Auburn Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Indiana.
- Location
- 1751 Wesley Road, Auburn, Indiana 46706
- CMS Provider Number
- 155666
- Inspections on file
- 33
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Auburn Village during CMS and state inspections, most recent first.
A resident with anxiety, depression, and respiratory failure experienced respiratory distress and urgently requested ADL assistance. A CNA reported the resident's breathing difficulty to an RN, who responded dismissively and refused to check on the resident. The CNA relayed this response to the resident, who became further distressed. Facility policy required staff to treat residents with dignity and respect, but this was not followed during the incident.
Surveyors observed multiple lapses in kitchen cleanliness, including unclean equipment, improper food labeling, and staff not restraining hair, with 70 residents consuming food prepared in these conditions. Staff and the Dietary Manager acknowledged the issues, which were not in line with facility policies for cleaning and food labeling.
A resident who was cognitively intact and required assistance with eating requested to dine in the main dining room for increased socialization, but was repeatedly seated in the assisted dining room despite expressing his preference. Staff cited dignity and safety concerns, though the resident was comfortable with assistance in public and had no documented safety or swallowing issues. The care plan and facility actions did not reflect the resident's choice, contrary to facility policy requiring respect for resident wishes.
A resident with chronic pain and frequent pain episodes interfering with sleep was not offered or documented to have received non-medication pain interventions as ordered by the physician prior to administration of PRN pain medications. Despite clear orders and facility policy, nursing staff did not document or provide these interventions, and the care plan lacked specific non-pharmacological strategies.
A resident with muscular dystrophy and pain requested massage therapy for discomfort, but despite repeated requests and documentation of need, the service was not provided in a timely manner. Staff were unclear about responsibility for arranging massage therapy, and the resident's care plan did not address this intervention, resulting in the resident not receiving the specialized rehabilitative service.
A resident with severe cognitive impairment and multiple mobility-limiting diagnoses was observed with wrist contractures and reported limited hand use. Although the care plan required daily ROM exercises, there was no documentation in the MAR, TAR, or aide task sheets that these were provided. The DON confirmed ROM was not documented or tracked due to the lack of a restorative program and policy.
The facility failed to follow public health recommendations during a Legionella outbreak investigation, affecting a resident who tested positive for Legionnaires' disease. Despite IDOH's advice to remove showers from service and use bottled water, the facility continued using showers due to resident preferences and did not install recommended filters. Staff lacked training on Legionella, and residents were not informed of the risks.
A facility failed to identify and address the underlying causes of distress in a resident with a history of childhood sexual trauma. The resident exhibited behaviors such as nonsensical speech, aggression, and inappropriate comments, but the care plans lacked specific strategies for managing these issues. Interviews with staff revealed that while the resident denied specific triggers, the facility did not adequately use observations to identify potential stressors, leading to insufficient individualized care.
Failure to Provide Dignified and Respectful Care During Resident Distress
Penalty
Summary
A deficiency occurred when staff failed to ensure respectful and dignified communication and care for a resident with anxiety, depression, and respiratory failure, who was cognitively intact and dependent on a tracheostomy and ventilator. The resident's care plan included interventions for anxiety and guidance for staff to use calm, consistent communication with firm boundaries. On the day in question, the resident experienced respiratory distress and expressed urgent needs for assistance with activities of daily living (ADLs). A CNA observed the resident appearing to have difficulty breathing and reported this to an RN, who responded that they did not care and refused to check on the resident. The CNA relayed this dismissive comment to the resident, further impacting the resident's emotional state. Progress notes indicated the resident was demanding immediate care, refused assistance from an available aide, and became upset when their needs were not met promptly. The RN, along with another nurse and a respiratory therapist, remained at the nurses' station and did not immediately respond to the CNA's concerns. The respiratory therapist eventually went to the resident after a delay. The resident reported feeling anxious, crying, and experiencing rapid breathing during the incident. Facility policy required staff to treat residents with dignity, respect, and sensitivity, especially during intimate care tasks, but this standard was not upheld in this instance.
Failure to Maintain Kitchen Cleanliness and Food Safety Standards
Penalty
Summary
The facility failed to maintain kitchen cleanliness and adhere to food safety protocols, as evidenced by multiple observations. Moisture was found in two out of three pans on the drying rack, and the stand mixer in the cooking and clean storage area had yellow particles and discoloration on its bowl, paddle, and main unit. An unlabeled fruit cup with a red liquid puddle was found in the mini fridge, and an employee was observed with unrestrained hair while working in the kitchen. Additionally, a food processor lid was placed right side up on a toaster with visible crumbs and dry brown particles, resulting in food and liquid transfer from the processor to the toaster. Brown stains and a dry, round, white food-like substance were also observed in the dining room near the coffee maker. Interviews with the Dietary Manager and staff confirmed awareness of these issues, including the need for hair restraints and proper cleaning and storage of kitchen appliances. The Dietary Manager indicated that 70 of 81 residents consumed food prepared in the facility's kitchen. Facility policies require proper cleaning of small appliances and labeling of food items, but these procedures were not consistently followed, contributing to the deficiency.
Failure to Honor Resident Dining Location Choice
Penalty
Summary
The facility failed to honor a resident's right to choose their dining location, despite the resident's clear and repeated requests. Observations showed the resident consistently seated in the assisted dining room with staff providing eating assistance. The resident, who is cognitively intact with a BIMS score of 15 and requires assistance with eating due to muscular dystrophy, expressed during a resident council meeting and in interviews that he wished to dine in the main dining room to increase socialization. Staff interviews confirmed that the resident's preference was communicated, but the Activities Director informed him he could not eat in the main dining room due to a perceived dignity issue, as directed by the Administrator and corporate staff. The resident stated he was comfortable receiving assistance in front of others. The Director of Nursing later cited safety concerns as the reason for the resident's placement in the assisted dining room, but did not specify any safety issues that could not be managed in the main dining room. The resident's care plan was updated to require all meals in the assisted dining room, but did not address his choice of dining location. Medical records indicated no swallowing or chewing problems, and the resident was on a regular diet. Facility policy requires resident wishes to be respected, but this was not followed in this case.
Failure to Implement Non-Medication Pain Interventions as Ordered
Penalty
Summary
The facility failed to implement non-medication pain interventions as ordered by the physician for a resident with chronic pain syndrome, low back pain, right leg pain, and polyneuropathy. The resident, who was cognitively intact, experienced frequent pain that interfered with sleep and was prescribed both pharmacological and non-pharmacological pain management strategies. Physician orders specifically required that non-medication pain interventions be offered prior to administering PRN pain medications. However, review of the resident's Medication Administration Record (MAR) and nursing notes showed that non-pharmacologic interventions were not documented or offered prior to the administration of PRN pain medications, despite the resident receiving Norco for moderate to severe pain on multiple occasions. Interviews with nursing staff and the DON confirmed that non-medication pain interventions were expected to be documented in the MAR when PRN pain medications were given, but this was not done for the resident in question. The DON also acknowledged that the resident's care plan did not specify non-medication pain interventions, even though such interventions were included in the physician's orders. The facility's pain management policy indicated that both pharmacological and non-pharmacological interventions may be implemented, but the required non-medication interventions were not provided or documented for this resident.
Failure to Provide Requested Massage Therapy for Resident with Muscular Dystrophy
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services, specifically massage therapy, were provided as required for a resident diagnosed with muscular dystrophy and major depressive disorder. The resident, who was cognitively intact and had limitations in range of motion in both upper extremities, repeatedly expressed his desire for massage therapy to address discomfort and pain. He communicated this need to staff and during a Resident Council meeting, and it was noted in progress notes that he had previously benefited from massage therapy. Despite a progress note indicating a referral to Physical Therapy for ultrasound and massage therapy, there was no corresponding physician order for physical therapy, and the resident was not evaluated for massage therapy until several weeks after his initial request. The care plan for the resident addressed pain management but did not include interventions related to massage therapy or range of motion relief. Staff interviews revealed confusion regarding responsibility for providing massage therapy, with the DON indicating Occupational Therapy was handling it, while the Director of Therapy confirmed the resident had not been evaluated for massage therapy until prompted by the survey. Additionally, the resident's request for transportation to receive massage therapy at the VA hospital was not facilitated, and his inquiries were not consistently communicated among staff. The lack of timely assessment and provision of the requested rehabilitative service resulted in the resident not receiving massage therapy as required.
Failure to Provide and Document Range of Motion Care for Resident with Contractures
Penalty
Summary
A resident with diagnoses of rheumatoid arthritis, Parkinson's Syndrome, and Alzheimer's was observed to have contractures in both wrists and reported limited use of their hands, which prevented participation in activities. The resident's care plan identified limited mobility and contractures, with a goal to prevent further immobility complications and an intervention for daily gentle range of motion (ROM) exercises as tolerated. Despite these documented needs and interventions, there was no evidence in the Medication Administration Record, Treatment Administration Record, or nurse aide task sheets that ROM exercises were provided or documented for the resident. The Director of Nursing confirmed that ROM was not documented due to the absence of an official restorative program and stated that nurse aides were expected to perform ROM exercises during routine care without recording them. Additionally, the facility did not have an official policy for contracture care.
Failure to Follow Legionella Outbreak Recommendations
Penalty
Summary
The facility failed to ensure education about and follow public health authority recommendations during the investigation of a communicable disease outbreak involving Legionella bacteria. An anonymous complaint to the Indiana Department of Health (IDOH) indicated that Legionella bacteria had been found in water samples collected at the facility, and recommendations made to prevent disease were not being followed. This deficiency affected one resident, Resident M, who tested positive for Legionnaires' disease after being hospitalized, and had the potential to affect 68 residents residing in the facility. The facility was notified by IDOH of a Legionella outbreak investigation based on Resident M's positive urine test for Legionella and diagnosis of Legionnaires' disease. The resident had spent 12 days of the 14-day incubation period at the facility, prompting an outbreak investigation. IDOH provided recommendations for immediate water precautions, including removing ice machines from service, using bottled water for drinking, and removing showers from service until point-of-use filters could be installed. However, the facility did not fully implement these recommendations, as they continued to use showers per residents' preferences and did not install the recommended filters on showerheads. Interviews with facility staff revealed a lack of training on Legionella or other waterborne illnesses. Staff were not instructed to monitor for symptoms of pneumonia in high-risk residents or themselves, and there was no documentation indicating that residents had been notified of the presence of Legionella in the water. The facility's water management program identified showers in resident rooms as high-risk locations for Legionella bacteria, yet the facility elected not to follow the full extent of IDOH's recommendations, citing cost and resident preferences.
Failure to Address Trauma-Related Distress in Resident
Penalty
Summary
The facility failed to adequately identify, assess, and address the underlying causes of distress in a resident who is a survivor of childhood sexual trauma. The resident, who has a complex medical history including anxiety, major depressive disorder, paranoid schizophrenia, and insomnia, displayed various behaviors indicative of distress. These behaviors included speaking in nonsensical terms, swearing, making sexually inappropriate comments, and exhibiting physical aggression. Despite these behaviors, the facility did not effectively determine specific triggers or stressors that could be contributing to the resident's distress. The resident's care plans were found to be lacking in several areas. While the care plans addressed some behaviors and provided general interventions, they did not include specific strategies for managing the resident's obsessive-compulsive disorder or depression. Additionally, the care plans did not consider pain or male caregivers as potential stressors for the resident's aggression or refusal of care. The facility's approach to the resident's care was not sufficiently individualized to address the resident's unique needs and history of trauma. Interviews with facility staff, including the Social Service Director and the Director of Nursing, revealed that while the resident denied having specific trauma-related triggers, the staff acknowledged that triggers could be identified through observation rather than self-report. However, the facility's care plan approach did not include specific traumatic topics to be avoided or specific stressors for aggression or resistance to care. This lack of detailed and individualized care planning contributed to the facility's failure to provide appropriate treatment and services to the resident.
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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