printed: 04/11/2018 department of health and human
TRANSCRIPT
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
F 0000
Bldg. 00
This visit was for the Investigation of Complaints
IN00256400, IN00256305 and IN00256573.
Complaint IN00256400 - Substantiated.
Federal/State deficiencies are cited at F609, F 610,
F655 and F698.
Complaint IN00256305 - Substantiated.
Federal/State deficiencies are cited at F609, F610,
F655 and F698.
Complaint IN00256573 - Substantiated.
Federal/State deficiencies are cited at F655, and
F698.
Survey dates: March 15, 16, 19, and 20, 2018.
Facility number: 000039
Provider number: 155685
AIM number: 100275130
Census bed type:
SNF/NF: 119
Total: 119
Census payor type:
Medicare: 1
Medicaid: 107
Other: 4
Total: 119
This deficiency reflects State findings cited in
accordance with 410 IAC 16.2-3.1.
Quality Review was completed on March 26, 2018.
F 0000 Preparation, submission and
implementation of this Plan of
Correction does not constitute an
admission of or agreement with
the facts and conclusions set forth
on the survey report. Our Plan of
Correction is prepared and
executed as a means to
continuously improve the quality of
care and to comply with all
applicable state and federal
regulatory requirements.
We respectfully request that you
consider our facility for paper
compliance as the severity of
citations was found to be of no
actual harm.
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: VMM611 Facility ID: 000039
TITLE
If continuation sheet Page 1 of 21
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
483.10(g)(14)(i)-(iv)
Notify of Changes (Injury/Decline/Room, etc.)
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the
resident; consult with the resident's
physician; and notify, consistent with his or
her authority, the resident representative(s)
when there is-
(A) An accident involving the resident which
results in injury and has the potential for
requiring physician intervention;
(B) A significant change in the resident's
physical, mental, or psychosocial status
(that is, a deterioration in health, mental, or
psychosocial status in either life-threatening
conditions or clinical complications);
(C) A need to alter treatment significantly
(that is, a need to discontinue an existing
form of treatment due to adverse
consequences, or to commence a new form
of treatment); or
(D) A decision to transfer or discharge the
resident from the facility as specified in
§483.15(c)(1)(ii).
(ii) When making notification under paragraph
(g)(14)(i) of this section, the facility must
ensure that all pertinent information specified
in §483.15(c)(2) is available and provided
upon request to the physician.
(iii) The facility must also promptly notify the
resident and the resident representative, if
any, when there is-
(A) A change in room or roommate
assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal
or State law or regulations as specified in
paragraph (e)(10) of this section.
(iv) The facility must record and periodically
update the address (mailing and email) and
phone number of the resident
F 0580
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 2 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
representative(s).
§483.10(g)(15)
Admission to a composite distinct part. A
facility that is a composite distinct part (as
defined in §483.5) must disclose in its
admission agreement its physical
configuration, including the various locations
that comprise the composite distinct part,
and must specify the policies that apply to
room changes between its different locations
under §483.15(c)(9).
Based on record review and interview, the facility
failed to notify a resident's physician of a missed
dialysis appointment, and of resident reported
pain to his bilateral casts after tendon repair for 1
of 3 residents reviewed for dialysis and pain.
(Resident B)
Finding includes:
1. The clinical medical record for Resident B was
reviewed on 3/16/18 at 11:00 A. M. Resident B
was admitted to the facility on 3/8/18 with
diagnoses included, but not limited to, end stage
renal disease, repeated falls, spontaneous rupture
of other tendons, unspecified site, nontraumatic
hematoma of soft tissue and muscle weakness.
A local hospital history and physical, dated
2/26/18, indicated "...History of Present Illness:
The patient is 48 -year-old...dialysis dependant...."
During an interview, on 3/16/18, the Admissions
Director indicated the resident was to receive
dialysis on Monday, Wednesday and Fridays and
that on 3/9/18 the resident missed his scheduled
dialysis appointment because transportation had
not been set up. She indicated she thought he
received dialysis on his next scheduled day but
F 0580 THE FACILITY NOTIFIES
RESIDENTS’S PHYSICIANS OF
CHANGE IN CONDITION
Resident B no longer resides at
the facility.
All residents with change of
condition in the last 14 days were
reviewed to ensure that the
physicians were notified of change
in condition.
Licensed nursing staff has been
in-serviced on physician
notification of changes in
resident’s condition. Director of
Nursing or designee will review
nurse’s notes during clinical start
up to identify any resident with a
change in condition to ensure that
physician has been notified of
changes. These audits to be
completed 5 days a week x 4
weeks, then 2 times weekly x 2
months, then 1x week x 3
months.
The results of the review will be
brought to QAPI x 6 months to
track for trends. If any trends are
identified in the review, the QAPI
04/10/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 3 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
was unsure.
A review of the nursing progress notes lacked
documentation that Resident B's physician had
been notified that he did not receive dialysis on
3/9/18 related to transportation difficulties.
During an interview, on 3/16/18 the DNS (Director
of Nursing Services) indicated a resident's
physician should be notified when a change
occurs in the resident's condition.
2. The clinical medical record for Resident B was
reviewed on 3/16/18 at 11:00A.M. Resident B was
admitted to the facility on 3/8/18 with diagnoses
included, but not limited to, end stage renal
disease, repeated falls, spontaneous rupture of
other tendons, unspecified site, nontraumatic
hematoma of soft tissue and muscle weakness.
A Progress Note dated 3/8/2018 at 10:35 P.M.,
indicated "...He complained of cast to left upper
leg being uncomfortable and hurting his leg. He
stated that the hospital had "put a thick pad in
there but my leg swells too much and it made it to
tight so I took it out...."
A Progress Note, dated 3/9/2018 at 6:42 A.M.,
indicated "...Complained of the cast to this left leg
irritating his skin. Edges of cast at the top are
jagged. Placed washcloth around edge of cast for
additional protection...."
A Progress Note, dated 3/10/18 at 5:57 P.M.,
indicated "...SBAR [situation, background,
assessment and response]...Situation: Resident
c/o [complained of] cast being too tight to the
upper leg et left ankle/heel...Background: Resident
received dialysis 3x/wk. [times per week] Lasix [a
medication used for the elimination of excess
minutes will reflect the
recommendations. If no trends are
identified in 6 months; the review
will be completed on PRN basis.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 4 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
fluids] 80 mg [milligrams] bid [twice a day].
Non-Compliant with elevating legs.
Diabetic...Assessment: ABD [abdominal pad]
applied to upper cast to prevent rubbing.
Encouraged to elevate. Resident states that it
"hurts" when I elevated them. Pain pill given for
discomfort...Response: NP [Nurse Practitioner]
notified...
A Progress Note, dated 3/10/2018 at 9:25 P.M.,
indicated "...NP did not return phone call...."
A Progress Note, dated 3/11/2018 at 10:26 P.M.,
indicated "...Called into ro [room] resident.
Informed this nurse that the top of the leg cast
was too rough against his skin. ABD dressing
applied around the circumference of the cast.
Resident stated that ABD was helpful...."
A Progress Note, dated 3/11/2018 at 12:15 P.M.,
indicated "...SBAR Change in Condition...
Situation: Resident c/o [complained] discomfort to
rt. [right] lower leg. Stated that he feels that his
legs has swollen...Background: Resident has end
stage renal disease...et bilat [bilateral] cast to
lower extremities from recent fall...Assessment:
Resident c/o rt lower leg swelling, general malaise
et [example] sob [short of breath]...Response: NP
notified of request to go to hospital...."
A Progress Note, dated 3/11/8 at 5:30 P.M.,
indicated "... Res. [resident] returned to facility
from hospital. hospital states they cut ble
[bilateral lower extremity] casts to relieve pressure.
at hosp [hospital] res K+ [potassium] was 6.1 so
res was given a injection of Vit [vitamin] k while
there. res states the pressure feels better...."
During an interview, on 3/16/18 at 10:30 A.M., the
MDS (Minimum Data Set) nurse indicated she was
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 5 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
aware the resident was having discomfort with his
bilateral lower leg casts but nursing interventions
were put into place to protect the residents skin
and to treat his pain so she did not notify the
resident's physician as she knew they would make
a visit to the facility on Friday of that week.
During an interview, on 3/16/18 at 12:00 P.M., LPN
(Licensed Practical Nurse) 2 indicated she did
notify the doctor of the resident complaints of his
casts hurting but she felt the facility was doing
what they could for him by padding his casts and
medicating him for pain. LPN 2 indicated she
passed on to the next shift that the NP had not
called back. She indicated it would be up to them
to call the NP to follow up.
A policy titled " Cast Care, of Resident with
Plaster Cast" with an effective date of 3/23/2016
was provided by the DNS on 3/20/18 at 1:00 P.M.,
the policy indicated "...Procedure Purpose: To
give proper care of resident in a fiberglass or
plaster cast to prevent infection, irritation and
provide continuous immobilization... Procedure
Details: 2. Assess circulation and any areas of
irritation above and below cast every shift. Notify
physician promptly of any abnormalities: ask
about pain, tingling or tightness under or near
cast...."
This Federal tag is related to Complaint
IN00256305 and IN00256400.
3.1-35(a)(3)
3.1-35(g)(2)
483.12(c)(1)(4)
Reporting of Alleged Violations
§483.12(c) In response to allegations of
abuse, neglect, exploitation, or mistreatment,
F 0609
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 6 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
the facility must:
§483.12(c)(1) Ensure that all alleged
violations involving abuse, neglect,
exploitation or mistreatment, including
injuries of unknown source and
misappropriation of resident property, are
reported immediately, but not later than 2
hours after the allegation is made, if the
events that cause the allegation involve abuse
or result in serious bodily injury, or not later
than 24 hours if the events that cause the
allegation do not involve abuse and do not
result in serious bodily injury, to the
administrator of the facility and to other
officials (including to the State Survey
Agency and adult protective services where
state law provides for jurisdiction in long-term
care facilities) in accordance with State law
through established procedures.
§483.12(c)(4) Report the results of all
investigations to the administrator or his or
her designated representative and to other
officials in accordance with State law,
including to the State Survey Agency, within
5 working days of the incident, and if the
alleged violation is verified appropriate
corrective action must be taken.
Based on record review and interview, the facility
failed to report an allegation of abuse for a
resident whose family reported a CNA had come
into his room to provide care for him and cursed at
him. This deficient practice affected 1 of 1
allegations of abuse reviewed. (Resident B)
Finding includes:
The clinical medical record for Resident B was
reviewed on 3/16/18 at 11:00A.M. Resident B was
F 0609 This facility does report all alleged
abuse, neglect, exploitation or
mistreatment.
Resident B no longer resides at
the facility
The allegation has been reported
and investigated on 3-20-18
The aide was re-educated on
providing good customer service
and perceptions
The management staff was
04/17/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 7 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
admitted to the facility on 3/8/18 with diagnoses
included, but not limited to, end stage renal
disease, repeated falls, spontaneous rupture of
other tendons, nontraumatic hematoma of soft
tissue and muscle weakness.
A Grievance Form dated 3/10/18 was provided by
the Director of Nursing Services (DNS) on 3/16/18
at 3:00 P.M. The Grievance Form indicated the
following, "...Resident Name: [name of
resident]...Today's date: 3/10/18...Date Grievance
received by Grievance Official: 3/10/18...Statement
of Concern/Grievance: Res. was placed on bed
pan but could not go. Put on call light CNA
[Certified Nursing Aide] would take him off. Res
would want to try again res could not go this went
on for several times res on and off then cna stated
"shut it down and [sic] go to bed!" Roommate
[name of room mate] also heard cna speak to
[name of resident]. [roommate] said cna tried to
explain to [name of resident] that she is busy and
if he really needs the bed pan please let her know
but if he is only going to try again please wait...."
During an interview, on 3/16/18 at 3:15 P.M., the
BOM (Business Office Manager) indicated that
she was the person who received the allegation
from Resident B's family member on 3/10/18. The
following is a statement written and signed by the
BOM and provided by the DNS on 3/16/18 at 3:00
P.M. "...3/10/18...Family member came to me at
approximately 2:00 P.M. and stated that a "nurse"
came into his fathers room the previous night and
said " shut that s*** off and go to bed."... I told
the family that I would come speak with his
father... I spoke with [Resident B] and asked him
what happened--with the aide. [Resident B]
stated, " no one cursed at me, she was just short
with me." "the problem is I have to use the bed
pan, she put me on, I didn't have to go, so I
re-educated on recognizing and
reporting abuse timely to the
Executive Director and The
Director of Nursing on 3-20-18 &
4-5-18
All staff were re-educated on
recognizing and reporting abuse
timely to the Executive Director
and/or the Director of Nursing by
4-17-18.
All grievances will be
reviewed/audited 5 times weekly in
morning meeting to ensure any
allegations were reported per
policy.
Results of these daily audits will
be brought to the QAA committee
monthly for 6 months to ensure
any abuse reported was followed
up, reported and educated on.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 8 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
pushed the call light and she took me off again...."
He admitted this went on numerous times and
stated, "I'm sure she was frustrated with me."The
last time she went to his room, she stated, " put
on the call light when you really really have to go
because I have other people I need to take care
of...Resident's daughter also stated that [Resident
B's] roommate heard the "nurse" be short with her
father...." The BOM indicated she reported the
information she gathered to the Unit Manager that
was working. The BOM did not name the CNA
involved.
During an interview, on 3/16/18 at 3:30 P.M., the
Unit Manager indicated she was told by the BOM
that a family member had come to her with an
allegation that a cna had swore at a resident and
she instructed the BOM to gather information
about who the cna was and what happened. The
Unit Manager indicated she did not feel there was
an allegation of abuse made. She indicated the
Assistant Director of Nurses (ADON) was
working and had been notified of the allegation
and she returned to her unit to work The Unit
Manager indicated she did not notify the
Executive Director. The Unit Manager did not
name the CNA involved.
During an interview, on 3/16/18 at 3:45 P.M., the
Executive Director (ED) indicated she had not
been made aware of the allegations made with
regard to Resident B. The ED indicated she had
been notified by the ADON of a allegation that
had been made for another resident and had
instructed the ADON to report the allegation as
per protocol. The ED indicated had she been
notified of the allegation made with regard to
Resident B she would have instructed the ADON
to begin a investigation and to report the incident.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 9 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
During an interview, on 3/16/18 at 4:08 P.M., the
ADON indicated she had been notified by the
BOM of an allegation that a family member had
made with respect to Resident B and she had
instructed her to find out who the CNA was and
to talk to the resident and the resident's roommate
as he was named as a witness and to put the
information on a grievance form. The ADON
indicated that she did not believe an allegation of
abuse had been made based on what had been
told to her by the BOM. She indicated she chose
to believe the the residents roommate who was
more cognitively intact than the resident. She
indicated she was working on another allegation
and was in the process of reporting it when this
allegation was brought to her. She indicated she
had spoken with both the DNS and ED but had
not notified them of the allegation with regard to
Resident B.
A late entry progress note dated 3/8/18 at 22:35
[10:35 P.M.], indicated "...He [Resident B] appears
to be adjusting well to room and roommate. Family
in to visit for awhile. He is alert and oriented x 3
able to make needs known...."
During an interview with Resident B's former
roommate, conducted on 3/19/18 at 10:50 A.M.,
the roommate indicated he was present when the
alleged incident of cursing occurred with regard to
Resident B. He indicated the resident had been
on and off the bedpan several times and was
unable to use the restroom when the CNA
attempted to explain to Resident B that she could
not keep coming into the residents room to put
him on the bedpan if he didn't have to go she
explained she was busy and had other residents
that required her assistance. The former roommate
indicated the CNA was very polite and never
cursed at Resident B but she did talk to him like a
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 10 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
"little boy". Resident B's former roommate did not
name the CNA when asked.
A current policy titled, " Investigation and
Reporting of Alleged Violations of Federal and
State Laws Involving Mistreatment, Neglect,
Abuse, Injuries of Unknown Source and
Misappropriation of Resident's Property " was
provided by the DNS on 3/16/18 at 4:15 P.M., and
reviewed on 3/20/18 at 10:00 A.M. The policy
indicated "...All employees shall immediately
report the Executive Director all alleged violation;
If the Executive Director is not immediately
available, all alleged violations should be reported
to the Designated Supervisor in charge, who will
report to the Executive Director...2 Hour Reports:
An initial report to the State Survey agency and
law enforcement must be made within 2 hours if a
patient sustains: - Allegations of abuse, neglect,
exploitation, mistreatment, including injuries of
unknown origin, and misappropriation of resident
property...Reporting Responsibility: The
supervisor in charge who receives such a report
shall immediately communicate the report to the
ED...."
This Federal tag is related to Complaint
IN00256305 and IN00256400.
3.1-28(c)
483.12(c)(2)-(4)
Investigate/Prevent/Correct Alleged Violation
§483.12(c) In response to allegations of
abuse, neglect, exploitation, or mistreatment,
the facility must:
§483.12(c)(2) Have evidence that all alleged
violations are thoroughly investigated.
F 0610
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 11 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
§483.12(c)(3) Prevent further potential abuse,
neglect, exploitation, or mistreatment while
the investigation is in progress.
§483.12(c)(4) Report the results of all
investigations to the administrator or his or
her designated representative and to other
officials in accordance with State law,
including to the State Survey Agency, within
5 working days of the incident, and if the
alleged violation is verified appropriate
corrective action must be taken.
Based on record review and interview, the facility
failed to investigate of an allegation of abuse for a
resident whose family reported a CNA had come
into his room to provide care for him and cursed at
him. This deficient practice affected 1 of 1
allegations of abuse reviewed. (Resident B)
Finding includes:
The clinical medical record for Resident B was
reviewed on 3/16/18 at 11:00A.M. Resident B was
admitted to the facility on 3/8/18 with diagnoses
included, but not limited to, end stage renal
disease, repeated falls, spontaneous rupture of
other tendons, unspecified site, nontraumatic
hematoma of soft tissue and muscle weakness.
A Grievance Form dated 3/10/18 was provided by
the Director of Nursing Services (DNS) on 3/16/18
at 3:00 P.M. The Grievance Form contained the
following, "...Resident Name: [name of
resident]...Today's date: 3/10/18...Date Grievance
received by Grievance Official: 3/10/18...Statement
of Concern/Grievance: Res. was placed on bed
pan but could not go. Put on call light CNA
[Certified Nursing Aide] would take him off. Res
would want to try again res could not go this went
on for several times res on and off then cna stated
F 0610 This facility does report all alleged
abuse, neglect, exploitation or
mistreatment.
Resident B no longer resides at
the facility
The allegation has been reported
and investigated on 3-20-18
The aide was re-educated on
providing good customer service
and perceptions
The management staff was
re-educated on recognizing and
reporting abuse timely to the
Executive Director and/or The
Director of Nursing on 3-20-18 &
4-5-18
All staff were re-educated on
recognizing and reporting abuse
timely to the Executive Director
and the Director of Nursing by
4-17-18.
All grievances will be
reviewed/audited 5 times weekly in
morning meeting to ensure any
allegations were reported per
policy.
Results of these daily audits will
be brought to the QAA committee
04/17/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 12 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
" shut it down and [sic] go to bed!" Roommate
[name of room mate] also heard cna speak to
[name of resident]. [roommate] said cna tried to
explain to [name of resident] that she is busy and
if he really needs the bed pan please let her know
but if he is only going to try again please wait...."
During an interview, on 3/16/18 at 3:15 P.M., the
BOM (Business Office Manager) indicated that
she was the person who received the allegation
from Resident B's family member on 3/10/18. The
following is a statement written and signed by the
BOM and provided by the DNS on 3/16/18 at 3:00
P.M. "...3/10/18...Family member came to me at
approximately 2:00 P.M and stated that a "nurse"
came into his fathers room the previous night and
said " shut that s*** off and go to bed."... I told
the family that I would come speak with his
father... I spoke with [Resident B] and asked him
what happened--with the aide. [Resident B]
stated, " no one cursed at me, she was just short
with me." "the problem is I have to use the bed
pan, she put me on, I didn't have to go, so I
pushed the call light and she took me off again...."
He admitted this went on numerous times and
stated, "I'm sure she was frustrated with me."The
last time she went to his room, she stated, " put
on the call light when you really really have to go
because I have other people I need to take care
of...Resident's daughter also stated that [Resident
B's] roommate heard the "nurse" be short with her
father...." The BOM indicated she reported the
information she gathered to the Unit Manager that
was working. The BOM did not name the CNA
involved.
During an interview, on 3/16/18 at 3:30 P.M., the
Unit Manager indicated she was told by the BOM
that a family member had come to her with an
allegation that a cna had swore at a resident and
monthly for 6 months to ensure
any abuse reported was followed
up, reported and educated on.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 13 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
she instructed the BOM to gather information
about who the cna was and what happened. The
Unit Manager indicated she did not feel there was
an allegation of abuse made. She indicated the
Assistant Director of Nurses (ADON) was
working and had been notified of the allegation
and she returned to her unit to work The Unit
Manager indicated she did not notify the
Executive Director. The Unit Manager did not
name the CNA involved.
During an interview, on 3/16/18 at 3:45 P.M., the
Executive Director (ED) indicated she had not
been made aware of the allegations made with
regard to Resident B. The ED indicated she had
been notified by the ADON of a allegation that
had been made for another resident and had
instructed the ADON to report the allegation as
per protocol. The ED indicated had she been
notified of the allegation made with regard to
Resident B she would have instructed the ADON
to begin a investigation and to report the incident.
During an interview, on 3/16/18 at 4:08 P.M., the
ADON indicated she had been notified by the
BOM of an allegation that a family member had
made with respect to Resident B and she had
instructed her to find out who the CNA was and
to talk to the resident and the resident's roommate
as he was named as a witness and to put the
information on a grievance form. The ADON
indicated that she did not believe an allegation of
abuse had been made based on what had been
told to her by the BOM. She indicated she chose
to believe the the residents roommate who was
more cognitively intact than the resident. She
indicated she was working on another allegation
and was in the process of reporting it when this
allegation was brought to her. She indicated she
had spoken with both the DNS and ED but had
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 14 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
not notified them of the allegation with regard to
Resident B.
A late entry progress note dated 3/8/18 at 22:35
[10:35 P.M.], indicated "...He [Resident B] appears
to be adjusting well to room and roommate. Family
in to visit for awhile. He is alert and oriented x 3
able to make needs known...."
During an interview with Resident B's former
roommate, conducted on 3/19/18 at 10:50 A.M.,
the roommate indicated he was present when the
alleged incident of cursing occurred with regard to
Resident B. He indicated the resident had been
on and off the bedpan several times and was
unable to use the restroom when the CNA
attempted to explain to Resident B that she could
not keep coming into the residents room to put
him on the bedpan if he didn't have to go she
explained she was busy and had other residents
that required her assistance. The former roommate
indicated the CNA was very polite and never
cursed at Resident B but she did talk to him like a
"little boy". Resident B's former roommate did not
name the CNA when asked.
A current policy titled, " Investigation and
Reporting of Alleged Violations of Federal and
State Laws Involving Mistreatment, Neglect,
Abuse, Injuries of Unknown Source and
Misappropriation of Resident's Property " was
provided by the DNS on 3/16/18 at 4:15 P.M., and
reviewed on 3/20/18 at 10:00 A.M. The policy
indicated "...All employees shall immediately
report the Executive Director all alleged violation;
If the Executive Director is not immediately
available, all alleged violations should be reported
to the Designated Supervisor in charge, who will
report to the Executive Director...2 Hour Reports:
An initial report to the State Survey agency and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 15 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
law enforcement must be made within 2 hours if a
patient sustains: - Allegations of abuse, neglect,
exploitation, mistreatment, including injuries of
unknown origin, and misappropriation of resident
property...Reporting Responsibility: The
supervisor in charge who receives such a report
shall immediately communicate the report to the
ED...."
This Federal tag is related to Complaint
IN00256305 and IN00256400.
3.1-28(d)
483.21(a)(1)-(3)
Baseline Care Plan
§483.21 Comprehensive Person-Centered
Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and
implement a baseline care plan for each
resident that includes the instructions needed
to provide effective and person-centered care
of the resident that meet professional
standards of quality care. The baseline care
plan must-
(i) Be developed within 48 hours of a
resident's admission.
(ii) Include the minimum healthcare
information necessary to properly care for a
resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.
§483.21(a)(2) The facility may develop a
comprehensive care plan in place of the
F 0655
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 16 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
baseline care plan if the comprehensive care
plan-
(i) Is developed within 48 hours of the
resident's admission.
(ii) Meets the requirements set forth in
paragraph (b) of this section (excepting
paragraph (b)(2)(i) of this section).
§483.21(a)(3) The facility must provide the
resident and their representative with a
summary of the baseline care plan that
includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications
and dietary instructions.
(iii) Any services and treatments to be
administered by the facility and personnel
acting on behalf of the facility.
(iv) Any updated information based on the
details of the comprehensive care plan, as
necessary.
Based on record review and interview, the facility
failed to ensure a baseline care plan was initiated
for a resident who was admitted to the facility with
end stage renal disease, dialysis dependant and
required cast care. This deficient practice affected
1 of 3 residents whose careplans were reviewed.
(Resident B)
Findings include:
On 3/16/18 at 12: 20 P.M., the clinical medical
record of Resident B was reviewed. Resident B
was admitted to the facility on 3/8/18 with
diagnoses included, but not limited to, end stage
renal disease, repeated falls, spontaneous rupture
of other tendons, type 2 diabetes mellitus with
hyperglycemia, hyperkalemia, nontraumatic
hematoma of soft tissue, gastroparesis, essential
primary hypertension, background retinopathy
F 0655 The facility initiates baseline care-
plan for new residents admitted to
the facility
Resident B no longer resides at
the facility.
All new admissions in the last 14
days were reviewed to ensure that
their baseline care plan was
initiated within 48 hours. Any
resident found to have been
affected by deficient practice had
a baseline care plan completed for
them.
IDT and all licensed nurses were
in-serviced on baseline care-plan
guidelines.
Director of nursing or designee will
review all new admissions 3
times/week for 4 weeks then
04/17/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 17 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
and hereditary and idiopathic neuropathy, and
anemia.
A local hospital history and physical, dated
2/26/18, indicated "...History of Present Illness:
The patient is 48 -year-old...dialysis dependant...."
A local hospital transfer form, dated 3/8/18 at
12:35 P.M., indicated "...Nurse Discharge/Current
Problem: Bilateral Open Patella Tendon repair...."
A facility Clinical Health Status form, dated 3/8/18
at 3:00 P.M., indicated "...Current Diagnosis:
Bilateral open Patella Tendon...Preventative Foot
Care: Cast to feet and legs...."
A Resident Centered Baseline Care Plan, dated
3/8/18 at 3:00 P.M., indicated
"...Problem/Need/Concern: Admission or
re-admission...Baseline Care Plan...Goal:
Resident/Responsible party have an
understanding of...Baseline Care
Plan...Interventions: Provide a summary
of...Baseline Care Plan to resident/responsible
party. Initiate IPOC's [immediate plan of care] as
indicated...."
A review of care plans lacked documentation of a
care plan that addressed the residents dialysis,
and cast care.
During an interview, on 3/20/18 at 2:06 P.M., the
DNS (Director Nursing Services) indicated the
facility followed the federal guidelines for the
initiation of baseline care plans. A policy titled "
Medical Record Guideline for Electronic
Careplans" dated effective on 12/10/2014 was
provided by the DNS but did not address baseline
care plans.
weekly x 5 months to ensure that
the baseline care plan was
initiated per guidelines until 100 %
compliance is achieved.
The results of the review will be
brought to QAPI for 6 months to
track trends. If trends are identified
in the review, the QAPI minutes
will reflect the recommendations. If
no trends are identified in 6
months; the review will be
completed on prn basis.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 18 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
This Federal tag is related to Complaint
IN00256573, IN00256305 and IN00256400.
3.1-30(a)
483.25(l)
Dialysis
§483.25(l) Dialysis.
The facility must ensure that residents who
require dialysis receive such services,
consistent with professional standards of
practice, the comprehensive person-centered
care plan, and the residents' goals and
preferences.
F 0698
SS=D
Bldg. 00
Based on record review and interview, the facility
failed to ensure a resident who was admitted
dependant on dialysis received dialysis as per the
physician's plan of care, and pre and post dialysis
assessments were completed for 1 of 3 residents
reviewed for dialysis. (Resident B)
Finding includes:
The clinical medical record for Resident B was
reviewed on 3/16/18 at 11:00 A.M. Resident B was
admitted to the facility on 3/8/18 with diagnoses
included, but not limited to, end stage renal
disease, repeated falls, spontaneous rupture of
other tendons, nontraumatic hematoma of soft
tissue and muscle weakness.
A local hospital history and physical, dated
2/26/18, indicated "...History of Present Illness:
The patient is 48 -year-old...dialysis dependant...."
The physician's orders lacked documentation of
when Resident B was to receive dialysis and
lacked any orders for post dialysis assessment.
During an interview, on 3/16/18 at 11:10 A.M., the
F 0698 The facility ensures that residents
who require dialysis receives
dialysis per plan of care
Resident B no longer resides at
facility.
All residents who received dialysis
in the past 14 days were reviewed
to ensure that they received
dialysis as ordered and that pre
and post assessments were
completed.
The IDT and all licensed
nursing staff were in-serviced
about care of residents on
dialysis. Director of Nursing or
designee will review all
residents who are receiving
dialysis during clinical start-up
meeting to ensure that
residents received dialysis as
ordered including a pre and
post assessment being
completed. These audits to be
completed every business day x 4
weeks, then 3 times weekly x 4
weeks, then monthly x 4 months.
04/17/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 19 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
Admissions Director indicated the resident was to
receive dialysis on Monday, Wednesday and
Fridays and that on 3/9/18 the resident missed his
scheduled dialysis appointment because
transportation had not been set up. She indicated
she thought he received dialysis on his next
scheduled day but was unsure.
Nursing Progress Notes for 3/12/18 indicated the
facility was in communication with the dialysis
center regarding medications and that Resident B
had been transported to nephrology via a local
transportation company.
During an interview, on 3/16/18 at 11:12A.M., the
DNS (Director of Nursing Services) indicated that
Resident B was to go out for dialysis on Monday
Wednesday and Friday and that there is a
communication book in which the dialysis center
documents his labs, vitals and other bits of
information for the facility to follow up on, she
indicated she did not know if he had an order to
check for a thrill and bruit.
During an interview, on 3/19/18 at 4:10 P.M., LPN
(Licensed Practical Nurse) 1 indicated she
conducted the admission assessment for Resident
B and he had an access site for dialysis.
On 3/20/18 at 10:30 A.M., the current policy titled
" Dialysis Guideline" and provided by the DNS on
3/16/18 at 1:00 P.M. was reviewed. The policy
indicated "...Guideline Statement: The
interdisciplinary team must ensure that residents
who require dialysis receive such services,
consistent with professional standards of
practice...Pre Dialysis Protocol: Be cognizant of
medications ordered and timing of
administration..Be aware of any meals that may be
missed and arrange for routine boxed lunches to
The results of these audits will
be brought to QAPI for 6
months to track for trends. If
any trends are identified in the
review, the QAPI minutes will
reflect the recommendations. If
no trends are identified in 6
months; the review will be
completed on PRN basis.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 20 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/11/2018PRINTED:
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
ELKHART, IN 46517
155685 03/20/2018
GOLDEN LIVING CENTER-ELKHART
1001 W HIVELY AVE
00
be provided by dietary if resident is transported
off site...Post Dialysis Protocol Review transfer
forms...for any pertienent information...Observe
for unusual symptoms such as lethargy, chest
pain, headache, unsteady gait or nausea...
Remove fistula/graft-dressing evening of dialysis
treatment...Check fistula for bruit (listening to
fistula) or feel for a thrill (by touching fistula.)
This must be done daily...."
This Federal tag is related to Complaint
IN00256305 and IN00256400.
3.1-37(a)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VMM611 Facility ID: 000039 If continuation sheet Page 21 of 21