PRINTED: 05/20/2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 000 INITIAL COMMENTS F 000

This visit was for the Investigation of Complaints

IN00324612 and IN00324657. This visit resulted
in an Immediate Jeopardy.

Complaint IN00324612 - Substantiated.

Federal/State deficiencies related to the
allegations are cited at F880.

Complaint IN00324657 - Substantiated.

Federal/State deficiencies related to the
allegations are cited at F880.

Survey dates: April 16, 17, 18, 19 and 20, 2020

Facility number: 000497

Provider number: 155606
AIM number: 100291530

Census Bed Type:

SNF/NF: 78
Total: 78

Census Payor Type:

Medicare: 13
Medicaid: 53
Other: 12
Total: 78

This deficiency reflects State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality Review completed on 4/22/2020.

F 880 Infection Prevention & Control F 880 4/20/20
SS=J CFR(s): 483.80(a)(1)(2)(4)(e)(f)

§483.80 Infection Control

The facility must establish and maintain an

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

04/28/2020
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 1 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 1 F 880

infection prevention and control program
designed to provide a safe, sanitary and
comfortable environment and to help prevent the
development and transmission of communicable
diseases and infections.

§483.80(a) Infection prevention and control

program.
The facility must establish an infection prevention
and control program (IPCP) that must include, at
a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying,

reporting, investigating, and controlling infections
and communicable diseases for all residents,
staff, volunteers, visitors, and other individuals
providing services under a contractual
arrangement based upon the facility assessment
conducted according to §483.70(e) and following
accepted national standards;

§483.80(a)(2) Written standards, policies, and

procedures for the program, which must include,
but are not limited to:
(i) A system of surveillance designed to identify
possible communicable diseases or
infections before they can spread to other
persons in the facility;
(ii) When and to whom possible incidents of
communicable disease or infections should be
reported;
(iii) Standard and transmission-based precautions
to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a
resident; including but not limited to:
(A) The type and duration of the isolation,
depending upon the infectious agent or organism
involved, and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 2 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 2 F 880

(B) A requirement that the isolation should be the
least restrictive possible for the resident under the
circumstances.
(v) The circumstances under which the facility
must prohibit employees with a communicable
disease or infected skin lesions from direct
contact with residents or their food, if direct
contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed
by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents

identified under the facility's IPCP and the
corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and
transport linens so as to prevent the spread of
infection.

§483.80(f) Annual review.

The facility will conduct an annual review of its
IPCP and update their program, as necessary.
This REQUIREMENT is not met as evidenced
by:
Based on interview, observation, and record
review, the facility failed to ensure infection
control practices for COVID-19 were followed to
ensure residents free from symptoms of the
COVID-19 infection, on the dementia care unit,
were not exposed to and roomed with residents
who were positive for the COVID-19 infection for
2 of 22 residents on the dementia unit (Residents
B and K). This deficiency had the potential to
affect 15 of 22 residents on the dementia care
unit.

The immediate jeopardy began on 4/11/20, when

the facility elected to make the dementia care unit
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 3 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 3 F 880

the COVID-19 isolation unit. The day prior,
4/10/20, two residents who already resided on the
dementia care unit had been determined to be
positive for the COVID-19 infection (Residents F
and G). On 4/11/20, Residents C, D and E were
moved from the 300 hall (the facility's initial
isolation unit) into the dementia care unit. The
other residents, who resided on the dementia
care unit, were not transferred out of the unit
when the COVID-19 positive residents were
moved onto the unit. Two of the positive
COVID-19 residents (Residents C and H) were
placed into rooms with two residents (Residents
B and K) who were not symptomatic of
COVID-19. This placed the two dementia care
residents, as well as the other residents on the
dementia care unit, at risk of developing the
COVID-19 infection. The Executive Director (ED)
and the Director of Nursing (DON) were notified
of the immediate jeopardy on 4/16/20 at 1:43 p.m.
The immediate jeopardy was removed on
4/19/20, but noncompliance remained at pattern,
no actual harm with potential for more than
minimal harm that is not immediate jeopardy.

Findings include:

During an interview, on 4/16/20 at 9:58 a.m., the

Executive Director (ED) indicated there were
seven positive COVID-19 infection cases in the
facility. They had established the dementia care
unit the isolation unit. On 4/10/20, two of the
residents who resided on the dementia unit had
tested positive for the COVID-19 infection. Both
of the residents wandered around the unit
regularly. The ED indicated, since the residents
had been in close contact with the other residents
on the unit, prior to being determined as positive
with the infection, the remainder of the residents
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 4 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 4 F 880

on the unit were considered presumptive positive
for the infection. It was at this time, the facility
elected to make the dementia care unit the
isolation unit for COVID-19 infections. Prior to
that time, they had been using a small portion of
the 300 hall as the isolation unit, since it had fire
doors that could close it off from the remainder of
the facility. On 4/11/20, the other COVID-19
positive residents were transferred to the
dementia care unit. Due to lack of available beds,
they had to place a positive female (Resident C)
into a room with a female dementia resident
(Resident B) who was asymptomatic and had not
been tested, and a positive male resident
(Resident H) into a room with a male dementia
resident (Resident K) who was asymptomatic and
had not been tested. No communal activities or
communal dining were being held on the unit.
The staff would redirect any wandering residents
in an attempt to maintain social distancing.

During an interview, on 4/16/20 at 11:15 a.m., the

ED indicated there were 22 residents who resided
on the dementia care unit, including the seven
residents who were positive for COVID-19. The
facility did not have a plan to test any resident
unless they exhibited sign/symptoms, or unless
requested by physician or family.

During an observation, on 4/16/20 at 11:52 a.m.,

the 200 hall was observed to be the locked
dementia and isolation unit.

On 4/16/20 at 12:20 p.m., the ED provided a

document, titled "Number of Residents
Presenting with Infectious Symptoms," and
indicated it contained the current facility
information for residents with active COVID-19
infection. The document indicated the dates of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 5 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 5 F 880

the COVID-19 testing and dates when the
residents had been determined to be COVID-19
positive. The information on the document
included, but was not limited to:

-Resident D: The resident had been tested on

4/6/20, due to cough. Positive results had been
received on 4/7/20. The resident had been initially
placed on the 300 hall and had been transferred
to the dementia unit on 4/11/20. The resident had
been placed into a room with another COVID-19
positive resident (Resident E).

-Resident E: The resident had been tested on

4/8/20, due to change in Activities of Daily Living
(ADL) status. Positive results had been received
on 4/9/20. The resident had been initially placed
on the 300 hall and had been transferred to the
dementia unit on 4/11/20. The resident had been
placed into a room with another COVID-19
positive resident (Resident D).

-Resident F: The resident had been tested on

4/9/20, due to complaint of sore throat. Positive
results had been received on 4/10/20. The
resident already resided on the dementia care
unit, with a COVID-19 positive resident (Resident
G).

-Resident G: The resident had been tested on

4/9/20, due to her roommate's complaint of sore
throat and the roommate being tested. Positive
results had been received on 4/10/20. The
resident already resided on the dementia care
unit, with a COVID-19 positive resident (Resident
F).

-Resident C: The resident had been tested on

4/10/20, due to a family request. Positive results
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 6 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 6 F 880

had been received on 4/11/20. The resident had
been initially placed on the 300 hall and had been
transferred to the dementia unit on 4/11/20. The
resident had been placed into a room on the
dementia unit with Resident B, who was
asymptomatic.

-Resident H: The resident had been tested on

4/13/20, due to cough and change in ADL status.
Positive results had been received on 4/14/20.
The resident was moved from his room on the
100 hall to the dementia unit on 4/14/20. The
resident had been placed into a room on the
dementia unit with Resident K, who was
asymptomatic.

-Resident J: This resident's name did not appear

on the document. According to the ED, the
resident had transferred from a sister facility. The
resident had been determined positive for the
COVID-19 infection prior to being transferred.
The resident required dialysis, and the dialysis
unit he had used prior to the transfer had refused
to serve him due to his COVID-19 positive status.
He was approved for dialysis in the area of the
facility and had been transferred and had been
placed on the dementia unit in a room by himself.
During an observation of the 200 hall dementia
unit on 4/17/20 from 4:20 p.m. to 4:50 p.m.,
Resident B's and Resident C's names were
observed on a room with a droplet isolation sign
on the door. Resident K's and Resident H's
names were also observed on a room with a
droplet isolation sign on the door.

During an observation of the 200 hall dementia

unit and interview on 4/17/20 at 4:35 p.m., the
Nurse Consultant came out of a room with a
droplet isolation sign on the door wearing a gown
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 7 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 7 F 880

and mask. She indicated she had taken her
gloves off and washed her hands before exiting
the room. She had not removed her gown
because they were wearing the same gown to all
positive rooms then changing into a new gown
and mask before entering a negative person's
room. She indicated staff was changing gowns for
non positive resident rooms to preserve gowns.
However, she was leaving the unit, so she would
be doffing her PPE. Nurse Consultant was
observed to go into a staff-only room next to the
nurse's station and doff gown and wash hands.

The CDC (Center for Disease Control) guidance

for "Use of PPE (personal protective equipment)
when caring for Patients with a Confirmed or
Suspected COVID-19" was reviewed. The
removal of PPE guidance included, but was not
limited to:
1. Remove gloves.
2. Remove gown.
3. Healthcare provider may now exit room.
4. Perform hand hygiene.
5. Remove face shield or goggles.
6. Remove respirator.
7. Perform hand hygiene.

1. On 4/17/20 at 5:10 p.m. Resident B's record

was reviewed. A form titled, "Admission Record,"
printed 4/17/20, indicated Resident B had
diagnoses including, but not limited to, COVID
-19, Alzheimer's disease, encephalopathy,
hypertension, cognitive communication deficit,
history of transient ischemic attack and cerebral
infarction, and anxiety disorder.

A physician order, dated 3/19/20, indicated check

vital signs every shift for 90 days.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 8 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 8 F 880

A form titled, "Weights and Vitals Summary,"
dated 3/25/20 to 4/17/20, indicated Resident B
had temperatures below 99 degree Fahrenheit
(F) except for 2 days. On 3/30/20 Resident B had
a temporal artery temperature of 99 degrees F
and on 4/16/20 she had a temporal artery
temperature of 99.5 F.

A physician order, dated 4/17/20, indicated

Contact/Droplet isolation for positive COVID- 19.

A physician order, dated 4/17/20, indicated check

vital signs every 4 hours for 90 days.

2. On 4/17/20 at 5:15 p.m. Resident K's record

was reviewed. A form titled, "Admission Record,"
printed 4/17/20, indicated Resident K had
diagnoses including, but not limited to, dementia,
atrial fibrillation, type 2 diabetes mellitus (DM),
malignant neoplasm of prostate, hypertension,
and cognitive communication deficit.

A physician order, dated 3/19/20, indicated check

vital signs every shift for 90 days.

A physician order, dated 4/17/20, indicated check

vital signs every 4 hours for 90 days.

A physician order, dated 4/17/20, indicated

Contact/Droplet isolation for exposure to COVID-
19.

A form titled, "Weights and Vitals Summary,"

dated 3/26/20 to 4/17/20, indicated Resident K
had temperatures below 99 degree Fahrenheit
(F) except for one day. On 4/9/20 Resident K had
a temporal artery temperature of 99.1 degrees F.

During an interview on 4/19/20 at 12:54 p.m., the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 9 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 9 F 880

ED indicated the remainder of the residents on
the dementia unit had been tested for COVID-19
on 4/17/20, and the results of COVID-19 testing
had indicated Resident B was positive for
COVID-19. They had not received all of the
results for the residents yet. Resident K's results
were "inconclusive," and the facility was going to
swab them today to get results.

During a telephone interview on 4/19/20 at 3:40

p.m., the ED indicated he had received a call with
results for the three residents who had been
"inconclusive," and they were positive. The ED
indicated all of the residents on the locked
dementia unit were now positive for COVID-19
except for two residents.

The Indiana State Department of Health (ISDH)

Guidance for out-of-hospital facilities, dated
3/29/20, indicated, "The following is guidance for
out of hospital facilities who house patients with a
confirmed or suspected case of COVID-19. There
are a few guiding principles:...Patients/residents
with known or suspected COVID-19 should be
cared for in a single-person (private) room with
the door closed...Patients/residents with known or
suspected COVID-19 should not share
bathrooms with other patients/residents. All
patients/residents returning from the hospital with
suspected or confirmed COVID-19 should be
cared for in a private room, or cohorted with other
patients of the same status in the same unit,
wing, hallway, or building...."

CDC guidance, accessed at

https://www.cdc.gov/coronavirus/2019-ncov/hcp/l
ong-term-care.html, on 4/17/2020, entitled,
"Preparing for COVID-19: Long-term Care
Facilities, Nursing Homes," included the following:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 10 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 10 F 880

"Dedicate space in the facility to care for
residents with confirmed COVID-19. This could
be a dedicated floor, unit, or wing in the facility or
a group of rooms at the end of the unit that will be
used to cohort residents with COVID-19.
Assign dedicated HCP to work only in this area of
the facility.
Have a plan for how residents in the facility who
develop COVID-19 will be handled (e.g., transfer
to single room, prioritize for testing, transfer to
COVID-19 unit if positive).
Closely monitor roommates and other residents
who may have been exposed to an individual with
COVID-19 and, if possible, avoid placing
unexposed residents into a shared space with
them.
Create a plan for managing new admissions and
readmissions whose COVID-19 status is
unknown. Options may include placing the
resident in a single-person room or in a separate
observation area so the resident can be
monitored for evidence of COVID-19. Residents
could be transferred out of the observation area
to the main facility if they remain afebrile and
without symptoms for 14 days after their
exposure (or admission). Testing at the end of
this period could be considered to increase
certainty that the resident is not infected.
If an observation area has been created,
residents in the facility who develop symptoms
consistent with COVID-19 could be moved from
their rooms to this location while undergoing
evaluation.
All recommended PPE should be worn during
care of residents under observation; this includes
use of an N95 or higher-level respirator (or
facemask if a respirator is not available), eye
protection (i.e., goggles or a disposable face
shield that covers the front and sides of the face),
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 11 of 12
 PRINTED: 05/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
155606 B. WING _____________________________
04/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

8616 W 10TH ST
WESTSIDE RETIREMENT VILLAGE
INDIANAPOLIS, IN 46234

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 880 Continued From page 11 F 880

gloves, and gown."

CDC guidance, accessed at

https://www.cdc.gov/coronavirus/2019-ncov/hcp/i
nfection-control-recommendations.html, on
4/17/2020, entitled, "Interim Infection Prevention
and Control Recommendations for Patients with
Suspected or Confirmed Coronavirus Disease
2019 (COVID-19) in Healthcare Settings,"
included the following:
"It might not be possible to distinguish patients
who have COVID-19 from patients with other
respiratory viruses. As such, patients with
different respiratory pathogens might be housed
on the same unit. However, only patients with the
same respiratory pathogen may be housed in the
same room. For example, a patient with
COVID-19 should ideally not be housed in the
same room as a patient with an undiagnosed
respiratory infection."

The immediate jeopardy that began on 4/11/20

was removed on 4/19/20 when the facility had
inserviced staff, tested all residents on the
dementia unit and cohorted and/or isolated
residents appropriately. Noncompliance remained
at the reduced scope and severity of pattern, no
actual harm with potential for more than minimal
harm that is not immediate jeopardy, because of
the facility's need to continue to monitor.

This Federal tag related to Complaints

IN00324612 and IN00324657.

3.1-18(a)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ECEA11 Facility ID: 000497 If continuation sheet Page 12 of 12