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(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
F 0000
Bldg. 00
This visit was for a Recertification and State
Licensure Survey. This visit included the
Investigation of Complaint IN00269561.
Complaint IN00269561 - Substantiated.
Federal/State deficiencies related to the
allegations are cited at F744.
Survey dates: July 31, August 1, 2, 3, & 6, 2018
Facility number: 000073
Provider number: 155153
AIM number: 100288820
Census Bed Type:
SNF/NF: 122
SNF: 9
Total: 131
Census Payor Type:
Medicare: 21
Medicaid: 81
Other: 27
Total: 131
These deficiencies reflect State Findings cited in
accordance with 410 IAC 16.2-3.1.
Quality Review was completed on August 14,
2018.
F 0000 This plan of correction also
represents the facility's
allegations of compliance. The
following combined plan of
correction and allegations of
compliance is submitted solely
because it is required by law
and is not an admission to any
of the alleged deficiencies or
violations. Furthermore, none
of the actions taken in this plan
of correction are an admission
that additional steps should
have or could have been taken
by the facility to prevent the
alleged deficiency. These steps
are only included because a
plan of correction is required
by law.
The facility was in compliance
with all licensure and
certification requirements at
the time of the survey and
disputes that any alleged
deficiency or violation existed.
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
F 0656
SS=D
Bldg. 00
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: 03B411 Facility ID: 000073
TITLE
If continuation sheet Page 1 of 22
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
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.
(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 F 0656 Healthwin requests 09/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 2 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
failed to ensure appropriate, complete and
individualized care plans were developed related
to targeted behaviors (Residents C, D, & E),
hospice care (Resident 9), and dialysis care
(Resident 106) for 5 of 25 residents whose care
plans were reviewed.
Findings Include:
1. A clinical record review was conducted on
08/02/18, at 2:45 PM, for Resident 9. Her
diagnoses included, but were not limited to: heart
failure, chronic kidney disease stage 3, gout,
insomnia, anxiety, hypertension, diaphragm
hernia, weakness, and atrial fibrillation.
The MDS (Minimum Data Set) assessment, dated
05/09/18, indicated a BIMS (Brief Interview for
Mental Status) score of 15, cognitively intact. A
significant change MDS was in process, but not
completed at time of review.
A hospice order was in place and indicated she
was started on hospice services as of 07/20/18.
The diagnosis was indicated as congestive heart
failure.
A hospice care plan was in place, but did not
contain the provision of ADL (Activities of Daily
Living) care, advance directive information,
hospice contact and coordination of care.
No hospice binder was found on the unit.
Scanned hospice documents were present in the
chart, but did not have contact information for the
hospice provider, or when to contact.
During an interview, on 08/03/18 at 8:57 AM, MR
(Medical Records) employee indicated there was
not a hospice book kept on unit, as the facility
consideration for a desk review
for all citations.
Healthwin will continue to ensure
that comprehensive care plans are
developed and implemented for all
residents.
- What corrective action(s)
will be accomplished for those
residents found to have been
affected by the deficient
practice;
CMS regulations and Critical
Element Pathways for Hospice,
Dialysis, and Behavioral/Emotional
Status were reviewed. Care plans
for residents 106 and 9 were
updated to include required
Hospice and Dialysis information.
Care plans for residents C, D, and
E were reviewed and updated to
reflect appropriate focus, goals,
and interventions for Dementia
and/or Behavioral Health
Diagnosis.
- How other residents
having the potential to be
affected by the same deficient
practice will be identified and
what corrective action(s) will
be taken;
Any resident receiving Hospice or
Dialysis services as well as
residents displaying behaviors or
on psychotherapeutic medications
have the potential to be affected.
- What measures will be put
into place and what systemic
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 3 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
does not use them. All hospice documents were
expected to be scanned into the chart.
During an interview, on 08/06/18 at 10:08 AM, the
DON (Director of Nursing) indicated she was not
aware of the hospice care plan requirements and
the current care plan in place did not contain the
appropriate information.
2. During an interview, on 08/01/18 at 9:32 AM,
Resident 106 indicated the facility does assess
their dialysis access site as appropriate, has
pre-visit vitals completed, and utilized a
communication binder.
A clinical record review was conducted on
08/02/18, at 9:09 AM, for Resident 106 and
indicated an admission date of 06/07/18. His
diagnoses included, but were not limited to: adult
failure to thrive, superventricular tachycardia, end
stage renal disease, diabetes, hypertension,
weakness, sleep apnea, and anemia.
The MDS (Minimum Data Set) assessment, dated
07/17/18, indicated a BIMS (Brief Interview for
Mental Status) score of 15, cognitively intact.
Dialysis was indicated as active.
A care plan was in place related to dialysis care,
but did not contain specific type, location,
transportation, and goals/interventions for
dialysis care, contact information for emergencies,
complication monitoring, or advance directive
information.
A physician order was in place. The
documentation indicated site care and assessment
completed as appropriate. The dialysis
communication book was in place with
appropriate information.
changes will be made to
ensure that the deficient
practice does not recur;
IDT will be in-serviced on Care
Plan Policy and Procedure. IDT
will also review the CMS
regulations for Comprehensive
Care Planning and Critical
Element Pathway relating to
Behavioral/Emotional Status,
Dementia, Dialysis, and Hospice.
Baseline Care Plans will continue
to be completed within 48 hours.
Comprehensive Care Plans will be
initiated within 48 hours.
.
- How the corrective
action(s) will be monitored to
ensure the deficient practice
will not recur, i.e., what quality
assurance program will be put
into place;
DON, CCO, or designee will audit
baseline care plans to ensure they
are thoroughly completed and
comprehensive care plans are
initiated within 48 hours for new
admits weekly x 4 then 10
monthly x5. If any concerns are
noted the audits will continue for
an additional 6 months.
- By what date the systemic
changes for each deficiency
will be completed. After
submitting an acceptable Plan
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 4 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
During an interview, on 08/06/18 at 10:08 AM, the
DON (Director of Nursing) indicated she was not
aware of the required care plan information and it
would be corrected.3. The clinical record for
Resident D was reviewed on 8/2/18 at 1:35 P.M.
The diagnoses included, but were not limited to
dementia, anxiety and depression.
The admission MDS (Minimum Data Set)
assessment, dated 6/6/18, indicated Resident D
had a BIMS (Brief Interview of Mental Status)
score of 5, severe cognitive impairment and was
receiving antidepressant and antianxiety
medications with no GDR (gradual dose
reduction) dates.
A care plan, revised on 6/8/18, indicated Resident
D was at risk for decline in mood due to diagnosis
of depression and anxiety and she was taking
both antidepressants and antianxiety medications.
There were not no targeted behaviors or
individualized interventions present for anxiety
symptoms.
The Medication Review Report, dated 8/6/18,
indicated Resident D had an order for Ativan
(antianxiety) 0.5 mg (milligrams) every eight (8)
hours for anxiety with a start date of 8/28/17 and
Lexapro 10 mg at bedtime for depression with a
start date of 3/21/17.
The Documentation Survey Report, dated July
2018, indicated Resident D had behaviors of being
combative during care, searching for family
members and wandering on and off the unit with
no documentation of interventions that were
attempted.
of Correction, if it is
determined that the correction
will not be completed by the
date previously submitted, The
Division needs to be contacted
as soon as possible. The
facility will need to submit an
amended plan of correction
with the updated plan of
correction date.
9/5/18
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 5 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
During an interview, on 8/6/18 at 9:53 A.M., the
DON (Director of Nursing) indicated the
depression and anxiety should be in separate
plans of care and plan of care should contain
targeted behaviors and individualized
interventions.
4. The clinical record for Resident E was reviewed
on 8/3/18 at 11:28 A.M. The diagnoses included,
but were not limited to, dementia, anxiety and
depression.
The admission MDS (Minimum Data Set)
assessment, dated 6/5/18, indicated Resident E
had a BIMS (Brief Interview of Mental Status)
score of 12, moderate cognitive impairment, and
was receiving antipsychotic and antidepressant
medication.
The Medication Review Report, dated 8/6/18,
indicated Resident E had an order for Seroquel 25
mg (milligrams) at bedtime related to Parkinson's
Disease.
A care plan, dated 6/18/18, indicated Resident E
uses antipsychotic medications related to the
disease process of Parkinson's.
There were no targeted behaviors or
individualized interventions present for the use of
antipsychotic medications.
During an interview, on 8/6/18 at 12:00 P.M., the
DON (Director of Nursing) indicated the
antipsychotic care plan should include targeted
behavior with individualized interventions and
appropriate diagnosis.5. A clinical record review
was conducted, on 8/2/18 at 2:04 P.M., for
Resident C and indicated she was admitted on
5/18/18. Her diagnoses included, but were not
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 6 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
limited to Alzheimer's disease, delusional
disorders, depressive disorder, vascular dementia
with behavioral disturbance.
The MDS (Minimum Data Set) assessment, dated
6/16/18, indicated a BIMS (Brief Interview for
Mental Status) score of 3, severe cognitive
impairment and a PHQ-9 (Patient Health
Questionnaire) assessment indicated a score of 0,
minimal or no depression.
The care plan indicated a care plan, undated, for
mood. The care plan did not include specific
behaviors related to the use of quetiapine
fumarate, an antipsychotic medication or
mirtazapine, an antidepressant. The interventions
indicated to administer medications as ordered,
observe/document for side effects and
effectiveness.
A hospital discharge summary, dated 5/16/16,
indicated she had a psychiatric hospital stay due
to paranoid delusions, yelling at staff and other
residents at a previous facility prior to admission.
During an interview, on 8/3//18 at 4:29 P.M., the
DON (Director of Nursing) indicated Resident C
had not been having any behaviors and was not
aware of what specific behaviors she was having
prior to admission. The DON indicated she should
have been monitored for behaviors that the
psychiatric hospital indicated she was put on the
quetiapine and mirtazapine for and she should
have had a care plan indicating those behaviors.
A policy was provided by the DON on 8/6/18 at
9:30 A.M., titled, "...Care Plan-Comprehension",
no date, and indicated the policy was the one
currently being used by the facility. The policy
indicated "...It is the policy of this facility to
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 7 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
develop and implement a comprehensive
person-centered care plan for each resident ,
consistent with resident rights, that includes
measurable objectives and timeframes to meet a
resident's medical, nursing, and mental and
psychosocial needs that are identified in the
resident's comprehensive assessment...."
3.1-35(a)
483.40(b)(3)
Treatment/Service for Dementia
§483.40(b)(3) A resident who displays or is
diagnosed with dementia, receives the
appropriate treatment and services to attain
or maintain his or her highest practicable
physical, mental, and psychosocial
well-being.
F 0744
SS=D
Bldg. 00
Based on record review and interview, the facility
failed to meet the needs of a resident with the
diagnosis of severe vascular dementia in 1 of 3
residents reviewed for dementia care. (Resident B)
Finding includes:
The clinical record for Resident B was reviewed
on 7/31/18 at 11:00 A.M. The diagnoses included,
but were not limited to, vascular dementia and
multiple right posterior cerebral artery
cerebrovascular accident.
The admission MDS (Minimum Data Set)
assessment, dated 7/19/18, indicated Resident B
had a BIMS (Brief Interview of Mental Status)
score of 6, severe cognitive impairment and had
displayed behaviors that significantly interfered
with her ADLs (activities of daily living).
There was no care plan available for diagnosis of
dementia.
F 0744 Healthwin requests
consideration for a desk review
for all citations.
Healthwin will continue to ensure
that behavioral health care plans
and tracking are developed and
implemented for all residents to
maintain the highest level of
psychosocial well-being.
- what corrective action(s)
will be accomplished for those
residents found to have been
affected by the deficient
practice;
CMS regulation and Dementia
Care and Behavioral/Emotional
Status Critical Element Pathway
reviewed. Resident B was
discharged 7/20/18. Social
Service and Nursing departments
began reviewing all care plans for
residents with a behavioral health
09/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 8 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
A care plan, no date, indicated Resident B used
anti-anxiety medication related to adjustment
issues and anxiety disorder that included the
following interventions: educate
resident/family/caregivers about risks, benefits
and the side effects and/or toxic symptoms of
anti-anxiety medication drugs being given, give
anti-anxiety medications as ordered and
observe/document side effects and effectiveness,
and monitor for safety.
A care plan, no date, indicated Resident B resisted
care and noncompliant with care that included,
but was not limited to, the following interventions:
assess resident's understanding of situation,
coping skills and support system, inform resident
of risks of noncompliance, and involve resident in
setting goals.
A care plan, no date, indicated Resident B used
antidepressant medication related to depression
and anxiety that included the following
interventions: give antidepressant medication as
ordered ph physician and observe/document side
effects and effectiveness and
observe/document/report to physician as needed
ongoing signs and symptoms of depression
unaltered by antidepressant medications.
There were no targeted behaviors or
individualized interventions present in the plan of
care related to depression.
There was no documentation of behavior tracking
available to indicate the interventions that were
attempted and the effectiveness of interventions
for behaviors.
The Discharge Summary from local hospital, dated
diagnosis or dementia diagnosis.
Care plans and behavior tracking
are being updated to reflect
individualized goals and
interventions for maintaining the
highest level of well-being.
- how other residents having
the potential to be affected by
the same deficient practice will
be identified and what
corrective action(s) will be
taken;
All residents who may have a
behavioral health diagnosis or
dementia diagnosis
what measures will be put into
place and what systemic
changes will be made to
ensure that the deficient
practice does not recur;
All staff will be provided the new
Dementia Care Policy. Social
Services and Nursing
administration will ensure behavior
tracking tasks are entered into
POC. Nursing aides will be
in-serviced on documenting
behaviors for tracking purposes.
Baseline Care Plans will continue
to be completed within 48 hours.
Comprehensive Care Plans will be
initiated within 48 hours.
- how the corrective
action(s) will be monitored to
ensure the deficient practice
will not recur, i.e., what quality
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 9 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
7/12/18, indicated Resident B had severe vascular
dementia for years, lived at home with her son,
and was found at home with profound left sided
weakness. She was evaluated by therapy and it
was recommended that she receive some rehab for
her deficits.
The History & Physical from the facility, dated
7/13/18, indicated Resident B had a history of
severe dementia.
The Order Summary Report, dated 7/13/18,
indicated Resident B had a diagnosis of vascular
dementia without behavioral disturbances and
had an order for rivastigmine patch for dementia.
The Medication Administration Record, dated
7/1/18 through 7/31/18, indicated Resident B had
an order for Trazadone 50 mg (milligrams) at
bedtime for anxiety/depression with start date of
7/20/18 and Ativan 0.5 mg every eight (8) hours
for anxiety with start date of 7/15/18.
A Progress Note, dated 7/13/18 at 12:33 P.M.,
indicated Resident B continued to express desire
to return home and was belligerent in therapy per
therapy personnel stating she wanted to go home.
A Progress Note, dated 7/13/18 at 12:48 P.M.,
indicated a wander guard was applied to Resident
B's wheelchair.
A Progress Note, dated 7/13/18 at 1:42 P.M.,
indicated the facility had reassured Resident B's
daughter that they would call the resident's son if
she became belligerent or hard to handle.
A Progress Note, dated 7/15/18 at 6:53 P.M.,
indicated the physician was notified of resident's
severe anxiety and increase in behaviors and a
assurance program will be put
into place; and
DON, CCO, or designee will audit
the baseline care plans to ensure
they are thoroughly completed and
comprehensive care plans are
initiated within 48 hours for new
admits weekly x 4 then 10
monthly x5. If any concerns are
noted the audits will continue for
an additional 6 months. DON,
CCO, or designee will ensure that
behavior tracking is reviewed
weekly during behavior
management meetings.
- by what date the systemic
changes for each deficiency
will be completed. After
submitting an acceptable Plan
of Correction, if it is
determined that the correction
will not be completed by the
date previously submitted, The
Division needs to be contacted
as soon as possible. The
facility will need to submit an
amended plan of correction
with the updated plan of
correction date.
9/5/18
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 10 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
new order for lorazepam (Ativan) 0.5 mg every 8
hours as needed for anxiety was received.
A Progress Note, dated 7/15/18 at 5:06 P.M.,
indicated Resident B had became agitated and
verbally abusive to staff because she could not
go home and staff tried to explain to her why she
was at the facility.
A Progress Note, dated 7/16/18 at 1:05 P.M.,
indicated Resident B had underlying dementia and
had increased anxiety since coming to the facility
and was started on lorazepam 0.5 mg.
A Progress Note, dated 7/16/18 at 9:14 P.M.,
indicated Resident B had asked nursing staff why
she placed in the facility and the nurse told the
resident was placed in the facility by her
physician, which upset the resident.
A Progress Note, dated 7/18/18 at 5:00 P.M.,
indicated Social Services had discussed with
Resident B's family the possibility of a Dementia
Unit due to dementia with sundowners.
A Progress Note, dated 7/19/18 at 12:04 P.M.,
indicated Social Services had discussed with
Resident B if she felt safe and the resident
indicated she was being held against her will and
she did not want to hurt herself but she would if
she didn't get out of the facility.
A Progress Note, dated 7/19/18 at 12:15 P.M.
indicated Social Services had spoke with
resident's family about either finding another
placement in a Dementia Unit or sending the
resident to the a psychiatric hospital due to the
comments she was making.
A Progress Note, dated 7/19/18 at 1:05 P.M.,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 11 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
indicated another facility was willing to accept the
facility on 7/23/18.
A Progress Note, dated 7/19/18 at 1:26 P.M.,
indicated Social Services had made referral to local
psychiatric hospital.
A Progress Note, dated 7/19/18 at 1:50 P.M.,
indicated Social Services had notified family
regarding the other facility would potentially be
willing to accept resident and that a referral had
been made to the local psychiatric hospital. The
family member indicated she was not happy about
the referral to a psychiatric unit as she felt the
resident did not need a psychiatric unit.
A Progress Note, dated 7/19/18 at 3:44 P.M.,
indicated Resident B's daughter called the facility
and asked if she could stay at the facility with her
mother until she was discharged to another
facility and she felt her mom didn't need to go to
psychiatric unit. The facility felt since the resident
was discharging to a Dementia Unit that she still
needed a psychiatric evaluation and the daughter
was upset.
A Progress Note, dated 7/19/18 at 3:45 P.M.,
indicated the facility felt the local psychiatric
hospital would take to long to make a decision on
excepting Resident B and it was decided to she
resident to local ER (emergency room) for an
emergency psychiatric evaluation.
A Progress Note, dated 7/19/18 at 5:05 P.M.,
indicated Social Services had spoke with family
and indicated if the local hospital felt that
Resident B was suicidal they would admit her to
local psychiatric hospital and if they didn't the
hospital would send her back to the facility.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 12 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
The ER Physician Note, dated 7/19/18, indicated
Resident B had a past medical history of dementia
and anxiety and facility had sent her to ER for a
psychiatric evaluation because the resident had
expressed the she wanted to die and that she was
going to step out in front of traffic. The resident's
son and daughter-in-law were present for the
evaluation at the hospital and Resident B was
very fixated on getting back home. She was
transferred back the facility.
A Progress Note, dated 7/19/18 at 8:51 P.M.,
indicated Resident B was still making statements
of wanting to go home and she would "break a
window if I have to".
A Progress Note, dated 7/19/18 at 9:08 P.M.,
indicated Resident B was attempting to leave floor
heading towards elevator stating "If I can's leave
here I'll just go kill myself."
A Progress Note, dated 7/19/18 at 9:49 P.M.,
indicated a new order for Trazadone (sedative and
antidepressant) 50 mg was received
There was no documentation of any interventions
that were attempted prior to Trazadone being
given.
A Progress Note, dated 7/20/18 at 10:40 A.M.,
indicated Social Services had discussed with
daughter about admitting Resident B to a
psychiatric hospital and that a psychiatric
evaluation was not completed at the hospital.
A Progress Note, dated 7/20/18 at 10:50 P.M.,
Resident B was transferred to local psychiatric
hospital.
A Progress Note, dated 7/24/18 at 3:37 P.M.,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 13 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
indicated Social Services had spoke with local
psychiatric hospital and that Resident B was
doing poorly, stating she wants to die because
she could not go home.
During an interview, on 8/02/18 at 3:45 P.M., the
CCO (Chief Clinical Officer) indicated a plan of
care for dementia with behaviors should have
developed and implemented with targeted
behaviors and interventions for Resident B upon
admission.
On 8/6/18 at 11:45 A.M., a policy for Dementia
Care was requested and the DON (Director of
Nursing) indicated no policy was available.
This Federal tag relates to complaint IN00269561.
3.1-37(a)
483.45(c)(3)(e)(1)-(5)
Free from Unnec Psychotropic Meds/PRN
Use
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any
drug that affects brain activities associated
with mental processes and behavior. These
drugs include, but are not limited to, drugs in
the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic
Based on a comprehensive assessment of a
resident, the facility must ensure that---
§483.45(e)(1) Residents who have not used
psychotropic drugs are not given these drugs
unless the medication is necessary to treat a
F 0758
SS=D
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 14 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
specific condition as diagnosed and
documented in the clinical record;
§483.45(e)(2) Residents who use
psychotropic drugs receive gradual dose
reductions, and behavioral interventions,
unless clinically contraindicated, in an effort
to discontinue these drugs;
§483.45(e)(3) Residents do not receive
psychotropic drugs pursuant to a PRN order
unless that medication is necessary to treat
a diagnosed specific condition that is
documented in the clinical record; and
§483.45(e)(4) PRN orders for psychotropic
drugs are limited to 14 days. Except as
provided in §483.45(e)(5), if the attending
physician or prescribing practitioner believes
that it is appropriate for the PRN order to be
extended beyond 14 days, he or she should
document their rationale in the resident's
medical record and indicate the duration for
the PRN order.
§483.45(e)(5) PRN orders for anti-psychotic
drugs are limited to 14 days and cannot be
renewed unless the attending physician or
prescribing practitioner evaluates the resident
for the appropriateness of that medication.
Based on interview and record review, the facility
failed to ensure individualized behaviors and
interventions were monitored and documented
related to antidepressant, antipsychotic and
antianxiety use (Residents C, D, E) for 3 of 5
residents reviewed for unnecessary medications.
Finding Include:
1. A clinical record review was conducted, on
F 0758 Healthwin requests
consideration for a desk review
for all citations.
Healthwin will continue to ensure
that residents remain free from
unnecessary medications and
individualized interventions are
provided to reduce behaviors and
maintain the highest level of
psychosocial well-being.
09/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 15 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
8/2/18 at 2:04 P.M., for Resident C and indicated
she was admitted on 5/18/18. Her diagnoses
included, but were not limited to Alzheimer's
disease, delusional disorders, depressive disorder,
vascular dementia with behavioral disturbance.
The MDS (Minimum Data Set) assessment, dated
6/16/18, indicated a BIMS (Brief Interview for
Mental Status) score of 3, severe cognitive
impairment and a PHQ-9 (Patient Health
Questionnaire) assessment indicated a score of 0,
minimal or no depression. The MDS indicated she
received 7 days of an antidepressant and
antipsychotic.
Medication orders included, but were not limited
to quetiapine fumarate 50 mg daily at bedtime, an
antipsychotic, and mirtazapine 15 mg daily at
bedtime, an antidepressant.
The care plan indicated a care plan, undated, for
mood. The care plan did not indicate specific
behaviors related to the use of quetiapine
fumarate or mirtazapine. The interventions
indicated to administer medications as ordered
and observe and document for side effects and
effectiveness.
There were no behavior monitoring sheets
available for specific behaviors related to the use
of quetiapine and mirtazapine.
A hospital discharge summary, dated 5/16/16,
indicated she had a psychiatric hospital stay due
to paranoid delusions, yelling at staff and other
residents at a previous facility prior to admission.
During an interview, on 8/3//18 at 4:29 P.M., the
DON (Director of Nurses) indicated Resident C
had not been having any behaviors and was not
- What corrective action(s)
will be accomplished for those
residents found to have been
affected by the deficient
practice;
CMS regulations and Critical
Element Pathway for Unnecessary
Medications were reviewed. Care
plans for residents C, D, and E
were updated to reflect behaviors
with personalized
non-pharmacological interventions
as well as behavior tracking tasks
were updated in the electronic
health record. Medications for
residents C & D were reduced.
- How other residents
having the potential to be
affected by the same deficient
practice will be identified and
what corrective action(s) will
be taken;
Residents who have displayed or
have a history of behaviors and are
on psychotropic medications.
- What measures will be put
into place and what systemic
changes will be made to
ensure that the deficient
practice does not recur;
Residents on psychotropic
medications will be monitored for
behaviors and efficacy of
medications during behavior
management meetings and as
needed. Non-pharmacological
interventions will be monitored for
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 16 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
aware of what specific behaviors she was having
prior to admission. The DON indicated she should
have been monitored for behaviors that the
psychiatric hospital indicated she was put on the
quetiapine and mirtazapine for and she should
have had a care plan indicating those behaviors.
2. The clinical record for Resident D was reviewed
on 8/2/18 at 1:35 P.M. The diagnoses included,
but were not limited to dementia, anxiety and
depression.
The admission MDS (Minimum Data Set)
assessment, dated 6/6/18, indicated Resident D
had a BIMS (Brief Interview of Mental Status)
score of 5, severe cognitive impairment and was
receiving antidepressant and antianxiety
medications with no GDR (gradual dose
reduction) dates.
A care plan, revised on 6/8/18, indicated Resident
D was at risk for decline in mood due to diagnosis
of depression and anxiety and she was taking
both antidepressants and antianxiety medications.
There were not no targeted behaviors or
individualized interventions present for anxiety
symptoms.
The Medication Review Report, dated 8/6/18,
indicated Resident D had an order for Ativan
(antianxiety) 0.5 mg (milligrams) every eight
(8)hours for anxiety with a start date of 8/28/17
and Lexapro 10 mg at bedtime for depression with
a start date of 3/21/17.
The Documentation Survey Report, dated July
2018, indicated Resident D had behaviors of being
combative during care, searching for family
members and wandering on and off the unit with
no documentation of interventions that were
efficacy and updated/changed as
needed. Medications will be
reduced per CMS guidelines. If a
GDR is clinically contraindicated
documentation indicating a
rationale will be in the resident’s
chart. GDR tracking will be
maintained per policy.
- How the corrective
action(s) will be monitored to
ensure the deficient practice
will not recur, i.e., what quality
assurance program will be put
into place; and
DON, CCO, or designee will audit
behavior tracking results, progress
notes, GDR history, and
psychotherapeutic medications on
a minimum of 5 residents weekly
x 4, then 10 residents monthly
x11 months. GDR tracking will be
maintained for each resident on
psychotherapeutic medications.
- By what date the systemic
changes for each deficiency
will be completed. After
submitting an acceptable Plan
of Correction, if it is
determined that the correction
will not be completed by the
date previously submitted, The
Division needs to be contacted
as soon as possible. The
facility will need to submit an
amended plan of correction
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 17 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
attempted.
During an interview, on 8/6/18 at 9:53 A.M., the
DON (Director of Nursing) indicated the
depression and anxiety should be in separate
plans of care and plan of care should contain
targeted behaviors and individualized
interventions. The DON indicated behaviors
should be tracked daily to included interventions
that were attempted with effectiveness.
During an interview, on 8/6/18 at 10:54 A.M., the
DON indicated a GRD should have been
attempted since the start date of the medications.
3. The clinical record for Resident E was reviewed
on 8/3/18 at 11:28 A.M. The diagnoses included,
but were not limited to, dementia, anxiety and
depression.
The admission MDS (Minimum Data Set)
assessment, dated 6/5/18, indicated Resident E
had a BIMS (Brief Interview of Mental Status)
score of 12, moderate cognitive impairment, and
was receiving antipsychotic and antidepressant
medication.
The Medication Review Report, dated 8/6/18,
indicated Resident E had an order for Seroquel 25
mg (milligrams) at bedtime related to Parkinson's
Disease.
A care plan, dated 6/18/18, indicated Resident E
uses antipsychotic medications related to the
disease process of Parkinson's.
There were no targeted behaviors or
individualized interventions present for the use of
antipsychotic medications.
with the updated plan of
correction date.
9/5/18
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 18 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
During an interview, on 8/6/18 at 12:00 P.M., the
DON (Director of Nursing) indicated a diagnosis
of Parkinson's was not an appropriate diagnosis
for antipsychotic medication use.
On 8/6/18 at 11:45 A.M., the DON provided the
Behavioral Health Services policy, dated 2018, and
indicated this was the policy currently be used by
the facility. The policy indicated the plan of care
should be person-centered, provide for
meaningful activities which promote engagement
and positive, meaningful relationships, reflect
resident's goals for acre, account for the resident's
experiences and preferences and maximize the
resident's dignity, autonomy, privacy,
socialization, independence and safety. The
facility staff should receive education to ensure
appropriate competencies and skills sets for
meeting the behavioral health needs of residents.
Behavioral health care and services should be
provided in an environment that promotes
emotional and psychosocial well being, supports
each resident's need and includes individualized
approaches to care.
On 8/6/18 at 11:45 A.M., the DON provided the
Gradual Dose Reduction on Psychotropic Drugs,
dated 2018, and indicated this was the policy
currently being used by the facility. The policy
indicated reducing the need for and maximuzung
the effectiveness of medications shall be
considered for all residents who use psychotropic
drugs. For any individual who is recieving a
psychotropic medication to treat expressions or
indications of distress related to dementia, the
GDR may be considered clinically contraindicated
for reasons that include, but that are not limited
to, target symtpoms return after most recent GDR
within facility and there is documented clinical
rationale.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 19 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
3.1-48(a)(3)
3.1-48(a)(4)
483.60(i)(1)(2)
Food
Procurement,Store/Prepare/Serve-Sanitary
§483.60(i) Food safety requirements.
The facility must -
§483.60(i)(1) - Procure food from sources
approved or considered satisfactory by
federal, state or local authorities.
(i) This may include food items obtained
directly from local producers, subject to
applicable State and local laws or
regulations.
(ii) This provision does not prohibit or prevent
facilities from using produce grown in facility
gardens, subject to compliance with
applicable safe growing and food-handling
practices.
(iii) This provision does not preclude residents
from consuming foods not procured by the
facility.
§483.60(i)(2) - Store, prepare, distribute and
serve food in accordance with professional
standards for food service safety.
F 0812
SS=D
Bldg. 00
Based on observation, interview and record
review, the facility failed to ensure appropriate
hand hygiene was completed during meal service,
thumbs did not come into contact with eating
surfaces, and gloves were used appropriately for 2
of 6 dining rooms observed. (Main and
Specialized Dining Rooms)
Findings include:
During an observation of the main dining room,
F 0812 Healthwin requests
consideration for desk review
for all citations.
It is the practice of Healthwin to
store, prepare, distribute, and
serve food in accordance with
professional standards for food
service safety
- What corrective action(s)
will be accomplished for those
09/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 20 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
on 07/31/18 at 11:18 AM, HA 3 (Hospitality
Associate) pulled up her socks, wiped her hands
on pants, and served 3 plates. Thumb was placed
on the eating surface of one plate. She took a
dessert plate to a table and placed it in front of a
resident, then took the same plate to another table
and gave it to a different resident. She served 2
more plates, pulled up her pants, served jello,
threw away trash from a table and served 4 more
plates. She reached into her back pockets and
served 2 more plates. No hand washing was
observed at any time.
During an observation of the specialized dining
room, on 07/31/18 at 12:25 PM, RN 2 (Registered
Nurse) put on gloves, placed a clothing protector
on a resident, moved a wheelchair, poured drinks,
touched a resident's hand, then back to serving
drinks. She then touched another resident's hand,
placed a napkin in a resident's lap, proceeded to
serve drinks, removed silverware and placed in a
resident's food. She removed her gloves and
washed hands for 15 seconds. No glove change
or additional hand hygiene occurred.
During an interview, on 08/06/18 at 12:09 PM, the
DON (Director of Nursing) indicated none of the
things observed should have occurred.
A policy was provided by the DON (Director of
Nursing) on 08/06/18 at 9:30 AM, titled
"Handwashing Guidelines-Dietary Employees",
undated, and indicated this was the policy
currently used by the facility. The policy
indicated "...Dietary employees shall keep their
hands and exposed portions of their arms
clean...shall clean their hands...immediately before
engaging in food preparation...after having
touched anything unsanitary. c. After hands have
touched bare human body parts...after engaging
residents found to have been
affected by the deficient
practice;
CMS regulations and Dining
Observation Critical Pathway
reviewed. Hospitality Aide and RN
inserviced with return
demonstration on handwashing
and food handling.
All dietary staff were also informed
with education ongoing through
September 5th, 2018.
- How other residents
having the potential to be
affected by the same deficient
practice will be identified and
what corrective action(s) will
be taken;
All resident that consume food by
mouth have the potential to be
affected.
- What measures will be put
into place and what systemic
changes will be made to
ensure that the deficient
practice does not recur;
Inservices for Dietary and Nursing
departments conducted by dietary
management/staff
development/designee
8/20/18-9/5/18.
- How the corrective
action(s) will be monitored to
ensure the deficient practice
will not recur, i.e., what quality
assurance program will be put
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 21 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
08/29/2018PRINTED:
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
SOUTH BEND, IN 46637
155153 08/06/2018
HEALTHWIN
20531 DARDEN RD
00
in any activity that may contaminate the hands...."
A policy was provided by the DON (Director of
Nursing) on 08/06/18 at 9:30 AM, titled "Food
Handling Principles for Infection Control",
undated, and indicated this was the policy
currently used by the facility. The policy
indicated "...Wash hands prior to preparing and
serving meals...Avoid touching hair, face or other
body parts while serving food...Do not touch the
ends of utensils (e.g., tips of spoons, or drinking
edge of cups)...Do not touch the eating surfaces
of plates...."
3.1-21(h)(3)
into place; and
Dietary Manager or designee
dining observation daily for 30
days; one audit weekly for 6
months;
monthly for 5 months
Results will be reviewed at QA
meetings
- By what date the systemic
changes for each deficiency
will be completed. After
submitting an acceptable Plan
of Correction, if it is
determined that the correction
will not be completed by the
date previously submitted, The
Division needs to be contacted
as soon as possible. The
facility will need to submit an
amended plan of correction
with the updated plan of
correction date.
9/5/18
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 22 of 22