printed: 05/01/2018 department of health and human … · 2018-05-01 · (x1)...
TRANSCRIPT
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
F 0000
Bldg. 00
This visit was for a Recertification and State
Licensure Survey. This visit included a State
Residential Licensure Survey.
Survey dates: April 5, 6, 9, 10, 11 & 12, 2018
Facility number: 000283
Provider number: 155586
AIM number: 100275020
Census Bed Type:
SNF/NF: 120
SNF: 2
Total: 122
Census Payor Type:
Medicare: 11
Medicaid: 108
Other: 3
Total: 122
These deficiencies reflects State Findings cited in
accordance with 410 IAC 16.2-3.1.
Quality review completed April 16, 2018.
F 0000 Please accept this as our credible
allegation of compliance to our
recent ISDH annual survey.
Submission of this Plan of
Correction does not constitute an
admission or agreement by the
provider of the truth of facts
alleged or the corrections set forth
on the statement of deficiencies.
This Plan of Correction is prepared
and submitted because of
requirements under State &
Federal Law.
We are also scanning in several
attachments as supportive
documentation.
We respectfully request the
opportunity to have this POC
reviewed and accepted with paper
compliance.
Thank you.
James Schmidt, HFA
483.10(g)(14)(i)-(iv)
Notify of Changes (Injury/Decline/Room, etc.)
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the
resident; consult with the resident's
physician; and notify, consistent with his or
her authority, the resident representative(s)
when there is-
(A) An accident involving the resident which
results in injury and has the potential for
requiring physician intervention;
F 0580
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete
Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: WWB111 Facility ID: 000283
TITLE
If continuation sheet Page 1 of 33
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
(B) A significant change in the resident's
physical, mental, or psychosocial status
(that is, a deterioration in health, mental, or
psychosocial status in either life-threatening
conditions or clinical complications);
(C) A need to alter treatment significantly
(that is, a need to discontinue an existing
form of treatment due to adverse
consequences, or to commence a new form
of treatment); or
(D) A decision to transfer or discharge the
resident from the facility as specified in
§483.15(c)(1)(ii).
(ii) When making notification under paragraph
(g)(14)(i) of this section, the facility must
ensure that all pertinent information specified
in §483.15(c)(2) is available and provided
upon request to the physician.
(iii) The facility must also promptly notify the
resident and the resident representative, if
any, when there is-
(A) A change in room or roommate
assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal
or State law or regulations as specified in
paragraph (e)(10) of this section.
(iv) The facility must record and periodically
update the address (mailing and email) and
phone number of the resident
representative(s).
§483.10(g)(15)
Admission to a composite distinct part. A
facility that is a composite distinct part (as
defined in §483.5) must disclose in its
admission agreement its physical
configuration, including the various locations
that comprise the composite distinct part,
and must specify the policies that apply to
room changes between its different locations
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 2 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
under §483.15(c)(9).
Based on observation, interview, and record
review, the facility failed to ensure the physician
in a timely manner for 1 of 1 resident reviewed
with a change in condition.
(Resident 105)
Findings include:
1. On 4/10/18 at 10:00 a.m., the clinical record of
Resident 105 was reviewed. Diagnoses included,
but were not limited to the following, enterocolitis
due to Clostridium difficile (germ which can cause
diarrhea), not specified as recurrent, congestive
heart failure, cardiomyopathy, acute kidney
failure, type 2 diabetes mellitus, and hypertension.
The admission Minimum Data Set (MDS)
Assessment, dated 3/21/18, indicated the
following: Resident 105 was independent
cognition; received antibiotics during the last 7
days.
On 4/6/18 at 2:00 p.m., the Administrator provided
a current copy of the policy and procedure for
"Infection Control" dated 4/3/17. The policy and
procedure included the following: "...The nurse is
responsible for alerting the attending physician of
resident's symptoms..."
On 4/10/18 at 4:04 p.m., the DON (Director of
Nursing) provided a current copy of the facility
policy and procedure for "...Clostridium Difficile (c
diff)" dated 2/12/18. The policy and procedure
included the following: "...Residents considered
at high risk for developing symptoms associated
with Clostridium difficile include those with
advancing age...previous gastrointestinal illness
caused by Clostridium difficile and
antibiotic...residents with these risks have
F 0580 F 580 NOTIFY OF CHANGES
(INJURY/DECLINE/ROOM, etc.)
1.The NP was notified on
4/10/18 of the continued loose
stool for resident #105. See
Attached F580A.
2.All other residents were
audited to determine if they had a
significant change of condition that
would require physician
notification. No other concerns
identified.
3.The facility has a policy, see
attached F580B, entitled
“Resident Rights-Notification of
Changes”, that was reviewed, no
revisions necessary.
DON/designee will re-educate all
licensed nurses on the Resident
Rights-Notification of Changes
policy.
4.Quality Monitoring: An audit
form was developed on 4/27/18 for
the DON/designee to audit 10
residents monthly for a total of 6
months to ensure physician
notification for significant changes
were completed. Results of these
audits will be reported to the QAA
committee monthly through
November 2018.
05/11/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 3 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
symptoms of diarrhea (i.e. three (3) loose stools in
a twenty-four (24) hour period), Clostridium
difficile should be considered as a
cause...Residents with previous infection who
develop diarrhea should be evaluated as soon as
practical..."
Current physician "Order Summary Report", dated
3/18, indicated to give the following: Vancomycin
25 mg/ml(milligrams/milliliter) give 5 ml d/c date
4/6/18..."
Review of the April 2018 MAR (medication
administration record) indicated the following:
"Vancomycin 25 mg/ml give 5 ml by mouth every
48 hours." The last documented dose was on
4/5/18 at 19:57 (7:57 p.m.).
A 4/6/18 progress note at 7:27 a.m., indicated
"...Stools formed w/slight foul odor..."
A 4/6/18 progress note at 12:48 p.m., indicated
"...Res continues with loose, foul smelling stools."
Documentation was lacking of the NP and/or
physician having been notified of the resident
having loose, foul smelling stools.
On 4/7/18, the BM report indicated the resident
was continent, had a medium loose/diarrhea stool
documented. Documentation was lacking in the
progress notes of characteristics (presence or
absence of odor) of resident's loose/diarrhea
stools. Documentation was lacking of the NP
and/or physician having been notified of the
resident having loose/diarrhea stools.
On 4/8/18, the BM report indicated the resident
was continent, had a small, loose/diarrhea stool
documented. Documentation was lacking in the
progress notes of characteristics (presence or
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 4 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
absence of odor) of resident's loose/diarrhea
stools. Documentation was lacking of the NP
and/or physician having been notified of the
resident having loose/diarrhea stools.
On 4/9/18, the BM report indicated the resident
was continent, had a large and a medium
loose/diarrhea stool documented. Documentation
was lacking in the progress notes of
characteristics (presence or absence of odor) of
resident's loose/diarrhea stools. Documentation
was lacking of the NP and/or physician having
been notified of the resident having
loose/diarrhea stools.
Progress note, dated 4/10/18 at 11:16 a.m.,
indicated: "Res having diarrhea today, since he
woke up. Writer called and spoke with (name of
NP). Orders received for res (resident) to have prn
(as needed) Imodium (antidiarrheal medication)
started and collected another specimen for
C-Diff...specimen collected and sent to lab for
testing..."
A "Lab Results Report", collected 4/10/18 at 10:30
a.m., indicated the following: Clostridium difficile
4/10/18: "positive. "
On 4/11/18 at 3:08 p.m., the DON was interviewed.
She indicated the nurse caring for the resident
today, LPN 1, indicated the NP doesn't retest for a
week after Vancomycin was completed. The DON
indicated another C difficile sample was obtained
on 4/10/18, with a positive result. She indicated
LPN 1 indicated the reason the NP ordered the
Vancomycin to be restarted was because LPN 1
made the NP aware, on 4/10/18, the resident had
"complained" to her.
On 4/12/18 at 12:05 p.m., the NP was interviewed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 5 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
She indicated she was called on Tuesday, 4/10/18,
and was made aware at that time, the resident was
having diarrhea, but should have been notified if
the resident continued with loose stools after the
medication had been discontinued on 4/6/18.
3.1-5(a)(3)
483.20(b)(2)(ii)
Comprehensive Assessment After Signifcant
Chg
§483.20(b)(2)(ii) Within 14 days after the
facility determines, or should have
determined, that there has been a significant
change in the resident's physical or mental
condition. (For purpose of this section, a
"significant change" means a major decline
or improvement in the resident's status that
will not normally resolve itself without further
intervention by staff or by implementing
standard disease-related clinical
interventions, that has an impact on more
than one area of the resident's health status,
and requires interdisciplinary review or
revision of the care plan, or both.)
F 0637
SS=D
Bldg. 00
Based on interview and record review, the facility
failed to ensure a significant change in status
assessment was completed for 1 of 1 residents
reviewed for significant change assessments
(Resident 128).
Findings include:
On 4/12/18 at 9:22 A.M., the record for Resident
128 was reviewed. Diagnoses included, but were
not limited to, cerebrovascular accident (stroke
8/17), history of falls, hypertension (high blood
pressure), chronic kidney disease, and insomnia.
The resident was admitted to the facility following
her stroke for rehabilitation.
F 0637 F 637 Comprehensive
Assessment after Significant
Change
1.Resident 128 no longer
resides in the facility.
2.All other residents were
reviewed regarding significant
change in medical status to
determine if a significant change
had occurred. No other residents
were identified.
3.The facility has a policy, see
attached F637A, entitled “Care
Plans”, that was reviewed, no
05/11/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 6 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
An Admission MDS (Minimum Data Set)
assessment, dated 8/31/17, indicated the resident
had a BIMS (Brief Interview Mental Status) score
of 14 which signified she had no cognitive
impairment, required limited assistance of 1 staff
member with bed mobility, walking in her room,
and with dressing, required extensive assistance
of 2 staff members with transfers, required
supervision with eating and supervision with 2
staff members for toileting. The resident was
continent of bowel and bladder and the resident
had no mood issues.
A Nutrition/Dietary Note: 5 day Review, dated
8/31/17 at 6:52 A.M., indicated the resident's
weight on admission was 134.6. The note
indicated the resident was a "light eater" and on
average, her meal intakes were 75%. The resident
fed herself a regular diet and had no chewing or
swallowing problems.
A Nurse Note, dated 12/1/2017 at 8:47 A.M.,
indicated the resident's family had spoken with
the social worker at the facility and had requested
the resident be placed on palliative/comfort
measures care.
A Nurse Practitioner Progress Note, dated
12/1/2017 at 11:17 A.M., indicated the resident
was seen for review of medications and change to
comfort measures/palliative care. The NP (Nurse
Practitioner) discontinued several medications
including, but not limited to, Remeron (medication
for insomnia) and Lasix (water pill).
A Quarterly MDS assessment, dated 12/1/17,
indicated a BIMS score of 9 which signified
moderately impaired cognition. The MDS
indicated the resident had the following mood
revisions necessary.
DON/designee will re-educate the
MDS Coordinators on this policy,
as well as, educate licensed
nurses to inform MDS
Coordinators of significant
changes.
4.Quality Monitoring: An audit
form was developed on 4/27/18 for
the DON/designee to audit all care
plans monthly for the next 6
months regarding significant
change criteria necessitating a
significant change MDS
assessment using the RAI
manual. Results of these audits
will be reported to the QAA
committee monthly through
November 2018.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 7 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
issues: little interest or pleasure, feeling down,
depressed and hopeless, tired with little energy,
poor appetite, and feeling bad about and letting
self and family down. The residents weight was
111. The MDS indicated the resident needed
extensive assistance of 1 staff member with bed
mobility, transfers, walking in room, dressing, and
toilet use. The MDS indicated the resident was
occasionally incontinent of bowel and bladder.
On 4/12/18 at 11:09 A.M., the MDS Coordinator
was interviewed. During the interview, she
indicated she was unsure of why a significant
change MDS assessment had not been
completed. She indicated staff followed the RAI
(Resident Assessment Instrument) process for
determining a significant change in residents
condition and revision of the care plan.
On 4/12/18 at 11: 57 A.M., MDS Nurse 2 was
interviewed. During the interview, she indicated a
significant change in status MDS should have
been completed on 12/1/17.
3.1-31(d)(1)
483.21(b)(2)(i)-(iii)
Care Plan Timing and Revision
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan
must be-
(i) Developed within 7 days after completion
of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that
includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for
the resident.
(C) A nurse aide with responsibility for the
resident.
F 0657
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 8 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
(D) A member of food and nutrition services
staff.
(E) To the extent practicable, the
participation of the resident and the resident's
representative(s). An explanation must be
included in a resident's medical record if the
participation of the resident and their resident
representative is determined not practicable
for the development of the resident's care
plan.
(F) Other appropriate staff or professionals in
disciplines as determined by the resident's
needs or as requested by the resident.
(iii)Reviewed and revised by the
interdisciplinary team after each assessment,
including both the comprehensive and
quarterly review assessments.
Based on interview and record review, the facility
failed to ensure care plans were updated for 1 of 1
residents reviewed with significant change in
condition (Resident 128).
Findings include:
On 4/12/18 at 9:22 A.M., the record for Resident
128 was reviewed. Diagnoses included, but were
not limited to, cerebrovascular accident (stroke
8/17), history of falls, hypertension (high blood
pressure), chronic kidney disease and insomnia.
The resident was admitted to the facility following
her stroke for rehabilitation. She had a significant
change in her condition and expired at the facility
on 1/7/18.
An Admission MDS (Minimum Data Set)
assessment, dated 8/31/17, indicated the resident
had a BIMS (Brief Interview Mental Status) score
of 14 which signified she had no cognitive
impairment, required limited assistance of 1 staff
member with bed mobility, walking in her room,
F 0657 F 657 Care Plan Timing and
Revision
1.Resident 128 no longer
resides in the facility.
2.All other residents were
reviewed regarding significant
change in medical status to
determine if a significant change
had occurred. No other residents
were identified.
3.The facility has a policy, see
attached F637A, entitled “Care
Plans”, that was reviewed, no
revisions necessary.
DON/designee will re-educate the
MDS Coordinators on this policy,
as well as, licensed nurses.
Dining Services was educated on
4-26-2018, see attached F657K.
SS staff were educated on
4-26-2018, see attached F842D.
4.Quality Monitoring: An audit
05/11/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 9 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
and with dressing, required extensive assistance
of 2 staff members with transfers and required
supervision with eating and supervision with 2
staff members for toileting. The resident was
continent of bowel and bladder. The MDS
indicated the resident had no mood issues.
1. A Quarterly MDS assessment, dated 12/1/17,
indicated a BIMS score of 9 which signified
moderately impaired cognition. The MDS
indicated the resident had the following mood
issues: little interest or pleasure, feeling down,
depressed and hopeless, tired with little energy,
poor appetite, and feeling bad about and letting
self and family down. The residents weight was
111. The MDS indicated the resident needed
extensive assistance of 1 staff member with bed
mobility, transfers, walking in room, dressing, and
toilet use and supervision of 1 staff member for
eating. The MDS indicated the resident was
occasionally incontinent of bowel and bladder.
A Care Plan with a focus on ADL's (Activities of
Daily Living) initiated on 8/28/17 and updated
1/9/18, indicated the resident had "an expected
decline in ADL self-care performance deficit r/t
(related to) Palliative Comfort Care. Palliative
Comfort Care for the resident was not started until
12/1/17. The care plan did not indicatethe reason
for Comfort Care, nor which ADL declines were
expected to occur and interventions to address
those declines. There was no care plan for bowel
and bladder incontinence identified on the MDS
dated 12/1/17.
2. A Nutrition/Dietary Note: Late Entry: 14 day
Review, dated 9/7/17 at 1:36 P.M., indicated the
resident's current weight was 122 (noted on
9/4/17) which showed a 9.4% weight loss since
admission on 8/24/17. The resident continued to
form was developed on 4/27/18 for
the DON/designee to audit all care
plans monthly for the next 6
months to ensure they thoroughly
and completely reflect the current
state of the residents. Results of
these audits will be reported to the
QAA committee monthly through
November 2018.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 10 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
feed herself a regular diet.
A Nutrition/Dietary Note, dated 9/21/17 at 11:43
A.M., indicated during a care plan meeting, the
residents family discussed her intakes and eating.
The family suggested to give more soft foods at
meals. "Staff to encourage softer foods, soft
sweets, etc."
A Care Plan with a focus on nutrition, initiated on
8/25/17 and updated 1/9/18, indicated the resident
was on a regular diet. Interventions included, but
were not limited to, monitor weights and
Fluid/Food intakes, provide diet as ordered, and
encourage me to drink plenty of fluids and eat
what I order. The care plan did not address the
residents weight loss identified on 9/7/17. The
care plan did not indicate staff were to encourage
softer foods and soft sweets.
3. A Social Service Note, dated 8/29/17 at 12:24
P.M., indicated Resident 128 had resided in
assisted living and was admitted to the facility
following hospitalization for rehabilitation. The
resident was cognitively intact with a BIMS score
of 14. She had a diagnosis of insomnia and was
taking Remeron (anti-depressant) to treat this.
The resident's discharge plans were to return to
her apartment in assisted living.
A Social Service Note, dated 9/21/17 at 9:38 A.M.,
indicated a BIMS had been completed and
indicated a score of 8 which signified moderately
impaired cognition. The note indicated the
residents previous BIMS score, completed on
9/5/17 had been 14 which signified no cognitive
impairment. The note indicated the resident
"voiced no concerns" and "did not exhibit any
moods" during the visit.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 11 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
A Social Service Note, dated 11/30/2017 at 11:55
A.M., indicated an assessment was completed.
The resident was "alert, smiled slightly" and did
not voice any concerns. She remained on
Remeron for insomnia. The residents BIMS score
was 9 which indicated moderately impaired
cognition. The resident was asked about her
mood and she expressed that she was
"tired-physically and emotionally"and indicated
family had requested "comfort measures/palliative
care per the resident's wishes. The note indicated
"Care plan reviewed and remains appropriate".
A Care Plan, initiated on 11/30/17, indicated the
resident had a mood problem related to insomnia
and anxiety. The goal was for the resident to have
improved sleep pattern and improved mood state
and decreased anxiety. The care plan did not
address the cause of anxiety identified on the
quarterly MDS dated 12/1/17. There was no care
plan to address the resident's decline in cognition
and end of life needs.
On 4/12/18 at 11:09 A.M., the MDS Coordinator
was interviewed. During the interview, she
indicated she was unsure of why care plans had
not been updated or initiated to reflect the
resident's significant change. She indicated staff
followed the RAI (Resident Assessment
Instrument) process for determining a significant
change in residents condition and revision of the
care plan.
3.1-35(a)
483.35(a)(3)(4)(c)
Competent Nursing Staff
§483.35 Nursing Services
The facility must have sufficient nursing staff
with the appropriate competencies and skills
F 0726
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 12 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
sets to provide nursing and related services
to assure resident safety and attain or
maintain the highest practicable physical,
mental, and psychosocial well-being of each
resident, as determined by resident
assessments and individual plans of care and
considering the number, acuity and
diagnoses of the facility's resident population
in accordance with the facility assessment
required at §483.70(e).
§483.35(a)(3) The facility must ensure that
licensed nurses have the specific
competencies and skill sets necessary to
care for residents' needs, as identified
through resident assessments, and
described in the plan of care.
§483.35(a)(4) Providing care includes but is
not limited to assessing, evaluating, planning
and implementing resident care plans and
responding to resident's needs.
§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are
able to demonstrate competency in skills and
techniques necessary to care for residents'
needs, as identified through resident
assessments, and described in the plan of
care.
Based on observation and interview, the facility
failed to ensure proper technique was used for
subcutaneous injections for 1 of 2 residents
observed during administration of subcutaneous
injections.
(Resident 21)
Findings included:
A review of Resident 21's clinical record on
F 0726 F726 Competent Nursing Staff
1.The RN was re-educated, see
attached F726B, on proper SQ
administration technique/policy,
see attached F726A, on 4/24/18.
2.Nurses were observed for
proper SQ administration
technique and no further problems
were identified
3.DON/or designee will
05/11/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 13 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
4/10/2018 at 12:30 p.m., indicated a BIMS (Brief
Interview of Mental Status) score of 15 out of 15,
meaning cognitively intact. Diagnoses included ,
but were not limited to: diabetes.
On 4/10/2018 at 11:22 a.m., RN (Registered Nurse)
6 was observed administering 5 units of insulin by
subcutaneous (fatty layer of skin tissue) injection
to Resident 21's abdomen with one hand.
On 4/10/2018 at 11:35 a.m., RN 6 was observed
using only one hand to administer 4 units of
insulin by subcutaneous injection in Resident 9's
abdomen.
During an interview on 4/10/2018 at 12:30 p.m., the
DON (Director of Nursing) indicated the facility
had no skills check for subcutaneous injections.
During an interview on 4/12/18 at 12:04 p.m., LPN
(Licensed Practical Nurse) 9, indicated when
giving a subcutaneous injection you are to pinch
the skin up with a your first finger and thumb
before injecting the needle with the other hand.
During an observation on 04/12/18 at 12:54 p.m.,
LPN 5, demonstrated pinching up the fatty tissue
with one hand prior to insertng the needle into the
skin and injeecting with the other hand.
During an interview on 4/12/2018 at 1:04 p.m., RN
10, indicated fatty tissue is squeezed up prior to
injecting the insulin.
3.1-14(i)
re-educate all licensed nurses
regarding proper SQ
administration technique.
4.Quality Monitoring: An audit
form was developed on 4/27/18 for
the DON/designee to randomly
audit 10 SQ injection
administrations monthly for the
next 6 months to ensure proper
SQ injection administration
technique is used. Results of
these audits will be reported to the
QAA committee monthly through
November 2018.
483.45(g)(h)(1)(2)
Label/Store Drugs and Biologicals
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility
F 0761
SS=E
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 14 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
must be labeled in accordance with currently
accepted professional principles, and include
the appropriate accessory and cautionary
instructions, and the expiration date when
applicable.
§483.45(h) Storage of Drugs and Biologicals
§483.45(h)(1) In accordance with State and
Federal laws, the facility must store all drugs
and biologicals in locked compartments
under proper temperature controls, and
permit only authorized personnel to have
access to the keys.
§483.45(h)(2) The facility must provide
separately locked, permanently affixed
compartments for storage of controlled drugs
listed in Schedule II of the Comprehensive
Drug Abuse Prevention and Control Act of
1976 and other drugs subject to abuse,
except when the facility uses single unit
package drug distribution systems in which
the quantity stored is minimal and a missing
dose can be readily detected.
Based on observation, interview, and record
review, the facility failed to ensure medications
were properly labeled, dated, and stored properly
for 3 out of 6 medication carts, and 1 out of 3
medication rooms reviewed for medication
storage.
Findings included:
On 4/10/18 at 10:52 a.m., the 300 Hall, cart 1 was
observed with LPN (Licensed Practical Nurse) 11
and the following items were found:
A Combivent Respimat inhaler with no date
opened.
F 0761 F761 Label/Store Drugs and
Biologicals
1.The Combivent Respimat
inhaler was properly labeled with a
date opened during the survey
period. ProStat Cherry was
properly labeled for the resident
that it is in use for during the
survey period. The expired apisol
was destroyed during the survey
period.
2.Reviewed all medication carts
and medication refrigerators to
identify additional storage issues,
05/11/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 15 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
On 4/10/18 at 12:08 p.m., the 100 Hall, cart 2 was
observed for storage with LPN 12 and the
following items were found:
An opened bottle of Pro Stat Cherry, with no
resident name, no Physician's name, no date
opened, and no specific instructions for the
resident it was being used for.
During an interview on 4/10/2018 at 12:09 p.m.,
LPN 12 indicated the Pro Stat was not used for
multiple residents, and should have been labeled.
On 4/12/2018 at 12:24 p.m., the 500 Hall
Medication room was observed for med storage
with LPN 9. An opened bottle of Apisol was
found in the refrigerator with a date opened label
of 3/7/2018.
At this time, an interview with LPN 9 indicated the
Apisol was only good for 30 days once opened.
During an interview on 4/12/18 12:33 p.m., the Unit
Manager of the 500 Hall indicated the Apisol vials
were only good for 30 days after opened.
On 4/10/2018 at 12:30 p.m., a current facility policy,
dated 2/9/2018, "Medication Storage" provided by
the DON (Director of Nursing) indicated "...the
facility shall store all drugs and biologicals in a
safe, secure, and orderly manner. 3. Drug
containers that have missing, incomplete,
improper, or incorrect labels shall be returned to
the pharmacy for proper labeling before storing.
8. Drugs shall be stored in an orderly manner in
cabinets, drawers, carts or automatic dispensing
systems. Each resident's medications shall be
assigned to an individual cubicle, drawer, or other
holding area to prevent the possibility of mixing
none were noted.
3.The facility has a policy, see
attached F761A, entitled
“Medication Storage”, that was
reviewed, no revisions necessary.
DON/designee will re-educate
licensed nurses on medication
storage regarding labeling.
4.Quality Monitoring: The DON
/designee will utilize a medication
storage audit to audit medication
carts and med rooms monthly for
six months regarding medication
storage. Results of these audits
will be reported to the QAA
committee monthly through
November 2018.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 16 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
medications of several residents..."
3.1-25(j)
483.20(f)(5); 483.70(i)(1)-(5)
Resident Records - Identifiable Information
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that
is resident-identifiable to the public.
(ii) The facility may release information that is
resident-identifiable to an agent only in
accordance with a contract under which the
agent agrees not to use or disclose the
information except to the extent the facility
itself is permitted to do so.
§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted
professional standards and practices, the
facility must maintain medical records on
each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
§483.70(i)(2) The facility must keep
confidential all information contained in the
resident's records,
regardless of the form or storage method of
the records, except when release is-
(i) To the individual, or their resident
representative where permitted by applicable
law;
(ii) Required by Law;
(iii) For treatment, payment, or health care
operations, as permitted by and in
compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of
abuse, neglect, or domestic violence, health
F 0842
SS=E
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 17 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
oversight activities, judicial and administrative
proceedings, law enforcement purposes,
organ donation purposes, research purposes,
or to coroners, medical examiners, funeral
directors, and to avert a serious threat to
health or safety as permitted by and in
compliance with 45 CFR 164.512.
§483.70(i)(3) The facility must safeguard
medical record information against loss,
destruction, or unauthorized use.
§483.70(i)(4) Medical records must be
retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge
when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident
reaches legal age under State law.
§483.70(i)(5) The medical record must
contain-
(i) Sufficient information to identify the
resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and
services provided;
(iv) The results of any preadmission
screening and resident review evaluations and
determinations conducted by the State;
(v) Physician's, nurse's, and other licensed
professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic
services reports as required under §483.50.
Based on observation, interview, and record
review, the facility failed to ensure documentation
was complete and accurate for 4 out of 8 resident
records reviewed.
(Resident 86, Resident 43, Resident 28, and
Resident 65)
F 0842 F 842 Resident
Records-Identifiable
Information
1.A) Residents #86, 43, 28,
charts were reviewed on 4/20/18
05/11/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 18 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
1. A review of Resident 86's clinical record on
4/6/2018 at 11:05 a.m., indicated a BIMS (Brief
Interview of Mental Status) could not be
completed due to severe cognitive impairment.
Diagnoses included, but were not limited to:
dementia.
Progress Notes indicated the following
documented entries:
On 2/28/2018 at 4:47 p.m., a visit was documented
by the NP (Nurse Practitioner).
On 3/1/2018 at 7:46 a.m., a Nurse's Note was
documented, "...Res (resident) continues on F/U
(follow up) incident charting. All VS (vital signs)
and neuros (neurological assessment) WNL
(within normal limits). No c/o (complaints of) pain,
shows no s/s (signs or symptoms) of distress
thus far, no injuries noted. No s/s of AMS
(altered mental status), and shows no change in
LOC (level of consciousness). WCTM (will
continue to monitor) for change in cond
(condition)..."
A review Resident 86's Progress Notes indicated
documented entries for fall follow up through
3/4/2018 at 9:52 p.m.
On 4/10/18 at 12:55 p.m., Resident 86 was
observed sitting at a dining room table, on the
Memory Care Unit.
On 4/10/18 at 3:48 p.m., Resident 86 was observed
sitting at a dining room table, on the Memory Care
Unit.
On 4/12/18 at 11:50 a.m., Resident 86 was
observed walking in the hallway of the Memory
and missing documentation in the
progress notes were identified for
fall follow-up (#86, 43, 28). The
residents did not sustain any
measurable negative outcomes as
a result of this practice. B) The
information from the completed
concern/grievance form for
resident #65, with all
documentation and resolution,
were entered into resident #65’s
EMR on 4-23-2018. See attached
F842C.
2.Current risk management and
concern/grievance logs will be
reviewed and documentation will
be entered in the EMR, per
policies, see attached F842A and
F842B.
3.The facility has policies, see
attached F842A, entitled “Fall
Policy - Resident Safety AB”, no
revisions; and policy, see attached
F842B, “Concerns/Grievances”
revisions included adding
documentation in the EMR, #2 in
the policy. A) The DON/designee
will re-educate the Resident Care
Coordinators to ensure follow up
documentation for risk
management is completed in the
progress notes. B) The
SSD/designee will re-educate
Social Services staff on 4-26-2018,
see attached F842D, regarding the
Concerns/Grievance Policy on the
necessity to have documentation
in the EMR.
4.Quality Monitoring: A) An
audit form was developed on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 19 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
Care Unit.
There were no other entries on the record to
indicate the reason for the follow up or any facts
concerning Resident 86's fall.
During an interview on 4/6/2018 at 11:06 a.m., LPN
(Licensed Practical Nurse) 13 indicated Resident
86 had a fall on 3/1/2018 in his room. The fall
information was entered into the Risk
Management section of the electronic record and
therefore, could not be shared with the surveyor.
2. A review of Resident 43's clinical record on
4/9/2018 at 5:22 p.m., indicated a BIMS of 3 out of
15, meaning severe cognitive impairment.
Diagnoses included, but were not limited to:
dementia.
On 4/9/18 at 3:23 p.m. Resident 43 was observed
propelling self in her wheelchair, in the hallway,
on the Memory Care Unit, while eating a cookie.
The resident was observed having a purple
discoloration around her right eye orbit with
swelling.
Progress Notes indicated the following
documented entries:
On 4/6/2018 at 10:56 a.m., a Social Service Note
was documented for a Care Plan.
On 4/7/2018 at 4:59 p.m., an Activity Visitation
was documented.
On 4/7/2018 at 8:23 p.m., a Nurse's Note was
documented "... No psychosocial harm noted res
(resident) pleasant and participating in activities
this am (morning) no concerns offered..."
Progress Notes indicated documented entries
4/26/18 for the DON /designee to
audit risk management EMR
documentation for 10 residents
monthly to ensure documentation
is completed in the progress notes
for a total of 6 months. B) The
SSD/designee will audit current
concern/grievance report logs, see
attached F842E, to ensure
follow-up documentation has also
been entered into the EMR for all
concerns/grievances, auditing for
the next 6 months. . Results of
these audits will be reported to the
QAA committee monthly through
November 2018.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 20 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
until 4/10/2018 at 8:48 p.m., referencing no pain, no
complaints about the bruise to her right eye.
There were no other notes to indicate how or any
facts surrounding how the resident received the
black eye.
During an interview on 4/9/2018 at 3:25 p.m., CNA
(Certified Nurse Aide) 8 indicated she did not
know how Resident 43 got a black eye.
During an interview on 4/9/2018 at 3:27 p.m., QMA
(Qualified Medication Aide) 7 indicated there was
an altercation with another resident, but she was
unsure of the details because she did not work the
weekend.
During an interview on 4/10/18 at 12:33 p.m., the
Memory Care Unit Manager indicated incidents
and altercations were documented in the Risk
Management section of the facility computer
program and was not sure if it was part of the
permanent record, and could not be shared with
the surveyor. She further indicated the follow ups
were documented in the Progress Notes.
3. A review of Resident 28's clinical record on
4/9/2018 at 4:33 p.m., indicated a BIMS was unable
to be completed due to severe cognitive
impairment. Diagnoses included, but were not
limited to: dementia, spinal and back disease, and
osteoporosis (fragile, brittle bones) .
On 4/9/18 at 3:35 p.m., Resident 28 was observed
in her room, laying in her bed. The resident's right
eye orbit was discolored dark purple.
Progress Notes indicated the following:
On 4/5/2018 at 3:45 p.m., an Activity Visitation not
was documented and indicated Resident 28
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 21 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
visited with her sister in the afternoon.
On 4/6/2018 at 6:51 a.m., an Administration Note
was documented that Resident 28 refused a
medication.
On 4/7/2018 at 8:14 p.m., a Nurse's Note was
documented and indicated "...Res (resident)
returned from the hospital with new diagnosis
maxillary sinus fracture, simple periorbital
laceration, and inferior & superior right pubic
ramus fracture. New orders for Keflex (antibiotic)
500 mg (milligrams) po (by mouth) q (every) 6
hours times 40 tabs (tablets), and hydrocodone
bitartate-acetaminophen (narcotic for pain) 5-325
mg 1 tab po..."
Progress Notes indicated documented entries
through 4/12/2018 at 12:40 p.m.
During an interview on 4/9/2018 at 4:50 p.m., the
DON indicated incidents were documented in a
Risk Management note, not in the Progress Notes.
She looked up the incident on her lap top and
indicated the following: "...On 4/7/2018 at 7:30
a.m., Resident 28 stood from the table she was
sitting at, while holding her plate of food and
glass of juice. Resident 28 fell forward losing
control of the plate and glass, laying on the floor,
on her right side, she was tensed, moaning,
groaning, crying, she had facial grimacing, and
pain to her right hip and neck. Resident 28 had
impaired memory, ambulated without assistance a
predisposed situation. LPN 13 and RN Supervisor
witnessed the incident and called the Physician
and family member. Resident 28's right outer brow
was bleeding..."
The DON indicated incidents entered into the Risk
Management section were not part of the
permanent record, and could not be shared with
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 22 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
the surveyor.
During an interview on 4/12/18 at 12:54 p.m., LPN
5 indicated she would document issues in the Risk
Management report and also documented in the
Progress Notes as to what had happened to a
resident. She would talk to the staff and resident
about what happened and the Unit Manager
would investigate any issues.4. The clinical
record review for Resident 65 began on 4/9/18 at
3:46 p.m. Diagnoses included, but were not
limited to, hemiplegia following a
CVA(cerebrovascular accident, a stroke), muscle
weakness, abnormalities of gait and mobility, PVD
(peripheral vascular disease), lymphedema
(swelling in extremity caused by lymph system
blockage), autonomic neuropathy (damage to
nerves that manage every day body functions),
major depressive disorder, and anxiety disorder,
urinary tract infection. Resident 65's current
Quarterly MDS (Minimum Data Set) dated 2/15/18
indicated a BIMS (Brief Interview of Mental
Status) score was 15/15 which indicated resident
was cognitively intact.
Review of Resident 65's Progress Notes for March
2018 and April 2018 were reviewed. A progress
note was lacking about missing ID cards.
An interview with Resident 65 on 04/06/18 at 11:51
a.m., indicated a couple of Saturday's ago, she got
her wallet from the top drawer of the dresser and
found all of her ID (identification) cards were
missing. Resident 65 indicated the her Social
Security Card, Health Insurance Card, Out of State
ID card and her birth certificate were missing.
Resident 65 also indicated none of her money was
missing, which was only a few coins. Resident 65
indicated she did not report the missing ID cards
until the following Monday and then reported the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 23 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
missing items to Social Service 3. Resident 65
further indicated the Administrator had even
reported the missing ID cards to the police.
On 4/10/18 at 11:35 a.m., a review of the incident
reported to ISDH provided by Social Service 3,
indicated, "...Incident Date 03/26/18...Involved:
Resident 65[Name]...Description...Resident
reported to SS (Social Service) around noon
today, that she was missing some items
from...wallet...noticed they were missing on
Saturday, but did not tell anyone until today.
Resident stated...missing the ID, SS (Social
Security) Card, and birth certificate from...wallet,
while money remained in...wallet...FWPD (City
Police) was notified of missing items (included
police report number). Other residents were
interview, nothing else was reported missing...."
An interview with Social Service 3 on 4/10/18 at
11:02 a.m., indicated Resident 65 had reported her
missing ID card, on 3/26/18 which included her
Social Security Card, Birth Certificate and ID Card,
which was from another State. Social Service 3
indicated she had reported the missing ID cards to
the Administrator. She also indicated the
Administrator had reported the missing ID cards
to the police and to ISDH (Indiana State
Department of Health). Social Service 3 indicated
they searched for the Resident's ID cards in their
room and in the facility laundry. Social Service 3
indicated Resident 65's Inventory Sheet listed a
brown wallet, but did not list the contents of the
wallet. Social Service further indicated she was
currently working on replacing Resident 65's ID
cards.
An interview with Social Service on 4/12/18 at
11:34 a.m., indicated she was ordering Resident
65's birth certificate and had applied for a Social
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 24 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
Security Card. Social Service 3 indicated she was
the first staff Resident 65 had reported the ID
Cards were missing from her wallet. Social Service
3 indicated she documented the missing items in
Resident 65's electronic record and completed a
Concern/Grievance Report and reported to the
Administrator right away. Social Service 3
reviewed Resident 65's electronic progress notes
for her documentation about the missing items,
but reported she must not have documented in
Resident 65's progress notes. She provided a
copy of the Concern/Grievance Report and the
Missing Item/Concern Log. Social Service 3
further indicated she should have documented the
missing items in the resident's record and
indicated she would add a late entry to Resident
65's progress notes.
On 4/12/18 at 12:59 p.m., review Resident 65's
electronic progress notes, which indicated,
"...Late Entry...Social Service Note...Effective
Date: 3/26/2018 08:49...Created by: [Name, Social
Service 3]...Created Date: 4/12/2018 11:51...Note:
Resident told writer she had missing items from
wallet from the weekend. Resident is stating...is
missing her SS card, ID and birth cerf [sic]
(certificate). Resident stated all of her change was
still in wallet, she had no money. Writer did give
[Name of family member] a call to verify items.
Writer reported this to Admin. (Administrator).
Concern form filled out...."
An interview with the Social Service Director on
04/12/18 at 12:35 p.m., indicated if a resident was
missing personal items, Social Service Staff
should document the missing property on the
Concern/Grievance Form and enter the items on
the Missing Item/Concern log, search for the item,
and notify appropriate staff. She then indicated if
a resident's dentures were missing, a progress
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 25 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
note should be enter into the resident's record,
but a resident's missing clothing may not be
documented in the resident's record but on a
Concern/Grievance Form should be completed
and the missing items listed on the Missing
Item/Grievance Log. She further indicated the
resident's missing ID cards should have been
documented in the resident's clinical record.
An interview with the Administrator on 04/12/18
at 1:25 p.m., indicated usually missing items such
as clothing would not be documented in the
resident's clinical record, but missing money,
hearing aids, dentures should be documented in
the resident's record to alert the other facility
department, such as the dietary department if a
resident's dentures were missing. The
Administrator further indicated Resident 65's
missing ID cards were reported to the city police
and ISDH, and an investigation was completed
which included interviewing other alert residents.
An interview with the DON (Director of Nursing)
on 04/12/18 at 1:28 p.m., indicated the facility did
not have a policy regarding documentation
required for missing items/concerns/grievances in
a resident's clinical record. She indicated Resident
65's missing ID cards should be documented on a
Concern/Grievance Form and further indicated
missing items were usually not part of the
resident's clinical record.
A current facility policy with a revision date of
3/1/18, titled, Concerns/Grievance Policy, was
provided by the DON on 4/12/18 at 1:40 p.m. The
policy indicated, "...The resident has the right to
voice grievances to the facility...Grievances
include those with respect to care and treatment
which has been furnished as well as that which
has not been furnished, the behavior of staff and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 26 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
of other residents, and other concerns regarding
their LTC (Long Term Care) facility stay. The
Administrator is identified as the Grievance
Officer....A resident may voice or file a written
concern/grievance with the charge nurse, social
worker or Grievance Officer...The assigned nurse
or social worker to the resident shall initially
address any concerns/grievances, problems, or
complaints. Every effort will be mad to correct
any concerns/grievance...If the reported
concern/grievance has to do with an allegation of
abuse, the Administrator should be notified
immediately, but not later than 2 hours after the
allegation is made. The Administrator will then
notify the appropriate agencies and initiate an
investigation. The investigation will be completed
within 5 days of the reported incident; follow up
will be provided to the respective party and
appropriate agencies...."
3.1-50(a)
483.80(a)(1)(2)(4)(e)(f)
Infection Prevention & Control
§483.80 Infection Control
The facility must establish and maintain an
infection prevention and control program
designed to provide a safe, sanitary and
comfortable environment and to help prevent
the development and transmission of
communicable diseases and infections.
§483.80(a) Infection prevention and control
program.
The facility must establish an infection
prevention and control program (IPCP) that
must include, at a minimum, the following
elements:
§483.80(a)(1) A system for preventing,
F 0880
SS=E
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 27 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
identifying, reporting, investigating, and
controlling infections and communicable
diseases for all residents, staff, volunteers,
visitors, and other individuals providing
services under a contractual arrangement
based upon the facility assessment
conducted according to §483.70(e) and
following accepted national standards;
§483.80(a)(2) Written standards, policies,
and procedures for the program, which must
include, but are not limited to:
(i) A system of surveillance designed to
identify possible communicable diseases or
infections before they can spread to other
persons in the facility;
(ii) When and to whom possible incidents of
communicable disease or infections should
be reported;
(iii) Standard and transmission-based
precautions to be followed to prevent spread
of infections;
(iv)When and how isolation should be used
for a resident; including but not limited to:
(A) The type and duration of the isolation,
depending upon the infectious agent or
organism involved, and
(B) A requirement that the isolation should be
the least restrictive possible for the resident
under the circumstances.
(v) The circumstances under which the facility
must prohibit employees with a
communicable disease or infected skin
lesions from direct contact with residents or
their food, if direct contact will transmit the
disease; and
(vi)The hand hygiene procedures to be
followed by staff involved in direct resident
contact.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 28 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
§483.80(a)(4) A system for recording
incidents identified under the facility's IPCP
and the corrective actions taken by the
facility.
§483.80(e) Linens.
Personnel must handle, store, process, and
transport linens so as to prevent the spread
of infection.
§483.80(f) Annual review.
The facility will conduct an annual review of
its IPCP and update their program, as
necessary.
Based on observation, interview, and record
review, the facility failed to ensure infection
control and prevention intervention strategies
were implemented for 1 of 1 resident reviewed with
active Clostridium Difficile (C Difficile) infection.
This deficient practice had the potential to affect 5
residents residing in rooms adjacent to the
resident(Resident 105)
Findings include:
1. On initial tour of the facility on 4/5/18 at 2:38
p.m., Resident 105's room was observed. An
overlay, with 3 pockets was positioned on the
outside of the closed, entry door was observed.
The overlay was observed to have horizontal
pouches on the front. No sign was observed on
the door and/or the frame of door to the room to
instruct staff or visitors to see the nurse prior to
entering the room.
On 4/6/18 at 10:07 a.m., the overlay remained
hanging on the outside of Resident 105's entry
door. No sign was observed on the door and/or
the door frame.
F 0880 F 880 Infection Control
1.A) A sign was placed on
resident #105’s door during the
survey process. B) The adjacent
room was cleaned, correctly, per
policy, see attached F880A,
during the survey process that
day.
2.No other residents are
currently in isolation.
3.A) The facility has a policy,
see attached F880A, entitled
“IC-Isolation Policy” that was
reviewed, no revisions necessary.
The DON/designee will re-educate
licensed nursing staff regarding
placing a sign on the door of
residents in isolation. B)
Environmental services staff were
inserviced on 4-11-2018, attached
F880B, regarding the facility
“IC-Isolation Policy”, attached
F880A, on how to properly change
housekeeping equipment, mop
water, etc., after cleaning an
isolation room before moving onto
05/11/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 29 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
On 4/9/18 at 8:38 a.m. the overlay remained
hanging on the outside of Resident 105's entry
door. No sign was observed on the door and/or
the door frame.
On 4/10/18 at 8:50 a.m., the door to Resident 105's
room was closed with the overlay on the outside
of the closed entry door. No sign was observed
on the door and/or door frame.
On 4/10/18 at 11:45 a.m., a female was observed to
leave the resident's room and was interviewed.
She indicated she was the Resident 105's family
member. She indicated the resident was not
feeling well today and still had diarrhea. She
indicated the Vancoymcin was stopped, she
thought "about a week ago."
On 4/11/18 at 1:48 p.m., Housekeeper 4 was
interviewed, She indicated she was made aware of
a resident being in isolation by the door to the
room having a sign on the door. She indicated the
sign would direct people to "see the nurse"
before entering the room. She indicated there was
no such sign on Resident 105's door and/or door
frame. She also indicated when she noticed the
overlay on the door with items in it, this may also
indicate the resident was in isolation.
On 4/11/18 at 1:51 p.m., the CNA 2 was
interviewed. She indicated she was aware the
room was an isolation room because of the
overlay on the door. She indicated no sign was
visible on Resident 105's door and/or door frame.
She indicated she normally works on the other hall
and wasn't really sure what was going on with this
resident .
On 4/11/18 at 2:00 p.m,. the Director of Nursing
(DON) was interviewed. She indicated isolation
the next room. Additionally, staff
received follow up/hands on
training from 4-13-2018 through
4-23-2018, attached F880C.
4.Quality Monitoring: A) An
audit form was developed on
4/27/18 for the DON /designee to
audit isolation room signage for
the next 6 months. Results of
these audits will be reported to the
QAA committee monthly through
November 2018. B) The EVS
Director/or designee will observe
and audit, see attached F880D,
environmental services cleaning of
isolation rooms, at least 3 times a
week, for the duration of the
isolation period for 6 months.
Results of these audits will be
reported to the QAA committee
monthly through November 2018
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 30 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
rooms would have an overlay on the door. She
indicated they should also have a sign on the
door to indicated "See nurse before entering."
A current copy of the facility policy and
procedure "IC (Infection Control) Isolation
Policy" dated 11/2017, provided by the DON on
4/11/18 at 2:07 p.m., included the following:
"...Contact precautions: Signage at the entrance
to the resident room..."
On 4/11/18 at 3:05 p.m., the Unit Manager 15 was
interviewed. She indicated she had put the
isolation sign on the door previously. She
indicated the sign was not currently visible on the
door. She indicated she had just found the
isolation sign crumpled up in a pocket on the
overlay on the door. The Unit Manager indicated
a new sign would be put on the outside of the
door. The Unit Manager provided the crumpled
up sign which had printed on it "Please report to
nursing station BEFORE entering the room...."
2. On 4/11/18 at 1:40 p.m., Housekeeper 4 was
observed to have placed her housekeeping cart in
the hall outside Resident 105's room. She was
observed to put the wet floor sign in the doorway
to the room. The floor to Resident 105's room was
observed to be moist. Housekeeper 4 was then
observed to push her cart to the next room down
the hall. After Housekeeper 4 was observed to
clean the room beside the Isolation room, she was
observed to take the cotton strand mop from her
mop bucket on the cart and mop the room on the
other side to Resident 105. Housekeeper 4 was
not observed to change the cotton mop head
and/or mop water after mopping the isolation
room and before mopping the non isolation rooms
next to Resident 105's room. At 1:43 p.m., she was
observed to pull the housekeeping cart outside
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 31 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
the room and put the wet floor sign in the door
way to the non isolation room.
On 4/11/18 at 1:48 p.m., Housekeeper 4 was
interviewed. She indicated she changed the mop
water after mopping every 4-5 rooms. She
indicated she had used the same cotton mop head
and mop water when she cleaned the isolation
room and when she cleaned the room next to it.
She indicated she did not change the mop head
and/or water after mopping the isolation room and
before mopping the next room.
On 4/11/18 at 2:53 p.m., the Director of
Environmental Services, was interviewed. He
indicated the Housekeeping staff should change
the mop head and mop water after cleaning an
isolation room and before cleaning another
resident room. He indicated to clean isolation
rooms, there were "micro mops" to be used,
which were separate mops entirely. The staff can
take off the rectangular mop head and discard it
so as to ensure the same mop head and water are
not used from an isolation room to another room.
3.1-18(a)
R 0000
Bldg. 00
This visit was for a State Residential Licensure
Survey. This visit included a Recertification and
State Licensure Survey.
Survey dates: April 5, 6, 9, 10, 11 & 12, 2018
Facility number: 000283
Residential Census: 57
R 0000 Please accept this as our credible
allegation of compliance to our
recent ISDH annual survey.
Submission of this Plan of
Correction does not constitute an
admission or agreement by the
provider of the truth of facts
alleged or the corrections set forth
on the statement of deficiencies.
This Plan of Correction is prepared
State Form Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 32 of 33
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
05/01/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
FORT WAYNE, IN 46816
155586 04/13/2018
LUTHERAN LIFE VILLAGES
6701 S ANTHONY BLVD
00
Lutheran Life Villages Assisted Living was found
to be in compliance with 410 IAC 16.2-5 in regard
to the State Residential Licensure Survey.
Quality review completed April 16, 2018.
and submitted because of
requirements under State &
Federal Law.
We are also scanning in several
attachments as supportive
documentation.
We respectfully request the
opportunity to have this POC
reviewed and accepted with paper
compliance.
Thank you.
James Schmidt, HFA
State Form Event ID: WWB111 Facility ID: 000283 If continuation sheet Page 33 of 33