PRINTED: 08/29/2016 DEPARTMENT OF HEALTH AND HUMAN ... · Medicare: 16 Medicaid: 101 Other: 33...
Transcript of PRINTED: 08/29/2016 DEPARTMENT OF HEALTH AND HUMAN ... · Medicare: 16 Medicaid: 101 Other: 33...
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
F 0000
Bldg. 00
This visit was for a Recertification and
State Licensure Survey. This visit
included the Investigation of Complaint
IN00205640.
Complaint IN00205640 -
Unsubstantiated due to lack of evidence.
Survey dates: July 31, August 1, 2, 3, 4,
& 5, 2016.
Facility number: 000220
Provider number: 155327
AIM number: 100267650
Census bed type:
SNF: 16
SNF/NF: 134
Total: 150
Census payor type:
Medicare: 16
Medicaid: 101
Other: 33
Total: 150
These deficiencies reflect State findings
cited in accordance with 410 16.2-3.1.
Q.R. completed by 14466 on August 12,
2016.
F 0000 This plan of correction is to
serve as University Heights
Health and Living Community's
credible allegation of
compliance. Submission of
this plan of correction does not
constitute an admission by
University Heights Health and
Living or its management
company that the allegations
contained in the survey report
is a true and accurate portrayal
of the provision of nursing care
and other services in this
facility. Nor does this
submission constitute an
agreement or admission of the
survey allegations.
We respectfully request a desk
review in lieu of a post-survey
revisit.
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 determined that
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
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 disclosable 14
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: G3O411 Facility ID: 000220
TITLE
If continuation sheet Page 1 of 30
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
483.15(c)(6)
LISTEN/ACT ON GROUP
GRIEVANCE/RECOMMENDATION
When a resident or family group exists, the
facility must listen to the views and act upon
the grievances and recommendations of
residents and families concerning proposed
policy and operational decisions affecting
resident care and life in the facility.
F 0244
SS=E
Bldg. 00
Based on record review and interview,
the facility failed to ensure that the
grievances being filed by residents,
resident council, and family were being
acted upon and resolved.
Findings include:
Review of the Resident Council Minutes,
with permission of the Council President
given 8/4/16 at 11:20 A.M., indicated
February of 2016 to July of 2016, The
residents had complained of call lights
not being responded to in a timely
manner.
1) Resident Council minutes for Feb 5,
2016... Residents have stated call lights
are not getting answered in a timely
manner on the 100, 400, 600, and 800
halls on afternoon and evening shifts...
Facility response was as follows: Call
light audits will be continued.
F 0244 F244 483.15(c)(6) LISTEN/ACT
ON GROUP
GRIEVANCE/RECOMMENDATI
ON I.Residents will have
their grievances resolved.
Administrator/designee will
follow up with residents #1,
#34, #73, #8, #35 to determine if
the grievance regarding call
lights has been resolved. II.All
residents have the potential to
be affected by the alleged
deficient practice.
Administrator/Designee will
review current resident council
minutes, as well as the
grievance log to determine if
there are unresolved,
grievances and ensure they
have been resolved. III.All
staff will be re-educated on
grievance resolution. The
systematic change includes the
Resident Council minutes will
be reviewed by the
Administrator and the
following resolution plans will
be put into place.
·Resident name, room
number, date of concern, time
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 2 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
2) Resident council Minutes for April 8,
2016, Residents expressed call lights are
not being answered in a timely manner...
Facility response was as follows: In-
serviced staff on abuse prevention and
resident rights. Will follow up with
resident consistently to ensure
compliance completing QA assessment
for response times. ( to include action
plan if warranted)
3) Resident council Minutes for May 6,
2016, Residents expressed call lights are
not being answered in a timely manner on
afternoon or evening shifts... Facility
response was as follows:Community
initiated increased awareness of all lights
through "Lights, Cameras, Action"
initiative. Staff has been in-serviced & is
being monitored in call light response
times to improve overall satisfaction.
Will monitor progress.
4) Resident council Minutes for June 3,
2016, Residents expressed call lights are
not being answered in a timely manner on
afternoon and evening shifts... Facility
response was as follows: Random Call
light audits will continue to improve
response times.
5) Resident council Minutes for July 8,
2016, Residents expressed concern that
call lights need to be monitored and
of concern, person receiving
the concern and department
responsible for the concern
will be reviewed.
·Department head review and
action taken.
·Follow up with Resident
Council concern
·Concern must be referred to
the Administrator for approval.
Additionally,grievances will
be logged by the Social
Services Director/Designee and
assigned to the appropriate
department for follow up. The
Administrator/Designee will
audit to ensure resolution.
IV. Administrator/Designee will
audit systematic changes
utilizing an audit tool daily for 4
weeks, weekly for 4 weeks then
monthly for 4 months. Results
of this audit will be reviewed at
the monthly Quality Assurance
Committee meeting and
frequency and duration of the
reviews will be adjusted as
needed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 3 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
answered in a timely manner from 2:00
P.M.- 3:00 P.M.... Facility response was
as follows: We continue to promote
"Lights Camera Action" and complete
call light audits.
6) On 4/8/2016 Resident #1 filed a
resident grievance form stating that Call
lights are not being answered timely.
Facility Staff's response was as follows:
Inservice given for staff implementing
lights camera action protocol.
7) On 4/8/2016 Resident #34 filed a
resident grievance form stating call lights
are not being answered timely. Facility
staff's response was as follows: Inservice
given for staff implementing lights
camera action protocol
8) On 6/2/16 at 10:00 A.M. a family
member of Resident #73 indicated she
visits 5-7 days a week on both day and
evening shifts and she observed Resident
#73 had to wait long periods of time for
call lights to be answered, it had been a
recurring issue for a couple of months.
9) On 8/4/16 at 11:20 A.M., Resident #8
indicated residents have discussed in
resident council meetings, for the last
several months, concerns of call lights
not being answered timely and that
although staff have been inserviced, and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 4 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
there had been audits done which
indicated it was still an ongoing issue.
Wait time for call light response, she
indicated, was up to an hour.
10) In an interview on 8/5/16, Resident
#34 indicated residents had discussed in
resident council meetings, for the last
several months, concerns of call lights
not being answered timely. She had also
filed a resident grievance form
concerning the issue but still felt it was
ongoing because she still has to wait an
extended period of time before her call
light is answered.
11) In an interview on 8/5/16 at 2:45
P.M. Resident #1 indicated residents had
discussed in resident council meetings,
for the last several months, concerns of
call lights not being answered timely and
he had filed a resident grievance form
concerning the issue. He still felt it was
an ongoing issue because wait times for a
call light response were 30 minutes to an
hour.
12) In an interview on 8/5/16 at 8:25
P.M. Resident #35 indicated residents
had discussed in resident council
meetings, for the last several months,
concerns of call lights not being
answered timely and she felt it was still
an issue. She indicated wait times for a
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 5 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
call light response vary and she has to
wait the longest on nights. Weekends
are" just a mess."
In an interview on 8/5/16 at 4:45 P.M.
with the Administrator , Director of
Nursing (DON), and the Assistant
Director of Nursing, they indicated the
following interventions to improve the
call light response times are as follows:
- Call light Audits
- Staggering of staffing times to cover
high frequency times
- Implementation " Lights, Camera,
Action" initiative to heighten awareness
of call lights and response times.
-Created an evening shift supervisor
- An ongoing staff education
-Weekend supervisor audits call lights
- DON Staggers schedules to cover
weekend auditing.
The DON indicated staff was inserviced
on all above interventions except Lights,
Camera, Action, on 4/19/16. They were
inserviced on Lights, Camera, Action on
5/4/16. The DON did not indicate when
these interventions were implemented.
3.1-3(l)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 6 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
483.15(h)(7)
MAINTENANCE OF COMFORTABLE
SOUND LEVELS
The facility must provide for the
maintenance of comfortable sound levels.
F 0258
SS=D
Bldg. 00
Based on observation and interview, the
facility failed to ensure comfortable
sound levels were maintained in all areas
for residents.
Findings include:
1) On 08/01/2016 12:45 PM, Resident
#201 indicated staff were loud during the
night. She indicated some halls were
worse than others. Housekeeping and
Certified Nursing Aide (CNA) staff, "act
like it's big party sometimes." Resident
had complained to staff who say they
would look into it. The resident indicated
there had been no change in the staff's
noise level. The noise level kept her
awake at night and/or woke her up and
she would have trouble going back to
sleep.
During the interview with Resident #201,
in the resident's room with the door
closed, very loud voices were heard
talking in the hallway. When the door
was opened a group of 4 housekeeping
staff were observed walking up the hall,
past the resident's room, talking very
loud, almost shouting. The resident
indicated the staff was loud like that at
F 0258 F258 483.15 (h)
(7)MAINTENANCE OF
COMFORTABLE SOUND
LEVELS I. The facility will
ensure comfortable sound
levels will be maintained in all
areas for
residents.DON/Designee will
follow up with resident #201 to
ensure that comfortable sound
levels have been achieved. II.
All residents have the potential
to be affected by the alleged
deficient practice. Full house
audit will be completed by
Caring Hearts
Representatives/Designee to
ensure comfortable sound
levels. III.All staff will be
educated on maintaining a
comfortable sound level in all
areas for residents. The
systematic change includes
educating all new staff in
general orientation and
annually thereafter on
maintaining an appropriate
sound level in all resident
areas. Signs will be posted in
non-resident areas to remind
staff to maintain comfortable
noise levels in resident areas.
IV. Administrator/Designee will
audit systematic changes
utilizing an audit tool daily for 4
weeks, weekly for 4 weeks then
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 7 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
night.
3.1-19(f)
monthly for 4 months. Results
of this audit will be reviewed at
the monthly Quality Assurance
Committee meeting and
frequency and duration of the
reviews will be adjusted as
needed.
483.20(g) - (j)
ASSESSMENT
ACCURACY/COORDINATION/CERTIFIED
The assessment must accurately reflect the
resident's status.
A registered nurse must conduct or
coordinate each assessment with the
appropriate participation of health
professionals.
A registered nurse must sign and certify that
the assessment is completed.
Each individual who completes a portion of
the assessment must sign and certify the
accuracy of that portion of the assessment.
F 0278
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 8 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
Under Medicare and Medicaid, an individual
who willfully and knowingly certifies a
material and false statement in a resident
assessment is subject to a civil money
penalty of not more than $1,000 for each
assessment; or an individual who willfully
and knowingly causes another individual to
certify a material and false statement in a
resident assessment is subject to a civil
money penalty of not more than $5,000 for
each assessment.
Clinical disagreement does not constitute a
material and false statement.
Based on record review and interview,
the facility failed to ensure a Minimum
Data Set (MDS) assessment accurately
reflected a resident's urinary continence
status for 1 of 3 residents reviewed for
urinary continence assessments.
(Resident #264)
Findings include:
The clinical record review for Resident
#264 was completed on 8/5/16 at 10:23
a.m. Diagnoses included, but were not
limited to, hypertension and chronic
kidney disease.
The Admission MDS assessment Section
H0300 completed on 4/7/16, assessed
Resident #264 as always being continent
of urine.
A review of the voiding record dated
4/1/16 through 4/7/16, for Resident #264
F 0278 F278 483.20 (g)-(j)
ASSESSMENT
ACCURACY/COORDINATION/C
ERTIFIED l. The MDS for
resident #264 was modified in
accordance with the Resident
Assessment Instrument
Comprehensive User Manual
and re-submitted. II. All
current residents will have
their most recent MDS
reviewed for accuracy of
urinary continence status and
any concern will be addressed.
III. Education will be provided
to MDS personnel and nursing
administration regarding
correct coding of the MDS for
urinary continence status. The
systemic change includes the
MDS coordinator /designee will
review the vital signs and the
Point of Care report for urinary
continence. Based on the RAI
manual guidelines, the MDS
coordinator/designee will
complete the assessment. IV.
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 9 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
for 7 days prior to the Admission MDS
assessment, indicated Resident #264 had
1 urine incontinence episode on 4/2/16.
During an interview on 8/5/16 at 12:51
p.m., the MDS Coordinator indicated the
4/7/16 MDS assessment section H0300
for Resident #264 was coded incorrectly.
The MDS Coordinator indicated section
H0300 should have been coded as
occasionally incontinent of urine.
A review of Signature of Persons
Completing the Assessment or
Entry/Death Reporting section Z0400,
dated 4/12/16, indicated the MDS
Coordinator signed this section,
certifying that the accompanying
information accurately reflected resident
assessment information for Resident
#264.
The Resident Assessment Instrument
Comprehensive User Manual, Version
3.0, copy right 2009, page 352 indicated,
" ...H0300: Urinary Incontinence coding
instructions - code occasionally
incontinent: if during the 7-day look-back
period the resident was incontinent less
than 7 episodes. This includes
incontinence of any amount of urine...."
3.1-31(d)
The MDS coordinator will audit
for accuracy of urinary
continence status on the
assessment prior to any MDS
being submitted. This audit will
be ongoing at 100% x 2
months, then 10 assessments
per week x 1 month, then 5
assessments per week x 1
month, then 3 assessments per
week x 2 month. The MDS
consultant/designee will
randomly audit 5 residents for
MDS accuracy related to
continence weekly for 8 weeks
then monthly for 4 months.
Results of this audit will be
reviewed at the monthly
Quality Assurance Committee
meeting and frequency and
duration of the reviews will be
adjusted as needed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 10 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
483.20(k)(3)(i)
SERVICES PROVIDED MEET
PROFESSIONAL STANDARDS
The services provided or arranged by the
facility must meet professional standards of
quality.
F 0281
SS=D
Bldg. 00
Based on observation, interview, and
record review, the facility failed to ensure
services provided by the facility met
professional standards of quality, in that a
nurse did not remain with a resident to
observe that medications were
swallowed. (Resident #173)
Findings include:
During an observation on 8/1/16 at 11:42
a.m., Licensed Practical Nurse (LPN) #3
was observed administering medications
to Resident #173 in the resident's room.
LPN #3 was observed to walk into
Resident #173's room and hand him a
medicine cup with medications. LPN #3
then proceeded to leave the resident's
room without observing the resident
swallow the medications.
During an interview on 8/5/16 at 4:30
p.m., the Director of Nursing (DON)
indicated a nurse is not to leave residents
during a medication administration
without observing the resident take the
medications.
F 0281 F281 483.20(k)(3)(i)SERVICES
PROVIDED
MEET PROFESSIONAL STAND
ARDS I. LPN #3 has
received 1:1 education related
to correct procedure with
medication administration.
Resident #173 is observed by a
licensed nurse when taking
medications. II. All residents
receiving medications from a
licensed nurse have the
potential to be affected by the
alleged deficient practice. On
08/05/2016 full house
inspection was conducted to
ensure no medications were
left at bedside. III.Education
will be provided to all licensed
nurses related to correct
procedures of medication
administration. The systemic
change includes all licensed
nurses will receive education
related to the correct
procedure for medication
administration upon hire and
annually thereafter. IV.The
DON/Designee will audit by
observation medication
administration on all shifts 5
times weekly for 4 weeks,
weekly for 4 weeks then
monthly for 4 months. Any
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 11 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
On 8/5/16 at 9:30 a.m., the DON
provided an undated policy titled
Medication Administration General
Policies and Procedures, and indicated it
was the policy currently used by the
facility. The policy indicated, "...The
nurse or approved designee should
always remain with the resident to
observe that the medication is
swallowed...."
3.1-35(g)(1)
identified concerns from these
audits will be addressed
immediately. Results of this
audit will be reviewed at the
monthly Quality Assurance
Committee meeting and
frequency and duration of the
reviews will be adjusted as
needed.
483.25(h)
FREE OF ACCIDENT
HAZARDS/SUPERVISION/DEVICES
The facility must ensure that the resident
environment remains as free of accident
hazards as is possible; and each resident
receives adequate supervision and
assistance devices to prevent accidents.
F 0323
SS=E
Bldg. 00
Based on observation, interview, and
record review, the facility failed to ensure
the environment remained free of
accident hazards for 9 residents on the
800 hall, 8 residents on the 700 hall, 10
residents on the 600 hall, and 12
residents on the 900 hall.
Findings include:
During an initial tour of the facility on
7/31/16 at 7:00 p.m., the following were
observed:
F 0323 F323 483. 25 (h) FREE OF
ACCIDENT
HAZARDS/SUPERVISION/DEVI
CES I. · The medication cart
near room 807 was locked at
the time it was identified during
the tour. · The closet near
room 703 was locked at the
time it was identified during the
tour. · The electrical room near
room 600 was locked at the
time it was identified during the
tour. · The mechanical room
near room 916 was locked at
the time it was identified during
the tour. · The three millimeter
syringes of Heparin in room
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 12 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
1. An unlocked, unattended medication
cart was observed near room 807.
During an interview on 7/31/16 at 7:05
p.m., Licensed Practical Nurse (LPN)
indicated the medication cart should have
been locked and not left unattended while
unlocked.
On 8/5/16 at 5:18 p.m., the Regional
Nurse Consultant provided an undated
policy titled Drug Storage, and indicated
it was the policy currently used by the
facility. The policy indicated,
"...Medication rooms, carts, and
medication supplies are to be locked or
attended by persons with authorized
access...."
2. An unlocked, unattended closet was
observed near room 703. The unlocked
closet contained the following:
a. 1 gallon Extraction Cleaner, with a
label indicating, "...may cause serious eye
irritation...."
b. 2.5 liters Neutral Cleanser, with a
label indicating, "...may be harmful, if
swallowed, call poison control...."
c. 1.5 liters Heavy Duty Prespray Plus,
with a label indicating, "...call physician
or poison control center if ingested...."
710 was removed and disposed
of. II.All residents have the
potential to be affected by the
alleged deficient practice. Full
house safety inspection
conducted 07/31/2016 to
ensure environment was free
of accident hazards.
III.Education will be provided to
all staff that medications and
other drugs,including
treatment items need to be
stored in a locked cabinet or
room inaccessible to residents
and visitors. This education
will also include locking
closets that contain chemicals,
mechanical rooms and
electrical rooms.The systemic
change will include educating
all new hires of potential
hazards and storage of
potential hazards upon hire
and annually thereafter.
IV.Administrator/Designee will
audit by observation
medication carts, closets
containing chemicals, electrical
rooms and mechanical rooms
utilizing an audit tool daily for 4
weeks, weekly for 4 weeks then
monthly for 4 months. Results
of this audit will be reviewed at
the monthly Quality Assurance
Committee meeting and
frequency and duration of the
reviews will be adjusted as
needed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 13 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
During an interview on 8/5/16 at 4:30
p.m., the Director of Nursing (DON)
indicated the closet should have been
locked.
3. An electrical room near room 600 was
observed unlocked and unattended. The
room contained breaker boxes and cables.
During an interview on 8/5/16 at 4:30
p.m., the DON indicated the electrical
room should have been locked.
4. A mechanical room near room 916
was observed unlocked and unattended.
The room contained a furnace.
During an interview on 8/5/16 at 4:30
p.m., the DON indicated the mechanical
room should have been locked.
5. Three 5 millimeter syringes of heparin
(medication used to thin blood) were
observed unattended on a table in room
710.
During an interview on 8/5/16 at 4:30
p.m., the DON indicated the heparin
should not have been left unattended in a
resident room.
On 8/5/16 at 5:18 p.m., the Regional
Nurse Consultant provided an undated
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 14 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
policy titled Drug Storage, and indicated
it was the policy currently used by the
facility. The policy indicated, "...All
medications and other drugs, including
treatment items, need to be stored in a
locked cabinet or room, inaccessible to
residents and visitors...."
3.1-45(a)(1)
483.25(m)(2)
RESIDENTS FREE OF SIGNIFICANT MED
ERRORS
The facility must ensure that residents are
free of any significant medication errors.
F 0333
SS=D
Bldg. 00
Based on record review and interview,
the facility failed to ensure a resident
received the correct dose of medication,
for 1 of 4 residents reviewed for
receiving medications as ordered by their
physician. (Resident #A)
Findings include:
The clinical record of Resident #A was
reviewed on 8/2/16 at 4:40 p.m.
Diagnoses for the resident included, but
were not limited to, pain, anxiety and
neuropathy (nerve damage which can
cause pain).
F 0333 F333 483.25 (m)(2)RESIDENTS
FREE OF SIGNIFICANT MED
ERRORS I. Resident A is
receiving the dose of
Gabapentin as ordered. II. All
residents receiving Gabapentin
have the potential to be
affected by the alleged
deficient practice. All residents
on Gabapentin have been
reviewed to ensure they are
receiving the correct dose of
medication. III. 1:1 education
was provided to RN #1 related
to correct procedures for
medication administration
including the 5 rights and
monitoring for adverse
reactions if a medication error
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 15 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
A care plan dated 7/7/16, indicated
Resident #A had a potential for pain.
Interventions included, "Administer
medications per MD orders..."
A physician's order dated July 7, 2016,
indicated Resident #A was to receive
gabapentin 100 mg (milligrams), 2 times
per day. Gabapentin is a medication used
to treat nerve pain.
A July, 2016 recapitulated physician's
order, with an original order date of
7/9/16, indicated Resident #A's
gabapentin was increased to 300 mg, 3
times per day.
RN #1 documented on the Medication
Administration Record (MAR) Resident
#A was given her evening dose of
gabapentin at 9:33 p.m.
A nurses's note, dated 7/13/16 at 9:29
p.m., indicated, "Resident's medication
was side by side in medication cart.
When I took the three capsules out of the
box I had taken them out I thought I had
checked and were the correct dosage, but
actually was incorrect causing her to
receive the wrong dosage..."
A nurse's progress note, dated 7/13/16 at
9:30 p.m.,(1 minute after the first note)
indicated, "Resident displayed no adverse
occurs. Education will be
provided to all licensed nurses
related to correct procedures
related to medication
administration. The education
will also include monitoring of
adverse reactions if a
medication error occurs. The
systemic change includes all
licensed nurses will receive
education related to the correct
procedure for medication
administration upon hire and
annually thereafter. IV. The
DON/Designee will audit by
observation medication
administration on all shifts 5
times weekly for 4 weeks,
weekly for 4 weeks then
monthly for 4 months. Any
identified concerns from these
audits will be addressed
immediately. Results of this
audit will be reviewed at the
monthly Quality Assurance
Committee meeting and
frequency and duration of the
reviews will be adjusted as
needed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 16 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
medical changes as the result of receiving
increased dosage.."
An Event Report, dated 7/14/16, at 4:44
p.m., indicated Resident #A received the
wrong dose of medication, and there were
no adverse side effects. No other
documentation was found for 9/14/16
which indicated the resident had been
monitored for adverse side effects.
In an interview on 8/4/16 at 12:15 p.m.,
RN #4 indicated, "I realized I made a
mistake,"..."I missed reading the dosage
closely."
During an interview on 8/5/16 at 1:00
p.m., Resident #A indicated she was
aware the nurse made an error because
"...the 100 mg tablets of gabapentin are
white, and the 300 mg tablets of
gabapentin are yellow. I told her 2 or 3
times that the 3 pills she was giving me
were the wrong pills but the nurse just
kept telling me I was wrong...I finally
just thought, well maybe I am wrong and
I took them...I felt dizzy about 45
minutes later and the next day I was
woozy, tired, and fuzzy most of the day.
She gave me 3 yellow pills, which is 900
mg., instead of the 300 mg I was
supposed to receive."
On 8/5/16 at 9:30 a.m., the Director of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 17 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
Nursing (DON) provided an undated
policy, titled, "Medication
Administration: General Policies &
Procedures," and indicated it was the
policy currently used by the facility. The
policy indicated, "...The label on each
medication container shall be read 3
times and compared against the order on
the MAR: a) When taking from the shelf
or drawer b) Before pouring it c) When
putting it back onto the shelf or into the
drawer..."
On 8/5/16 at 9:30 a.m., the DON
provided an undated policy, titled,
"Medication Errors," and indicated it was
the policy currently used by the facility.
The policy indicated. "...8. Any adverse
effects from the medication error will be
noted in the resident's medical record..."
3.1-48(c)(2)
483.60(c)
DRUG REGIMEN REVIEW, REPORT
IRREGULAR, ACT ON
The drug regimen of each resident must be
reviewed at least once a month by a
licensed pharmacist.
The pharmacist must report any
F 0428
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 18 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
irregularities to the attending physician, and
the director of nursing, and these reports
must be acted upon.
Based on record review and interview,
the facility failed to ensure a consultant
pharmacist initiated a request for a
gradual dose reduction for a resident who
was taking an antipsychotic medication,
as indicated by their policy. (Resident
#137)
Findings include:
The clinical record of Resident #137 was
reviewed on 8/4/16 at 3:13 p.m.
Diagnoses for the resident included, but
were not limited dementia, anxiety,
depressive episodes and delusional
disorders.
A recapitulated physician's order for
August, 2016, with an original date of
5/14/15, indicated Resident #137 was to
receive Risperdal, 0.25 milligrams (mg),
daily. Risperdal is an antipsychotic
medication used to treat mental/mood
disorders.
No documentation was found in the
Resident #137's record which indicated a
gradual dose reduction had been
attempted or considered since 5/14/16.
On 8/5/16 at 2:24 p.m., the Social
F 0428 F428 483.60 (c) DRUGREGIMEN
REVIEW, REPORT
IRREGULAR, ACT ON I.
Resident #137 is no longer
receiving Risperdal. Res
suffered no adverse effects
related to receiving medication.
II. All residents receiving
anti-psychotic medications
have the potential to be
affected. Social Services
conducting full house audit of
psychotropic medications to
ensure the consultant
pharmacist initiated a GDR.
III. The consultant pharmacist
will receive 1:1 education
related to recommended drug
reduction guidelines. The
systemic change includes the
consultant pharmacist will
review all residents on
anti-psychotic drugs for
possible drug reductions per
the federal guidelines and
facility policy during the
monthly consultation visit.
Social Services/designee will
implement a log with all
anti-psychotic medications
being used within the facility
with order date, diagnosis for
use, and gradual dose
reduction history. Social
Services/Designee to monitor
for necessary GDR’s, and is to
notify pharmacy if not received.
IV. Social Services/Designee
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 19 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
Services Director indicated Resident
#137 had been hospitalized on 5/8/15, at
which time her Risperdal dosage had
been decreased to 0.25 mg. She returned
to the facility on 5/14/15 with an order
for Risperdal 0.25 mg every day.
During an interview with the RNC
(Regional Nurse Consultant) on 8/5/16 at
4:35 p.m., the Regional Nurse Consultant
indicated it was the pharmacist's job to
notify the facility when a gradual dose
reduction was due, and the pharmacy
consultant had indicated to the RNC she
did not think a gradual dose
recommendation was necessary because
Resident #137 was taking, "the lowest
possible dose."
On 8/5/16 at 4:35 p.m., the RNC
provided an undated policy, titled,
"Psychotropic Drug Use," and indicated it
was the policy currently used by the
facility. The policy indicated, "The
facility will notify the attending physician
when a gradual dose reduction is due.
This may occur as a recommendation
from the consultant pharmacist" and
"After the first year, the gradual dose
reduction should be attempted at least
once a year..."
3.1-25(i)
will audit all anti-psychotic
medications for drug reduction
attempts that are due monthly.
These audits will occur for 12
months. Any identified
concerns from these audits will
be addressed immediately.
Results of this audit will be
reviewed at the monthly
Quality Assurance Committee
meeting and frequency and
duration of the reviews will be
adjusted as needed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 20 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
483.60(b), (d), (e)
DRUG RECORDS, LABEL/STORE DRUGS
& BIOLOGICALS
The facility must employ or obtain the
services of a licensed pharmacist who
establishes a system of records of receipt
and disposition of all controlled drugs in
sufficient detail to enable an accurate
reconciliation; and determines that drug
records are in order and that an account of
all controlled drugs is maintained and
periodically reconciled.
Drugs and biologicals used in the facility
must be labeled in accordance with currently
accepted professional principles, and
include the appropriate accessory and
cautionary instructions, and the expiration
date when applicable.
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.
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
F 0431
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 21 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
dose can be readily detected.
Based on observation, interview, and
record review, the facility failed to ensure
narcotic medications (controlled
substances) were double locked at all
times for 1 of 1 medication room
observed.
Findings include:
08/2/2016 at 9:30 a.m., During
medication storage observation, observed
two lock boxes in the refrigerator located
in locked medication room. The box on
the left was locked and secure, the box on
the right was easily pulled open by the
Director Of Nursing (D.O.N.). The
D.O.N. removed the contents (controlled
substances) of the unsecured box on the
right and put them in the box on the left
and locked the box on the left. Contents
removed by D.O.N: Three boxes of liquid
lorazepam 2 mg/ml (a controlled
substance Schedule: IV). One box had
been opened and currently being used the
other two boxes had not yet been opened.
On 8/5/2016 at 9:30 a.m., During
interview with D.O.N. indicated,
housekeeping did go into the locked
medication room, but a nurse stayed with
her until she was done mopping. The
maintenance staff had an emergency key
and could enter the medication storage
F 0431 F431 483.60(b), (d),(e) DRUG
RECORDS, LABEL/STORE
DRUGS BIOLOGICALS I. The
locked narcotic box in the
refrigerator was placed back
on the track on 8-2-16 during
the survey. II. All residents
receiving refrigerated narcotics
have the potential to be
affected by the alleged
deficient practice. Full house
audit done of narcotic boxes
located in med room
refrigerators. III. All licensed
nurses have received
education on drug storage
including ensuring refrigerated
narcotics are secured. The
systemic change includes new
lock boxes with double locks
were purchased for the
refrigerated controlled
medication. IV. The
DON/Designee will audit all
refrigerated narcotics for
double locked storage 5 times
weekly for 4 weeks, weekly for
4 weeks then monthly for 4
months. Any identified
concerns from these audits will
be addressed immediately.
Results of this audit will be
reviewed at the monthly
Quality Assurance Committee
meeting and frequency and
duration of the reviews will be
adjusted as needed.
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 22 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
room at any time.
On 8/4/2016 at 2:41 p.m., During
interview with the D.O.N, The D.O.N.
indicated, the refrigerator was old and the
box was actually locked on 8/2/2016, "It
was just off track."
On 8/4/2016 at 9:30 a.m., During
interview with the D.O.N. indicated a
new box for the refrigerator has been
purchased. New box has two locked
units, side by side and will replace the
old box.
On 8/3/2016 at 11:30 a.m., The
Administrator provided Controlled
Substance Reconciliation dated
12/31/2011, indicated currently being
used by facility. Policy: "All facilities
should utilize the following procedure or
a similar procedure meeting the same
criteria to reconcile controlled substances
at the end of each nursing shift. ...6.
Refrigerated controlled substances should
be kept under double lock. A locked box
or refrigerator within a locked room or
cabinet would meet this criteria. If a
numbered, plastic lock is utilized, then
the lock number should be verified at the
change of each shift. changes in lock
number should prompt the off-going and
on-coming nurse to verify the quantity of
each refrigerated controlled substance on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 23 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
hand."
3.1-25(n)
483.70(h)
SAFE/FUNCTIONAL/SANITARY/COMFOR
TABLE ENVIRON
The facility must provide a safe, functional,
sanitary, and comfortable environment for
residents, staff and the public.
F 0465
SS=E
Bldg. 00
Based on observation the facility failed
provide a safe, functional, sanitary, and
comfortable environment for residents.
Findings include:
During initial tour of facility at 7:20 P.M.
on 7/31/16 the following was observed:
1) The stand-up lift located outside of
resident room #609 was observed to be in
an unkempt condition. The footrest had
dirt, debris,and multiple food crumbs on
it varying in size.
2) The stand-up lift located in the alcove
near room #401 that was observed to be
in the same condition with dirt, debris,
and crumbs on the footrest.
3) In the dinning room located on the 500
F 0465 F465 483.70
(h)SAFE/FUNCTIONAL/SANITA
RY/COMFORTABLE
ENVIRONMENT. I. The
stand-uplifts, dining room floor
and window in the dining room
were cleaned. II. All residents
using lift equipment or eating
in the 500 hall dining room
have the potential to be
affected. All lifts, dining room
windows and floors were
cleaned. III. Education will be
provided to all staff related to
cleaning floors, windows and
lift equipment. The systemic
change includes education for
all staff related to maintaining a
clean environment and clean
equipment upon hire and
annually thereafter. A cleaning
schedule has been developed
for lifts, windows, and dining
room floors. IV.The
Administrator/designee will
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 24 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
hall, the floor was observed to be
unsanitary. There were multiple areas
with spilled liquids in different stages of
drying up. There were food crumbs
littering the floor throughout. Potato
chips were observed scattered amongst
the liquids and a stringy unknown
substance. The window facing the
courtyard was covered with a thick film
of dirt making it difficult to get a clear
view of the courtyard outside.
3.1-19(f)
audit dining rooms, the dining
room windows and lift
equipment for cleanliness 5
times weekly for 4 weeks,
weekly for 4 weeks then
monthly for 4 months.Any
identified concerns from these
audits will be addressed
immediately.Results of this
audit will be reviewed at the
monthly Quality Assurance
Committee meeting and
frequency and duration of the
reviews will be adjusted as
needed.
483.75(e)(5)-(7)
NURSE AIDE REGISTRY VERIFICATION,
RETRAINING
Before allowing an individual to serve as a
nurse aide, a facility must receive registry
verification that the individual has met
competency evaluation requirements unless
the individual is a full-time employee in a
training and competency evaluation program
approved by the State; or the individual can
prove that he or she has recently
successfully completed a training and
competency evaluation program or
competency evaluation program approved
by the State and has not yet been included
in the registry. Facilities must follow up to
ensure that such an individual actually
becomes registered.
Before allowing an individual to serve as a
nurse aide, a facility must seek information
from every State registry established under
sections 1819(e)(2)(A) or 1919(e)(2)(A) of
F 0496
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 25 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
the Act the facility believes will include
information on the individual.
If, since an individual's most recent
completion of a training and competency
evaluation program, there has been a
continuous period of 24 consecutive months
during none of which the individual provided
nursing or nursing-related services for
monetary compensation, the individual must
complete a new training and competency
evaluation program or a new competency
evaluation program.
Based on record review, and interview
the facility failed to ensure a Certified
Nursing Assistant (CNA #1) had
completed an evaluation program
approved by the State.
Findings include:
On 8/5/2016 at 10:30 a.m., During record
review, Ohio Department of Health Form
dated 3/10/2016, indicated Certified
Nursing Assistant (CNA) #1, was
certified through Ohio Department of
Health. Registry number:
322224340904. Original approval Date:
8/13/2007. Expires: 7/12/2017.
Employee records indicated CNA #1's
date of employment at the facility was
3/9/2016.
On 8/5/2016 at 11:00 a.m. during
interview with Director of Nursing
F 0496 F496 483.75(e)(5)-(7) NURSE
AIDE REGISTRY
VERIFCATION, RETRAINING I.
C.N.A. #1 is no longer
employed by the facility. All
other C.N.As employed in the
facility have had their
certifications verified and are
in compliance. II. In order to
identify others, a full house
audit of employee files was
completed. III. The Staff
Development Coordinator has
received 1:1 education related
to ensuring a C.N.A.registered
in another state completes
registration in Indiana within
the allotted time frame. The
systemic change includes any
C.N.A. hired with a certification
from out of state will be
tracked to determine the
Indiana registration is
completed within 120 days
and/or Facility will no longer
hire C.N.A’s from out of state
without an active Indiana
Certification. IV.The HR
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 26 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
indicated CNA #1 did work on the day
that surveyors entered the building for
three hours. "Staff developer new." I
(D.O.N.) told the CNA to leave at that
time. "Explained to the CNA (CNA #1)
that she could not work without a
certificate."
On 8/5/2016 at 11:30 a.m. DON provided
time sheet #16195 dated July 7th -
August 5th 2016 for CNA #1, Indicated
CNA #1 worked July 7th from 3:07 p.m
.until 7:08 a.m., July 8th from 3:00 p.m.
until 7:03 p.m., July 12th from 2:44 p.m.
until 7:27 a.m., (no date) from 8:37 p.m.
until 7:08 a.m., July 13, 4:54 p.m. until
7:06 p.m., July 14th 2:58 p.m. until 11:54
p.m., July 15th from 7:52 a.m. until 7:13
p.m. and July 31st 3:38 p.m. until 7:29
p.m.
Records indicated, CNA #1 worked in
compliance from March 9th - July 7th.
CNA #1 worked after July 7th as
uncertified by the State of Indiana.
08/05/2016 2:06:08 PM during interview
with the Executive Director indicated no
written policy, they "follow regulations."
3.1-14(e)(1)
Director will audit any C.N.A.s
hired from out of state weekly
to ensure they become certified
in Indiana within 120 days. This
will be ongoing monitoring.
Results of this audit will be
reviewed at the monthly
Quality Assurance Committee
meeting and frequency and
duration of the reviews will be
adjusted as needed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 27 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
483.75(l)(1)
RES
RECORDS-COMPLETE/ACCURATE/ACCE
SSIBLE
The facility must maintain clinical records on
each resident in accordance with accepted
professional standards and practices that
are complete; accurately documented;
readily accessible; and systematically
organized.
The clinical record must contain sufficient
information to identify the resident; a record
of the resident's assessments; the plan of
care and services provided; the results of
any preadmission screening conducted by
the State; and progress notes.
F 0514
SS=B
Bldg. 00
Based on record review and interview,
the facility failed to to ensure clinical
records were maintained accurately
regarding an admission weight for 1 of 3
residents reviewed for having accurate
documentation of admission weights.
(Resident #289
Findings include:
The clinical record of Resident #289 was
reviewed on 8/3/16 at 2:32 p.m.
Diagnoses for the resident included, but
were not limited to, fractured femur and
fluid overload.
A Hospital Discharge Summary, dated
6/29/16, indicated Resident #289's
discharge weight was 99 lbs.
F 0514 F514 483.75 (I) (1)RES
RECORDS-COMPLETE/ACCUR
ATE/ACCESSIBLE I. Resident
#289 no longer resides in the
community. II. All new
admission residents have the
potential to be affected by the
alleged deficient practice.
DON/Designee will complete
full house audit of admission
weights. III. Education will be
provided to all nursing staff
related to the weight policy
including admission weights,
weekly weights and when re
weights are indicated. The
systemic change will include
the following:
·New admissions to be
re-weighed within 24 hours of
admission.
·Medical records to audit
09/04/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 28 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
A careplan for Resident #289, dated
7/7/16 and current through 11/9/16,
indicated the resident was a nutritional
risk. Interventions included,
"Monitor/record weight routinely..."
Resident #289 was admitted to the
facility on 6/30/16. A Nursing
Admission Assessment dated 6/30/16,
indicated her weight at the time of
admission was 148.3 pounds (lbs).
Weights on a Vitals Report indicated:
7/12/16 weight = 95.7 lbs
7/26/16 weight = 82.3 lbs
A Nutrition Assessment note, dated
7/26/16, indicated the admission weight
of 148.3 was a, "suspected" error in
documentation.
No other facility weights were found in
the resident's record.
On 8/5/16 at 9:48 a.m., the Director of
Nursing (DON) indicated Resident #289's
admission weight of 148.3 was not
accurate.
On 8/5/16 at 8:45 a.m. the Executive
Director provided an undated policy
admission weight and compare
to residents most recent
known weight.
IV. The Medical Records
Coordinator will audit weights
for completion 5 times weekly
for 4 weeks, weekly for 4 weeks
then monthly for 4 months. Any
identified concerns from these
audits will be addressed
immediately. Results of this
audit will be reviewed at the
monthly Quality Assurance
Committee meeting and
frequency and duration of the
reviews will be adjusted as
needed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 29 of 30
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46227
155327 08/05/2016
UNIVERSITY HEIGHTS HEALTH AND LIVING COMMUNITY
1380 E COUNTY LINE RD S
00
titled, "[name of facility] Weight
Management Policy, and indicated it was
the policy currently used by the facility.
The policy indicated, "New
admission/readmission residents will be
weighed at admission and weekly X 4...If
the resident has a previous weight in the
medical record that weight will be
compared to the current weight being
obtained to ensure that a reweigh is done
immediately if there is a significant
change in weight...if the resident's weight
100 lbs or less and there is a weight
change from the previous of +/- 3 lbs
then he/she will be reweighed..."
3.1-50(a)(2)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3O411 Facility ID: 000220 If continuation sheet Page 30 of 30