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Findings describe inadequate evaluation and response to a resident’s change in condition (Resident B), including missed acknowledgment of out-of-range vital signs and related clinical review gaps.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/rwmc11-facility-id-010680-statement-of-deficiencies-and-plan-of-correction/252895/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/rwmc11-facility-id-010680-statement-of-deficiencies-and-plan-of-correction/252895.png","ImageObject",442,249,{"name":42,"@type":43},"Asher","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-27","2026-09-13",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What is the purpose of the Statement of Deficiencies and Plan of Correction in this document?","Question",{"text":63,"@type":64},"It documents CMS survey findings, links them to specific regulatory requirements, and records the provider’s plan of correction associated with cited deficiencies.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which complaints were investigated and what were their outcomes?",{"text":68,"@type":64},"The visit investigated complaints IN00333976, IN00334119, and IN00334127, with IN00333976 and IN00334119 substantiated and IN00334127 unsubstantiated due to lack of evidence.",{"name":70,"@type":61,"acceptedAnswer":71},"What deficiency is cited regarding the resident’s change in condition?",{"text":72,"@type":64},"The facility failed to adequately evaluate and address a resident’s change in condition for Resident B, including not acknowledging or addressing out-of-normal-range vital signs in the clinical record.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},252895,1789263343,{"code":4,"msg":82,"data":83},"success",[84,88,93,98,103,108,112,117,122],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":120,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":80,"read_time":26},687197207639,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES  \nPRINTED: 08/24/2020 FORM APPROVED  \nOMB NO. 0938-0391  \n\n| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |  | (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: | (X2) MULTIPLE CONSTRUCTION\u003Cbr>A. BUILDING  00 \u003Cbr>B. WING\u003Cbr>|  |  | (X3) DATE SURVEY\u003Cbr>COMPLETED\u003Cbr>08/06/2020 |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| NAME OF PROVIDER OR SUPPLIER\u003Cbr>KEEPSAKE VILLAGE OF COLUMBUS |  |  |  | STREET ADDRESS, CITY, STATE, ZIP CODE\u003Cbr>2564 FOXPOINTE DR\u003Cbr>COLUMBUS, IN 47203 |  |  |  |  |  |\n| (X4) ID\u003Cbr>PREFIX\u003Cbr>TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |  | ID\u003Cbr>PREFIX\u003Cbr>TAG |  | PROVIDER'S PLAN OF CORRECTION\u003Cbr>(EACH CORRECTIVE ACTION SHOULD BE\u003Cbr>CROSS-REFERENCED TO THE APPROPRIATE\u003Cbr>DEFICIENCY) |  | (X5) COMPLETION\u003Cbr>DATE |  |  |\n| R 0000\u003Cbr>Bldg. 00\u003Cbr>R 0216\u003Cbr>Bldg. 00 | This visit was for the Investigation of Complaints IN00333976, IN00334119, and IN00334127 .\u003Cbr>This visit included a COVID-19 Quality Assurance Walk Through.\u003Cbr>Complaint IN00333976-Substantiated. State Residential Finding related to the allegations is cited at R00216 .\u003Cbr>Complaint IN00334119-Substantiated. No deficiencies related to the allegations are cited.\u003Cbr>Complaint IN00334127-Unsubstantiated due to lack of evidence.\u003Cbr>Survey dates: August 5 and 6, 2020.\u003Cbr>Facility number: 010680\u003Cbr>Residential Census: 32\u003Cbr>These State Residential Findings are cited in accordance with 410 IAC 16.2-5.\u003Cbr>Quality review completed on August 12, 2020.\u003Cbr>410 IAC 16.2-5-2(c)(1-4)(d) Evaluation-Noncompliance\u003Cbr>(c) The scope and content of the evaluation shall be delineated in the facility policy manual, but at a minimum the needs assessment shall include an evaluation of the following:\u003Cbr>(1) The resident ' s physical, cognitive, and mental status.\u003Cbr>(2) The resident ' s independence in the activities of daily living. |  | R 0000 |  |  |  | |  |  |\n\nLABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE  \nAny defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.  \nState Form Event ID: RWMC11 Facility ID: 010680 If continuation sheet Page 1 of 5  \nDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES  \nPRINTED: 08/24/2020 FORM APPROVED  \nOMB NO. 0938-0391  \n\n| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |  | (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: | (X2) MULTIPLE CONSTRUCTION\u003Cbr>A. BUILDING  00 \u003Cbr>B. WING\u003Cbr>|  |  | (X3) DATE SURVEY\u003Cbr>COMPLETED\u003Cbr>08/06/2020 |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| NAME OF PROVIDER OR SUPPLIER\u003Cbr>KEEPSAKE VILLAGE OF COLUMBUS |  |  |  | STREET ADDRESS, CITY, STATE, ZIP CODE\u003Cbr>2564 FOXPOINTE DR\u003Cbr>COLUMBUS, IN 47203 |  |  |  |  |  |\n| (X4) ID\u003Cbr>PREFIX\u003Cbr>TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |  | ID\u003Cbr>PREFIX\u003Cbr>TAG |  | PROVIDER'S PLAN OF CORRECTION\u003Cbr>(EACH CORRECTIVE ACTION SHOULD BE\u003Cbr>CROSS-REFERENCED TO THE APPROPRIATE\u003Cbr>DEFICIENCY) |  | (X5) COMPLETION\u003Cbr>DATE |  |  |\n|  | (3) The resident ' s weight taken on admission and semiannually thereafter.\u003Cbr>(4) If applicable, the resident ' s ability to self-administer medications.\u003Cbr>(d) The evaluation ","cbCaiut1siUXD4SO","https://ap.wps.com/l/cbCaiut1siUXD4SO","pdf",109149,"English","# Statement of Deficiencies and Plan of Correction\n## Complaint and Survey Summary\n## Regulatory Evaluation Requirements\n## Resident Change in Condition Finding\n## Plan of Correction Submission Notes","[{\"question\":\"What is the purpose of the Statement of Deficiencies and Plan of Correction in this document?\",\"answer\":\"It documents CMS survey findings, links them to specific regulatory requirements, and records the provider’s plan of correction associated with cited deficiencies.\"},{\"question\":\"Which complaints were investigated and what were their outcomes?\",\"answer\":\"The visit investigated complaints IN00333976, IN00334119, and IN00334127, with IN00333976 and IN00334119 substantiated and IN00334127 unsubstantiated due to lack of evidence.\"},{\"question\":\"What deficiency is cited regarding the resident’s change in condition?\",\"answer\":\"The facility failed to adequately evaluate and address a resident’s change in condition for Resident B, including not acknowledging or addressing out-of-normal-range vital signs in the clinical record.\"}]","RWMC11 Facility ID 010680 - Statement of Deficiencies and Plan of Correction | PDF"]