Autumn Woods Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in New Albany, Indiana.
- Location
- 2911 Green Valley Rd, New Albany, Indiana 47150
- CMS Provider Number
- 155681
- Inspections on file
- 35
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Autumn Woods Health Campus during CMS and state inspections, most recent first.
Glucometers were not cleaned per manufacturer guidelines after blood sugar checks for three residents. An LPN wrapped a glucometer in a bleach wipe without first wiping it down, another LPN wiped a glucometer for only seconds before letting it dry, and an RN also wiped a glucometer for only seconds before placing it in a drawer to dry. The DON stated staff should follow the manufacturer’s cleaning directions, which required wiping the entire meter and keeping it wet for the 2-minute contact time.
Indwelling Catheter Drainage System Left on Floor: A resident with CKD and a UTI had an indwelling urinary catheter, but staff observed the catheter tubing and drainage bag on the floor on multiple occasions. An LPN also lifted the bag above the level of the bladder while repositioning it, and staff interviews confirmed the bag and tubing should not touch the floor.
Two residents with dementia and behavioral disturbances exhibited repeated aggressive and resistive behaviors, including physical aggression toward staff and other residents, but their care plans did not reflect or address these documented behaviors as required by facility guidelines.
Multiple residents with cognitive and mobility impairments experienced falls or unsafe transfers due to staff not following care plan interventions, such as using wheelchair foot pedals and mechanical lifts. In several cases, residents were left unattended or transported without required safety equipment, resulting in falls and injuries. Staff interviews and documentation confirmed that prescribed fall prevention measures were not consistently implemented.
A resident with multiple cardiac and respiratory diagnoses developed increased lower extremity edema, pain, and shortness of breath. Despite these significant changes, there was no documentation that the physician was notified in a timely manner, as confirmed by staff interviews and facility policy.
A resident with a history of UTIs and cognitive impairment was observed multiple times with a urinary catheter bag and tubing lying on the floor while seated in a wheelchair in the dining room. The bag was partially full and dragged along the floor as the resident moved, with staff present but not intervening. The resident's care plan required maintaining a closed system and keeping the bag off the floor, but these interventions were not followed, and staff interviews revealed inconsistent practices regarding catheter care.
A resident with multiple medical conditions experienced a significant, unverified weight loss over a short period. Despite care plan interventions and regular weight monitoring, staff did not document verification of the weight change or notify the physician as required. Interviews revealed uncertainty about the cause and accuracy of the weight loss, and facility policy on risk assessment was not followed.
Glucometers Not Cleaned Per Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure glucometers were cleaned according to manufacturer guidelines for infection control when obtaining blood sugar readings for three residents. During an observation, an LPN obtained a resident’s blood sugar reading and then returned the glucometer to the medication cart, where she wrapped it in a bleach wipe for two minutes without first cleaning or wiping down the device. She then removed the glucometer and placed it in the bottom of the top drawer of the medication cart to dry, with no barrier on the drawer bottom. The LPN stated she cleaned the glucometer for two minutes and then let it dry. During another observation, an LPN wiped the glucometer for ten seconds, discarded the wipe, and laid the device on a paper towel to dry for two minutes before obtaining another resident’s blood sugar reading. After the reading, she again wiped the glucometer for nine seconds, discarded the wipe, and laid it on the paper towel to dry. In a third observation, an RN obtained a resident’s blood sugar reading and then wiped the glucometer on the front and back for a total of five seconds before placing it in the top drawer of the medication cart on a napkin to dry. The RN stated she had been trained to wipe the front and back of the glucometer and was not sure of the exact wiping time. The DON stated staff should clean the glucometer per manufacturer guidelines, and the manufacturer instructions required wiping the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette, then allowing the exterior to remain wet for the 2-minute contact time.
Indwelling Catheter Drainage System Left on Floor
Penalty
Summary
The facility failed to ensure proper management of a resident’s indwelling urinary catheter drainage system by keeping it off the floor. Resident 25 had a diagnosis that included chronic kidney disease and had a care plan dated 3/26/26 identifying the use of an indwelling urinary catheter. The care plan interventions included maintaining a closed system with the urinary bag below the resident’s bladder and covering and observing the tubing while avoiding obstructions. The resident also had a nurse’s note dated 4/22/26 indicating a urine culture was received and reported to the physician, and a new order was received for Augmentin for a urinary tract infection. During observations, the resident’s catheter tubing was seen lying flat directly on the floor with the tubing coiled around the catheter, the drainage bag was hanging on the bedrail with the bottom slightly off the floor and was then placed onto the bed, and the bag later was observed scrunched up on the floor. During one observation, an LPN lifted the catheter bag above the level of the resident’s bladder while moving it onto the bed. Interviews with CNA 8 and the IP/LPN indicated the catheter bag and tubing should not be on the floor, and the IP/LPN stated that if the bag was on the floor it could cause infections or possible leaks.
Failure to Update Care Plans for Documented Resident Behaviors
Penalty
Summary
The facility failed to ensure that comprehensive care plans accurately reflected the documented behaviors of two residents with dementia and behavioral disturbances. For one resident with Alzheimer's disease, dementia, and psychotic disorder, multiple progress notes documented repeated incidents of aggression and resistiveness toward staff, including attempts to hit, grab, punch, and throw objects at staff and other residents. Despite these documented behaviors and medication adjustments for agitation, the resident's care plan did not include a comprehensive plan addressing these specific behaviors. Another resident with dementia and generalized anxiety was noted in progress notes to have demonstrated physically aggressive and resistive behaviors, including punching another resident. However, the care plan for this resident did not document the behavior or address the risk for aggression toward other residents. Facility guidelines require that new areas of concern, such as these behaviors, be addressed in the care plan, but this was not done for either resident.
Failure to Implement Fall Prevention Interventions and Ensure Safe Transfers
Penalty
Summary
The facility failed to implement appropriate interventions to prevent falls and ensure resident safety for five out of seven residents reviewed for accidents. In multiple instances, staff did not use required equipment such as foot pedals on wheelchairs or mechanical lifts during transfers, despite care plans and physician orders specifying their necessity. For example, one resident with a history of falls, dementia, and a left artificial hip joint was transferred from a shower to a bed without the use of a mechanical lift or wheelchair foot pedals, resulting in a fall that caused abrasions and a skin tear. Staff interviews confirmed that the required interventions were not followed at the time of the incident. Another resident with progressive neurological disease, severe obesity, and osteoporosis experienced two falls while ambulating with staff assistance. In both cases, the staff member left the resident unattended or did not maintain proper supervision, contrary to the care plan interventions that required the use of a gait belt and close assistance. The falls were attributed to lower extremity weakness, and the care plan was updated only after the incidents occurred. Staff interviews revealed that the CNA recognized the error in leaving the resident alone, and the DON acknowledged that the required supervision was not provided. Additional observations showed residents being transported in wheelchairs without foot pedals, resulting in their feet dragging or being positioned unsafely. In one case, a resident with dementia and recent fractures was pushed in a wheelchair without foot pedals, despite the care plan instructing staff to encourage their use. Another resident with repeated falls and severe cognitive impairment slid out of a wheelchair when their feet hit the floor during transport, as foot pedals were not in place. Staff interviews and documentation confirmed that the facility's fall management policy was not consistently followed, and interventions to prevent accidents were not reliably implemented.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician in a timely manner regarding a significant change in condition for a resident. The resident had multiple diagnoses, including pleural effusion, acute respiratory syncytial virus, hypertensive heart disease with heart failure, endocarditis, dementia, cardiomegaly, and edema. On assessment, the resident presented with pitting edema in both lower extremities, with the left leg showing 2+ edema and the right leg 1+ edema. The resident also complained of mild pain in the lower legs, which worsened on palpation, and was observed to be short of breath with expiratory wheezes. The nurse's note documented these findings, but there was no evidence in the record that the physician was notified promptly about these changes. Interviews with nursing staff and the Director of Nursing confirmed that the physician should have been contacted immediately when the resident exhibited increased edema, pain, and respiratory symptoms. The facility's policy also required timely notification of the physician for any change in condition to ensure appropriate interventions. The lack of timely physician notification in this case constituted a failure to follow established protocols for resident care.
Improper Management of Urinary Catheter Drainage System
Penalty
Summary
A deficiency was identified when a resident with a history of urinary tract infections (UTIs), chronic kidney disease, dementia, and urinary retention was observed with improper management of their urinary catheter drainage system. On two separate occasions, the resident was seen in the dining room sitting in a wheelchair with the urinary catheter bag and tubing lying on the floor. The catheter bag was partially full of urine, and the tubing contained yellow urine and sediment. The resident's feet were stepping on the tubing, and as the resident moved the wheelchair, the catheter bag and tubing dragged and scraped along the floor. Multiple staff members were present during these observations but did not intervene to correct the situation. The resident's medical record indicated a history of recurrent UTIs, agitation, and episodes of pulling out the catheter, requiring repeated reinsertion. The care plan included interventions to maintain a closed catheter system, keep the drainage bag below the bladder and covered, and prevent the catheter from being pulled out. Despite these documented interventions, the observations showed that the catheter system was not maintained properly, as the bag and tubing were allowed to rest on the floor, contrary to facility policy and standard infection control practices. Interviews with staff revealed a lack of awareness and inconsistent practices regarding the proper placement of the catheter bag. One CNA stated she had attached the bag to the underside of the wheelchair, as she had been taught, but was unaware that the bag had ended up on the floor. The supervisor confirmed that the catheter bag should not be on the floor and noted the resident's tendency to play with the bag and tubing. Facility policy explicitly stated that catheter tubing and drainage bags should not touch the floor to avoid infection, yet this protocol was not followed during the observed incidents.
Failure to Verify Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to ensure a resident's weight was accurately verified following significant changes, resulting in a lack of documentation confirming the accuracy of a substantial weight loss. The resident, who had multiple diagnoses including pleural effusion, heart failure, endocarditis, dementia, and edema, was prescribed furosemide for bilateral lower extremity edema and was identified as clinically at risk due to significant weight fluctuations. Despite care plan interventions that included regular weight monitoring and nutritional support, the resident experienced a marked drop in weight from 188.7 pounds to 145.4 pounds within a short period, with no documentation that the weight loss was verified or rechecked for accuracy. Interviews with facility staff revealed uncertainty regarding the cause of the weight loss, with the DON and RD both acknowledging the need to investigate and verify the resident's weight, including consideration of possible errors such as not subtracting the weight of a wheelchair. The facility's policy required assessment and analysis of risk factors, including the use of diuretics, but there was no evidence that the significant weight change was properly verified or that the physician was notified as required. The deficiency was identified through review of records and staff interviews, which confirmed that the resident should have been reweighed to ensure accuracy.
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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