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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 F 0000 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 (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 like to use it because it did not really raise his feet will be monitored to ensure the and the crate was uncomfortable on his heels. deficient practice will not recur, i.e., what quality On 5/14/18 at 11:25 a.m., Resident 95 was assurance program will be put observed sitting up in his wheelchair in his room into place? with the milk crate beside his chair. He indicated The Customer Care for a second time, he was supposed to have his Coordinator or designee will be feet elevated three times a day, but he removed responsible for the completion of his feet from the milk crate because it was the Accommodation of Needs uncomfortable. QAPI Tool weekly times 4 weeks, bi-monthly times 2 months, On 5/14/18 at 11:30 a.m., in and interview with the monthly times 4 and then Executive Director, he indicated, if a resident did quarterly until continued not have a reclining chair in their room, they compliance is maintained for 2 should be provided an ottoman and a milk crate consecutive quarters. The results was not appropriate to accommodate the residents of these audits will be reviewed by needs. the QAPI committee overseen by the ED. If threshold of 95% is not On 5/14/18 ay 11:40 a.m. a brief medical review for achieved, an action plan will be Resident 95 was completed. A copy of Resident developed. 95's current physician orders were provided by the Clinical Consultant. The physician orders included, but were not limited to, an order to have patient back in bed with feet elevated 2 hours every morning and 2 hours every evening, due to edema (fluid retention and swelling) in both right and left lower legs. 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.

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