Core Of Dale
Inspection history, citations, penalties and survey trends for this long-term care facility in Dale, Indiana.
- Location
- 510 W Medcalf Road, Dale, Indiana 47523
- CMS Provider Number
- 155270
- Inspections on file
- 42
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Core Of Dale during CMS and state inspections, most recent first.
Surveyors found that the facility used non-pasteurized shell eggs to prepare over-easy eggs for three residents each morning for about a month, while other residents received liquid eggs. Kitchen staff were unsure whether the eggs were pasteurized, and the supplier later confirmed they were not. On two observations of the dry storage area, scoops for bulk flour and sugar were left uncovered on top of the containers, and the dietary manager and DON acknowledged there was no specific policy for handling these scoops, despite an existing food procurement policy addressing egg purchasing specifications.
A resident with diabetes, severe cognitive impairment, and total dependence on staff for ADLs had physician orders for routine blood glucose monitoring with instructions to call the physician for values below 60 or above 400. The MAR showed multiple blood glucose readings outside these parameters, yet the clinical record contained no documentation that the physician was notified. The DON confirmed that no such documentation could be found and that staff were expected to notify the physician per orders and the facility’s Notification of Changes policy.
The facility failed to follow medication orders and ensure proper medication administration for multiple residents. A resident with diabetes received Tresiba insulin doses despite blood glucose levels below the ordered hold parameter. Another resident with hypertension received amlodipine and lisinopril even when systolic BP readings were below the ordered threshold to hold the medications. In a separate event, a housekeeper found unidentified pills under a resident’s bed, and an LPN later reported that staff had been instructed to monitor that resident for pill pocketing and to watch all residents swallow their medications.
The facility did not keep its survey results in a location that was readily accessible to residents, visitors, family members, and legal representatives. Although a sign at the entrance directed individuals to the East side nurse’s station for the survey binder, the binder was actually stored in a closed room behind that nurse’s station and typically kept on a shelf there, requiring staff (such as a CNA) to retrieve it. This practice conflicted with the facility’s Resident Rights Policy, as provided by the DON, which stated that residents have the right to examine the most recent annual survey, any plan of correction, and subsequent surveys in a place readily accessible to residents, consistent with 410 IAC 16.2-3.1-3(b)(1).
The facility did not comply with its posted nurse staffing policy by repeatedly posting daily staffing forms that lacked the facility name and the total hours worked by unlicensed staff (CNA/QMA). Over several consecutive days, forms displayed near the entrance listed only individual CNA hours per shift rather than the required total hours for unlicensed staff. The Business Office Manager, who posted unlicensed staff information while the DON posted licensed nurse staffing, reported she was unaware that the facility name and total unlicensed staff hours were required, despite the written policy specifying that total numbers and actual hours worked by licensed and unlicensed nursing staff per shift must be included.
The facility did not ensure that the Dietary Manager held the required certification for the position, as confirmed by interviews and review of job descriptions specifying certification as a minimum qualification.
Staff lacked knowledge and failed to properly test the chemical sanitizer levels in the facility's low-temperature dishwasher, resulting in chlorine levels well below the required range. The issue was identified when the Maintenance Supervisor used a test strip and found only 10 ppm chlorine, despite the facility's policy requiring 50-100 ppm.
Care plans for several residents with a history of sexual offenses were not revised to include individualized behaviors, restrictions, or interventions. Instead, only general interventions were listed, and staff were not consistently informed of specific restrictions or offender status. This resulted in a lack of resident-specific care planning and communication regarding the management of sexual offenders in the facility.
Surveyors identified strong urine odors in several rooms and shared bathrooms, soiled call light cords, and loose grab bars and toilet seats. Incontinence care products were found stored in a resident's refrigerator with food items. Housekeeping staff noted ongoing odor issues related to improper toilet flushing, and the DON reported no specific environmental policy in place.
A resident with dementia and significant weight loss did not have monthly weights properly recorded in the clinical record, and the medical provider was not notified of the weight loss. The dietitian's recommendation to increase a nutritional supplement was not implemented, and the resident continued to receive the supplement only once daily. The lack of documentation and communication among staff resulted in missed interventions to address the resident's ongoing weight loss.
A CNA took a resident's debit card without consent and withdrew $305.00 from the resident's bank account, failing to follow facility policy requiring administrative approval and documentation for such transactions. The resident, who had no cognitive impairment, did not authorize the withdrawal or receive the funds, and the incident was confirmed by video evidence.
A resident with a history of behavioral issues was involved in an incident where a CNA retaliated after being hit by the resident during care. The resident reported feeling the CNA was too rough and was threatened with retaliation. The facility's investigation found that the CNA did not follow proper protocol for handling aggressive behavior, leading to a deficiency in protecting the resident from abuse.
The facility failed to supervise two cognitively impaired residents, leading to their elopement. One resident exited through a malfunctioning side door and walked to a gas station, while another left through a faulty front door. Both residents had histories of wandering, but their care plans were not updated. Additionally, the facility did not implement fall risk interventions for two residents, resulting in multiple falls without care plan updates or proper notifications.
The facility failed to provide required transfer or discharge notices to residents or their representatives during hospitalizations. This deficiency was identified for five residents, including those with Parkinson's, dementia, and stroke. The DON confirmed the lack of documentation for these transfers, indicating a systemic issue.
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, affecting five residents. Despite the facility's policy requiring a written reservation agreement, documentation was missing for residents with various medical conditions, including Parkinson's disease, dementia, and stroke. The DON confirmed the absence of necessary documentation for these cases.
The facility failed to follow infection control practices during incontinence and wound care for several residents. Staff did not sanitize hands or change gloves between tasks, and handwashing was not performed for the required duration. The Infection Preventionist did not use an infection assessment tool, relying on nursing judgment instead. Facility policies on hand hygiene and infection control were not followed.
A facility failed to update a resident's code status, resulting in a mismatch between the resident's signed DNR form and the physician's orders indicating full code status. The resident, who was cognitively intact, expressed a desire to be a DNR, but staff were unaware of this preference. The DON confirmed the resident should be a DNR and highlighted the responsibility of nursing staff to update code status promptly.
The facility failed to ensure accurate MDS Assessments for three residents, leading to omissions and misclassifications of critical medical information. A resident's history of CVA was not marked, another's antiplatelet use was incorrectly coded as an anticoagulant, and a third resident's TBI was not included as an active diagnosis. The MDS Coordinator acknowledged these errors, and it was noted that the facility lacked a specific policy for MDS Assessments.
The facility failed to create care plans for three residents receiving antiplatelet medications. A resident with rheumatoid arthritis and atrial fibrillation, another with peripheral vascular disease, and a third with a traumatic brain injury were all prescribed antiplatelets without documented care plans. The MDS Coordinator admitted to the oversight, typically including antiplatelets with anticoagulant plans, but did not do so for these residents.
The facility failed to update care plans and physician orders for two residents, leading to deficiencies in care. A resident's care plan for a respiratory illness was not removed after recovery, and a pre-op diet order was not rescinded post-procedure. Another resident's care plans for antianxiety and anticoagulant medications remained active despite discontinuation of the medications. The DON acknowledged these oversights, which were contrary to the facility's policy on care plan revisions upon status change.
The facility failed to adequately track and assess behaviors for two residents at risk for behavioral issues. For one resident, the behavior tracking system was inconsistent, with missing documentation for behaviors like wandering and insomnia. The SSD acknowledged the lack of a comprehensive tracking system, and the RN was unaware of the resident's insomnia. For another resident, discrepancies existed in behavior documentation across the MAR, progress notes, and task records. The facility's policy required behavior monitoring every shift, but documentation did not align with this policy.
The facility failed to maintain accurate documentation for two residents. One resident's records inaccurately showed them as present in the facility during hospitalization, with incorrect activity and medication monitoring entries. Another resident's fall risk assessments were inconsistent, failing to reflect their history of falls and predisposing conditions. The DON acknowledged errors in documentation and the need for consistent protocol adherence.
The facility failed to provide necessary treatment and services for residents with dementia, leading to multiple incidents of aggressive and inappropriate behavior. Care plans were not updated, recommended treatments were not followed, and residents were left unsupervised, resulting in physical altercations and sexually inappropriate conduct.
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident. The investigation did not include interviews with all potential witnesses or other residents who received care from the accused CNA, contrary to the facility's policy on abuse investigation.
Improper Use of Non-Pasteurized Eggs and Uncovered Bulk Scoops in Kitchen
Penalty
Summary
The facility failed to ensure safe storage and preparation of food in the kitchen, specifically regarding the use of non-pasteurized shell eggs and improper storage of scoops in bulk dry goods. During a kitchen tour, surveyors observed that eggs stored in the refrigerator were not labeled as pasteurized, and the box did not indicate pasteurization. A dietary aide confirmed she did not see any indication that the eggs were pasteurized and was unsure of their status. Subsequent interviews revealed that the supplier later confirmed the eggs were not pasteurized and that these eggs had been ordered and used for approximately a month. During this time, three identified residents were routinely served over-easy eggs made from these non-pasteurized shell eggs every morning, while liquid eggs were used for other residents. One CNA reported that one of these residents consistently had loose stools and that his breakfast eggs were always runny. In addition to the egg issue, surveyors observed food handling concerns in the dry storage area on two separate days. Scoops used for bulk containers of flour and sugar were found lying uncovered on top of the containers. The dietary manager initially stated she did not know whether the scoops needed to be covered, and the DON later indicated there was no existing policy for scoops used with bulk items, although she stated they should be covered similarly to an ice scoop. The facility’s Food Procurement policy referenced purchasing graded infertile eggs, fresh and frozen, but did not address the pasteurization status of shell eggs or the handling of scoops for bulk dry goods.
Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician as ordered when a resident’s blood glucose levels were outside the prescribed parameters. The resident had diagnoses including diabetes mellitus and a most recent MDS showing severe cognitive impairment, and was dependent on staff for toileting, transferring, bed mobility, showering, and eating. Physician orders in effect during the review period required blood glucose monitoring (initially before meals and at bedtime, later twice daily) with instructions to call the physician if blood sugar was less than 60 or greater than 400. Review of the Medication Administration Record showed multiple blood glucose readings outside these parameters, including values of 421, 54, 44, 47, 41, 57, 49, 402, 412, 50, and 59 at various times. The clinical record lacked documentation that the physician was notified for any of these out-of-range blood glucose readings. During interview, the DON stated she was unable to locate documentation of physician notification and acknowledged that nursing staff should call the physician as indicated in the order when a blood sugar was out of range. The facility’s Notification of Changes policy required staff to consult with the resident’s physician and notify the resident and family or legal representative when there is a change requiring such notification. Despite this policy and the explicit physician orders, there was no evidence that the physician was contacted regarding the abnormal blood glucose results identified in the record review.
Failure to Follow Medication Hold Parameters and Ensure Ingestion
Penalty
Summary
The facility failed to ensure medications were administered according to prescriber orders and professional standards for multiple residents. For a resident with diabetes mellitus and severe cognitive impairment, the physician’s order for Tresiba insulin specified that 26 units were to be given in the afternoon and held if blood sugar was less than 150. Review of the MAR showed that on two separate dates, Tresiba insulin was administered when the resident’s blood sugar levels were 102 and 121, both below the ordered hold parameter. For a resident with hypertension and moderate cognitive impairment, physician orders for amlodipine 10 mg and lisinopril 20 mg directed that each medication be held if the systolic blood pressure (SBP) was less than 110. Record review showed that on three separate dates, both antihypertensive medications were administered despite SBP readings of 107, 100, and 101, all below the ordered threshold. The DON confirmed that the blood pressure medications should not have been given when the SBP was less than 110. In a separate incident, a housekeeper discovered two white oblong pills and one circular orange pill under a resident’s bed during a room cleaning. The housekeeper asked an LPN to identify the pills, and the LPN stated she did not know what they were. During interview, the LPN reported that nursing staff had a note to watch this resident to ensure pills were not pocketed in the mouth and that staff were expected to observe all residents swallowing their medications. The facility’s current Administering Medications policy stated that medications are to be administered in a safe and timely manner and in accordance with prescriber orders.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that past survey results were readily accessible to residents, visitors, family members, and legal representatives for the entire survey period. A sign posted in the entrance area directed individuals to the East side nurse’s station to access the survey binder, but the binder itself was kept in a closed room behind the East Hall nurse’s station rather than in an open, easily accessible location. On one occasion, a CNA had to retrieve the survey binder from this closed room and stated that the binder was usually stored on a shelf there. The facility’s Resident Rights Policy, provided by the DON, stated that residents have the right to examine the results of the most recent annual survey, any plan of correction, and subsequent surveys, and that these results must be available in a place readily accessible to residents, as required by 410 IAC 16.2-3.1-3(b)(1). This discrepancy between the posted sign, the actual storage location of the survey binder, and the requirements in the Resident Rights Policy and state regulation resulted in the survey results not being easily accessible for 5 of 5 days during the survey period.
Incomplete Daily Nurse Staffing Postings for Unlicensed Staff
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing forms contained all required information, specifically the facility name and the total working hours of unlicensed staff (CNA/QMA), for five consecutive days reviewed during the survey period. On multiple observations, including 3/31/26, 4/1/26, 4/2/26, 4/6/26, and 4/7/26, the forms were seen posted in the hallway across from the entrance without the facility name and without the total hours worked by unlicensed staff, although individual CNA hours per shift were listed. During an interview, the Business Office Manager stated she posted the unlicensed staff information while the DON posted the licensed nurse staffing, and she was not aware that the facility name needed to be on the form or that the total hours worked for unlicensed staff were required to be posted. Review of the facility’s Posted Nurse Staffing policy, dated 7/26/23, showed that the nurse staffing sheet was required to be posted daily and to include the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, which was not followed in practice. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on incomplete and noncompliant nurse staffing postings.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, as required. The Dietary Manager, who began in the role on 9/5/25, did not possess a current certification at the time of the survey and was in the process of becoming re-certified. During an interview, the Dietary Manager confirmed the lack of current certification. The Director of Nursing provided a job description for the Dietary Manager position, which specified that certification as a dietary manager or food service manager is a minimum requirement, along with meeting state requirements. The deficiency was identified through interviews and record review, with no mention of specific residents or patient conditions.
Failure to Properly Test Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to properly test and monitor the dishwasher's sanitation process, as staff were not knowledgeable about the correct use of chlorine test strips required for a low-temperature dishwasher. The Dietary Manager was unsure of the dishwasher type and reported that staff only checked the temperature, not the chemical sanitizing levels, and could not locate the necessary test strips. Maintenance staff confirmed that while they checked the temperature daily, they did not test the chemical levels, as this was not their responsibility. When the Maintenance Supervisor eventually tested the dishwasher with a chlorine strip, the reading was 10 ppm, which was below the required 50-100 ppm as stated in the facility's manual. The DON indicated that kitchen staff were expected to notify maintenance of any issues, but they were unaware of the problem until it was discovered during the survey. No specific residents or patient conditions were mentioned in relation to this deficiency.
Failure to Revise Care Plans for Residents with Sexual Offender Status
Penalty
Summary
The facility failed to ensure that care plans for residents with a history of sexual offenses were specific, comprehensive, and revised to include individualized behaviors, restrictions, and interventions. Four residents with sexual offender status were reviewed, and in each case, their care plans lacked detailed information about their specific sexual offender history, the nature of their offenses, and any individualized restrictions or interventions required. The care plans contained only general interventions such as monitoring for inappropriate sexual behaviors, involving residents in activities, and encouraging appropriate communication, without addressing resident-specific risks or restrictions. For example, one resident with moderate cognitive impairment and a history of multiple sclerosis was listed as a sex offender, but their care plan did not specify their offense or any unique restrictions. Another resident, identified as a sexually violent predator and cognitively intact, had a care plan that did not include details about their specific behaviors or restrictions, despite a history of verbal aggression and medication refusal. A third resident with psychoactive substance abuse and a history of noncompliance had a care plan focused on physical aggression, with no mention of their sexual offender status or related restrictions. A fourth resident, who was later discharged for parole violations involving prohibited electronic devices and inappropriate images, also had a care plan lacking individualized details about their sexual offender history and restrictions. Interviews with facility staff revealed a lack of clear communication and documentation regarding which residents were sexual offenders and what specific restrictions applied to them. Staff often learned about residents' offender status informally, and restrictions were not consistently incorporated into care plans or communicated to all staff. The facility's policies required care plan revisions and safety plans for offenders, but these were not effectively implemented, resulting in care plans that did not address the unique needs and risks associated with residents who were sexual offenders.
Environmental Deficiencies: Odors, Soiled Equipment, and Unsafe Fixtures
Penalty
Summary
The facility failed to maintain a homelike and safe environment for residents, as evidenced by strong urine odors in multiple resident rooms and shared bathrooms, soiled call light cords, and loose grab bars and toilet seats. Observations on two separate dates revealed persistent strong urine odors in several rooms and bathrooms, with no improvement noted between visits. Additionally, call light cords in several bathrooms were found to be brown and soiled, with some cords wrapped around grab bars, and grab bars and toilet seats were reported as loose. Further deficiencies were identified when peri-cleanser and cream, both used for incontinence care, were found stored in a resident's refrigerator alongside food items. A CNA confirmed that these items should not be stored in the refrigerator and removed them. Housekeeping staff acknowledged that some rooms had persistent odors due to residents not flushing toilets properly and stated that they used odor eliminators and cleaned rooms daily. The DON indicated there was no specific policy for maintaining the environment, but that regulations were followed.
Failure to Monitor and Address Resident Weight Loss and Nutrition Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards for a resident with significant nutritional needs. A resident with dementia, dependent on staff for eating and other activities of daily living, experienced ongoing weight loss. The resident was on a mechanical soft diet and had orders for monthly weights and a daily nutritional supplement (magic cup). However, the resident's weights for August and September were not entered into the clinical record, and there was no documentation that the medical provider or family were notified of the weight loss. The dietitian's recommendation to increase the supplement to twice daily was not implemented, and the resident continued to receive the supplement only once daily with supper. Interviews and record reviews revealed that the registered dietitian had not evaluated the resident since July, and the dietary manager was unaware of current residents with weight loss. The process for monitoring and reporting weight changes was not followed, as weights were not consistently recorded or communicated to the appropriate staff. The lack of documentation and communication led to missed interventions, including the failure to increase nutritional supplementation and notify the medical provider of significant weight loss, as required by facility policy.
Unauthorized Withdrawal of Resident Funds by Staff
Penalty
Summary
A certified nursing assistant (CNA) took a resident's debit card without consent and used it to withdraw $305.00 from the resident's bank account. The incident occurred in the early morning hours, and the resident was alerted to the unauthorized withdrawal by a notification from his bank. The resident, who had diagnoses including heart failure, COPD, and chronic pain, was assessed as having no cognitive impairment at the time of the incident. During interviews, the resident stated that he did not give the CNA his debit card or ask her to withdraw money, nor did he receive any of the withdrawn funds. Facility policy required that any staff member taking a resident's debit card for transactions must have approval from the Administrator or DON, especially after hours, and that a Money Transaction Shopping Form must be completed. Staff interviews confirmed that the proper procedures were not followed, as there was no documentation or approval for the transaction, and the whereabouts of the withdrawn cash remained unknown. Video evidence from the local ATM corroborated that the CNA made the withdrawal without proper authorization.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nurse Aide (CNA) and a resident. The incident occurred when the resident, who has a history of behavioral issues due to multiple diagnoses including traumatic brain injury and schizoaffective disorder, became agitated during incontinence care. The resident allegedly hit the CNA in the face, and in retaliation, the CNA struck the resident in the ribs. The resident later reported feeling that the CNA was being too rough during care and claimed that the CNA threatened to hit back if struck. The facility's investigation revealed that the CNA did not follow proper protocol when dealing with aggressive behavior from the resident. According to another CNA, staff members are instructed to remove themselves from situations where a resident is being aggressive and to re-approach the resident later. The facility's policy emphasizes the prohibition of abuse, including physical and verbal threats, but this protocol was not adhered to in this instance, leading to the deficiency.
Inadequate Supervision and Elopement Policy Failures
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to its elopement policy, resulting in two cognitively impaired residents eloping from the facility. Resident B, who had a history of wandering and was wearing a WanderGuard, exited the facility through a side door that was not properly secured due to a malfunctioning alarm system. The resident walked 0.5 miles to a gas station before being picked up by staff. The facility's records did not document any exit-seeking behavior prior to the incident, and the care plan was not updated with new interventions to prevent further elopement. Resident C, who was moderately cognitively impaired and also wore a WanderGuard, exited the facility through the front door after returning from an overnight stay with family. The front door was found to be malfunctioning, and the alarm did not sound as expected. The resident was found outside the facility by a staff member and returned safely. Despite previous notes indicating wandering behavior, the care plan was not updated after the elopement incident. Additionally, the facility failed to implement interventions to reduce fall risks for two residents. Resident 18 experienced multiple falls without updates to the care plan or proper notifications to family and physicians. Similarly, Resident 33 had falls without documented post-fall risk assessments or care plan updates. The facility's failure to complete fall risk assessments and update care plans after falls contributed to ongoing safety risks for these residents.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents or their representatives, as required by regulations. This deficiency was identified for five residents who were hospitalized. The clinical records for these residents lacked documentation of a notice of transfer or discharge being given at the time of hospitalization. Specifically, Resident 12, diagnosed with Parkinson's disease and dementia, was transferred to the hospital without receiving the necessary notice. Similarly, Resident 33, with a history of stroke and dementia, was also transferred without proper notification. Further instances of this deficiency were noted with Resident 18, who was hospitalized on multiple occasions, and Resident 6, who was transferred to the hospital without receiving the required notice. Additionally, Resident 7's records did not contain documentation of a transfer notice during their hospitalization. Interviews with the Director of Nursing confirmed the absence of documentation for these transfers, indicating a systemic issue in the facility's process for notifying residents and their representatives of transfers or discharges.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, as required. This deficiency was identified for five residents who were hospitalized. Resident 12, diagnosed with Parkinson's disease and dementia, was transferred to the hospital and returned without documentation of receiving a bed hold policy. Similarly, Resident 33, with a history of stroke and dementia, was also transferred and returned without the necessary documentation. The Director of Nursing (DON) confirmed the absence of documentation for both residents. Further review revealed that Resident 18, who was hospitalized on multiple occasions, did not receive a bed hold policy during any of these transfers. Resident 6, hospitalized on a specific date, also lacked documentation of receiving the policy. Additionally, Resident 7's records did not show that a bed hold policy was provided during their hospitalization. The DON acknowledged the lack of documentation for these residents, despite the facility's policy requiring a written reservation agreement prior to discharge or as soon as possible in emergency situations.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during incontinence and wound care for several residents. During a dressing change for a resident, a registered nurse did not wash or sanitize hands before putting on gloves, failed to change gloves between tasks, and did not sanitize hands after removing gloves. The nurse also did not lather for the recommended 20 seconds when washing hands. This lack of proper hand hygiene and glove use was observed during the care of Resident 35. Incontinence care for multiple residents was also performed without adherence to infection control protocols. Certified Nurse Aides (CNAs) were observed not sanitizing hands before donning gloves, failing to change gloves between dirty and clean tasks, and not washing hands for the required duration. For instance, during care for Resident 2, CNAs used the same gloves throughout the process, including when handling clean items, and did not offer the resident an opportunity to wash hands afterward. Similar lapses were noted in the care of Residents 12, 15, and 31, where CNAs did not change gloves or perform hand hygiene between tasks. The facility's Infection Preventionist admitted to not using an infection assessment tool or management algorithm, relying instead on nursing judgment. The facility's policies on hand hygiene, perineal care, and infection control were not followed, as evidenced by the observations. These policies require hand hygiene before and after glove use, changing gloves between tasks, and ensuring residents' hands are cleaned during care. The Infection Preventionist provided these policies during the survey, but they were undated and not adhered to by the staff.
Failure to Clarify Resident's Code Status
Penalty
Summary
The facility failed to clarify a resident's code status, leading to a discrepancy between the resident's wishes and the documented orders. Resident 41, who was cognitively intact and diagnosed with conditions including hypertension and hyperlipidemia, had a signed Do Not Resuscitate (DNR) form. However, the current physician's orders and care plans indicated a full code status, meaning CPR would be performed. During interviews, Resident 41 expressed a desire to be a DNR, but RN 25 stated that the resident was a full code. The Director of Nursing acknowledged that Resident 41 should be a DNR and emphasized that nursing staff are responsible for updating code status immediately when changes occur. The facility's Advance Directive Policy, provided by the DON, underscored the importance of respecting residents' healthcare choices, yet the policy was undated.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) Assessments for three residents, leading to deficiencies in documenting critical medical information. For Resident 5, the MDS Assessment did not mark a history of cerebrovascular accident (CVA) despite it being a part of the resident's diagnosis. This oversight was acknowledged by the MDS Coordinator as an error. Similarly, Resident 14's MDS Assessment incorrectly coded the use of Clopidogrel, an antiplatelet medication, as an anticoagulant, despite the absence of any anticoagulant orders or administration during the assessment period. This misclassification was also confirmed by the MDS Coordinator. Resident B's MDS Assessment failed to include traumatic brain injury (TBI) as an active diagnosis, despite it being part of the resident's medical history. The MDS Coordinator admitted that TBI should have been included but was missed. Additionally, it was noted that the facility did not have a specific policy for conducting MDS Assessments, relying instead on the Resident Assessment Instrument (RAI) manual. These inaccuracies in the MDS Assessments highlight a lack of attention to detail in documenting residents' medical conditions accurately.
Failure to Develop Care Plans for Antiplatelet Use
Penalty
Summary
The facility failed to develop a care plan for three residents who were receiving antiplatelet medications. Resident C, diagnosed with conditions including rheumatoid arthritis, paroxysmal atrial fibrillation, and dementia, was prescribed aspirin for atrial fibrillation but lacked a care plan for its use. Similarly, Resident 3, with peripheral vascular disease and cognitive impairment, was on a daily aspirin regimen without an accompanying care plan. Resident 10, who had a traumatic brain injury and moderate cognitive impairment, was prescribed clopidogrel for stroke prevention, yet no care plan was documented for the antiplatelet medication. During an interview, the MDS Coordinator acknowledged the omission, stating that she typically included antiplatelet medications with anticoagulant care plans but had not done so for these residents. The facility's policy mandates the development of a comprehensive, person-centered care plan for each resident, which was not adhered to in these cases. The Director of Nursing provided a policy document confirming this requirement, highlighting the oversight in care planning for the residents involved.
Failure to Update Care Plans and Physician Orders
Penalty
Summary
The facility failed to update care plans and physician orders to reflect the current status of residents, leading to deficiencies in care for two residents. Resident 14, diagnosed with dementia and depression, had a care plan for a respiratory illness that was not removed after recovery. Additionally, a pre-operative diet order was not rescinded after the procedure, resulting in an unnecessary dietary restriction. The Director of Nursing acknowledged that the restrictive diet order should have had an end date and that the care plan for the respiratory illness should have been resolved. Resident 10, with diagnoses including traumatic brain injury, anxiety, and depression, had care plans for antianxiety and anticoagulant medications that were not updated after the medications were discontinued. The clinical record lacked current orders for these medications, yet the care plans remained active. The Director of Nursing confirmed that the care plans should have been removed following the discontinuation of the medications. The facility's policy on care plan revisions upon status change was not adhered to, contributing to these deficiencies.
Inadequate Behavior Tracking for Residents
Penalty
Summary
The facility failed to ensure the safety of residents by inadequately tracking and assessing behaviors for two residents, Resident B and Resident 4, who were at risk for behavioral issues. For Resident B, the behavior tracking system was inconsistent and ineffective, as evidenced by the lack of documentation for behaviors such as wandering, fatigue, and trouble sleeping, despite these being noted in progress notes and the MAR. The Social Services Director (SSD) acknowledged the absence of a comprehensive tracking system and indicated that behaviors were not consistently documented across different records, leading to a failure to complete a Behavior Risk Assessment after Resident B's elopement. Resident B had a history of elopement and wore a WanderGuard, yet the facility did not track his wandering behaviors, considering them normal activity. The SSD, who started in March 2024, was in the process of implementing a tracking system but had not yet established one. The inconsistency in behavior documentation was evident as the SSD maintained a Behavior Tracking Binder, which lacked comprehensive entries for Resident B's behaviors. Additionally, the RN was unaware of Resident B's insomnia, highlighting a communication gap during shift changes. For Resident 4, the facility also failed to maintain consistent behavior tracking. The MAR, progress notes, and task portions of the clinical record showed discrepancies in documented behaviors. The SSD had not started tracking behaviors for Resident 4, and the Director of Nursing (DON) indicated that behavior reviews were based on 24-hour reports, which did not pull information from all relevant sections of the clinical record. The facility's Behavior Management policy required behavior monitoring every shift, but the documentation did not align with this policy, leading to incomplete tracking and assessment of Resident 4's behaviors.
Inaccurate Documentation for Residents' Status and Fall Risk
Penalty
Summary
The facility failed to ensure accurate documentation for two residents reviewed for accidents. Resident 4's clinical record inaccurately reflected their presence in the facility while they were hospitalized. Despite being hospitalized from July 2 to July 19, 2024, the resident's progress notes and Medication Administration Record (MAR) indicated activities and medication monitoring as if the resident were present in the facility. The Activities Director acknowledged an oversight in marking the wrong person on the log, and the Director of Nursing (DON) noted that the resident should have been marked as out of the facility, which would have prevented the incorrect documentation. For Resident 5, the facility failed to accurately document fall risk assessments. The resident, diagnosed with dementia, aphasia, depression, and a psychotic disorder, had experienced a fall on April 6, 2024. However, the fall risk assessments were inconsistent, with some indicating no falls or predisposing diseases, despite the resident's history of stroke and occasional falls due to weakness. The DON admitted that the fall risk assessments were not filled out correctly and emphasized the need for consistent protocol adherence. The facility's policy on documentation required it to be factual, objective, and accurate, which was not adhered to in these cases.
Failure to Provide Necessary Treatment and Services for Residents with Dementia
Penalty
Summary
The facility failed to provide necessary treatment and services for residents diagnosed with dementia with behavioral disturbances. Specifically, the care plans for residents were not updated following persistent behaviors, recommended treatments and orders were not followed, outside services were not updated on continuing behaviors, and residents were left unsupervised. This resulted in multiple incidents of aggressive and inappropriate behavior among residents, including physical altercations and sexually inappropriate conduct. Resident B, diagnosed with dementia with psychotic disturbance, anxiety, major depressive disorder, bipolar disorder, and conduct disorder, exhibited aggressive behaviors towards other residents. Despite being placed on 15-minute checks, documentation of these checks was inconsistent, and no new behavioral interventions were implemented since 11/17/23. Incidents included Resident B choking Resident D and engaging in a physical altercation with Resident F. Additionally, Resident B was not seen by a psychotherapist as recommended by the Psychiatric Nurse Practitioner (NP). Resident D, diagnosed with dementia with other behavioral disturbance, anxiety, paraphilia, mood disorder, psychosis, major depressive disorder, and insomnia, exhibited behaviors that distressed other residents, such as invading personal space and taunting. Despite these behaviors being documented, no new interventions were added to his care plan. Resident C, diagnosed with dementia with other behavioral disturbance, impulsiveness, and anxiety, exhibited sexually inappropriate behaviors, including exposing himself and asking another resident to perform oral sex. Despite these behaviors, no new interventions were added to his care plan since 11/30/23, and communication with psychiatric services was inadequate.
Incomplete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation for an allegation of verbal abuse involving Resident B. A nurse overheard a CNA yelling and cursing at Resident B, and the incident was reported. The facility's investigation included a statement from the accused CNA and an interview with Resident B's roommate. However, the investigation did not include an interview with another CNA who allegedly witnessed the incident, nor did it include interviews with other residents who received care from the accused CNA on the day of the incident. During interviews, the facility administrator and the DON acknowledged that the investigation was incomplete, as it did not include all potential witnesses and other residents on the unit where the alleged abuse occurred. The facility's policy on abuse prohibition and investigation requires a thorough investigation to gather pertinent information and verify the occurrence, which was not fully adhered to in this case.
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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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