch to Resident 82.

During an interview on 5/10/18 at 9:11 a.m., the Interim Administrator (IA) indicated hand washing should have been 30-40 second lather, the rinse.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 45 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

3.1-21(3)

F 0880 483.80(a)(1)(2)(4)(e)(f) SS=D 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,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 46 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

§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.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 47 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

(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 §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. Based on record review and interview, the facility F 0880 What corrective action(s) will 06/14/2018 12:00:00AM failed to ensure a resident received appropriate be accomplished for those annual tuberculosis (TB) screening for 1 of 5 residents found to have been residents reviewed for tuberculosis screening affected by the deficient (Resident 57). practice? · Resident 57 continues to Findings include: refuse PPD testing. Annual TB questionnaire has been completed Record review for Resident 57 was completed on 5/14/18 at 10:12 a.m. The record indicated the How will you identify other resident refused an annual purified protein residents having the potential derivative (PPD) skin test for TB on 2/1/18 and to be affected by the same there was no follow up documentation of the test deficient practice and what having been completed. corrective action will be taken? · All residents have the Review of nursing progress notes, dated 2/1/18 - potential to be affected. 5/14/18, had no documentation that the annual · An audit of all residents within PPD had been completed. the facility was completed to ensure proper administration of On 5/14/18 at 1:30 p.m., the Regional Vice PPD testing had occurred along President of Operations provided a document, with proper documentation in titled, "Medication Administration", dated 2/1/18 - place. Corrective action was 2/28/18. The administration record indicated, the taken as appropriate resident had refused an annual PPD on 2/1/18. What measures will be put into place or what systemic On 5/15/18 at 9:41 a.m., The Regional Consultant changes you will make to indicated, when a resident refused to have a PPD, ensure that the deficient the process should have been to offer the PPD practice does not recur? testing again at a later date, and if a resident · All nurses will be reeducated continued to refuse, a TB assessment should on the facility’s Resident have been completed. Residents 57 did not have Screening-Tuberculosis policy by an annual PPD or TB screen completed in 2018. June 11, 2018 · The Clinical Education On 5/15/18 at 1:51 p.m., the Director of Nursing Coordinator will keep a running log Services (DNS) indicated, a 2 step PPD should of when all Resident screening is have been completed upon admit, and an annual to occur and what steps are taken

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 48 of 49 PRINTED: 06/11/2018 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 155291 B. WING 05/15/2018

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3017 VALLEY FARMS RD EAGLE VALLEY MEADOWS INDIANAPOLIS, IN 46214

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK8R11 Facility ID: 000188 If continuation sheet Page 49 of 49