(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
F 0000
Bldg. 00
This visit was for the Investigation of
Complaint IN00242103.
Complaint IN00242103 - Substantiated.
Federal/state deficiencies related to the
allegations are cited at F692, F740, F745,
and F773 .
Survey dates:
December 18, 19, 20, 2017
Facility number: 000438
Provider number: 155390
AIM number: 100274170
Census Bed Type:
SNF/NF: 57
Total: 57
Census Payor Type:
Medicare: 6
Medicaid: 51
Total: 57
These deficiencies reflect State Findings
cited in accordance with 410 IAC 16.2-3.1.
Quality review completed on December 28,
2017.
F 0000 This plan of correction is to serve as
Golden LivingCenter – Woodbridge’s
credible allegation of compliance.
Submission of this plan of
correction does not constitute an
admission by Golden
LivingCenter-Woodbridge or its
management company that the
allegations contained in the survey
report are 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.
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: LPIY11 Facility ID: 000438
TITLE
If continuation sheet Page 1 of 40
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
483.25(g)(1)-(3)
Nutrition/Hydration Status Maintenance
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy
tubes, both percutaneous endoscopic
gastrostomy and percutaneous endoscopic
jejunostomy, and enteral fluids). Based on a
resident's comprehensive assessment, the
facility must ensure that a resident-
§483.25(g)(1) Maintains acceptable
parameters of nutritional status, such as
usual body weight or desirable body weight
range and electrolyte balance, unless the
resident's clinical condition demonstrates
that this is not possible or resident
preferences indicate otherwise;
§483.25(g)(2) Is offered sufficient fluid intake
to maintain proper hydration and health;
§483.25(g)(3) Is offered a therapeutic diet
when there is a nutritional problem and the
health care provider orders a therapeutic diet.
F 0692
SS=G
Bldg. 00
Based on interview and record review, the
facility failed to ensure a resident was
weighed on admission; failed to notify the
physician of weight losses; and failed to
monitor fluid intake in a resident with a
F 0692 F692
What corrective action(s) will be
accomplished for those residents
found to have been affected by the
deficient practice: Resident B no
longer resides at the facility. No
01/12/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 2 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
decreased intake and thickened liquids,
resulting in hospitalization with diagnoses
including dehydration, for 1 of 3 residents
reviewed for weight and hydration status, in
a sample of 3.
( Resident B)
Findings include:
The closed clinical record of Resident B
was reviewed on 12/18/17 at 10:10 A.M.
The resident was admitted to the facility on
9/21/17 with diagnoses including, but not
limited to, anterior dislocation of left
humerus (shoulder), severe intellectual
disabilities, cerebral palsy, dysphagia
[difficulty swallowing], and schizoaffective
disorder.
An admission assessment, dated 9/21/17 at
5:00 P.M., indicated Resident B was
"non-verbal," and was able to understand
others. The "Nutritional Risk" section of the
assessment was left blank. The admission
weight was left blank.
An admission Minimum Data Set (MDS)
assessment, dated 9/28/17, indicated
Resident B had a short term and long term
memory problem, and was severely
impaired in cognitive skills for daily decision
making. Behavior assessment 1 (occurred
corrections will be necessary. How
will other residents having the
potential to be affected by the same
deficient practice be identified and
what corrective action(s) will be
taken: Medical records for current
residents admitted within the last
30 days will be reviewed to ensure
admission weights were obtained
and recorded in their medical
record. Any resident who has
admitted within the last 30 days
who does not have a weight
recorded in the medical record will
be weighed and the weight will be
documented in the medical record.
Nutritionally At Risk meeting notes
for the last 30 days will be reviewed
to ensure significant weight losses
were communicated to the
physician and that the facility
received the physician’s
acknowledgement of receipt. If a
significant weight loss was not
communicated to the physician
within the last 30 days, the facility
will notify the physician of the
significant weight loss. Residents
with a significant weight loss and
residents that receive thickened
liquids will be monitored for fluid
intake and will be reviewed daily in
the Clinical Start Up meeting.
What measures will be put into
place or what systemic changes will
be made to ensure that the
deficient practice does not recur:
The DNS or designee will in-service
the staff on weighing residents on
admission, monitoring residents’
weights, the reporting of weight
losses to the attending physician,
receiving physician
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 3 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
1-3 days in the previous 7 days) was
Physical 1, Verbal 1, Other 1 and 1
rejection of care. The resident required
extensive assistance of one staff for eating.
There was no weight documented.
The first recorded weight, dated 10/4/17,
was 146 lbs [pounds].
A Nurses Note, dated 10/4/17 at 3:54
P.M., indicated, "Order changed to puree,
she got chocked [sic] on a cookie yesterday
and we are changing diet so res [resident]
can swallow easier."
A Nutrition Assessment, dated 9/28/17 and
"locked" 10/5/17, indicated Resident B's
current body weight was 146#. The
assessment indicated she required
approximately 1991 calories daily, and
required approximately 1991 cc fluid daily.
The assessment indicated, "Admit [with] dx
[diagnosis] of dislocation L [left] humerus
[shoulder]...dysphagia. Diet pureed;
consuming 77% of meals. Fed per staff.
Recent swallowing episode leading to
downgrade of diet to puree...Nutrition
Interventions: Diet per MD, Meds per MD,
Monitor weight, Monitor intake...."
A Nursing Progress Note, dated 10/13/17
at 11:14 A.M., indicated, "Resident
acknowledgement of the weight loss
and fluid intake monitoring for
resident with significant weight
losses and/or receiving thickened
liquids. How the corrective
action(s) will be monitored to
ensure the deficient practice will
not recur, i.e., what quality
assurance program will be put into
place: The ED or her designee will
monitor the admission weights,
physician notification of weight
losses and fluid intake monitoring
on a daily basis, 7 days per week for
two week and then 5 days per week
for 6 months. The results will be
reviewed monthly in QAPI for 6
months and then PRN if no trends
are noted. Date the systemic
change(s) will be completed:
January 12, 2018.
We are requesting paper
compliance for F692.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 4 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
followed due to new admission, weight is
146# on 10-04-2017, no weight this week
due to unable to obtain due to behavior, diet
is pureed, intake 84%, will continue to
monitor...."
The resident's weight on 10/18/17 was
153#.
Nursing Progress Notes continued:
10/26/17 at 10:55 A.M.: "...weight is 148#,
weight loss of 5# in 1 week, diet is pureed,
intake 92%, will continue to monitor...."
Documentation that the physician was
notified of the weight loss was not found in
the clinical record.
Nursing Progress Notes continued:
11/2/17 at 12:21 P.M.: "...weight is 148#,
no change x 1 week, diet is pureed, fluids
changed to NTL [nectar thickened liquids]
with thin water on 10/31/17, intake 80% will
continue to monitor...."
11/6/17 at 2:42 P.M.: "Resident with
productive cough; light yellow per
therapy...Ordered chest xray stat...."
11/7/17 at 10:16 A.M.: "Resident unable to
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 5 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
swallow medications/or eat - currently NPO
[nothing by mouth]. ST [speech therapy]
evaluated...[POA] request send to ER for
evaluation/treatment...."
The resident returned to the facility on
11/7/17 at 6:54 P.M. with no new orders.
Nurses Notes continued:
11/9/17 at 10:45 A.M.: "...Weight is 140#,
down 8# x 1 week, diet is
pureed...recommend [sic] two cal 90 cc
TID [three times daily] will continue to
monitor...."
Documentation that the physician was
notified of the weight loss was not found in
the clinical record.
Nurses Notes continued:
11/16/17 at 10:22 A.M.: "...weight is 141#,
up 1# x 1 week...will continue to monitor...."
11/21/17 at 12:05 P.M.: "Resident having
problems swallowing. Speech therapy
aware...Is still having loose stools. Is on all
liquid diet for next day...will continue to
monitor."
11/22/17 at 2:57 P.M.: "Notified [physician]
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 6 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
of refusal of supplements, will review in
NAR [nutrition at risk]...."
11/24/17 at 7:37 A.M.: "...noted more
lethargic compared to baseline...appetite &
hydration have been decreased compared to
baseline, total care with feedings...."
11/24/17 at 3:50 P.M.: "Pt [patient] has
increased congestion, refusing to eat, and
afebrile...New order for [lab work] and
chest x ray...."
11/25/17 at 2:11 A.M.: "Resident has had a
decrease in level of functioning...having
difficulty swallowing...chest x-ray came
back clear...will continue to monitor."
11/27/17 at 8:27 A.M.: "[Name of POA]
returned call regarding refusing supplements.
ST [speech therapy] recommendation for
barium swallow, but resident may be
uncooperative with instructions.
POA...agreeable for placement of a feeding
tube. Will update [physician]."
11/28/17 at 1:50 P.M.: "[Name of
physician's nurse] will contact [surgeon] to
set up an appt [appointment] for feeding
tube. Awaiting reply."
11/28/17 at 2:16 P.M.: "...Having to remind
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 7 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
resident to swallow with medication
administration. Ate a little breakfast and
slept through lunch...."
11/29/17 at 6:30 A.M.: "Resident did not
swallow medication. This nurse attempted to
swab mouth clean, resident a little resistive
to clean her mouth."
11/29/17 at 7:27 A.M.: "...Respirations
became very raspy...Suctioned the
resident...called 911...resident sent to ER
per ambulance...."
A hospital history and physical, dated
11/29/17 at 9:53 A.M., indicated, "...Recent
concern for possible aspiration and poor
oral intake on puree diet with nectar thick
liquids...Lab work on admission showed a
sodium of 160 (normal 136-145),
BUN/Creatinine was 42/1.9 (normal
8-23/.4-1.1)...Assessment/Plan: Sepsis -
Likely 2nd to aspiration pneumonia. Chest
x-ray negative but could be dehydrated.
Hypernatremia [elevated sodium level]
Likely 2nd to extreme volume depletion.
Acute kidney injury Likely 2nd to volume
loss...."
On 12/19/17 at 2:40 P.M., the
Administrator indicated there was no intake
and output monitoring for Resident B. The
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 8 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
DON indicated at that time that the facility
would only do intake and output monitoring
if a resident was on restricted fluids, or if a
resident had a catheter.
On 12/20/17 at 2:05 P.M., the Dietary
Manager (DM) was interviewed. She
indicated Resident B was weighed weekly at
first because she was a new admission, and
then was weighed because her weights were
fluctuating. She indicated, "We monitor food
consumption in our NAR meetings." She
indicated they did not monitor fluid
consumption.
On 12/20/17 at 2:10 P.M., the DM
provided the current facility policy
"Hydration," dated 12/17/15. The policy
included: "The dietician calculates daily fluid
requirements for all patients annually or with
changes in condition. The following are risk
factors for dehydration: Coma/decreased
sensorium, Fluid loss and increased fluid
needs (e.g. diarrhea...), Functional
impairments making it difficult to drink,
reach for fluids or communicate fluid needs
(e.g. aphasia [difficulty communicating],
thickened liquids)...Refusal of fluids...."
This Federal tag relates to Complaint
IN00242103.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 9 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
3.1-46(a)(1)
3.1-46(b)
483.40
Behavioral Health Services
§483.40 Behavioral health services.
Each resident must receive and the facility
must provide the necessary behavioral health
care and services to attain or maintain the
highest practicable physical, mental, and
psychosocial well-being, in accordance with
the comprehensive assessment and plan of
care. Behavioral health encompasses a
resident's whole emotional and mental
F 0740
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 10 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
well-being, which includes, but is not limited
to, the prevention and treatment of mental
and substance use disorders.
Based on interview and record review, the
facility failed to develop and implement a
plan to manage behaviors, for 2 of 3
residents reviewed for behaviors, in a
sample of 3.
(Residents B and F)
Findings include:
1. The closed clinical record of Resident B
was reviewed on 12/18/17 at 10:10 A.M.
The resident was admitted to the facility on
9/21/17 with diagnoses including, but not
limited to, anterior dislocation of left
humerus (shoulder), severe intellectual
disabilities, cerebral palsy, ad schizoaffective
disorder.
An admission assessment, dated 9/21/17 at
5:00 P.M., indicated Resident B was
"non-verbal," was able to understand others,
was unable to transfer independently, could
ambulate with limited assist, was frequently
incontinent of bladder, and was at risk for
falls and pain. "Immediate Plans of Care"
indicated "Pain, Behavioral, Falls, and
Anticoagulant" were warranted. There were
no interventions documented regarding those
needs.
F 0740 F740
What corrective action(s) will be
accomplished for those residents
found to have been affected by the
deficient practice: Resident B no
longer resides at the facility. No
corrections will be necessary. Care
plans, interventions and
documentation will be reviewed for
Resident F and corrected as
indicated. How will other
residents having the potential to be
affected by the same deficient
practice be identified and what
corrective action(s) will be taken:
The medical records of residents
with behaviors will be reviewed for
completed care plans, interventions
and documentation. Corrections
will be made as indicated. What
measures will be put into place or
what systemic changes will be made
to ensure that the deficient practice
does not recur: The DNS or designee
will in-service the staff on the
facility behavior management
policy. Behaviors will be reviewed
daily in the Clinical Start Up
meeting. How the corrective
action(s) will be monitored to
ensure the deficient practice will
not recur, i.e., what quality
assurance program will be put into
place: The ED or her designee will
monitor the care plans,
interventions and documentation on
01/12/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 11 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
An admission Minimum Data Set (MDS)
assessment, dated 9/28/17, indicated
Resident B had a short term and long term
memory problem, and was severely
impaired in cognitive skills for daily decision
making. Behavior assessment 1 (occurred
1-3 days in the previous 7 days) was
Physical 1, Verbal 1, Other 1 and 1
rejection of care. The resident required
extensive assistance of one staff for eating.
There was no weight documented.
Nursing Progress Notes included the
following notations:
9/22/17 at 2:44 A.M.: "Resident arrived to
facility from [name of hospital] around 5
PM...having trouble adapting to facility. has
[sic] been grunting and moaning since
arrived. Can walk with assist. Can answer
yes and no questions otherwise
non-verbal...continuously strips self...."
9/22/17 at 12:46 P.M.: "Her previous care
giver [name] gave some insight to keep her
occupied. She likes food that crunches...
She like [sic] to color and look at
magazines...."
9/25/17 at 4:34 A.M.: "Resident is alert not
able to voice any needs or wants yells
all behaviors on a daily basis, 7
days per week for 2 weeks then 5
days per week for 6 months. The
results will be reviewed monthly in
QAPI for 6 months and then PRN if
no trends are noted. Date the
systemic change(s) will be
completed: January 12, 2018
We are requesting paper
compliance for F740.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 12 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
screams constantly left arm in
sling...attempts to remove sling as soon as
applied attempts unassisted transfers
constantly gait is unsteady...[Name of
physician] here to visit on Saturday
increased resident routine Xanax
[anti-anxiety medication] to 1 mg QID [four
times a day]...still needs constant 1/1
supervision tonight...total care."
9/26/17 at 2:05 P.M.: "Caregivers here
today, they called and wanted res [resident]
sent to er [emergency room], for eval
[evaluation] et [and] tx [treatment]...."
9/26/17 at 7:05 P.M.: "Res [resident]
returned from er, no new orders...res resting
in bed at this time."
9/28/17 at 6:51 A.M.: "Resident is alert to
self...yells screams throughout
shift...attempts unassisted transfers
numerous times...takes prn [as needed]
Percocet for s/s [signs/symptoms]
pain/discomfort to left arm/shoulder & is
helpful for pain control sleeps only for short
intervals...pulls briefs off constantly...."
A "Weekly Care Management Meeting,"
dated 9/28/17 at 9:23 A.M., indicated,
"...Ongoing issues r/t [related to]
non-compliance [with] sling...crawls on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 13 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
floor/restless...res has been more
lethargic/drowsy since ER visit/return - less
participation [with] therapies...."
Nursing Progress Notes continued:
10/1/17 at 2:36 A.M.: "Resident has been
awake yelling most of night...continuously
takes off clothes and arm immobilizer. Will
continue to monitor."
10/2/17 at 7:03 A.M.: "Resident has been
up most of night. called [sic] MD and
received orders to give 50 mg Benadryl one
time...will continue to monitor."
10/3/17 at 3:43 P.M.: "Alert and orientated
to self only. Staff anticipates all needs. Can
ambulate with assist of one. Continues with
therapy...attempts to get out of wheelchair
& bed without assistance. Pulls clothes and
depends off...Will continue to monitor."
10/5/17 at 12:57 A.M.: "Resident has been
up moaning all night, fighting sleep. MD
faxed about situation to help sleep at night.
Does have staff in room with her.
10/5/17 at 2:17 P.M.: "Notified [name of
physician] of increased agitation, insomnia at
night. Order received increase Trazadone
150 mg [sedative and anti-depressant],
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 14 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
decrease Xanax 1 mg TID [three times a
day]...."
10/5/17 at 7:24 P.M.: "Res alert &
oriented...she is able to make wants known,
she yells a lot, but is able to be distracted
with coloring and she likes ice cream, and
she loves to walk around the facility, she has
walked up and down the hall today will cont
[continue] to monitor...."
10/7/17 at 7:14 P.M.: "Resident was one on
one with sitter for shift. Resident yelled,
screamed, moaned, kicked & hit staff for
approximately 11 hours of the 0700-1900
[7:00 A.M.-7:00 P.M.] shift. Attempts
made to relax resident...PRN Percocet
given every 4 hours as ordered. Validated
resident's discomfort, gave her distraction
activities, food/drink...no interventions
helped. Will continue to monitor."
10/8/17 at 5:09 P.M.: "Notified by staff
resident continues to be very combative &
not able to distract or console. Medications
given as ordered with being effective...order
received by [name of physician] to sent [sic]
to [name] ER for evaluation...."
10/8/17 at 7:35 P.M.: "Resident staying in
wheelchair much better today. Yelled out a
couple times, but was not a constant.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 15 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
Attempts made to get out of chair, but
wasn't near as bad as yesterday. Resident
has not been combative. Will continue to
monitor."
10/10/17 at 11:00 A.M.: "Late Entry: care
conference held at this time with review of
residents [sic] POC [plan of care] and
progress/condition/behaviors...discussed
how the LTC [long term care] facility
atmosphere stimuli is impeding on residents
ability to succeed [with]
therapy...representatives from prior living
setting state resident had those behaviors...in
the past but not for about two years...."
10/11/17 at 11:26 A.M.: "Resident continue
[sic] to be restless at times, attempting to
remove clothes and arm sling. Requested
Geodon [an anti-psychotic] from [name of
physician]. [Name of psychiatrist] contacted
per request to review medications &
suggestion if necessary for additional
meds...."
10/13/17 at 7:34 A.M.: "Resident slept from
1 to 7 am, rest of shift she yelled and kicked
at staff. Staff sat one on one with resident
repositioning and offering snack and
alternative activities with no success."
10/14/17 at 8:17 P.M.: "Pt [patient]
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 16 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
ambulated x 5 with assist of 2 occasional
boughts [sic] of yelling this shift...Pt engages
with play activities with toys."
10/18/17 at 3:16 A.M.: "...resident noted
more alert last noc [night] answering
questions (yes/no) when staff asks...noted
resident enjoys sucking on blow pop
suckers smiling & talkative with
staff...resting quietly reclined in reclining
chair screams & yells when attempt to put
her into bed...prefers to sleep in chair...."
10/22/17 at 6:24 P.M.: "...Staff anticipates
all needs. Can ambulate with assist of one.
Did not ambulate this shift. Continues with
therapy...Attempts to get out of wheelchair
& bed without assistance. Pulls clothes &
depends off...Will continue to monitor."
10/26/17 at 4:13 A.M.: "...restless yells out
frequently...given prn Percocet...sleeps for
couple hours then awake & yelling again will
monitor."
11/3/17 at 3:32 P.M.: "...Able to answer
simple yes/no questions... Can ambulate
with an assist of one...Resident attempts to
get out of wheelchair & bed without
assistance. Pulls clothes & depends
off...Will continue to monitor."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 17 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
11/10/17 at 4:20 A.M.: "...noted had BM
played in it put hands into brief pulled out
BM rubbed all over self, face, threw piles in
floor...restless yells out non-stop...all
interventions attempted not helpful...."
11/11/17 at 2:35 A.M.: "Resident slept until
230 am...dug feces out of brief and smeared
all over bed...Will continue to monitor."
11/12/17 at 6:44 A.M.: "...had a large BM
and was playing in it...Will continue to
monitor."
11/14/17 at 2:47 P.M.: "...Pulls clothes &
depends off. Puts hands down pants
frequently. Resident reminded that is not
appropriate behavior...."
11/17/17 at 7:05 P.M.: "11/14/17 at 2:47
P.M.: "...Pulls clothes & depends off. Puts
hands down pants frequently. Resident
reminded that is not appropriate
behavior...."
11/20/17 at 6:31 A.M.: "Repeated attempts
to get up out of chair/bed unless
sleeping...up in reclining chair with assist x 2
propel per staff restless...wakes up
roommate...wakes other resident...all
interventions attempted not helpful...."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 18 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
11/28/17 at 12:46 A.M.: "...restless yells out
frequently, takes off clothing frequently puts
hands in crotch frequently...."
Documentation of a care plan to manage the
resident's behaviors was not found in the
clinical record.
On 12/19/17 at 11:30 A.M., the Social
Services Designee (SSD) was interviewed.
He indicated there was no care plan
regarding behaviors for Resident B. He
indicated that the Interdisciplinary Team
(IDT) was supposed to meet and discuss
behaviors, and come up with a plan to
manage the behaviors.
On 12/19/17 at 2:45 P.M., the Director of
Nursing (DON) indicated she was very
involved in the care of Resident B. She
indicated staff usually sat "one on one" with
her.
2. On 12/18/17 at 8:45 A.M., during the
initial tour, the DON indicated Resident F
exhibited behaviors, such as cursing.
The clinical record of Resident F was
reviewed on 12/19/17 at 10:30 A.M.
Diagnoses included, but were not limited to,
intracranial hemorrhage, major depressive
disorder, and alcohol abuse.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 19 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
A Nurses Note, dated 11/2/17 at 7:30
A.M., indicated, "Resident is very
demanding when he request [sic] something,
he expects staff to drop what they are
currently doing and take care of him. If
resident is asked to wait, resident will cuss
at staff...."
An admission Minimum Data Set (MDS)
assessment, dated 11/7/17, indicated the
resident scored a 13 out of 15 on a brief
interview for mental status, with 15
indicative of no memory problems. The
resident exhibited no altered mood or
behavior symptoms in the previous 7 days.
Nursing Progress Notes continued:
11/8/17 at 1:02 P.M.: "Resident awoke in a
foul mood. Resident stated he was kept
awake by a thumping noise all
night...Resident also blew up at this Nurse
for not having his pain medication...."
11/9/17 at 9:45 A.M.: "IDT note: regarding
behavior on 11/8/2017, resident became
upset r/t [related to] pain medication - pain
medication is prn...resident explained that
medication is on a prn basis...res voiced
understanding."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 20 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
11/10/17 at 8:44 A.M.: "Seen this date by
[name of psychiatrist], for review of
mood/behavior/meds. No new orders to
note at this time."
12/11/17 at 3:36 P.M.: "Resident upset &
throwing foam drinking cups at the CNA's
[sic]...DON & ED [Executive Director]
attempted to find out cause; very difficult to
understand...yelling, cursing, hitting
bathroom door...unable to calm him down.
[Name of physician] updated & given order
to call 911...."
A hospital "Behavioral Health" note, dated
12/11/17, indicated, "...The pt got angry
with an aide on his unit and threw a cup of
cold coffee on her. He admitted he also
made the statement 'If you want to fight me,
come on'...Recommendation:...[Resident F]
will be monitored by medical staff at the
facility for any further deterioration in mood
and behaviors...."
Nursing Progress Notes continued:
12/11/17 at 9:30 P.M.: "Resident returned
at this time from [hospital]...Alert et
oriented...No mood issues...placed on 15
minute precaution checks."
12/12/17 at 2:51 P.M.: "...Resident had long
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 21 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
conversation with this Nurse voicing his
frustrations. Resident stated he would try to
control his temper better...."
Documentation by Social Services regarding
the resident's behavior was not found in the
clinical record.
A plan to manage the resident's behaviors
was not found in the clinical record.
On 12/19/17 at 11:30 A.M., the Social
Services Designee (SSD) was interviewed.
He indicated Resident F exhibited mainly
verbal behaviors. He indicated there was no
care plan regarding behaviors for Resident
F. The SSD indicated the previous Assistant
Director of Nursing (ADON) had changed
his behavior logs, and had taken the
behaviors off and added mood symptoms.
He indicated he was aware that staff did not
fill out those logs.
On 12/20/17 at 9:35 A.M., the
Administrator provided the current facility
policy "Behavior Management Guideline,"
dated 9/26/17. The policy included:
"Guideline Statement: To develop behavior
plans and medication regimens, when
appropriate, to optimize the functional
abilities of patients/residents while
monitoring for adverse side effects and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 22 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
improved behaviors...Licensed staff
completes the Plan of Care following
identification of psychotropic medication
usage or behavioral concerns...Identify the
behavior being monitored via the
Antecedent Behavior Monitoring Log...the
log is reviewed...to identify patterns and
causative or triggering events for the
behavior(s) and effectiveness of
interventions...Non-pharmacological
interventions implemented and assessed for
effectiveness, PRIOR to considering
initiation of psychoactive medications...The
use of any medication to control behaviors
should always be considered a last resort to
assist with managing a patient's/resident's
behavior...care plan is developed for
patients/residents exhibiting negative
behavior or with antipsychotic drug use. A
monitoring system is established for targeted
behaviors, interventions, and medication
effectiveness and side effects...."
This Federal tag relates to Complaint
IN00242103.
3.1-34(a)(1)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 23 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
483.40(d)
Provision of Medically Related Social Service
§483.40(d) The facility must provide
medically-related social services to attain or
maintain the highest practicable physical,
mental and psychosocial well-being of each
resident.
F 0745
SS=D
Bldg. 00
Based on interview and record review, the
facility failed to provide social services to
develop and implement a plan to manage
behaviors, for 2 of 3 residents reviewed for
F 0745 F745
What corrective action(s) will be
accomplished for those residents
found to have been affected by the
deficient practice: Resident B no
01/12/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 24 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
behaviors, in a sample of 3. (Residents B
and F)
Findings include:
1. The closed clinical record of Resident B
was reviewed on 12/18/17 at 10:10 A.M.
The resident was admitted to the facility on
9/21/17 with diagnoses including, but not
limited to, anterior dislocation of left
humerus (shoulder), severe intellectual
disabilities, cerebral palsy, ad schizoaffective
disorder.
An admission assessment, dated 9/21/17 at
5:00 P.M., indicated Resident B was
"non-verbal," was able to understand others,
was unable to transfer independently, could
ambulate with limited assist, was frequently
incontinent of bladder, and was at risk for
falls and pain. "Immediate Plans of Care"
indicated "Pain, Behavioral, Falls, and
Anticoagulant" were warranted. There were
no interventions documented regarding those
needs.
An admission Minimum Data Set (MDS)
assessment, dated 9/28/17, indicated
Resident B had a short term and long term
memory problem, and was severely
impaired in cognitive skills for daily decision
making. Behavior assessment 1 (occurred
longer resides at the facility. No
corrections will be necessary. Care
plans, interventions and
documentation will be reviewed for
Resident F and corrected as
indicated. How will other
residents having the potential to be
affected by the same deficient
practice be identified and what
corrective action(s) will be taken:
The medical records of residents
with behaviors will be reviewed for
completed care plans, interventions
and documentation. Corrections
will be made as indicated. What
measures will be put into place or
what systemic changes will be made
to ensure that the deficient practice
does not recur: The DNS or designee
will in-service the staff on the
facility behavior management
policy. Behaviors will be reviewed
daily in the Clinical Start Up
meeting. Facility will actively seek
to employee a degreed/experienced
social service worker. Until such
time, facility will contract with a
degreed/experienced consultant.
How the corrective action(s) will be
monitored to ensure the deficient
practice will not recur, i.e., what
quality assurance program will be
put into place: The ED or her
designee will monitor the care
plans, interventions and
documentation on all new
behaviors on a daily basis, 7 days
per week for 2 weeks the 5 days per
week for 6 months. The results will
be reviewed monthly in QAPI for 6
months and then PRN if no trends
are noted. Date the systemic
change(s) will be completed:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 25 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
1-3 days in the previous 7 days) was
Physical 1, Verbal 1, Other 1 and 1
rejection of care. The resident required
extensive assistance of one staff for eating.
There was no weight documented.
Nursing Progress Notes included the
following notations:
9/22/17 at 2:44 A.M.: "Resident arrived to
facility from [name of hospital] around 5
PM...having trouble adapting to facility. has
[sic] been grunting and moaning since
arrived. Can walk with assist. Can answer
yes and no questions otherwise
non-verbal...continuously strips self...."
9/22/17 at 12:46 P.M.: "Her previous care
giver [name] gave some insight to keep her
occupied. She likes food that crunches...
She like [sic] to color and look at
magazines...."
9/25/17 at 4:34 A.M.: "Resident is alert not
able to voice any needs or wants yells
screams constantly left arm in
sling...attempts to remove sling as soon as
applied attempts unassisted transfers
constantly gait is unsteady...[Name of
physician] here to visit on Saturday
increased resident routine Xanax
[anti-anxiety medication] to 1 mg QID [four
January 12, 2018
We are requesting paper
compliance for F745.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 26 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
times a day]...still needs constant 1/1
supervision tonight...total care."
9/26/17 at 2:05 P.M.: "Caregivers here
today, they called and wanted res [resident]
sent to er [emergency room], for eval
[evaluation] et [and] tx [treatment]...."
9/26/17 at 7:05 P.M.: "Res [resident]
returned from er, no new orders...res resting
in bed at this time."
9/28/17 at 6:51 A.M.: "Resident is alert to
self...yells screams throughout
shift...attempts unassisted transfers
numerous times...takes prn [as needed]
Percocet for s/s [signs/symptoms]
pain/discomfort to left arm/shoulder & is
helpful for pain control sleeps only for short
intervals...pulls briefs off constantly...."
A "Weekly Care Management Meeting,"
dated 9/28/17 at 9:23 A.M., indicated,
"...Ongoing issues r/t [related to]
non-compliance [with] sling...crawls on
floor/restless...res has been more
lethargic/drowsy since ER visit/return - less
participation [with] therapies...."
Nursing Progress Notes continued:
10/1/17 at 2:36 A.M.: "Resident has been
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 27 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
awake yelling most of night...continuously
takes off clothes and arm immobilizer. Will
continue to monitor."
10/2/17 at 7:03 A.M.: "Resident has been
up most of night. called [sic] MD and
received orders to give 50 mg Benadryl one
time...will continue to monitor."
10/3/17 at 3:43 P.M.: "Alert and orientated
to self only. Staff anticipates all needs. Can
ambulate with assist of one. Continues with
therapy...attempts to get out of wheelchair
& bed without assistance. Pulls clothes and
depends off...Will continue to monitor."
10/5/17 at 12:57 A.M.: "Resident has been
up moaning all night, fighting sleep. MD
faxed about situation to help sleep at night.
Does have staff in room with her.
10/5/17 at 2:17 P.M.: "Notified [name of
physician] of increased agitation, insomnia at
night. Order received increase Trazadone
150 mg [sedative and anti-depressant],
decrease Xanax 1 mg TID [three times a
day]...."
10/5/17 at 7:24 P.M.: "Res alert &
oriented...she is able to make wants known,
she yells a lot, but is able to be distracted
with coloring and she likes ice cream, and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 28 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
she loves to walk around the facility, she has
walked up and down the hall today will cont
[continue] to monitor...."
10/7/17 at 7:14 P.M.: "Resident was one on
one with sitter for shift. Resident yelled,
screamed, moaned, kicked & hit staff for
approximately 11 hours of the 0700-1900
[7:00 A.M.-7:00 P.M.] shift. Attempts
made to relax resident...PRN Percocet
given every 4 hours as ordered. Validated
resident's discomfort, gave her distraction
activities, food/drink...no interventions
helped. Will continue to monitor."
10/8/17 at 5:09 P.M.: "Notified by staff
resident continues to be very combative &
not able to distract or console. Medications
given as ordered with being effective...order
received by [name of physician] to sent [sic]
to [name] ER for evaluation...."
10/8/17 at 7:35 P.M.: "Resident staying in
wheelchair much better today. Yelled out a
couple times, but was not a constant.
Attempts made to get out of chair, but
wasn't near as bad as yesterday. Resident
has not been combative. Will continue to
monitor."
10/10/17 at 11:00 A.M.: "Late Entry: care
conference held at this time with review of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 29 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
residents [sic] POC [plan of care] and
progress/condition/behaviors...discussed
how the LTC [long term care] facility
atmosphere stimuli is impeding on residents
ability to succeed [with]
therapy...representatives from prior living
setting state resident had those behaviors...in
the past but not for about two years...."
10/11/17 at 11:26 A.M.: "Resident continue
[sic] to be restless at times, attempting to
remove clothes and arm sling. Requested
Geodon [an anti-psychotic] from [name of
physician]. [Name of psychiatrist] contacted
per request to review medications &
suggestion if necessary for additional
meds...."
10/13/17 at 7:34 A.M.: "Resident slept from
1 to 7 am, rest of shift she yelled and kicked
at staff. Staff sat one on one with resident
repositioning and offering snack and
alternative activities with no success."
10/14/17 at 8:17 P.M.: "Pt [patient]
ambulated x 5 with assist of 2 occasional
boughts [sic] of yelling this shift...Pt engages
with play activities with toys."
10/18/17 at 3:16 A.M.: "...resident noted
more alert last noc [night] answering
questions (yes/no) when staff asks...noted
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 30 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
resident enjoys sucking on blow pop
suckers smiling & talkative with
staff...resting quietly reclined in reclining
chair screams & yells when attempt to put
her into bed...prefers to sleep in chair...."
10/22/17 at 6:24 P.M.: "...Staff anticipates
all needs. Can ambulate with assist of one.
Did not ambulate this shift. Continues with
therapy...Attempts to get out of wheelchair
& bed without assistance. Pulls clothes &
depends off...Will continue to monitor."
10/26/17 at 4:13 A.M.: "...restless yells out
frequently...given prn Percocet...sleeps for
couple hours then awake & yelling again will
monitor."
11/3/17 at 3:32 P.M.: "...Able to answer
simple yes/no questions... Can ambulate
with an assist of one...Resident attempts to
get out of wheelchair & bed without
assistance. Pulls clothes & depends
off...Will continue to monitor."
11/10/17 at 4:20 A.M.: "...noted had BM
played in it put hands into brief pulled out
BM rubbed all over self, face, threw piles in
floor...restless yells out non-stop...all
interventions attempted not helpful...."
11/11/17 at 2:35 A.M.: "Resident slept until
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 31 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
230 am...dug feces out of brief and smeared
all over bed...Will continue to monitor."
11/12/17 at 6:44 A.M.: "...had a large BM
and was playing in it...Will continue to
monitor."
11/14/17 at 2:47 P.M.: "...Pulls clothes &
depends off. Puts hands down pants
frequently. Resident reminded that is not
appropriate behavior...."
11/17/17 at 7:05 P.M.: "11/14/17 at 2:47
P.M.: "...Pulls clothes & depends off. Puts
hands down pants frequently. Resident
reminded that is not appropriate
behavior...."
11/20/17 at 6:31 A.M.: "Repeated attempts
to get up out of chair/bed unless
sleeping...up in reclining chair with assist x 2
propel per staff restless...wakes up
roommate...wakes other resident...all
interventions attempted not helpful...."
11/28/17 at 12:46 A.M.: "...restless yells out
frequently, takes off clothing frequently puts
hands in crotch frequently...."
Documentation of a care plan to manage the
resident's behaviors was not found in the
clinical record.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 32 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
Documentation of a Social Service note
regarding the resident's behaviors was not
found in the clinical record.
On 12/19/17 at 11:30 A.M., the Social
Services Designee (SSD) was interviewed.
He indicated there was no care plan
regarding behaviors for Resident B. He
indicated that the Interdisciplinary Team
(IDT) was supposed to meet and discuss
behaviors, and come up with a plan to
manage the behaviors. The SSD indicated
he had been very busy, and was doing the
best he could, but he did not have anyone
helping him.
2. On 12/18/17 at 8:45 A.M., during the
initial tour, the DON indicated Resident F
exhibited behaviors, such as cursing.
The clinical record of Resident F was
reviewed on 12/19/17 at 10:30 A.M.
Diagnoses included, but were not limited to,
intracranial hemorrhage, major depressive
disorder, and alcohol abuse.
A Nurses Note, dated 11/2/17 at 7:30
A.M., indicated, "Resident is very
demanding when he request [sic] something,
he expects staff to drop what they are
currently doing and take care of him. If
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 33 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
resident is asked to wait, resident will cuss
at staff...."
An admission Minimum Data Set (MDS)
assessment, dated 11/7/17, indicated the
resident scored a 13 out of 15 on a brief
interview for mental status, with 15
indicative of no memory problems. The
resident exhibited no altered mood or
behavior symptoms in the previous 7 days.
Nursing Progress Notes continued:
11/8/17 at 1:02 P.M.: "Resident awoke in a
foul mood. Resident stated he was kept
awake by a thumping noise all
night...Resident also blew up at this Nurse
for not having his pain medication...."
11/9/17 at 9:45 A.M.: "IDT note: regarding
behavior on 11/8/2017, resident became
upset r/t [related to] pain medication - pain
medication is prn...resident explained that
medication is on a prn basis...res voiced
understanding."
11/10/17 at 8:44 A.M.: "Seen this date by
[name of psychiatrist], for review of
mood/behavior/meds. No new orders to
note at this time."
12/11/17 at 3:36 P.M.: "Resident upset &
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 34 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
throwing foam drinking cups at the CNA's
[sic]...DON & ED [Executive Director]
attempted to find out cause; very difficult to
understand...yelling, cursing, hitting
bathroom door...unable to calm him down.
[Name of physician] updated & given order
to call 911...."
A hospital "Behavioral Health" note, dated
12/11/17, indicated, "...The pt got angry
with an aide on his unit and threw a cup of
cold coffee on her. He admitted he also
made the statement 'If you want to fight me,
come on'...Recommendation:...[Resident F]
will be monitored by medical staff at the
facility for any further deterioration in mood
and behaviors...."
Nursing Progress Notes continued:
12/11/17 at 9:30 P.M.: "Resident returned
at this time from [hospital]...Alert et
oriented...No mood issues...placed on 15
minute precaution checks."
12/12/17 at 2:51 P.M.: "...Resident had long
conversation with this Nurse voicing his
frustrations. Resident stated he would try to
control his temper better...."
Documentation by Social Services regarding
the resident's behavior was not found in the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 35 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
clinical record.
A plan to manage the resident's behaviors
was not found in the clinical record.
On 12/19/17 at 11:30 A.M., the Social
Services Designee (SSD) was interviewed.
He indicated Resident F exhibited mainly
verbal behaviors. He indicated there was no
care plan regarding behaviors for Resident
F. The SSD indicated the previous Assistant
Director of Nursing (ADON) had changed
his behavior logs, and had taken the
behaviors off and added mood symptoms.
He indicated he was aware that staff did not
fill out those logs.
On 12/20/17 at 9:35 A.M., the
Administrator provided documentation of
the SSD completing his 48 hour training for
the Social Service Designee Course on
6/16/16. The Administrator indicated the
facility had not had any consultation
regarding social services since 9/25/17. She
indicated the current Marketing/Admissions
Director had a Bachelor's degree in
Sociology, and "sat in on the morning
meeting" and helped out when he could. The
Administrator indicated the facility was
seeking a qualified Social Worker, since the
majority of the facility's residents exhibited
some kind of behavior or mental health
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 36 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
issue.
On 12/20/17 at 12:30 P.M., during an
interview with the Marketing /Admissions
Director, he indicated he did not do any
care plans regarding behaviors.
This Federal tag relates to Complaint
IN00242103.
3.1-34(a)(2)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 37 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
483.50(a)(2)(i)(ii)
Lab Srvcs Physician Order/Notify of Results
§483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only
when ordered by a physician; physician
assistant; nurse practitioner or clinical nurse
specialist in accordance with State law,
including scope of practice laws.
(ii) Promptly notify the ordering physician,
physician assistant, nurse practitioner, or
clinical nurse specialist of laboratory results
that fall outside of clinical reference ranges in
accordance with facility policies and
procedures for notification of a practitioner or
per the ordering physician's orders.
F 0773
SS=D
Bldg. 00
Based on interview and record review, the
facility failed to ensure lab results were
communicated to the physician and
documented in the clinical record, for 1 of 3
residents reviewed for lab orders, in a
sample of 3. Resident B
Findings include:
The closed clinical record of Resident B was
reviewed on 12/18/17 at 10:10 A.M.
Nurses Notes included the following
notations:
11/24/17 at 3:50 P.M.: "Pt [patient] has
F 0773 F773
What corrective action(s) will be
accomplished for those residents
found to have been affected by the
deficient practice: Resident B no
longer resides at the facility. No
corrections will be necessary. How
will other residents having the
potential to be affected by the same
deficient practice be identified and
what corrective action(s) will be
taken: Lab results for the last 30
days for current residents will be
reviewed to ensure results were
communicated to the attending
physician and that the facility
received the physician’s
acknowledgement of receipt. If a
resident’s lab values were not
communicated to the physician, the
DNS or designee will notify the
01/12/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 38 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
increased congestion, refusing to eat, and
afebrile. Pt has very congested cough. New
order for cbc, BMP, and chest x ray...."
The results of the lab work were not found
in the clinical record.
Documentation of physician notification of
the lab results was not found in the clinical
record.
On 12/19/17 at 10:00 a.m., during an
interview with the Director of Nursing
(DON), she indicated she assumed the lab
results had been faxed to the physician. She
indicated she would call the physician's
office to see if they had any results.
On 12/19/17 at 10:15 A.M., the DON
provided a copy of the lab results, sent from
the physician's office. The results indicated,
"Received November 27, 2017." The results
included: "BUN H [high] 27 (normal 8-23),
Sodium H 147 (normal 136-145)...." The
DON indicated that was on a weekend,
which is why the physician probably didn't
receive it until 11/27/17.
On 12/20/17 at 9:35 A.M., the
Administrator provided the current facility
policy, "Notification of Change in Resident
Health Status," dated 10/20/16. The policy
physician of the resident’s lab
results. What measures will be put
into place or what systemic changes
will be made to ensure that the
deficient practice does not recur:
The DNS or designee will in-service
the staff on Lab Processing/Tracking
Guideline. How the corrective
action(s) will be monitored to
ensure the deficient practice will
not recur, i.e., what quality
assurance program will be put into
place: The DNS or her designee will
monitor diagnostic lab ordering and
tracking, 7 days per week for 2
weeks the 5 days per week for 6
months. The results will be
reviewed monthly in QAPI for 6
months and then PRN if no trends
are noted. Date the systemic
change(s) will be completed:
January 12, 2018.
We are requesting paper
compliance for F773.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 39 of 40
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/22/2018PRINTED:
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
EVANSVILLE, IN 47710
155390 12/20/2017
GOLDEN LIVING CENTER-WOODBRIDGE
816 N FIRST AVE
00
included: "Guideline Statement: To ensure
that proper notifications are made when a
resident has a change in health status...."
This Federal tag relates to Complaint
IN00242103.
3.1-49(f)(2)
3.1-49(f)(4)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet Page 40 of 40
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