Allison Pointe Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 5226 E 82nd Street, Indianapolis, Indiana 46250
- CMS Provider Number
- 155272
- Inspections on file
- 54
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Allison Pointe Healthcare Center during CMS and state inspections, most recent first.
A resident with peripheral artery disease and chronic wounds on the left fourth and fifth toes experienced a delay in scheduling a vascular specialist visit after an NP ordered a referral based on abnormal arterial Doppler results. Facility documentation showed no referral activity for several weeks, and the vascular office later confirmed receiving the referral much later than ordered. During this time, the resident’s foot condition worsened, with an open, draining wound on the fourth toe and later CT evidence of osteomyelitis that was not promptly communicated to the wound care NP or treated with antibiotics by the primary NP. The resident’s family reported ongoing concerns about a blackened, non-healing foot wound and lack of antibiotics, and hospital records documented that the resident arrived without prior vascular evaluation or antibiotic therapy, was started on IV antibiotics, diagnosed with acute osteomyelitis and cellulitis, and ultimately required toe amputation.
A resident with metastatic breast cancer, who was cognitively intact, was approached by an LPN about selling her vehicle after the LPN noticed it had not been moved for some time. The resident felt the inquiry was inappropriate and was upset that staff were discussing her personal matters. Facility leadership confirmed that staff soliciting to purchase items from residents is not acceptable and violates resident rights policies.
A controlled substance medication delivered for a resident was not properly processed or secured after being signed for by an LPN and handed to an RN. The medication was not entered into the narcotic log, was delivered in an incorrect bag, and was never located, with staff unable to account for its disposition. Facility policies requiring dual nurse verification and secure storage were not followed.
Surveyors found that the facility failed to properly document and reconcile controlled medication administration, resulting in missing or illegible records, inconsistent narcotic counts, and incomplete staff signatures for several residents. Additionally, some residents did not receive IV antibiotics and antifungal medications as ordered, with delays in order entry and missed doses. These deficiencies were identified through interviews, record reviews, and examination of facility policies.
Two residents did not receive their prescribed medications and treatments as ordered upon admission, due to delays and errors in entering and transmitting orders to the pharmacy. One resident missed several doses of critical medications, while another did not receive IV antibiotics and TPN as required, resulting in unmanaged symptoms and distress. Nursing staff interviews revealed issues with the admission process and order entry, leading to these deficiencies.
A resident with a history of intestinal perforation and peritoneal abscess did not receive ordered TPN upon admission due to a medication ordering error and lack of follow-up with the pharmacy. The resident experienced pain and vomiting while waiting for the TPN, which was not administered until the following day after staff intervention and a STAT pharmacy delivery.
A resident admitted with significant pain and an order for oxycodone did not receive her pain medication until the day after admission, despite repeated requests and the medication being available in the emergency drug kit. Nursing staff were aware of the resident's pain but did not administer the ordered medication in a timely manner.
A resident with complex pain management needs received incorrect narcotic pain medications on multiple occasions due to failure to follow physician orders and inconsistent medication administration. The resident was given oxycodone without an active order and did not consistently receive the prescribed Percocet, resulting in significant medication errors.
A resident with significant neurological impairments and nonverbal status did not receive appropriate pain management, as staff failed to document pain levels prior to administering PRN oxycodone, did not attempt or record non-pharmacological interventions, and inconsistently assessed the effectiveness of pain medication. Family concerns about the resident's pain and inability to self-report were not adequately addressed in the clinical documentation.
Staff did not follow enhanced barrier precautions when providing personal care to a resident with a tracheostomy, gastric tube, and wounds, as a CNA failed to wear a gown during perineal care and placed feces-soiled linen directly on the floor instead of bagging it, contrary to facility policy.
The facility failed to address grievances reported during resident council meetings, as concerns about staff not answering call lights timely were not documented or addressed. The Activities Director indicated grievances were only recorded if the entire group reported a concern, and residents were encouraged to fill out individual grievance forms for quicker resolution. The facility's policy required administrators to attend meetings and document concerns, but this was not followed.
The facility failed to serve food at appropriate temperatures for four cognitively intact residents with various medical conditions. Residents reported that hot items were cold and cold items were warm. A test tray confirmed food temperatures below the required 135 degrees Fahrenheit. The Dietary Manager was unaware of the need to maintain this temperature until delivery, contrary to facility policy.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in communication and PASRR documentation. One resident's communication abilities were misrepresented, while another's PASRR condition was not accurately documented, despite prior evaluations. Staff interviews confirmed these inaccuracies.
The facility failed to provide adequate nail care and lotion application for two residents, leading to deficiencies in their personal hygiene. A resident with cognitive impairment had long fingernails despite requiring assistance with bathing, while another resident with diabetes and malnutrition had dry, flaky skin and lacked lotion in his room. Staff interviews confirmed the need for better hygiene care and appropriate lotion use.
A resident with a history of traumatic brain injury and dementia did not receive timely podiatry services despite a signed consent form. Observations showed the resident had extremely thick, long, yellowish toenails, and there was no documentation of podiatry consultations in the resident's health record. Interviews confirmed the absence of podiatry services, and the facility's Foot Care policy was not followed.
A resident at risk for falls was observed multiple times without a required mat at the bedside, as specified in their care plan. Despite the care plan's interventions, including a mat on the floor, being initiated, they were not consistently implemented. A CNA was unaware of the reason for the missing mat, highlighting a failure to adhere to the facility's Fall Prevention and Management Policy.
A facility failed to adhere to infection control protocols when a respiratory therapist provided care to a resident with acute respiratory conditions without wearing a gown, as required by the Enhanced Barrier Precaution policy. The resident was under enhanced barrier precautions due to conditions like acute respiratory distress syndrome and tracheostomy. The Regional President of Risk Management acknowledged the lapse in PPE usage.
Two residents experienced environmental deficiencies in their rooms, including a leaky commode, brownish ceiling spots, and a dirty grab bar. The Maintenance Director was unaware of these issues, and cleaning attempts by a CNA were ineffective, highlighting a lack of communication and oversight in maintaining a clean and safe environment.
A resident on anticoagulant therapy for lung cancer and pulmonary embolism was not properly monitored, as the facility failed to conduct daily INR tests as ordered. Despite receiving enoxaparin and warfarin, the resident's medical record lacked a care plan and INR test results. Interviews revealed a missed INR test and a lack of documentation for a delay in testing, leading to a deficiency.
The facility failed to document urine outputs for two residents with urinary catheters, despite physician orders to record every shift. Resident G, with paraplegia and bladder dysfunction, and Resident F, with a neurogenic bladder, both had multiple instances of missing documentation in September 2024. The Assistant DON confirmed the requirement for staff to document outputs every shift, indicating a lapse in care protocols.
A resident with a below the knee amputation reported a verbal altercation with an LPN over pain medication, where the LPN allegedly used offensive language and called the resident a drug addict. The resident's roommate confirmed hearing the argument. The LPN denied the accusations but admitted to calling the resident drug-seeking to another staff member. The incident followed a reduction in the resident's pain medication, which he believed was due to the LPN.
A resident with diabetes and other health conditions experienced elevated blood glucose levels on two occasions, but the facility failed to notify the physician as required. The resident reported self-administering insulin due to missed doses by the facility. Discrepancies in blood glucose readings were also noted without explanation.
A resident with paraplegia experienced swelling in the left thigh/leg, later identified as a hip fracture. The facility delayed reporting the incident to the State Survey Agency, despite policy requiring immediate reporting of such incidents. The fracture was confirmed on an x-ray, but the report was not made until days later, constituting a failure to comply with timely reporting requirements.
A facility failed to thoroughly investigate an abuse allegation involving a resident with fractures and pain. The resident reported that an LPN responded inappropriately to his pain complaints. The investigation lacked statements from key staff, including CNAs and the assigned nurse, violating the facility's abuse policy.
A facility failed to administer medications as ordered for a resident with a leg skin graft, leading to incorrect dosages of oxycodone and early application of a fentanyl patch. Another resident with paraplegia and a fracture experienced delays in scheduling a DEXA scan and orthopedic consultation due to transportation issues and lack of communication, resulting in significant delays in follow-up care.
A resident with multiple fractures experienced inadequate pain management due to the facility's failure to assess and address their pain needs. Despite a care plan outlining both pharmacological and non-pharmacological interventions, the facility did not consistently implement these measures. The resident reported significant pain and dissatisfaction with the nursing staff's response, and the clinical record lacked documentation of pain assessments and interventions.
A resident with a below-the-knee amputation experienced issues with narcotic medication reconciliation and documentation. The facility's records showed discrepancies in oxycodone tablet counts and missing nurse signatures and times. Interviews confirmed errors in the narcotic count sheets, with the administering nurse admitting to forgetting to sign and incorrectly counting remaining tablets.
A facility failed to maintain accurate clinical records for two residents, leading to deficiencies in care. One resident's enteral feeding residuals were incorrectly documented, while another resident's insulin administration and blood glucose readings were inconsistently recorded. The facility did not adhere to its Medication Administration policy, resulting in incomplete records and gaps in care documentation.
Failure to Provide Timely Vascular Referral and Osteomyelitis Treatment for Foot Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate foot care, including delay in arranging a vascular specialist referral and failure to initiate treatment for osteomyelitis for a resident with peripheral artery disease. The resident had a history of impaired skin integrity to the left fourth and fifth toes, with a care plan goal to prevent complications and an intervention to administer treatments as ordered. On 2/12/26, an NP documented a wound to the left fifth toe and abnormal arterial Doppler results showing mild trifurcation/outflow disease, and ordered a referral to a vascular specialist, expecting the appointment to be made as soon as possible. However, there was no documentation that the facility attempted to make this vascular appointment until 3/24–3/25/26, and the vascular provider confirmed they received the referral only on 3/24/26, with imaging and an office visit scheduled for 3/30/26 and 4/7/26. During this period, the resident’s foot condition progressed. The wound care NP reported being notified on 3/26/26 of an injury to the resident’s left foot and, upon assessing the resident on 3/31/26, found an open wound with drainage on the left fourth toe. She was concerned about an underlying issue needing further investigation but did not have CT results at that time and understood that vascular evaluation was pending. She recommended local wound care (betadine with calcium alginate between the toes and daily dressing changes) until the vascular visit. The wound care NP stated she was not informed that the 3/30/26 CT scan showed osteomyelitis until her next facility visit on 4/7/26, after the resident had already been hospitalized, and indicated that if she had been able to confirm osteomyelitis, she would have recommended an antibiotic. The primary care NP, who would have ordered antibiotics, reported she was not aware of the issue with the fourth toe until after it had already developed and never saw the resident’s left foot after the fourth toe problem was identified. The resident’s family member reported that the foot wound had been ongoing for months, appeared black, and that he repeatedly questioned staff about the condition, stating the resident was not given needed antibiotics and was told they were not necessary. The hospital records documented that the resident presented with a non-healing left foot wound that began as presumed athlete’s foot, later involved the fourth and fifth toes, and continued to deteriorate despite debridement and dressing changes at the facility. The hospital noted the resident had not been seen by a vascular specialist and had not started antibiotics at the facility. Imaging at the hospital confirmed cellulitis and acute osteomyelitis of the left fourth toe, and the resident was started on IV doxycycline and later underwent amputation of the affected toe. These events occurred despite the facility’s written policy stating that staff strive to prevent skin impairment and promote healing through interdisciplinary evaluation and treatment based on clinical best practices.
Staff Inappropriately Solicits Resident's Personal Property
Penalty
Summary
A facility failed to honor a resident's rights when a staff member, specifically an LPN, approached a resident to inquire about purchasing the resident's personal vehicle. The LPN had noticed a car in the facility parking lot that had not been moved for some time and, after learning it belonged to the resident, directly asked if the vehicle was for sale, stating it was for her daughter to use for college. The resident, who was cognitively intact and had a diagnosis of metastatic breast cancer, expressed concern about staff discussing her personal matters and felt the inquiry was inappropriate, especially given her medical condition. The resident reported feeling upset by the interaction and questioned the appropriateness of staff discussing her situation among themselves. The Executive Director and Director of Nursing confirmed that the action of a staff member attempting to purchase an item from a resident was inappropriate and not in line with resident rights policies. The facility's policy requires that residents be treated with respect and dignity, including the right to retain and use personal possessions. The LPN acknowledged in a written statement that she had inquired about the car and stated she meant no harm. The incident was identified through interviews and record review, and it was determined that the resident's rights to dignity and self-determination were not upheld in this situation.
Failure to Properly Process and Secure Controlled Substance Medication
Penalty
Summary
A controlled substance medication, oxycodone, intended for a resident was delivered to the facility by the contracted pharmacy, but the medication was not properly processed or safely stored. The medication was signed for by an LPN and then handed over to an RN, but there was no subsequent record of the medication in the facility's narcotic logbook. The facility's policies required that controlled substances be processed by two nurses, with a count and proper documentation, but this procedure was not followed. Additionally, the medication was delivered in a white gift bag instead of the facility's standard purple plastic bag used to visually identify controlled substances, which may have contributed to the confusion. The RN who received the medication could not specifically recall receiving it, as he was reportedly distracted by sending another resident to the hospital at the time. Two staff members recalled seeing the RN receive the medication from the LPN, but the medication and associated paperwork were never located. The pharmacy's manifest documentation showed signatures from both the LPN and a second, illegible staff member, but the medication was never entered into the narcotic log or secured as required by policy. The resident for whom the medication was intended did not miss any doses of pain medication, according to the Director of Nursing, and was later sent to the hospital for unrelated medical issues. The facility's investigation found multiple failures to follow established procedures for the receipt and handling of controlled substances, including lack of proper documentation, failure to secure the medication, and deviation from standard delivery protocols.
Deficient Documentation and Administration of Controlled Medications and IV Antibiotics
Penalty
Summary
The facility failed to document and administer controlled medications and intravenous (IV) antibiotics in accordance with physician orders and regulatory requirements for several residents. For one resident with end stage renal disease and opioid dependence, controlled drug administration records for oxycodone were incomplete and illegible, with missing dates, times, and staff signatures. The records showed inconsistencies with the prescribed dosing interval and as-needed administration, and the medication counts did not reconcile with the documented administrations. Similar documentation issues were found for another resident receiving oxycodone, where the count correction lacked a date, time, and signature, and the administration record contained illegible and crossed-out entries. For another resident with hypertension and lymphedema, the facility failed to ensure timely and complete administration of IV ceftriaxone, resulting in two missed doses out of fourteen ordered. Additionally, a newly admitted resident with multiple bowel perforations and intra-abdominal abscesses did not receive timely IV antibiotics and antifungal medications upon admission. Orders for these medications were not entered until the day after admission, leading to missed doses. The resident and her family reported delays in medication administration, and the medication administration record did not reflect the administration of all ordered medications. The facility's controlled drug administration records also lacked proper reconciliation for medications delivered and administered, including missing documentation for narcotic counts and administration of pain medications and sedatives. The facility's policy required shift-to-shift narcotic counts and immediate investigation of discrepancies, but the records reviewed did not consistently meet these requirements. These deficiencies were identified through interviews, record reviews, and review of facility policies.
Failure to Timely and Accurately Administer Admission Medications and Treatments
Penalty
Summary
The facility failed to ensure that admission orders for medications and treatments were entered timely and accurately for two residents. For one resident with diagnoses including anxiety disorder and a right upper humerus fracture, the clinical record showed that several prescribed medications were not administered as ordered upon admission. Specifically, aspirin was initially given at the wrong frequency, clonazepam was not administered at all, and both paroxetine and lorazepam were not started until several days after admission. The resident reported difficulty obtaining medications over the weekend, resulting in missed doses of several prescribed drugs. Another resident, admitted with multiple complex medical needs including bowel perforations, intra-abdominal abscess, candidemia, and requiring total parenteral nutrition (TPN) and IV antibiotics, also experienced delays and omissions in medication administration. The hospital discharge instructions included a comprehensive list of medications and treatments, but upon admission, some orders such as IV antibiotics and TPN were not entered or transmitted to the pharmacy in a timely manner. The resident and her family reported that medications and treatments were not provided as expected, and the resident experienced pain and vomiting while waiting for her medications. Interviews with nursing staff revealed that there were issues with the admission process, including missing pages from the hospital medication list, confusion about which medications needed to be entered, and errors in how orders were entered into the system, resulting in some orders not being sent to the pharmacy. The facility's policy required nurses to execute physician orders or ensure a safe hand-off, but this was not consistently followed, leading to delays and omissions in medication and treatment administration for both residents.
Failure to Timely Obtain and Administer TPN for Resident
Penalty
Summary
A deficiency occurred when the facility failed to timely obtain and administer Total Parenteral Nutrition (TPN) for a resident with diagnoses including perforation of intestine and peritoneal abscess. Upon admission, the resident was alert and oriented and had orders for Clinimix (a form of TPN) and Clinolipid to be administered intravenously. Despite these orders being entered on the day of admission, the TPN was not available or administered until the following day. The resident reported asking staff about her medications and experiencing pain, vomiting, and crying during this period. The resident’s family member also inquired about the missing TPN and IV antibiotics, prompting a nurse to review the medication list and obtain one antibiotic from the emergency drug kit, while the TPN was delivered via STAT order later. The delay was traced to a failure in the medication ordering process, where the TPN order was entered incorrectly and not transmitted to the pharmacy, resulting in no delivery or follow-up communication from the facility to the pharmacy. Interviews with staff and the pharmacy representative confirmed that the pharmacy did not receive the TPN order due to this error, and no notes indicated a STAT request was made on the evening of admission. The facility did not have a policy specific to TPN administration, relying instead on standard practice.
Failure to Timely Address Resident Pain Using Available Medication
Penalty
Summary
A resident with diagnoses including perforation of intestine and peritoneal abscess was admitted to the facility and had an order for oxycodone immediate release 10 mg as needed every six hours for moderate to severe pain. Upon arrival, the resident repeatedly requested her pain medication, reporting significant pain, vomiting, and crying, but was informed by staff that the pharmacy delivery was pending. The resident did not receive her ordered pain medication until the following day, despite continued complaints of pain. Nursing staff were aware of the resident's pain and the outstanding medication order, with one LPN reporting the need to follow up with the pharmacy or utilize the emergency drug kit, which contained the required medication. However, documentation shows that the pain medication was not administered on the day of admission, and the first dose was given the next day after a STAT order was placed. Facility policy required that residents receive pain management in accordance with professional standards, but staff did not utilize available resources to address the resident's pain in a timely manner.
Failure to Ensure Resident Remained Free from Significant Medication Errors
Penalty
Summary
A resident with diagnoses including end stage renal disease, opioid dependence, and chronic pain was not consistently administered the correct narcotic pain medication as ordered by the physician. The resident's care plan required medication to be provided per physician's orders to manage pain. However, review of medication administration records revealed that after an order for oxycodone-acetaminophen (Percocet) was initiated, the resident continued to receive oxycodone 5 mg tablets, for which there was no active order during that period. The records showed 28 administrations of oxycodone 5 mg without a valid order, while the ordered Percocet was not administered as prescribed. Additionally, when the order for oxycodone 5 mg was reinstated, the resident was inconsistently administered the medication as ordered, and there were instances where Percocet was given despite the absence of an active order for it. The facility's policy on controlled drugs required proper removal and destruction of discontinued medications, but the records indicated ongoing administration of discontinued medications. These actions resulted in the resident receiving incorrect narcotic medications on multiple occasions.
Failure to Document Pain Assessments and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with significant medical conditions, including cerebral infarction, aphasia, and hemiplegia. The resident was nonverbal and unable to request pain medication independently. Physician orders were in place to monitor pain every shift and to administer oxycodone as needed for moderate to severe pain, and acetaminophen as needed for mild pain. The care plan included the use of non-pharmacological interventions and required pain assessments upon admission, quarterly, with significant changes, and as needed. However, the clinical record did not document the use of non-pharmacological interventions, nor did it consistently record pain levels prior to the administration of as-needed pain medication. Medication Administration Records (MAR) and Controlled Drug Administration Records showed that oxycodone was administered multiple times, but there was a lack of documentation regarding the resident's pain level before administration and the effectiveness of the medication after administration, except for a few instances. There was also no documentation that acetaminophen was ever administered. The care plan interventions, such as repositioning, diversional activities, and other non-pharmacological measures, were not documented as being attempted prior to administering narcotic pain medication. Interviews with the resident's family member and nursing staff revealed that the family had requested scheduled pain medication due to the resident's inability to verbalize pain, and had observed nonverbal signs of pain such as lip biting, grimacing, and tensing up. The staff indicated they relied on family input and observation of facial expressions to assess pain. Despite these observations and requests, the facility did not document the required pain assessments or non-pharmacological interventions, leading to a deficiency in pain management practices for the resident.
Failure to Follow Enhanced Barrier Precautions and Proper Linen Handling
Penalty
Summary
Staff failed to maintain proper infection control practices for a resident who was under enhanced barrier precautions (EBP) due to a tracheostomy, gastric tube, and wounds. During an observation, a certified nurse aide (CNA) provided perineal care to the resident while only wearing disposable gloves and did not don a required disposable gown. The CNA stated she was unaware of the need to wear a gown during incontinent care for this resident, despite the physician's order specifying EBP for activities such as dressing, bathing, transferring, changing linen, providing hygiene, and toileting assistance. Additionally, soiled linen contaminated with feces was observed placed directly on the floor in the resident's room, rather than being properly bagged as required by facility policy. The resident involved was non-verbal, dependent on staff for bed mobility and toileting, and had significant medical conditions including cerebral infarction, aphasia, hemiplegia, and a tracheostomy. Facility policies provided by the clinical nurse consultant confirmed the requirements for gown and glove use during high-contact care and proper handling of soiled linens to prevent infection transmission.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address grievances reported during resident council meetings for nine residents who attended a meeting. The resident council minutes from November 2024, December 2024, and January 2025 did not reflect any concerns discussed with various departments such as nursing, housekeeping, laundry, business office, activities, and maintenance. During a resident council meeting on January 29, 2025, residents expressed concerns about staff not answering call lights in a timely manner, an issue that had been ongoing without improvement. This concern had not been documented in previous resident council meetings. An interview with the Activities Director revealed that grievances were only recorded in the meeting minutes if the entire group reported a concern. Residents were encouraged to fill out individual grievance forms available throughout the facility for quicker resolution, rather than waiting for the next resident council meeting. The facility's policy, provided by the Regional President of Risk Management, stated that administrators should attend resident council meetings to assure residents that their grievances are important and should document any concerns on a Concern Form to be distributed to the appropriate department head. However, this procedure was not followed, leading to the deficiency.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at palatable temperatures for four residents, all of whom were cognitively intact and had various medical conditions such as heart failure, chronic obstructive pulmonary disease, and anxiety disorder. These residents reported that their meals were not served at appropriate temperatures, with hot items being cold and cold items being warm. This issue was confirmed through interviews conducted with the residents, who consistently expressed dissatisfaction with the temperature of their meals. Further investigation revealed that a test tray from the Cambridge Hall food cart had food items at temperatures below the required 135 degrees Fahrenheit. The Dietary Manager (DM) acknowledged that food was served from the steam table at a minimum of 135 degrees Fahrenheit but was unaware that this temperature should be maintained until the food was delivered to the residents' rooms. The facility's policy on food quality and palatability emphasized that food should be prepared and served at safe and appetizing temperatures, but this was not adhered to, leading to the deficiency.
Inaccurate MDS Assessments for Communication and PASRR
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for two residents, leading to deficiencies in communication assessment and Preadmission Screening and Resident Review (PASRR) documentation. For Resident E, the Annual MDS assessment inaccurately indicated that the resident was rarely or never able to understand or make himself understood, despite interviews with the Unit Manager and Social Service Assistant confirming that Resident E could communicate his needs, albeit inconsistently. The Float MDS Coordinator acknowledged that the assessment could have been coded differently to reflect the resident's actual communication abilities. For Resident 28, the facility did not accurately document the resident's PASRR condition in the MDS assessment. Although a PASRR Level II evaluation had been conducted, indicating the presence of a PASRR condition, the Admission MDS assessment failed to reflect this, marking that the resident had not been evaluated by PASRR Level II and did not identify any PASRR conditions. The Corporate MDS Coordinator confirmed the inaccuracy in the MDS assessment, which was not aligned with the facility's policy of using the Resident Assessment Instrument (RAI) for completing MDS assessments.
Deficiencies in Nail Care and Lotion Application for Residents
Penalty
Summary
The facility failed to provide adequate nail care and lotion application for two residents, leading to deficiencies in their personal hygiene. Resident B, who was cognitively impaired and required substantial assistance with bathing, was observed on multiple occasions with long fingernails, indicating a lack of proper nail care. Despite the care plan specifying shower days, the resident's representative expressed concerns about the quality of hygiene care provided. An LPN acknowledged that nail care should be performed on shower days and committed to trimming the resident's nails. Resident E, diagnosed with diabetes and malnutrition, required maximum assistance with personal hygiene and had a history of chronic wounds. Observations revealed dry, flaky skin on his legs and arms, and the resident expressed a desire for lotion, which was not available in his room. Although a care plan included the use of emollient for skin dryness, there was no physician's order for lotion application. A CNA confirmed that Resident E required total assistance with ADL care and did not refuse care. An RN suggested that a different type of lotion might be needed, but the deficiency remained unaddressed.
Failure to Provide Timely Podiatry Services
Penalty
Summary
The facility failed to provide timely foot care to a resident with a history of traumatic brain injury, dementia, chronic pain, and chronic obstructive pulmonary disease. The resident required substantial assistance with activities of daily living, including putting on and taking off footwear. Despite a podiatry consent form signed in May 2023 requesting podiatry services for thickened and painful nails, there was no documentation of any podiatry consultations in the resident's electronic health record. Observations revealed the resident had extremely thick, long, yellowish toenails, with the right big toenail raised a quarter inch from the base, indicating a lack of necessary foot care. Interviews with the Social Services Assistant and Unit Manager confirmed the absence of podiatry consultations for the resident, despite the facility's procedure of faxing consent forms to the podiatry provider. The Unit Manager was unaware of the resident's foot condition and acknowledged the need for podiatry referral. The facility's Foot Care policy indicated that foot care, including trimming of nails, should be performed by nursing personnel or a professional when necessary. However, the facility was unable to verify that the resident received the required podiatry services after signing the consent form.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care planned fall interventions for a resident identified as being at risk for falls. The resident, who had a history of transient ischemic attack, muscle weakness, and abnormal posture, was observed multiple times without a mat on the floor at the bedside, which was a specified intervention in their care plan. The care plan, dated April 4, 2024, included placing a mat on the floor at the bedside, keeping the bed in the lowest position, and ensuring bed locks were engaged. These interventions were initiated on July 25, 2022, but were not consistently followed. On several occasions, the resident was observed lying in bed without the mat in place, despite the care plan's requirements. A Certified Nurse Aide (CNA) interviewed during the survey was unaware of why the mat was not in use and confirmed that if it was part of the care plan, it should have been implemented. The facility's Fall Prevention and Management Policy, provided by the Regional President of Risk Management, emphasized the importance of care plans to address fall risks, including environmental and medical factors. However, the facility did not adhere to these guidelines, resulting in a deficiency.
Infection Control Breach During Respiratory Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the provision of respiratory care for a resident. Resident 75, who had diagnoses including acute respiratory distress syndrome, tracheostomy, and acute respiratory failure, was under enhanced barrier precautions as per a physician's order. During an observation, a respiratory therapist was seen providing care to the resident without wearing a gown, which is a required component of personal protective equipment (PPE) under the facility's Enhanced Barrier Precaution policy. This policy mandates the use of gowns and gloves during high-contact resident care activities, such as tracheostomy or ventilator care, to prevent the transmission of multi-drug resistant organisms. The Regional President of Risk Management confirmed that the respiratory therapist should have been wearing PPE while providing care.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for two residents, leading to deficiencies in their living conditions. Resident 60's room was observed to have several issues, including a restroom floor initially lacking tile or flooring, brownish spots on the ceiling above her bed, and a ceiling vent cover pulling away from the ceiling. Despite the placement of new flooring, a puddle of water was present due to a leaky commode, which Resident 60 had reported to staff but remained unfixed. The Maintenance Director was unaware of these issues, indicating a lack of communication and oversight in addressing the environmental concerns. Resident 47's room also exhibited cleanliness issues, with a dried tan substance on the grab bar beside her bed. This substance, likely dried food, was not removed despite attempts by a CNA, indicating inadequate cleaning practices. The facility's Resident Rights policy emphasizes providing safe and secure housing and attending to residents' needs, which was not upheld in these instances, leading to the noted deficiencies.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure proper monitoring of a resident on anticoagulant medications, specifically enoxaparin and warfarin, for one of the three residents reviewed. Resident B, who was diagnosed with lung cancer and a pulmonary embolism, was admitted to the facility with orders to receive enoxaparin injections twice daily and warfarin daily, with daily INR tests to monitor therapeutic levels. However, the resident's medical record lacked a developed care plan for anticoagulant usage and did not include the INR test results as ordered. Interviews with the Assistant Director of Nursing and the Nurse Consultant revealed that the Nurse Practitioner intended for the resident to receive the medications for at least a week before obtaining INR test results, but there was no documentation to support this delay. An order for a daily INR test was placed on 9/19/24 but was missed by the lab technician, leading to a STAT INR test order on 9/20/24. The facility's warfarin monitoring policy outlined procedures for INR monitoring and communication, but these were not followed, resulting in the deficiency.
Failure to Document Urine Output for Residents with Catheters
Penalty
Summary
The facility failed to record urine outputs for two residents utilizing urinary catheters, leading to a deficiency in care. Resident G, diagnosed with paraplegia and neuromuscular dysfunction of the bladder, had orders to measure and record urine output every shift for both a Foley catheter and a urostomy bag. However, the September 2024 Medication and Treatment Administration Records (MAR/TAR) showed multiple instances where urine outputs were not recorded across various shifts. This lack of documentation was noted despite specific physician orders to do so. Similarly, Resident F, who had a neurogenic bladder and a suprapubic catheter, also experienced lapses in urine output documentation. The care plan for Resident F included recording urine output every shift, yet the September 2024 TAR indicated several shifts where this was not done, with some entries marked as not applicable. An interview with the Assistant Director of Nursing confirmed that staff should have been documenting urine output for both residents every shift, highlighting a failure in adhering to the prescribed care protocols.
Failure to Maintain Resident Dignity During Medication Dispute
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident F, who was cognitively intact and had a diagnosis including below the knee amputation. The incident involved a night shift LPN, referred to as LPN 3, who allegedly used inappropriate language towards Resident F during an interaction about pain medication. Resident F reported that LPN 3 had called him a drug addict and used offensive language, which led to a verbal altercation between them. Resident F's roommate, who has hearing difficulties, confirmed overhearing an argument about pain medication but could not discern all the words exchanged. LPN 3 denied using offensive language directly to Resident F but admitted to referring to him as drug-seeking to another staff member, which Resident F might have overheard. The issue arose after Resident F's pain medications were reduced following a medical procedure, leading to his belief that LPN 3 was responsible for the changes. Another LPN, identified as LPN 11, corroborated that Resident F had expressed concerns about LPN 3's attitude towards him. The Regional Nurse emphasized the importance of staff being respectful when a resident is upset.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of elevated blood glucose readings as required by the physician's order. Resident C, who has a medical history including diabetes type I, end-stage renal disease, major depressive disorder, and neuropathy, reported that the facility did not administer her insulin on numerous occasions, leading her to use her own supply. The physician's orders specified that the resident should receive Glargine insulin twice daily and Humalog insulin according to a sliding scale, with instructions to call the physician if blood glucose levels exceeded 400 or fell below 70. On two occasions, the facility did not follow these instructions. On July 12, 2024, Resident C's blood glucose reading was recorded at 461, and on July 20, 2024, it was recorded at 425. Despite these elevated readings, there was no documentation indicating that the physician was notified. Additionally, discrepancies in the recorded times and values of blood glucose readings were noted, with no explanations provided. The facility's medication administration policy requires documentation of medication administration and physician contact for critical medications like insulin, which was not adhered to in this case.
Failure to Timely Report Resident's Hip Fracture
Penalty
Summary
The facility failed to report a resident's unusual swelling and subsequent hip fracture to the State Survey Agency in a timely manner. Resident P, who has paraplegia and requires assistance for transfers, experienced swelling in the left thigh/leg, which was later identified as a left hip fracture. The swelling was first noted on 1/29/24, and an x-ray on 1/30/24 confirmed a moderately displaced subtrochanteric hip fracture. Despite this, the facility did not report the incident until 2/2/24, after the fracture was confirmed and Resident P had been sent to the emergency room for evaluation and treatment. The facility's policy requires immediate reporting of incidents that threaten the welfare, safety, or health of a resident, including fractures, within 24 hours of discovery. However, the fracture was identified on 1/31/24, and the report was delayed until 2/2/24. An interview with the Regional Nurse confirmed that the facility should have reported the fracture when the x-ray results were available. This delay in reporting constitutes a failure to comply with the facility's policy and regulatory requirements for timely reporting of significant incidents.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving Resident N, who was cognitively intact and had been admitted with diagnoses including a fractured mandible and fourth metatarsal bone, as well as pain. The incident in question occurred when Resident N reported that a nurse, LPN 3, allegedly responded inappropriately to his complaints of pain by telling him to get back in bed and later refusing to give him his pain medication. The investigation into this incident was incomplete, as it did not include statements from all relevant staff members, such as the certified nursing assistants (CNAs) and the resident's assigned nurse, LPN 6, who was on break during the incident. The investigation file contained several statements, including one from LPN 3, who described Resident N as agitated and aggressive, and claimed that she did not touch the resident but instructed him to return to bed. LPN 3 also mentioned that the resident's pain medication was adjusted, which upset him. Another statement from an unnamed nurse indicated that they did not witness any yelling and had left before the incident occurred. Additionally, MDS staff documented that Resident N expressed concerns about the night shift nurse being rude and refusing medication, which was explained as a result of the facility's admission process. Despite these statements, the investigation was deemed insufficient because it lacked input from CNAs and LPN 6, who was the assigned nurse for Resident N that night. LPN 6 later provided a statement indicating that she was unaware of the interaction between Resident N and LPN 3, as she was on break at the time. The facility's abuse policy requires comprehensive statements from all involved parties, including witnesses, which were not obtained in this case, leading to the deficiency citation.
Medication Administration and Follow-Up Care Deficiencies
Penalty
Summary
The facility failed to administer medications as ordered for Resident F, who had a below-the-knee amputation and underwent a leg skin graft procedure. Despite a physician's order for Resident F to receive 15 milligrams of oxycodone, three tablets, twice a day for pain, the resident only received one tablet at various times. Additionally, the administration of a fentanyl patch was not conducted according to the prescribed schedule, leading to an early application of the patch. These discrepancies were brought to the attention of the staff by Resident F, who reported not receiving the correct dosage of pain medication. For Resident P, who was diagnosed with paraplegia and had an acute distal tibial and fibula fracture, the facility failed to schedule necessary follow-up appointments in a timely manner. Despite orders for a DEXA scan and an orthopedic consultation, there was no evidence that these appointments were scheduled or completed promptly. The DEXA scan was delayed due to transportation issues and lack of communication, resulting in a significant delay in completing the order. The orthopedic appointment was also not scheduled until much later, despite the urgency indicated by the physician's order. These deficiencies were identified during a review of the clinical records and interviews with the residents and staff. The lack of timely medication administration and follow-up care coordination for Residents F and P highlights the facility's failure to adhere to physician orders and ensure appropriate treatment and care for its residents.
Inadequate Pain Management for Resident with Fractures
Penalty
Summary
The facility failed to adequately assess and address the pain management needs of Resident N, who was admitted with multiple fractures and reported significant pain. Upon admission, Resident N was noted to have a pain level of 8 out of 10, with pain occurring every four hours, particularly in the morning and at night. Despite having a care plan that included both pharmacological and non-pharmacological interventions, the facility did not consistently implement these measures. The resident's clinical record lacked documentation of pain assessments, including the location and intensity of pain, and there was no evidence that non-pharmacological interventions were attempted or offered. On the night of admission, Resident N experienced an interaction with LPN 3, where the resident requested pain medication but was told it was not time for the next dose. The resident reported being in pain and expressed dissatisfaction with the response from the nursing staff. The medication administration record indicated that pain medication was administered at 4:00 a.m., but there was no documentation of any pain assessment or alternative interventions being offered prior to this time. The facility's pain management policy emphasizes the importance of resident-centered care and the need for comprehensive pain assessments. However, the staff did not adhere to these guidelines, as evidenced by the lack of documentation and the resident's report of inadequate pain management. The Regional Nurse acknowledged that the staff should have addressed the resident's pain more effectively, highlighting a deficiency in the facility's pain management practices.
Narcotic Medication Reconciliation and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate reconciliation of narcotic medications and proper documentation on the narcotic control record for a resident. The clinical record for a resident, who had a below-the-knee amputation and was cognitively intact, showed a physician's order for 15 milligrams of oxycodone every 4 hours for pain, which was discontinued on a specific date. However, discrepancies were found in the controlled drug administration record, including incorrect tablet counts and missing nurse signatures and times for medication administration. Interviews revealed that the narcotic count sheets were not accurately filled out, with errors in the total remaining tablet counts and missing signatures from the administering nurse. The nurse admitted to forgetting to sign her name after administering the medication and acknowledged an incorrect count of remaining tablets. The facility's medication administration policy required narcotics to be signed out when given, which was not adhered to in this case.
Deficiencies in Clinical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, Resident E and Resident C, leading to deficiencies in their care. For Resident E, the clinical records were reviewed and revealed discrepancies in the documentation of enteral feeding residuals. The Medication Administration Record (MAR) showed that staff recorded 'NA' (nonapplicable) for several days instead of actual residual amounts, which was incorrect. Additionally, the recorded amounts on certain days were mistakenly documented as formula totals rather than residuals, indicating errors in the documentation process. For Resident C, the facility did not consistently administer insulin as per the physician's orders, and there were multiple instances where blood glucose readings were not recorded or documented correctly. Resident C, who had a history of diabetes type I and other medical conditions, reported administering her own insulin due to missed doses by the facility. The MAR indicated several instances where blood glucose readings were marked as 'NA' or left blank, and there were no corresponding notes in the clinical record to explain these omissions. This lack of documentation and failure to administer insulin as prescribed led to significant gaps in Resident C's medical records. The facility's Medication Administration policy requires that medications be charted when given, and any medications that are refused, withheld, or not given must be documented. However, the facility did not adhere to these standards, resulting in incomplete and inaccurate records for both residents. These deficiencies were identified during a survey related to specific complaints, highlighting the facility's failure to follow accepted standards of nursing practice in maintaining accurate clinical records.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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