Brickyard Healthcare - Lincoln Hills Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tell City, Indiana.
- Location
- 402 19th Street, Tell City, Indiana 47586
- CMS Provider Number
- 155384
- Inspections on file
- 32
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Brickyard Healthcare - Lincoln Hills Care Center during CMS and state inspections, most recent first.
Resident information was left visible on medication cart computer screens in Hall A and Hall B while staff were away, and an LPN entered a resident’s room multiple times without knocking or announcing herself. The resident was startled when the LPN approached the bedside, and the DON stated staff should knock before entering resident rooms and should not leave resident information visible on unattended screens.
Failure to follow physician orders was identified for residents receiving insulin and BP medication. A resident with diabetes had low blood sugars documented without the ordered re-checks, and an LPN was observed priming insulin pens in a way that did not match the facility’s policy. A resident with HTN also received hydralazine on multiple occasions even though the systolic BP was below the ordered hold parameter.
A facility failed to ensure residents were provided activities that met their interests and well-being during a weekend review. Residents said there were no weekend activities, while the posted calendar listed multiple Saturday and Sunday programs. The Activity DOR said the activity dept was not staffed on weekends and the weekend mgr on duty should do activities, but the BOM said she had other tasks and could not help, payroll staff said they did not do activities on Sundays because they had church, and CNA staff said weekend activities depended on who was available. Participation lists were not initially available and later provided lists were handwritten in the same handwriting.
An LTC facility failed to follow infection control practices during medication administration and perineal care. Two LPNs picked up pills that fell onto the medication cart with bare hands and administered them to residents, and staff performing perineal care for two residents did not consistently change gloves and perform hand hygiene between dirty and clean tasks, including during handling of soiled briefs, pads, and clean incontinence supplies.
A facility failed to properly assess two residents for self-administration of meds. One resident with CHF, stroke, DM2, Afib, and bipolar disorder had a medication cup left on the bedside table, while another resident with stroke, dysphagia, anxiety, and DM2 was left alone in the dining room with eight pills still to take. Both residents’ records lacked an order, care plan, and assessment for safe self-administration, and the DON stated no residents were approved to self-administer meds.
The facility did not ensure a qualified Infection Preventionist (IP) was working at least part-time. The DON was covering both the DON and IP roles without documented hours dedicated to infection control. RN 7, assisting the DON, had not completed IP training. The facility's policy required a designated qualified individual for the infection prevention program, which was not met.
The facility did not provide RN coverage for 8 consecutive hours on four occasions, as required. A review of staffing records revealed insufficient RN coverage on specific weekends, with only partial or no RN presence on certain days. The DON acknowledged efforts to maintain coverage, including using other staff to assist on weekends.
A facility failed to ensure a dependent resident's call light was within reach, compromising his ability to alert staff for help. The resident, with a history of stroke and left-side paralysis, was observed multiple times unable to access his call light, and staff did not respond promptly to his calls for assistance. This deficiency highlights a failure to adhere to the facility's policy of ensuring call light accessibility.
The facility failed to follow physician orders and care plans for two residents, leading to deficiencies in medication administration and equipment management. A resident's oxygen concentrator was set incorrectly, and their blood pressure was not consistently checked before administering Metoprolol. Another resident lacked a care plan for hypertension, and their heart rate was not checked before medication administration. These oversights indicate non-compliance with prescribed medical protocols.
A facility failed to update a resident's care plan to remove outdated interventions for unnecessary medications. Despite discontinued physician's orders for fluid restriction and daily weights, these interventions remained in the care plan. The Director of Nursing confirmed that care plans should be revised with changes, but the facility's policy was not followed.
A resident with significant medical conditions was incorrectly identified as DNR during a medical emergency due to reliance on an outdated printed code status list at the nurse's station. The LPN notified the physician of the incorrect status, delaying appropriate emergency interventions until the resident's full code status was verified in the medical record. The facility's policy required code status verification through the medical record, but this was not followed.
The facility failed to ensure accurate MDS Assessments for four residents, missing critical information such as PASRR II status and hospice care. The errors were attributed to the absence of a social services coordinator and reliance on the RAI Manual instead of a specific MDS policy.
The facility failed to ensure palatable food was served, as evidenced by resident complaints and direct observation. Residents described the food as horrid, overcooked, dry, and not worth eating. A meal tray was found to be bland and tasteless, with the french toast having hard edges. The Dietary Manager was unaware of any complaints and acknowledged that certain items often dry out. The facility's Food Preparation policy was not met.
The facility failed to ensure resident dignity for two residents. One resident continued to receive Styrofoam dishes after a suicide watch was discontinued, and another resident was fed by a standing CNA who later asked a nurse, 'What do you want me to do with her?' The facility's policy emphasized treating residents with respect and dignity.
The facility failed to notify the ombudsman of the transfer or discharge of three residents who were hospitalized. The issue was confirmed through interviews and record reviews, revealing that no one at the facility was responsible for sending the required notifications. The facility's Discharge Planning Policy was not being followed.
The facility failed to follow the smoking care plans for two residents, allowing them to smoke unsupervised and keep smoking materials despite care plan directives requiring supervision and staff-held smoking materials.
The facility failed to conduct quarterly care plan conferences for two residents with severe cognitive impairments. The absence of a Social Services Director led to the Activities Director temporarily coordinating care plan meetings, resulting in missed conferences.
The facility failed to provide care consistent with professional standards to prevent and manage pressure ulcers for two residents. One resident developed a stage IV pressure ulcer on the right heel, and another resident's stage 3 sacral pressure ulcer worsened due to inconsistent wound care and failure to follow care plan interventions.
The facility failed to ensure adequate supervision for a high-risk resident, resulting in multiple falls. Despite documented interventions such as keeping the call light within reach and ensuring the bed was in the lowest position, these were not consistently followed. The resident, with severe cognitive impairment and a history of falls, experienced seven falls due to the lack of adherence to the care plan.
The facility failed to accurately document care planned interventions for a resident with renal failure, heart failure, and depression. Staff documented walking and AROM exercises that did not occur, contrary to the facility's policy on accurate and complete documentation.
The facility failed to ensure proper infection control measures for two residents. Staff did not use Enhanced Barrier Precautions for a resident with a pressure ulcer and failed to perform proper hand hygiene during incontinence care for another resident.
The facility failed to ensure that resident call lights were accessible while residents were in their beds. Multiple residents were observed with call lights out of reach, despite care plans and facility policies requiring them to be within reach. Interviews with staff confirmed that call lights should be accessible, but this was not consistently practiced.
The facility failed to maintain safe water temperatures and proper equipment storage. Water temperatures in multiple rooms and shower areas exceeded the safe limit of 120 degrees Fahrenheit, and a raised toilet seat was improperly stored on the bathroom floor. Staff were either unaware of the proper temperature limits or did not report the issues.
The facility failed to post complete nurse staffing information for five consecutive days. The posted sheets lacked the facility name, clear actual hours worked by nursing staff, and on one occasion, the correct census information. The Scheduler was unaware of the requirements and admitted to errors in the postings.
Resident Information Left Visible and Room Privacy Not Maintained
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential during multiple observations on Hall A and Hall B. On 4/9/26 at 8:37 A.M., Hall A’s medication cart was observed in the hallway with resident information, including the resident’s name, picture, and room number, visible on the computer screen while no staff were present at the computer. On 4/13/26 from 6:13 A.M. to 6:19 A.M., Hall A’s medication cart was again observed with resident information visible on the screen without staff present, and on 4/13/26 from 6:24 A.M. to 6:29 A.M., Hall B’s medication cart was observed in the hallway with resident information visible on the screen without staff present. The facility also failed to provide privacy when an LPN entered Resident D’s room without knocking or announcing herself. On 4/13/26 at 6:49 A.M., the LPN entered the room to obtain a blood sugar reading, and when she reached the bedside and said the resident’s name, Resident D was startled and jumped. The LPN left the room, returned with medications, and entered again without knocking or announcing herself. She later went back out to get the resident a snack and prepare insulin, and again did not knock or announce herself before entering Resident D’s room. The DON stated that nursing staff should knock before entering resident rooms and should not leave computer screens with resident information visible while they are not at the computer.
Failure to Follow Physician Orders for Blood Sugar Checks, Insulin Pen Use, and Blood Pressure Medication
Penalty
Summary
Physician orders were not followed for a resident with diabetes mellitus when ordered blood sugar re-checks were not documented after low pre-meal blood sugars. The resident’s quarterly MDS dated 2/15/26 indicated no cognitive impairment and insulin injections 7 of 7 days. The physician order for insulin aspart required that if blood sugar was less than 100, the resident should eat a small snack and have blood sugar rechecked in 15 minutes before insulin was administered. The MAR showed blood sugars of 85 at lunch on 4/3/26, 74 at lunch on 4/4/26, and 96 at dinner on 4/7/26 with no documented re-checks, and the progress notes lacked documentation of a re-check on those dates. The record also lacked documentation explaining why blood sugar was not completed or insulin was not given at dinner on 4/2/26. Insulin pen administration was observed for two residents and the pens were primed in a manner that did not match the facility’s written insulin pen policy. On 4/13/26, an LPN prepared Novolog FlexPen for one resident and Humalog KwikPen for another resident, wiped the tip, attached the needle, and held each pen horizontally while pushing the plunger to prime with one unit of insulin before administering the dose. During interview, the LPN stated she primed insulin pens with one unit of insulin. The facility’s insulin pen policy stated insulin pens are to be primed prior to each use and described dialing 2 units and holding the needle pointing up until at least one drop of insulin appears. A resident with hypertension had a physician order for hydralazine 50 mg three times daily with instructions to hold for systolic blood pressure less than 140, but the medication was administered on multiple occasions when the resident’s systolic blood pressure was below 140. The resident’s annual MDS dated 3/19/26 indicated the resident was cognitively intact. Review of the MAR showed hydralazine was given on numerous dates when systolic blood pressure readings ranged from 105 to 139. During interview, an RN stated that if the resident’s systolic blood pressure is less than 140, the medication should not be given. The facility’s medication administration guidance stated to obtain and record vital signs when applicable or per physician orders and to hold medication for vital signs outside the physician’s prescribed parameters.
Weekend Activities Not Provided as Scheduled
Penalty
Summary
The facility failed to ensure residents were provided activities to meet the interests of and well-being of each resident for 1 of 1 weekends reviewed. During the resident council meeting, residents stated they did not have activities on the weekends, and one resident said he could not get around to host them or even tell people there were any. An activity calendar posted in Hall 2 listed weekend activities for Saturday and Sunday, including magnet game, mealtime memories, daily chronicles, music and conversations, TV time, mealtime music, friendly conversations, and church services. During interviews, the Activity Director stated the activity department was not staffed on weekends and the weekend manager on duty should do the activities. The weekend manager schedule showed the BOM was manager on duty on Saturday and payroll staff was on duty on Sunday. The Activity Director could not initially provide participation lists for the weekend activities, and later provided handwritten participation lists that were written in the same handwriting, including a Sunday list that was identical to the Saturday list except for the date. The BOM stated she was on duty on Saturday but had other tasks and was not able to help with activities, and she said staff really did not round up residents. Payroll staff stated they did not do activities on Sundays because they had church, and CNA staff said weekend activities depended on what staff was available. The facility’s Weekend Manager Checklist included duties for appropriate activities in the lobby and weekend activities with participation lists left for the Activity Director, and the Activities Policy stated the facility was to provide an ongoing program to support residents in their choice of activities.
Infection Control Lapses During Medication Administration and Perineal Care
Penalty
Summary
The facility failed to ensure infection control practices were followed during medication administration for two residents. On 4/13/26 at 6:13 A.M., an LPN was observed preparing medications for Resident G when a pill fell onto the medication cart; the LPN picked it up with a bare hand and placed it into the medication cup before administering the medications to the resident. Later that morning, another LPN was observed preparing medications for Resident D and, after a pill fell onto the medication cart, picked it up with a bare hand and administered it to the resident. During interview, an RN stated that if a medication falls out of the package during administration, staff should use gloves so they are not touching the medication with bare hands and should dispose of the medication rather than administer it. The facility also failed to follow infection control practices during perineal care for two residents. During observation of care for Resident C, a CNA performed perineal care and handled both dirty and clean tasks without changing gloves and sanitizing between tasks, including wiping the perineal area, placing a clean incontinence pad, removing a soiled pad, and then placing a clean pad under the resident. During observation of care for Resident B, an LPN performed perineal care, changed gloves after handling soiled items, but did not sanitize hands before putting on clean gloves while continuing care. The Infection Preventionist stated staff should change gloves and perform hand hygiene between dirty and clean tasks, and the facility's PPE policy stated gloves should be changed and hand hygiene performed between clean and dirty tasks and when moving from one body part to another.
Improper Medication Self-Administration Oversight
Penalty
Summary
The facility failed to ensure residents were properly assessed for self-administering medications for 2 of 2 random observations. One resident, whose diagnoses included chronic heart failure, stroke, diabetes mellitus type II, atrial fibrillation, and bipolar disorder, was observed lying in bed in the dark with a medication cup containing medications sitting on the bedside table. The resident’s clinical record showed intact cognition on the most recent quarterly MDS, but it lacked an order, care plan, and assessment to safely self-administer medications. During interview, the LPN stated she was unsure what the pills were on the bedside table and later confirmed they were the resident’s morning medications. A second resident, admitted with diagnoses including stroke, dysphagia, anxiety, and diabetes mellitus type II, was observed in the dining room taking medications when the resident dumped the pills out of the medication cup onto the table. The resident asked for more water, and the LPN left the resident alone with eight pills still to administer while she went back to the medication cart, leaving the resident blocked from view by a wall. The resident’s clinical record also lacked an order, care plan, and assessment to safely self-administer medications. The DON stated there were no residents in the facility who self-administer medications and that nursing staff should not leave medications alone with a resident to administer.
Inadequate Infection Preventionist Coverage
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, as required. During an interview, the Director of Nursing (DON) indicated she was covering both the DON and IP positions for the past two months. Although the DON was certified, there was no documentation of the hours she dedicated to infection control duties. Additionally, RN 7, who was assisting the DON, had not completed the necessary training to be certified as an IP. The facility's policy required a designated qualified individual to coordinate the infection prevention and control program, but this was not adhered to, as evidenced by the lack of documentation and the incomplete training of RN 7.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for 8 consecutive hours, seven days a week, as required. This deficiency was identified during a review of weekend staffing records from July 1, 2024, through September 30, 2024, which was triggered by the Payroll Based Journal (PBJ) indicating low weekend staffing. Specifically, there was no RN coverage for 8 consecutive hours on four days: Sunday, July 21, 2024, Sunday, August 4, 2024, Saturday, August 31, 2024, and Saturday, September 28, 2024. On July 21, 2024, and September 28, 2024, RN coverage was only for 4.03 hours and 4 hours, respectively, while there was no RN coverage at all on August 4, 2024, and August 31, 2024. During an interview, the Director of Nursing (DON) acknowledged the efforts to maintain RN coverage daily, including utilizing the wound nurse and Unit Manager to help cover weekends. The facility's nursing services policy requires the use of an RN for at least 8 consecutive hours a day, 7 days a week, unless waived.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a totally dependent resident was treated with respect and dignity by not having the call light within reach. On multiple occasions, the resident's call light was observed to be out of reach, preventing him from alerting staff when he needed assistance. For instance, a Certified Nurse Aide left the call light on the left side of the pillow, which the resident could not reach due to his condition. The resident, who had a history of stroke with hemiplegia and hemiparalysis of the left side, was unable to find the call light and expressed that it was often out of reach, especially during the night shift. Additionally, staff did not respond promptly when the resident called out for help. On one occasion, two CNAs walked past his room without checking on him while he was calling for assistance. The resident's clinical records indicated that he was totally dependent on staff for various activities, including bed mobility and toileting. Despite the facility's policy requiring staff to ensure the call light is within reach, this was not adhered to, as evidenced by the resident's repeated inability to access his call light and the staff's failure to respond to his calls for help.
Failure to Follow Physician Orders and Care Plans for Residents
Penalty
Summary
The facility failed to adhere to physician orders and care plan interventions for two residents, leading to deficiencies in medication administration and equipment management. For Resident 38, the oxygen concentrator was incorrectly set at 2 liters per minute (LPM) instead of the prescribed 3 LPM, and the bedside table was not locked as required by the care plan. Additionally, the resident's blood pressure was not consistently checked before administering Metoprolol, despite the physician's order to hold the medication if the systolic blood pressure was under 60 mmHg. The clinical record lacked documentation of blood pressure readings on numerous dates, indicating a failure to follow the care plan and physician orders. Resident 38's medical history includes heart failure, COPD, hypertension, pneumonia, and other conditions requiring careful monitoring and adherence to prescribed interventions. The resident's cognitive status was moderately impaired, necessitating substantial assistance with daily activities. Despite these needs, the facility did not ensure that the oxygen concentrator was set correctly or that the bedside table was locked, as outlined in the care plan. Furthermore, the failure to document blood pressure readings before administering medication suggests a lack of compliance with physician orders. For Resident 56, the facility did not have a care plan related to hypertension, despite the resident's diagnosis and physician orders for Metoprolol administration. The nurse administered the medication without checking the resident's heart rate, contrary to the physician's instructions to hold the medication if the heart rate was below 55. The Director of Nursing acknowledged the absence of a policy but stated that the expectation was to follow physician orders and care plan interventions. This oversight highlights a gap in the facility's adherence to prescribed medical protocols for residents with specific health needs.
Failure to Revise Resident Care Plan for Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current care needs, specifically for unnecessary medications. The care plan for a resident with diagnoses including Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and pneumonia was not updated to remove interventions that were no longer relevant, such as antibiotic use, fluid restriction, and daily weights. The resident's clinical record showed discontinued physician's orders for fluid restriction and daily weights, yet these interventions remained in the care plan. The deficiency was identified during a review of the resident's clinical record and confirmed through an interview with the Director of Nursing (DON), who acknowledged that care plans should be revised with changes to the resident's plan of care. The facility's Care Plan Revision Policy, provided by the DON, indicated that care plans should be updated with new or modified interventions as needed by the MDS Coordinator or other designated staff member. However, this policy was not followed, resulting in the outdated care plan for the resident.
Failure to Accurately Communicate and Verify Code Status During Emergency
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately known and communicated during an emergency situation. A resident with multiple diagnoses, including aortic valve disorder, pulmonary disease, type II diabetes, and heart failure, experienced a change in condition and was found unresponsive with abnormal vital signs. At that time, the nurse notified the physician and incorrectly reported the resident as having a Do Not Resuscitate (DNR) status, based on a printed document at the nurse's station. The physician instructed staff to monitor the resident due to the reported DNR status. Shortly after, the nurse realized that the resident's actual code status, as indicated in the medical record and a signed POST form, was full code, not DNR. Emergency responses, including the use of an AED and initiation of CPR, were then started. The error was traced to an outdated printed code status list at the nurse's station, which incorrectly listed the resident as DNR. The facility's policy required staff to verify code status using the medical record, but this was not followed at the time of the incident.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of MDS (Minimum Data Set) Assessments for four residents. Resident 39's MDS did not indicate a PASRR (Preadmission Screening and Resident Review) II, despite having a valid PASRR II completed by an external company. The MDS Coordinator attributed this to an entry error due to the absence of a social services coordinator. Similarly, Resident 31's MDS incorrectly marked the absence of a PASRR II, which was later found in the resident's chart. The MDS Coordinator acknowledged this as an error, again citing the lack of a social worker as the reason for the mistake. Resident 1's MDS also failed to indicate a PASRR II, which was present in the resident's chart, and the MDS Coordinator admitted to the error, attributing it to the same staffing issue. Additionally, Resident 51's MDS did not reflect that the resident was receiving hospice care, despite having a current hospice care plan and physician's orders for hospice services. The MDS Coordinator admitted to missing this information. The MDS Coordinator also revealed that there was no specific MDS policy in place, and she relied on the RAI (Resident Assessment Instrument) Manual for guidance. These inaccuracies in the MDS assessments were identified through interviews and record reviews conducted by the surveyors.
Failure to Ensure Palatable Food
Penalty
Summary
The facility failed to ensure palatable food was served, as evidenced by resident complaints and direct observation. During anonymous resident interviews, multiple residents described the food as horrid, overcooked, dry, and not worth eating. At a resident council meeting, residents indicated they had complained about the food but were told the menu was restricted by corporate. On a specific date, a meal tray containing oatmeal, a sausage patty, and a piece of french toast was found to be bland and tasteless, with the french toast having hard edges. The Dietary Manager was unaware of any complaints about the taste of the food and acknowledged that certain items like french fries and french toast often dry out. The facility's Food Preparation policy stated that food and drinks should be palatable, attractive, and at a safe and appetizing temperature, but this standard was not met.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure each resident was treated with dignity for two residents reviewed for choices. One resident, who had been on suicide watch, continued to receive meals on Styrofoam dishes even after the suicide watch was discontinued. The resident expressed dislike for the Styrofoam dishes, and staff acknowledged the oversight but had not yet contacted dietary to cancel the Styrofoam dishes. The resident's clinical records indicated she was cognitively intact and had diagnoses including depression and anxiety. Another resident was observed being fed by a CNA who was standing up, and later the CNA asked a nurse, 'What do you want me to do with her?' when the resident was done eating. The resident had severe cognitive impairment and required extensive assistance for various activities. The Director of Nursing indicated that staff should sit when feeding residents and acknowledged the need to inservice staff on using proper names and respectful language when discussing residents' care. The facility's policy on promoting and maintaining resident dignity emphasized treating each resident with respect and dignity, including speaking respectfully and avoiding discussions about residents that could be overheard.
Failure to Notify Ombudsman of Resident Transfers or Discharges
Penalty
Summary
The facility failed to notify the ombudsman of the transfer or discharge of three residents who were hospitalized. Resident 23 was sent to the hospital on 4/9/24, but their clinical record lacked documentation of notification to the ombudsman. Similarly, Resident 35 was hospitalized on 12/22/23, and their record also lacked the required notification. Resident 25, who had diagnoses including COPD, atrial fibrillation, and diabetes mellitus type II, was hospitalized from [DATE] through 7/10/23, but no notification was sent to the ombudsman. The issue was confirmed during interviews and record reviews. On 4/19/24, the Regional Consultant indicated that notifications for the three residents could not be located. The state ombudsman confirmed via email that no notification reports had been received for the relevant months. The Administrator admitted that no one at the facility was responsible for sending the discharge notifications to the ombudsman. The facility's Discharge Planning Policy, provided by the DON, stated that Social Services should notify the ombudsman of all discharges, but this was not being followed.
Failure to Follow Smoking Care Plans
Penalty
Summary
The facility failed to ensure care was provided in accordance with the written plan of care for two residents reviewed for smoking. One resident, who was cognitively intact and had a history of diabetes mellitus, hypertension, seizure disorder, and chronic obstructive pulmonary disorder, was observed smoking unsupervised on the front porch and keeping cigarettes in their room, contrary to the care plan that required smoking materials to be held by staff and smoking to occur in designated areas only. Staff interviews revealed inconsistencies in the enforcement of the care plan, with some staff indicating that the resident could keep smoking materials despite the care plan's directives. Another resident, who was moderately cognitively impaired and had diagnoses including paranoid schizophrenia, dementia, extrapyramidal movement disorder, and epilepsy, was observed smoking outside without supervision and without a smoking apron, contrary to the care plan that required supervision and the use of a smoking apron. The resident was also found to keep cigarettes in their rollator walker and dresser, despite the care plan stating that the resident should not have smoking materials on their person. Staff interviews confirmed that the resident was allowed to keep cigarettes and smoke unsupervised, indicating a failure to follow the care plan.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to provide care plan conferences quarterly for two residents reviewed for unnecessary medications. Resident 35, diagnosed with dementia and anxiety disorder, had a severe cognitive impairment as indicated by the most recent Quarterly MDS Assessment dated 4/11/24. The last care plan meeting for Resident 35 was held on 12/13/23, and there was no record of a care plan meeting since then. The Administrator mentioned that the facility did not have a current Social Services Director since January 2024, and the Activities Director was temporarily coordinating care plan meetings until a new SSD could be hired. Resident 52, diagnosed with Parkinson's disease, Alzheimer's disease, and anxiety disorder, also had a severe cognitive impairment as indicated by the most recent Quarterly MDS. The clinical record for Resident 52 lacked a care plan conference between 9/19/23 and 3/12/24. The Administrator indicated that social services were responsible for arranging care plan conferences, but due to the absence of a social services provider, the Activities Director was assisting with this task. The Administrator was unsure of the required frequency for care plan conferences. The Regional Consultant provided an undated policy indicating that care plan conferences should be held at routine intervals and after significant changes.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers and promote healing of existing pressure ulcers for two residents. Resident 64, who was admitted with a deep tissue injury (DTI) and incontinence-associated dermatitis (IAD), experienced worsening conditions, leading to the development of a stage IV pressure ulcer on the right heel. Despite having a care plan that included turning and repositioning every two hours, the resident was observed sitting in bed for extended periods without repositioning, and staff did not consistently follow the care plan interventions. The resident's sacral wound, initially acquired from the hospital, also worsened over time, with multiple observations and assessments indicating a lack of improvement and proper care management. The facility's wound care practices were inconsistent, and staff failed to adhere to the prescribed treatment protocols, contributing to the deterioration of the resident's condition. Resident 23, who had a diagnosis of dementia, traumatic brain injury, and anxiety, returned from hospitalization with a stage 3 sacral pressure ulcer. The resident's care plan included turning and repositioning every two hours and specific wound care treatments. However, observations revealed that the resident was not consistently repositioned, and the wound care provided did not always follow the physician's orders. The resident's sacral pressure ulcer showed signs of deterioration, with measurements indicating an increase in size and severity over time. The facility's failure to implement and adhere to the prescribed interventions and care plan contributed to the resident's declining condition. Both residents' clinical records and observations highlighted significant lapses in the facility's wound care management and adherence to care plans. The facility's staff did not consistently follow the prescribed interventions, such as turning and repositioning, and failed to provide timely and appropriate wound care treatments. These deficiencies in care led to the worsening of existing pressure ulcers and the development of new ones, indicating a failure to meet professional standards of practice in pressure ulcer prevention and management.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for Resident 26, who was at high risk for falls. Despite multiple interventions being documented in the resident's care plan, such as keeping the call light within reach, ensuring the bed was in the lowest position, and implementing a toileting plan, these interventions were not consistently followed. Observations showed that the call light was often out of reach, the bed was not always in the lowest position, and the resident was not toileted as per the care plan. This lack of adherence to the care plan resulted in multiple falls for the resident. Resident 26, who had diagnoses including anxiety, weakness, and Alzheimer's disease, was admitted on [DATE] and had a severely impaired cognition as per the most recent Quarterly Minimum Data Set (MDS) Assessment. The resident required extensive assistance for bed mobility, toileting, and transfers. Despite being identified as a high fall risk, the resident experienced seven falls from 11/22/23 to 4/18/24, with interventions either not being implemented or not being effective. For instance, 15-minute checks were not consistently performed, and the resident was often found on the floor after attempting to get up unassisted. Interviews with staff and the Director of Nursing (DON) revealed a lack of clarity and consistency in following the care plan interventions. Staff were unsure of the specific interventions in place for the resident, and the DON acknowledged that the bed should have been in the lowest position and the call light within reach, even though the resident could not use it. The facility's Accidents and Supervision Policy emphasized the need for adequate supervision and assistive devices to prevent accidents, but this was not effectively implemented for Resident 26, leading to repeated falls and potential harm.
Failure to Accurately Document Care Planned Interventions
Penalty
Summary
The facility failed to accurately document care planned interventions for a resident, specifically regarding restorative walking nursing tasks. Resident 18, who has diagnoses including renal failure, heart failure, and depression, indicated that she was instructed by the therapy department to use her walker and walk as much as possible with staff assistance. However, she reported that staff were often too busy to assist her, leading her to stop asking for help. The clinical record for Resident 18 showed discrepancies between documented activities and actual events, with records indicating walking and AROM exercises that did not occur as reported by the resident and staff. On multiple occasions, staff members documented that Resident 18 had completed walking and AROM exercises, despite the resident and staff interviews indicating otherwise. For instance, CNA 17 documented that the resident walked 150 feet and performed AROM exercises, but later admitted that these tasks had not been completed yet. Similarly, CNA 50 documented walking activities that did not align with the resident's dialysis schedule. The facility's policy on documentation requires that records be accurate, relevant, and complete, which was not adhered to in this case.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for two residents. For one resident with a stage 3 pressure ulcer, staff did not use Enhanced Barrier Precautions (EBP) as required. Despite a sign indicating the need for gown and glove use, a Certified Nurse Aide (CNA) entered the resident's room without the necessary protective equipment and made direct contact with the resident. The resident's clinical record also lacked an order for EBP, which was necessary given the resident's condition and care plan interventions. In another instance, a CNA failed to perform proper hand hygiene while providing incontinence care to a resident. The CNA did not wash hands between dirty and clean tasks and did not lather hands with soap during handwashing. The Infection Preventionist confirmed that staff should sanitize or wash hands between tasks and that hands should be scrubbed and lathered for at least 20 seconds. The facility's policies on Personal Protective Equipment and Hand Hygiene were not followed, leading to these deficiencies.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that resident call lights were accessible while residents were in their beds. Resident 64 was observed with her call light on the floor between her bed and her roommate's bed, making it inaccessible. Despite being cognitively intact and requiring extensive assistance for bed mobility, transfers, and toileting, the call light was not within her reach as per her Falls Care Plan. Similarly, Resident 51's call light was wrapped around the bed rail and out of reach, causing her to pull the cord out of the wall in an attempt to find it. The CNA who responded to the call light did not reposition it to make it accessible for the resident. Resident 51 was also cognitively intact and required assistance for bed mobility and transfers, indicating a need for the call light to be within reach at all times. Resident 17 was observed multiple times with her call light out of reach, either lying on a cabinet next to the bed or behind her while she was in a wheelchair. Despite being severely cognitively impaired and requiring extensive assistance for bed mobility, transfers, and toilet use, the call light was not positioned within her reach. The care plans for Resident 17 included interventions to ensure the call light was within reach, but these were not followed. Interviews with CNAs and an LPN confirmed that call lights should be within reach and secured, but this was not consistently practiced. The facility's policy on call light accessibility and timely response was not adhered to, leading to the deficiencies observed.
Unsafe Water Temperatures and Improper Equipment Storage
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. The water temperatures in multiple rooms and shower areas on A and B Halls were found to be above the safe limit of 120 degrees Fahrenheit. Specific instances included water temperatures reaching as high as 132.5 degrees Fahrenheit in one room and fluctuating temperatures in others. Staff interviews revealed that some were unaware of the proper water temperature limits, and one staff member admitted to noticing overly hot water but did not report it. Additionally, a raised toilet seat was observed stored on the bathroom floor, which is not a sanitary practice. The Maintenance Director indicated that a mixing valve had to be replaced due to issues with water temperatures and acknowledged that the water temperature should not exceed 120 degrees Fahrenheit. However, the facility's policy on safe water temperatures was not adhered to, as evidenced by the recorded temperatures. The Director of Nursing provided a policy that emphasized the importance of keeping resident care equipment clean and properly stored, which was also not followed, as seen with the improperly stored raised toilet seat. These deficiencies highlight lapses in maintaining a safe and sanitary environment for the residents and staff.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing sheets contained the required information daily for five consecutive days. On each day from 4/15/24 to 4/19/24, the staffing sheets posted at the front entrance lacked the facility name and did not clearly indicate the actual hours worked by the nursing staff. Additionally, on 4/18/24, the posted sheet also lacked the correct census information. The sheets were observed to be too dark to be readable, and the times listed were not decipherable as the actual hours worked by the nursing staff. During an interview on 4/19/24, the Scheduler acknowledged the deficiencies, stating that she was unaware that the facility name needed to be filled out and that the times listed were not clear. She also admitted to erasing the census on the 4/18/24 sheet and forgetting to rewrite it correctly. The facility's current posted nurse staffing policy, dated 11/28/17, requires the daily posting of the facility name, the total number and actual hours worked by licensed and unlicensed nursing staff per shift, and the resident census.
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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