West Bend Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in South Bend, Indiana.
- Location
- 4600 W Washington Ave, South Bend, Indiana 46619
- CMS Provider Number
- 155355
- Inspections on file
- 26
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at West Bend Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including dementia and anxiety, was prescribed Ativan to be given before dialysis sessions. Facility staff did not notify the resident's responsible party about the new medication or discuss its risks and benefits prior to administration, despite facility policy requiring such notification. Documentation only indicated that medications were reviewed, without specifying that Ativan was discussed.
A resident was administered Ativan prior to dialysis treatments without adequate assessment or documentation of behavioral need, following only a single reported incident of restlessness. Facility staff did not complete required behavioral assessments or monitor the resident's response to the medication, and the responsible party was not informed of its use. The resident was observed to be alert and without negative behaviors during this period, indicating the medication was used as a chemical restraint without sufficient justification.
A resident with dementia and anxiety was prescribed Ativan for use before dialysis, but staff failed to create a care plan addressing this psychotropic medication until more than two months after it was started, contrary to facility policy and best practices.
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and pantries, affecting all residents who consumed food from these areas. Observations revealed significant cleanliness issues, including buildup of substances on kitchen equipment, unsanitary conditions in dining areas, and inadequate food storage practices. Staff interviews highlighted a lack of clarity on cleaning responsibilities and food disposal, despite the existence of a cleaning schedule and adherence to the FDA Food Code.
A resident's surgical wound condition worsened, showing signs of infection, but the facility failed to notify the surgeon. Despite the resident's requests for dressing changes, the wound was not properly managed, and the facility's wound team made treatment changes without the surgeon's input. Interviews revealed a lack of communication and follow-up, with the surgeon's office confirming they were not informed of the condition change.
The facility failed to provide the required Notice of Transfer/Discharge forms for two residents transferred to an acute care facility. One resident, with chronic conditions, was sent to the ER unresponsive, and although her husband was notified, the necessary documentation was missing. Another resident, transferred due to back pain and vomiting, also lacked documented transfer paperwork for two hospitalizations. The absence of documentation was confirmed by the Administrator.
The facility failed to provide the Bed Hold Policy to two residents during hospital transfers. One resident, with chronic conditions, was sent to the ER unresponsive, and her husband was notified, but no documentation of the policy was provided. Another resident, hospitalized twice, did not recall receiving the policy, and the record lacked documentation of its provision. The ED confirmed the absence of necessary transfer paperwork.
The facility failed to conduct timely Care Plan meetings with two residents, leading to a deficiency in care planning. One resident did not have Care Plan meetings following several MDS assessments, except for one conducted after an annual MDS assessment. Another resident did not have quarterly Care Plan meetings as required, despite having an intact cognition and multiple diagnoses. The facility's policy mandates timely meetings, which were not adhered to in these cases.
A facility failed to perform and document daily dressing changes for a resident with a surgical wound, as ordered by a physician. The resident reported that the dressing had not been changed for two days, and upon inspection, it was found to be dated four days prior with signs of infection. An LPN admitted to not changing the dressing and incorrectly signing off on the Treatment Administration Record. The facility could not provide a relevant policy when requested.
A resident with a surgical wound did not receive daily dressing changes as ordered by the physician. The dressing was not changed for two days, despite the resident's requests, and was found to be loose with drainage. An LPN failed to communicate the need for dressing changes to the evening shift, and the Treatment Administration Record was inaccurately signed. The DON noted the absence of a specific policy on following physician orders.
A resident was prescribed cephalexin for a UTI, but a lab report showed no bacterial growth, indicating the antibiotic was unnecessary. The facility failed to notify the NP to discontinue the medication until five days after receiving the lab results, leading to a deficiency.
A resident with a history of hemiplegia, diabetes, and anxiety did not receive fresh ice water as per his preference, impacting his hydration needs. Despite the facility's policy to provide fresh water to all residents, the resident had to request water from the nurse's station, and his care plan did not address his preference for fresh ice water. Observations confirmed the absence of water in his room, and a CNA stated she only provided water upon request.
A facility failed to maintain infection control standards during a dressing change for a resident with multiple health conditions. An LPN did not perform hand hygiene after removing a soiled dressing and placed clean supplies on the bed without a barrier, contrary to facility policy. The LPN later acknowledged these lapses in procedure.
Failure to Notify Responsible Party of New Medication Prior to Administration
Penalty
Summary
The facility failed to ensure timely notification of a resident's responsible party regarding the initiation of a new medication, Ativan, and the associated risks and benefits prior to its administration. Interviews with the Social Service Director at a local dialysis center revealed that the resident, who had diagnoses including Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety, was prescribed Ativan to be administered before dialysis sessions. The dialysis center staff observed the resident arriving lethargic and requested discontinuation of the medication after several weeks. Documentation showed that the responsible party was not informed about the new medication at the time of its initial administration, and the addition of Ativan was not discussed during a care plan meeting, despite a note indicating that medications were reviewed. Further interviews with the Memory Care Director, Assistant Director of Nursing, and Director of Nursing confirmed that the responsible party was not notified about the prescription of Ativan prior to its administration. The only documentation of notification was a care plan note stating that medications were reviewed, but it did not specify that Ativan had been discussed. The facility's policy required that all changes in a resident's condition, including new medications, be communicated to the responsible party prior to the end of the assigned shift, with documentation of the notification and response. This policy was not followed in this instance, resulting in a deficiency.
Failure to Prevent Unnecessary Use of Psychotropic Medication as Chemical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraint when Ativan, a psychotropic medication, was administered prior to off-site dialysis treatments without adequate assessment or documentation of need. The medication was prescribed following a single report of the resident being 'figgity' and pulling at his dialysis port, but there were no further documented incidents of negative behaviors or agitation. Despite this, Ativan was ordered and administered three times weekly before dialysis appointments for several months. Interviews with facility staff, including the Memory Care Director and Assistant Director of Nursing, revealed that no behavioral assessments were completed prior to the initiation of Ativan, nor were there follow-up assessments to monitor the resident's response or potential side effects. The Psychiatric Nurse Practitioner prescribed the medication based on a request from the Director of Nursing, who had been informed by the dialysis center of the resident's agitation. However, the only documented behavioral incident was from several weeks prior, and subsequent observations showed the resident to be alert, well-groomed, and without negative behaviors. The dialysis center later reported that the resident was arriving lethargic and that the responsible party was unaware of the Ativan use. The facility's own policy required assessment and documentation of symptoms and therapeutic goals prior to initiating psychotropic medications, but this was not followed. The lack of assessment, documentation, and monitoring led to the administration of a psychotropic medication without clear evidence of medical necessity, resulting in the resident being chemically restrained.
Failure to Timely Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan in a timely manner for a resident who was prescribed an anti-anxiety medication, Ativan, to be administered prior to dialysis sessions. The resident had multiple diagnoses, including Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety. The order for Ativan was given by the Psychiatric Nurse Practitioner following a request from the Memory Care Director, and the medication was administered regularly as prescribed. However, review of the resident's clinical record and care plans revealed that a care plan addressing the use of Ativan for anxiety was not initiated until over two months after the medication was started. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that a care plan should have been created immediately after the Ativan was ordered, but this was not done. The facility's policy on psychotropic management requires that symptoms and therapeutic goals be documented prior to initiating such medications, and that care plans be developed to promote the resident's highest practicable well-being. The lack of a timely care plan for the use of Ativan constituted a failure to meet these requirements.
Sanitation Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and pantries, affecting all 57 residents who consumed food from these areas. During a series of observations, surveyors noted significant cleanliness issues, including a thick buildup of black substance on the burner grates and grease accumulation on the gas range and surrounding areas. Additionally, a ceiling vent above a prep table was covered in a black substance resembling mold, and the handwashing sink was dirty with a red dried substance. The Culinary and Nutrition Manager acknowledged the need for cleaning, despite the existence of a cleaning checklist. In the dining areas, further unsanitary conditions were observed. The 2nd Floor Dining Room had a range and oven with food debris and grease buildup, which staff acknowledged should be cleaned by the kitchen. The Main Dining Room had a leaking ice machine with lime buildup and dirty walls, and several chairs had food debris on them. The Housekeeping Supervisor and Maintenance Director confirmed the issues, with responsibilities for cleaning divided between kitchen and housekeeping staff. In the pantries and kitchenettes, food storage practices were inadequate. Expired and undated food items were found, including hot chocolate, condiments, yogurt, and pizza sauce, some of which were leaking. Staff interviews revealed a lack of clarity on responsibilities for discarding expired items and cleaning. The Executive Director and Corporate Nurse indicated the facility followed the FDA Food Code but lacked a specific policy for kitchen maintenance. A cleaning schedule was provided, but it was not effectively implemented, leading to the observed deficiencies.
Failure to Notify Surgeon of Wound Condition Change
Penalty
Summary
The facility failed to notify a resident's surgeon of a change in the condition of a surgical wound, which was a requirement for one of the residents reviewed for skin conditions. The resident, who had undergone a left above-the-knee amputation revision and treatment for a wound infection, reported that her dressing had not been changed for two days, despite her requests to the evening shift staff. Upon observation, the dressing was found to be loose, with a large amount of reddish-brown drainage, and the wound showed signs of infection, including redness and an open area. The resident's medical history included chronic hematogenous osteomyelitis, chronic obstructive pulmonary disease, chronic diastolic heart failure, and peripheral vascular disease, among other conditions. The facility's records indicated that the wound had initially been well-approximated with no signs of infection. However, subsequent assessments showed a worsening condition, with the wound dehiscing and showing signs of infection. Despite these changes, the surgeon was not notified, and the facility's wound team and nurse practitioner made treatment changes without the surgeon's input. Interviews with facility staff revealed a lack of communication and follow-up regarding the notification of the surgeon. The LPN responsible for notifying the surgeon did not confirm whether the surgeon had received the notification or provided any treatment recommendations. The surgeon's office confirmed that they had not been contacted about the change in the wound's condition, and the facility's documentation did not include any record of communication with the surgeon regarding the changes in the resident's wound condition.
Failure to Provide Transfer/Discharge Documentation
Penalty
Summary
The facility failed to provide the required Notice of Transfer/Discharge form when residents were transferred to an acute care facility. For Resident 4, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and heart failure, the record review showed that after being found unresponsive, the resident was sent to the emergency room. Although the resident's husband was notified by phone, there was no documentation that the Notification of Transfer/Discharge form was provided to either the resident or her husband. An interview with the Executive Director confirmed the absence of transfer paperwork in the resident's records. Similarly, for Resident 16, who was transferred to the hospital due to lower back pain and vomiting, the facility did not document the completion of a transfer/discharge assessment or provide the necessary forms. Despite the family and primary care physician being notified of the transfer, the records lacked documentation of the transfer paperwork for two separate hospitalizations. The Administrator confirmed the absence of the required documentation, and no policy regarding the documentation of a transfer/discharge assessment was provided during the survey.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to residents when they were admitted to the hospital, as required. This deficiency was identified for two residents who were reviewed for hospitalization. Resident 4, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and heart failure, was found unresponsive and sent to the emergency room. Although her husband was notified by phone of the transfer, there was no documentation that the Bed Hold Policy was provided to either the resident or her husband. Additionally, the facility's Executive Director (ED) confirmed the absence of transfer paperwork, including the Transfer/Discharge form for Resident 4. Similarly, Resident 16, who had been hospitalized twice in the last four months, did not recall receiving a bed hold policy. The nursing progress notes indicated that Resident 16 was sent to the emergency department due to lower back pain and vomiting, and later admitted to the hospital. Despite the notifications to the Director of Nursing, the resident's family, and the Primary Care Physician, the record lacked documentation that the Bed Hold Policy was provided during the transfers. The ED acknowledged the absence of transfer paperwork, including the notice of transfer and bed hold policy paperwork, and provided the current Bed Hold Policy, which mandates that residents be given the policy at the time of hospital transfer or therapeutic leave.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct timely Care Plan meetings with residents and/or their representatives for two residents, leading to a deficiency in care planning. Resident 47 did not have Care Plan meetings following several Minimum Data Set (MDS) assessments, except for one conducted after the annual MDS assessment in February 2024. Despite regular meetings with the Social Services Director, formal Care Plan meetings were not held as required. The Executive Director confirmed the lack of regular Care Plan meetings for Resident 47 after MDS assessments. Similarly, Resident 38 did not have Care Plan meetings on a quarterly basis as required. Despite having an intact cognition and a diagnosis of hypertension, general anxiety disorder, and depression, there was no documentation of Care Plan meetings from June 2024 through December 2024. The Social Service Director acknowledged the absence of formal Care Plan meetings after the quarterly assessments in August and November 2024. The facility's policy, dated August 2023, mandates that the Interdisciplinary Team (IDT) meet with residents and/or their representatives at a mutually agreed time and location, which was not adhered to in these cases.
Failure to Perform and Document Dressing Changes
Penalty
Summary
The facility failed to meet professional standards of quality care by not ensuring that a resident's dressing changes were completed as ordered. During an observation and interview, the resident reported that her dressing, which was supposed to be changed daily, had not been changed for two days. The dressing was dated four days prior, and upon inspection, it was found to have a large amount of reddish-brown thick drainage, an opening in the center of the wound, and erythema around the surgical site. The resident had requested the dressing change to be completed later in the day due to outings, but it was not done. A review of the resident's records showed a physician's order for daily dressing changes, which were documented as completed on the Treatment Administration Record for the days in question. However, during an interview, the LPN admitted to not changing the dressing and acknowledged that the dressing changes should not have been signed off as completed. The facility was unable to provide a policy regarding the dressing change procedure when requested.
Failure to Follow Physician's Order for Dressing Change
Penalty
Summary
The facility failed to ensure that a resident received treatment per the physician's order, specifically regarding the changing of a dressing on a surgical wound. The resident, who had a left above-the-knee amputation, was supposed to have her dressing changed daily. However, during an observation and interview, the resident indicated that the dressing had not been changed for the past two days, despite her requests to the evening shift staff. The dressing was dated four days prior, and upon inspection, it was found to be loose with a large amount of reddish-brown thick drainage, and the wound area was red and open. The resident's medical history included chronic hematogenous osteomyelitis, infection following a procedure, and other chronic conditions. The physician's order specified a detailed dressing change procedure, which was not followed. An LPN acknowledged that the dressing change was not communicated to the evening shift, and the Treatment Administration Record was inaccurately signed as completed. The Director of Nursing indicated that there was no specific policy on following physician orders, only a standard practice.
Failure to Discontinue Unnecessary Antibiotic
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary antibiotic medication, leading to a deficiency. Resident 41, who had diagnoses including acute osteomyelitis of the left ankle and foot and a stage 2 pressure ulcer on the left heel, was prescribed cephalexin for a urinary tract infection. The antibiotic was ordered on 11/28/2024 and was supposed to be discontinued on 12/4/2024. However, a lab report dated 11/30/2024 indicated no bacterial growth in the urine specimen, suggesting that the antibiotic was no longer necessary. Despite this, the facility did not notify the Nurse Practitioner to discontinue the antibiotic treatment until 12/5/2024, five days after the lab results were received. The Infection Preventionist confirmed that it was standard practice to stop antibiotics based on such lab results.
Failure to Provide Fresh Ice Water to Resident
Penalty
Summary
The facility failed to ensure that a resident received fresh ice water according to his preference, which was necessary to maintain proper hydration. Resident 21, who had a history of hemiplegia, hemiparesis, type 2 diabetes mellitus with hyperglycemia, and anxiety disorder, expressed during interviews that he did not receive fresh ice water daily as he desired. He reported that the last time water was delivered to his room was on two specific dates in November, and he had to go to the nurse's station to request water. Observations confirmed the absence of a water cup in his room. The resident's care plan, which required assistance or monitoring of nutrition, hydration, and elimination, did not address his preference for fresh ice water. A CNA indicated that she only provided water to residents who requested it and did not leave water in rooms unless asked. The facility's Hydration Management policy, which was revised in 2017, stated that fresh water or other preferred beverages should be passed to all residents on each shift unless medically contraindicated. However, this policy was not followed for Resident 21, leading to the deficiency.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain acceptable infection control standards during a surgical dressing change for a resident. During the observation, an LPN removed a soiled dressing from the resident's wound, then removed her gloves and donned a new pair from her uniform pocket without performing hand hygiene. Additionally, the LPN placed the clean dressing supplies directly on the resident's bed without using a barrier, which is against the facility's policy. The resident involved had multiple diagnoses, including chronic hematogenous osteomyelitis, infection following a procedure, chronic obstructive pulmonary disease, chronic diastolic heart failure, and peripheral vascular disease, among others. During an interview, the LPN acknowledged that she should have washed her hands after removing the soiled dressing and should have used a barrier for the dressing supplies. The facility's policy on dressing change clean technique, provided by the DON, specifies the need for a clean field and hand hygiene, which were not followed in this instance.
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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