Beaumont Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anderson, Indiana.
- Location
- 1345 N Madison Ave, Anderson, Indiana 46011
- CMS Provider Number
- 155005
- Inspections on file
- 41
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Beaumont Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents with significant mobility, neurologic, and cognitive impairments experienced multiple falls, but staff failed to implement immediate, individualized fall-prevention interventions at the time of each event. One resident with lower extremity impairments and a history of falls repeatedly rolled or fell from bed or between the bed and wall, sometimes sustaining abrasions and facial lacerations, while staff responses focused on vital signs, neuro checks, and returning the resident to bed without adding new, resident-specific fall measures. Another resident with ESRD, TBI, stroke, and weakness sustained a witnessed fall while attempting to get into bed unassisted, resulting in head impact, skin tears, and thigh pain; staff actions were limited to clinical assessment, monitoring, and a therapy screen rather than implementing an immediate, tailored intervention to address the fall circumstances. Staff and DON interviews confirmed that assessments such as vital signs and neuro checks were not considered fall interventions and that, in these cases, no appropriate immediate, individualized interventions were put in place following the falls.
A resident with HTN, atrial fibrillation, and end-stage renal disease had a physician order for midodrine with instructions to hold the dose if systolic BP was greater than 130 mm Hg. Review of the clinical record showed that staff repeatedly administered midodrine when the resident’s systolic BP readings were above this parameter, including significantly elevated values, without documented reasons for not following the order. The resident’s care plan identified risk for medication side effects and directed that medications be given per physician orders, and facility policy required adherence to all physician orders with documentation of any deviations, but these requirements were not followed.
A resident with multiple neurologic and mobility impairments, moderate cognitive impairment, and a documented high fall risk had a fall-prevention care plan that included a low bed, call-for-assistance signage, non-skid strips, a reacher, wheelchair modifications (lowered seat, anti-tippers, anti-roll-back device, brightly marked brakes), a floor mat, and other environmental and equipment-based interventions. After the resident changed rooms, surveyors observed that many of these interventions were not present in the current room or on the wheelchair, and staff interviews confirmed the absence of the call-for-assistance signs, non-skid strips, reacher, and wheelchair safety features. The resident experienced a witnessed fall while attempting to get into bed without assistance, and facility leadership acknowledged that some interventions may not have been transferred with the room change despite policies requiring implementation of the comprehensive care plan.
The facility failed to complete required pre- and post-dialysis assessments for two residents receiving hemodialysis. One resident with ESRD, prior nephrectomy, and diabetic CKD had physician orders for detailed monitoring of a chest dialysis access site and for pre/post-dialysis assessments on dialysis days, but multiple assessments were missing in the electronic record even though dialysis was documented as completed. Another resident with ESRD and CKD stage 5 had orders for daily infection checks of a chest port, AV access assessment for thrill and bruit, and catheter site monitoring, yet post-dialysis assessments were not documented on numerous treatment days. LPNs and the DON stated that nurses were expected to perform and document these assessments in the EHR, and the DON acknowledged that this was not done, contrary to facility dialysis and hemodialysis access care policies requiring such documentation.
Surveyors found that resident-use refrigerators on two nursing units contained improperly stored and unlabeled food items, as well as staff personal food and other items. On one unit, an LPN reported that a nurses' station refrigerator was used for residents, yet it held outdated and undated food, open beverage containers, and uncovered frozen items inconsistent with the facility’s Food Storage policy. On another unit, a dining/kitchen refrigerator and freezer contained a staff lunch tote, a candy bar, a bag of flour, and ice packs used on a resident’s breast for cancer-related care. The Regional Director of Operation confirmed that staff were not supposed to store personal food in these refrigerators and that a separate break room was available for staff food storage.
Two residents with end stage renal disease had inaccurate and inconsistent documentation of their dialysis access sites and related assessments. One resident’s records alternately described access in the left arm and left chest, with documentation of a bruit and thrill, while the resident and an LPN confirmed the only access was a left chest port that did not require bruit/thrill assessment. The other resident’s hospital records showed a failed right AV fistula and use of a right chest tunneled catheter, yet facility dialysis evaluations and EMAR/ETAR entries repeatedly documented arm and chest access sites with a bruit and thrill and included orders to assess an AV fistula and chest port for bruit/thrill every shift. Several shifts lacked any documentation, and the DON and nursing staff later acknowledged that neither resident had a functional AV fistula and that bruits and thrills cannot be assessed in a chest port, making the recorded assessments and orders inaccurate and inconsistent with the facility’s documentation policy.
Multiple residents with significant mobility impairments and obesity were not provided showers or bed baths according to their documented preferences and scheduled care in their MDS assessments and ADL care plans. Facility shower sheets and electronic documentation showed repeated missed bathing on designated days over several months for residents who preferred specific days and time frames for showers or bed baths. Some residents reported going extended periods without bathing and one reported frequently missing showers and attending physician appointments feeling unclean. Staff interviews acknowledged that showers were not always given as scheduled and that staffing absences contributed to the issue, while facility policy required prescribed orders to be followed or reasons for noncompliance to be documented, which was not consistently done.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes insufficient safety measures and supervision but does not specify the individuals involved or the exact hazards present.
The facility did not provide up-to-date education on influenza vaccines or obtain current vaccination consents for several residents. In multiple cases, education materials were outdated, consents were missing or not current, and documentation of vaccine administration was incomplete. Staff confirmed that current CDC information was not used and required consents were not consistently obtained.
The facility failed to ensure shift-to-shift narcotic reconciliation for six medication carts, including the Rehab cart and carts for the 200, 300, 400, and 500 halls. Observations revealed missing reconciliations on various shifts throughout June 2024. Interviews with the Family Tree Unit Manager and DON indicated that the expected procedure of signing the Controlled Substances Check Form was not followed, risking drug diversion.
The facility failed to implement effective Quality Assurance and Performance Improvement (QAPI) measures to address the issue of nurses not signing in and out for narcotic medication reconciliation at shift changes. The Director of Nursing (DON) initiated a Performance Improvement Plan (PIP) but lacked audit tools and documentation to support its implementation. Despite some reviews being conducted, the absence of a 'Clean Fridays' tool and evidence of corrective actions led to the deficiency.
Three residents reported unresolved dietary grievances, including missed meals before dialysis, repeated receipt of disliked foods, and inadequate portion sizes. Despite raising these issues with staff, the facility failed to document or address the concerns, violating its grievance policy.
A facility failed to report an allegation of abuse involving a resident with severe cognitive impairment. A CNA reported that an RN was rough with the resident, including yelling and forcefully handling her, causing distress. Despite the facility's policy requiring immediate reporting of such allegations, the Administrator did not report the incident to the IDOH, believing it was not abuse.
A facility failed to implement a safety plan for a resident with dementia and a history of wandering, resulting in the resident being hit and choked by another resident. Despite the facility's awareness of the resident's behavior, 15-minute monitoring checks were not conducted, leading to two altercations within 24 hours. Staff interviews confirmed the lack of monitoring, and the facility's policies were not effectively followed to ensure safety.
The facility failed to complete Quarterly MDS assessments on time for four residents, with delays ranging from 1 to 13 days. The MDS Coordinator acknowledged the late completions, despite using the RAI manual for guidance. The RAI manual requires completion within 14 days after the ARD.
A facility failed to submit a resident's MDS assessment on time, resulting in a deficiency. The resident, diagnosed with sepsis, congestive heart failure, and diabetes mellitus, was discharged, and their Discharge MDS assessment was completed on time but transmitted 68 days late. The MDS Coordinator, who shared transmission duties with an offsite consultant, missed the assessment in error. The RAI manual requires transmission within 14 days of completion.
The facility failed to conduct timely care plan meetings for three residents on a secured dementia unit, despite multiple MDS assessments. The last documented meetings for these residents were in January 2024 or earlier, contrary to the facility's policy requiring meetings within seven days of MDS completion. The Dementia Unit Manager cited scheduling difficulties due to the new MDS frequency.
A facility failed to complete physician-ordered wound care for a resident with a foot abrasion. The treatment administration record showed missing entries for several dates, with no documentation explaining the omissions. Interviews with staff confirmed that the treatments should have been completed as ordered, and the facility's policy requires documentation of any deviations.
A facility failed to provide wound care as ordered for a resident with a pressure injury, resulting in a deficiency. The resident had a physician's order for specific wound care treatments, which were not consistently completed, as evidenced by missing documentation and unchanged dressings. Interviews with staff confirmed the treatments were not administered as required, contrary to the facility's policy on pressure ulcer care.
The facility failed to follow physician orders for oxygen administration for two residents with respiratory conditions. One resident with COPD had their oxygen concentrator set above the prescribed 2-3 liters per minute, while another resident with COPD and emphysema had their concentrator set above the prescribed 2 liters per minute. Staff interviews confirmed the expectation to adhere to physician orders, which was not met.
The facility failed to properly label and dispose of insulin vials, leading to the use of expired insulin for residents. Observations revealed expired and undated insulin vials on two medication carts. LPNs were either unaware of the correct expiration period or did not date the vials upon opening, contrary to facility policy.
The facility did not follow infection prevention and control procedures during wound care for two residents under Enhanced Barrier Precautions (EBPs). An LPN and a CNA performed wound care without wearing gowns, despite visible EBP signage indicating the need for gown and glove use. Interviews confirmed that EBPs should have been followed, and the facility's policy required gown and glove use for high-contact activities like wound care.
A resident's phone was reported missing after a hospital transfer, and the facility failed to report the alleged misappropriation to the Indiana Department of Health within the required timeframe. The phone was later tracked to a CNA's residence, leading to a police investigation. The facility did not report the incident until 18 days after the initial allegation.
The facility failed to thoroughly investigate an allegation of misappropriation of a resident's phone. The investigation was delayed, lacked detailed communication, and did not include interviews with all relevant staff members. The phone was later tracked to a CNA's residence, but the facility did not provide updates to the resident or their representative.
Failure to Implement Immediate, Individualized Fall Interventions After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate, individualized fall interventions were developed and implemented following falls for two residents identified as being at risk for accidents. For Resident C, who had diagnoses including peripheral vascular disease, lower extremity impairments, weakness, unsteadiness on feet, muscle wasting, and a cognitive communication deficit, the care plan identified fall risk factors and listed general interventions such as maintaining the call light and frequently used items within reach, using a fall mat, placing the bed against the wall, and keeping the wheelchair within reach. Despite this, Resident C experienced multiple falls over several months, including rolling or falling out of bed and being found on the floor or between the bed and wall, sometimes with injuries such as abrasions and facial lacerations. The immediate responses documented after these falls primarily consisted of assessing vital signs, assisting the resident back to bed, performing neurological checks, and cleansing and covering wounds, without documentation of new, individualized fall-prevention measures implemented at the time of each fall. Resident C’s falls included an incident where he reported dreaming and reaching out, leading to a fall from bed, another where he rolled out of bed and complained of shoulder pain, and a fall where he was found on his back between the wall and bed with an empty wine cooler bottle and stated he did not know what happened. Additional falls occurred when he attempted to get into his wheelchair and when he rolled out of bed and struck his face on the bedside table, resulting in lacerations around his left eye. Interviews with nursing staff indicated that actions such as obtaining vital signs and lifting the resident from the floor were not considered fall interventions, and that staff sometimes relied on a paper of suggested interventions or DON guidance when they could not identify an immediate intervention. This pattern showed that, despite repeated falls and existing fall-related care plan entries, there were no clearly documented, immediate, individualized interventions added in direct response to each new fall event. For Resident E, who had diagnoses including end stage renal disease, traumatic brain injury, cerebral infarction, unsteadiness on feet, weakness, and lack of coordination, the care plan for impaired safety and fall risk included interventions such as non-skid footwear, reminders to lock wheelchair brakes, brightly colored tape on wheelchair brakes, education on proper transfers, and maintaining a clutter-free environment. Resident E sustained a witnessed fall when he stood up unassisted and attempted to get into bed, resulting in him hitting his head, sustaining skin tears to his right elbow, and complaining of right thigh pain with grimacing and guarding on movement. The immediate actions taken were assessment for injuries, obtaining vital signs, initiating neurological checks, notifying the physician and family, and obtaining an x-ray order. An IDT note later referenced a therapy screen, and the DON stated that the therapy screening was the only intervention implemented for this fall. Staff interviews clarified that nursing assessments such as checking for injuries and vital signs were not considered immediate fall interventions, and that an immediate, resident-specific intervention was expected at the time of the fall, which did not occur for this resident.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s medication order with specific blood pressure parameters for a resident receiving midodrine. The resident had diagnoses including hypertension, atrial fibrillation, and end-stage renal disease, and had a current order for midodrine 10 mg by mouth twice a day on Mondays, Wednesdays, and Fridays, with instructions to hold the medication if the systolic blood pressure was greater than 130 mm Hg. Record review showed that on multiple dates the resident’s systolic blood pressure exceeded 130 mm Hg, yet midodrine was still administered. Documented readings included 139/73, 138/82, 169/93, 132/65, 141/73, and 205/100 mm Hg, and on each of these occasions midodrine was given despite the order to hold the medication above the specified systolic threshold. The resident’s care plan, revised in early March, identified the resident as being at risk for medication side effects related to multiple conditions, including hypotension, renal failure, and anticoagulant use, and included an intervention to administer medications as indicated by physician orders. During an interview, the DON reviewed the midodrine order and the electronic medication administration record and confirmed that the order contained blood pressure parameters and that midodrine had been administered on the identified dates. The facility’s policy on physician services and orders required that all physician orders be followed as prescribed and that any deviation be documented in the medical record, but the records showed the medication was administered contrary to the ordered parameters without documented justification.
Failure to Implement Care-Planned Fall-Prevention Interventions After Room Change
Penalty
Summary
The deficiency involves the facility’s failure to ensure that fall-prevention care plan interventions for a resident at high risk for falls were actually implemented in the resident’s current environment. The resident had multiple diagnoses including end stage renal disease, traumatic brain injury, cerebral infarction, unsteadiness on feet, weakness, and lack of coordination, and a quarterly MDS showed moderately impaired cognition and a need for substantial to maximal assistance with mobility-related ADLs and transfers. A fall care plan, revised previously, identified the resident as at risk for impaired safety, injury, and falls and listed numerous specific interventions such as call-for-assistance signage in the room and bathroom, non-skid strips in the room and bathroom pathways, an anti-roll-back device and lowered seat for the wheelchair, brightly colored tape on wheelchair brakes, a reacher, a low bed, a floor mat at bedside, non-skid footwear, a scoop mattress, and a toilet riser with handles. The resident sustained a witnessed fall in his room when he attempted to get into bed unassisted, resulting in head impact, new right hip/thigh pain, and two small skin tears to the right elbow. Documentation indicated he was found on the floor on his right side after trying to get into bed without assistance, and he complained of pain with passive range of motion to the right lower extremity, with internal rotation noted. Fall risk assessments before and after the fall identified him as at risk for falls, and an interdisciplinary note confirmed the fall occurred while he was attempting to get into bed. Subsequent observations and staff interviews showed that several care-planned fall interventions were not in place in the resident’s current room or with his wheelchair. Surveyors observed that the bed was not in a low position, there was no call-for-assistance sign in the general area of the room, non-skid strips were not present by the bed, in the room pathway, or in the bathroom, and a reacher was not present. The resident’s wheelchair appeared to be standard height, lacked anti-tippers, and did not have brightly colored tape on the brake handles. CNAs and LPNs confirmed the absence of these interventions and indicated they had not seen certain devices in use for this resident. The DON acknowledged that the resident had changed rooms in 2024 and that some fall interventions may have been associated with the previous room and not transferred, despite facility policies requiring that resident-centered fall care plans be developed, implemented, reviewed, and that care plan interventions be followed and in place.
Failure to Complete Ordered Pre- and Post-Dialysis Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete physician-ordered pre- and post-dialysis assessments for residents receiving hemodialysis. One resident with end stage renal disease, dependence on renal dialysis, acquired absence of a kidney, and type 2 diabetes mellitus with diabetic chronic kidney disease had orders for daily monitoring of the left chest dialysis access site for infection, vital signs, and detailed pre- and post-dialysis assessments every shift on dialysis days, including monitoring for altered mental status, lethargy, edema, chest pain, shortness of breath, abdominal pain, nausea, vomiting, unusual itching, bleeding at the site, bruises, abnormal muscle cramps, redness, swelling, tenderness, or signs of infection at the dialysis site. Record review showed that pre-dialysis assessments were not completed on multiple specified dates, and post-dialysis assessments were also missing on numerous dates, despite the dialysis binder indicating that dialysis had been completed on those days. Another resident with end stage renal disease, dependence on renal dialysis, and chronic kidney disease stage 5 had physician orders to monitor the right chest port for infection daily, administer apixaban, check the AV access site every shift for thrill and bruit, avoid blood pressures and venipuncture on the access arm, maintain dressings post-treatment, and check the dialysis catheter site every shift for drainage and dressing condition. For this resident, post-dialysis assessments were not completed on multiple documented treatment dates, even though the dialysis binder confirmed that dialysis occurred. Interviews with LPNs and the DON confirmed that nurses were expected to complete pre-dialysis assessments before residents left for dialysis and post-dialysis assessments upon return, and to document these in the electronic health record, but the DON acknowledged that these assessments were not completed for the two residents. Facility policies on dialysis and hemodialysis access care required monitoring and documentation of dialysis-related observations, which were not carried out as ordered.
Improper Food Storage and Use of Resident Refrigerators
Penalty
Summary
Surveyors identified a deficiency in the sanitary storage of food in resident-use refrigerators on two nursing units (Intermediate and Arcadia). On the Intermediate unit, a small refrigerator in the nurses' station contained a packaged deli sandwich dated 4/14/26, a frozen entrée, an unopened bottle of strawberry soda, an unopened strawberry/banana Greek yogurt, four open partial bottles of water, an open partial bottle of mandarin orange water, and an undated foam container holding cabbage, sausage, cornbread, and an unidentifiable yellow substance. The freezer section contained a sticky, soft ice cream sandwich, two frozen nutritional supplements, and an uncovered Dairy Queen cup stuck to the freezer shelf. An LPN stated this refrigerator was for residents and that staff had a separate break room for their own food. The facility’s Food Storage policy required leftover food to be covered, clearly labeled, dated, and used within seven days or discarded, and required all refrigerator units to be kept clean, with all foods covered, labeled, dated, and routinely monitored. On the Arcadia unit, a refrigerator in the dining/kitchen area contained a staff member’s lunch tote, and the freezer contained an unopened candy bar, a clear storage bag of flour, and a plastic grocery bag with two ice packs. The Memory Care Director reported that the ice packs were used on a resident’s breast for a new diagnosis of breast cancer. The Regional Director of Operation stated that staff should not store personal food in these refrigerators and that a break room was available for staff food storage. These observations showed that food and items in the resident-use refrigerators were not consistently stored in accordance with the facility’s Food Storage policy and professional standards, including requirements for labeling, dating, covering, and appropriate use of the refrigerators.
Inaccurate Dialysis Access Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and factual documentation in the medical records of two residents receiving dialysis. For one resident with end stage renal disease, acquired absence of a kidney, and type 2 diabetes with diabetic chronic kidney disease, multiple dialysis pre/post evaluations documented the dialysis access location inconsistently as the left upper extremity, left arm, and later the left chest, with notation of a bruit and thrill at the chest site. In interviews, this resident consistently stated that the only dialysis access site was in the left upper chest and that there was no AV fistula in the left arm. An LPN confirmed that the resident’s only access was in the left upper chest and that assessment for a bruit and thrill was not needed for that type of access, contradicting the prior documentation. For a second resident with end stage renal disease and chronic kidney disease stage 5, a hospital nephrology note documented that the right AV fistula had failed, was nonfunctional, and had no thrill, and that the resident had a right tunneled dialysis catheter. Despite this, multiple dialysis pre/post evaluations over several months documented dialysis access locations variously in the left upper extremity, right arm, and right chest, and repeatedly indicated the presence of a bruit and thrill at these sites. The resident reported having only a dialysis port in the right upper chest, with a previously used right upper arm fistula that had been deactivated and not used for more than six months. Physical observation noted a dressing to the right upper chest and scarring on the right upper arm. The resident’s ETARs and EMARs further reflected inaccurate and incomplete documentation. Orders indicated that an AV fistula site and an AV access site to the right chest port were to be checked every shift for a bruit and thrill, and nurses documented these assessments as completed, even though a chest port does not have a bruit and thrill and the resident no longer had a functional AV fistula. Several shifts in February, March, and April lacked any documentation and were left blank, which the DON stated meant the task was either not done or not documented. The DON and an LPN later confirmed that neither resident had an AV fistula, that bruits and thrills could not be assessed in a chest port, and that the nursing assessments, EMAR, ETAR, and dialysis orders contained incorrect and false information, contrary to the facility’s documentation policy requiring factual, accurate, and complete records.
Failure to Provide Scheduled and Preferred Bathing for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance according to residents’ assessed preferences and scheduled care. Multiple residents with significant physical impairments and obesity, including paraplegia and hemiplegia, had care plans and MDS assessments specifying preferred days and time frames for showers or bed baths. For Resident B, who had paraplegia and morbid obesity, the admission MDS and ADL care plan indicated a preference for bed baths on Tuesdays and Fridays between 2:00 p.m. and 10:00 p.m., yet shower sheets and Documentation Survey Reports showed numerous missed scheduled bed baths across January, February, and March 2026. Resident C, with morbid obesity and paraplegia, had an admission MDS and ADL care plan indicating a preference for showers on Tuesdays and Fridays between 6:00 a.m. and 2:00 p.m. Facility records showed that several of these scheduled showers were not provided in each of the three months reviewed. Resident D, diagnosed with paraplegia, had a quarterly MDS and ADL care plan indicating a preference for showers or bed baths on Monday, Wednesday, and Friday evenings. Documentation revealed repeated missed showers/bed baths on multiple scheduled days in January, February, and March 2026. In an interview, Resident D reported having gone an extended period of time without receiving a shower or bed bath, although he indicated the situation had recently improved. Resident E, with acute respiratory failure with hypoxia and obesity, had an admission MDS and ADL care plan indicating a preference for showers or bed baths on Wednesdays and Saturdays between 2:00 p.m. and 10:00 p.m., but facility records showed multiple missed scheduled showers over the three-month review period. In an interview, Resident E stated that showers were frequently not given as scheduled and that she had attended physician appointments feeling unclean and uncomfortable, apologizing for her condition at a recent outside appointment. Resident F, with hemiplegia and hemiparesis following cerebral infarction, had a quarterly MDS and ADL care plan indicating a preference for showers on Tuesday and Friday evenings, yet documentation showed numerous missed scheduled showers in January, February, and March 2026. Interviews with the Administrator, a QMA, and the DON confirmed that showers were not always given as scheduled, that staffing issues due to employee absences contributed to the problem, and that showers were to be documented in the electronic record, with shower sheets corroborating the missed care. The facility’s policy on physician services and orders required all physician orders to be followed as prescribed or reasons for noncompliance to be recorded in the medical record during that shift, which was not reflected in the documentation for these missed baths and showers.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report. No additional information about the residents involved, their medical history, or their condition at the time of the deficiency is provided.
Failure to Provide Current Vaccine Education and Obtain Consents
Penalty
Summary
The facility failed to provide current education on influenza vaccines and to obtain current influenza vaccination consents for four out of six residents reviewed for immunizations. In several cases, the education provided regarding the risks and benefits of the influenza vaccine was outdated, with documentation dating back to 2021, and not updated for the most recent vaccination season. Additionally, some residents' records either lacked a signed and dated consent form for the influenza vaccine or had consents that were not current for the 2024-2025 season. For one resident, the administration record for the influenza vaccine was incomplete, missing the dose and location of administration, and there was also missing documentation regarding the administration or refusal of the COVID-19 vaccine. Interviews with facility staff confirmed that residents and their families had not been educated using the most current information from the CDC, and that consents for the 2024-2025 influenza season had not been provided as required. The facility's policies require that current CDC vaccine information statements be given and that signed consents be obtained prior to vaccine administration, but these procedures were not consistently followed. The deficiencies were identified through record reviews and staff interviews, which revealed gaps in both education and documentation for immunizations.
Failure in Narcotic Reconciliation Across Multiple Medication Carts
Penalty
Summary
The facility failed to ensure shift-to-shift narcotic reconciliation was completed for all six medication carts reviewed, which included the Rehab cart, Intermediate back cart, and carts for the 200, 300, 400, and 500 halls. During observations and record reviews, it was found that the Controlled Substances Check Form records lacked shift-to-shift reconciliation on multiple dates throughout June 2024. This deficiency was noted across various shifts, including day, evening, and night shifts, indicating a systemic issue in the facility's medication management practices. Interviews with the Family Tree Unit Manager and the Director of Nursing (DON) revealed that the expectation was for nursing staff to sign the Controlled Substances Check Form at the start and end of each shift. However, this task was not being completed as expected, posing a risk for drug diversion. The facility's policy on narcotic nurse-to-nurse reconciliation required two signatures for each reconciliation, but this was not adhered to, as evidenced by the incomplete counts and lack of signatures on the narcotic count sheets.
Failure to Implement Effective QAPI Measures for Narcotic Reconciliation
Penalty
Summary
The facility failed to develop and implement effective approaches to correct identified deficient practices as part of their Quality Assurance and Performance Improvement (QAPI) program. Specifically, the deficiency involved the failure of nurses to sign in and out to acknowledge reconciliation of narcotic medication at the change of shift. The Director of Nursing (DON) initiated a Performance Improvement Plan (PIP) to address this issue, with a start date of June 13, 2024, and a completion date set for September 13, 2024. The plan included reviewing sign-in/sign-out sheets, conducting a staff in-service, and initiating 'Clean Fridays' audits. However, during an interview on July 2, 2024, the DON admitted to not having any audit tools, additional documentation, or evidence to support the implementation of the approaches listed in the PIP guidance tool. Although the Family Tree Unit Manager was conducting reviews of the medication cart narcotics binders on Fridays, the DON had not yet created the 'Clean Fridays' tool. This lack of documentation and evidence of implementation led to the deficiency, as the facility did not demonstrate the development, implementation, and evaluation of corrective actions or performance improvement activities as required by their QAPI policy.
Failure to Address Resident Dietary Grievances
Penalty
Summary
The facility failed to address and resolve resident grievances in a timely manner, affecting three residents who voiced concerns about their dietary needs and preferences. Resident 30, who required dialysis three times a week, reported not receiving breakfast before his early morning appointments. Despite raising the issue with the dietary manager and the administrator, no resolution was provided, leading to the resident attending dialysis without breakfast. The dietary staff confirmed the resident's complaints but did not take action to ensure breakfast was provided, and the dietary manager was unaware of the issue, indicating a lack of communication and grievance documentation. Resident 33 experienced repeated instances of receiving food items listed on her dislikes, such as carrots, rice, and oatmeal. Despite reporting these issues to various staff members, including nurses and CNAs, the facility did not address her concerns or document them in the grievance log. The absence of a care plan for her dietary preferences and dislikes further highlights the facility's failure to acknowledge and act on her grievances, resulting in continued dissatisfaction with her meals. Resident 81 also reported receiving dietary dislikes and inadequate portion sizes, which were not addressed by the facility. Despite informing multiple staff members, including the SSD, her concerns were not documented in the grievance log, and no corrective action was taken. The facility's grievance policy outlines the process for addressing resident concerns, but the lack of adherence to this policy resulted in unresolved grievances and unmet dietary needs for the residents involved.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report an allegation of resident abuse to the Indiana State Department of Health (IDOH) for one resident, identified as Resident C, who was severely cognitively impaired with diagnoses including anxiety, depression, and dementia. On a specific date, a CNA reported to the Administrator that an RN had been rough with Resident C during care, including yelling, grabbing the resident's arm, pulling her by the back of her pants, and causing her to fall hard onto the bed, which made the resident cry. The CNA considered these actions as abuse and provided a written statement to the Administrator. However, the Administrator did not report the incident to IDOH, believing it was not abuse and considering it a matter of verbiage. The facility's policy required immediate reporting of abuse allegations to IDOH, but the Administrator did not comply with this policy. Interviews with the CNA and the RN involved revealed discrepancies in the accounts of the incident, with the CNA insisting she had witnessed abuse and the RN recalling being informed of an allegation but not remembering specifics. The Administrator maintained that he did not receive a written statement from the CNA and did not perceive the actions as abusive, leading to the failure to report the incident as required by the facility's policy.
Failure to Implement Safety Plan for Resident with Wandering Behavior
Penalty
Summary
The facility failed to develop and implement a safety plan to prevent resident-to-resident abuse for a resident with dementia and a history of intrusive wandering. This deficiency resulted in the resident being hit in the face and choked by another resident. The incidents occurred when the resident, who had a known behavior of wandering into others' rooms, entered another resident's room and was attacked. Despite the facility's awareness of the resident's behavior, appropriate monitoring measures were not effectively implemented. The resident involved, identified as Resident E, had a history of dementia, anxiety, depression, and Alzheimer's disease, and was known to wander daily. The facility had previously identified the resident's behavior of rummaging through other residents' belongings and had care plan approaches to redirect the resident when exhibiting such behaviors. However, the facility's failure to implement 15-minute monitoring checks, as indicated in their preventative measures, contributed to the resident being involved in two altercations within a 24-hour period. Interviews with staff revealed that the 15-minute checks were not conducted, and the Director of Nursing confirmed that the resident was not placed on such monitoring following the initial altercation. The clinical record lacked documentation of the 15-minute checks, and the facility's policy on behavior crisis and abuse reporting was not effectively followed to ensure the resident's safety.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of Quarterly Minimum Data Set (MDS) assessments for four residents, as required every three months. Resident 22's assessments were completed 4 days late in November 2023 and 3 days late in May 2024. Resident 35's assessment was completed 11 days late in June 2024. Resident 60's assessments were completed 5 days late in December 2023 and 1 day late in March 2024. Resident 73's assessment was completed 13 days late in June 2024. These delays were identified through a review of clinical records and interviews. The MDS Coordinator acknowledged the late completion of assessments, indicating that the team utilized the Resident Assessment Instrument (RAI) manual for managing MDS tasks. The work was divided between the MDS Coordinator and a co-worker. According to the RAI manual, the Quarterly MDS completion date must be no later than 14 days after the assessment reference date (ARD). The facility's failure to adhere to this timeline resulted in the identified deficiencies.
Late Submission of MDS Assessment
Penalty
Summary
The facility failed to ensure the timely submission of Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. The resident, who had a clinical diagnosis of sepsis, congestive heart failure, and diabetes mellitus, was discharged from the facility. The Discharge MDS assessment for this resident had an Assessment Reference Date (ARD) of the discharge date and was completed on time. However, the assessment was transmitted electronically for submission 68 days late. The MDS Coordinator indicated that the task of assessment transmission was shared with an offsite corporate consultant, and the discharge assessment was missed in error during the transmission process. The error was discovered later, and the assessment was transmitted immediately upon discovery. The RAI manual specifies that the Discharge assessment transmission date should be no later than 14 days after the MDS completion date.
Failure to Conduct Timely Care Plan Meetings for Residents
Penalty
Summary
The facility failed to schedule, hold, and invite resident representatives to care plan meetings in conjunction with the assessment process for three residents residing on a secured dementia unit. These residents, identified as E, F, and 92, had not had care plan meetings since January 2024 or earlier, despite having multiple Minimum Data Set (MDS) assessments completed throughout the year. The facility's policy requires care plan meetings to be held within seven days of the completion of an MDS assessment, but this was not adhered to. Resident F had an annual MDS assessment completed in May 2024 and quarterly assessments in March and December 2023, with the last care plan meeting documented in June 2023. Resident 92 had quarterly MDS assessments in May and February 2024, with the last care plan meeting in January 2024. Resident E had quarterly MDS assessments in May and February 2024, with the last care plan meeting in January 2024. The Dementia Unit Manager acknowledged difficulties in scheduling these meetings due to the new frequency of MDS assessments, and no care plan meetings had been held for these residents since January 2024.
Failure to Complete Physician-Ordered Wound Care
Penalty
Summary
The facility failed to complete physician-ordered wound care treatments for a resident with an abrasion on the left foot, as observed during a survey. The resident, who was cognitively intact and used a wheelchair for mobility, had a physician's order to clean the wound with Dakins, apply collagen, and secure it with a bordered dressing every night shift on specific days. However, the treatment administration record for June 2024 showed that the wound treatments were not completed on several dates and shifts, with no documentation explaining the omissions. Interviews with facility staff, including an LPN and the DON, confirmed that the wound treatments should have been completed as ordered, and the lack of documentation left no way to verify if the treatments were administered. The facility's policy requires that all physician orders be followed as prescribed, and any deviations should be recorded in the resident's medical record. The resident's care plan indicated a risk for impaired skin integrity, and wound assessments showed changes in the wound's size and drainage over time.
Failure to Provide Ordered Wound Care for Pressure Injury
Penalty
Summary
The facility failed to provide wound care treatment as ordered for a resident with a pressure injury, leading to a deficiency in care. The resident, who had diagnoses including atrial fibrillation, weakness, and chronic pain, had a physician's order for wound care that was not consistently followed. The treatment administration record showed that wound treatments were missed on several dates and shifts, with no documentation explaining the omissions. The resident's care plan included interventions for an unstageable pressure injury on the right buttock, which was not present on admission and had evolved from a stage 2 wound. Despite the care plan and physician orders, the facility did not complete the necessary wound care treatments, as evidenced by the lack of documentation and observations of unchanged dressings. Interviews with facility staff, including an LPN and the DON, confirmed that the ordered treatments were not completed as required, which was deemed unacceptable. The facility's policy on pressure ulcer care emphasized the need for resident-centered care and adherence to professional standards to promote healing and prevent new ulcers. However, the facility's failure to consistently administer the prescribed wound care treatments resulted in a deficiency, as the resident's wound care needs were not met according to the physician's orders and the facility's policy.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding oxygen administration for two residents, leading to a deficiency in respiratory care. Resident 60, diagnosed with chronic obstructive pulmonary disease (COPD), acute bronchitis, unspecified asthma, and chronic pain, was observed multiple times with her oxygen concentrator set above the prescribed 2-3 liters per minute. Despite the physician's orders and the respiratory care plan indicating the need for continuous oxygen at the specified rate, the concentrator was set at 4 liters per minute on several occasions and at 3.5 liters per minute on another occasion. The Family Tree Unit Manager confirmed the discrepancy, noting that the nurse on shift was responsible for ensuring the correct oxygen setting. Similarly, Resident 73, with diagnoses including COPD, emphysema, and unspecified atrial fibrillation, was observed with his oxygen concentrator set above the prescribed 2 liters per minute. The resident himself indicated that his oxygen should be set at 2 liters, yet observations showed it set at 3 liters and later at 3.5 liters per minute. The facility's policy mandates that all physician orders be followed as prescribed, and any deviations should be recorded in the resident's medical record. Interviews with staff, including an LPN and the Director of Nursing, highlighted the expectation that nursing staff ensure compliance with physician orders, which was not met in these instances.
Improper Labeling and Disposal of Insulin Vials
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin vials, which are critical for managing diabetes mellitus in residents. During an observation of the 400 hall medication cart, it was found that there were open vials of Lispro and Glargine insulin that were not disposed of despite being expired. The LPN present during the observation believed insulin was good for 30 days, but the facility's documentation indicated a 28-day expiration period. This discrepancy led to the continued use of expired insulin for three residents on the 400 hall. Similarly, during an observation of the Rehab hall medication cart, two opened and undated vials of Lispro insulin and one opened undated vial of Lantus insulin were found. The LPN on duty was unaware of when these vials were opened and had not administered insulin during her shift. The facility's policy required that insulin vials be dated when opened, but this was not adhered to, resulting in a lack of proper tracking and potential use of expired medication for two residents on the Rehab hall.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control procedures during wound care for two residents under Enhanced Barrier Precautions (EBPs). For Resident 70, both an LPN and a CNA entered the room, which had a visible EBP sign, and performed wound care without wearing gowns, despite the requirement for gown and glove use during high-contact care activities. The LPN and CNA leaned against the resident's mattress with unprotected clothing, and the resident's clinical record confirmed the need for EBPs, including gown and glove use for wound care. Similarly, for Resident 83, the LPN conducted wound care without donning a gown, even though the EBP sign was visible and indicated the necessity of gown and glove use for high-contact care. The LPN acknowledged the oversight and was uncertain if the EBP sign applied to the residents or their roommates. Interviews with staff, including the DON, confirmed that EBPs should have been followed, and the facility's policy outlined the requirement for gown and glove use during high-contact activities like wound care.
Failure to Timely Report Allegation of Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of property within the required timeframe to the Indiana Department of Health for a resident. The resident, who was cognitively intact and had a history of a displaced intertrochanteric fracture of the left femur, alcohol abuse, difficulty in walking, and weakness, was transferred to the hospital for lethargy. Upon transfer, the resident's phone and glasses were not documented as sent with him. The resident's representative discovered the phone was missing and later tracked it to a CNA's residence, leading to a police investigation. The facility did not report the alleged misappropriation until 18 days after the initial allegation was made by the resident's representative. The resident's representative visited the facility every other day and confirmed the resident had his phone and glasses before being transferred to the hospital. When the representative visited the facility to collect the resident's belongings, the phone was missing. The facility's Administrator initially claimed the phone was sent with the resident, but the representative later received inappropriate messages from the missing phone, indicating it was stolen. Despite being informed of the theft on 3/6/24, the facility did not report the incident to the Indiana Department of Health until 3/22/24, after the police were involved and the phone was tracked to the CNA's residence. The facility's policy requires that all alleged violations involving misappropriation of resident property be reported immediately, but not later than 24 hours after the allegation is made. The Administrator acknowledged that the facility should have reported the allegation on 3/6/24 when they became aware of the theft. The delay in reporting the incident violated the facility's policy and state regulations, resulting in a deficiency citation.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of resident property for Resident C. Resident C, who was cognitively intact and required moderate assistance for transfers, toileting, and dressing, was transferred to the hospital for lethargy. Upon transfer, the resident's phone was reported lost, and the facility's investigation into the missing phone was delayed and incomplete. The investigation began on 3/22/24, despite the phone being reported lost on 3/4/24, and lacked detailed communication between the Administrator and the resident's representative. Additionally, the investigation did not include interviews with other staff members who were on duty at the time of the incident, and the facility did not have surveillance footage available for review. The resident's representative reported the phone missing to the police on 3/22/24 after receiving inappropriate messages from the resident's phone. The police tracked the phone to the residence of CNA 3, who was on duty during the resident's transfer. Despite this, the facility had not provided any updates on the investigation to the resident or their representative between 3/6/24 and 3/22/24. The facility's investigation included interviews with the resident's representative, the police officer, and the alleged perpetrator, but lacked interviews with other staff members and residents who might have had relevant information. Confidential interviews with several employees revealed that they were not asked any questions regarding the missing items or suspicions of misappropriation until the survey. The facility's policy on abuse prevention and reporting requires thorough investigations, including interviews with all involved parties and staff members. However, the facility's investigation into the misappropriation of Resident C's phone did not meet these standards, resulting in a deficiency in the facility's handling of the incident.
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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