PRINTED: 04/26/2019 DEPARTMENT OF HEALTH AND HUMAN ...
Transcript of PRINTED: 04/26/2019 DEPARTMENT OF HEALTH AND HUMAN ...
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
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
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 2 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 656 Continued From page 2 F 656
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.
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 3 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 656 Continued From page 3 F 656
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.
2. A clinical record review was conducted on
01/18/19, at 3:20 PM, for Resident 118 and
indicated an admission date of 10/26/16. Her
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.
The MDS (Minimum Data Set) assessment,
dated 12/19/18, indicated a BIMS (Brief Interview
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.
3. A clinical record review was conducted on
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 4 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 656 Continued From page 4 F 656
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).
The MDS (Minimum Data Set) assessment,
dated 12/30/18, indicated a BIMS (Brief Interview
for Mental Status) score of 13, cognitively intact.
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 5 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 656 Continued From page 5 F 656
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...."
4. A clinical record review was conducted on
01/17/19, at 3:42 PM, for Resident 231 and
indicated an admission date of 12/19/18. Her
diagnoses included, but were not limited to: lung
cancer, liver cancer, c-diff, depression,
rheumatoid, and weakness.
The MDS (Minimum Data Set) assessment,
dated 12/26/18, indicated a BIMS (Brief Interview
for Mental Status) score of 13, cognitively intact.
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.
During an interview, on 01/18/19 at 4:16 PM, the
DON indicated no care plan was in place for the
MASD.
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 6 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 656 Continued From page 6 F 656
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 "...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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 7 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 7 F 686
promote healing, prevent infection and prevent
new ulcers from developing.
This REQUIREMENT is not met as evidenced
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 8 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 8 F 686
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 9 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 9 F 686
noted and no updates noted to at risk for skin
break down and no care plan for new area was
completed.
A Progress Note, dated 12/25/18 at 10:23 P.M.,
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.
A Progress Note, dated 1/2/19 at 3:20 P.M.,
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 10 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 10 F 686
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.
A Physician Progress Note, dated 1/2/19,
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 11 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 11 F 686
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.
During an observation, on 1/17/19 at 2:30 P.M.,
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).
During an observation, on 1/17/19 at 3:05 P.M.,
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.
A Wound Note, dated 1/17/19 at 3:26 P.M.,
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.
A Wound Note, dated 1/17/19 at 3:33 P.M.,
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.
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 12 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 12 F 686
A Wound Note, dated 1/17/19 at 5:59 P.M.,
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.
A Wound Note, dated 1/17/19 at 6:01 P.M.,
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.
A Physician Progress Note, dated 1/17/19,
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.
During an interview, on 1/17/19 at 3:40 P.M., the
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.
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 13 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 13 F 686
During an interview, on 01/18/19 at 2:40 PM, the
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.
During an interview, on 1/18/19 at 2:40 P.M., the
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 14 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 14 F 686
x 1 cm wound to right buttocks, shearing noted to
buttocks and 3 cm x 2. 4 cm redness to left heel.
A Progress Note, dated 10/21/18 at 9:20 P.M.,
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.
A Progress Note, dated 10/24/18 at 12:26 P.M.,
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.
A Progress Note, dated 10/29/18 at 3:05 P.M.,
indicated the dietician reported no pressure
ulcers.
A Progress Note, dated 10/29/18 at 4:23 P.M.,
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.
A Progress Note, dated 11/7/18 at 1:16 P.M.,
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 15 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 15 F 686
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.
A Progress Note, dated 11/8/18 at 1:45 P.M.,
indicate Resident B was discharged to Assisted
Living.
During an interview, on 1/17/18 at 1:45 P.M., the
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.
During an interview, on 1/17/19 at 2:01 P.M., the
DON (Director of Nursing) indicated she was
aware wound documentation had been missed
and wound assessment from admission was not
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 16 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 16 F 686
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.
3. A clinical record review was conducted on
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
cancer, obstructive uropathy, weakness,
diabetes, heart failure, atrial fibrillation,
depression, and hypertension.
The MDS (Minimum Data Set) assessment,
dated 12/30/18, indicated a BIMS (Brief Interview
for Mental Status) score of 13, cognitively intact.
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 17 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 17 F 686
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.
During an interview, on 01/18/19 at 2:40 PM, the
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 18 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 686 Continued From page 18 F 686
came together when sitting in his chair.
During an interview, on 01/18/19 at 4:16 PM, the
DON indicated no care plan was in place for the
MASD.
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
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.
This REQUIREMENT is not met as evidenced
by:
F 689 2/13/19
Based on observation, record review and
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 19 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 689 Continued From page 19 F 689
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.
During an observation, on 1/14/18 at 12:03 P.M.,
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.
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 20 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 689 Continued From page 20 F 689
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.
A Progress Note, dated 12/29/18 at 12:22 P.M.,
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.
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 21 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 689 Continued From page 21 F 689
A Progress Note, dated 1/2/19 at 1:10 P.M.,
indicated Resident G was noncompliant with
asking for assistance and frequently stood up
from wheelchair and required redirection.
A Progress Note, dated 1/4/19 at 1:30 P.M.,
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.
A Progress Note, dated 1/4/19 at 1:56 P.M.,
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.
A Progress Note, dated 1/5/19 at 2:44 P.M.,
indicated Resident G had to continuously be
redirected due to restlessness and constantly
standing up to walk off.
A Progress Note, dated 1/6/18 at 6:30 P.M.,
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 22 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 689 Continued From page 22 F 689
bladder. Resident G was to have tip of catheter
removed surgically in urologist office on 1/9/18.
During an interview, on 1/15/18 at 2:30 P.M., the
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.
During an interview, on 1/18/19 at 3:20 P.M., the
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
indicated an admission date of 02/22/16. Her
diagnoses included, but were not limited to:
hypertension, depression, anxiety, Guillian-Barre
syndrome, chronic pain, spinal stenosis, and
glaucoma.
The MDS (Minimum Data Set) assessment,
dated 10/17/18, indicated a BIMS (Brief Interview
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 23 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 689 Continued From page 23 F 689
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.
During an interview, on 01/16/19 at 2:40 PM, the
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.
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 24 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 689 Continued From page 24 F 689
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.
During an interview, on 01/17/119 at 3:00 PM, the
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.
During an interview, on 01/18/19 at 10:20 AM, the
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 25 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 689 Continued From page 25 F 689
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 26 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 761 Continued From page 26 F 761
be readily detected.
This REQUIREMENT is not met as evidenced
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.
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 27 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 761 Continued From page 27 F 761
During an interview, on 1/16/19 at 2:05 P.M., the
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.
This REQUIREMENT is not met as evidenced
by:
F 804 2/13/19
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 28 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 804 Continued From page 28 F 804
Based on observation and interview, the facility
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.
A policy was provided by the DON (Director of
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
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 29 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 812 Continued From page 29 F 812
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.
This REQUIREMENT is not met as evidenced
by:
Based on observation and interview, the facility
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.
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 30 of 31
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 04/26/2019FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
155269 01/18/2019
C
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 812 Continued From page 30 F 812
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.
During an interview, on 01/14/19 at 11:55 AM, the
RD indicated she was unsure of how the items
should be dated or how long the facility keeps
items.
A policy was provided by the DON (Director of
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)
FORM CMS-2567(02-99) Previous Versions Obsolete WRMT11Event ID: Facility ID: 000169 If continuation sheet Page 31 of 31