(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
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 Page 1 of 40
(X6) DATE
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 2 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
§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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 3 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
During an interview, on 1/2/18 at 1:10 p.m.,
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 4 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
During an interview, on 1/2/18 at 1:47 p.m.,
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 5 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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...."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 6 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 7 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
(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
1/05/2018 at 5:55 p.m. Diagnoses included,
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.
2.All residents in the Health
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 8 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
2. Resident 55's record was reviewed on
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 9 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
"...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)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 10 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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
Bldg. 00
Based on observation, interview and record
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.
2.All residents in the Health
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.
3.As a measure of ongoing
compliance, the Director of Health
Services and/or Designee will
observe dressing changes on up
02/10/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 11 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
4.For quality assurance, the
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 12 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 13 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 14 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
§483.25(d)(2)Each resident receives
adequate supervision and assistance devices
to prevent accidents.
Based on observation, interview and record
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.
2.All residents in the Health
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
Services and/or Designee will
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.
1.As a measure of ongoing
compliance, the DHS or designee
will complete an audit to ensure
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.
1.For quality assurance, the
DHS or Designee will review any
findings, and subsequent
02/10/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 15 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 16 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
A fall report, dated 11/10/17, indicated,
"...While attempting to transfer self from
wheelchair to standing position Resident Fell
to the floor...."
A fall report, dated 11/17/17, indicated,
"...Resident in wheelchair in bathroom...was
reaching for hair brush on sink and slipped
out of wheelchair...."
A fall report, dated 12/19/17, indicated,
"...Res. found on floor in bathroom...."
A fall report, dated 12/26/17, indicated,
"...Resident was in the bathroom attempting
to toilet herself, when she fell...."
A fall report, dated 12/30/17, indicated,
"...Resident noted to have fall in room...."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 17 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 18 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
On 1/02/18 at 1:19 p.m., Resident F was
observed sitting in her wheelchair in her
bedroom unattended.
On 1/03/18 at 2:16 p.m., Resident F was
observed sitting in her wheelchair in her
bedroom unattended
On 1/04/18 at 1:43 p.m., Resident F was
observed sitting in her wheelchair in her
bedroom unattended.
On 1/09/18 at 9:17 a.m., Resident F was
observed sitting in her wheelchair in her
bedroom unattended.
On 1/09/18 9:49 a.m., Resident F was
observed sitting in her wheelchair in her
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 19 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 20 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
Based on observation, interview and record
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:
1. Resident 43's record was reviewed on
1/04/2018 at 3:45 p.m. Diagnoses included,
but were not limited to, heart failure,
dementia, schizophrenia, depressive
disorders and epilepsy.
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 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
health Services and\or Designee
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 21 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
2. Resident 55's record was reviewed on
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.
and results as a second check
daily on regularly scheduled days.
Any problems noted will be
reviewed in the daily Clinical Care
Meeting.
3.As a measure of ongoing
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.
4.For quality assurance, the
DHS or Designee will review any
findings, and subsequent
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 22 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
A document titled "Resident BM
description," received from the Director of
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.
During an interview on 1/05/18 at 5:30 p.m.,
the MDS coordinator indicated she only
checked the BM charting to ensure it was
completed on each shift, but she did not
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 23 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
During an interview on 1/08/18 at 2:50 p.m.,
the medical records nurse indicated no one
had ever assigned her the responsibility of
reviewing BM charting.
During an interview on 1/08/18 at 2:55 p.m.,
the DON indicated she did not know what
staff member, if any, was responsible for
monitoring resident's bowel movements.
During an interview on 1/08/18 at 2:59 p.m.,
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 24 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
A review of Resident 56's record was
completed on 1/05/18 at 8:56 a.m.
Diagnoses included, but were not limited to,
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 25 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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
included, but were not limited to,
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 26 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
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. At that time, Resident C
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 27 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
During an interview, on 1/2/18 at 1:10 p.m.,
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 28 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
During an interview, on 1/2/18 at 1:47 p.m.,
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...."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 29 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 30 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
Based on observation, interview and record
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)
1. Resident 43's record was reviewed on
1/04/2018 at 3:45 p.m. Diagnoses included,
but were not limited to, heart failure,
dementia, schizophrenia, depressive
disorders and epilepsy.
Physician's orders included, but were not
limited to,
F 0757 1.Resident # 42,43,55,56 were
immediately assessed and no
adverse effects noted.
1.All residents in the Health
Care Center that are prescribed
medications that require side
effect monitoring have the potential
to be affected. The Director of
health Services and\or Designee
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 31 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
" ...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.
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 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.
2.As a measure of ongoing
compliance, the DHS or designee
will complete an audit to ensure
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.
3.For quality assurance, the
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 32 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
2. Resident 55's record was reviewed on
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,
" ...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.
A document titled "Resident BM
description," received from the Director of
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 33 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 34 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
During an interview on 1/05/18 at 5:30 p.m.,
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.
During an interview on 1/08/18 at 2:50 p.m.,
the Medical Records Nurse indicated no
one had ever assigned her the responsibility
of reviewing BM charting.
During an interview on 1/08/18 at 2:55 p.m.,
the DON indicated she did not know what
staff member, if any, was responsible for
monitoring resident's bowel movements.
During an interview on 1/08/18 at 2:59 p.m.,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 35 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
3. A review of Resident 56's record was
completed on 1/05/18 at 8:56 a.m.
Diagnoses included, but were not limited to,
irritable bowel syndrome with constipation,
Alzheimer's disease and muscle weakness.
The physician orders included, but were not
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 36 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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.
4. A review of Resident 42's record was
completed on 1/05/18 2:15 p.m. Diagnoses
included, but were not limited to,
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).
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 37 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
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 Page 38 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
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.
State Form Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 39 of 40
(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
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LEBANON, IN 46052
155680 01/11/2018
HOMEWOOD HEALTH CAMPUS
2494 N LEBANON ST
00
State Form Event ID: IOFB11 Facility ID: 002703 If continuation sheet Page 40 of 40
Top Related