Aperion Care Lincoln
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 1236 Lincoln Ave, Evansville, Indiana 47714
- CMS Provider Number
- 155820
- Inspections on file
- 27
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Aperion Care Lincoln during CMS and state inspections, most recent first.
Surveyors found that one unit was not maintained in a clean, safe, and homelike condition, with debris and dirt buildup on stairs, hallways, and around door frames, cove base pulling away from walls, and soiled carpets in a common room. A kitchenette near the main dining room had debris on the floor and under a storage rack, a large dead bug, a soiled trashcan exterior, a refrigerator interior contaminated with black and red substances, and a freezer with excessive ice buildup. Debris was also present under desks and around walls at two nurses’ stations. Resident Council minutes documented repeated complaints that rooms, bathrooms, toilets, and floor edges and corners were not being cleaned well, despite the housekeeping policy and the Housekeeping Director’s statement that floors were to be mopped daily.
A resident with traumatic brain injury, paraplegia, and a recent history of pressure injuries was admitted with a documented stage 2 right hip ulcer and toe wounds, but the admitting LPN did not perform a head-to-toe skin assessment and relied on verbal handoff instead. Subsequent skin assessment reports recorded only a shoulder surgical incision and no other skin issues, while the MDS documented no pressure ulcers or scars despite prior documentation of a right hip ulcer and toe wounds. A facility-acquired unstageable pressure ulcer on the right great toe was later identified, and treatment orders for toe wounds and a pillow boot were initiated, revealing that required admission skin assessments, ongoing wound documentation, and monitoring per facility policy were not completed.
An LPN was hired and allowed to work independently on multiple units without verification of an active nursing license, contrary to facility policies and job requirements that mandate proof of current licensure and adherence to professional standards and state regulations. Review of the personnel file showed no documentation of a valid license, and the Administrator acknowledged that licensure had not been confirmed before the LPN provided nursing care to residents.
Surveyors found that pharmaceutical services did not ensure timely availability of routine medications, resulting in multiple missed doses for two residents. One resident with depression and anxiety missed scheduled doses of Ativan when the facility ran out and the pharmacy was awaiting a new prescription. Another resident with vitamin deficiency, cerebral palsy, and reduced mobility missed several doses of a multivitamin, a vaginal lubricant, and Chlorzoxazone over multiple days, with nursing notes repeatedly citing medications as on order, pending pharmacy arrival, or not available. An RN reported that nurses are responsible for reordering medications before they run out, and facility policy requires pharmacies to refill prescriptions in time to prevent interruption of drug regimens.
A facility did not report an alleged sexual abuse incident between two residents, one of whom was unable to give consent, to the State Survey Agency. The DON and Administrator were aware of the incident but did not report it, citing lack of awareness of the requirement and absence of a specific reporting policy.
A facility failed to thoroughly investigate and document an alleged incident of sexual abuse between two residents. Although staff were made aware of inappropriate sexual requests and possible exposure, there was no formal documentation or comprehensive investigation as required by facility policy. Interviews confirmed that while the event was discussed and capacity assessments were performed, the necessary investigative steps and documentation were not completed.
A resident with a surgical wound and diabetes had physician orders for a wound vac to be changed every three days, but the wound vac was not changed on two scheduled dates. The DON confirmed the missed treatments, and facility policy required documentation of such treatments, which was not completed.
A resident requiring moderate staff assistance with bathing did not receive scheduled baths or hair shampooing for several weeks, as confirmed by both observation and record review. The resident was noted to have poor hygiene and reported not having had a bath or bed linen change in weeks, despite facility policy requiring bathing to be offered at least twice weekly.
A resident with a history of mental health and behavioral issues made inappropriate sexual advances toward another resident with cognitive impairment. The incident was not documented, care plans were not updated, and there was no evidence of monitoring or follow-up, despite facility policies requiring these actions. Staff interviews revealed a lack of awareness and documentation regarding the event and the residents' behavioral health needs.
Surveyors found that the medication room, treatment cart, and medication refrigerator containing insulin and other medications were left unlocked. A QMA confirmed these areas were supposed to be locked, and facility policy required all medications and biologicals to be securely stored.
Staff did not knock or announce themselves before entering rooms to deliver meal trays, as observed and confirmed by staff and resident council complaints. Facility policy requires staff to protect residents' privacy by knocking and requesting permission before entering.
A resident reported that meals were sometimes served cold, and food temperature checks during a meal revealed that hot foods were below the facility's preferred standard of 120°F. Facility guidelines require monitoring and investigation of food temperature complaints, but observations showed these were not consistently met.
Surveyors found that food items in the kitchen were not consistently labeled or properly sealed after opening, and kitchen floors behind equipment remained soiled despite facility policies requiring daily cleaning. The Dietary Manager and staff described practices that did not align with written procedures, resulting in unsanitary food storage and preparation areas.
A resident with dementia and severe cognitive impairment exhibited wandering and elopement behaviors, but the facility failed to complete and document required elopement risk assessments in the clinical record as per policy. The lack of documentation persisted even after incidents of wandering and an actual elopement, resulting in incomplete and inaccurate records.
A resident with a history of hypertension and hypertensive encephalopathy did not receive prescribed antihypertensive medications on multiple occasions, as documented in the MAR. These medication omissions led to two separate hospitalizations for hypertensive emergencies. Staff interviews revealed a lack of clear policy on blood pressure parameters and adherence to physician orders.
Surveyors found that food items in both dry storage and the reach-in refrigerator were not labeled with open, preparation, or use-by dates. The Dietary Manager confirmed that labeling is required, and facility policy mandates all food items be labeled with the name and consumption date.
The facility did not ensure a certified Infection Preventionist was designated and assigned at least part-time hours to oversee the infection prevention and control program. The DON was responsible for the program in addition to her full-time DON duties, and there was no signed job description confirming assignment of the IP role.
The facility did not complete required quarterly care plan conferences for several residents, including those with cognitive impairment and complex medical conditions. Documentation was missing for recent conferences, and some residents had not had a care plan conference since admission, despite facility policy requiring quarterly participation by residents or their representatives.
Surveyors observed persistent offensive odors, including urine and feces, in hallways, alcoves, and stairwells, as well as unsanitary conditions in two residents' rooms, such as dirty floors and showers and food crumbs. Staff interviews revealed inconsistent cleaning practices and the absence of a daily cleaning list, despite facility policy requiring a clean and odor-free environment.
Multiple residents dependent on staff for ADLs did not receive scheduled showers or hair care as outlined in their care plans, with observations and interviews revealing missed showers, unwashed hair, and inadequate hygiene. Residents with significant medical needs reported infrequent bathing and lack of haircuts, and staff cited ongoing staffing shortages as a contributing factor. The DON confirmed the facility was aware of these ongoing issues, and documentation showed repeated failures to meet residents' bathing preferences.
A meal tray served to a resident included carrots at 115°F, which was below the facility's required holding temperature of 140°F as stated in policy. The Dietary Manager confirmed the expected standard, and the deficiency was identified during a survey in response to a complaint.
A resident who was cognitively intact and dependent on staff for transfers was not consistently able to attend mass as desired due to delays in morning care and insufficient staffing. The resident's care plan documented her preference to get up by a certain time, but staff were unable to consistently meet this preference, resulting in missed opportunities to participate in religious activities.
A resident was not properly informed of her rights and did not receive or sign her admission paperwork, despite documentation indicating otherwise. The resident reported being unaware of her rights and stated the signature on the admission packet was not hers. The Social Services Director confirmed that copies of admission packets are only provided upon request.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant weight loss over a short period, but this was not accurately coded on the MDS assessment as required. Clinical records and staff interviews confirmed the weight loss, yet the MDS continued to indicate no weight loss, contrary to facility policy and assessment guidelines.
QMAs administered PRN pain medications and insulin to two residents without obtaining required nurse authorization or following documentation protocols. One resident with diabetes received hydrocodone-acetaminophen from a QMA without nurse approval, while another resident with cerebral palsy and diabetes received insulin and multiple PRN pain medications from QMAs, contrary to facility policy and QMA scope of practice.
Two residents developed facility-acquired heel pressure ulcers due to the facility's failure to identify risk, perform routine skin checks, and consistently follow wound care plans. Both residents were assessed as at risk for pressure ulcers, but comprehensive care planning and monitoring were lacking prior to ulcer development. Multiple wound treatments were missed without documentation of refusal, and physician orders for wound care were not consistently followed, as confirmed by interviews and record review.
Two residents with severe cognitive impairment and repeated falls were not consistently provided with required fall prevention interventions, supervision, or prompt assistance. Numerous falls were not followed by timely care plan updates, IDT reviews, or fall risk assessments, and essential safety measures such as call lights within reach and non-skid footwear were often missing. Documentation and communication lapses further contributed to ongoing fall incidents and injuries.
A resident with dementia, diabetes, and dysphagia experienced a significant, unaddressed weight loss, with no documentation of physician notification, dietitian referral, or nutritional assessment. Despite repeated notes from a mental health NP and the resident's own report of weight loss, the facility failed to re-weigh the resident, update the care plan, or involve the IDT, contrary to facility policy.
A resident with a feeding tube did not consistently receive enteral nutrition as ordered by the physician, with frequent undocumented interruptions in feeding, incomplete documentation of intake, and failure to change feeding equipment daily. Facility staff did not consistently document refusals or notify the physician when the resident did not receive the prescribed amount of nutrition, contrary to facility policy.
Staff failed to follow infection control protocols during care for two residents, including not changing gloves or performing hand hygiene between dirty and clean tasks during incontinence and wound care. Facility policy requires glove changes and hand hygiene, but these steps were not consistently followed by the CNA and RN involved.
A resident with cerebral palsy and other conditions was injured during a transfer using a Hoyer lift due to improper use and inadequate staffing. The lift tipped over because the resident's weight was not centered, and the procedure for safe transfers was not followed, resulting in the resident sustaining knee and back injuries.
Failure to Maintain Clean, Safe, and Homelike Environment on One Unit
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, sanitary, and homelike environment on one of two units (the 100 Unit). On multiple observations, debris buildup was noted on the stairs leading to the unit, including a folded band-aid on the steps. Walls in common areas, including by the stairwell and across from a room marked medical suite, had cove base coming off. Dirt was built up under water fountains, around double fire doors, and in the corners and around door frames in the hallways and resident room entrances. A room containing a fireplace and piano had soiled, stained carpets. A kitchenette near the main dining room had debris on the floor and under a metal storage rack, a large dead bug under the rack, a soiled exterior trashcan, a refrigerator interior soiled with a black and red substance, and a freezer with ice buildup. The two nurses’ stations on the unit had debris buildup on the floor under the desks and around the walls. Resident Council meeting minutes further documented concerns about inadequate cleaning. On one date, residents reported that rooms were not being cleaned well, bathrooms were being left dirty, and toilets were not being cleaned. On another date, residents reported that floors were not being cleaned well, especially along the edges and in the corners. The Housekeeping Director stated that floors were supposed to be mopped daily in resident rooms and throughout the units. The Administrator provided a housekeeping services policy stating the facility was to maintain a clean, odor-free, comfortable, and orderly environment in all health care and public areas. These observations and resident reports showed that the facility did not follow its own policy and did not maintain the required environmental standards on the 100 Unit.
Failure to Complete Admission Skin Assessment and Monitor Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and skin assessment for a resident admitted with existing pressure areas and at risk for pressure injuries. The resident, who had traumatic brain injury, paraplegia, a lower leg amputation, and a cognitive communication deficit, had been hospitalized shortly before admission and received specialty bed support and wound care for pressure injuries. Hospital information and the facility’s admission/readmission observation on the day of admission documented a stage 2 pressure ulcer on the right trochanter (hip), and an admission checklist the following day noted wound care to the right great and second toes with betadine. However, the admission MDS completed shortly after admission indicated the resident had no pressure ulcer/injury, no scar over a bony prominence, and no non-removable dressing or device. Skin assessment reports completed on two dates after admission documented only a right shoulder surgical incision and no other skin impairments. The admitting LPN reported she completed the admission/readmission form based on hospital report of a right hip stage 2 pressure ulcer but did not perform a head-to-toe skin assessment because the resident did not want to get into bed, and she relied on passing the need for a skin assessment to the night nurse. The DON later acknowledged that the admission checklist comments about buttock and toe skin areas were not followed up on and that the right hip should have been documented on skin assessments. A facility-acquired unstageable pressure ulcer on the right first toe was identified on a wound assessment dated approximately two weeks after admission, and subsequent physician orders were written for pillow boot use and iodine treatment to the right great and second toe wounds. At the time of survey observation, the right hip showed pink scar tissue with a dry callous and no open area, and the resident stated he had this area for a long time. Facility policies required a head-to-toe skin condition assessment and pressure ulcer risk assessment at admission/readmission, completion of a skin condition report with any wound or skin breakdown, and weekly assessment and documentation of pressure and other ulcers, but these processes were not carried out as required for this resident.
Unverified LPN Licensure Resulting in Unqualified Nursing Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing care was provided by qualified personnel in accordance with each resident’s written plan of care. During review of an employee file for an LPN hired in late September and terminated in early November, surveyors found no documentation of an active LPN license. The Administrator reported that the LPN had been hired without verification of licensure and that the facility was unable to confirm that this individual ever held an active nursing license. The Administrator further indicated that the LPN worked on all units in the facility and provided dates on which the LPN worked independently after an initial orientation period. The facility’s own documents required proof of current licensure upon application for employment and at least annually thereafter, and the LPN job description specified that the position required a current, unencumbered state LPN license. Additional policies and role descriptions referenced that an LPN must accept assignments consistent with education, training, and competency, and adhere to professional standards, facility policies, and applicable state laws and regulations. Despite these written requirements, the LPN’s personnel file lacked evidence of a valid license, and the Administrator acknowledged that licensure had not been verified before the LPN was allowed to work and provide nursing care to residents on multiple units.
Failure to Ensure Timely Availability of Routine Medications
Penalty
Summary
The facility failed to ensure that pharmaceutical services provided physician-prescribed routine medications as ordered, resulting in missed doses for two residents. One resident with diagnoses including depression and anxiety had a physician order for Ativan 1 mg three times daily starting in December. Review of the January Medication Administration Record (MAR) showed that the 2:00 p.m. and 8:00 p.m. doses on one day were not documented as administered. Nursing progress notes for that day documented that the pharmacy was waiting on a new prescription and that the pharmacy was aware of the need for the medication, and the resident reported she had recently not received her routine antianxiety medication because the facility had run out. Another resident, with diagnoses including vitamin deficiency, cerebral palsy, and reduced mobility, had physician orders for a daily multivitamin, daily vaginal lubricant (Replens gel), and Chlorzoxazone 500 mg four times daily. The January MAR showed multiple days when these medications were not administered. The multivitamin was not given on one day; Replens gel was not given on four separate days; and Chlorzoxazone was not given on multiple consecutive and nonconsecutive days. Nursing notes repeatedly documented that these medications were pending pharmacy arrival, on order, not available, or waiting on pharmacy delivery, and that the facility was out of Replens and had reordered it. An RN stated it was the nurse’s responsibility to reorder medications before they ran out. The facility’s pharmaceutical services policy stated that residents may use a pharmacy of their choice as long as the pharmacy refills prescription drugs when needed to prevent interruption of drug regimens.
Failure to Report Alleged Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving two residents to the State Survey Agency. According to interviews, a CNA informed the DON that one resident entered another resident's room, asked inappropriate sexual questions, and requested to be her boyfriend. The resident who was approached was not capable of giving consent. The DON also learned that the resident exposed her breasts to the other resident. Both the DON and the Administrator were aware of the incident but did not report it to the State Survey Agency, as they were unaware of the reporting requirement. The Administrator also stated that the facility did not have a policy related to reporting alleged violations and instead followed state regulations.
Failure to Investigate and Document Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving two residents. According to interviews and record review, a CNA reported to the DON that one resident entered another resident's room and made inappropriate sexual requests. The DON completed a capacity for sexual consent assessment for both residents and instructed the resident not to ask such questions again. However, there was no documentation of the incident or the investigation, despite the facility's policy requiring such documentation. Further, it was reported that the resident who was approached may have exposed herself, but this was also not documented or investigated thoroughly. Interviews with the DON, Administrator, and Regional President of Operations revealed that while the incident was discussed among staff and both residents were interviewed, there was no formal documentation or evidence of a comprehensive investigation. The facility's policy mandates that any suspicion of non-consensual sexual relations or questions about a resident's capacity to consent should trigger an investigation, with findings documented in the resident's record. In this case, the required documentation and investigative steps were not completed.
Missed Wound Vac Changes for Resident with Surgical Wound
Penalty
Summary
The facility failed to ensure that wound treatments were completed as ordered for a resident with a surgical wound and a diagnosis of type 2 diabetes mellitus. The resident had a physician's order for a wound vac to be changed every three days, starting from a specified date. Review of the electronic treatment administration record showed that the wound vac was not changed on two scheduled dates in September, as required by the physician's order. During interviews, the DON confirmed that the wound vac changes were missed on those dates. Facility policy required that physician-ordered treatments be documented by staff after each administration, but this was not done for the missed treatments.
Failure to Provide Required Bathing Assistance
Penalty
Summary
The facility failed to provide necessary assistance with bathing and personal hygiene for a resident who required moderate staff help. The resident, who was cognitively intact and diagnosed with type 2 diabetes mellitus, reported not having received a bath or had bed linens changed in weeks. During observation, the resident exhibited a strong sour odor, greasy hair, and long, soiled fingernails. Review of both paper and electronic records confirmed that the resident had not received or refused a bath or shower on multiple documented dates over the past month, and had not had their hair shampooed during that period. Facility policy required that showers, tub baths, or bed/sponge baths be offered according to resident preference at least twice weekly, but this was not followed for the resident in question.
Failure to Document and Address Sexual Behaviors and Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of mental health disorders, substance use, and behavioral issues. An incident occurred in which the resident made inappropriate sexual advances toward another resident who had moderate cognitive impairment. The incident was not documented in the clinical record, and there was no evidence that the care plan was updated to address sexual behaviors or that the resident was monitored for such behaviors following the event. Interviews revealed that staff, including the Social Services Director and Certified Nurse Aides, were either unaware of the incident or did not document the behaviors and follow-up actions. The Director of Nursing acknowledged that a report was made about the incident and that capacity for sexual consent assessments were completed for both residents, but there was no documentation of the incident, investigation, or subsequent monitoring in the clinical records. Additionally, the family of the resident with cognitive impairment was not notified of the incident, despite claims to the contrary. The facility's documentation systems, including progress notes and care plans, lacked information about the sexual incident, the behaviors exhibited, and the interventions or monitoring implemented. The facility's policies required investigation, documentation, and care plan updates in response to such incidents, but these procedures were not followed. As a result, the necessary behavioral health services and protections were not provided to the residents involved.
Failure to Secure Medication Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage of medications in the first floor medication room. On observation, the medication room containing the Emergency Drug Kit (EDK) was found unlocked, and within the room, both the treatment cart and the medication refrigerator, which contained insulin, suppositories, and other cold medications, were also unlocked. During the observation, a Qualified Medication Aide (QMA) confirmed that the medication room, treatment cart, and medication refrigerator were all supposed to be locked. Review of the facility's current Medication Storage policy indicated that all medications and biologicals, including treatment items, should be securely stored in locked compartments or rooms inaccessible to residents and visitors.
Failure to Knock or Announce Before Entering Resident Rooms During Meal Delivery
Penalty
Summary
Staff failed to honor residents' rights to dignity and respect by not knocking or announcing themselves before entering resident rooms during meal tray delivery. This was observed when a CNA delivered lunch trays to multiple rooms without knocking or introducing herself. Resident council minutes also documented a complaint regarding staff not knocking or introducing themselves prior to entering rooms. Another CNA confirmed that the expected practice is to knock and inform residents before entering with food. The facility's policy requires staff to protect and value residents' private space, including knocking and requesting permission before entering rooms.
Failure to Serve Food at Appetizing and Safe Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing and safe temperature for residents, as evidenced by observations and interviews on unit 200. One resident reported that food was not always served hot and was sometimes ice cold depending on delivery time. During a meal service, food temperatures were measured and found to be below the facility's preferred standard, with the pork loin at 115°F, stuffing at 85°F, and peas at 79°F. The facility's guidelines require hot foods on room trays to be at 120°F or greater to promote palatability, and complaints about food temperature are to be documented and investigated. However, the observed temperatures and resident complaint indicate that these procedures were not consistently followed.
Failure to Maintain Sanitary Food Storage and Kitchen Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to serve food in a sanitary manner according to professional standards during two separate kitchen inspections. In the walk-in freezer, partially used bags of breaded chicken, mixed vegetables, and garlic bread were found unlabeled, and later, an open box of fish squares was left unsealed and exposed to air. The kitchen floor behind the stove, deep fryer, and under a stainless steel table with a sink had visible soil buildup and debris, and these areas remained soiled several days later. The Dietary Manager stated that floors under equipment are typically cleaned once a week, while facility policy requires daily cleaning. Additionally, although the facility's policy mandates labeling and dating opened food items, this was not consistently followed, as evidenced by the unlabeled and improperly stored food items.
Failure to Maintain Accurate Elopement Risk Assessments and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a history of dementia and cognitive impairment. Although the care plan identified the resident as being at risk for elopement and required quarterly reassessment, there was no documentation of elopement risk assessments in the clinical record except for one completed after an actual elopement event. The facility's policy required new assessments after any actual or attempted elopement or when exit-seeking behaviors were identified, but these were not documented as required. The resident exhibited wandering behaviors, including an incident where the resident left the floor, exited the building, and was found outside by a staff member. Despite these behaviors and the facility's policy, the required elopement risk assessments were not completed or documented in the clinical record prior to the elopement event. The administrator confirmed that paper assessments could not be located and that the assessments were not transcribed into the clinical record, resulting in incomplete and inaccurate documentation.
Failure to Administer Antihypertensive Medications Leads to Hospitalizations
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the resident not receiving prescribed blood pressure medications on multiple occasions. The resident, who had a diagnosis of hypertensive encephalopathy and was moderately cognitively intact, had physician orders for several antihypertensive medications, including Carvedilol, Isosorbide Mononitrate, Lisinopril, and later Hydralazine. On at least two documented occasions, the resident did not receive these medications as ordered, with the electronic medication administration record (MAR) showing missed doses and a lack of blood pressure recordings. Following these missed doses, the resident experienced hypertensive emergencies that required hospitalization. On one occasion, the resident was found on the floor complaining of pain, and his blood pressure was significantly elevated upon hospital admission. On another occasion, after missed medication doses and absent blood pressure documentation, the resident developed chest pain and was again hospitalized for a hypertensive emergency. Interviews with facility staff revealed that there was no policy provided regarding blood pressure parameters and following physician orders, and the DON stated that staff should use nursing judgment and follow physician orders.
Failure to Label and Date Food Containers in Storage and Refrigeration
Penalty
Summary
Surveyors observed that the facility failed to store food in a sanitary manner during kitchen inspections. In the dry storage area, a bag of noodles and a bag of marshmallows were found without open dates. In the reach-in refrigerator, multiple containers of juices and fluids were present without labels, preparation dates, or use-by dates. The Dietary Manager confirmed during an interview that containers should be labeled with preparation and use-by dates. The facility's food storage policy, provided by the Director of Nursing, also requires all food items to be labeled with the name of the food and the date it should be consumed by.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified and certified Infection Preventionist (IP) responsible for the infection prevention and control program. Review of the Director of Nursing's (DON) employee file revealed the absence of a signed job description for the IP role. The DON confirmed she was currently responsible for the infection prevention and control program while also working full time as the DON. Although a current IP job description was available, it was not signed or assigned, and the DON's job description did not reflect the IP responsibilities. This resulted in the lack of a dedicated staff member with at least part-time hours assigned specifically to the IP role, as required.
Failure to Hold Quarterly Care Plan Conferences for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plan conferences were completed quarterly for six out of seven residents reviewed. For several residents, including those with diagnoses such as cerebral palsy, diabetes mellitus, major depressive disorder, dementia, repeated falls, wedge compression fracture, hypertensive encephalopathy, and hypertension, the most recent care plan conferences were either not held within the required quarterly timeframe or had not been conducted since admission. Clinical records showed that some residents had not had a care plan conference for several months, and in two cases, no care plan conference had been held since the residents were admitted. Interviews and record reviews confirmed that the facility's policy required residents and/or their representatives to be invited to participate in care plan conferences at least quarterly, either in person, by phone, or via video conference. However, documentation for recent care plan conferences was missing for multiple residents, and the Director of Nursing acknowledged that these conferences were supposed to be held quarterly. Requests for records of care plan conferences for certain residents could not be fulfilled, further confirming the deficiency.
Failure to Maintain a Safe, Clean, and Odor-Free Environment
Penalty
Summary
The facility failed to provide a safe, clean, and odor-free environment for residents, staff, and the public, as evidenced by multiple observations of offensive odors and unsanitary conditions over a five-day period. Strong smells of urine were repeatedly detected in public hallways, alcoves, stairwells, and near the chapel, as well as outside specific resident rooms and the Holy Family Nurses Station. Additionally, the smell of feces was noted in alcoves on the second floor. These conditions were observed on several occasions, indicating a persistent issue rather than isolated incidents. Further, interviews and direct observations revealed that resident rooms and bathrooms were not being cleaned adequately. One resident reported that her room was not cleaned daily, and brown dried mud and dirty shower floors were observed in her room on separate days. Another resident's family member reported finding food crumbs behind drawers, and subsequent inspection confirmed the presence of food crumbs, a sticky bathroom floor, and a dirty shower floor. A housekeeper stated there was no daily cleaning list and described inconsistent cleaning practices. The DON confirmed that there should be no offensive smells in the building and provided a policy stating the facility's intent to maintain a clean, odor-free environment, which was not being met.
Failure to Provide Scheduled Showers and Hair Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs), specifically bathing and hair care, for 9 out of 10 residents reviewed. Multiple residents who were dependent on staff for bathing and personal hygiene did not receive showers or hair shampooing according to their care plans and preferences. Observations and interviews revealed that residents often received bed baths without hair washing, and some residents' hair appeared oily, unkempt, or unwashed. Several residents and family members reported infrequent showers, lack of haircuts, and inadequate hygiene, with some residents expressing dissatisfaction with the timing and quality of care provided. Clinical record reviews indicated that these residents had significant medical conditions such as cerebral palsy, diabetes mellitus, dementia, depression, hypertensive encephalopathy, and malignant neoplasm, and required varying levels of staff assistance for ADLs. Documentation showed missed showers on multiple scheduled days for each resident, and in some cases, no documentation of hair washing since admission. Care plans consistently indicated a preference for showers two times per week, but these preferences were not met. Staff interviews confirmed ongoing issues with staffing shortages, which contributed to the inability to complete all required ADL care. The Director of Nursing acknowledged that the facility was aware of the ongoing problem with missed ADL care, including showers, and that there was no designated staff member responsible for ensuring showers were given. Facility policy required that residents be offered showers or baths according to their preferences at least twice weekly, but this was not consistently implemented. The deficiency was cited under 3.1-38(a)(3) and related to specific complaints.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature, as evidenced by an observation of a meal tray on the 200 Unit where the carrots measured 115 degrees F. According to the Dietary Manager, the expected holding temperature on the steam table should be 145 degrees F or higher. The facility's policy on Monitoring Food Temperatures for Meal Service requires serving/holding temperatures to be at least 140 degrees F prior to meal service, and hot foods on room trays should be at 120 degrees F or greater for palatability. The deficiency was identified during a survey and relates to a specific complaint.
Failure to Accommodate Resident's Choice to Attend Religious Activity
Penalty
Summary
A resident with diagnoses including cerebral palsy and major depressive disorder, who was cognitively intact and dependent on staff for toileting and bathing, was not accommodated in her choice to attend mass due to delays in morning care. The resident expressed that staff did not always get her up in time for mass, which was scheduled daily at 11:00 A.M. Observations confirmed that on one occasion, the resident was still in bed waiting for staff to use a mechanical lift to transfer her, despite her care having just been completed. The resident's care plan indicated a preference to get up for the day at 10:00 A.M. or as desired, and that she required assistance from two staff members and a mechanical lift for transfers. Staff interviews revealed that there was insufficient staffing to complete all required tasks in a timely manner. The facility's Resident Rights policy stated that residents have the right to self-determination, including the right to choose activities and schedules consistent with their interests, such as participating in religious activities. The failure to accommodate the resident's choice to attend mass was attributed to staffing limitations and delays in providing necessary morning care and transfers.
Failure to Provide and Verify Resident Rights and Admission Paperwork
Penalty
Summary
The facility failed to ensure that a resident was properly informed of her rights and provided with the required admission paperwork. During interviews, the resident stated she was unaware of her rights and had not received or signed an admission packet. Review of the clinical record showed an admission packet was signed electronically by both the Social Services Director and the resident, but the resident later stated the signature was not hers. The Social Services Director confirmed that residents sign admission packets electronically and are only given a copy if they request it. The facility's policy requires healthcare professionals to make prompt, factual, and complete documentation entries.
Failure to Accurately Code Significant Weight Loss on MDS Assessment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment was completed accurately for a resident with significant weight loss. The resident, who had diagnoses including dementia, diabetes mellitus, and dysphagia, was documented as having severe cognitive impairment and requiring setup assistance for eating. The Annual MDS Assessment recorded the resident's weight as 179 pounds with no weight loss, while the subsequent Quarterly MDS Assessment listed the weight as 132 pounds, also indicating no weight loss. However, clinical records showed the resident's weight dropped from 179.3 pounds to 131.7 pounds between assessments, representing a 26.55% loss, and further decreased to 123.3 pounds, totaling a 31.23% loss since the initial weight. Staff interviews confirmed the weight loss should have been coded on the MDS, but it was not, despite facility policy to follow the Resident Assessment Instrument (RAI) Manual for MDS coding.
QMAs Administered PRN Medications and Insulin Outside Scope of Practice
Penalty
Summary
The facility failed to ensure that Qualified Medication Aides (QMAs) practiced within their defined scope of practice for two residents who were reviewed for unnecessary medications. For one resident with type 2 diabetes mellitus, a QMA administered hydrocodone-acetaminophen, a pain medication, on multiple occasions without prior authorization from a nurse, as required by policy and the QMA scope of practice. The resident was noted to be moderately cognitively intact, and the medication was ordered to be given as needed for pain. For another resident with cerebral palsy, diabetes mellitus, and pain, QMAs administered both insulin and various PRN pain medications, including hydrocodone-acetaminophen, Tylenol, and Excedrin, without obtaining prior authorization from a nurse. The facility's policy did not permit QMAs to administer insulin, even if they were insulin certified. The QMA scope of practice and job description both required that PRN medications only be administered with nurse authorization, and that such administration be properly documented and cosigned by a licensed nurse. These requirements were not followed, as evidenced by the medication administration records and interviews with facility staff.
Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
The facility failed to identify and address the risk of pressure ulcer development, perform routine skin checks, and follow care plans to promote wound healing for two residents who developed facility-acquired heel wounds. In the first case, a resident admitted for therapy after fracture surgery, with diagnoses including diabetes mellitus with polyneuropathy, was assessed as at risk for pressure ulcers but had no comprehensive care plan addressing this risk. The clinical record lacked weekly skin observations for over a month, and a new pressure injury to the right heel was only documented after this period, by which time the wound had progressed and required advanced interventions, including a wound vac and surgical procedures. In the second case, another resident admitted for therapy after an accident was also assessed as at risk for pressure ulcers but did not have monitoring for skin breakdown prior to the development of a pressure injury. The resident developed a deep tissue injury to the left heel, and although a care plan was created after the ulcer appeared, there were multiple documented instances where prescribed wound treatments were not administered as ordered and not refused by the resident. This included several missed dressing changes over multiple months, as evidenced by gaps in the treatment administration record. Observations and interviews confirmed that wound care orders were not consistently followed, and dressings were not changed as scheduled. The facility's policy required regular skin inspections and adherence to physician orders for wound care, but these were not implemented as documented. The Director of Nursing acknowledged that staff should be following physician's orders as written, but the records and observations indicated otherwise.
Failure to Implement and Document Fall Prevention Protocols for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls were adequately supervised and protected from accident hazards, as evidenced by repeated failures to follow fall protocols, update care plans, and implement or maintain fall prevention interventions. Both residents had extensive histories of falls, with one resident experiencing 23 falls and the other 34 falls within a year. Despite documented high fall risk and multiple interventions listed in their care plans, there were numerous instances where interventions were not in place, such as call lights not being within reach, lack of non-skid footwear, and absence of required safety equipment like dycem or non-skid strips. Observations also revealed that residents were left unattended in their rooms, contrary to care plan instructions. The clinical records for both residents showed significant gaps in documentation and follow-through after falls. Many falls lacked Interdisciplinary Team (IDT) notes, timely updates to care plans with new interventions, and completion of fall risk assessments. In several cases, there was no evidence that the physician or responsible party was notified after a fall, and some falls were only referenced in 72-hour charting notes without details on the circumstances or follow-up. Additionally, some interventions added to care plans after IDT reviews were not observed to be implemented during surveyor observations. Both residents had complex medical histories, including dementia, muscle weakness, repeated falls, and other comorbidities that increased their vulnerability. Despite these risks, the facility did not consistently anticipate or meet their needs, failed to ensure prompt response to call lights, and did not always provide appropriate supervision or assistance with toileting and transfers. The lack of consistent documentation, communication, and implementation of fall prevention strategies contributed to ongoing falls and injuries for these residents.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional care and services for a resident with multiple diagnoses, including dementia, diabetes mellitus, and dysphagia. The resident experienced a significant and unaddressed weight loss, dropping from 179 pounds to 131.7 pounds within a short period, representing a 26.55% decrease. Despite this substantial weight loss, there was no documentation of physician notification, referral to the dietitian, or a nutritional assessment by the dietitian. The care plan identified the resident as being at risk for altered nutritional status, but no updated interventions or reviews were documented in response to the weight loss. The clinical record lacked evidence that the resident was re-weighed after the initial significant weight loss was identified, despite repeated notes from the mental health nurse practitioner highlighting the issue and requesting re-weighs. There was also no documentation of review by the Interdisciplinary Team (IDT) regarding the weight loss. The resident herself reported noticeable weight loss and ill-fitting clothes, yet no action was documented to address her nutritional needs or investigate the cause of the weight loss. Interviews with facility staff, including the DON and MDS Coordinator, confirmed that the weight loss was not properly identified or coded, and that the dietitian did not follow up as required. The facility's own policy required reporting significant weight changes to the physician and dietitian, as well as obtaining re-weights for discrepancies, but these steps were not taken for this resident. The deficiency was identified during a complaint investigation.
Failure to Follow Physician Orders and Document Enteral Nutrition Administration
Penalty
Summary
The facility failed to ensure that physician orders for enteral nutrition were followed and that appropriate documentation and care were provided for a resident receiving tube feedings. Observations over several days revealed that the resident's enteral nutrition was frequently turned off outside of the physician-ordered two-hour break, and feeding equipment, such as syringes, was not changed daily as required. The feeding formula and equipment were observed to be dated from previous days, and the feeding tube was found uncapped and wrapped around the pole when not in use. The resident in question had diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, and dementia, and was dependent on staff for transfers. The care plan required monitoring of caloric intake, and physician orders specified a continuous enteral feeding regimen with specific amounts and times, as well as regular flushing and equipment changes. However, the Medication Administration Record (MAR) showed inconsistent documentation of the amounts of formula administered, with several days lacking complete records or showing significant deviations from the ordered volume. There was also a lack of documentation regarding when the enteral nutrition was turned off or when the resident refused nutrition, except for two documented refusals with physician notification. Facility policies required close monitoring of tube feeding tolerance, intake and output, and prompt documentation of changes in the resident's condition, including refusals and notifications to the physician. Despite these policies, the clinical record did not consistently reflect refusals, changes in feeding administration, or timely notifications to the physician when the resident did not receive the prescribed amount of nutrition. Interviews with the DON and Regional Nurse confirmed that documentation and adherence to physician orders were expected but not consistently followed in this case.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during care for two of three residents observed. In one instance, during incontinence care, a CNA sanitized hands and donned gloves, while an RN only donned gloves. The CNA then gathered supplies with gloved hands, provided care, and applied barrier cream without changing gloves or performing hand hygiene between tasks. The same gloves were used to place barrier cream and to put on a clean incontinence brief, with the CNA wiping the gloved hands inside the clean brief. The RN removed soiled gloves and washed hands after care, but the CNA did not change gloves or perform hand hygiene as required by facility policy. In another instance, during wound care, an RN applied hand sanitizer, donned a gown and gloves, and performed wound care procedures. After removing the gown and gloves, the RN put on a new pair of gloves to apply a heel boot but did not perform hand hygiene during or after the procedure. The facility's policy requires gloves to be changed and hand hygiene to be performed when moving from dirty to clean tasks and after glove removal, which was not followed in these observed cases.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate safety measures during the transfer of a resident, resulting in an accident. Resident B, who has a history of cerebral palsy, knee pain, osteoarthritis, and asthma, was being transferred from her bed to a shower chair using a Hoyer lift. During the transfer, the lift tipped over due to uneven weight distribution, causing the resident to sustain injuries, including a bruised knee and back pain. The incident occurred with only one staff member initially assisting, despite the resident's care plan indicating the need for two staff members for transfers. The incident was further complicated by the improper use of the Hoyer lift. The CNAs involved in the transfer did not follow the correct procedure, which requires the resident's weight to be centered over the base of the lift's legs and the resident to face the attendant operating the lift. Instead, the lift was brought in sideways, and the shower chair was tilted, leading to the lift tipping over. The CNAs attempted to stabilize the situation, but the resident still ended up on the floor, although she did not hit her head. The facility's Director of Nursing confirmed that staff receive training on Hoyer lift use during orientation and at quarterly skills fairs. However, the incident revealed a lapse in following the established procedures for safe transfers. The facility's procedure guide emphasizes the importance of keeping the lift's base spread to its widest position for stability and ensuring the resident faces the attendant, which was not adhered to in this case.
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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