PRINTED: 02/21/2018 DEPARTMENT OF HEALTH AND …Therapist asked an CNA to assist Resident C, the CNA...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

02/21/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

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B. WING

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NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

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DEFICIENCY)

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DATECROSS-REFERENCED TO THE APPROPRIATE

LEBANON, IN 46052

155680 01/11/2018

HOMEWOOD HEALTH CAMPUS

2494 N LEBANON ST

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey. This visit included the

Investigation of Nursing Home Complaint

IN00241909. This visit included the

Investigation of Residential Complaint

IN00242615.

Nursing Home Complaint IN00241909 -

Substantiated. Federal / State deficiencies

related to allegations are cited at F550,

F689, F690, and F697.

Residential Complaint IN00242615 -

Substantiated. No deficiencies related to

allegations are cited.

Survey dates: January 2, 3, 4, 5, 8, 9, 10

and 11, 2018

Facility number: 002703

Provider number: 155680

AIM number: 200309250

Census Bed Type:

SNF/NF: 42

SNF: 20

Residential: 34

Total: 96

Census Payor Type:

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

Recertification and Complaint visit

with exit on January 11, 2018.

Please accept this plan of

correction as the provider's credible

allegation of compliance as of

February 10, 2018. The provider

respectfully requests a desk review

with paper compliance to be

considered in establishing that the

provider is in substantial

compliance.

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: IOFB11 Facility ID: 002703

TITLE

If continuation sheet of 40

(X6) DATE




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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

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Medicare: 10

Medicaid: 31

Other: 21

Total: 62

These deficiencies reflect State Findings

cited in accordance with 410 IAC 16.2-3.1.

Quality Review was completed on January

22, 2018.

483.10(a)(1)(2)(b)(1)(2)

Resident Rights/Exercise of Rights

§483.10(a) Resident Rights.

The resident has a right to a dignified

existence, self-determination, and

communication with and access to persons

and services inside and outside the facility,

including those specified in this section.

§483.10(a)(1) A facility must treat each

resident with respect and dignity and care for

each resident in a manner and in an

environment that promotes maintenance or

enhancement of his or her quality of life,

recognizing each resident's individuality. The

facility must protect and promote the rights of

the resident.

F 0550

SS=D

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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet of 40




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§483.10(a)(2) The facility must provide equal

access to quality care regardless of

diagnosis, severity of condition, or payment

source. A facility must establish and

maintain identical policies and practices

regarding transfer, discharge, and the

provision of services under the State plan for

all residents regardless of payment source.

§483.10(b) Exercise of Rights.

The resident has the right to exercise his or

her rights as a resident of the facility and as

a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that

the resident can exercise his or her rights

without interference, coercion, discrimination,

or reprisal from the facility.

§483.10(b)(2) The resident has the right to be

free of interference, coercion, discrimination,

and reprisal from the facility in exercising his

or her rights and to be supported by the

facility in the exercise of his or her rights as

required under this subpart.

Based on observation, interview and record

review the facility failed to ensure a resident

was treated with dignity, had needs met

timely and was not spoken to in a scolding

manner for 1 of 3 residents observed for

dignity. (Resident C).

Finding includes:

The record for Resident C was reviewed on

1/8/18 at 12:25 p.m. Diagnoses included,

but were not limited to cerebral infarction,

F 0550 1.Resident # C had necessary

care provided, Social Services

interviewed resident to evaluate for

any psychosocial distress, and

resident reported no distress and

stated that staff treat him with

dignity and respect. Social

Services will continue to follow up

as needed.

2.All residents in the Health

Care Center have the potential to

be effected by the alleged deficient

practice. Director of health

Services and\or Designee will

conduct interviews with like

02/10/2018 12:00:00AM





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155680 01/11/2018


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major depressive disorder and dysphasia.

During an interview, on 1/2/18 at 1:00 p.m.,

Resident C indicated since his recent arrival

to the facility he has often had to wait over

an hour to receive help with incontinent care

and getting into bed. Resident C indicated

he often pushes his call light, an aid would

respond to the light, turn the light off and say

she would come back, but would not return

for a long time. Resident C indicated he

was frustrated and afraid of retaliation from

the aids and that his care would be affected

if he complained about the call light response

times. At that time, Resident C indicated he

had returned from physical therapy at 12:00

p.m., he had requested from the Physical

Therapist to change his soiled brief and to

be put back into bed. The Physical

Therapist asked an CNA to assist Resident

C, the CNA responded she would find help

and come back to help Resident C. The

Physica Therapist was unable identify the

CNA.


Physical Therapist Assistant 1 indicated

Resident C had communicated his brief was

solid and he needed assistance to be put into

bed. Physical Therapist Assistant 1

indicated she told an CNA, at about 12:00

p.m., concerning Resident C's request for

residents on the Health Care

Center to ensure they are

receiving care in a timely manner

and being treated with Dignity and

Respect.

3.As a measure of ongoing

compliance, The Director of Health

Services and/or Designee will

complete education with nursing

staff related to providing care in a

timely manner, and resident

rights. Daily rounds will be

completed at the Health Care

Center to ensure residents are

receiving care in a timely manner,

any concerns related to Dignity

and Respect will be addressed

immediately. The Director of

health Services or Designee will

complete an audit to include five

residents three times weekly for

30 days, then weekly for 30 days,

then monthly ongoing to ensure

residents rights are honored in

regards to being treated with

dignity and respect, having needs

met timely, and spoken to in a

kind manner.

4.For quality assurance, DHS or

designee will review any findings,

and subsequent corrective actions

at least quarterly in the campus

quality assurance meeting. The

plan will be revised, as warranted.

The QA team will review audits at

least quarterly and increase

frequency of audits if increased

concerns noted and will decrease

the frequency of audits if no

concerns are noted.





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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

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help and the CNA indicated she would get

help and be right back to help. The physical

therapist was unable identify the CNA.

During a continuous observation of Resident

C on 1/2/18 from 1:00 p.m. to 1:47 p.m.,

Resident C was observed sitting in his

wheelchair alone in his room, a strong odor

was noted. Resident C had a grimace on his

face and his head was bent down resting in

his hands. CNA 3 and CNA 4 were

observed during this time on the unit, but did

not check on Resident C or assist him in any

way.


CNA 3 indicated she had been told at 12:00

p.m., Resident C needed assistance with

incontinent care, was having pain, and

needed help to go to bed. CNA 3 indicated

almost two hours was too long for a resident

to have to wait for care, and usually a

resident would wait between fifteen to

twenty minutes.

On 1/2/18 at 1:57 p.m., LPN 5 was

observed using a harsh tone, criticizing

Resident C for not pushing his call light again

after his first request for assistance went

unanswered. Resident C had a troubled

expression on his face during his encounter

with LPN 5. Resident C told LPN 5 he had





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requested help, but did not receive help.

LPN 5 again, scolded Resident C for not

pushing the call light again.

A Care Plan for Resident C, titled, "Social

Aspects", dated 12/18/17, indicated,

"Resident C demonstrates altered mood due

to recent life losses and admission to the

facility...Goal: Resident C's altered mood

will not result in uncompensated

depression...Approach...Observe resident's

adjustment to the facility, rehab program and

daily activity...offer routine schedules and

consistency of care...."

A Care Plan for Resident C, dated

12/30/17, indicated, "Resident C had an

impairment in functional status in regards to

bed mobility, toileting and eating related to

recent decline and history of cardiovascular

accident...Approach: Resident C requires

dependant assist with transfers with

mechanical lift and assistance of two staff

members...Extensive assist with toileting...."

A current facility policy, titled, "Perineal

Care for the Incontinent Guideline", received

from the Corporate Consultant on 1/4/18 at

9:15 a.m., indicated, "...Purpose: to provide

incontinence care that will keep skin from

being exposed to prolonged periods of urine

and feces...."





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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

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This Federal tag relates to Complaint

IN00241909.

3.1-3(t)

483.21(b)(1)

Develop/Implement Comprehensive Care Plan

§483.21(b) Comprehensive Care Plans

§483.21(b)(1) The facility must develop and

implement a comprehensive person-centered

care plan for each resident, consistent with

the resident rights set forth at §483.10(c)(2)

and §483.10(c)(3), that includes measurable

objectives and timeframes to meet a

resident's medical, nursing, and mental and

psychosocial needs that are identified in the

comprehensive assessment. The

comprehensive care plan must describe the

following -

(i) The services that are to be furnished to

attain or maintain the resident's highest

practicable physical, mental, and

psychosocial well-being as required under

§483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be

required under §483.24, §483.25 or §483.40

but are not provided due to the resident's

exercise of rights under §483.10, including

the right to refuse treatment under §483.10(c)

(6).

(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with

the findings of the PASARR, it must indicate

its rationale in the resident's medical record.

F 0656

SS=D

Bldg. 00





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(iv)In consultation with the resident and the

resident's representative(s)-

(A) The resident's goals for admission and

desired outcomes.

(B) The resident's preference and potential for

future discharge. Facilities must document

whether the resident's desire to return to the

community was assessed and any referrals

to local contact agencies and/or other

appropriate entities, for this purpose.

(C) Discharge plans in the comprehensive

care plan, as appropriate, in accordance with

the requirements set forth in paragraph (c) of

this section.

Based on interview and record review the

facility failed to develop a person centered

care plan to meet resident's needs regarding

pressure ulcers (Resident 60), risk of

constipation and use of narcotic pain

medication (resident 55) for 2 of 7 residents

reviewed for care plans.

Findings include:

1. Resident 60's record was reviewed on


but were not limited to: neuropathy,

dementia and anxiety disorder.

A facility document titled, "wound

management," provided by the corporate

clinical support nurse on 1/05/2018 at 5:55

p.m., indicated a DTI (deep tissue injury),

measuring 2 cm (centimeters) by 2 cm was

identified on resident 60's left heel on

F 0656 1.Resident # 60 Care Plan was

updated to reflect Deep tissue

injury. Resident # 55 Care Plan

was updated to reflect risk for

constipation and Narcotic Pain

medication use.


Care Center that are at risk for

constipation, use narcotic pain

medication, or that currently have

a pressure ulcers have the

potential to be affected by alleged

deficient practice. Director of

health Services and\or Designee

will complete a care plan audit of

residents at risk for constipation,

use narcotic pain medication, and

have Current pressure ulcer to

ensure care plans reflect

resident’s current needs. The

Director of Health Services and/or

Designee will conduct an

in-services with nurse leaders

related to Resident specific care

plans, including constipation,

pressure ulcers, and narcotic pain

02/10/2018 12:00:00AM





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12/23/2017 at 6:03 a.m.

A physician's order, dated 12/26/2017,

indicated," ... Left heel DTI...Apply skin

prep [a topical medication which creates a

barrier to protect sensitive skin] to heel and

allow to dry. Apply Allevyn [an adhesive

foam dressing] to heel; change weekly and

PRN [as needed]...."

The complete care plan for resident 60 did

not address the DTI to Resident 60's left

heel.


1/05/2018, at 3:26 p.m. Diagnoses

included, but were not limited to, Diabetes

Mellitus, anxiety disorder, hypertension, end

stage renal disease and cognitive

communication deficit.

Physician's orders included, but were not

limited to,

"...docusate sodium 100 mg [milligrams]

twice a day...Hold for loose bowels or

diarrhea...." Dated 05/01/2017.

"...Senna-S [a stool softener and laxative]

8.6-50 mg at bedtime...." Dated

08/11/2017.

"...Percocet [a narcotic pain medication]

10/325 mg at bedtime...." Dated

08/01/2017.

medication use. Additionally, new

orders received will be reviewed in

the daily morning meeting with the

IDT team to ensure care plans

addressing new orders are in

place as indicated.

3.As a measure of quality

assurance, the DHS or designee

will complete an audit to ensure

care plans are developed and

revised as appropriate. The audit

will include five residents care

plans reviewed three times weekly

for 30 days, then weekly for 30

days, then monthly ongoing.

4.For quality assurance, the

DHS or designee will review any

findings, and subsequent

corrective actions at least

quarterly in the campus quarterly

quality assurance meeting. The

plan will be revised, as warranted.

The QA team will review audits at

least quarterly and increase

frequency of audits if increased

concerns noted and will decrease

the frequency of audits if no

concerns are noted.





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"...Percocet 10-325 mg every 6 hours -

PRN...." Dated 08/08/2017.

"...polyethylene glycol 3350 [a laxative] 17

grams in 5 ounces of fluid of choice each

day...." Dated 05/01/2017.

A document titled "Resident BM

description," received from the Director of

Health Services (DHS) on 1/05/2018 at

8:30 a.m., indicated resident 55 had no

bowel movements on the dates of

12/02/2017 through 12/05/2017 (four days)

and 12/07/2017 through 12/10/2017 (four

days).

The record lacked a plan or care for

constipation or pain.

During an interview on 1/11/2018, the DHS

indicated interventions were in place for

resident 60's DTI. She also indicated

resident 55 should have had a care plan to

address her risk for constipation and

narcotic pain medication use. The facility

was unable to provide care plans addressing

the DTI to resident 60's left heel, risk of

constipation, or use of a narcotic pain

medication for resident 55 dated before

1/11/2018.

3.1-35(a)

3.1-35(b)(1)





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483.25(b)(1)(i)(ii)

Treatment/Svcs to Prevent/Heal Pressure

Ulcer

§483.25(b) Skin Integrity

§483.25(b)(1) Pressure ulcers.

Based on the comprehensive assessment of

a resident, the facility must ensure that-

(i) A resident receives care, consistent with

professional standards of practice, to prevent

pressure ulcers and does not develop

pressure ulcers unless the individual's clinical

condition demonstrates that they were

unavoidable; and

(ii) A resident with pressure ulcers receives

necessary treatment and services, consistent

with professional standards of practice, to

promote healing, prevent infection and prevent

new ulcers from developing.

F 0686

SS=D

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review the facility failed to maintain infection

control standards, failed to perform hand

hygiene before and after providing direct

patient care when changing gloves during a

dressing change for a resident with a

pressure ulcer (Resident 60).

Finding includes;

During a dressing change for resident 60, on

1/09/18 at 11:55 a.m., the DHS (Director of

Health Services) and RN 9 were in

attendance and the following was observed:

F 0686 1.Resident # 60 was pressure

ulcer was assessed with no

adverse effects noted. Staff

involved were immediately

re-educated on handewashing and

glove use standards.


Care Center That have orders for a

dressing change have the potential

to be affected by alleged deficient

practice. Nursing staff will receive

education on the dressing change

procedure, handwashing, and

glove use.


compliance, the Director of Health


observe dressing changes on up

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RN 9 applied sanitizer to her hands and

gathered supplies from the treatment cart.

The DHS entered Resident 60's room, took

a pair of gloves from the bathroom,

proceeded to the resident's bedside and put

on the gloves without performing hand

hygiene. RN 6 entered Resident 60's room

and placed the dressing supplies on the

bedside table. She used the bathroom sink

to wash her hands with soap and water

before putting on clean gloves. With gloved

hands RN 9 adjusted the height of the

resident's bed and pulled the privacy curtain

closed. She then positioned Resident 60 on

to her right side where the DHS was

standing to ensure the resident would not fall

off the bed and to hold the resident onto her

side. RN 9 then placed resident 60's left

foot on a cloth barrier, removed her soiled

gloves and without performing hand hygiene,

she put on a clean pair of gloves. RN 9

removed the soiled dressing, cleansed the

wound with a gauze pad moistened with

wound cleanser, then used a dry gauze pad

to pat the area dry. She once again

removed her soiled gloves and put on clean

gloves without performing hand hygiene.

RN 9 applied skin prep (a topical

medication which creates a barrier to

protect sensitive skin), to the area and

measured the length and width of the

to 5 residents three times weekly

for 30 days, then weekly for 30

days, then monthly ongoing to

ensure handwashing and glove

use is performed per policy and

standards. Any concerns noted

will be addressed immediately and

re-education provided as needed.


DHS or Designee will review any



quarterly in the campus quality

assurance meeting. The plan will

be revised, as warranted. The QA

team will review audits at least

quarterly and increase frequency

of audits if increased concerns

noted and will decrease the

frequency of audits if no concerns

are noted.





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wound. She then applied an Allevyn (an

adhesive foam dressing) over the wound,

replaced resident 60's boot, repositioned

her ensuring to float her heels, returned the

bed to the lowest position and checked the

call light location . The DHS opened a trash

bag and RN 9 disposed of the trash. The

DHS and RN 9 removed their soiled gloves

and exited the resident's room without

performing hand hygiene.

During an interview at that time, the DHS

indicated she did not perform hand hygiene

prior to putting on gloves because she was

only going to be holding the resident.

Resident 60's record was reviewed on

1/05/2018 at 5:55 p.m. Diagnoses

included, but were not limited to;

neuropathy, dementia and anxiety disorder.

A physician's order dated 12/26/2017,

indicated,"...Apply skin prep (a topical

medication which creates a barrier to

protect sensitive skin) to left heel DTI (deep

tissue injury) allow to dry. Apply Allevyn (an

adhesive foam dressing) to heel; change

weekly and PRN (as needed)...."

A facility document titled "SOP for dressing

changes," provided by the DHS on

1/09/2018 at 2:30 p.m., indicated, " ...4.





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Open dressing pack ...5. Wash hands with

soap and water ...6. Put on first pair of

disposable gloves ...7. Removed soiled

dressing ...8. dispose of gloves ...9. Wash

hands with soap and water ...10. Put on

second pair of disposable gloves ...11.

Follow doctors' recommendations for

treatment ...12. Apply dressing ...14.

Remove gloves and discard with all unused

supplies ...15. Wash hands with soap and

water ...."

A facility document titled "guideline for hand

washing/and hygiene", provided by the

executive director on 01/03/2018 at 8:22

a.m., indicated, " ... 3. Health Care workers

shall use hand hygiene at times such as ... c.

before/after having direct physical contact

with residents ...d. After removing gloves

...."

3.1-40(a)(2)

483.25(d)(1)(2)

Free of Accident

Hazards/Supervision/Devices

§483.25(d) Accidents.

The facility must ensure that -

§483.25(d)(1) The resident environment

remains as free of accident hazards as is

possible; and

F 0689

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(X5)

COMPLETION


LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

00

§483.25(d)(2)Each resident receives

adequate supervision and assistance devices

to prevent accidents.


review the facility failed to implement fall

interventions for 3 of 3 residents observed

for accidents (Resident B, Resident E and

Resident F).

Finding includes:

1. On 1/03/18 at 2:16 p.m., Resident B was

observed sitting in his wheelchair in his

bedroom unattended by staff.

The record for Resident B was reviewed on

1/04/18 at 10:06 a.m. Diagnoses included,

but were not limited to, neoplasm of the

brain, anxiety disorder and dysphasia.

A fall report, dated 11/20/17, indicated,

"...Resident B noted to have slid out of

wheelchair after getting up from afternoon

nap...Intervention is to educate caregivers to

not leave Resident B in room unattended

unless in bed.

A care plan, dated 03/23/17, indicated,

"Resident B has a history of falls related to

brain cancer, seizures, cognitive and mobility

impairment ...Do not leave unattended in

room unless in bed ...Please offer to assist

Resident B with laying down in bed after

F 0689 1.Resident # B, E, and F were

effected. Fall interventions were

updated and care plans revised as

indicated for these residents.


Care Center at risk for falls have

the potential to be affected by

alleged deficient practice. Director

of health Services and\or Designee

will complete Health Care Center

audit to review residents fall

interventions to ensure they are

appropriate and care planned as

appropriate. The Director of Health


conduct an in-service with nursing

staff related to fall interventions.

New falls that occur will be

reviewed in the daily morning

meeting by the IDT to ensure

appropriate interventions are in

place and care planned as such.


compliance, the DHS or designee


interventions are in place as care

planned. This audit will include five

residents’ interventions being

observed three times weekly for 30

days, then weekly for 30 days,

then monthly ongoing.




02/10/2018 12:00:00AM





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OMB NO. 0938-039




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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

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meals to prevent falls and/or fall related

injuries ...."

2. A record review for Resident E was

completed on 1/03/18 at 1:28 p.m.

Diagnoses included, but were not limited to,

Alzheimer's Disease, dementia with

behavioral disturbance and age-related

osteoporosis with current pathological

fracture of left femur.

A care plan, with a start date of 11/15/17,

indicated, "...Resident at risk for

falling...decreased safety awareness...

Do not leave in room unattended ...."

An IDT (interdisciplinary team) note,

recorded as a late entry on 11/15/17, was

provided by the DHS (Director of Health

Services) on 01/03/18 at 4:05 p.m.,

indicated "...new intervention...not to leave

resident in wheelchair in her room alone...."

During an observation on 1/05/18 at 9:07

a.m., Resident E was up in her wheelchair

alone in her room. At that time, LPN 1

indicated the CRCA (Certified Resident

Care Associate) got Resident E up and the

current CRCA information sheets did not

have all the information the CRCAs needed.

LPN 1 indicated Resident E's care plan did

include Resident E could not be left alone in

her room.




be revised as warranted. The QA






are noted.





02/21/2018PRINTED:

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OMB NO. 0938-039




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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

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During an observation on 1/05/18 at 3:35

p.m., Resident E was observed sitting in her

wheelchair alone in her room. At that time,

LPN 6 indicated Resident E's daughter left

Resident E alone in her room.

3. The record for Resident F was reviewed

on 1/05/18 at 3:30 p.m. Diagnoses

included, but were not limited to,

degenerative disease of the nervous system,

hypertension and osteoporosis.


"...While attempting to transfer self from

wheelchair to standing position Resident Fell

to the floor...."


"...Resident in wheelchair in bathroom...was

reaching for hair brush on sink and slipped

out of wheelchair...."


"...Res. found on floor in bathroom...."


"...Resident was in the bathroom attempting

to toilet herself, when she fell...."


"...Resident noted to have fall in room...."





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OMB NO. 0938-039




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LEBANON, IN 46052

155680 01/11/2018


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A care plan, dated 10/17/17, indicated,

Resident F was at risk for falling related to

weakness. An intervention dated 10/17/17,

indicated the staff was to assist the resident

with transfers as needed. Keep frequently

utilized items for grooming in easily

accessible location in bathroom. An

intervention dated 10/25/17, indicated do

not leave the resident unattended in room.

An undated CNA assignment sheet,

provided by the Director of Health Services

(DHS), on 1/04/18 at 2:00 p.m., indicated

Resident F was not to be left unattended in

room unless in recliner or bed. At that time

the DHS indicated Resident F should not be

left unattended in the bathroom or her

bedroom.

An Admission MDS (Minimum Data set),

dated 10/19/17, indicated Resident F's

functional status was an extensive assist with

transfers and toilet use. Resident F was not

steady and only able to stabilize herself with

staff assistance, this included moving on and

off the toilet and surface to surface transfers

between bed and wheelchair.

On 1/02/18 at 11:03 a.m., Resident F was

observed sitting in her wheelchair in her

bedroom unattended.





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OMB NO. 0938-039




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155680 01/11/2018


2494 N LEBANON ST

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On 1/02/18 at 1:19 p.m., Resident F was


bedroom unattended.



bedroom unattended



bedroom unattended.

On 1/09/18 at 9:17 a.m., Resident F was


bedroom unattended.

On 1/09/18 9:49 a.m., Resident F was


bedroom unattended.

A current policy titled "Fall Management

Program Guidelines" dated 5/31/17,

provided by the DON on 1/03/18 at 3:45

p.m., indicated "...b. Care plan interventions

should be implemented that address the

resident's risk factors...."

A current policy titled "Interdisciplinary

Team Care Guideline," provided by the

Corporate RN, on 1/09/18 at 9:50 a.m.,

indicated "...g. Nurse managers shall

communicate pertinent care plan approaches





02/21/2018PRINTED:

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LEBANON, IN 46052

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to the nursing staff...."

This Federal Tag relates to Complaint

IN00241909.

3.1-45(a)(2)

483.25(e)(1)-(3)

Bowel/Bladder Incontinence, Catheter, UTI

§483.25(e) Incontinence.

§483.25(e)(1) The facility must ensure that

resident who is continent of bladder and

bowel on admission receives services and

assistance to maintain continence unless his

or her clinical condition is or becomes such

that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary

incontinence, based on the resident's

comprehensive assessment, the facility must

ensure that-

(i) A resident who enters the facility without

an indwelling catheter is not catheterized

unless the resident's clinical condition

demonstrates that catheterization was

necessary;

(ii) A resident who enters the facility with an

indwelling catheter or subsequently receives

one is assessed for removal of the catheter

as soon as possible unless the resident's

clinical condition demonstrates that

catheterization is necessary; and

(iii) A resident who is incontinent of bladder

F 0690

SS=E

Bldg. 00





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155680 01/11/2018


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receives appropriate treatment and services

to prevent urinary tract infections and to

restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal

incontinence, based on the resident's

comprehensive assessment, the facility must

ensure that a resident who is incontinent of

bowel receives appropriate treatment and

services to restore as much normal bowel

function as possible.


review the facility failed to monitor bowel

movements and intervene as needed to

promote bowel movements for 4 of 4

residents reviewed for bowel movements.

(Resident 43, Resident 42, Resident 55 and

Resident 56) and the facility failed to

provide urinary incontinent care timely for 1

of 3 residents reviewed for urinary

incontinence. (Resident C)

Findings include:



but were not limited to, heart failure,

dementia, schizophrenia, depressive

disorders and epilepsy.



Health Services (DHS), on 1/05/2018 at

8:30 a.m., indicated Resident 43 had not

F 0690 1.Resident # 43, 55, 56, and 42

were immediately assessed and

no adverse effects were noted.

Resident # C was immediately

provided care.

2.All residents have the potential

to be effected. The Director of


will complete a Health Care Center

audit to identify residents that

require assistance with

toileting/incontinence care, and

will ensure toileting and

assistance plans are in place as

appropriate. All residents’ bowel

movements were reviewed to

ensure they were having bowel

movements routinely, bowel

protocol orders were initiated as

ordered.

The Director of Health Services

and/or Designee will conduct

in-services with nursing staff

related to monitoring for bowel

movements, the bowel movement

protocol and toileting/ incontinent

plans. The MDS Coordinator will

monitor resident bowel movements

and initiation of the bowel protocol

02/10/2018 12:00:00AM





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OMB NO. 0938-039




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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

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had any bowel movements on the dates of

12/04/2017 through 12/07/2017 (four

days), 12/09/2017 through 12/14/2017

(seven days) and 12/17/2017 through

12/19/2017 (three days).

A care plan, revised on 8/21/2017

indicated, " ...I am at risk for constipation r/t

[related to] decreased mobility, medications

...Administer my bowel medications as

ordered ...If I have no BM [bowel

movement] x 3 days, initiate bowel care. If,

after you have exhausted all interventions, I

still have not had a bowel movement, notify

the doctor ...Observe me for and record my

BMs every shift ...."

The medication administration record for

December 2017 indicated none of the

bowel protocol treatments including: natural

laxative, milk of magnesia, Dulcolax

suppository, or fleets enema were

administered to Resident 43 from

12/01/2017 through 12/31/2017.



included, but were not limited to, diabetes

mellitus, anxiety disorder, hypertension, end



and results as a second check

daily on regularly scheduled days.

Any problems noted will be

reviewed in the daily Clinical Care

Meeting.


compliance, the Director of Health

Services and\or Designee will

complete and audit of bowel

movements and ensure residents

are toileted and/or incontinence

care is provided timely. This audit

will include five residents three

times weekly for 30 days, then

weekly for 30 days, then monthly

ongoing.




corrective action at least quarterly

in the campus quality assurance

meeting. The plan will be revised

as warranted. The QA team will

review audits at least quarterly and

increase frequency of audits if

increased concerns noted and will

decrease the frequency of audits f

no concerns are noted.





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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

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Health Services on 1/05/2018 at 8:30 a.m.,

indicated resident 55 had not had any bowel

movements on the dates of 12/02/2017

through 12/05/2017 (four days) and

12/07/2017 through 12/10/2017 (four

days).

The MAR for December 2017, received

from the DHS on 01/05/2018 at 8:30 a.m.,

indicated none of the bowel protocol

treatments including: natural laxative-, milk

of magnesia, Dulcolax suppository, or fleets

enema were administered to Resident 55

from 12/01/2017 through 12/31/2017.

The facility was unable to produce a current

care plan which addressed Resident 55's

risk for constipation.

During an interview on 1/05/18 at 4:15 p.m.,

the DON indicated the MDS (minimum data

set) coordinator reviewed the charting of

bowel movements to identify any residents

who had not had a bowel movement in three

days or more.


the MDS coordinator indicated she only

checked the BM charting to ensure it was

completed on each shift, but she did not





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evaluate the content of the charting or assess

the clinical implications it had on the

residents. She also indicated that the

previous Medical records nurse had

evaluated BM charting to ensure residents

had regular bowel movements but she was

unsure if the current medical records

coordinator took over the task.


the medical records nurse indicated no one

had ever assigned her the responsibility of

reviewing BM charting.


the DON indicated she did not know what

staff member, if any, was responsible for

monitoring resident's bowel movements.


LPN 1 indicated he was unaware of who

was responsible for monitoring BMs. Night

shift nurses used to run BM reports, then

medical records did it for a while, but he had

not seen any BM reports in a long time.

3. During an observation on 1/04/18 at 1:41

p.m., Resident 56 complained of abdominal

cramping. At that time, LPN 2 indicated

Resident 56 had complained of menstrual

cramps and she would check on her.





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155680 01/11/2018


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A review of Resident 56's record was

completed on 1/05/18 at 8:56 a.m.


irritable bowel syndrome with constipation,

Alzheimer's disease and muscle weakness.

A report titled, "Resident BM Description"

was provided by the Corporate RN on

1/05/18 at 4: 10 p.m. The report indicated

Resident 56 had not had a bowel movement

from 12/06/17 to 12/21/17 (16 days) and

from 1/01/18 to 1/04/18 (4 days).

A care plan dated 7/27/17, provided by the

DHS (Director of Health Services)

indicated, "...goal... to have no GI

pain/discomfort...Observe me

for...abdominal cramps...."

The nurse's notes and events for Resident

56 were reviewed on 01/05/18 at 3:37

p.m., no progress note or bowel event was

present.

During an interview with RN 8, on 1/08/18

at 2:59 p.m., she indicated she had not seen

a bowel movement follow up list for well

over a month. The monitoring use to be

done by the unit manager but she was no

longer with the facility and RN 8 was not

sure who did the monitoring and made a

follow up list for treating residents who had





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not had regular bowel movements.

In an interview with the DHS on 1/11/18, at

9:12 a.m., the DHS indicated Resident 56

was not given any medications, on an as

needed basis, during the periods

documented that indicated Resident 56 had

not had a bowel movement.

4. A review of Resident 42's record was

completed on 1/05/18 2:15 p.m. Diagnoses


gastro-esophageal reflux disease without

esophagitis, arthropathy and acute kidney

failure.

The physician orders included, but were not

limited to, polyethylene glycol (a medication

used to treat constipation) give 17 grams by

mouth daily and may use bowel protocol as

needed.

A report titled "Resident BM Description"

was provided by the DHS on 1/05/18 at

8:30 a.m. The report indicated Resident 42

had not had a bowel movement from

12/04/17 to 12/07/17 (4 days).

A current policy provided by the DHS, on

1/05/18 at 10:55 a.m., titled "Bowel

Protocol Guidelines," indicated "... 3. The

Ineffective Bowel Pattern Event should be





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initiated for any resident not having a BM

within 72 hours...a. A progress note

associated to the Ineffective Bowel Event,

should be completed until the resident has a

BM... Nursing staff shall assess for

effectiveness, orders may be written as

follows; a. If no bowel movement within 72

hours, 2 tablespoons...of 'Natural Laxative'

b. If no results within 24 hours...give 30 cc

Milk of Magnesia.. If no results within

approximately 12 hours after MOM

administer Dulcolax suppository. d. If results

of suppository are not satisfactory within 2

hours give Fleets enema...7. Nursing staff

will enter bowel movements in the

CareTracker system [shiftly] sic...."

5. The record for Resident C was reviewed

on 1/8/18 at 12:25 p.m. Diagnoses

included, but were not limited to cerebral

infarction, major depressive disorder and

dysphasia.


Resident C indicated since his recent arrival

to the facility he has often had to wait over

an hour to receive help with incontinent care

and getting into bed. Resident C indicated

he often pushes his call light, an aid would

respond to the light, turn the light off and say

she would come back, but would not return

for a long time. At that time, Resident C





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indicated he had returned from physical

therapy at 12:00 p.m., he had requested

from the physical therapist to change his

soiled brief and to be put back into bed.

The Physical Therapist asked an CNA to

assist Resident C, the CNA responded she

would find help and come back to help

Resident C. The physical therapist was

unable identify the CNA.


Physical Therapist Assistant 1 indicated

Resident C had communicated his brief was

solid and he needed assistance to be put into

bed. Physical Therapist Assistant 1

indicated she told an CNA, at about 12:00

p.m., concerning Resident C's request for

help and the CNA indicated she would get

help and be right back to help. The physical

therapist was unable identify the CNA.

During a continuous observation of Resident

C on 1/2/18 from 1:00 p.m. to 1:47 p.m.,

Resident C was observed sitting in his

wheelchair alone in his room, a strong odor

was noted. Resident C had a grimace on his

face and his head was bent down resting in

his hands. CNA 3 and CNA 4 were

observed during this time on the unit, but did

not check on Resident C or assist him in any

way.





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CNA 3 indicated she had been told at 12:00

p.m., Resident C needed assistance with

incontinent care. CNA 3 indicated almost

two hours was too long for a resident to

have to wait for care, and usually a resident

would wait between fifteen to twenty

minutes.

On 1/2/18 at 1:57 p.m., LPN 5 was

observed using a harsh tone and demeaning

manor criticizing Resident C for not pushing

his call light again after his first request for

assistance went unanswered. Resident C

had a troubled expression on his face during

his encounter with LPN 5. Resident C told

LPN 5 he had requested help, but did not

receive help. LPN 5 again, scolded

Resident C for not pushing the call light

again.

A Care Plan for Resident C, titled, "Social

Aspects", dated 12/18/17, indicated,

"Resident C demonstrates altered mood due

to recent life losses and admission to the

facility...Goal: Resident C's altered mood

will not result in uncompensated

depression...Approach...Observe resident's

adjustment to the facility, rehab program and

daily activity...offer routine schedules and

consistency of care...."





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A Care Plan for Resident C, dated

12/30/17, indicated, "Resident C had an

impairment in functional status in regards to

bed mobility, toileting and eating related to

recent decline and history of cardiovascular

accident...Approach: Resident C requires

dependant assist with transfers with

mechanical lift and assistance of two staff

members...Extensive assist with toileting...."

A current facility policy, titled, "Perineal

Care for the Incontinent Guideline", received

from the Corporate Consultant on 1/4/18 at

9:15 a.m., indicated, "...Purpose: to provide

incontinence care that will keep skin from

being exposed to prolonged periods of urine

and feces...."

This Federal tag relates to Complaint

IN00241909.

3.1-38(a)(2)(C)

3.1-41(a)(2)

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

F 0757

SS=E

Bldg. 00





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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

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.


review the facility failed to monitor residents

for side effects and effectiveness of

medications administered for 4 of 5

residents reviewed for unnecessary

medications. (42, 43, 55 and 56)



but were not limited to, heart failure,

dementia, schizophrenia, depressive

disorders and epilepsy.


limited to,

F 0757 1.Resident # 42,43,55,56 were

immediately assessed and no

adverse effects noted.


Care Center that are prescribed

medications that require side

effect monitoring have the potential

to be affected. The Director of


will complete Health Care Center

audit to identify residents that

have medications requiring side

effect monitoring to ensure

appropriate monitoring is in place.

The Director of Health Services

and/or Designee will conduct an

in-service with nurses related to

02/10/2018 12:00:00AM





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" ...Anti-Depressant Medication Use -

Observe resident closely for ... chronic

constipation ...every shift ...." Dated

3/02/2017.

" ...Anti-Psychotic Medication Use -

Observe resident closely for ... chronic

constipation ...every shift ...." Dated

3/11/2017.



Health Services (DHS), on 1/05/2018 at

8:30 a.m., indicated Resident 43 had no

bowel movements on the dates of

12/04/2017 through 12/07/2017 (four

days), 12/09/2017 through 12/14/2017

(seven days) and 12/17/2017 through

12/19/2017 (three days).

A care plan revised on 08/21/2017

indicated, " ...I am at risk for constipation r/t

[related to] decreased mobility, medications

...Observe me for and record my BMs

every shift ...."

The medication administration record for

December 2017 indicated none of the

bowel protocol treatments including natural

laxative, milk of magnesia, Dulcolax

suppository, or fleets enema were

administered to Resident 43 from

12/01/2017 through 12/31/2017.

Side Effect Monitoring and

documentation. New orders

received that require side effect

monitoring will be reviewed in the

daily morning meeting with the IDT

team to ensure required

monitoring orders are in place.


compliance, the DHS or designee


side effect monitoring and

effectiveness of medications is

monitored. This audit will ensure

medications that require side

effect monitoring have side effect

monitoring orders in place and/or

assessment for reason for use and

effectiveness PRN pain

medications . This audit will

include five residents three times

weekly for 30 days, then weekly

for 30 days, then monthly ongoing.







be revised as warranted. The QA






are noted.





02/21/2018PRINTED:

FORM APPROVED

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2494 N LEBANON ST

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included, but were not limited to, diabetes

mellitus, anxiety disorder, hypertension, end




limited to,

" ...Anti-Psychotic Medication

Use...Observe resident closely for

...constipation ...every shift ...." Dated

8/21/2017.

"...docusate sodium 100 mg twice a

day...Hold for loose bowels or diarrhea...."

Dated 5/01/2017.

"...Senna-S [a stool softener and laxative]

8.6-50 mg at bedtime...." Dated 8/11/2017.

"...Percocet [a narcotic pain medication]

10/325 mg at bedtime...." Dated 8/01/2017.

"...Percocet 10-325 mg every 6 hours -

PRN...." Dated 8/08/2017.

"...polyethylene glycol 3350 [a laxative], 17

grams in 5 ounces of fluid of choice each

day...." Dated 5/01/2017.



Health Services on 1/05/2018 at 8:30 a.m.,

indicated resident 55 had no bowel

movements on the dates of 12/02/2017

through 12/05/2017 (four days) and





02/21/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

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12/07/2017 through 12/10/2017 (four

days).

The MAR for December 2017, received

from the DHS on 1/05/2018 at 8:30 a.m.,

indicated none of the bowel protocol

treatments including: natural laxative, Milk of

Magnesia, Dulcolax suppository, or Fleets

enema were administered to Resident 55

from 12/01/2017 through 12/31/2017. The

MAR also indicated Resident 55 received

PRN Percocet on the following dates and

times without a pain level evaluation.

12/04/2017 at 3:34 a.m.

12/07/2017 at 8:16 p.m.

12/08/2017 at 1:23 p.m.

12/10/2017 at 2:21 p.m.,

12/13/2017 at 5:43 a.m.

12/16/2017 at 5:27 a.m.

12/17/2017 at 522 a.m.

12/17/2017 at 4:25 p.m.

12/18/2017 at 4:50 a.m.

12/18/2017 at 1:38 p.m.

12/24/2017 at 12:30 a.m.

12/27/2017 at 1:27 p.m.

12/29/2017 at 1:19 p.m.

12/30/2017 at 9:37 a.m.

The facility was unable to produce a current

care plan which addressed Resident 55's

risk for constipation or pain.





02/21/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

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the DON indicated the MDS (minimum data

set) coordinator reviewed the charting of

bowel movements to identify any residents

who had not had a bowel movement in three

days or more.


the MDS coordinator indicated she only

checked the BM charting to ensure it was

completed on each shift, but she did not

evaluate the content of the charting or assess

the clinical implications it had on the

residents. She also indicated that the

previous medical records nurse had

evaluated BM charting to ensure residents

had regular bowel movements but she was

unsure if the current medical records

coordinator took over the task.


the Medical Records Nurse indicated no

one had ever assigned her the responsibility

of reviewing BM charting.


the DON indicated she did not know what

staff member, if any, was responsible for

monitoring resident's bowel movements.






02/21/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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2494 N LEBANON ST

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LPN 1 indicated he was unaware of who

was responsible for monitoring BMs. He

further indicated night shift nurses used to

run BM reports, then medical records did it

for a while, but he had not seen any BM

reports in a long time.


completed on 1/05/18 at 8:56 a.m.


irritable bowel syndrome with constipation,

Alzheimer's disease and muscle weakness.


limited to, Linzess (a medication used to

treat irritable bowel syndrome with

constipation) 145 mcg (micrograms) by

mouth daily and may use bowel protocol (a

plan put in place to treat constipation) as

needed.

A report titled, "Resident BM Description,"

provided by the Corporate RN (Registered

Nurse) on 1/05/18 at 4:10 p.m. The report

indicated Resident 56 had not had a bowel

movement from 12/06/17 to 12/21/17 (16

days) and from 1/01/18 to 1/04/18 (4

days).

During an interview with RN 8 on 01/08/18

at 2:59 p.m., she indicated she had not seen

a bowel movement follow up list for well

over a month. The monitoring use to be





02/21/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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(X3) DATE SURVEY

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155680 01/11/2018


2494 N LEBANON ST

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done by the unit manager but she is no

longer with the facility and RN 8 is not sure

who does the monitoring and makes a

follow up list for treating residents who have

not had regular bowel movements.

In an interview with the DHS on 1/11/18

9:12 a.m., the DHS indicated Resident 56

was not given any prn (as needed)

medications, during the periods documented

that indicated Resident 56 had not had a

bowel movement.


completed on 1/05/18 2:15 p.m. Diagnoses


gastro-esophageal reflux disease without

esophagitis, arthropathy and acute kidney

failure.


limited to; polyethylene glycol (a medication

used to treat constipation) give 17 grams by

mouth daily and may use bowel protocol as

needed.

A report titled, "Resident BM Description"

was provided by the DHS on 1/05/18 at

8:30 a.m. The report indicated Resident 42

had not had a bowel movement from

12/04/17 to 12/07/17 (4 days).





02/21/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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A current policy provided by the DHS, on

1/05/18 at 10:55 a.m., titled "Bowel

Protocol Guidelines," indicated "... 3. The

Ineffective Bowel Pattern Event should be

initiated for any resident not having a BM

(bowel movement) with 72 hours...a. A

progress note associated to the Ineffective

Bowel Event, should be completed until the

resident has a BM... Nursing staff shall

assess for effectiveness, orders may be

written as follows; a. If no bowel movement

within 72 hours, 2 tablespoons...of 'Natural

Laxative' with no results within 24

hours...give 30 cc Milk of Magnesia.. If no

results within approximately 12 hours after

MOM administer Dulcolax suppository. d.

If results of suppository are not satisfactory

within 2 hours give Fleets enema...7.

Nursing staff will enter bowel movements in

the CareTracker system [shiftly] sic...."

3.1-48(a)(3)

R 0000

Bldg. 00

This visit was for a State Residential

Licensure Survey. This visit included the

Investigation of Residential Complaint

R 0000 Preparation or execution of this

plan of correction does not

constitute admission or agreement

of provider of the truth of the facts

State Form Event ID: IOFB11 Facility ID: 002703 If continuation sheet of 40




02/21/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


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DEFICIENCY)

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COMPLETION


LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

00

IN00242615. This visit included the

investigation of Nursing Home Complaint

IN00241909.

Residential Complaint IN00242615 -

Substantiated. No deficiencies related to

allegations are cited.

Nursing Home Complaint IN00241909 -

Substantiated. Federal / State deficiencies

related to allegations are cited at F557,

F689, F690 and F697.

Survey dates: January 2 ,3, 4, 5, 8, 9, 10

and 11, 2018

Facility number: 002703

Residential Census: 34

Homewood Health Campus was found to

be in compliance with 410 IAC 16.2-5 in

regard to the State Residential Licensure

Survey and the Investigation of Complaint

IN00242615.

Quality Review was completed on January

22, 2018.

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

Recertification and Complaint visit

with exit on January 11, 2018.

Please accept this plan of

correction as the provider's credible

allegation of compliance as of

February 10, 2018. The provider

respectfully requests a desk review

with paper compliance to be

considered in establishing that the

provider is in substantial

compliance.





02/21/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

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(X4) ID

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LEBANON, IN 46052

155680 01/11/2018


2494 N LEBANON ST

00


PRINTED: 02/21/2018 DEPARTMENT OF HEALTH AND …Therapist asked an CNA to assist Resident C, the CNA...

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