Page 1
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
F 0000
Bldg. 00
This visit was for a Recertification and State
Licensure Survey. This visit included a State
Residential Licensure Survey.
Survey dates: October 7, 8, 9, 10, 11, and 15, 2019
Facility number: 012305
Provider number: 155779
AIM number: 200987990
Census Bed Type:
SNF/NF:27
SNF: 16
Total: 43
Census Payor Type:
Medicare: 16
Medicaid: 24
Other: 3
Total: 43
These deficiencies reflect State Findings cited in
accordance with 410 IAC 16.2-3.1.
Quality reveiw completed on October 21, 2019.
F 0000 Preparation or execution of
this plan of correction does not
constitute admission or
agreement of provider of the
truth of the facts alleged or
conclusions set forth on the
Statement of Deficiencies. The
Plan of Correction is prepared
and executed solely because it
is required by the position of
Federal and State Law. The
Plan of Correction is submitted
in order to respond to the
allegation of noncompliance
cited during a Recertification
and State Licensure Survey
that was conducted on,
October 15, 2019. Please
accept this plan of correction
as the provider's credible
allegation of compliance as of,
November 12, 2019. The
provider respectfully requests a
desk review with paper
compliance to be considered in
establishing that the provider is
in substantial compliance.
483.10(c)(7)
Resident Self-Admin Meds-Clinically Approp
§483.10(c)(7) The right to self-administer
medications if the interdisciplinary team, as
defined by §483.21(b)(2)(ii), has determined
that this practice is clinically appropriate.
F 0554
SS=D
Bldg. 00
Based on observation, record review and
interview, the facility failed to evaluate residents
F 0554 F-554: Facility failed to evaluate
residents for self-administration of
medications for 2 of 2 residents
11/12/2019 12:00:00AM
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: 3T9X11 Facility ID: 012305
TITLE
If continuation sheet Page 1 of 24
(X6) DATE
Page 2
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
for self-administration of medications for 2 or 2
residents observed to have medications at
bedside. (Residents 14 and 203)
1. During an interview with Resident 14 on 10/8/19
at 9:17 a.m., a bottle of fluticasone nasal spray was
observed on the resident's bedside table. The
resident indicated she administered it herself.
The resident's clinical record was reviewed on
10/09/19 at 10:24 a.m. Diagnoses included, but
were not limited to, acute cystitis without
hematuria, muscle weakness, allergic rhinitis, and
encephalopathy.
The clinical record lacked an evaluation for the
resident to self administer the medication.
A current physician's order, dated 1/8/18,
indicated fluticasone spary 50mcg/actuation, 2
sprays in each nostril one time a day between 6:00
a.m. and 10:00 a.m.
During an interview on 10/10/19 at 1:43 p.m., the
Nurse Consultant indicated the fluticasone nasal
spray should not have been left in the resident's
room. 2. A random observation on 10/09/19 9:38
a.m., Resident 203 was walking toward her room.
She indicated she had to come back and take her
pills, she left them in her room and went to eat
because she wanted something on her stomach.
The resident walked into her room, a cup of three
pills was sitting on her over the bed table, and the
resident took the medication without a nurse
present.
The clinical record for Resident 203 was reviewed
on 10/09/19 at 08:29 a.m., Diagnoses for the
resident included but were not limited to,
hypertension, head injury, localized edema.
observed to have medication at
bedside.
Corrective actions
accomplished for those
residents found to be affected
by the alleged deficient
practice: No ill effects were
noted for 2 of the 2 residents
observed, nasal spray was
removed from resident 14 bedside,
resident 203 consumed all
morning scheduled medications
without incident. RN #4, was
immediately educated on the,
“Guidelines for Self Administration”
and medication administration
guidelines. At time of notification,
all other resident rooms were
observed to ensure no other
medications were left at resident
bedside, no other concerns
identified at that time.
Identification of other residents
having the potential to be
affected by the same alleged
deficient practice and
corrective actions taken: All
residents have the potential to be
affected by the alleged deficient
practice. DHS began immediate
education on the “Guidelines for
Self-Administration” for nursing
staff, education is on-going.
Measures put in place and
systemic changes made to
ensure the alleged deficient
practice does not recur: DHS or
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 2 of 24
Page 3
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
Current signed physician's orders for the resident
included, but were not limited to, the following
orders:
a. Senna with Docusate sodium (stool softener
medication) give 17.2-100 milligrams by mouth
twice a day; 6:00 a.m. - 10:00 a.m., and 7:00 p.m. -
10:00 p.m. The order originated on 9/28/19.
b. Cholecalciferol (Vitamin D3) give 1,000 units by
mouth once a day; 6:00 a.m. - 10:00 a.m. The order
originated on 9/29/19.
c. Folic acid (supplement) give one tablet by
mouth once a day; 6:00 a.m. - 10:00 a.m. The order
originated on 9/29/19.
The resident had a 8/12/19, quarterly Minimum
Data Set (MDS) assessment, which indicated the
resident had moderate cognitive impairment, poor
decision making.
The resident's clinical record lacked an order for
self administration of medication, or an
assessment to self administrate medication.
During an interview on 10/9/19 at 9:43 a.m., RN 4
indicated she took the residents medication into
her room, sat them down on the table. She came
out of the resident's room due to the resident was
in the bathroom. The nurse indicated she did not
see the resident take her medication. RN 4
indicated she should had remained in the room
until the residents had taken her medication.
During an interview on 10/09/19 at 1:06 p.m., the
DON indicated no residents in the health center
self administrates medications.
designee will educate all nursing
staff on “Guidelines of
Self-Administration” and
“Medication Administration”.
How the corrective measures
will be monitored to ensure the
alleged deficient practice does
not recur: DHS or designee will
observe 5 resident rooms during
general medication pass times to
ensure no medications are left at
bedside without proper evaluation
and orders in place, 2 times per
week X8 weeks, weekly X4 weeks,
bi-weekly X4 weeks, then monthly
ongoing.
For quality assurance, the ED or
designee will review audit results
and subsequent corrective action
at least quarterly in the campus
Quality Assurance Committee
meeting. The plan will be revised
as warranted. If increased
problems noted, audit frequency
may increase. If no problems
noted after six months, the
frequency of audits may decrease.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 3 of 24
Page 4
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
Review of the current facility policy, revised
5/22/2018, titled "Guidelines for Self
Administration of Medication" provided by the
Corporate Nurse on 10/9/19 at 10:17 a.m.,
included, but was not limited to,
"Policy: To ensure the safe administration of
medication for residents who request to self -
medicate or when self -medication is a part of their
pan of care.
Procedure:
1. Residents shall be assessed using the
observation Trilogy-Self Administration of
Medication... results of the assessment will be
presented to the physician for evaluation and an
order for self - medication..."
3.1-11(a)
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
F 0692
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 4 of 24
Page 5
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
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.
Based on record review and interview, the facility
failed to ensure a fluid restriction was followed per
physician's order for 1 of 1 resident's reviewed for
hydration. (Resident 33)
Findings include:
A review of Resident 33's clinical record was
completed on 10/11/19 at 12:53 p.m. Diagnoses
included, but were not limited to, dementia
without behaviors, heart failure, and
hyponatremia.
He had current physician order, dated 8/9/19, for a
fluid restriction of 1200 ml (milliliter) per day. The
order included the following:
a. 240 ml per meal from dining services.
b. 240 ml per day shift from nursing.
c. 120 ml per evening shift from nursing.
d. 120 ml per night shift from nursing.
A significant change Minimum Data Set (MDS)
assessment, dated 8/30/19, indicated he had
severe cognitive impairment and required
extensive assistance to eat and drink.
Review of the resident's care plan lacked any
information for a diagnosis of hyponatremia or
indication of a fluid restriction.
A review of a progress note, dated 8/22/19, the
nurse practitioner indicated the following:
"Plan:
1. Hyponatrimia...not improving. Off diuretic, on
F 0692 F-692: Facility failed to ensure a
fluid restriction was followed per
physician’s order for 1 of 1
resident’s reviewed for hydration
Corrective actions
accomplished for those
residents found to be affected
by the alleged deficient
practice: No ill effects noted for
resident 33, fluid restriction has
been discontinued.
Identification of other residents
having the potential to be
affected by the same alleged
deficient practice and
corrective actions taken: All
resident’s with fluid restriction
orders have the potential to be
affected by the alleged deficient
practice. Orders and fluid
consumption for the last 30 days
were reviewed for all residents with
fluid restrictions at time of
identification, findings reviewed
with provider. New process in
place for documentation of fluid
consumption.
Measures put in place and
11/12/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 5 of 24
Page 6
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
fluid restriction 1200 cc..."
Review of the nursing fluid intake documentation
from the eMAR (electronic medication
administration record), indicated the following:
a. For September 2019, documentation was
present for greater than 240 ml's as provided on 8
of 30 day shifts; greater than 120 ml's provided on
16 of 30 evening shifts; and greater than 120 ml's
provided on 1 of 30 night shifts.
b. For October 2019, documentation was present
for greater than 240 ml's as provided on 2 of 11
day shifts and greater than 120 ml's provided on 4
of 10 evening shifts.
Review of the CNA's fluid intake documentation
from the electronic health record (EHR) indicated
the following:
a. For September 2019, documentation was
present for greater than 720 ml's per day, or 240
ml's per meal, for 30 of 30 days reviewed, with an
average overage of fluids documented at 1605 ml's
per day.
b. For October 2019, documentation was present
for greater than 720 ml's per day, or 240 ml's per
meal, for 10 of 10 days reviewed, with an average
overage of fluids documented at 1206 ml's per day.
During an interview on 10/15/19 at 9:55 a.m., the
Nurse consultant indicated the resident's fluid
restriction documentation had been reviewed and
had not been followed.
Review of a current facility policy, titled
"Guidelines for Fluid Restriction," dated 5/11/16
and provided by the Nurse Consultant on
systemic changes made to
ensure the alleged deficient
practice does not recur: DHS or
designee will re-educate all
nursing staff on “Guidelines for
Fluid Restriction” and the current
process for documentation of fluid
consumption.
How the corrective measures
will be monitored to ensure the
alleged deficient practice does
not recur: DHS or designee will
review fluid consumption records
for up to 5 residents with fluid
restrictions in place, 2 times per
week X8 weeks, weekly X4 weeks,
bi-weekly X4 weeks, then monthly
on-going.
For quality assurance, the ED or
designee will review audit results
and subsequent corrective action
at least quarterly in the campus
Quality Assurance Committee
meeting. The plan will be revised
as warranted. If increased
problems noted, audit frequency
may increase. If no problems
noted after six months, the
frequency of audits may decrease.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 6 of 24
Page 7
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
10/15/19 at 9:56 a.m., indicated the following:
"PURPOSE: To ensure fluids are provided within
the physician order guidelines.
PROCEDURES...
5. The Nursing Department shall record
established breakdown by shift and document in
the EHR.
6. Fluid consumption shall be reviewed by shift to
determine adjustments necessary in the fluid
intake of the resident on the restriction in order to
meet their established fluid needs."
3.1-46(a)(1)
483.45(a)(b)(1)-(3)
Pharmacy
Srvcs/Procedures/Pharmacist/Records
§483.45 Pharmacy Services
The facility must provide routine and
emergency drugs and biologicals to its
residents, or obtain them under an agreement
described in §483.70(g). The facility may
permit unlicensed personnel to administer
drugs if State law permits, but only under the
general supervision of a licensed nurse.
§483.45(a) Procedures. A facility must
provide pharmaceutical services (including
procedures that assure the accurate
acquiring, receiving, dispensing, and
administering of all drugs and biologicals) to
meet the needs of each resident.
§483.45(b) Service Consultation. The facility
must employ or obtain the services of a
licensed pharmacist who-
F 0755
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 7 of 24
Page 8
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
§483.45(b)(1) Provides consultation on all
aspects of the provision of pharmacy services
in the facility.
§483.45(b)(2) Establishes a system of
records of receipt and disposition of all
controlled drugs in sufficient detail to enable
an accurate reconciliation; and
§483.45(b)(3) Determines that drug records
are in order and that an account of all
controlled drugs is maintained and
periodically reconciled.
Based on record review, and interview, the facility
failed to ensure physician orders were followed
related to dementia care for 1 of 3 residents
reviewed for dementia care. (Resident 3)
Findings include:
The clinical record for Resident 3 was reviewed on
10/10/19 at 9:09 a.m., Diagnoses for the resident
included but were not limited to, dementia with
behavioral disturbance, psychotic disorder with
hallucinations, Alzheimer's disease, and anxiety
disorder.
Current signed physician's orders for the resident
included, but were not limited to, the following
orders:
a. Olanzapine (psychotic medication) give 2.5
milligram by mouth once a day at 9:00 a.m. for
psychotic disorder with hallucinations. The order
originated on 7/11/19.
The resident had a 6/18/19, quarterly Minimum
Data Set (MDS) assessment, which indicated the
F 0755 F-755: Facility failed to ensure
physician orders were followed
related to dementia care for 1 of 3
residents reviewed for dementia
care.
Corrective actions
accomplished for those
residents found to be affected
by the alleged deficient
practice: Resident 3, medication
administration history for the last
30 days were reviewed, current
orders were compared to
medications available for
administration in the med cart to
ensure all medications were
available for administration, all
medications were available at time
of review, all findings were
reviewed with provider. Resident
remained at baseline with moods
and behaviors at that time.
11/12/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 8 of 24
Page 9
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
resident had severe cognitive impairment, with
hallucinations (perceptual experiences in the
absence of real external sensory stimuli) and
delusions (misconceptions or beliefs that are
firmly held, contrary to reality).
The resident had a current, start date 12/13/18,
health care plan with the problem of
"Psychotropic drug use. The resident is at risk for
adverse consequences related to receiving
antipsychotic medication for: psychotic disorder
with hallucinations . Approaches for this problem
included but were not limited to: administer
medication per physician order, and pharmacy
consultant review as needed.
A review of the residents medication
administration history indicated the following:
8/16/19 at 8:30 a.m., medication not administered
due to drug unavailable, comment: refilled
requested.
8/19/19 at 8:39 a.m., medication not administered
due to drug unavailable, comment: refilled
requested.
b. Olanzapine (psychotic medication) give 2.5
milligram by mouth once a day at 2:00 p.m. - 10:00
p.m. for psychotic disorder with hallucinations.
The order originated on 1/9/19.
A review of the residents medication
administration history indicated the following:
8/13/19 at 7:22 p.m., medication not administered
due to drug unavailable, the comment indicated
the medication was refilled on 7/26/19, but they
were unable to locate.
Identification of other residents
having the potential to be
affected by the same alleged
deficient practice and
corrective actions taken: All
residents with dementia with an
order for an antipsychotic
medication, have the potential to
be affected by the alleged deficient
practice. All resident’s with
dementia who take an
antipsychotic medication, had
administration records reviewed for
the last 30 days. Medication
orders were compared to meds
available in the cart for
administration, all meds were
available to administer, all findings
reviewed with provider.
Measures put in place and
systemic changes made to
ensure the alleged deficient
practice does not recur: DHS or
designee will re-educate all
nursing staff on “Medication
Ordering and Receiving From
Pharmacy” and provider
notification. Nursing leadership
educated on the, “Administration
Compliance Report/review”.
How the corrective measures
will be monitored to ensure the
alleged deficient practice does
not recur: DHS or designee will
review administration compliance
and observe medication carts to
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 9 of 24
Page 10
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
8/14/19 at 9:51 p.m., medication not administered
due to drug unavailable.
8/15/19 at 8:35 p.m., medication not administered
due to drug unavailable.
8/16/19 at 8:20 p.m., medication not administered
due to drug unavailable.
8/17/19 at 8:25 p.m., medication not administered
due to drug unavailable.
8/18/19 at 8:44 p.m., medication not administered
due to drug unavailable.
8/19/19 at 8:46 p.m., medication not administered
due to drug unavailable.
8/20/19 at 6:43 p.m. medication not administered
due to drug unavailable, comment: refilled to early.
The resident's clinicial record lacked notification
to the physician related to his missed medication.
During an interview on 10/15/19 at 8:53 a.m., the
Corporate Nurse indicated the Olanzapine
scheduled at 2:00 p.m. - 10:00 p.m., had been
transcribed as an additional order. She indicated
it should had been written for two times a day.
The facility did not have Olanzapine available for
emergencies or missed doses.
Review of the current facility policy, revised 1/17,
titled "MEDICATION ORDERING AND
RECEIVING FROM PHARMACY" provided by
the Corporate Nurse on 10/15/19 at 10:25 a.m.,
included, but was not limited to,
"Policy: Medication and related products are
received from the dispensing pharmacy. The
ensure meds are available as
ordered, for up to 5 residents with
a diagnosis of dementia with an
active order for an antipsychotic
medication; 2 times per week X8
weeks, weekly X8 weeks,
bi-weekly X8 weeks, then monthly
on-going.
For quality assurance, the ED or
designee will review audit results
and subsequent corrective action
at least quarterly in the campus
Quality Assurance Committee
meeting. The plan will be revised
as warranted. If increased
problems noted, audit frequency
may increase. If no problems
noted after six months, the
frequency of audits may decrease.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 10 of 24
Page 11
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
facility maintains accurate records of medication
order and receipt.
Procedures:
...2. Reorder medication several days in advance
of need, as directed by the pharmacy order and
delivery schedule, to assure an adequate supply
is on hand...
3. "Stat" and emergency medications are ordered
as follows:
During regular pharmacy hours, the pharmacy is
notified of the emergency order; the order is then
phoned, sent electronically, or faxed to the
pharmacy. Such medications are delivered and
administered upon delivery..."
3.1-25(a)
483.45(d)(1)-(6)
Drug Regimen is Free from Unnecessary
Drugs
§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free
from unnecessary drugs. An unnecessary
drug is any drug when used-
§483.45(d)(1) In excessive dose (including
duplicate drug therapy); or
§483.45(d)(2) For excessive duration; or
§483.45(d)(3) Without adequate monitoring;
or
§483.45(d)(4) Without adequate indications
for its use; or
§483.45(d)(5) In the presence of adverse
F 0757
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 11 of 24
Page 12
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
consequences which indicate the dose
should be reduced or discontinued; or
§483.45(d)(6) Any combinations of the
reasons stated in paragraphs (d)(1) through
(5) of this section.
Based on record review, and interview the facility
failed to ensure all medication had an order prior
to administration for for 1 of 5 residents reviewed
for unnecessary medication. (Resident 47)
Findings include:
The clinical record for Resident 47 was reviewed
on 10/11/19 at 9:21 a.m., Diagnoses for the
resident included but were not limited to,
dementia, cerebrovascular disease, hypertension,
chronic atrial fibrillation, hemiplegia and
hemiparesis.
The resident had a 6/28/19,quarterly Minimum
Data Set (MDS) assessment, which indicated the
resident had severe cognitive impairment.
Current signed physician's orders for the resident
included, but were not limited to, the following
orders:
a. check blood pressure every six (6) hours, if SBP
(systolic blood pressure) is greater than 180 give
as needed hydralazine (blood pressure
medication) per order. The order originated on
10/11/18.
The residents medication administration history
lacked an order for hydralazine.
The residents administration history indicated the
order for hydralazine 25 milligrams give one tablet
every six (6) hours as needed for SBP greater than
F 0757 F-757: Facility failed to ensure all
medications had an order prior to
administration for 1 of 5 residents
reviewed for unnecessary
medication.
Corrective actions
accomplished for those
residents found to be affected
by the alleged deficient
practice: Resident 47 without ill
effects noted, medication card
immediately removed from med
cart, blood pressure order clarified,
“prn hydralazine” discontinued.
Identification of other residents
having the potential to be
affected by the same alleged
deficient practice and
corrective actions taken: All
residents have the potential to be
affected by the same deficient
practice. All residents residing in
health center had their medication
orders compared to the
medications available in the
medication cart, all findings
reviewed with provider and
pharmacy, no medications remain
available for administration without
active physician orders in place.
11/12/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 12 of 24
Page 13
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
180 was discontinued on 4/29/19.
The medication administration history indicated
hydralizine was administered without an order on
the following dates and times:
a. On 7/28/19 at 12:00 a.m.
b. On 8/21/19 at 6:00 a.m.
c. On 9/21/19 at 6:00 p.m.
Review of the current facility policy, revised 1/17,
titled "MEDICATION ORDERING AND
RECEIVING FROM PHARMACY" provided by
the Corporate Nurse on 10/15/19 at 10:25 a.m.,
included, but was not limited to,
"Policy: Medication and related products are
received from the dispensing pharmacy. The
facility maintains accurate records of medication
order and receipt.
3.1-25(e)(3)
Measures put in place and
systemic changes made to
ensure the alleged deficient
practice does not recur: DHS or
designee will re-educate all
nursing staff on “Medication
Ordering and Receiving From
Pharmacy” and provider
notification.
How the corrective measures
will be monitored to ensure the
alleged deficient practice does
not recur: DHS or designee will
observe 5 residents residing in
health center, comparing active
physician orders with medications
available in medication cart to
ensure there are no medications
available for administration without
provider orders in place, 2 times
per week X8 weeks, weekly X4
weeks, bi-weekly X4 weeks, then
monthly on-going.
For quality assurance, the ED or
designee will review audit results
and subsequent corrective action
at least quarterly in the campus
Quality Assurance Committee
meeting. The plan will be revised
as warranted. If increased
problems noted, audit frequency
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 13 of 24
Page 14
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
may increase. If no problems
noted after six months, the
frequency of audits may decrease.
483.45(c)(3)(e)(1)-(5)
Free from Unnec Psychotropic Meds/PRN
Use
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any
drug that affects brain activities associated
with mental processes and behavior. These
drugs include, but are not limited to, drugs in
the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic
Based on a comprehensive assessment of a
resident, the facility must ensure that---
§483.45(e)(1) Residents who have not used
psychotropic drugs are not given these drugs
unless the medication is necessary to treat a
specific condition as diagnosed and
documented in the clinical record;
§483.45(e)(2) Residents who use
psychotropic drugs receive gradual dose
reductions, and behavioral interventions,
unless clinically contraindicated, in an effort
to discontinue these drugs;
§483.45(e)(3) Residents do not receive
psychotropic drugs pursuant to a PRN order
F 0758
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 14 of 24
Page 15
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
unless that medication is necessary to treat
a diagnosed specific condition that is
documented in the clinical record; and
§483.45(e)(4) PRN orders for psychotropic
drugs are limited to 14 days. Except as
provided in §483.45(e)(5), if the attending
physician or prescribing practitioner believes
that it is appropriate for the PRN order to be
extended beyond 14 days, he or she should
document their rationale in the resident's
medical record and indicate the duration for
the PRN order.
§483.45(e)(5) PRN orders for anti-psychotic
drugs are limited to 14 days and cannot be
renewed unless the attending physician or
prescribing practitioner evaluates the resident
for the appropriateness of that medication.
Based on record review, and interview, the facility
failed to monitor for antipsychotic medication side
effects and behavior monitoring for 1 of 5
residents review for psychotropic medication.
(Resident 3)
Findings include:
The clinical record for Resident 3 was reviewed on
10/10/19 at 9:09 a.m., Diagnoses for the resident
included but were not limited to, dementia with
behavioral disturbance, psychotic disorder with
hallucinations, Alzheimer's disease, anxiety
disorder, and major depressive disorder.
The resident had a 9/18/19, quarterly Minimum
Data Set (MDS) assessment, which indicated the
resident had severe cognitive impairment, with
hallucinations (perceptual experiences in the
absence of real external sensory stimuli) and
delusions (misconceptions or beliefs that are
F 0758 F-758: Facility failed to monitor
for antipsychotic medication side
effects and behavior monitoring for
1 of 5 residents reviewed for
psychotropic medication.
Corrective actions
accomplished for those
residents found to be affected
by the alleged deficient
practice: Resident 3, side
effect and target behavior
monitoring was reinitiated for
resident psychotropic
medications. Resident has
shown improvement in moods
and behaviors since return to
facility with current regimen in
place, continues to be followed
by psych services, findings
reviewed with provider.
11/12/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 15 of 24
Page 16
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
firmly held, contrary to reality).
Current signed physician's orders for the resident
included, but were not limited to, the following
orders:
a. Olanzapine (antipsychotic medication) give 2.5
milligram by mouth twice a day at 8:00 a.m. and
5:00 p.m., for psychotic disorder with
hallucinations. The order originated on 9/13/19.
b. Depakote Sprinkles (mood stabilizer) give 250
milligrams twice a day at 6:00 a.m.-10:00 a.m., and
6:00 p.m.-10:00 p.m., for mood instability. The
order originated on 9/13/19.
The resident had a current, start date 8/27/19,
health care plan with the problem of Psychotropic
drug use. The resident had a diagnosis of
psychotic disorder with hallucinations due to
known physiological condition he requires the
use of antipsychotic medication Zyprexa
(Olanzapine) as evident by agitation, accusatory
statements, restlessness, insomnia and repetitive
questions/statements. Approaches for this
problem included but were not limited to:
administer medication per physician order, and
monitor for changes in status and inform
physician /family.
The resident had a current, start date 9/19/19,
health care plan with the problem of Psychotropic
drug use. The resident had a diagnoses of major
depression disorder he requires the use of
medications Depakote as evident by up/down
mood, statements of feeling down, lack of interest,
feeling tired, change in sleep, changes in appetite
and isolation in room. Approaches for this
problem included but were not limited to:
administer medication per physician order.
Identification of other residents
having the potential to be
affected by the same alleged
deficient practice and
corrective actions taken: All
residents with an order for an
antipyschotic medication have the
potential to be affected by the
alleged deficient practice. All
residents with an active
antipsychotic medication order
had a chart review conducted to
ensure all side effect and target
behavior monitoring is in place.
Findings reviewed with provider.
All residents with antipsychotic
medication orders have side effect
and target behavior monitoring in
place.
Measures put in place and
systemic changes made to
ensure the alleged deficient
practice does not recur: DHS or
designee will re-educate all
nursing staff on “Psychotropic
Medication Usage”, side effect
monitoring, target behavior
tracking, and care tracker
documentation.
How the corrective measures
will be monitored to ensure the
alleged deficient practice does
not recur: DHS or designee will
review up to 5 resident charts, for
residents with an active
antipsychotic order in place, to
ensure side effect and target
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 16 of 24
Page 17
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
A progress note, dated 9/9/19 at 3:20 p.m.,
indicated the resident was transported to a
psychiatric treatment facility for treatment.
A progress note, dated 9/13/19 at 8:07 p.m.,
indicated the resident returned to the facility.
A review of the resident medication administration
history for September 13, 2019 through October
10, indicated the targeted behavior monitoring
was discontinued on 9/9/19 and was not
reinitiated upon the resident's return to the
facility.
During an interview on 10/10/19 at 1:05 p.m., LPN
1 indicated behavior and medication monitoring
should be done on the medication administration
sheet or in the nurse notes.
During an interview on 10/10/19 at 1:37 p.m., the
Corporate Nurse indicated the antipsychotic
medication and targeted behavior monitoring
should have been reinitiated upon the residents
return to the facility
Review of the current facility policy, revised
10/9/17, titled "Psychotropic Medication Usage"
provided by the Corporate Consultant on
10/15/19 at 10:10 a.m., included, but was not
limited to,
"PURPOSE: To ensure every effort is made for
residents receiving psychoactive medications to
obtain the maximum benefit with minimal
unwanted side effects through appropriate use,
evaluation and monitoring by the interdisciplinary
team.
Procedures:
behavior monitoring orders are in
place, 2 times per week X8
weeks, weekly X8 weeks,
bi-weekly X8 weeks, then monthly
on-going.
For quality assurance, the ED or
designee will review audit results
and subsequent corrective action
at least quarterly in the campus
Quality Assurance Committee
meeting. The plan will be revised
as warranted. If increased
problems noted, audit frequency
may increase. If no problems
noted after six months, the
frequency of audits may decrease.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 17 of 24
Page 18
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
...7. Review of medication use will be conducted
by the consultant pharmacist monthly and will
monitor psychotropic drug use in the campus
to ensure that medications are not used in
excessive doses or for excessive duration..."
3.1-48(a)(3)
483.45(g)(h)(1)(2)
Label/Store Drugs and Biologicals
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility
must be labeled in accordance with currently
accepted professional principles, and include
the appropriate accessory and cautionary
instructions, and the expiration date when
applicable.
§483.45(h) Storage of Drugs and Biologicals
§483.45(h)(1) In accordance with State and
Federal laws, the facility must store all drugs
and biologicals in locked compartments
under proper temperature controls, and
permit only authorized personnel to have
access to the keys.
§483.45(h)(2) The facility must provide
separately locked, permanently affixed
compartments for storage of controlled drugs
listed in Schedule II of the Comprehensive
Drug Abuse Prevention and Control Act of
1976 and other drugs subject to abuse,
except when the facility uses single unit
package drug distribution systems in which
the quantity stored is minimal and a missing
dose can be readily detected.
F 0761
SS=D
Bldg. 00
Based on observation and interview, the facility
failed to appropriately label medications brought F 0761 F-761: Facility failed to
appropriately label medications 11/12/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 18 of 24
Page 19
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
to the facility by the resident or resident
representative in 2 of 2 medication carts observed
for medication storage. (100 hall and 200 hall
medication carts)
Findings include:
1. During a medication storage observation of the
100 hall medication cart on 10/7/19 at 10:21 a.m.,
accompanied by LPN 1, the following was
observed:
a. An opened bottle of Dye-free Wal-Dry
(medication to treat allergies) 12.5mg (milligram),
lacked a resident name. LPN 1 indicated the
container had 15 of 20 doses remaining.
b. An opened bottle of Mucus Relief ER 600 mg,
lacked a resident name. LPN 1 indicated the
container had 11 of 20 doses remaining.
2. During a medication storage observation of the
200 hall medication cart on 10/7/19 at 10:41 a.m.,
accompanied by CRMA 3, the following was
observed:
a. An opened bottle of Acetaminophen PM
(medication to treat pain and promote sleep),
lacked a resident name. CRMA 3 indicated the
container was approximately 1/2 full.
During an interview on 10/10/19 at 9:52 a.m., the
Nurse Consultant indicated medications brought
to the facility by residents or resident families
should be labeled with the resident name.
Review of current facility policy provided by the
Nurse Consultant on 10/15/19 at 11:25 a.m., titled
"Medication Ordering and Receiving From
Pharmacy", indicated the following:
brought to the facility by the
resident or resident representative
in 2 of 2 medication carts
observed for medication storage.
Corrective actions
accomplished for those
residents found to be affected
by the alleged deficient
practice: All medication carts
were audited to ensure all
medications brought into the
facility and stored in the
medication carts were labeled
appropriately with the resident
name/room #, medication and
strength, directions, doctor,
and date received.
Identification of other residents
having the potential to be
affected by the same alleged
deficient practice and
corrective actions taken: All
residents who provide medication
from an outside source have the
potential to be affected by the
alleged deficient practice. All
medication carts were audited to
ensure all medications brought
into the facility and stored in the
medication carts were labeled
appropriately with the resident
name/room #, medication and
strength, directions, doctor, and
date received.
Measures put in place and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 19 of 24
Page 20
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
"MEDICATIONS BROUGHT TO THE FACILITY
BY A RESIDENT OR RESPONSIBLE PARTY...
A. Use of medications brought to the facility by a
resident or responsible party is allowed only when
the following conditions are met:...
3) The medication container is clearly labeled in
accordance with facility procedures for medication
labeling..."
3.1-25(j)
systemic changes made to
ensure the alleged deficient
practice does not recur: DHS or
designee will re-educate all
nursing staff on the pharmacy
policy for “Medications Brought to
the Facility by a Resident or
Responsible Party”, labeling of
these medications, and
“Medication Storage”.
How the corrective measures
will be monitored to ensure the
alleged deficient practice does
not recur: DHS or designee will
audit all health center medication
carts, to ensure all medications
brought into the facility by the
resident or responsible party are
labeled appropriately, 2 times per
week X8 weeks, weekly X4 weeks,
bi-weekly X4 weeks, then monthly
on-going.
For quality assurance, the ED or
designee will review audit results
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 20 of 24
Page 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
and subsequent corrective action
at least quarterly in the campus
Quality Assurance Committee
meeting. The plan will be revised
as warranted. If increased
problems noted, audit frequency
may increase. If no problems
noted after six months, the
frequency of audits may decrease.
R 0000
Bldg. 00
This visit was for a State Residential Licensure
Survey.
Survey dates: October 7, 8, 9, 10, 11, and 15, 2019
Facility number: 012305
Residential Census:13
These State Residential Findings are cited in
accordance with 410 IAC 16.2-5.
Quality review completed on October 21, 2019.
R 0000 Preparation or execution of
this plan of correction does not
constitute admission or
agreement of provider of the
truth of the facts alleged or
conclusions set forth on the
Statement of Deficiencies. The
Plan of Correction is prepared
and executed solely because it
is required by the position of
Federal and State Law. The
Plan of Correction is submitted
in order to respond to the
allegation of noncompliance
cited during a Recertification
and State Licensure Survey
that was conducted on,
October 15, 2019. Please
accept this plan of correction
as the provider's credible
allegation of compliance as of,
November 12, 2019. The
provider respectfully requests a
desk review with paper
State Form Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 21 of 24
Page 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
compliance to be considered in
establishing that the provider is
in substantial compliance.
R 9999
Bldg. 00
Based on interview and record review, the facility
failed to ensure a staff member was CPR certified
for 3 of 21 shifts reviewed for the week of staffing
provided by the facility.
Findings include:
A review of the employee schedule on 10/15/19 at
11:43 a.m., lacked any staff members that were
CPR certified for three of 21 shifts, reviewed for
the week of 9/30/19 through 10/6/19.
During an interview, on 10/15/19 at 1:33 p.m., the
Corporate Consultant indicated they did not have
CPR coverage for the three shifts.
No further information received from facility.
R 9999 R-9999: Facility failed to ensure
that a CPR certified staff member
was present for 3 out of 21 shifts.
Corrective actions
accomplished for those
residents found to be affected
by the alleged deficient
practice: No incidents
requiring CPR occurred during
the 3 identified shifts of
non-coverage, HC staff was
available during these 3 shifts
for CPR coverage of the AL unit
had a situation arisen requiring
intervention.
Identification of other residents
having the potential to be
affected by the same alleged
deficient practice and
corrective actions taken: All
residents have the potential to be
affected by the alleged deficient
practice. All residential nursing
staff employee records were
reviewed to determine CPR
certification status. DHS or
designee will educate all nursing
staff on R9999, ensuring a CPR
certified staff member is present at
all times in the residential setting;
all nursing employees working in
11/12/2019 12:00:00AM
State Form Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 22 of 24
Page 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
the residential setting will renew or
obtain CPR certification.
Measures put in place and
systemic changes made to
ensure the alleged deficient
practice does not recur: DHS or
designee will educate all nursing
staff on R9999, ensuring a CPR
certified staff member is present at
all times in the residential setting;
all nursing employees working in
the residential setting will renew or
obtain CPR certification.
How the corrective measures
will be monitored to ensure the
alleged deficient practice does
not recur: DHS or designee will
audit the schedule to ensure a
nursing staff member with CPR
certification is scheduled on the
residential unit at all times, 3
times per week X8 weeks, 2 times
per week X4 weeks, weekly X4
weeks, then monthly ongoing.
For quality assurance, the ED or
State Form Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 23 of 24
Page 24
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/14/2019PRINTED:
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
NOBLESVILLE, IN 46060
155779 10/15/2019
PRAIRIE LAKES HEALTH CAMPUS
9730 PRAIRIE LAKES BLVD EAST
00
designee will review audit results
and subsequent corrective action
at least quarterly in the campus
Quality Assurance Committee
meeting. The plan will be revised
as warranted. If increased
problems noted, audit frequency
may increase. If no problems
noted after six months, the
frequency of audits may decrease.
State Form Event ID: 3T9X11 Facility ID: 012305 If continuation sheet Page 24 of 24