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PRINTED: 07/08/2019 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 -- COMPLETED 155255 B. WING 06/03/2019 STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805 (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 E 0000 Bldg. -- An Emergency Preparedness Survey was E 0000 It is the intent of this Facility to conducted by the Indiana State Department of develop an Emergency Health in accordance with 42 CFR 483.73. Preparedness Manual which will meet the requirements for Survey Date: 06/03/19 Medicare and Medicaid, which is required for Participating Facility Number: 000158 Providers. Provider Number: 155255 AIM Number: 100291490 At this Emergency Preparedness survey, Woodview A Waters Community was found not in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73. The facility has a capacity of 128 and had a census of 64 at the time of this survey. The requirement at 42 CFR, Subpart 483.73 is NOT MET as evidenced by: Quality Review on 06/07/19 E 0006 SS=C Bldg. -- Based on record review and interview, the facility E 0006 It is the intent of this Facility to 07/01/2019 12:00:00AM failed to maintain an emergency preparedness develop an Emergency plan that was (1) based on and includes a Preparedness Manual which will documented, facility-based and community-based meet the requirements for risk assessment, utilizing an all-hazards approach, Medicare and Medicaid, which is including missing residents and (2) included required for Participating strategies for addressing emergency events Providers. identified by the risk assessment in accordance with 42 CFR 483.73(a) (1) and 42 CFR 483.73(a) (2). All residents have the potential to This deficient practice could affect all occupants. be affected by this practice, and it is the intent of the facility to 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: 3P2C21 Facility ID: 000158 If continuation sheet Page 1 of 44 PRINTED: 07/08/2019 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 -- COMPLETED 155255 B. WING 06/03/2019 STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805 (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 Findings include: correct any issues that need to be corrected concerning this tag. During record review with the Maintenance Director from 9:00 a.m. to 10:30 a.m. on 06/03/19, a. Emergency plan has been no documentation could be found regarding a developed and has been reviewed documented facility-based and community-based by required Staff and will be risk assessment utilizing an all-hazards approach. reviewed annually as required. Based on interview at the time of record review, the Maintenance Director stated there was a risk 1. The facility-based and assessment but it was inadequate and was remove community-based risk from the plan. Also stated, a new risk assessment assessment using the all-hazards has not been conducted. approach to include missing clients has been completed. 2. The risk assessment identifies strategies for addressing emergency events including the management of the consequences of power failures, natural disasters, and other emergencies that would affect resident care and safety. The Facility Administrator/designee has reviewed and signed off on the EPM and will review Annually and as needed for changes or updated. E 0037 SS=F Bldg. -- Based on record review and interview, the facility E 0037 It is the intent of this facility to 07/01/2019 12:00:00AM failed to ensure the emergency preparedness provide initial training in training and testing program includes a training emergency preparedness using program. The LTC facility must do all of the policies and procedures to all new following: (i) Initial training in emergency and existing staff. Employees will preparedness policies and procedures to all new be trained and demonstrate their FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 2 of 44 PRINTED: 07/08/2019 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 -- COMPLETED 155255 B. WING 06/03/2019 STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805 (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 existing staff, individuals providing services knowledge of emergency under arrangement, and volunteers, consistent procedures. The facility will with their expected roles; (ii) Provide emergency maintain documentation of the preparedness training at least annually; (iii) training and demonstrate staff Maintain documentation of the training; (iv) knowledge of emergency Demonstrate staff knowledge of emergency procedures. Both Community procedures in accordance with 42 CFR 483.73(d) based and annual exercise will be (1). This deficient practice could affect all conducted prior to expected residents in the facility. completed date. And documentation will be maintained Findings include: by the Facility. Based on record review with the Maintenance Director on 06/03/19 at 11:39 a.m., there was no All residents have the potential to documentation of a community based annual be affected by this practice, and it exercise nor documentation of an additional is the intent of the facility to annual exercise within the last year. Based on correct any issues that need to be interview at the time of records review, the corrected concerning this tag. Maintenance Director stated no annual exercises were conducted since he was hired in April 2019 and could not find documentation to show two Employees will be trained and exercises were conducted with in the last year. demonstrate their knowledge of emergency procedures. The facility will maintain documentation of the training and demonstrate staff knowledge of emergency procedures. Both Community based and annual exercise will be conducted prior to expected completed date. And documentation will be maintained by the Facility. Vice President of Operations will ensure that Training in emergency preparedness is done to include emergency procedures and demonstrate staff knowledge at both FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 3 of 44 PRINTED: 07/08/2019 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 -- COMPLETED 155255 B. WING 06/03/2019 STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805 (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 E 0039 SS=F Bldg. -- Based on record review and interview, the facility E 0039 It is the intent of this facility to 07/01/2019 12:00:00AM failed to conduct exercises to test the emergency provide initial training in plan at least annually. The LTC facility must do emergency preparedness using all of the following: (i) participate in a full-scale policies and procedures to all new exercise that is community-based or when a and existing staff. Employees will community-based exercise is not accessible, an be trained and demonstrate their individual, facility-based. If the LTC facility knowledge of emergency experiences an actual natural or man-made procedures. The facility will emergency that requires activation of the maintain documentation of the emergency plan, the LTC facility is exempt from training and demonstrate staff engaging in a community-based or individual, knowledge of emergency facility-based full-scale exercise for 1 year procedures.

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