PRINTED: 04/26/2019 DEPARTMENT OF HEALTH AND HUMAN

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(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

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PRINTED: 04/26/2019FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

155269 01/18/2019

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STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1900 JEANWOOD DREAST LAKE NURSING & REHABILITATION CENTER

ELKHART, IN 46514

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

This visit was for a Recertification and State

Licensure Survey. This visit included the

Investigation of Complaint IN00283871 and

IN00283460.

Complaint IN00283871 - Substantiated.

Federal/State deficiencies related to the

allegations are cited at F689.

Complaint IN00283460 - Substantiated.

Federal/State deficiencies related to the

allegations are cited at F656 and F686.

Survey dates: January 14, 15, 16, 17 & 18, 2019

Facility number: 000169

Provider number: 155269

AIM number: 100267100

Census Bed Type:

SNF/NF: 126

SNF: 7

Total: 133

Census Payor Type:

Medicare: 8

Medicaid: 80

Other: 45

Total: 133

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality Review was completed on January 25,

2019.

F 656

SS=D

Develop/Implement Comprehensive Care Plan

CFR(s): 483.21(b)(1)

F 656 2/13/19

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

02/08/2019

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 1 of 31

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F 656 Continued From page 1 F 656

§483.21(b) Comprehensive Care Plans

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

implement a comprehensive person-centered

care plan for each resident, consistent with the

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

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

objectives and timeframes to meet a resident's

medical, nursing, and mental and psychosocial

needs that are identified in the comprehensive

assessment. The comprehensive care plan must

describe the following -

(i) The services that are to be furnished to attain

or maintain the resident's highest practicable

physical, mental, and psychosocial well-being as

required under §483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be required

under §483.24, §483.25 or §483.40 but are not

provided due to the resident's exercise of rights

under §483.10, including the right to refuse

treatment under §483.10(c)(6).

(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with the

findings of the PASARR, it must indicate its

rationale in the resident's medical record.

(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


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plan, as appropriate, in accordance with the

requirements set forth in paragraph (c) of this

section.

This REQUIREMENT is not met as evidenced

by:

Based on record review and interview, the facility

failed to develop appropriate individualized care

plans, with the required information, related to

dementia care (Resident 73), hospice (Residents

73, 118, & 231), anxiety, dementia care and

anticonvulsant medication use (Resident 73),

impaired skin integrity (Resident D), depression

(Residents D & 73) for 4 of 26 residents whose

care plans were reviewed.

Findings Include:

1. A clinical record review was conducted on

01/16/19, at 11:06 AM, for Resident 73 and

indicated an admission date of 10/26/16. Her

diagnoses included, but were not limited to:

anxiety, palliative care, dementia with behaviors,

pain, weakness, depression, atrial fibrillation,

heart failure, and glaucoma. Her medications

included: depakote (dementia), eliquis (a-fib),

lexapro (depression), norco (pain), lopressor

(HTN), lisinopril (HTN), lopressor (HTN), and

risperdal (dementia).

The MDS (Minimum Data Set) assessment,

dated 11/28/18, indicated a BIMS (Brief Interview

for Mental Status) score of 2, severe cognitive

impairment. Heart failure, HTN, dementia,

depression, anxiety, palliative care, pain , a-fib,

and glaucoma were indicated as current

diagnoses. Antipsychotic, opiod, and

anticoagulant medications were indicated as

taken all 7 days of the look back period.


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Care plans were in place related to behaviors,

psychosocial well-being, dementia, psychotropic

med use, glaucoma, and depression. The

depression and dementia care plans were not

individualized. No care plan was identified for

anxiety or anticonvulsant medication use. Her

hospice care plan did not include the required

information related to whom to contact in case of

emergency, provider and discipline to provide

care, end of life choices, advanced directives,

and coordination of care between hospice and

the facility.


01/18/19, at 3:20 PM, for Resident 118 and


diagnoses included, but were not limited to: right

below the knee amputation (RBKA), malnutrition,

blindness, reflux/obstructive uropathy,

schizoaffective disorder, convulsions, gout,

anxiety, diabetes, and personality disorder.



for Mental Status) score of 14, cognitively intact.

Hospice was indicated as being received while a

resident.

The care plan in place related to hospice did not

contain required the required information related

to whom to contact in case of emergency,

provider and discipline to provide care, end of life

choices, advanced directives, and coordination of

care between hospice and the facility.


01/16/19, at 10:22 AM, for Resident D and

indicated an admission date of 07/14/18. His

diagnoses included, but were not limited to: lung


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cancer, obstructive uropathy, weakness,

diabetes, heart failure, atrial fibrillation,

depression, and hypertension. His medication

included: aldactone (HTN), amiodarone (HTN),

eliquis (a-fib), remeron (depression), and

humalog (diabetes).




Heart failure, HTN, diabetes, depression, lung

cancer, and a-fib were indicated as current

diagnoses. Antidepressant, diuretic, and

anticoagulant medications were indicated as

taken all 7 days of the look back period. One

stage 2 and one unstageable pressure area were

indicated. Neither were present upon admission.

MASD (Moisture Associated Skin Damage) was

not indicated.

A care plan was in related to pressure areas to

right and left heels, right buttock, and sacrum.

No additional care plans in were place related to

impaired skin integrity. Additional care plans

were in place related behaviors, psychosocial

well-being, depression, anticoagulant use,

diabetes, psychotropic med use, pressure ulcers,

and skin integrity. The depression care plan in

place was not individualized.

A policy was provided by the DON (Director of

Nursing) on 01/18/19 at 3:00 PM, titled "Skin

Management Program", dated 04/2018, and

indicated this was the policy currently used by the

facility. The policy indicated "...The licensed

nurse is responsible for assessing all skin

alterations by the direct caregivers on the shift

reported. 7. Facility skin sweeps

(head-to-toe-assessment) are conducted monthly


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to assess all residents' current skin conditions...A

plan of care will be initiated to include resident

specific risk factors and contributing factors with

appropriate interventions implemented...."


01/17/19, at 3:42 PM, for Resident 231 and



cancer, liver cancer, c-diff, depression,

rheumatoid, and weakness.




Hospice care was indicated.

The hospice care plan did not include the

required information related to whom to contact in

case of emergency, provider and discipline to

provide care, end of life choices, advanced

directives, and coordination of care between

hospice and the facility.

During an interview, on 01/18/19 at 11:26 AM, the

SSD (Social Service Designee) indicated the care

plans were not individualized and should have

been. She also indicated no care plan was in

place related to anxiety, for Resident 73, because

the resident was not symptomatic. She could not

identify what specific symptoms to monitor for.

During an interview, on 01/18/19 at 4:02 PM, the

DON (Director of Nursing) indicated the required

information should have been included.


DON indicated no care plan was in place for the

MASD.


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facility. The policy indicated "...A plan of care will

be initiated to include resident specific risk factors

and contributing factors with appropriate

interventions implemented...."

On 1/18/19 at 4:31 P.M., the DON provided the

Comprehensive Care Plan Policy, dated 11/2018,

and indicated this was the policy currently being

used by the facility. The policy indicated care

plans would include measurable goals and

resident specific interventions based on resident

needs and preferences to promote the residents

highest level of functionin including medical,

nursing, mental and psychosocial needs.

This Federal tag is related to Complaint

IN00283460.

3.1-35(a)

F 686

SS=G

Treatment/Svcs to Prevent/Heal Pressure Ulcer

CFR(s): 483.25(b)(1)(i)(ii)

§483.25(b) Skin Integrity

§483.25(b)(1) Pressure ulcers.

Based on the comprehensive assessment of a

resident, the facility must ensure that-

(i) A resident receives care, consistent with

professional standards of practice, to prevent

pressure ulcers and does not develop pressure

ulcers unless the individual's clinical condition

demonstrates that they were unavoidable; and

(ii) A resident with pressure ulcers receives

necessary treatment and services, consistent

with professional standards of practice, to

F 686 2/13/19


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promote healing, prevent infection and prevent

new ulcers from developing.


by:

Based on observation, interview and record

review, the facility to properly assess and provide

treatment to a pressure ulcer to a residents right

hip resulting in a DTI (deep tissue injury)

developing (Resident C), an unstageable

pressure to buttocks (Resident B) and

unstageable pressure ulcers to heels and Stage 2

pressure ulcers to buttocks (Resident D) for 3 of

3 residents reviewed for pressure ulcers.

Findings include:

1. The clinical record for Resident C was

reviewed on 1/17/19 at 1:46 P.M. The diagnoses

included, but were not limited to, history of CVA

(cerebrovascular accident - stroke) with

hemiplegia and diabetes mellitus.

The significant change MDS (Minimum Data Set)

assessment, dated 10/19/18, indicated Resident

C required extensive assist with ADLs (activities

of daily living), had a catheter and was at risk for

pressure area development and currently did not

have any pressure areas.

A care plan for at risk for skin breakdown related

to CVA with right hemiplegia, dated 4/24/12,

included, but was not limited to the following

interventions, dycem to wheelchair (12/12/18),

resident up for lunch daily but prefers to stay up

and participate in activities (9/20/17), low air loss

mattress (9/12/15) and roho cushion to

wheelchair (2/18/13).

There was no care plan available for review for


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actual skin breakdown.

The Physician Order Report, dated 12/31/18 -

1/2/19, indicated Resident C had orders for

cleanse an open area to right right posterior hip

with normal saline or wound cleanser, pat dry and

apply chalet and ABD (abdominal pad) every shift

with started date of 12/6/18. There were no

orders present to monitor area to right hip for

worsening or signs/symptoms of infection.

A Progress Note, dated 12/6/18 at 2:32 P.M.,

indicated Resident C was observed by Physical

Therapy to have open areas noted to right

posterior thigh and right posterior hip. Areas were

pink with a small amount of serous (clear)

drainage noted.

A Non-ulcer Pressure Skin Event, dated 12/6/18

at 12:00 P.M., indicated Resident C had a partial

thickness wound to right posterior thigh that

measured 3 cm (centimeters) x 5 cm with a small

amount of serous drainage noted.

A Progress Note, dated 12/11/18, indicated the

Wound NP (Nurse Practitioner) was in to see

moisture associated areas to right side.

A Physician Progress Note, dated 12/11/18,

indicated Resident C had superficial skin injury

noted to right posterior thigh, erythema and

moisture. The diagnoses included dermatitis

associated with moisture, impaired skin integrity

and superficial injury of skin. The plan was for

limiting head of bed elevation, consider use of

dimethicone, no pads under resident and

consider topical antifungal.

There were no changes in treatment to areas


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noted and no updates noted to at risk for skin

break down and no care plan for new area was

completed.


indicated Resident C was sent to the local

hospital for evaluation and treatment.

The ER (Emergency Room) Report, dated

12/25/18, indicated Resident C presented to the

ER with dry, diffuse breakdown to skin to the

buttocks and coccyx area and open areas to right

posterior buttock and upper thigh.

A Consultation Note, dated 12/26/18, indicated

Resident C had multiple decubitis ulcers that

were pink with granulation tissue.

A Discharge Summary, dated 12/31/18, indicated

Resident C was readmitted to facility with a

diagnoses of multiple decubitus ulcers, with 2

full-thickness ulcers to right thigh and left coccyx

stage 2 ulcer.

The Extended Care Facility Patient/Resident

Transfer Form- Physician orders,dated 12/31/18,

indicated orders for wound care.

There were no orders present for the stage 2 to

coccyx upon readmission and no care plans for

areas were noted.


indicated Resident C areas to right hip were

present before resident was transferred to

hospital on 12/25/18.

A Non-Ulcer Skin Event, dated 1/2/19 at 2:24

P.M., indicated Resident C had a partial thickness


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wound noted to right thigh measuring 4.5 cm x

1.2 cm with a small amount of blood noted,

classified as moisture associated skin damage.

A Non-Ulcer Skin Event, dated 1/2/19 at 2:26

P.M., indicated Resident C had a partial thickness

wound noted to right thigh measuring 1.8 cm x

1.8 cm with a small amount of blood noted,

classified as moisture associated skin damage.


indicated the Wound NP was in to see Resident

C on wound rounds for area to right posterior leg.

The current order was for Hydrofera Blue

Baterisotatic Wound dressing considering

resident's skin is 80% tensile strength related to

history of skin grafts. Resident C had returned

from hospital stay on 12/31/18. No new skin

concerns were reported. Wound nurse would

follow up in two weeks.

There was no documentation present that the

Wound NP was aware of the documented

observation and diagnoses from the ER physician

report, the consultation, or the discharge

summary.

There was no wound documentation available to

review from 1/2/19 to 1/17/19.

During an observation, on 1/17/19 at 2:26 P.M.,

the wound to Resident C's right posterior thigh

presented as a DTI with Stage 2 pressure ulcers

noted within the DTI area. The DTI was noted on

the posterior thigh, below the scar from the skin

graft.

During an interview, on 1/17/19 at 2:26 P.M., the

Wound NP indicated the area to the right thigh


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was caused by moisture and pressure. She

indicated the area did not have good tensile

strength due to history of skin graft to area and

was fragile. She indicated the open areas to right

thigh were stage 2 pressure ulcers and DTI to

surrounding tissue, she was not aware how long

pressure had been applied to the area.

A Wound Note, dated 1/17/19 at 2:49 P.M.,

indicated Resident C had a Unstageable/Deep

Tissue that measured 13 cm x 7 cm and wound

was declining. The tissue was dark purple and

boggy upon palpation.


Resident C's wheelchair was noted to be a geri

chair with roho cushion in place that was did not

have sufficient amount of air in it (when pressure

as applied the wheelchair could be felt through

the roho cushion, air was not being distributed

through out cushion).


Resident C was observed in wheelchair with roho

cushion low air, right leg was turned out with

flaccid right arm resting on leg. The area to the

right posterior thigh aligned were pressure area.


indicated a Stage 2 pressure ulcer to right hip

measuring 1 cm x 1 cm x 0.1 cm with granulation

tissue present and surround tissue was dark

purple.


indicated a Stage 2 pressure ulcer to right medial

thigh measuring 0.3 cm x 0.3 cm x 0.1 cm with

granulation tissue present and surround tissue

was dark purple.


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indicated a Stage 2 pressure ulcer to right lateral

thigh measuring 1 cm x 0.8 cm x 0.2 cm with

granulation tissue present and surround tissue

was dark purple.


indicated a Stage 2 pressure ulcer to right distal

posterior thigh measuring 6 cm x 1 cm x 0.25 cm

with granulation tissue present and surround

tissue was dark purple.


indicated the Wound NP was in to see Resident

C for area to right posterior thigh and per nursing

the wound was worsening and it was reported

with increased discoloration t skin hip and skin

was boggy. The wound measurements to right

hip were 13 cm x 7 cm and classification was

SDTI (suspected deep tissue injury), the right

upper hip had 2 areas measuring 0.3 cm x 0.3 cm

x 0.1 cm and 2.1 cm x 1 cm x 0.1 cm, posterior

right hip wound measured 1 cm x 0.8 cm x 0.2

cm and left upper hip wound measured 1 cm x 1

cm x 0.1 cm. The diagnoses with SDTI of

unknown depth of right trochanteric region of hip

and Stage 2 pressure ulcers. The plan was to trial

wedge cushion to wheelchair, offloading right hip,

wound required daily monitoring and therapy to fit

resident for larger wheelchair.


DON (Director of Nursing) wounds should be

monitored weekly by the wound nurse and a care

plan for impaired skin integrity should have been

started. She indicated that it was the

responsibility of the MDS (Minimum Data Set)

Nurse to start and update wound care plans.


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wound nurse indicated she was not aware the

areas classified as moisture associated skin

damage with skin loss were to be documented as

Stage 2 pressure ulcers. She indicated she

classified moisture damaged skin as redness,

drainage, and maceration.


DON indicated roho cushion air level was not

checked routinely and that there were no wound

certified nurses in the facility. She indicated the

facility employed a Wound NP that was to

oversee the resident with wounds weekly but

Resident C had not been seen since 1/2/18 by

the Wound NP.

2. The clinical record for Resident B was

reviewed on 1/27/19 at 12:51 P.M. The diagnosed

included, but were not limited to, dementia and

coronary artery disease.

The admission MDS (Minimum Data Set)

assessment, dated 10/21/18, indicated Resident

B required extensive assist with ADLs (activities

of daily living) and did not have any pressure

ulcers noted on admission.

A Nurses' Transfer/Discharge Condition

Assessment Form, dated 10/21/18, indicated

Resident B was readmitted back into facility with

a Stage 2 pressure area noted left buttocks and a

Stage 1 Pressure ulcer to right buttocks.

An Admission Observation, dated 10/21/18 at

2:32 P.M., indicated Resident B had a 2 cm

(centimeter) x 1 cm wound to left buttocks, 1 cm


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x 1 cm wound to right buttocks, shearing noted to

buttocks and 3 cm x 2. 4 cm redness to left heel.


indicated Resident B had a reddened area to left

heel measuring 3 cm x 2.4 cm. He had shearing

noted to buttocks and an abrasion to left buttocks

measuring 2 cm x 1 cm and an abrasion to right

buttocks measuring 1 cm x 1 cm.

The Physician Order Report, dated 10/22/18 -

1/17/19, indicated an order for Destitin to sore on

bottom every six hours as needed.

There were no care plans available for areas

noted upon admission.

There were no wound notes available for areas

noted upon admission.


indicated Resident B had open areas noted to

coccyx.

A Progress Note, dated 10/26/18 at 11:13 A.M.,

indicated Resident B had open areas noted to

coccyx.


indicated the dietician reported no pressure

ulcers.


indicated Resident B was a extensive transfer of

two people, required extensive assist of 2 people

with bed mobility and preferred to sleep in his

recliner. He had open areas noted to buttocks.



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indicated wound care was provided to area on

buttocks.

The Home Discharge Instructions and

Information, dated 11/8/18 at 1:17 P.M., indicated

no skin issues where present.


indicate Resident B was discharged to Assisted

Living.


DON from the assisted living center indicated that

Resident B was admitted on 11/8/18 with 2 small

open areas and dark red, yellow slough noted to

surrounding tissue. Resident was started on

antibiotics for 11 days and bactroban. The

physician had been doctor and wound center

consult was ordered. She indicated Resident B

was sent the local hospital on 11/24/18 from

assisted living.

The Discharge Summary, dated 11/28/18,

indicated Resident B was admitted to local

hospital with sacral decubitus infection.

The History & Physical, dated 11/25/18, indicated

Resident B's family member was convinced the

deterioration started after his recent discharge on

10/21 to an inpatient rehabilitation facility due to

poor care and his sacral decub was a Stage 3

located in gluteal fold and was 7 cm x 5 cm with

green pustulant drainage and surrounding tissue

had erythema.


DON (Director of Nursing) indicated she was

aware wound documentation had been missed

and wound assessment from admission was not


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reviewed by the wound nurse nor was the wound

nurse aware of wounds. She indicated the wound

should have been looked at the following day by

wound nurse and the wounds were never

assessed by wound nurse. There was no

physician notification documented. She indicated

the discharge summary did not include

information regarding wound for the receiving

facility.


01/16/19, at 10:22 AM, for Resident D and

indicated an admission date of 07/14/18. His


cancer, obstructive uropathy, weakness,

diabetes, heart failure, atrial fibrillation,

depression, and hypertension.




One stage 2 and one unstageable pressure area

were indicated. Neither were present upon

admission. MASD (Moisture Associated Skin

Damage) was not indicated as present.

A care plan was in related to pressure areas to

right and left heels, right buttock, and sacrum.

The problem start date was 10/19/18. An

intervention was in place to assess the wounds

weekly and to document the measurements and

description. No additional care plans in were

place related to impaired skin integrity.

The onset of a wound area to the right buttock

and sacrum began 01/04/19 and were originally

classified as pressure, but changed to MASD on

01/08/19. The measurements at the time of

onset were as follows: 0.4cm x 0.4cm x 0cm and

was identified as a stage 2. No indicated of an


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area to the left buttock. The sacrum wound

measured as follows on 01/04/19: 1.5cm x 1.0cm

x 0cm and a stage 2. The onset of the right heel

wound was 10/19/18. The area measured as

follows: 3cm x 2cm x 0.5cm and a stage 3. The

onset of the left heel was 12/24/18. The area

measured as follows: 2cm x 3cm x 0cm and a

stage 2.

On 01/18/19, at 10:30 AM, wound care was

observed with the wound nurse. Wound care

provided per order, with appropriate hand

hygiene. The area to the sacral area measured

1.4cm x 0.6cm x 0.1 cm. The left buttock area

measured 0.3cm x 0.3cm x 0.1cm. The wound

nurse indicated the areas were now classified as

MASD and no longer considered pressure.

On 01/18/19, at 2:20 PM, wound care was

observed with the wound nurse for bilateral heels.

Measurements were as follows: Left heel - 4.0cm

x 4.3cm x 0cm; draining serosanginous drainage,

unstageable. Right heel - closed: no

measurements, unstageable. Wound care

proved per order, with appropriate hand hygiene.


wound nurse and the DON (Director of Nursing)

indicated when residents have identified areas of

concern related to pressure the wound nurse

must assess them within 1 business day. If it

occurs on a Friday, the floor nursing staff would

assess, but were not allowed to stage. The DON

indicated she was the back up wound nurse when

the original nurse was out. They indicated the

areas to the bottom were considered moisture

based on the appearance of maceration, despite

his catheter. The wound nurse indicated the

moisture was coming from the way his buttocks


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came together when sitting in his chair.


DON indicated no care plan was in place for the

MASD.





facility. The policy indicated "...The licensed

nurse is responsible for assessing all skin

alterations by the direct caregivers on the shift

reported. 7. Facility skin sweeps

(head-to-toe-assessment) are conducted monthly

to assess all residents' current skin conditions...A

plan of care will be initiated to include resident

specific risk factors and contributing factors with

appropriate interventions implemented...."

This Federal tag is related to Complaint

IN00283460.

3.1-40(a)(1)

F 689

SS=G

Free of Accident Hazards/Supervision/Devices

CFR(s): 483.25(d)(1)(2)

§483.25(d) Accidents.

The facility must ensure that -

§483.25(d)(1) The resident environment remains

as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate

supervision and assistance devices to prevent

accidents.


by:

F 689 2/13/19

Based on observation, record review and


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interview, the facility failed to ensure appropriate

safety interventions were implemented for an

ambulatory resident with poor safety awareness

and indwelling catheter use resulting in a fall

requiring surgical intervention to remove catheter

tip from bladder (Resident G) and ensuring a

resident was safely transferred with two staff

members using a hoyer lift resulting a fall with

head laceration and a brain bleed (Resident E)

for 2 of 3 residents residents reviewed for

accidents.

Finding includes:

1. During an observation, on 1/14/19 at 12:00

P.M., Resident G was observed laying in low bed

with an indwelling catheter hanging on the side of

bed with the tubing ran down the inside of his

sweat pants that he was wearing. There was

approximately 1 1/2 to 2 feet of tubing from the

pant leg to the bed where the bag was hanging

from a plastic hook on urinary collection bag

which was touching the floor. There was small

areas of dryed blood noted to pants around the

region where the catheter tip was inserted into the

tip of the penis.


Resident G was observed attempting to get out

bed independently with indwelling foley catheter

in place. The urinary drainage bag was attached

to bed frame with a plastic hook and the tubing

was coming from the bottom of the resident's

pants he had on. Staff had to intervene to keep

resident from attempting to ambulate with

indwelling catheter bag attached to bed and the

tubing coming from pants presented a trip hazard

for the the resident with cognitive impairment.


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The clinical record for Resident G was reviewed

on 1/16/19 at 2:13 P.M. The diagnoses included,

but were not limited to, brain cancer and

obstructive uropathy.

The admission MDS (Minimum Data Set)

assessment, dated 1/4/19, indicated Resident G

had a BIMS score of 5, severe cognitive

impairment, and resident had an indwelling

catheter in place.

A care plan for risk was falls related to equipment

that tethers patient, impaired cognition,

impulsivity, decreased mobility and diagnoses of

brain cancer, dated 12/28/18, included, but was

not limited to, the following interventions: bed

alarm/chair alarm and environmental checks for

mobility obstacles.

A care plan for indwelling catheter use, dated

12/28/18, included, but was not limited to, the

following interventions: do not allow tubing or any

part of the drainage system to touch the floor and

manipulate tubing as much as possible.

A care plan for cognitive impairment, dated

1/7/19, indicated Resident G had severe cognitive

impairment.


indicated Resident G was frequently standing and

unable to tell nurse why, he ambulated with

assistance and has indwelling Foley catheter.

A Progress Note, dated 12/30/18 at 10:16 A.M.,

indicated Resident G stood up frequently and was

kept at the nursing station throughout day for

safety.


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indicated Resident G was noncompliant with

asking for assistance and frequently stood up

from wheelchair and required redirection.


indicated Resident G was noncompliant with

asking for assistance, spontaneous and

repetitively stands up from wheelchair, required

cueing every 5 minutes and needed to stay in

sight for safety.


indicated Resident G was observed sitting on

floor next to bed and call out for help. Resident

was placed by nursing station for one-on-one.


indicated Resident G had to continuously be

redirected due to restlessness and constantly

standing up to walk off.


indicated Resident G continued to get up and

down and stepped on catheter and dislodged it.

Resident G was sent to local hospital to assist

with dislodged catheter because the balloon tip

was still lodged inside.

The ER (Emergency Room) Report, dated 1/6/18

at 7:09 P.M., indicated that Resident G had

presented to the ER with catheter issue. It was

reported per nursing home records, that resident

attempted to get out bed independently and

accidentally ripped out his urinary catheter. The

nursing home staff was unsure whether the

balloon of the catheter or part of the tubing was

still present in urethra. An ultrasound showed 3.8

cm (centimeters) broken catheter tip in the


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bladder. Resident G was to have tip of catheter

removed surgically in urologist office on 1/9/18.


DON (Director of Nursing) indicated the facility

did not previously use a leg bag for Resident G

with his getting up and down, they had been using

a drainage bag system as observed.


UM (Unit Manager) 8 indicated that the facility did

use leg bags on residents with indwelling

catheters on case by case. The decision to use

leg bags was based on guidelines and one of the

guidelines was to use a leg bag if the resident

was mobile.

On 1/18/19 at 4:31 P.M., a policy for leg bag use

was requested but no policy was provided.

2. On 01/15/19 at 3:35 PM, Resident E was not

interviewable. Her roommate indicated to me

that Resident E had an accident several days ago

where she fell from the hoyer lift. She stated "that

middle strap wasn't on right and she fell right out

of the sling and there was just that one aide in

here. You might want to talk to her daughter

because she is kind of confused and can't really

answer questions."

A clinical record review was conducted on

01/16/19, at 9:18 AM, for Resident 11 and


diagnoses included, but were not limited to:

hypertension, depression, anxiety, Guillian-Barre

syndrome, chronic pain, spinal stenosis, and

glaucoma.




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for Mental Status) score of 4, severe cognitive

impairment. The assessment indicated Resident

E was an extensive assist for transfers and

required 2+ people for that task.

The ADL (Activities of Daily Living) care plan in

place indicated all transfers were to be completed

with the hoyer lift.

A reportable incident, dated 01/06/19, indicated

Resident E experienced a fall during bedtime

care. A laceration was indicated as an injury.

Staff statements were obtained, no additional

resident interviews were indicated. Statements

from the staff were inconsistent. The nurse

indicated she found the resident sitting upright on

the floor, in front of her wheelchair, during the

interview. The nurse's original noted indicated

she found the resident laying flat on her back on

the floor. One statement indicated the sling was

on top of her and the other indicated it was under

her. The ED (Executive Director) indicated in the

investigation the hoyer lift was 3 feet from

Resident E but also indicated her leg was draped

across the lift when found.

The emergency room report, dated 01/07/19,

indicated Resident E was evaluated for a fall from

approximately 4 feet high. She presented with a

head laceration, that required 3 staples. The

report indicated a 5mm hyperdensity was

identified on the CT scan, indicative of a

parenchymal bleed, which was not present on the

previous study.


daughter of Resident E indicated the facility had

called her the night of the incident and informed

her the resident had fallen from the hoyer lift.


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She indicated she came right over and was told

by Resident 11's roommate that the aide was

transferring her mother to bed with the hoyer lift

and the middle strap was undone and she slipped

from the sling, landing on the floor. She also

indicated the evening nurse told her she did not

believe the aide's story of sliding out of the

wheelchair. She asked her mother what

happened and she indicated to her that she had

fallen from the lift.


wound nurse indicated Resident E's roommate

was alert with some confusion, but able to answer

questions.

During an interview, on 01/17/19 at 4:13 PM, a

second interview was conducted with the

roommate. She indicated Resident E had a fall

from the hoyer last week in her room, by her bed.

She indicated she was raised in the air when she

fell from the sling.

On 01/17/19, at 4:00 PM, the SSD (Social

Services Designee) completed an updated BIMS

assessment for Resident E's roommate, which

indicated a score of 8, moderate cognitive

impairment. Multiple progress notes for the

roommate indicated she was alert and responsive

with some confusion.


ED indicated he did not feel the roommate was

reliable due to a low BIMS score of 5. He also

indicated he did not interview any other residents

because he felt it was an accident. When asked

about a second staff in the room during transfers,

he indicated there should be two people and he

assumed there were. He could not provide a


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name or interview with a second staff member

present during care.

On 01/18/19, at 10:50 AM, a policy related to

transfers was requested, but one was not

available.

This Federal tag relates to Complaint

IN00283871.

3.1-45(a)(2)

F 761

SS=D

Label/Store Drugs and Biologicals

CFR(s): 483.45(g)(h)(1)(2)

§483.45(g) Labeling of Drugs and Biologicals

Drugs and biologicals used in the facility must be

labeled in accordance with currently accepted

professional principles, and include the

appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and

Federal laws, the facility must store all drugs and

biologicals in locked compartments under proper

temperature controls, and permit only authorized

personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately

locked, permanently affixed compartments for

storage of controlled drugs listed in Schedule II of

the Comprehensive Drug Abuse Prevention and

Control Act of 1976 and other drugs subject to

abuse, except when the facility uses single unit

package drug distribution systems in which the

quantity stored is minimal and a missing dose can

F 761 2/13/19


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be readily detected.


by:

Based on observation and interview, the facility

failed to ensure 3 of 5 medication storage areas

were free from expired medications and multiple

routes of medication stored in the same drawer.

(Medication room Unit 2, 400 hall cart and 500

hall cart).

Findings include:

1. During a medication room storage area

observation, on 1/16/19 at 1:20 P.M., with LPN 3

(License Practical Nurse), insulin kwik pens,

suppositories and 2 bottles of pills were found to

be stored in the same drawer and a bottle of

aplisol and suppositories found in another drawer

being stored in the same drawer in the

refrigerator on Unit 2's Medication Room.

2. During a medication cart observation, on

1/16/19 at 1:30 P.M., with LPN 2, the 400 cart

was observed to have a Humalog kwikpen,

opened 12/14/18, and a Basaglar insulin pen,

opened 12/14/18.

During an interview, on 1/16/19 at 1:35 P.M., LPN

2 indicated the insulin pens were good for 28

days and they had expired.

3. During a medication cart observation, on

1/16/19 at 1:40 P.M., with LPN 1, the 500 cart

was observed to have a bottle of brimonidine 2%

eye drops, opened 11/30/18 and a bottle of

dorzolamide 2% eye drops, opened 11/17/8.

During an interview, on 1/16/19 at 1:45 P.M., LPN

1 indicated they were expired.


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DON (Director of Nurses) indicated insulin,

suppositories, oral medications and injectable

medications should not be stored in the same

drawer and expired medications should not be

kept in the medication carts.

A policy was provided by the DON, on 1/6/19 at

2:21 P.M., titled, ..."Storage and Expiration of

Medications, Biologicals, Syringes and Needles",

revised 1/1/13, and indicated the policy was the

one currently being used by the facility. The

policy indicated "...3.2 Facility should ensure that

external use medications and biologicals are

stored separately from internal use medications

and biologicals. 3.5 Topical (external) use

medications or other medications should be

stored separately from oral medications... 4.2

...Have not been retained longer than

recommended by manufacturer/supplier

guidelines...."

3.1-25(o)

F 804

SS=D

Nutritive Value/Appear, Palatable/Prefer Temp

CFR(s): 483.60(d)(1)(2)

§483.60(d) Food and drink

Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that

conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable,

attractive, and at a safe and appetizing

temperature.


by:

F 804 2/13/19


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failed to ensure food was served at the

appropriate temperatures for 1 of 1 kitchens

observed. (Main kitchen)

Finding Includes:

During an interview, on 01/15/19 at 11:41 AM,

Resident 104 indicated the food was cold and she

would have to tell the staff to heat it up.

During an observation, on 01/17/19 at 12:15 PM,

food temperatures were as follows: Hamburger

patty - 128F. Baked fish - 113F. Baked chicken

- 126F. Soup - 131. Pureed chicken breast -

116F.

During an interview, on 01/17/19 at 12:20 PM,

Cook 7 indicated the target holding temperature

was 141F.


Nursing) on 01/18/19 at 4:31 PM, titled "Food

Temperatures", dated 11/2017, and indicated this

was the policy currently used by the facility. The

policy indicated "...Hot foods that are potentially

hazardous will leave the kitchen (or steam table)

at or above 135F...."

3.1-21(a)(2)

F 812

SS=E

Food Procurement,Store/Prepare/Serve-Sanitary

CFR(s): 483.60(i)(1)(2)

§483.60(i) Food safety requirements.

The facility must -

§483.60(i)(1) - Procure food from sources

approved or considered satisfactory by federal,

F 812 2/13/19


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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.


by:


failed to ensure food items were properly dated

and labeled for 1 of 1 kitchens observed. (Main

kitchen)

Finding Includes:

During an initial kitchen tour, on 01/14/19 at 11:35

AM with the RD (Registered Dietician) the

following was observed: Bulk powder sugar, use

by 12/08/18. 2 raw hamburger packs thawing in

walk-in cooler, no received by date. 2 bags of

shredded cheddar cheese, no dates. Package of

sliced cheese, no date. 2 bags of elbow noodles,

no dates. 2 bags of open, undated buns. 2

containers of ranch dressing, received date

05/30. Container of cocoa powder, opened

07/13, no use by date. Chocolate cake mix,

opened 01/12, no use by date. Bran muffin mix,

opened 12/24, no use by date. 2 damaged

packages of pancake mix, no dates. Open, cut

celery on 01/08/19, no use by date.


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During a second kitchen tour, on 01/17/18 at

12:30 PM, the following was observed: Bulk

powder sugar, use by date of 12/08/18. 2

containers of ranch, received 05/30. Opened

cocoa powder, from 07/13, no use by date. Open

chocolate cake mix, dated 01/12, no use by date.

Open bran muffin mix, dated 12/24, no use by

date.


RD indicated she was unsure of how the items

should be dated or how long the facility keeps

items.


Nursing) on 01/18/19 at 4:31 PM, titled "Food

Storage", dated 11/2017, and indicated this was

the policy currently used by the facility. The policy

indicated "...All containers must be accurately

labeled and dated...All foods should be covered

or wrapped tightly, labeled and dated...."

3.1-21(i)(3)


Documents

PRINTED: 04/26/2019 DEPARTMENT OF HEALTH AND HUMAN