Caroleton Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Connersville, Indiana.
- Location
- 2500 Iowa Ave, Connersville, Indiana 47331
- CMS Provider Number
- 155387
- Inspections on file
- 24
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Caroleton Healthcare Center during CMS and state inspections, most recent first.
A resident with pneumonia had incomplete McGeer criteria documentation for IV ceftriaxone use, and two other residents had refusals of care that were not accurately charted. One cognitively impaired resident refused heel boots during an observation, but the behavior log did not reflect the refusal, and another resident with stroke and alcohol-induced dementia frequently refused nail care, yet the behavior record showed only one refusal despite staff reporting repeated refusals.
A resident with urinary retention and an indwelling catheter had catheter care provided while a size 22 Fr catheter was in place, even though the physician’s order specified a size 20 Fr catheter. An LPN reviewed the order, confirmed the mismatch, and stated the needed catheter size was not available in facility supplies.
A resident who was cognitively intact and required substantial to maximal staff assistance with personal hygiene was observed with a full beard, long fingernails, and black substance under both hands' nails on multiple occasions. The resident stated he preferred to be clean shaven and said staff had not offered to shave him since admission, while the DON stated CNA staff were responsible for trimming and cleaning fingernails and shaving facial hair.
Failure to apply ordered tubi grip to a resident’s bilateral arms for edema. The resident was observed with swollen lower arms and at times did not have the tubular sleeves in place, despite a physician order and care plan directing tubi grip to both arms in the morning and off at bedtime. The resident stated he had never refused the sleeves and that they provided some relief from the swelling; the DON stated the nurse was responsible for applying them.
A resident with diabetes-related nerve damage, impaired mobility, and foot wounds developed an unstageable pressure injury to the heel after the facility did not consistently implement ordered heel boots and documented betadine treatment that staff later said could not have been applied because the heel was not visible under non-removable dressings. The resident’s care plan and physician orders called for pressure relief and heel suspension boots, but the treatment record did not reflect heel boot use and the heel wound was first identified after the dressing was removed.
Failure to perform hand hygiene and change gloves during catheter care: A resident with an indwelling catheter and a history of UTIs was observed receiving catheter and incontinent care from a QMA and CNA who put on gloves without hand hygiene, cleaned the genital area and catheter tubing, and later drained the catheter bag without performing hand hygiene after changing gloves. The staff stated they normally would complete hand hygiene and change gloves during catheter care, but they were nervous and did not do it.
A resident with a Foley catheter and another resident with multiple wounds were observed receiving care without required infection control practices. Staff did not perform hand hygiene before or during catheter care, did not wear gowns for EBP, and drained the catheter bag without hand hygiene. During wound care, an LPN used unclean scissors, did not change gloves or perform hand hygiene between wound treatments, and reapplied dressings without following standard precautions.
Survey results were not posted in a location readily accessible to residents, family members, or legal representatives for all residents. During a resident council meeting, residents said they did not know where the most recent survey results were located. An observation showed the survey binder and posted notice were placed above wheelchair level near the entrance, and a resident in a wheelchair could not reach the binder or read the sign without assistance.
Incomplete infection documentation and missed refusal-of-care charting
Penalty
Summary
The facility failed to maintain complete and accurate documentation related to antibiotic use for Resident 1, who had pneumonia and was ordered ceftriaxone 1 gram IV every 24 hours. The infection surveillance criteria report for the resident indicated the facility used McGeer criteria to determine whether antibiotic treatment was supported, but the report was incomplete because criterion 1c was not marked. During interview, the infection control nurse stated she forgot to document the mental status change and decline in activities of daily living criterion for the resident on the infection control criteria report. The facility also failed to accurately document refusals of care for Resident 3 and Resident 32. Resident 3, who was cognitively impaired, dependent for hygiene, turning, and transferring, and had delirium, confusion, skin impairments, surgical wounds, and a non-removable dressing, refused pressure-reducing heel boots during an observation and asked to float his heels with a pillow instead, but behavior monitoring documentation for that day did not show any refusals of care. Resident 32, who had stroke and alcohol-induced dementia and was cognitively impaired and dependent for grooming and hygiene, was observed with long, jagged fingernails, and staff stated the resident refused nail care frequently; however, the behavior management log documented only one episode of refusal for the review period, despite staff and leadership stating refusals occurred often.
Incorrect Foley Catheter Size
Penalty
Summary
The facility failed to follow the physician’s order for the correct size indwelling catheter for one resident. During an observation, QMA 3 and CNA 7 provided catheter care to the resident, and the catheter in place was size 22 French. When LPN 6 reviewed the physician’s order, the resident was supposed to have a size 20 French catheter. LPN 6 also stated the resident’s catheter had last been changed on 4/19/26 and later indicated she could not find a size 20 French catheter in the facility’s medical supplies. The resident’s record showed diagnoses including urinary tract infection and urinary retention. The care plan identified the resident as at risk for urinary complications related to urinary retention and an indwelling catheter, with an intervention to change the catheter as ordered by the physician. The physician’s order dated 4/15/26 specified a catheter size 20 with continuous drain. The quarterly MDS dated 1/6/26 indicated the resident was cognitively intact for daily decision making and had an indwelling catheter.
Failure to Provide Personal Grooming Assistance
Penalty
Summary
The facility failed to assist a dependent resident with fingernail care and facial hair removal. During observation and interview, the resident had a full beard and long fingernails with black substance underneath on both hands. The resident stated he did not prefer to have a beard, liked to be clean shaven, and said no staff had offered to shave him since admission. He also stated that when he was at home, he used an electric razor to trim his facial hair and then a disposable razor to cut his facial hair, and that staff sometimes trimmed his fingernails. Additional observations over the next two days showed the resident repeatedly sitting in common areas and eating lunch with moderately long fingernails on both hands, black substances under the nails, and a full long beard. The record showed diagnoses including Parkinson disease, muscle weakness, and need for assistance with personal care. The admission MDS indicated the resident was cognitively intact for daily decision making, had no behaviors of rejecting care, and required substantial to maximal staff assistance with personal hygiene. The care plan also indicated the resident required substantial to maximal staff assistance with personal hygiene. The DON stated it was the CNA's responsibility to ensure the resident's fingernails were trimmed and cleaned and his facial hair was shaven, and the routine resident care policy stated resident care was intended to promote dignity and honor resident lifestyle preferences.
Failure to Apply Ordered Tubular Compression to Resident’s Arms
Penalty
Summary
The facility failed to implement the physician-ordered tubular compression bandages to both arms for a resident with bilateral arm edema. The resident was observed with swelling of the lower arms on 4/21/2026 and again on 4/23/2026, when the tubular sleeves were not in place on either arm. The resident stated he did not know what caused the swelling and reported that he had never refused to wear the tubular sleeves. He also stated the sleeves provided some relief from the swelling. The resident’s record identified bilateral arm edema, and the physician recapitulation dated April 2026 ordered tubi grip to both arms every day and evening shift for edema, to be applied in the morning and removed at bedtime. The care plan also directed tubi grip to both arms in the morning and off at bedtime. The resident was cognitively intact, had no behavior of refusal of care, and required substantial to maximal staff assistance with upper body dressing. The DON stated the nurse was responsible for applying the resident’s tubular sleeves, and the facility policy stated the licensed nurse was responsible for executing physician orders.
Failure to Implement Heel Boots and Follow Wound Treatment Orders
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with partial traumatic amputation of two or more toes, diabetic nerve damage, and impaired mobility and gait. The resident’s admission MDS indicated cognitive impairment and dependence on staff for hygiene, turning, and transferring. The care plan included pressure ulcer interventions, and an intervention added on 3/17/2026 directed the use of heel boots to both feet while in bed. Hospital discharge orders also directed betadine to the left heel twice daily and pressure relief to both heels with heel suspension boots. However, the treatment record showed betadine was documented as applied to the left heel only from 3/9/2026 through 3/11/2026, and the treatment record and care plan did not reflect heel boot use between 3/8/2026 and 3/11/2026. The resident’s admission nursing assessment did not identify skin impairment to the left heel, but the resident had non-removable dressings to both feet. A wound care report later identified an unstageable pressure injury to the left heel measuring 2 cm by 5 cm, with no depth, and noted it was first measured after removal of the non-removable dressing. At that time, additional wounds were also found, including diabetic foot ulcers, a deep tissue injury to the left lateral foot, and a Stage 1 pressure injury to the right lateral foot. The ADON stated the resident’s heels were not visible on admission because of the non-removable dressings and that the left heel was not visible until the first dressing change on 3/25/2026. The ADON also stated staff would not have been able to apply betadine to the left heel as signed on the treatment record and that direct floor staff were responsible for wound care and implementing interventions, including bilateral heel boots.
Failure to Perform Hand Hygiene and Change Gloves During Catheter Care
Penalty
Summary
The facility failed to perform hand hygiene and change gloves during catheter care for a resident with an indwelling catheter. During an observation, the resident stated he had the catheter before admission and reported having been diagnosed with a urinary tract infection a few times since being at the facility. The resident had an indwelling catheter bag hanging on the side of the bed, and during care the QMA and CNA entered the room, applied gloves, and began care without hand hygiene first. The QMA lowered the bed, removed the resident’s incontinent brief, cleaned the genital area with a wet soapy washcloth, rinsed and dried the area, and then used the same soapy washcloth to clean the catheter tubing. The QMA and CNA applied a clean brief and pad, the CNA removed soiled linen, and then the QMA removed gloves, donned another pair, and drained the catheter bag into a urinal without performing hand hygiene. The QMA and CNA stated they normally would complete hand hygiene and change gloves during catheter care, but they were nervous and did not do it. The resident’s record showed diagnoses including UTI and urinary retention, a quarterly MDS indicating cognitive intactness and an indwelling catheter, and a physician order for an antibiotic for a UTI.
Failure to Follow EBP and Wound Care Infection Control Practices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions during catheter care for a resident with an indwelling Foley catheter and a diagnosis that included a UTI. The resident had an EBP sign at the doorway and EBP gowns and gloves hanging on the door, and the care plan dated 1/7/26 indicated EBP was required for the indwelling medical device. During observed catheter care, a QMA and CNA entered the room and applied gloves without hand hygiene, did not wear gowns, and provided personal care and catheter care while the resident’s incontinent brief was removed and the catheter tubing was cleaned. The QMA later drained the catheter bag into a urinal without performing hand hygiene, and both staff indicated they only kind of remembered training on wearing a gown during catheter care. The facility also failed to follow infection control practices during wound care for another resident with multiple wounds, including a blister to the left knee, diabetic foot ulcers, and pressure injuries to the left heel and both lateral feet. During observed wound care, an LPN had scissors removed from her pocket by the ADON, and the scissors were not cleaned before being used to cut xeroform for the left knee wound. The LPN did not change gloves or perform hand hygiene between removing and cleaning the left knee wound and applying a clean dressing, and then repeated the same process for the left heel wound without hand hygiene when changing gloves. The resident’s record identified cognitive impairment and a pressure care plan with wound care interventions, and the ADON stated hand hygiene was expected before the procedure, each time gloves were changed, and after the procedure, with scissors cleaned before use.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives for 46 of 46 residents. During a resident council meeting, residents stated they were unaware of the location of the most recent survey results. An observation of the survey binder showed it was placed in a bin attached to the wall by the facility entrance, with a sign above it indicating survey results availability, but neither the binder nor the sign were at wheelchair level. When the binder and posting were observed with Resident 18, the co-president of resident council, and the Executive Director, Resident 18 required assistance in her wheelchair to reach the binder and stated she could not read the posting above it.
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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