East Lake Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkhart, Indiana.
- Location
- 1900 Jeanwood Dr, Elkhart, Indiana 46514
- CMS Provider Number
- 155269
- Inspections on file
- 28
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at East Lake Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that staff repeatedly administered antihypertensive medications to two residents despite physician orders to hold the drugs when BP readings were below specified parameters, as documented on multiple MARs. A resident on antiplatelet therapy, care planned as at risk for bruising, was observed with multiple purple and red bruises on both arms, yet there were no corresponding physician orders to monitor bruising, no nursing documentation of the bruises over a documented period, and a missed weekly skin assessment. Another resident with vascular disease and cellulitis, care planned and ordered to have heel boots on at all times with heel checks every shift, was repeatedly observed without heel boots in place while MAR entries indicated they had been applied, and the resident reported he was also supposed to have compression socks that were not provided.
Surveyors found that three residents receiving oxygen therapy did not have care consistent with physician orders. One resident with chronic respiratory failure and heart disease was repeatedly observed on 7 L/min via nasal cannula despite an order for 2 L/min. Another resident with COPD and pleural effusion was observed on 2.5–3 L/min even though the order specified 2 L every shift, and an agency LPN confirmed and corrected the incorrect setting. A third resident with dementia, CHF, pleural effusion, and emphysema was observed on 3.5 L/min oxygen after the prior order for 2.5 L/min had been discontinued, with no current physician order in place while oxygen continued to be administered.
Staff failed to follow infection control practices by not using required PPE for residents on Enhanced Barrier Precautions and Droplet Precautions and by not disinfecting shared equipment between residents. During pressure ulcer care and toileting assistance for residents with sacral wounds, a wound nurse, ADON, an LPN, and a CNA provided high-contact care while wearing only gloves and no gowns, despite posted Enhanced Barrier Precautions requiring both gown and gloves. An LPN disconnecting an IV antibiotic for a resident on Enhanced Barrier Precautions also wore only gloves, and another LPN administering medications to a resident on Droplet Precautions for pneumonia did not use required eye protection, even though face shields were available. Additionally, an LPN and an RN used a multi-use blood pressure and pulse oximetry machine on several residents without cleaning and disinfecting it between uses, and the DON confirmed there was no specific policy for cleaning this equipment, contrary to the facility’s standard precautions policy requiring disinfection of shared equipment between residents.
A resident with multiple chronic conditions and a Stage 2 sacral pressure ulcer did not receive daily wound care as ordered by the physician. The care plan required daily cleansing, triad paste, and foam dressing, but staff observations on separate shifts found the sacral dressing unchanged and still dated from a prior day, even though the MAR reflected that treatments had been signed out as completed. An LPN acknowledged not changing the dressing despite believing it was a daily treatment, and the wound nurse later confirmed that weekday wound care was her responsibility while nursing staff were responsible on weekends, stating the treatment should have been done as ordered.
Surveyors found that the facility failed to document food and fluid intake for three residents with dementia, renal disease, heart failure, dysphagia, and significant weight loss, despite care plans and MD orders requiring monitoring and recording of meal percentages and additional fluids. Review of food consumption logs and point‑of‑care charting over several months showed numerous missing entries for breakfast, lunch, and dinner, including multiple days with no intake documented at all, while the DON confirmed staff were expected to chart meal consumptions after each meal and acknowledged that meals and fluids were not documented.
A facility failed to provide timely assistance with ADLs for a resident, specifically regarding nail care and shaving. The resident, with a history of chronic conditions and an amputation, expressed a preference for weekly shaving and indicated willingness to trim his own nails if provided with clippers. Despite receiving bed baths, staff only offered shaving assistance infrequently, and the facility lacked a specific policy for nail care or shaving.
A facility failed to follow a care plan requiring two staff members to assist a resident with multiple health conditions, including hypertension and diabetes, during personal care. Observations showed a CNA providing care alone, contrary to the care plan's instructions. Interviews revealed staff were unaware of the paired care requirement, and the DON confirmed the absence of a policy to ensure compliance.
The facility failed to follow infection control measures during medication administration and linen handling. A QMA dropped a calcium tablet onto a medication cart, picked it up with bare hands, and placed it with other medications for a resident. The QMA and Assistant DON were unsure of the policy for contaminated medications. Additionally, a linen cart was left uncovered, exposing clean linens and an open bleach wipes container. CNAs acknowledged the linens should have been covered, and the wipes container should not have been left open.
Failure to Follow BP Medication Parameters, Monitor Bruising, and Apply Ordered Heel Boots
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered blood pressure parameters and medication holds for two residents receiving antihypertensive medications. One resident with hypertension and atherosclerotic heart disease had an order for Clonidine 0.3 mg three times daily with instructions to hold the dose if the systolic blood pressure was less than 140. Despite this, the MARs for March and April 2026 show numerous administrations of Clonidine at ordered times when the recorded systolic blood pressure was below 140. Another resident with dementia, diabetes, atrial fibrillation, heart disease, heart failure, and mood disorders had orders for Carvedilol 12.5 mg twice daily and Hydralazine 50 mg three times daily, both to be held if blood pressure was under 110/60. Across multiple months (January through April 2026), the MARs document repeated administrations of both medications at ordered times when the resident’s blood pressure was below the ordered parameters. The deficiency also includes failure to assess and monitor bruising for a resident at risk for bruising related to antiplatelet therapy. This resident, cognitively intact and diagnosed with heart disease, heart failure, and hypertension, had a care plan identifying risk for bruising with an approach to observe for bruises and a physician’s order for daily Aspirin 81 mg. During observations, surveyors noted purple and red bruises on both arms, but there were no physician’s orders to monitor bruising, no nursing progress note documentation of bruising between early April and mid-April, and a weekly skin assessment documented no bruising. Additionally, a weekly skin assessment due mid-April was not completed. When later assessed, multiple dark purple bruised areas of varying sizes were documented on both lower arms. A further deficiency concerns failure to implement ordered heel protection for a resident at risk for skin breakdown. This resident, cognitively intact and diagnosed with cellulitis of the left lower limb, heart disease, peripheral vascular disease, and heart failure, was care planned as at risk for skin breakdown due to limited mobility and rare skin moisture, with approaches including heel boots to both lower extremities to be on at all times. A physician’s order also directed heel checks every shift and heel boots on at all times each shift. During multiple observations, the resident was seen in a wheelchair with both legs dependent, darkened, and edematous, without heel boots in place. The resident reported he was supposed to have compression socks but was told the facility had run out, and he had no heel boots on. Despite this, the MAR indicated heel boots were signed out as applied over several days when observations showed they were not on the resident.
Failure to Follow Oxygen Orders and Maintain Current Oxygen Therapy Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care by not ensuring oxygen was set at the correct flow rate and not obtaining current physician orders for oxygen therapy for three residents. For one resident with chronic respiratory failure with hypoxia, heart disease, peripheral vascular disease, and heart failure, surveyors repeatedly observed oxygen being administered via nasal cannula at 7 L/min from a concentrator, while the physician’s order dated 4/2/26 specified oxygen at 2 L/min via nasal cannula. The resident’s care plans, dated 4/2/26, directed staff to administer oxygen as ordered for risks related to heart failure and impaired gas exchange, but the observed oxygen flow rate did not match the physician’s order. Another resident with COPD, pleural effusion, heart disease, chronic kidney disease, hypertension, and depression was observed multiple times receiving oxygen via nasal cannula at 2.5 L/min and later at 3 L/min on the concentrator, despite a physician’s order dated 4/3/26 for oxygen at 2 L every shift. An agency LPN confirmed the concentrator was set at 3 L/min and then adjusted it back to 2 L/min, acknowledging it should have been set at 2 L/min. A third resident with dementia, heart failure, hypotension, depression, dysphagia, pleural effusion, and emphysema was observed on two occasions receiving oxygen via nasal cannula at 3.5 L/min. The record showed a prior physician’s order for continuous oxygen at 2.5 L/min via nasal cannula dated 4/6/26 that had been discontinued on 4/8/26, and there was no current physician’s order for oxygen therapy at the time of observation, despite the resident’s care plan directing staff to administer oxygen as ordered.
Inadequate PPE Use and Failure to Disinfect Shared Equipment
Penalty
Summary
The deficiency involves multiple failures to follow the facility’s infection prevention and control practices, particularly related to the use of personal protective equipment (PPE) for residents on Enhanced Barrier Precautions and Droplet Precautions. In one instance, during a sacral pressure ulcer treatment for a resident, the Wound Nurse and Assistant Director of Nursing (ADON) repositioned the resident and removed the sacral dressing without donning gowns, despite the resident being on Enhanced Barrier Precautions requiring gown and gloves for direct resident contact. Later, an LPN assisting the same resident back into bed after administering nasal spray also only wore gloves and did not don a gown, even though the door signage specified Enhanced Barrier Precautions. The Infection Preventionist confirmed that gowns should have been worn before repositioning and assisting the resident. Additional failures to use appropriate PPE occurred with other residents on Enhanced Barrier Precautions and Droplet Precautions. An LPN disconnected an IV antibiotic and flushed the line for a resident on Enhanced Barrier Precautions while wearing only gloves and no gown, contrary to the posted requirement for gown and gloves during direct resident contact. Another LPN entered the room of a resident on Droplet Precautions for pneumonia wearing a gown, N95 mask, and gloves to administer medications but did not wear eye protection, despite the droplet precaution signage specifying the need for eye protection and face shields being available on the isolation cart. For another resident with a sacral pressure ulcer and a bandage to the sacral area, a CNA assisted with toileting and an LPN performed a skin assessment; both staff members wore only gloves and did not don gowns, even though a sign later observed on the resident’s door indicated Enhanced Barrier Precautions requiring gown and gloves for high-contact care activities such as toileting and wound care. The facility also failed to ensure that multi-use vital sign equipment was disinfected between residents. An LPN checked a resident’s blood pressure and pulse oximetry using a multi-function blood pressure machine and then placed the machine in the hallway near the medication cart without sanitizing it, and it remained unsanitized several minutes later while the LPN continued medication administration. In another series of observations, an RN used the same type of multi-use blood pressure machine to obtain vital signs for one resident in the dining room, returned it to the wall and plugged it in without cleaning, and later used it again in another resident’s room without disinfecting it between uses. The RN acknowledged not sanitizing the machine after each resident, and the DON reported there was no facility policy for cleaning the multi-use blood pressure machine, despite the facility’s Standard and Transmission-Based Precautions policy stating that shared equipment should be cleaned and disinfected between each resident use.
Failure to Perform Ordered Daily Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer treatment as ordered by the physician for a resident with a sacral Stage 2 pressure ulcer. The resident, who had multiple diagnoses including compression fracture, COPD, pleural effusion, heart disease, chronic kidney disease, hypertension, and depression, and was moderately impaired for daily decision making, reported that her pressure ulcer bandage was not changed every day. During an observation, a CNA assisted the resident to the bathroom and noted that the sacral dressing was dated 4/11/26, which was confirmed again later the same day when an LPN performed a skin assessment and observed the same 4/11/26 date on the dressing. The LPN acknowledged she had not changed the bandage and believed the treatment was supposed to be done daily. The resident’s care plan documented impaired skin integrity with a sacral pressure ulcer and directed staff to provide treatment as ordered by the physician. A physician’s order dated 4/6/26 specified cleansing the wound, patting it dry, applying triad paste, and covering with a foam dressing once a day. The MAR for April 2026 showed the treatment signed out as completed on 4/11 and 4/12/26, despite the dressing still being dated 4/11/26 on 4/13/26. A wound NP note on 4/6/26 documented the ulcer at 1 cm by 0.5 cm with 100% epithelial tissue, and a subsequent note on 4/14/26 documented the ulcer at 0.5 cm by 0.5 cm with 100% epithelial tissue. During a wound treatment on 4/16/26, the wound nurse removed the sacral dressing and observed minimal drainage and a red wound base. The wound nurse stated she worked Monday through Friday and that nursing staff were responsible for treatments on weekends, and indicated the treatment should have been done as ordered by the physician.
Failure to Document Food and Fluid Intake for Residents With Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to document food and fluid intake for residents with known weight loss and identified nutritional risk. One resident with Alzheimer’s disease and end stage renal disease on dialysis had a care plan directing staff to monitor food and fluid intake at meals. However, review of the Food Consumption Log over a one‑month period showed numerous missing entries for breakfast, lunch, and dinner, including multiple days with no intake documented for any meal. The DON stated the resident’s food intake should have been documented and suggested the resident may have been at dialysis for some breakfasts, while the Unit Manager reported the resident received breakfast before going to dialysis. Another resident with dementia, type 2 diabetes, heart disease, heart failure, and depression had documented significant weight loss and was care planned for altered nutrition with approaches requiring documentation of breakfast, lunch, and dinner intake percentages. Weight records showed a decline from 144 pounds to 126 pounds over several months, with a later increase to 133 pounds. Despite this, point‑of‑care charting revealed extensive gaps in documentation of breakfast, lunch, and dinner intake across multiple months, with many dates lacking any recorded meal consumption. The DON confirmed that staff were expected to complete meal consumption documentation after every meal and reported there was no facility policy available for review. A third resident with dementia, heart failure, low blood pressure, depression, dysphagia, and a mechanically altered diet had experienced a 19.8% weight loss over six months. Physician’s orders and care plans directed staff to offer an additional 120 ml of fluid every shift, record fluid intake, monitor food and fluid intake at meals, monitor weight, and document meal percentages and fluid consumption. Review of the Food Consumption Log over approximately six weeks showed numerous missing entries for breakfast, lunch, and dinner, including several days with no food consumption documented at all. The DON acknowledged that there were meals and fluids not documented and did not provide additional information.
Failure to Provide Timely ADL Assistance for Resident
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADLs) for a dependent resident, specifically related to nail care and shaving. Observations and interviews revealed that the resident, who had a full beard and jagged nails with a brown substance under them, was not regularly offered assistance with shaving and nail care. The resident expressed a preference for weekly shaving and indicated that he would attempt to trim his own nails if provided with clippers, but these were not offered. Despite receiving bed baths twice a week, the resident reported that staff only offered shaving assistance once or twice a month. The resident's medical history includes hypertension, heart and chronic kidney disease, peripheral vascular disease, type 2 diabetes mellitus, and a right above-the-knee amputation. A Quarterly Minimum Data Set (MDS) assessment indicated that the resident's cognition was intact, and he required substantial assistance with personal hygiene and was dependent on staff for bathing. Interviews with CNAs revealed that while they provided various aspects of personal care, they did not consistently notice or address the resident's need for nail care and shaving. The facility lacked a specific policy for nail care or shaving, relying instead on regulations related to resident rights.
Failure to Follow Care Plan for Paired Assistance
Penalty
Summary
The facility failed to adhere to the care plan for a resident who required assistance from two staff members for care. During observations, it was noted that a CNA exited the resident's room alone after providing toileting assistance, despite the care plan specifying that care should be provided in pairs. The resident confirmed that typically only one caregiver assisted him, citing staffing limitations as the reason. The care plan, initiated in 2017 and updated in 2020, clearly indicated the need for paired care, which was emphasized in capital letters. Interviews with CNAs revealed a lack of awareness regarding the requirement for paired care for any residents in the hall. The Director of Nursing (DON) confirmed that the facility did not have a policy in place to ensure adherence to the care plan. The resident involved had multiple diagnoses, including hypertension, heart and chronic kidney disease, peripheral vascular disease, type 2 diabetes, and a right above-knee amputation, necessitating substantial assistance with personal hygiene and bathing.
Infection Control Lapses in Medication Administration and Linen Handling
Penalty
Summary
The facility failed to adhere to infection control measures during a medication administration observation for one resident and in the handling of clean linens. During a medication pass, a Qualified Medication Aide (QMA) dropped a calcium tablet onto the medication cart and then picked it up with her bare hand, placing it into a medication cup with other medications for the resident. The QMA acknowledged that she should not have administered the contaminated medications and was unsure of the facility's policy for the destruction of such medications. The Assistant Director of Nursing, present at the time, also indicated uncertainty regarding the policy. Additionally, a linen cart in one of the facility's halls was observed with its cover on top, exposing clean linens and an open container of micro kill bleach wipes with a wipe hanging out. Certified Nursing Assistants (CNAs) acknowledged that the linens should have been covered and the bleach wipes container should not have been left open. The facility's policy requires clean linen to be protected from contamination, and carts must be covered during transportation. The Director of Nursing provided a policy indicating that medications not in protective containers should be discarded if dropped, but the staff involved were not aware of these procedures.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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