Wellbrooke Of South Bend
Inspection history, citations, penalties and survey trends for this long-term care facility in South Bend, Indiana.
- Location
- 52565 State Road 933, South Bend, Indiana 46637
- CMS Provider Number
- 155824
- Inspections on file
- 25
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Wellbrooke Of South Bend during CMS and state inspections, most recent first.
A CNA made a disrespectful comment to a resident, telling her to shut up, in front of a family member. The resident had vascular dementia with behavioral disturbance, disorientation, and a fractured femur neck, with significant cognitive impairment and need for partial to moderate assistance with bed mobility, toileting, and transfers. The allegation was substantiated during the facility investigation.
Guardian Not Informed of Antipsychotic Dose Increase: A resident with schizophrenia and dementia had Haldol increased from 1 mg BID to 2 mg AM and 3 mg HS, but the record lacked documentation that the court-appointed guardian was informed or that guardian consent was obtained for the psychotropic dose change. The DON stated the guardian should have been notified and signed the consent, while the consent form in the record was signed by the resident.
The facility failed to administer a resident's midodrine according to the ordered BP parameters; the MAR showed doses missed when BP was within range and a dose given when BP was above the hold parameter, and the DON stated the nurse had read the order wrong. The facility also failed to follow a physician order for another resident's Tubigrips for edema, as the resident was observed without compression wraps while in bed and later wearing only non-slip socks, despite the treatment record showing the wraps as administered.
A resident with a right heel DTI, Sezary disease, severe protein calorie malnutrition, moderate cognitive deficits, and hospice care did not receive the full ordered wound tx. The Wound Nurse cleansed the wound, applied collagen and Xeroform, and wrapped the heel with Kerlix, but did not apply the ordered skin prep to the surrounding skin.
Fall interventions were not fully care planned or in place for a resident with a history of falls. A resident with significant cognitive impairment, prior falls, and a recent femoral neck fracture was observed leaning out of a wheelchair near the nurse's station until a CNA caught the resident as she slipped out of the chair. No alarm sounded during the event, and a floor mat was found propped against a dresser rather than in use. Staff interviews indicated the resident should have had additional fall interventions, including a mat when sleeping and avoidance of the recliner.
An LPN failed to follow infection control guidance during a medication pass when she poured a resident’s solid meds into her ungloved hands, picked up each pill, and placed them in a medicine cup before administering them. The LPN also discarded spironolactone that was being held because the resident’s BP was below ordered parameters. The DON and Clinical Support Nurse later stated the nurse should have worn gloves if touching the pills.
A resident with severe cognitive impairment and multiple chronic conditions experienced a dislodged urinary catheter, which was replaced by a hospice nurse after facility staff contacted hospice services. However, the responsible party was not notified of this significant change in condition, contrary to facility policy, and there was no documentation of notification in the resident's health record.
A CNA did not follow a resident's fall prevention care plan, leaving a resident with dementia and impaired mobility unsupervised on the edge of the bed. The resident attempted to transfer alone, fell, and sustained acute fractures to both femurs, requiring hospitalization and surgery. The care plan required staff assistance for transfers, but this was not provided, leading to the incident.
Three CNAs did not follow required fall protocols after a resident with hemiplegia and altered mental status was lowered to the floor during a transfer. Instead of waiting for a nurse to assess the resident, the CNAs moved her to bed, contrary to state guidelines. The resident was later found to have sustained a displaced femur fracture and a foot fracture.
The facility failed to ensure a process for residents to file grievances anonymously, affecting all 54 residents. Residents were unaware of how to file grievances anonymously, and the facility's app required staff assistance, compromising anonymity. Interviews with staff confirmed that the grievance process did not support true anonymity, potentially affecting residents' rights.
The facility failed to serve food in a sanitary manner in one dining room, affecting nine residents. Dietary aides were observed touching the eating surface of plates with their thumbs while serving meals. The Director of Food Service confirmed that plates should be handled from the bottom, as per the facility's policy.
A facility failed to provide adequate grooming for a resident who was severely cognitively impaired and required assistance with ADLs. Despite having a care plan that included facial shaving on shower days, the resident was observed with multiple white hairs on her chin over several days. Interviews with staff confirmed that facial shaving should be provided unless the resident preferred facial hair, which was not the case. The facility's policy emphasized the importance of grooming, yet the deficiency was evident through observations and lack of documentation.
A facility failed to coordinate and document hospice care for a resident with diabetes and senile degeneration. Despite a physician's order for hospice admission, the hospice communication book lacked essential documentation such as care plans and medication lists. The DON confirmed the absence of these documents, and it was found that the facility lacked a policy for maintaining hospice communication. A hospice services contract outlined documentation responsibilities, which the facility did not fulfill, resulting in a deficiency.
A facility failed to follow standard precautions during blood glucose testing and insulin administration for a resident. An LPN did not perform hand hygiene before and after taking the resident's blood sugar and prior to administering insulin, despite facility policies requiring hand hygiene before and after direct contact with residents and after glove removal. The LPN acknowledged the oversight during an interview.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s dignity when a CNA made a disrespectful comment to the resident, telling her to shut up, in the presence of the resident’s family member. The incident was reported as an FRI, and the allegation of inappropriate language was substantiated during the facility’s investigation. The resident involved had vascular dementia with behavioral disturbance, disorientation, and a fractured femur neck, and the admission MDS indicated significant cognitive impairment, a history of falls, and a need for partial to moderate assistance with bed mobility, toileting, and transfers. The report states that the family member overheard the CNA’s comment while visiting the resident. The resident was moved to a safe place after the incident, and the CNA was suspended and escorted out of the building pending investigation. The facility later determined the allegation was substantiated and the CNA was terminated and reported to the Nurse Aide Registry.
Guardian Not Informed of Antipsychotic Dose Increase
Penalty
Summary
The facility failed to ensure a resident’s legal guardian was informed of a change in treatment related to psychotropic medication. Resident 7 had diagnoses including schizophrenia and dementia, and the quarterly MDS dated 3/5/26 indicated the resident was cognitively intact. The resident had a guardianship order dated 2/17/21 showing she had been adjudicated an incapacitated person and a guardian had been appointed by the court. She was receiving antipsychotic medication, including Haldol ordered on 10/2/25 at 1 mg daily and 1 mg at bedtime. A physician’s order dated 3/4/26 increased Haldol to 2 mg in the morning and 3 mg at bedtime. A psychotropic medication informed consent observation dated 3/5/26 documented the increased antipsychotic dose, and the consent was signed by the resident. The record did not contain documentation that the legal guardian was informed or that consent was obtained from the guardian when the antipsychotic dose was increased. During interview, the DON stated the guardian should have been notified and signed the consent, and also stated the guardian was aware the resident was taking antipsychotic medications and that both the guardian and resident had agreed to the medication.
Failure to Follow Medication and Compression Wrap Orders
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for a resident with heart failure, hypertension, and orthostatic hypotension. A physician ordered midodrine 10 mg three times daily with instructions to hold for systolic blood pressure greater than 130. Review of the April 2026 MAR showed the medication was not administered when the blood pressure was within the ordered parameters on 4/1/26 at 6:00-8:00 a.m. with BP 102/51 and on 4/1/26 at 12:00-1:00 p.m. with BP 122/74, and on 4/6/26 at 6:00-8:00 a.m. with BP 116/72. The medication was also administered on 4/6/26 at 12:00-1:00 p.m. when the BP was 138/77. The DON stated the nurse had read the order wrong and should have given the medication when the BP was below 130 and held it when the BP was over 130. The facility also failed to follow a physician's order for compression wraps for a resident with chronic kidney disease and localized edema. The resident's care plan directed staff to apply Tubigrips to both lower extremities as ordered, and a physician's order required compression wrap from mid-foot to knee, covering the heel, to be applied in the morning and removed at bedtime. During observation, the resident was found in bed with legs uncovered and no compression wraps or socks on, and the legs appeared swollen. Later the resident was observed in a wheelchair and then in the main lobby wearing non-slip socks on both feet. The April 2026 treatment record showed the Tubigrips were marked as administered on 4/17/26.
Failure to Follow Ordered Pressure Injury Treatment
Penalty
Summary
The facility failed to ensure pressure ulcer treatment was provided as ordered for a resident with a deep tissue injury to the right heel. The resident had diagnoses including Sezary disease and severe protein calorie malnutrition, and the admission MDS indicated moderate cognitive deficits and hospice care. A wound assessment dated 3/26/26 documented the right heel DTI, and a physician's order dated 4/11/26 directed staff to gently cleanse and dry the right heel, apply skin prep to the surrounding wound, apply collagen to the wound bed, cover with Xeroform, and wrap with Kerlix every Monday, Wednesday, and Friday. During observation on 4/15/26, the Wound Nurse cleansed the wound, applied collagen and Xeroform, and wrapped the heel with Kerlix, but did not apply the ordered skin prep to the surrounding skin. In interview, the Wound Nurse stated she did not apply the skin prep as ordered.
Fall interventions were not fully care planned or in place for a resident with a history of falls
Penalty
Summary
The facility failed to ensure fall interventions were care planned for and/or in place for a resident with a history of falls. Resident 34 had diagnoses including vascular dementia with behavioral disturbance, disorientation, and fracture of the femur neck. The admission MDS dated 2/10/26 indicated significant cognitive impairment, a history of falls, and the need for partial to moderate assistance with bed mobility, toileting, and transfers. The Fall Care Plan dated 2/5/26 identified the resident as at risk for falls and included interventions such as not transferring the resident to a recliner chair. After a facility-reported incident on 2/27/26, the resident was hospitalized for a left femoral neck fracture after attempting to ambulate in her room and falling. The care plan was updated on 3/9/26 to include a ghost alarm to the wheelchair and mattress, but there was no intervention that included use of a floor mat. During observation on 4/14/26, the resident was seated in her wheelchair near the nurse's station, fidgeting and leaning over until her buttocks came over the edge of the seat; a CNA caught her as she slipped out of the wheelchair. No alarm sounded during the observation. Later that day, a floor mat was observed propped against the dresser in the resident's room, and staff interviews indicated the resident should have had a mat on the floor or next to the recliner when sleeping, although the resident was not to be put in the recliner. The DON and Nurse Consultant were informed that the alarm had not activated and that the floor mats had not been care planned.
Improper Handling of Resident Medications During Pass
Penalty
Summary
The facility failed to ensure infection control guidelines were followed during medication administration when an LPN handled a resident’s solid medications with ungloved hands. During observation of medication pass for Resident 59, the LPN prepared the resident’s medications and stated that spironolactone would be held because the resident’s blood pressure was below the ordered parameters. She tore open a plastic pouch containing four tablets, poured them into her ungloved hands, picked up each pill and placed it in a medicine cup, then picked up the spironolactone and disposed of it before giving the resident the remaining pills. During the immediate interview, the LPN was informed that she had handled the pills with ungloved hands. Later, the Clinical Support Nurse and DON were informed of the observation and stated the nurse should have worn gloves if touching the pills. The facility policy on Specific Medication Administration Procedures stated that solid medications should be poured or pushed into a souffle cup while avoiding touching the tablet or capsule unless wearing gloves.
Failure to Notify Responsible Party of Catheter Dislodgement and Replacement
Penalty
Summary
The facility failed to notify a resident's responsible party when a significant change in condition occurred involving the dislodgement and replacement of a urinary catheter. The resident, who was admitted under hospice services for respite care and had severe cognitive impairment along with multiple diagnoses including degenerative disease of the nervous system, dementia, Alzheimer's disease, hypertension, and chronic kidney disease, stood up unassisted and pulled out her urinary catheter. Facility nursing staff immediately contacted hospice services, and a hospice nurse reinserted the catheter without difficulty. Documentation indicated that the dislodged catheter balloon had not been fully inflated as required. Despite the incident and the facility's policy requiring notification of the resident's legal representative in the event of a significant change in condition, there was no evidence that the responsible party was informed about the catheter incident. The facility Administrator believed hospice services had notified the family, but the Hospice Executive Director confirmed that the family had not been notified. The facility's policy also required documentation of notification or attempts in the resident's electronic health record, which was not present in this case.
Failure to Follow Fall Prevention Care Plan Results in Resident Injury
Penalty
Summary
A certified nursing aide (CNA) failed to follow a resident's comprehensive care plan for fall prevention, resulting in a significant accident. The resident, who had diagnoses including dementia, unsteadiness, muscle weakness, and impaired cognition, required substantial assistance for transfers and was at high risk for falls. The care plan specified interventions such as staff assistance with transfers, use of a fall mat, bed in the low position, and a perimeter mattress to define the bed's edges. Despite these directives, the CNA left the resident seated on the edge of the bed unsupervised while retrieving an item, during which time the resident attempted to transfer independently and fell to the floor. Following the fall, the resident was assessed and found to have pain in the torso and lower extremities. Emergency department evaluation revealed acute, displaced fractures of both femurs, with the left femur showing a comminuted fracture and the right femur an acute displaced oblique fracture. The resident required surgical intervention and hospitalization due to the severity of the injuries. The clinical record and staff interviews confirmed that the resident had severe cognitive deficits and did not remember needing assistance with transfers, further emphasizing the necessity of staff supervision as outlined in the care plan. Documentation indicated that the CNA had moved floor mats to position a wheelchair for transfer but left the resident unattended, directly contravening the care plan's requirement for one-person assistance during transfers. The facility's fall management policy aimed to maintain a hazard-free environment and implement preventative measures, but in this instance, the failure to provide adequate supervision and adhere to the care plan led to the resident's fall and subsequent injuries.
Failure to Follow Fall Protocols After Resident Fall
Penalty
Summary
The facility failed to ensure that three certified nurse aides (CNAs) followed established fall protocols after a resident experienced a fall. The incident involved a resident with a history of right-sided hemiplegia, osteoarthritis, and altered mental status, who required substantial to maximal assistance for transfers and was at high risk for falls. During a transfer from the toilet to a wheelchair, the resident was not able to sit back fully in the wheelchair, resulting in her knees hitting the wall and her being lowered to the floor by a CNA. The CNA, along with two other CNAs, subsequently assisted the resident from the floor to her bed without waiting for a nurse to assess the resident, despite the resident expressing pain and distress. Documentation revealed that the CNAs did not follow the Indiana State Department of Health Nurse Aide Curriculum, which instructs staff to call for help immediately and keep the resident in the same position until a nurse examines the resident after a fall. Instead, the CNAs moved the resident before a nurse could assess her condition. There were no written statements from two of the CNAs involved, and the facility lacked a specific policy guiding nurse aides on the required actions following a resident fall, aside from referencing the state curriculum. Subsequent medical evaluation found that the resident had sustained an acute, displaced fracture of the femoral metaphysis and a fracture of the metatarsal of the left foot. The resident was treated at a local emergency department and returned to the facility. Interviews confirmed that the CNAs moved the resident due to her complaints of pain and requests to be moved, but did not adhere to the required protocol of waiting for a nurse assessment before moving a resident after a fall.
Failure to Ensure Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to provide a process for residents to file grievances anonymously, affecting all 54 residents. During a Resident Council meeting, it was revealed that none of the eight residents present knew how to file a grievance anonymously. The facility utilized an application accessible only on facility computers and tablets, requiring residents to inform a staff member to access the app. This process compromised anonymity, as staff members would know who requested to file a grievance. Interviews with the Executive Director, Life Enrichment Director, and Social Services Director confirmed that the grievance app required staff assistance, which could reveal the identity of the resident filing the grievance. The facility's policy allowed for grievances to be filed verbally, in writing, or anonymously, but the current system did not support true anonymity due to the need for staff involvement in accessing the app. This deficiency in the grievance process potentially affected the dignity and rights of all residents in the facility.
Unsanitary Food Handling in Dining Room
Penalty
Summary
The facility failed to serve food in a sanitary manner in one of the three dining rooms observed, potentially affecting all nine residents who ate there. During an observation, a dietary aide was seen carrying two residents' plates with her thumb on the eating surface, which she acknowledged should have been carried from the bottom. Additionally, two other dietary aides were observed touching the eating surface of residents' plates with their thumbs while serving meals. The Director of Food Service confirmed that the food servers should have handled the plates from the bottom to avoid touching the eating surface. The facility's policy, dated 2009, indicated that plates should be handled so that hands do not touch the areas where food or the mouth will be placed.
Failure to Provide Adequate Grooming for a Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for a dependent resident, specifically in relation to facial shaving. Observations on multiple occasions revealed that the resident had multiple white hairs on her chin, approximately half an inch in length, indicating a lack of grooming. The resident, who was severely cognitively impaired and required supervision for personal hygiene, had a care plan that included facial shaving on shower days or as needed. However, despite receiving showers on several documented dates, there was no record of the resident refusing facial shaving, suggesting that the task was not performed as required. Interviews with facility staff, including CNAs and an LPN, confirmed that facial shaving should be provided to residents, including females, unless they preferred to have facial hair. The staff were unaware of any female residents who preferred facial hair, and the LPN acknowledged that the resident should have been shaved. The facility's policy on grooming emphasized the importance of maintaining hair and facial hair, yet the deficiency in care was evident through the observations and lack of documentation regarding the resident's grooming needs.
Failure to Coordinate and Document Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination and documentation of hospice care for a resident who was admitted to hospice. The resident, who had diagnoses including diabetes mellitus with neuropathy and senile degeneration of the brain, was admitted to hospice care as per a physician's order dated 1/9/2025. However, upon review of the hospice communication book on 2/5/2025, it was found that essential sections such as the comprehensive care plan, physician orders, medication list, narcotic count, and visit notes were blank. This lack of documentation was confirmed during an interview with the Director of Nursing (DON), who acknowledged that these documents should have been present in the hospice book. Further investigation revealed that the facility did not have a policy for maintaining a hospice book for communication between the facility and the hospice team. A contract for hospice services, dated 10/4/2021, outlined the responsibilities of both the hospice and the facility, including the provision of documentation such as the hospice plan of care, medication information, physician orders, and clinical notes. The contract also specified that the facility was responsible for maintaining an accurate medical record that included all services and events provided. Despite these contractual obligations, the facility failed to maintain the necessary documentation, leading to a deficiency in the coordination and continuity of care for the resident receiving hospice services.
Failure to Follow Hand Hygiene Protocols During Blood Glucose Testing and Insulin Administration
Penalty
Summary
The facility failed to adhere to standard precautions during routine blood glucose testing and insulin administration for a resident. During a medication administration pass, an LPN gathered supplies and entered the resident's room, donned gloves, and took the resident's blood sugar. After completing the task, the LPN exited the room with gloves on, disposed of the supplies, and removed the gloves. She then donned new gloves to clean the glucometer, removed those gloves, and prepared the insulin without performing hand hygiene at any point. The LPN then entered the resident's room again, donned gloves, and administered the insulin without using alcohol-based hand rub or washing her hands. During an interview, the LPN acknowledged that she should have used alcohol-based hand rub before and after taking the blood sugar and prior to administering the insulin. The facility's policies on medication administration and hand hygiene were reviewed, indicating that hand hygiene should be performed before and after direct physical contact with residents and after removing gloves.
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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