Addison Pointe Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chesterton, Indiana.
- Location
- 780 Dickinson Road, Chesterton, Indiana 46304
- CMS Provider Number
- 155805
- Inspections on file
- 26
- Latest survey
- May 7, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Addison Pointe Health & Rehabilitation Center during CMS and state inspections, most recent first.
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.
Medication storage and labeling were not maintained appropriately for two residents and two med carts. A resident had Nystatin powder left in her room for self-application without an order or care plan support, another resident had Nystatin powder at the bedside without a current order, and insulin pens on two med carts were expired or had conflicting handwritten expiration dates. An OTC Tums bottle also lacked proper labeling until an LPN added the resident’s last name.
A resident's dignity was not maintained during a blood sugar check when an RN performed the finger stick in the day room with two other residents and a visitor present and loudly announced the result. The RN did not ask permission before checking the resident's blood sugar in the common area, and the resident was described as alert, oriented, and new to the facility.
Failure to Provide Fingernail Care as Part of ADL Assistance: Two residents who were dependent on staff for ADLs were observed with long fingernails and stated they wanted them cut. One resident had stroke-related hemiplegia, depression, and a fungal nail issue, while the other had hemiplegia following a stroke and generalized weakness. Both residents were cognitively intact, had care plans for staff-assisted ADLs, and there was no documentation that their fingernails had been trimmed or offered for trimming.
Failure to provide activities for a resident with Parkinson’s disease, cerebrovascular disease, moderate cognitive impairment, and dependence in ADLs/transfers. The resident was repeatedly observed in bed in a quiet room without stimulation while music, art, and worship activities were available, and records showed only limited 1:1 visits with no documentation of activity attendance or refusal. The AD noted the resident liked music and art and had not been out of the room for an activity since March.
A resident with Parkinson's Disease, pneumonia, chronic respiratory failure, and dependence on supplemental O2 was observed resting in bed with nasal cannula O2 running at 3.5 lpm instead of the ordered 4 lpm. The resident also had no padding on the cannula tubing despite an order for padding to be in place and reapplied each shift. An LPN confirmed both the missing padding and the incorrect flow rate.
Failure to Use McGeer Criteria Before UTI Antibiotics Were Ordered: The facility did not document that two residents met McGeer Criteria before IV or oral antibiotics were started or continued for presumed UTI. One resident received meropenem and later Levaquin without documented UTI signs or symptoms or justification after culture results, and another resident received Cipro and then Macrobid despite no documentation supporting ongoing UTI symptoms. The DON stated the Macrobid order lacked documentation and did not meet McGeer criteria.
A resident who required full staff assistance for transfers sustained a left upper arm fracture after staff failed to keep the legs of a Hoyer lift in the maximum opened position during a transfer. The lift became unstable when a wheel got stuck on the wheelchair, causing it to tip over and the resident to fall. The resident, who had a history of falls and was at moderate risk, was sent to the hospital for evaluation and treatment.
Surveyors identified that the kitchen lacked proper temperature monitoring in both the walk-in freezer and reach-in cooler due to missing thermometers, and the dishwasher temperature log was pre-filled instead of being completed at the required times. Multiple food items were found unlabeled, undated, or left open in storage areas, contrary to facility policy, as confirmed by the Kitchen Manager.
A resident with severe cognitive impairment and limited mobility was observed without the required enabler bar for turning and repositioning, despite physician orders and care plan interventions specifying its use. Multiple observations confirmed the absence of the device, and staff were unaware of its status.
A resident with severe cognitive impairment and hemiplegia, who was dependent on staff for ADLs, was repeatedly observed lying on his back in bed without evidence of being turned or repositioned as required. Documentation for multiple shifts was missing, and staff did not record repositioning or refusals, contrary to the care plan and facility expectations.
Two residents with non-pressure skin conditions were not properly assessed or monitored for areas of discoloration and bruising. Despite visible signs of purpura and bruising, and care plans indicating the need for observation, nursing staff failed to document or monitor these conditions as required by facility policy.
A resident with severe cognitive impairment and a deep tissue injury to the left great toe was repeatedly observed in bed without required heel offloading boots or elevated feet, despite care plan and physician orders specifying these interventions. Staff did not ensure the use of pressure reduction devices as directed.
A resident with severe cognitive impairment and continuous oxygen orders did not have their oxygen tubing changed or documented as required by facility policy. Observations and record review confirmed the tubing was not dated and there was no evidence of weekly changes, despite daily oxygen use.
A resident's grievance about a missing wheelchair was not filed or resolved in a timely manner. The resident, who relies on a wheelchair due to lower extremity impairments, expressed dissatisfaction with the facility's handling of the issue. Although the wheelchair was found, the resident refused it, claiming it was incorrect. A grievance was only filed after a significant delay, highlighting a lapse in addressing the resident's concerns.
A facility failed to ensure staff used the correct PPE for a resident under Enhanced Barrier Precautions. A CNA and RN assisted a resident with a Hoyer lift transfer without wearing gowns and gloves, despite a sign indicating the need for such precautions. The resident had a chronic sacral wound infected with MRSA, requiring enhanced barrier precautions as per the care plan and physician's order. The facility's policy required PPE during high-contact activities to prevent MDRO transmission.
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.
Medication storage and labeling deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled appropriately for two residents with medications in their rooms and for two medication carts. Resident 42, who had diagnoses including anxiety disorder, major depressive disorder, type 2 diabetes, heart failure, high blood pressure, and acute kidney failure, was observed with a small plastic medication cup filled with white powder on her dresser. The resident stated the nurse had brought Nystatin powder for a rash under her breasts and left it there so she could apply it herself. Her record showed she was cognitively intact, had no care plan indicating she could self-administer medications, and had no order to leave the powder in her room for self-application. The DON stated the resident should have an order and assessment to apply the powder herself. Resident 9, who had diagnoses including osteoarthritis of the knee and cognitive communication deficit, was observed multiple times with a bottle of Nystatin topical powder on the bathroom counter next to the sink. The bottle was labeled with the resident's name, but the resident had no current order for the medication and the prior order had been discontinued. On the 100 hall medication cart, an insulin pen labeled with an expiration date of 4/22 was found, and RN 2 stated it should not have been in the cart. On the 400 hall medication cart, an insulin pen was observed with conflicting handwritten expiration information, and LPN 3 changed the expiration date on the pen. Also on that cart, a small bottle of tablets labeled only as TUMS had no other identifying information until LPN 3 wrote the resident's last name on it. The DON stated insulin pens should be discarded 28 days after opening, and the facility policy required OTC medications and opened multi-use vials to be labeled with specific identifying and expiration information.
Failure to Maintain Resident Dignity During Blood Sugar Check
Penalty
Summary
The facility failed to maintain a resident's dignity during a blood sugar check for Resident 97. During an observation on 5/1/26 at 11:21 a.m., RN 1 prepared to check the resident's blood sugar while the resident was sitting in her wheelchair in the day room with two other residents and a visitor present. RN 1 told the resident she was going to check her blood sugar, stuck the resident's finger, checked the blood sugar, and announced the result loudly in the common area. RN 1 did not ask the resident for permission to perform the blood sugar check in the common area with others present. During an interview later that day, Unit Manager 1 stated the resident was alert and oriented and new to the facility, and that they were working on a care plan indicating the resident was okay with having her blood sugar checked in common areas.
Failure to Provide Fingernail Care as Part of ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for ADLs received assistance with fingernail care for two residents. One resident, who had diagnoses including stroke, hemiplegia, and depression, was observed in bed with long, thick, yellowed fingernails on two occasions. The resident stated she wanted someone to cut her fingernails but had been told they could not be cut because she had a fungus in them. Her MDS indicated she was cognitively intact, had an impairment on one side of her upper extremities, and required substantial maximal assistance for personal hygiene. Her care plan identified a need for staff assistance with ADLs related to her stroke and hemiplegia, but there was no documentation that her fingernails had been trimmed or that she had been offered trimming. A second resident, with diagnoses including hemiplegia following a stroke, need for assistance with personal care, and generalized muscle weakness, was observed on multiple occasions resting in bed with the fingernails on her left hand very long. Her MDS indicated she was cognitively intact, had functional limitation in range of motion on one side, and was dependent in ADLs. Her care plan also directed staff to assist with ADLs. The resident stated she did not want her left-hand fingernails to be that long and wanted them cut. During interviews, an LPN stated nurses or CNAs should trim nails when needed, and the DON stated staff should have included fingernail trimming in the resident's ADL care and should have offered to cut the fingernails.
Failure to Provide Activities for a Resident with Cognitive and Physical Impairment
Penalty
Summary
The facility failed to provide activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of Resident 22. The resident’s diagnoses included Parkinson’s disease and cerebrovascular disease. The Quarterly MDS dated 2/10/26 indicated moderate cognitive impairment and dependence in ADLs and transfers. The Activities Care Plan, revised 4/27/26, directed staff to invite the resident to groups of interest such as worship, music events, social groups, and cognitive groups. During random observations, Resident 22 was repeatedly found lying in bed in a quiet room without television, music, or other stimulation on multiple dates and times. On 5/1/26, while a live music activity was occurring in the main dining room, the resident remained awake in bed in his room. The May 2026 Activities Calendar listed music, art, and worship activities, but the Activities Participation 30-day documentation showed only three one-on-one visits per week, one friendly visit, and one people watching entry, with no documentation that the resident attended or refused activities. The Activities Director stated the resident liked music and art, had previously participated with assistance, had not been out of his room for an activity since March, and that the only activity interaction he was receiving was three 20-30 minute one-on-one visits per week.
Oxygen Flow Rate and Tubing Padding Not Provided as Ordered
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident when oxygen was observed in use at 3.5 lpm by nasal cannula even though the physician's order dated 3/24/2026 specified oxygen at 4 lpm continuously. During multiple observations, the resident was resting in bed with oxygen in use, and there was no padding in place on the cannula tubing despite a physician's order dated 3/26/2026 directing that padding be applied to the oxygen tubing, ensured in place, and reapplied as needed every shift. The resident's record identified diagnoses including Parkinson's Disease, pneumonia, chronic respiratory failure, and dependence on supplemental oxygen, and the quarterly MDS indicated moderate cognitive impairment and dependence for ADLs. An LPN confirmed that the tubing had no padding and that the oxygen flow rate was set below the ordered rate.
Failure to Use McGeer Criteria Before Starting or Continuing UTI Antibiotics
Penalty
Summary
The facility failed to promote antibiotic stewardship by using antibiotic therapy for urinary tract infections without documentation that the residents met McGeer Criteria. For two of three residents reviewed, antibiotics were started or continued despite the record lacking documentation of the required signs or symptoms of UTI and, in one case, despite culture results that did not support the treatment decision. The deficiency involved Resident 42 and Resident 5, both of whom had complex medical histories including urinary issues and other chronic conditions. For Resident 42, the record showed a history of recurrent UTI concerns, prior ESBL in the urine, and a cystoscopy with urology follow-up that was not completed. In March 2026, a urinalysis was ordered for agitation, and the NP planned IV antibiotics before final culture results were available. The resident received IV meropenem for a complicated UTI even though the final culture showed 10-50,000 colonies of Proteus mirabilis not ESBL, and there was no documentation explaining why the IV antibiotic was continued after the final culture. The record did not document physical signs or symptoms of UTI. In late April 2026, another urinalysis was obtained after the resident reported bladder soreness, painful urination, and frequency, and the final culture showed Morganella morganii 10-50,000 colonies. Levaquin was ordered, but there was no documentation from the NP explaining why the antibiotic was ordered or documenting continued UTI signs or symptoms. For Resident 5, the record showed diagnoses including acute cystitis, bacteremia, kidney and bladder disorders, urinary retention, UTI, and ESBL. The resident was moderately impaired for daily decision making and always incontinent of bladder. In April 2026, a family request prompted a urinalysis to rule out infection, and the UA showed blood, nitrates, many bacteria, and leukocytes. Cipro was ordered before the final culture, but the culture later showed ESBL E. coli resistant to Cipro, and the antibiotic was discontinued. Shortly afterward, Macrobid was ordered for UTI/ESBL, yet there was no documentation from the NP explaining why it was ordered or documenting ongoing UTI signs or symptoms such as burning, pain, or frequency. The DON stated there was no documentation of why Macrobid was started when it did not meet McGeer criteria, and the record did not show that the resident had signs or symptoms of UTI.
Failure to Follow Mechanical Lift Protocol Results in Resident Fall and Fracture
Penalty
Summary
A resident who was cognitively intact and dependent on staff for transfers experienced a fall resulting in a left upper arm fracture during a mechanical lift transfer. The incident occurred when staff failed to follow the manufacturer's instructions for the Hoyer lift, specifically not keeping the legs of the lift in their maximum opened position before lifting the resident. During the transfer, a wheel on the lift became stuck on the wheelchair, and as staff attempted to move the lift, it tipped over, causing the resident to fall to the floor. The resident was found on her left side, crying and in pain, and was subsequently sent to the hospital for evaluation and treatment. The resident's medical record indicated a history of falls, use of psychotropic medications, involuntary movements, narcotic analgesics, and a need for a mechanical lift for transfers. At the time of the incident, the resident was at moderate risk for falls and required full assistance for transfers. Staff interviews confirmed that the legs of the Hoyer lift were closed during the transfer, contrary to manufacturer guidelines, which contributed to the instability and subsequent fall.
Failure to Maintain Kitchen Sanitation and Food Safety Standards
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to food storage, temperature monitoring, and labeling practices. During the kitchen sanitation tour, it was found that there were no thermometers present in the walk-in freezer or the reach-in cooler, preventing proper monitoring of food storage temperatures. Additionally, the dishwasher temperature log had been pre-filled for all meal times on the day of the survey, rather than being completed at the time of each temperature check as required by facility policy. Further inspection revealed several food items in both the walk-in and reach-in freezers that were either unlabeled, undated, or left open, including a tray of pre-filled juice cups, a bag of cookies, bread, unidentified meat, ice cream, ground sausage, tropical freezes, chicken breasts, potato wedges, and breaded chicken patties. The Kitchen Manager confirmed the absence of required thermometers and acknowledged that food items should have been labeled and dated when opened, in accordance with facility policies.
Failure to Implement Care Plan for Positioning with Enabler Bar
Penalty
Summary
A resident with a history of stroke, severe cognitive impairment, and multiple diagnoses including vascular dementia and chronic heart failure, was observed multiple times resting in bed with limited movement and a contracted left hand. The resident reported being unable to open his left hand without assistance from his right hand. During several observations, there were no rails or bars present on the resident's bed to assist with turning or repositioning. Record review revealed a physician's order for a left side enabler bar, dated over two months prior, and a care plan intervention specifying the use of this enabler bar for turning and repositioning. Despite these documented requirements, the enabler bar was not in place during the survey period. The unit manager acknowledged awareness that the resident previously had an enabler bar but was unaware of its current status and indicated the need to look into obtaining one.
Failure to Complete and Document Repositioning for Dependent Resident
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically turning and repositioning, were completed for a dependent resident. Multiple observations over several days showed the resident consistently lying on his back in bed, with limited movement and a contracted left hand. The resident's medical record indicated severe cognitive impairment, hemiplegia on the left side, and dependence on staff for ADLs and transfers. The care plan required frequent position changes with staff assistance or encouragement. A review of documentation revealed that there were several shifts where there was no record of the resident being turned or repositioned, nor any documentation of resident refusal. The Unit Manager confirmed that the resident did not get out of bed and that staff were expected to document repositioning or refusals every shift, which was not done for multiple shifts as listed in the report.
Failure to Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to assess and monitor areas of skin discoloration for two residents with non-pressure skin conditions. One resident was observed with reddish/purple discoloration on the right elbow over several days, but the medical record and physician's orders did not reflect any monitoring or assessment of these areas. The Wound Nurse later noted purpura on both arms and completed a skin form, but this was after the discoloration had already been present for multiple days without documentation or intervention. Another resident was observed with large dark purple bruises on both hands, which had been present since discharge from the hospital. Despite a care plan indicating the resident was at risk for abnormal bruising due to blood thinners and requiring observation for side effects, the treatment record and nurses' skin assessments did not document the presence of these bruises. The Unit Manager confirmed that the bruises should have been assessed and documented, but no such documentation was found in the record. Facility policy required weekly assessment and documentation of wounds and skin conditions, including bruises, but this was not followed.
Failure to Use Pressure Reduction Devices for Resident with Pressure Ulcer
Penalty
Summary
A resident with diagnoses including Alzheimer's disease and dementia was observed multiple times lying in bed without the use of prescribed pressure reduction devices. Specifically, the resident's heel boots, intended to offload pressure and prevent further skin breakdown, were seen placed on a chair next to the bed rather than on the resident. Additionally, the resident's feet were not elevated while in bed, contrary to the care plan interventions for a suspected deep tissue injury on the left great toe. The resident's care plan required that her heels be floated off the mattress or that she wear heel offloading boots while in bed, following a physician's order and a recent wound evaluation documenting a deep tissue injury. Despite these documented interventions, staff failed to ensure the use of the pressure reduction devices as ordered. Both the wound nurse and the DON confirmed that the resident's heels should have been offloaded or the boots in use during these observations.
Failure to Change Oxygen Tubing as Required for Resident on Continuous Oxygen
Penalty
Summary
A deficiency was identified when a resident who required continuous oxygen therapy did not have their oxygen tubing changed as required by facility policy. During observations on two consecutive days, the resident was seen using a nasal cannula connected to a portable oxygen tank, and the oxygen tubing was not dated. Review of the resident's medical record showed daily use of oxygen over several weeks, but there was no documentation indicating that the oxygen tubing had been changed during this period. The resident had significant medical needs, including severe cognitive impairment, dependence in activities of daily living, and a history of post-hip replacement and muscle weakness. Physician orders specified continuous oxygen therapy with adjustments as needed for low oxygen saturation or shortness of breath. Facility policy required weekly changes of oxygen tubing and documentation of these changes, but interviews with staff and record reviews confirmed that this was not done for the resident in question.
Failure to Resolve Grievance for Missing Wheelchair
Penalty
Summary
The facility failed to properly file and resolve a grievance regarding a missing wheelchair for Resident M. The resident, who was moderately intact for daily decision-making and dependent on a wheelchair due to impairments in both lower extremities, expressed dissatisfaction with the facility's handling of his missing wheelchair. Despite being aware of the issue since before Father's Day, the facility did not have a grievance on file until 7/30/24. The resident's son had communicated with the therapy director about getting the resident fitted for a new wheelchair, but there was uncertainty about whether a grievance had been filed. The Social Service Assistant indicated that the resident's wheelchair was found shortly after it went missing, but the resident refused it, claiming it was the wrong one. Attempts to measure the resident for a new wheelchair were unsuccessful as the resident refused to get out of bed. A grievance was only filed on 7/30/24, indicating a delay in addressing the resident's concerns. The Administrator acknowledged the grievance concern but had no additional information to provide.
Failure to Use Correct PPE for Resident Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff members used the correct Personal Protective Equipment (PPE) when providing care to a resident under Enhanced Barrier Precautions (EBP). During an observation, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN) were seen assisting a resident with a Hoyer lift transfer without wearing the required gowns and gloves, despite a sign on the resident's door indicating the need for such precautions. The RN later indicated that staff only applied PPE when directly touching the resident's wound, which contradicts the facility's policy. The resident in question had a chronic sacral wound infected with Methicillin Resistant Staphylococcus Aureus (MRSA) since April 2024, necessitating enhanced barrier precautions. The resident's care plan and physician's order both specified the need for these precautions. The facility's policy on infection prevention and control, as provided by the Director of Nursing, outlined the requirement for staff to use gloves and gowns during high-contact activities to prevent the transmission of Multi Drug Resistant Organisms (MDRO).
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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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