Aperion Care Marion Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Indiana.
- Location
- 614 West 14th Street, Marion, Indiana 46953
- CMS Provider Number
- 155799
- Inspections on file
- 45
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Aperion Care Marion Llc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure the designated Infection Preventionist (IP) had defined, dedicated hours to manage the Infection Prevention and Control Program (IPCP). The DON had served as IP for several years and reported working full-time as DON while addressing infection prevention duties "as needed," with occasional extra hours, and the ADON functioned only as backup for 30 hours per week. The Administrator stated the DON worked many additional hours as IP but could not provide documentation due to the salaried status. Facility documents outlined extensive IP responsibilities, including infection surveillance, antibiotic stewardship, vaccination tracking, rounding, education, and regulatory reporting, and specified that IP hours must be at least part-time and based on the facility assessment, yet there was no evidence of designated IP hours consistent with these requirements.
Surveyors found that a four-compartment steam table in the main dining room was repeatedly left on a high setting, unattended, and accessible, with chains meant to block the cooking area left down. Steam and simmering water were observed in the table’s compartments while multiple dietary staff and a CNA passed by without securing the area. The Dietary Manager and Administrator acknowledged that only dietary and nursing staff were allowed in the cooking area, that steam tables should not be left unattended or on when not in use, and that barriers should be in place when the tables are on. Nine cognitively impaired, independently mobile residents lived on the adjacent halls, and facility policy required steam tables to be continually staffed and never left unattended in areas readily accessible to residents.
A resident receiving Medicare Part A skilled services was transferred to a hospital, then readmitted under Medicare Part A and continued to receive therapy, but when Part A coverage was discontinued, the facility did not issue the required Notice of Medicare Non-Coverage (NOMNC). Documentation confirmed Medicare Part A as the payor and an OT visit shortly before coverage ended, yet there was no record of NOMNC being given to the resident or representative. The Administrator and Financial Coordinator reported that the team had decided to end Part A services while the resident was hospitalized and assumed that, because the resident remained in the facility and was Medicaid pending on readmission, a NOMNC was not needed, and the facility lacked a formal beneficiary notification policy.
A resident with a history of TBI, depression, anxiety, and dementia continued to receive risperidone for depression and later for a delusional disorder despite repeated assessments showing no delusions, hallucinations, or behavioral symptoms and staff and family reporting no such issues. Pharmacy reviews documented that there was no appropriate diagnosis to support antipsychotic use and that risperidone is not indicated for depression, yet the medication was continued with only one gradual dose reduction and later recommendations for further GDR declined or deferred. Although psychiatry suggested non-pharmacological interventions such as cognitive/emotion-oriented therapies, sensory stimulation, and behavior management techniques, the record contained no evidence that these interventions were developed or implemented, contrary to the facility’s psychotropic medication and GDR policy.
Two residents with complex respiratory and cardiac conditions were transferred to the hospital—one for altered mental status and one after becoming unresponsive following administration of lorazepam and oxycodone-acetaminophen—without documented review of the required written transfer/discharge notice and bed-hold policy with them or their representatives. In one case, the record showed notification of the representative and hospital but no evidence that the notice and policy were reviewed; in the other, a form was completed and signed by the Social Services Director indicating the resident was unable to sign, yet there was no documentation that the information was reviewed with the resident or representative. Staff interviews and record review confirmed that the required written notification process, as outlined in facility policy, was not documented for these hospital transfers.
Surveyors found that staff did not consistently complete and sign required shift-to-shift controlled substance counts on two medication carts. Review of controlled drug count sheets for these carts showed multiple dates where day, evening, or night shifts lacked signatures confirming narcotic counts and reconciliation, despite facility policy requiring staff to count controlled substances at the beginning and end of each shift and document the count with a signature, date, and time. Staff, including an LPN, a QMA, and the DON, acknowledged that the narcotic count sheets were incomplete.
A resident with PTSD, bipolar disorder, anxiety, and depression, who was cognitively intact and reported moderate pain and intermittent insomnia, was maintained on amitriptyline and trazodone for depression and sleep while also having a PRN quetiapine order for insomnia carried over from a hospital stay. The care plans for insomnia and mood focused on administering medications and monitoring for causes and side effects, but did not include individualized non-pharmacological interventions or specific documentation of insomnia symptoms related to bipolar disorder. Staff, including an LPN, QMA, and CNA, reported they had not observed significant sleep problems or behaviors, and medication records showed the PRN quetiapine was never administered, yet the NP and DON chose to keep the antipsychotic order in place for insomnia despite quetiapine not being FDA-indicated for that use and facility policy requiring psychotropics only when necessary for a specific condition.
Surveyors observed a cook handling ready-to-eat food with bare hands during a lunch meal service, including picking up rolls by hand to place on plates and using a bare hand to retrieve a portion of mashed potatoes that had fallen onto a pan handle and returning it to the main pan. In subsequent interviews, the cook acknowledged possibly touching bread with bare hands, while the Dietary Manager and DON confirmed staff are not permitted to touch food with bare hands. Review of the facility’s Safe Food Preparation and Handling policy showed it requires strict personal hygiene and prohibits direct bare-hand contact with ready-to-eat foods.
A CNA was observed assisting a resident with a meal tray and repeatedly handling the top bun of the resident’s ready-to-eat fish sandwich with bare hands while serving lunch. The CNA later acknowledged that food should not be touched with bare hands, and the DON confirmed that staff are expected to avoid bare-hand contact with food. The facility’s Safe Food Preparation and Handling policy requires strict personal hygiene and prohibits direct hand contact with ready-to-eat foods, but these requirements were not followed during the observed meal service.
A resident with diabetes, neuropathy, prior toe amputations, and multiple comorbidities developed severe necrotic wounds on the left foot after staff failed to consistently assess and monitor his feet and to implement targeted preventive interventions despite existing skin-impairment and non-compliance care plans. Documentation showed a recent Braden assessment rated him not at risk, weekly skin checks and shower-related assessments either reported no concerns or were incomplete due to refusals, and calloused feet were noted without further action. The resident, who often propelled his wheelchair with his feet and sometimes managed his own footwear, was ultimately found—only after a family member demanded an exam—to have a large necrotic plantar wound and additional darkened areas on the heel and toe, described as facility-acquired abrasions, with the plantar wound appearing trimmed or picked. This failure to recognize risk factors, perform thorough foot assessments per policy, and implement timely preventive measures led to a severely infected diabetic ulcer requiring hospital surgical incision and drainage of a deep tissue abscess and septic arthritis.
A resident with a right hip fracture, decreased mobility, ESRD on dialysis, heart failure, muscle wasting, and gait abnormalities was identified as at risk for pressure injuries and had a care plan for potential skin impairment, but the plan contained only a general directive to minimize pressure over bony prominences and lacked individualized interventions. Although orders included nutritional supplements and skin protectant and policies required frequent skin inspections and use of positioning devices to offload heels, documentation showed inconsistent skin checks during showers and routine care. A Braden assessment confirmed pressure injury risk, and a weekly skin note later described an open area on the right heel. A subsequent wound assessment documented a facility-acquired DTI on the right heel, 100% necrotic and 6 cm by 6 cm, which the ADON stated was first reported by therapy; at that time, pressure relief boots had not been implemented despite facility standards for turning, repositioning, and floating heels.
A resident with multiple chronic conditions and depression was verbally abused and threatened by a dietary aide after attempting to get a drink in the dining room. The aide used profane and intimidating language, escalating the situation and continuing to threaten the resident even after he walked away. The incident was confirmed through staff interviews and documentation, and the aide admitted to the unprofessional conduct, which violated the facility's abuse prevention policy.
The facility failed to follow physician orders for BP and HR parameters when administering antihypertensive medications for two residents. Medications were given outside of ordered parameters or not given when indicated, as shown in medication records and confirmed by staff interviews. Care plans directed staff to administer medications as ordered and monitor for side effects, but these instructions were not consistently followed.
Two residents with histories of smoking and vaping were found with smoking materials in their possession outside the designated area, despite facility policy requiring all smoking items to be turned in to staff. One resident, cognitively intact with multiple diagnoses, was observed carrying cigarettes and a lighter to her room without a smoking care plan or completed risk assessment. Another resident, with significant physical and cognitive impairments, had a vape device in her room and an incomplete smoking assessment, and was not listed among smokers requiring supervision. Facility records and interviews confirmed that required supervision and documentation were not in place.
The facility's Dietary Manager did not possess the required certification for the position, despite being employed in the role and responsible for food service to all residents. Interviews and record review confirmed the manager was not certified and was only preparing to take the certification exam, contrary to the job description's requirements.
Dietary staff failed to perform proper hand hygiene and used bare hands to handle food items during meal service. One employee handled a resident's wheelchair and then food without washing hands, while another touched his face and clothing before handling buns and plates, with his thumb contacting the food portion. The dietary manager confirmed these actions were not in line with expected food safety practices.
The facility did not distribute mail to residents on Saturdays because the BOM, responsible for sorting mail, only worked weekdays. Multiple residents reported not receiving mail on Saturdays, and staff interviews confirmed that mail delivery was limited to days when the BOM was present, despite facility policy requiring delivery Monday through Saturday.
The facility did not provide baseline care plans to residents or their representatives upon admission, as required before the comprehensive care plan was completed. Multiple residents with complex medical conditions were admitted without documentation that they or their representatives received or discussed the baseline care plan, a fact confirmed by staff interviews and record review.
Staff failed to consistently change, label, and date oxygen and nebulizer supplies for several residents, and did not ensure that the correct oxygen flow rates were administered. Observations showed that respiratory equipment was not always changed weekly or properly documented, and some residents received oxygen at rates different from physician orders, with staff unable to verify the correct settings.
Multiple residents reported receiving cold meals, including scrambled eggs, chili dogs, burgers, and French fries, due to delays in meal tray delivery and inadequate temperature monitoring. Staff confirmed that food was often not hot upon arrival and required reheating, and resident council feedback indicated this was a recurring issue, especially with room tray service in the evenings.
A resident who was dependent on staff for all ADLs and had moderate cognitive impairment was required by facility administration to disconnect phone calls with a family member during care, despite the resident and family member's wishes to remain connected for communication support. Staff enforced this practice citing privacy and dignity, but there was no facility policy addressing phone usage during care.
A resident with hypertension and dementia had conflicting code status documentation, with the electronic health record, physician's order, and care plan indicating DNR, while a signed POST form indicated full code status based on the POA's verbal consent. The administrator was unaware of the discrepancy, and the facility failed to ensure accurate and consistent documentation of the resident's advance directives.
A resident with multiple chronic conditions experienced weight gains that exceeded the physician-ordered thresholds for notification, but there was no documentation that the physician or nurse practitioner was informed as required. Nursing staff and the DON confirmed that the necessary notifications were not made or documented.
A resident with severe cognitive impairment and multiple medical conditions was found to be living in a room that was not kept clean or sanitary over several days. Observations revealed overflowing trash, debris and masks on the floor, a dirty bedside table with dried residue, and clothing left on the bathroom floor. Despite facility policies requiring daily cleaning, these tasks were not consistently performed, and the resident's care plan did not indicate any refusal of housekeeping services.
A resident with significant medical conditions and moderate cognitive impairment was not accurately assessed or documented for dental status during the MDS process. Despite having no upper teeth and only three lower teeth, the MDS did not reflect edentulism, and the care plan lacked dental information.
Two residents did not receive care according to physician orders: one was not weighed daily as ordered, and another received antihypertensive medication despite blood pressure readings below the prescribed threshold. Staff interviews confirmed missing documentation and administration outside of parameters, with no facility policy in place for such medication orders.
A facility failed to protect a resident from sexual abuse by an employee, CNA 3, who sent sexually explicit photos to the resident. The resident, who was cognitively intact but had a history of stroke and other conditions, confirmed receiving the photos and had given the CNA $50.00. The facility's DON and Administrator were informed, and CNA 3 was suspended. An investigation revealed attempts by CNA 3 and her husband to take the resident off the premises, which was prevented by staff.
A facility failed to ensure an LPN's active licensure, allowing her to provide resident care with an expired license over several months. The DON indicated that human resources was responsible for tracking licensure, but the oversight led to the LPN working without a valid license, contrary to facility policy.
The facility failed to maintain sanitary conditions in the kitchen and dining areas, affecting all residents who received meals. Observations included improperly stored and soiled dishes, undated food items, and a lack of structured cleaning protocols. Staff interviews revealed uncertainty about cleaning schedules, and the Corporate Regional Dietary Consultant noted the need for more education on food handling and cleaning.
A facility failed to report a resident-to-resident altercation to the State Agency. A resident was hit by another resident with a history of aggressive behavior, resulting in a bruise. The incident, witnessed by staff, was not documented in clinical records or reported as required by facility policy.
A resident with multiple health issues received both hydrocodone-acetaminophen and hydromorphone concurrently on several occasions, despite orders indicating they should not be given together. The MAR showed these medications were administered by an RN, with pain ratings documented as high. The DON confirmed the error, and the deficiency was noted during a complaint investigation.
A facility failed to ensure nursing staff competency in administering controlled medications, as a nurse administered two opioid analgesics together to a resident with multiple diagnoses, including spinal stenosis and diabetes. The resident had physician orders for hydrocodone-acetaminophen and hydromorphone, which were administered together on several occasions despite the DON's indication that they should not be combined. The report referenced increased health risks associated with taking opioids with other drugs.
The facility failed to have a qualified dietary manager supervising kitchen operations for several months, affecting 54 residents who received meals from the kitchen. The Administrator temporarily filled the role, and a new dietary manager was hired with a ServSafe certification. The deficiency was identified due to non-compliance with required qualifications for food and nutrition services management.
Two residents were found with medications in their rooms without proper physician orders or self-administration assessments. One resident had a nasal spray without a physician's order, while another had an ointment and inhaler, with only the inhaler having a proper order. Facility policy requires a 'may keep at bedside' order and assessment, which were missing.
A facility failed to ensure that advance directives were properly signed by a cognitively intact resident, who was their own representative. Despite being the responsible party, the resident's POST form was signed by a representative. Interviews revealed confusion among staff about who was responsible for completing advance directives, and the facility's policy on providing information to capable residents was not followed.
A facility failed to accurately code medications on MDS assessments for a resident with multiple diagnoses, including depression and vascular dementia. The resident was prescribed several medications, but the MDS assessments did not reflect the actual medications received. The MDS coordinator misinterpreted the MAR, believing the resident had refused medications, leading to inaccurate coding. The facility's use of the RAI manual for MDS policy was confirmed, but the failure to follow it resulted in a deficiency.
A resident with multiple health conditions, including diabetes and peripheral vascular disease, developed a pressure injury due to the facility's failure to implement individualized interventions. Despite having a care plan that included turning and repositioning every two hours, the plan lacked specific measures to prevent shearing or skin-to-skin contact. The resident, who preferred to stay in bed, was observed lying on his back with heel boots on multiple occasions, and the facility did not document refusals of care prior to the injury's development.
A facility failed to meet the dietary needs of a dialysis resident, who struggled with eating due to denture issues and inconsistent meal provision. The resident often missed meals before or during dialysis and received cold food upon return. Staff acknowledged inconsistent communication and meal provision, despite the resident's medical history indicating a need for careful nutritional management.
The facility failed to provide prescribed pain medications for two residents, leading to significant deficiencies in pain management. One resident experienced severe pain due to the unavailability of a fentanyl patch, while another resident did not receive hydrocodone-acetaminophen for several days. The facility's staff did not adequately communicate or document the medication shortages, and pain assessments were inconsistent, contributing to the deficiencies observed.
A facility failed to conduct a required AIMS assessment for a resident on Risperdal, despite two requests from a pharmacist. The resident, with multiple psychiatric diagnoses, had not received an AIMS assessment since 5/22/23. The DON was aware of the oversight but could not provide a reason for the missed assessments, leading to non-compliance with the care plan aimed at preventing psychotropic drug-related complications.
A resident with medical conditions including dementia and malnutrition experienced ill-fitting dentures for over three months without timely intervention from the facility. Despite requests from the resident's daughter and multiple notes indicating the need for dental adjustments, the resident was not seen by a dentist until several months later. Observations showed the resident struggled with eating and expressed frustration with the dentures. The facility's policy required prompt referral for dental services, which was not followed, and the MDS Coordinator was unaware of the issue.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with chronic wounds. A resident with a methicillin susceptible staphylococcus aureus infection and chronic wounds was not placed on EBP, lacking signage and PPE at the door, and staff did not wear a gown during wound care. Another resident with a pressure wound had an EBP sign, but the ADON did not wear a gown during care, contrary to facility policy. These actions indicate a deficiency in the infection prevention and control program.
Two residents in the facility did not receive adequate grooming assistance and scheduled showers as required. One resident was observed with dirty fingernails and inconsistent shower documentation, while another was unshaven with overgrown nails despite needing assistance due to limited mobility. Staff interviews revealed inconsistencies in care provision and documentation, contrary to facility policies.
A resident's preference to use a foot pedal for her wheelchair was not honored by the facility, despite her medical condition requiring leg elevation due to swelling and foot drop. The Administrator removed the foot pedal to encourage leg use, disregarding the resident's expressed discomfort and need for elevation.
A resident with an unstageable pressure ulcer on his right heel did not receive the prescribed Santyl ointment for treatment. Instead, an LPN applied medical grade honey, later admitting the error despite having reviewed the physician's order.
The facility failed to ensure that the Administrator completed the required annual resident rights training. During an interview, it was revealed that many inservices had not been opened yet, and employees should have completed the previous year's inservices. The facility's policy mandates annual education for all employees, including training on resident rights, which was not adhered to in this instance.
The facility failed to ensure that required annual abuse training was completed for two employees, specifically the Administrator and an LPN. Employee records indicated that neither had completed their annual abuse training. The Administrator acknowledged that many inservices had not been opened yet and that employees should have completed the previous year's inservices. The facility's policy mandates annual education for all employees, including training on abuse.
Inadequate Designation and Hours for Infection Preventionist Role
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a designated Infection Preventionist (IP) worked the required hours to effectively manage the Infection Prevention and Control Program (IPCP) for all 62 residents. The DON reported in interviews that she had served as the facility’s IP for the past five years and was the person in charge of infection prevention, with the ADON serving as backup. The ADON, who was also certified in infection prevention, worked 30 hours per week. The DON stated she worked 40 hours per week in her DON role and focused on infection prevention during her regular workday as needed, occasionally staying an extra hour or two. The Administrator stated the DON was the primary IP and estimated that she worked approximately 60 hours per week, but could not provide timecards or documentation of the actual hours worked because the DON was salaried. Facility documents showed that the IP job description included extensive responsibilities such as infection surveillance, tracking and trending infections, line listing reports, vaccination tracking, antibiotic stewardship oversight, infection control rounding, performance improvement, occupational health, OSHA respiratory protection oversight, pandemic emergency preparedness, infection control and antibiotic stewardship education, mandatory reporting and communication, regulatory compliance, and participation in the Quality Assurance Committee. Another facility document stated that designated IP hours must be at least part-time and determined by the facility assessment to ensure adequate resources for an effective IPCP, and that facilities should determine if the IP should be dedicated solely to the IPCP. Despite these defined responsibilities and expectations for designated IP hours, the facility did not demonstrate that the DON, as the designated IP, had specific, documented, or dedicated hours allocated to fulfill the IP role as required by the facility’s own guidance and regulatory expectations.
Unattended, Accessible Steam Tables in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment by leaving a four-compartment steam table in the main dining room turned on, unattended, and accessible to residents on multiple occasions. During one observation, the steam table between D and E halls was on the high setting with steam visible from all four compartments, and the chains that were supposed to block off the cooking area were down, allowing direct access to both sides of the steam table. The Dietary Manager stated that the chains should be up after each meal service, that steam tables were turned off after meal service and turned back on about an hour and twenty minutes before each meal so they would be hot, and that only dietary and nursing staff were permitted in the cooking area. At that time, the Dietary Manager reported he had turned on the steam tables 35–40 minutes earlier in preparation for lunch. In a subsequent observation, the same steam table was again found unattended and on the high setting, with steam coming from all four compartments and water simmering in the holding pans, while the chains blocking off the cooking area remained down. Multiple dietary staff members and a CNA walked past the dining room without raising the chains. The Administrator later indicated that steam tables should be turned off when not in use, that dietary staff should turn them on only 15–20 minutes before meals, and that if the steam tables were on, the chains should be up. The Administrator also reported that nine residents on the two halls were cognitively impaired and independently mobile. The facility’s 2020 policy stated that once a steam table is in the serving location and plugged in to maintain food temperatures, it must be continually staffed by an employee and never left unattended in any area readily accessible to residents.
Failure to Provide Required NOMNC at End of Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to provide a Skilled Nursing Facility Notice of Medicare Non-Coverage (NOMNC) to a resident at the end of Medicare Part A–covered services. Review of the SNF Beneficiary Notification Review Forms showed that the resident was admitted under Medicare Part A skilled services with a last covered day of 1/25/26, and that the facility initiated the discharge from Medicare Part A services before benefit days were exhausted. The resident was transferred to a hospital and then readmitted to the facility under Medicare Part A, with documentation on a Therapy Payor Verification Form that Medicare Part A remained the payor source and that the resident received an occupational therapy visit on 1/23/26. Despite the planned discontinuation of Medicare Part A coverage on 1/25/26, there was no evidence that a NOMNC was provided to the resident or the resident’s representative. During interviews, the Administrator stated that the resident readmitted as Medicaid pending and that NOMNCs would typically be discussed 48 hours before discharge, but the facility could not locate any record that the NOMNC was given. The Financial Coordinator reported that the team had discussed discharging the resident from Medicare Part A services while the resident was in the hospital and that, upon readmission, the resident would no longer be considered skilled. The Financial Coordinator did not speak with the resident or the representative about discontinuing Medicare Part A services and assumed that, because the resident remained in the facility and did not discharge home, a NOMNC was not required. In an email, the Administrator also indicated the facility did not have a policy regarding beneficiary notification and that they followed Indiana state regulations.
Unnecessary Antipsychotic Use Without Clinical Indication or Non-Pharmacological Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from chemical restraint through the unnecessary use of an antipsychotic medication without a clear clinical indication and without development and implementation of non-pharmacological interventions. The resident had diagnoses including a history of traumatic brain injury, major depressive disorder, psychotic disorder with hallucinations due to a known physiological condition, early-onset Alzheimer’s disease, and dementia without behavioral disturbance. Physician orders included risperidone 0.25 mg daily for a delusional disorder, lorazepam for anxiety and restlessness, and sertraline for depression. However, a quarterly MDS assessment documented that the resident was severely cognitively impaired but did not exhibit delusions, hallucinations, or behavioral symptoms, and active diagnoses listed only anxiety and depression. The care plan identified antipsychotic use related to depression and anxiety, with goals and interventions focused on monitoring for side effects and consulting pharmacy for possible dose reductions. A PASRR evaluation indicated no history of significant mental illness, and social services documentation stated that the resident’s communication issues were related to TBI, with no acute change in mental status, no indicators of psychosis, and no examples of hallucinations or delusions in the lookback period. Multiple progress notes from psychiatry and behavioral health over many months consistently reported that the resident was calm, cooperative, at baseline, accepting of care and medications, and without reported hallucinations, delusions, or problematic behaviors. Nursing staff and CNAs interviewed stated they had never observed hallucinations, delusions, or behavioral disturbances, describing the resident as calm, quiet, respectful, and generally happy, with only occasional frustration such as yelling or cursing when upset with family phone calls or dropping items. The resident’s representative also reported no awareness of any history of hallucinations or delusions. Despite this, the resident continued to receive risperidone, initially 0.5 mg daily and later reduced to 0.25 mg daily, with the stated indication shifting between depression and delusional disorder. A consultant pharmacist documented in May that there was no appropriate diagnosis in the record to support antipsychotic use and that risperidone was not indicated for depression, recommending discontinuation or addition of a supporting diagnosis; the provider did not respond. Subsequent pharmacy recommendations questioned the documentation of delusional disorder and requested updates to the diagnosis list. Psychiatry notes acknowledged the resident was admitted on risperidone and indicated an intent to gradually reduce and discontinue, but only one gradual dose reduction was performed in December, and later recommendations for further GDR were declined or deferred, sometimes without documented rationale. Although a psychiatry NP suggested various non-pharmacological interventions such as cognitive/emotion-oriented therapies, sensory stimulation, behavior management techniques, and psychosocial interventions, the clinical record lacked documentation that these non-pharmacological approaches were actually developed or implemented. The DON was unable to locate documentation of behaviors, hallucinations, or delusions to support the antipsychotic use, and the facility’s own psychotropic medication policy required that residents not receive psychotropic drugs unless necessary for a specific condition and that GDR and behavioral interventions be used to reduce or discontinue such medications, which was not demonstrated in this case.
Failure to Provide Required Transfer/Discharge Notice and Bed-Hold Information
Penalty
Summary
The deficiency involves the facility’s failure to provide residents and/or their representatives with written notice of transfer/discharge and information on the bed-hold policy when residents were sent to the hospital. For one resident with acute respiratory failure with hypoxia, COPD, chronic kidney disease, and atrial fibrillation, who was documented as cognitively intact, progress notes showed that he was sent to the hospital for altered mental status after becoming difficult to arouse. The record documented attempts and eventual success in notifying the resident’s representative and the hospital, but the clinical record did not contain documentation that the notice of transfer/discharge and bed-hold policy were reviewed with the resident or the representative, as required by facility policy. For another cognitively intact resident with acute and chronic respiratory failure with hypoxia, atrial fibrillation, COPD, and abnormal lung findings, progress notes indicated the resident became unresponsive after receiving lorazepam and oxycodone-acetaminophen, was treated with naloxone, and then sent to the hospital per NP order with the representative present and in agreement. Although a transfer/discharge notice and bed-hold policy form dated the same day was on file, it was marked that the resident was unable to sign and was signed instead by the Social Services Director, with no documentation that the notice and policy were reviewed with the resident or representative. Interviews with LPNs and the DON confirmed that the record lacked evidence of review of the transfer/discharge notice and bed-hold policy for these residents, despite facility policy requiring written notification to residents and their representatives.
Failure to Complete Shift-to-Shift Controlled Substance Counts on Medication Carts
Penalty
Summary
The facility failed to ensure shift-to-shift narcotic counts and reconciliations were consistently completed for controlled substances on two of three medication carts reviewed (D1 Hall and E1 Hall), as required by facility policy and state regulation. During a medication storage observation of the D1 Hall cart with an LPN, review of the Shift Change Controlled Substance Inventory Count Sheet and the Pharmscript Controlled Drug Count Sheets showed multiple dates in April 2026 where day, evening, and night shifts lacked required signatures documenting the controlled substance counts. Similarly, during a medication storage observation of the E1 Hall cart with a QMA, review of the Pharmscript Controlled Drug Count Sheet revealed several dates in April 2026 where evening or night shifts did not have signatures indicating that shift-to-shift controlled drug counts and reconciliations had been performed. The LPN, QMA, and DON acknowledged that the narcotic/controlled substance count sheets were incomplete, despite a current facility policy directing staff to always participate in counting controlled substances at the beginning and end of each shift and to sign, time, and date the completed count. No specific residents, their medical histories, or clinical conditions were identified in the report; the deficiency pertains to incomplete documentation and performance of required controlled substance counts on the medication carts.
Failure to Implement Non-Pharmacological Interventions Before Ordering Antipsychotic for Insomnia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs by not developing and implementing non-pharmacological interventions prior to ordering an antipsychotic medication for insomnia. The resident had diagnoses including PTSD, bipolar disorder, anxiety disorder, and depression, and was cognitively intact on both admission and significant change MDS assessments. These assessments documented that the resident reported trouble falling or staying asleep for 7–11 days in the look-back periods, frequent moderate pain that occasionally affected sleep, and receipt of multiple medications including antidepressants, opioids, and other high-risk drugs. The care plan for insomnia, initiated shortly after admission, listed only general interventions such as administering medications per order and monitoring for causes of insomnia like medications, caffeine, overstimulation, depression, and anxiety, without individualized identification of the resident’s insomnia symptoms related to bipolar disorder or specific non-pharmacological strategies. The resident’s medication regimen included amitriptyline and trazodone for depression and insomnia, and quetiapine, an antipsychotic, ordered as needed for insomnia. Hospital discharge orders on one occasion included quetiapine 25 mg at bedtime daily for insomnia, and on readmission the NP continued quetiapine 25 mg every 24 hours PRN for insomnia for 14 days, in addition to trazodone 50 mg at bedtime for insomnia. The clinical record did not document behaviors related to bipolar disorder that would support antipsychotic use, nor did it show that non-pharmacological interventions were attempted or implemented before adding or continuing quetiapine for insomnia. The care plan for mood fluctuation focused on administering medications and monitoring for side effects and signs of mania or hypomania, but did not address specific behavioral or environmental approaches to manage insomnia. Staff interviews further showed a lack of documented insomnia or behavioral issues that would justify the PRN antipsychotic for sleep. Nursing and QMA staff reported they had not observed the resident having difficulty sleeping or significant behaviors; one LPN described the resident as becoming antsy when medications or call light responses were not immediate, but also noted the resident calmed with listening and conversation. Another CNA reported that prior to a hospital stay the resident occasionally had difficulty sleeping and woke up angry, but since returning had no sleep problems. The medication administration records for the relevant months showed the resident did not receive any doses of the PRN quetiapine. Despite this, the NP and DON discussed and chose to keep the quetiapine order in place after hospital discharge because it had been used in the hospital for insomnia, even though the FDA-approved indications for quetiapine do not include insomnia and the facility’s psychotropic medication policy requires that such drugs only be used when necessary to treat a specific or suspected condition per current standards of practice.
Improper Bare-Hand Contact With Ready-to-Eat Food During Meal Service
Penalty
Summary
Surveyors identified a deficiency in safe and sanitary food handling when a cook handled ready-to-eat food with bare hands during a lunch meal service. During observation, the cook picked up a roll with her bare hand before placing it on a resident’s plate, and later plated three additional rolls for three plates using her bare hand before switching to tongs. The cook also used a scoop to serve mashed potatoes, and when a ping-pong-ball-sized portion fell onto the handle of the stainless-steel pan, she scooped the fallen mashed potatoes off the pan handle with her bare hand and tossed them back into the pan of mashed potatoes. In interviews, the cook acknowledged she could have slipped and touched bread with her bare hands, though she did not recall touching the mashed potatoes, and both the Dietary Manager and the DON stated staff should not touch food with their bare hands. Review of the facility’s Safe Food Preparation and Handling policy, dated 2009, showed it requires strict personal hygiene and that employees avoid direct contact using bare hands with ready-to-eat foods, consistent with 410 IAC 16.2-3.1-21(i)(3).
Failure to Maintain Safe and Sanitary Food Handling During Meal Service
Penalty
Summary
The facility failed to ensure food was served under safe and sanitary conditions when a CNA handled a resident’s ready-to-eat food with bare hands during a lunch meal service. During observation of a noon meal, CNA 9 assisted Resident 49 with his meal tray and was seen grabbing the top hamburger bun from the resident’s fish sandwich with her bare hands before placing the bun on the tray. After picking up a small plastic container of tartar sauce and asking the resident if he wanted any, which he declined, CNA 9 put down the container, again picked up the top bun with her bare hand, and placed it on top of the sandwich before leaving the table. In a subsequent interview, CNA 9 acknowledged that she had touched the resident’s hamburger bun with her bare hands and stated she should not touch any food bare handed. The DON also confirmed in an interview that staff should not touch food with their bare hands. The facility’s current Safe Food Preparation and Handling policy, dated 2009, states that strict personal hygiene will be followed and that employees will avoid direct contact, such as using bare hands, with ready-to-eat foods. These observations and interviews show that staff actions during the meal service did not comply with the facility’s written policy and applicable state regulations regarding safe food handling and infection prevention and control.
Failure to Identify Skin Risk and Prevent Severe Diabetic Foot Wound
Penalty
Summary
The deficiency involves the facility’s failure to identify a resident’s risk for skin breakdown and to develop and implement interventions to prevent the development of significant foot wounds. The resident had multiple diagnoses including vascular dementia, hemiplegia and hemiparesis, type 2 diabetes mellitus, morbid obesity, chronic respiratory failure, chronic heart failure, COPD, peripheral autonomic neuropathy, and prior toe amputations. A quarterly MDS indicated the resident was cognitively intact and at risk for pressure ulcers, with pressure-reducing devices in use. Existing care plans addressed potential for skin impairment and non-compliance with care, but the clinical record did not document that the resident picked at his skin or used implements to cut his skin or wounds. A Braden Scale assessment in January indicated he was not at risk for pressure injuries, and a weekly skin observation on 2/7/26 documented intact skin with no foot concerns. In the days leading up to the discovery of the wound, documentation showed incomplete or limited skin assessments. On 2/13/26, the resident refused a shower, and a nurse’s note indicated he did not feel well enough to shower and signed a refusal form. A shower sheet for that date indicated a full body check was completed with no concerns noted, and a CNA later reported that on that date there were no foot concerns other than a scab where a toe had been amputated, and nothing on the ball of the foot. A late-entry weekly skin observation note for 2/14/26, written on 2/19/26, indicated the resident’s skin was within normal limits but also stated he refused his shower and the skin assessment with the shower, so his feet were not assessed; it also noted he had calloused areas to his feet prior to that date. The facility’s policy required that each resident be observed for skin breakdown daily during care and on the assigned bath day by the CNA, with changes promptly reported to the charge nurse for detailed assessment. On 2/16/26, the resident’s family member approached the nurse’s station demanding that someone examine the resident’s left foot, prompting discovery of multiple wounds. The nurse practitioner and facility nurse found a circular necrotic wound on the plantar surface of the left forefoot measuring 5 cm by 4.5 cm with no depth, with pink granular tissue and peeling skin, a darkened area along the heel, a darkened area along the left third toe nail, and another darkened area with erythema and coolness along the lateral nail and dorsal foot. The plantar wound assessment described a facility-acquired abrasion with 40% pink/red non-granulating tissue and 60% hard, adherent necrotic tissue, and noted it appeared the resident had been picking at the wound and cutting surrounding tissue. A left heel wound assessment documented a facility-acquired abrasion with 100% necrotic tissue. Interviews with staff indicated they had not previously seen the resident with scissors or nail clippers, though the wound appeared trimmed or peeled back when first observed. The failure to identify the resident’s risk factors, consistently assess his feet in accordance with policy, and implement timely preventive interventions resulted in the development of a severely infected diabetic foot ulcer requiring hospitalization and surgical incision and drainage of a deep tissue abscess and septic arthritis in the left foot. Additional observations and interviews highlighted the resident’s mobility patterns and behaviors that were not fully addressed in preventive planning. The resident was very mobile in a wheelchair, often propelling himself with his feet rather than using his hands on the wheels, and he was sometimes able to put on his own socks and shoes. Staff reported he normally wore socks, shoes, non-skid socks, or slippers, and he had a history of picking at scabs, though this behavior was not reflected in the care plan. When the wound was discovered, the nurse practitioner noted the sock was off and the wound looked trimmed. Subsequent notes described the resident as non-compliant with wearing a protective heel boot and continuing to propel his wheelchair with the affected foot. These documented patterns, combined with incomplete foot assessments and lack of documented interventions specific to his known risk factors and behaviors, formed the basis of the cited deficiency for failing to provide appropriate treatment and care according to orders, resident preferences, and goals, and for failing to prevent the development of the wounds.
Failure to Implement Individualized Pressure Injury Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized pressure injury prevention interventions for a resident recovering from a right intertrochanteric femur fracture with decreased mobility and multiple comorbidities, including chronic combined systolic and diastolic heart failure, end stage renal disease on dialysis, muscle wasting, and gait abnormalities. The resident’s admission MDS showed he was cognitively intact, at risk for pressure ulcers, had a surgical wound, used a manual wheelchair, and had pressure-reducing devices for bed and chair. A care plan for potential skin impairment was initiated and included a general intervention to minimize pressure over bony prominences, but the clinical record lacked specific, individualized interventions to prevent or mitigate pressure injuries. Physician orders included several nutritional supplements and a skin protectant every shift, and facility policies required daily skin observation by CNAs and frequent skin inspection during bathing, hygiene, and repositioning, with use of positioning devices to offload heels as indicated. Despite these orders and policies, documentation and staff interviews showed gaps in implementation. A shower sheet documented a full body check on one date, but a subsequent shower sheet lacked documentation of a skin check. A Braden Scale assessment identified the resident as at risk for pressure injuries. A weekly skin observation later noted a small open area on the back of the right heel with treatment in place, and a facility-acquired ulceration assessment documented a deep tissue injury (DTI) to the right heel, first identified earlier in the month, described as 100% necrotic, hard, and measuring 6 cm by 6 cm with no depth. The ADON stated that the DTI was initially reported by therapy, that the resident’s surgical incision was on the same side as the DTI, and that pressure relief boots were not in place when the DTI was noticed, even though facility standards included turning and repositioning every two hours, floating heels, and offloading prominent areas. A physical therapist reported noticing the heel area while applying socks and then reporting it to the nurse, further indicating that the pressure injury was identified through therapy rather than through routine nursing skin assessments and individualized preventive measures.
Resident Subjected to Verbal Abuse and Intimidation by Staff
Penalty
Summary
A resident with diagnoses including COPD, hypertension, depression, atrial fibrillation, and congestive heart failure, who was cognitively intact and required supervision for daily activities, was subjected to verbal abuse and intimidation by a dietary aide. The incident occurred when the resident attempted to get a drink in the dining room and was told by the dietary aide that he was not allowed to do so. An exchange of words escalated, culminating in the dietary aide threatening the resident by stating he would "knock his dumb f****ing a** out." The resident reported that the aide continued to threaten him even after he walked away, and that this was not the first instance of disrespectful behavior from the aide. The facility's records and staff interviews confirmed that the dietary aide admitted to responding in an unprofessional manner and acknowledged the use of threatening language. The dietary manager and administrator were informed of the incident, and the aide was suspended pending investigation. Other staff present did not directly witness the verbal exchange, but one staff member noted the aide appeared visibly upset after the incident. The resident did not have a history of dishonesty, and the aide admitted to previous confrontations with the resident, including yelling at him outside the facility. The facility's abuse prevention policy explicitly prohibits any form of abuse, including verbal abuse and intimidation, and requires immediate reporting of such incidents. The policy defines verbal abuse as the use of language that includes threats of harm or statements intended to frighten a resident. In this case, the dietary aide's actions constituted a violation of the facility's policy and resulted in the resident being subjected to verbal abuse and intimidation.
Failure to Follow Physician Orders for Blood Pressure and Heart Rate Parameters
Penalty
Summary
The facility failed to ensure that physician orders for blood pressure (BP) and heart rate (HR) parameters were followed when administering antihypertensive medications for two residents. For one resident with diagnoses including hypertension, heart failure, and coronary artery disease, physician orders specified holding certain medications if BP or HR fell below set thresholds. Despite these orders, the medication administration records showed that medications such as metoprolol, amlodipine, and losartan were administered on multiple occasions when the resident's BP or HR were below the ordered parameters. The resident's care plans also directed staff to give medications as ordered and monitor for side effects, but these instructions were not consistently followed as evidenced by the documented administration outside of parameters. For another resident with a history of heart disease and hypertension, physician orders required administration of midodrine for systolic BP less than 90. However, the medication administration records indicated that on several occasions when the resident's BP was below this threshold, there was no documentation that midodrine was administered as ordered. The care plan for this resident also included monitoring BP and administering medications for hypertension as ordered, but the records did not reflect compliance with these directives. Interviews with nursing staff and the Director of Nursing confirmed that staff were expected to follow medication parameters and contact providers if there were questions or discrepancies. Despite this, the records demonstrated that medications were either administered when parameters were not met or not administered when indicated, contrary to physician orders. The facility did not have a specific policy on following physician orders, relying instead on federal and state guidelines.
Failure to Prevent Smoking Hazards and Incomplete Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents who smoked or vaped. One resident, who was cognitively intact and had diagnoses including hypertension, COPD, depression, and anxiety, was observed carrying cigarettes and a lighter away from the designated smoking area to her room. Her clinical record did not contain a physician's order for smoking, a completed smoking safety risk assessment, or a smoking care plan, despite documentation that she smoked daily and used smoking materials. The assessment section regarding the storage of smoking materials was incomplete, and there was no evidence that all smoking materials were being locked in the designated area as required by policy. Another resident, with a history of stroke, COPD, and requiring significant assistance with personal care, was found to have a vaping device in her possession in her room. Her clinical record included an order permitting smoking for psychosocial and medical necessity, but lacked a smoking care plan. The smoking safety risk assessment for this resident was incomplete and incorrectly indicated she did not use electronic smoking devices. Interviews revealed that she had not attended supervised smoking breaks for two months, was not listed as a dependent or independent smoker, and that all smoking materials for skilled nursing residents were supposed to be kept at the front desk. Facility policy required all residents to turn in smoking materials to staff, but this was not followed for these two residents.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the required qualifications for the position, specifically lacking the necessary dietary manager certification. The employee record indicated that the Dietary Manager had been employed since February 2025 without obtaining the required certification. Interviews with the Dietary Manager and the Nurse Consultant confirmed that the manager was not certified and was only in the process of preparing for the certification exam. The Dietary Manager reported having twenty years of food service experience but had not previously held the title of dietary manager before this employment. The job description for the position, signed by the Dietary Manager, explicitly required a Food Service Sanitation Manager Certification, which was not possessed at the time of the survey. This deficiency had the potential to impact all 58 residents receiving meals from the facility kitchen.
Failure to Maintain Sanitary Food Handling and Hand Hygiene
Penalty
Summary
During a lunch service observation, dietary staff failed to follow safe and sanitary food handling practices. One dietary employee locked a resident's wheelchair brake and then, without performing hand hygiene, handled tongs to place a lemon slice into a drink and touched the inside of a lemon slice container. This employee also touched the back of another staff member before handling food items, again without hand hygiene. Another dietary employee was observed grabbing hot dog and hamburger buns with bare hands, opening them, and plating them without performing hand hygiene. This employee also touched his waist, lower back, and face, then continued to handle food and plates, with his thumb repeatedly touching the food portion of the plates. Interviews with the employees confirmed these actions, and the dietary manager acknowledged that staff should not touch food or their clothing, glasses, or face without performing hand hygiene.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, as required by facility policy. During a Resident Council meeting, multiple residents reported not receiving mail on Saturdays. The process for mail distribution involved the Business Office Manager (BOM) sorting the mail and then the activity department delivering it to residents. However, the BOM only worked Monday through Friday, resulting in no mail being sorted or distributed on Saturdays. Interviews with the Activity Director and BOM confirmed that mail was only distributed on days when the BOM was present, and the current mail policy stated that mail should be delivered Monday through Saturday.
Failure to Provide Baseline Care Plans to Residents and Representatives Upon Admission
Penalty
Summary
The facility failed to ensure that residents and/or their representatives received a copy of the baseline care plan upon admission, as required prior to the completion of the comprehensive care plan. This deficiency was identified for five residents, each with complex medical histories, whose records lacked documentation that the baseline care plan was provided or discussed at the time of admission. The absence of this documentation was confirmed through both record review and staff interviews. For example, one resident with diagnoses including alcoholic hepatic failure, hepatic encephalopathy, diabetes, anemia, and thrombocytopenia was admitted without evidence that a baseline care plan was given to the resident or their representative. The Social Services Director (SSD) acknowledged that she had not provided the baseline care plan at admission and only met with the representative months later. Similarly, another resident with hypertension, gastroesophageal reflux disease, Charcot's joint, repeated falls, and cellulitis was admitted without documentation of receiving a baseline care plan, which the SSD confirmed had not been provided or discussed. Additional residents with significant health issues such as repeated falls, chronic viral hepatitis C, fractures, stroke sequelae, dysphagia, malnutrition, respiratory failure, heart failure, kidney failure, and cancer were also admitted without documented provision of the baseline care plan. The SSD indicated that she had only recently been educated on the requirement to provide baseline care plans at admission, and prior to this, baseline care plans were not consistently completed or distributed. Facility policy required that residents and/or their representatives receive a summary of the baseline care plan prior to the comprehensive care plan, but this was not followed for the residents reviewed.
Failure to Change, Label, and Date Respiratory Supplies and Ensure Correct Oxygen Flow Rates
Penalty
Summary
The facility failed to properly change, label, and date oxygen and nebulizer supplies for four residents who required respiratory care. Observations revealed that oxygen tubing bags, humidifier bottles, and nebulizer masks were either not changed according to facility policy, not labeled, or not dated as required. For example, one resident's oxygen tubing bag was dated nearly three months prior to the observation, and another resident's oxygen tubing had a date that was altered. Additionally, some residents' respiratory equipment lacked any labeling or dating, and staff interviews confirmed that the required weekly changes and documentation were not consistently performed. Furthermore, the facility did not ensure that residents received the correct oxygen flow rates as ordered by their physicians. In one instance, a resident was observed receiving a higher flow rate of oxygen than prescribed, and staff were unsure of the correct flow rate for that resident. The facility's policy required weekly changes and proper labeling of all respiratory equipment to minimize infection risk and ensure resident safety, but these procedures were not followed for the residents reviewed.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing and safe temperature for 12 of 15 residents reviewed. Multiple residents reported that their food, including items such as scrambled eggs, chili dogs, burgers, and French fries, was consistently served cold or not hot enough. Observations confirmed that meal trays were delivered to units with significant delays, and residents received their food well after the meal carts arrived. Staff interviews corroborated that food was often not hot upon arrival, and CNAs frequently had to reheat meals in microwaves before serving them to residents. Resident council feedback and individual interviews highlighted that the issue was particularly prevalent with room tray meals, especially during the evening meal service. Facility documentation indicated scheduled meal times, but observations showed that the actual delivery and serving of meals did not align with these times, resulting in cold food. The facility's policy required monitoring of food temperatures to ensure palatability and prevent foodborne illness, but this was not consistently followed, as evidenced by the repeated resident complaints and staff admissions.
Failure to Honor Resident's Right to Communication and Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination and communication. A resident with cerebral palsy, obsessive-compulsive disorder, mild intellectual disabilities, fibromyalgia, and mobility impairments was dependent on staff for all activities of daily living and was cognitively moderately impaired. The resident was unable to reposition herself or independently contact her family and relied on staff for assistance. The Administrator and Social Services spoke with the resident about her frequent phone calls to her family member, instructing her that she could not be on the phone during care and that all electronic devices would be shut off while care was provided. The stated reason was to protect the resident's privacy and dignity, and staff would assist the resident in resuming the call after care was completed. Despite the resident and her family member expressing a desire to remain connected by phone, even during care, the facility enforced the policy of disconnecting calls during care. The resident's family member indicated that being on the phone was necessary to help the resident communicate, as she was sometimes difficult to understand. Staff interviews confirmed that the family member was frequently on speaker phone during care, and some staff were not bothered by this, suggesting alternatives such as muting the call or lowering the volume. The facility did not have a policy addressing resident phone usage during care, and the local Ombudsman had suggested hanging up the phone during care for privacy reasons.
Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to maintain an accurate and consistent code status for a resident with a history of hypertension and dementia, who was assessed as moderately cognitively impaired. The resident's electronic health record, current physician's order, and care plan all indicated a Do Not Resuscitate (DNR) status, with documentation that a valid DNR was in place and interventions were aligned with this directive. However, a Physician Orders for Scope of Treatment (POST) form, signed and provided by the administrator, indicated that the resident was actually designated as full code, with instructions for CPR and full interventions, based on verbal consent from the resident's power of attorney (POA). The administrator was unaware of the conflicting information regarding the resident's advance directives, and the POST form was the only signed code status document available for the resident. The facility's policy required that advance directives be documented, maintained in the clinical record, and reviewed during care plan meetings, but this process was not followed, resulting in inconsistent documentation and a failure to honor the resident's or POA's most current wishes regarding code status.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to follow physician orders regarding the notification of a physician or nurse practitioner when a resident experienced significant weight gain. The resident, who had multiple diagnoses including hypertension, type 2 diabetes with neuropathy, chronic kidney disease, and cardiac pacemaker, had a physician order in place to weigh daily and notify the physician if there was a weight gain of three pounds in a day or five pounds in a week. Despite documented weight increases exceeding these thresholds on two occasions, there was no evidence that the physician was notified as required. Interviews with nursing staff and the Director of Nursing confirmed that the expected notifications did not occur and could not be found in the resident's records.
Failure to Maintain Clean and Sanitary Resident Room
Penalty
Summary
Surveyors observed that a resident's room was not maintained in a clean and sanitary condition over several days. The room had an overflowing trash can, trash and masks on the floor, a visibly dirty bedside table with a large area of dried, sticky residue, and a pile of clothing on the bathroom floor. These conditions persisted despite multiple observations on different days, with the same trash, masks, and residue remaining in place. The resident reported that housekeeping only occasionally emptied the trash and swept the floor, and could not recall when the bedside table was last cleaned. Interviews with housekeeping staff confirmed that daily cleaning was required, including vacuuming, mopping, sweeping visible debris, cleaning surfaces, and emptying trash, but these tasks were not consistently performed in this resident's room. The resident involved had significant medical conditions, including Guillain-Barre syndrome, difficulty walking, abnormal gait, COPD, and osteoarthritis, and was assessed as severely cognitively impaired, requiring varying levels of assistance with daily activities. The care plan did not indicate any refusal of housekeeping services. Facility policies required daily cleaning of resident rooms, including work surfaces, furniture, and floors, but these standards were not met in this case, resulting in a failure to provide a safe, clean, and homelike environment for the resident.
Failure to Accurately Assess and Document Resident's Dental Status
Penalty
Summary
The facility failed to accurately assess and document the dental status of a resident during the Minimum Data Set (MDS) assessment process. Observations and interviews revealed that the resident had no upper teeth and only three lower teeth, yet the admission MDS assessment did not indicate that the resident was edentulous or had any tooth fragments. Additionally, the resident's current care plan did not include information regarding their dental status. The resident also reported not having dentures, and direct observation confirmed the absence of upper teeth and the presence of only three lower teeth. The resident's clinical record showed diagnoses including malignant neoplasm of the stomach, gastric ulcer, unspecified cirrhosis of the liver, and major depressive disorder. The MDS assessment noted moderate cognitive impairment and a need for partial to moderate assistance with eating. Despite these findings and the resident's self-reported dental condition, the facility did not accurately document or assess the resident's oral health status as required by the Resident Assessment Instrument (RAI) guidelines.
Failure to Follow Physician Orders for Weight Monitoring and Medication Parameters
Penalty
Summary
The facility failed to follow physician orders for two residents regarding daily weight monitoring and administration of blood pressure medication according to specified parameters. For one resident with multiple diagnoses including hypertension, diabetes, chronic kidney disease, and cardiac issues, there was a physician order to obtain daily weights and notify the physician if certain weight gains occurred. However, the medication administration record showed that weights were not recorded for 11 out of 28 days, and staff interviews confirmed the missing documentation and inability to locate the required weights. For another resident with heart failure, COPD, chronic respiratory failure, hypertension, and dementia, there was an order for carvedilol to be held if the systolic blood pressure was below 120 mmHg. Despite this, the medication administration record indicated that the resident received carvedilol on multiple occasions when her systolic blood pressure was below the ordered threshold. Staff interviews confirmed that the medication was administered outside the prescribed parameters, and the facility did not have a specific policy regarding medication administration by parameters, relying instead on state guidelines.
Failure to Protect Resident from Sexual Abuse by Employee
Penalty
Summary
The facility failed to protect a resident from sexual abuse by an employee, CNA 3, who engaged in inappropriate behavior with Resident B. The incident involved CNA 3 sending sexually explicit photos to Resident B, who was cognitively intact but had a history of stroke, seizures, mild vascular dementia, and major depression. The inappropriate photos were discovered when another CNA assisted Resident B with his phone, leading to the discovery of the images. Resident B confirmed receiving the photos and expressed no concerns about the relationship, although he had given CNA 3 $50.00, which he claimed was not for the photos. The facility's Director of Nursing (DON) and Administrator were informed of the situation, and CNA 3 was suspended pending an investigation. The investigation revealed that CNA 3 and her husband attempted to take Resident B off the premises, but facility staff intervened. The facility's policy on abuse prevention and reporting was reviewed, which defines abuse as the willful infliction of harm, including through technology. The investigation file included staff statements, copies of the photos, and interviews with other residents. CNA 3's employee file showed she had completed training on abuse, neglect, and exploitation prior to the incident.
Expired Nursing License Overlooked
Penalty
Summary
The facility failed to ensure the active licensure of a Practical Nurse (PN) who provided care to residents. During a review of employee records, it was discovered that the PN's nursing license had expired, as indicated on the MyLicense.IN.gov website. Despite the expiration, the PN continued to work and provide resident care on multiple dates across three months. During an interview, the Director of Nursing (DON) stated that human resources was responsible for tracking staff licensure, and the facility was unaware of the expired license, allowing the PN to continue working. The facility's policy required staff to have valid licensure to provide resident care, which was not adhered to in this instance.
Facility Fails to Maintain Sanitary Kitchen and Dining Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dining areas, affecting all 59 residents who received meals from the facility kitchen. During a kitchen tour, numerous issues were observed, including an open bag of sugar with unknown particles, clean dishes stored improperly, and visibly soiled carts and utensils. Additionally, there were issues with food storage, such as undated and open food items, and the presence of trash and dried spillage on floors and equipment. The facility lacked a cleaning schedule, and staff were unsure of the last time the kitchen was thoroughly cleaned. Interviews with staff revealed a lack of structured cleaning protocols, with employees attempting to clean as needed without a formal schedule. The Corporate Regional Dietary Consultant acknowledged the need for more education on food handling and cleaning. The facility's policies on handling leftover food, cleaning rotation, and food storage were not being followed, contributing to the unsanitary conditions. This deficiency was related to complaints IN00448904 and IN00448992.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the State Agency, as required by their policy. During an interview, a resident, identified as Resident F, reported being hit in the chest by another resident, identified as Resident G, while attempting to enter the dining room. Resident G, who has a history of verbally aggressive behaviors and diagnoses including depression, dementia, anxiety, schizoaffective disorder, and hypertension, was blocking the entryway and became aggressive when asked to move. Resident F responded by hitting Resident G, and there were staff witnesses to the incident. However, the clinical records for both residents lacked documentation of behavioral concerns related to this incident. The Corporate Regional President of Operations acknowledged during an interview that the incident was not reported to the State Agency, although it should have been. The facility's current policy on Abuse Prevention and Reporting requires that any allegations of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property be reported to the Department of Public Health and local law enforcement, especially in cases of physical abuse involving injury inflicted by one resident on another. This incident was related to a complaint identified as IN00449266.
Significant Medication Error: Concurrent Opioid Administration
Penalty
Summary
The facility failed to prevent a significant medication administration error involving a resident with multiple diagnoses, including cervical region spinal stenosis, type 2 diabetes, muscle wasting and atrophy, abnormalities of gait and mobility, and depression. The resident had physician orders for hydrocodone-acetaminophen and hydromorphone, both opioid analgesics, to be administered as needed for pain. However, the Medication Administration Record (MAR) for October 2024 showed that these medications were administered together on multiple occasions by RN 1, despite the Director of Nursing (DON) indicating that they should not be given concurrently. The MAR indicated that on four separate occasions, RN 1 administered both hydrocodone-acetaminophen and hydromorphone to the resident, with documented pain ratings ranging from 8 to 10 out of 10. The administration of these medications together raised the likelihood of harm, as noted in a National Institute on Drug Abuse article, which highlighted the increased health risks and potential for overdose when opioids are taken with other drugs. RN 1 was unavailable for interview during the survey, and the deficiency was related to a complaint investigation.
Incompetent Administration of Opioid Analgesics
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the administration of controlled medications, as evidenced by a registered nurse (RN 1) administering two opioid analgesics together to a resident (Resident B). The clinical record for Resident B, who had diagnoses including cervical region spinal stenosis, type 2 diabetes, muscle wasting and atrophy, abnormalities of gait and mobility, and depression, was reviewed. Physician orders for October 2024 indicated that Resident B had an order for hydrocodone-acetaminophen 10-325 mg every 6 hours as needed for pain, and an order for hydromorphone 4 mg every 4 hours as needed for severe pain. Both orders were active from 10/10/24 to 10/18/24. The Medication Administration Record (MAR) for October 2024 showed that RN 1 administered both hydrocodone-acetaminophen and hydromorphone to Resident B on multiple occasions, despite the Director of Nursing (DON) indicating that these medications should not be given together. Specifically, RN 1 administered both medications on 10/12/24, 10/13/24, and 10/17/24, with documented pain ratings ranging from 8 to 10 out of 10. The report also referenced a National Institute on Drug Abuse article highlighting the increased health risks associated with taking opioids with other drugs, including the risk of overdose. RN 1 was unavailable for interview during the survey.
Deficiency in Dietary Management Staffing
Penalty
Summary
The facility failed to ensure a qualified dietary manager was supervising the kitchen staff and operations, which had the potential to affect 54 of 55 residents who received meals from the facility kitchen. Interviews revealed that the kitchen had been without a manager for six to seven months, and the Administrator was temporarily filling in as the dietary manager. Employee records confirmed the absence of a dietary manager, and the Head of the kitchen was not certified as a dietary manager, although discussions about certification were ongoing. The dietician visited the facility about three times a month, and one resident received nutrition through a feeding tube, while the remaining 54 residents received meals and snacks from the kitchen. A new dietary manager was hired and started on June 24, 2024, but the facility had been without a dietary manager for several months prior. The newly hired dietary manager had a ServSafe food production manager certification, which would expire in August 2025. The Indiana Department of Health Long-term Care Newsletter outlined the qualifications required for a director of food and nutrition services, which the facility had not met during the period without a dietary manager. The deficiency was identified as a failure to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service.
Failure to Obtain Physician Orders and Assessments for Self-Administration of Medications
Penalty
Summary
The facility failed to obtain physician orders and conduct assessments for self-administration of medications for two residents who had medications stored in their rooms. Resident 52 was observed with a mometasone furoate nasal spray on her bedside table, which she self-administered without a physician's order or a self-administration assessment. Interviews with LPNs and the DON confirmed that residents should not have medications in their rooms without a 'may keep at bedside' (MKABS) order and a completed assessment, which were missing in this case. Similarly, Resident 35 had a tube of nystatin triamcinolone ointment and an albuterol sulfate inhaler in her room. While there was a physician's order for the inhaler, there was no order for the ointment, and the clinical record lacked a self-administration assessment for both medications. The facility's policy requires a written order from the attending physician and a self-administration assessment before residents can retain medications in their rooms, which was not adhered to in these instances.
Failure to Ensure Proper Signing of Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were properly developed and signed by a cognitively intact resident, identified as Resident 35, who was their own representative. The resident's clinical record indicated diagnoses of unspecified adrenocortical insufficiency, epilepsy, and cirrhosis of the liver. Despite being cognitively intact, as noted in the Minimum Data Set assessment, the Indiana Physician Orders for Scope of Treatment (POST) form was signed by the resident's representative instead of the resident themselves. The resident's profile confirmed that they were the responsible party and health care decision maker, with no documentation of a guardian, healthcare representative, or power of attorney. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of advance directives. The Director of Nursing (DON) was uncertain why the POST form was signed by the representative, and the Social Services Director indicated that the nursing department was responsible for ensuring the completion of advance directives. The Administrator and Business Office Manager (BOM) also expressed uncertainty about who completed the advance directives, with the BOM confirming the absence of documentation for a guardian or healthcare representative. The Assistant Director of Nursing (ADON) mentioned that the resident was emotional upon admission, which might have led to the representative signing on their behalf. The facility's policy stated that advance directive information should be provided to the resident once they are capable of understanding and making decisions, but this was not adhered to in this case.
Inaccurate Medication Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately code medications on the Minimum Data Set (MDS) assessments for a resident reviewed for medication use. The resident, who had diagnoses including depression, delusional disorders, hallucinations, vascular dementia with agitation, and atherosclerotic heart disease, was prescribed several medications, including clopidogrel bisulfate (an antiplatelet), mirtazapine and sertraline (antidepressants), and risperidone (an antipsychotic). However, the MDS assessments for February and May did not accurately reflect the medications the resident received. The February assessment incorrectly indicated the resident received insulin but did not note the antidepressants or antiplatelet, while the May assessment failed to indicate the resident received an antipsychotic, antidepressants, or an antiplatelet. The MDS coordinator, during an interview, acknowledged reviewing the Medication Administration Record (MAR) but mistakenly believed the resident had refused medications during the assessment windows. The MAR showed that the resident had indeed received the medications during the specified periods. The facility's President of Operations confirmed the use of the Resident Assessment Instrument (RAI) manual for MDS policy, which requires coding all high-risk drug class medications according to their pharmacological classification. The failure to accurately code the medications on the MDS assessments led to the deficiency identified by the surveyors.
Failure to Prevent Pressure Injury Due to Inadequate Individualized Care Plan
Penalty
Summary
The facility failed to implement interventions to prevent the development of a pressure injury for a resident who was reviewed for pressure injuries. The resident, who was cognitively intact, had multiple diagnoses including methicillin susceptible staphylococcus aureus infection, peripheral vascular disease, and diabetes mellitus with neuropathy. The resident required substantial assistance for activities of daily living and was observed lying on his back in bed with heel boots on multiple occasions. Despite having a care plan that included interventions such as turning and repositioning every two hours, the plan lacked individualized interventions specific to avoiding shearing or skin-to-skin contact. The resident's clinical record indicated a history of an unstageable wound to the right heel, which was related to the disease process and immobility. The care plan included interventions like administering treatments as ordered, floating heels, and using pressure relief boots. However, the facility's documentation lacked evidence of resident refusals of care prior to the development of the pressure injury. Interviews with staff revealed that the resident preferred to stay in bed and was resistant to getting up, which was not adequately addressed in the care plan. The facility's policy on pressure ulcer prevention required turning dependent residents approximately every two hours and encouraging residents to change positions to promote circulation. However, the facility failed to document and implement individualized interventions for the resident's condition and preference to stay in bed, leading to the development of a pressure injury. The deficiency was identified through observations, interviews, and record reviews conducted by surveyors.
Failure to Address Dietary Needs for Dialysis Resident
Penalty
Summary
The facility failed to adequately address the dietary needs of a dialysis resident, identified as Resident 28, who was observed to have impaired nutrition. During multiple observations, it was noted that the resident struggled with eating due to issues with his dentures and the lack of condiments on his meal trays. On one occasion, the resident ate less than 25% of his meal and expressed difficulty eating with his dentures. Additionally, the resident reported not receiving lunch before or during dialysis sessions, which occurred three times a week, and often received cold food upon returning to the facility. The facility staff, including CNAs and the DON, acknowledged that the resident was sometimes offered an early lunch tray before dialysis or food upon return, but this was not consistently done. The resident was observed to return from dialysis without being checked on or offered food until dinner, which could be delayed. Interviews with staff revealed that there was no consistent communication between ambulance staff and facility staff regarding the resident's return from dialysis, leading to delays in providing meals or snacks. The resident's clinical record indicated a history of chronic kidney disease, dependence on dialysis, and protein-calorie malnutrition, with a care plan in place to monitor and maintain his nutritional intake. Despite this, there were inconsistencies in meal documentation, particularly on dialysis days, and a significant weight fluctuation was noted in the resident's weight history. The facility's agreement with the dialysis center required ensuring residents received proper nourishment before dialysis, which was not consistently met for Resident 28.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide pain medications as ordered for two residents, Resident 22 and Resident 108, leading to significant deficiencies in pain management. Resident 22, who had a history of chronic pain syndrome and opioid dependence, was observed in distress due to the unavailability of his prescribed fentanyl patch. Despite the resident's complaints of severe pain, rated as high as 10 on a 0-10 scale, the facility did not apply the fentanyl patch on multiple occasions due to supply issues. The facility's staff failed to notify the medical provider of the unavailability of the medication in a timely manner, and there was a lack of documentation regarding attempts to address the issue or provide alternative pain management solutions. Resident 108, who was admitted with a prescription for hydrocodone-acetaminophen for moderate pain, also experienced a lapse in pain management. The resident reported not receiving pain medication for several days, despite experiencing significant pain levels. The facility's records showed inconsistencies in pain assessments, and the resident indicated that pain levels were only addressed when he requested medication. The facility failed to maintain an adequate supply of the prescribed medication and did not ensure consistent pain assessments as ordered by the physician. Interviews with facility staff revealed a lack of communication and documentation regarding the unavailability of medications and the steps taken to address these issues. The Director of Nursing (DON) and other staff members were aware of the medication shortages but did not document their communications with the medical provider or take sufficient action to ensure the residents received appropriate pain management. The facility's policies on pain management and medication orders were not effectively implemented, contributing to the deficiencies observed.
Failure to Conduct Required AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to follow pharmacy recommendations for a resident who was receiving the antipsychotic medication Risperdal. The resident, diagnosed with schizophrenia, major depressive disorder, unspecified intellectual abilities, and anxiety disorder, was noted to be cognitively intact and required substantial to maximal assistance for activities of daily living. A pharmacist recommended a gradual dose reduction and highlighted the need for an AIMS (abnormal involuntary movement scale) assessment, which was overdue. The last AIMS assessment was conducted on 5/22/23, and despite two requests from the pharmacist, no subsequent assessment was completed. The Director of Nursing (DON) acknowledged awareness of the pharmacist's requests and confirmed that the last AIMS assessment was indeed performed on 5/22/23. However, the clinical record lacked documentation of any AIMS assessment after this date. The DON was unable to provide a reason for the missed assessments, indicating a lapse in following the established guidelines for monitoring residents on psychotropic medications. This oversight resulted in the facility's failure to ensure the resident remained free of psychotropic drug-related complications as outlined in the care plan.
Failure to Provide Prompt Dental Services for Ill-Fitting Dentures
Penalty
Summary
The facility failed to provide prompt dental services for a resident with ill-fitting dentures, leading to a deficiency. The resident, who had medical diagnoses including unspecified protein-calorie malnutrition, anemia in chronic kidney disease, and unspecified dementia, was noted to have no natural teeth and was on a regular diet with specific restrictions. Despite a care plan initiated in 2021 to prevent oral/dental complications, the resident's ill-fitting dentures were not addressed in a timely manner. The resident's daughter had requested dental services as early as November 2023, but the resident was not seen by a dentist until June 2024, despite multiple notes indicating the need for dental adjustments. Observations and interviews revealed that the resident struggled with eating due to the ill-fitting dentures and expressed frustration by throwing them away. A nurse noted the resident's refusal to wear the dentures because they had not fit for over three months. The facility's policy required prompt referral for dental services within three business days of identifying damaged dentures, but this was not adhered to. The MDS Coordinator was unaware of the issue, indicating a lack of communication within the facility's interdisciplinary team. The resident's representative confirmed that the facility had been aware of the issue since October 2023, yet no adjustments were made until June 2024.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection prevention strategies related to enhanced barrier precautions (EBP) for two residents. Resident 53, who had a methicillin susceptible staphylococcus aureus infection and chronic wounds, was not placed on EBP despite having a surgical wound and an unstageable pressure injury. Observations revealed that there was no signage or personal protective equipment (PPE) available at the resident's door, and staff did not apply a gown during wound care. Interviews with staff indicated a lack of awareness regarding the need for EBP for Resident 53, and the Director of Nursing (DON) confirmed that the resident should have been on EBP due to the chronic nature of the wounds. Resident 44, who had a pressure wound to the coccyx, was observed with an EBP sign on the door and a PPE cart outside the room. However, during wound care, the Assistant Director of Nursing (ADON) did not wear a gown, which was required as per the facility's policy for residents on EBP. The facility's policy indicated that EBP should be employed for residents with chronic wounds during high-contact activities, including wound care. The failure to adhere to these precautions for both residents highlights a deficiency in the facility's infection prevention and control program.
Failure to Provide Adequate Grooming and Shower Assistance
Penalty
Summary
The facility failed to provide adequate grooming assistance and scheduled showers for two residents, identified as Resident C and Resident D, who were reviewed for activities of daily living (ADLs). Resident D was observed with dirty fingernails on multiple occasions, and her clinical records indicated a need for substantial assistance with personal hygiene. Despite the care plan interventions, there was a lack of documentation for refusals of care, and the resident's showers were not consistently documented. Interviews with staff revealed inconsistencies in the provision of care and documentation practices. Resident C was observed to be unshaven and with overgrown fingernails on several occasions. His clinical records showed a need for maximal assistance with personal hygiene due to limited mobility from a stroke. Despite this, there were no documented refusals of care, and the resident expressed a need for help with shaving and nail care. Staff interviews indicated that shaving was typically done on shower days, but there were inconsistencies in the frequency and documentation of these activities. The facility's policies required showers to be offered twice a week and nail care to be provided with showers and as needed. However, the observations and interviews highlighted a failure to adhere to these policies, resulting in unmet personal hygiene needs for the residents. The documentation did not reflect any refusals of care, suggesting a gap in communication and record-keeping among the staff.
Failure to Honor Resident's Preference for Wheelchair Foot Pedal
Penalty
Summary
The facility failed to honor a resident's preference to utilize a foot pedal for her wheelchair, which was necessary due to her medical condition. Resident C had a history of a broken right leg, swelling, and foot drop, which made it difficult for her to flex her foot toward her knee. Despite her need to elevate her leg to reduce swelling, the Administrator removed the right foot pedal from her wheelchair, stating it was a therapy intervention to encourage the resident to use her leg more. This action was taken without considering the resident's expressed discomfort and need for elevation due to swelling. Interviews with Resident C and the Physical Therapist revealed that while Resident C was full weight-bearing, she experienced pain and swelling in her leg, which limited her mobility. The Physical Therapist acknowledged that Resident C had good potential for improvement but was self-limiting due to her pain and swelling. The facility's policy on Resident Rights emphasized the importance of autonomy and choice for residents, which was not upheld in this case. The deficiency was related to a complaint investigation, indicating a failure to respect the resident's rights and preferences regarding her care and mobility needs.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure competent treatment for a pressure injury was completed according to physician's orders for one resident. Resident D, who had a diagnosis of methicillin susceptible staphylococcus aureus infection, type 2 diabetes mellitus with diabetic neuropathy, and peripheral vascular disease, had an unstageable pressure ulcer on his right heel. The physician's orders specified the use of Santyl ointment for enzymatic debridement. However, during a wound care observation, an LPN applied medical grade honey instead of Santyl. The LPN later acknowledged the mistake, stating he had no idea why he used the wrong treatment despite reviewing the order beforehand.
Failure to Complete Annual Resident Rights Training
Penalty
Summary
The facility failed to ensure that annual resident rights training was completed for the Administrator, as required by their policy. Employee records reviewed indicated that the Administrator had not completed the necessary training. During an interview, the Administrator, with the Nurse Consultant present, acknowledged that many inservices had not been opened yet and that employees should have completed the previous year's inservices. The facility's policy mandates annual education for all employees, including training on resident rights, which was not adhered to in this instance. This deficiency was identified during a complaint investigation.
Failure to Complete Annual Abuse Training
Penalty
Summary
The facility failed to ensure that required annual abuse training was completed for two employees, specifically the Administrator and an LPN. Employee records reviewed indicated that neither the Administrator nor the LPN had completed their annual abuse training. During an interview, the Administrator acknowledged that many inservices had not been opened yet and that employees should have completed the previous year's inservices. The facility's policy, dated 10/1/22, mandates annual education for all employees, including training on abuse. This deficiency was identified during a complaint investigation.
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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