Creekside Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Mishawaka, Indiana.
- Location
- 1420 E Douglas Rd, Mishawaka, Indiana 46545
- CMS Provider Number
- 155784
- Inspections on file
- 33
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Creekside Village during CMS and state inspections, most recent first.
Staff failed to accurately carry out and document physician-ordered care for two residents. One resident with COPD and emphysema had a dirty oxygen concentrator and filter even though weekly cleaning was documented as completed on the MAR. Another resident with Parkinson’s disease, lymphedema, and pemphigus foliaceous had ordered Eucerin lotion and hydrocortisone ointment documented as given, but the resident said he had not received them, unopened ointment tubes were found in the treatment cart, and skin observation showed reddened, excoriated abdominal skin.
Failure to Administer Ordered Skin Treatments: A resident with Parkinson's disease, cellulitis, lymphedema, and pemphigus foliaceous was ordered Eucerin lotion and hydrocortisone ointment for dry skin and redness, but the resident reported not receiving the treatments despite MAR documentation showing they were given. Surveyors found unopened hydrocortisone tubes in the med room and an Eucerin bottle with an opened date that did not match the charted administration, and the resident had reddened, excoriated skin on the lower abdomen.
Oxygen equipment was not maintained according to orders and facility policy for two residents receiving respiratory care. One resident’s concentrator and filter were observed dirty and dusty despite orders for weekly cleaning, and another resident had undated oxygen tubing connected to a nasal cannula and portable O2 tank. The record and staff interview confirmed the expected cleaning and tubing-change schedule was not being followed.
Failure to complete ordered lab monitoring for a resident with dementia, MDD, morbid obesity, CHF, hypothyroidism, and DM2. The resident was receiving insulin, Jardiance, and levothyroxine, and had orders for Hgb A1C and TSH testing, but the chart lacked documentation that the labs were completed. The DON confirmed the labs had not been done timely, and the ED provided the facility's lab/radiology tracking policy.
A resident scheduled for oral extractions had the procedure cancelled because the facility did not hold Jardiance as instructed by the oral surgery center. The resident, who had dementia, MDD, morbid obesity, CHF, and DM2, continued to receive the medication on the days leading up to the procedure because the faxed hold order was not transcribed into the EMR.
A facility failed to secure a controlled narcotic medication, leaving it unattended at a resident's bedside. The resident had a cup of medications, including a narcotic pain medication, left on their table. An LPN confirmed the resident had refused the medication and planned to return later. The facility's procedure required medications to be observed being taken, not left at the bedside.
A facility failed to provide activities according to a resident's preferences, as the resident was often observed unengaged in front of a television despite having a care plan that included specific activities. The resident, with severe cognitive impairment and other medical conditions, had preferences for music and other activities, but there was no documentation of participation for several months. The facility also lacked an activity program policy.
A facility failed to assess and report a resident's skin condition, resulting in untreated scratches on the head. The resident, with multiple health issues, had scratches in various healing stages, but no weekly skin assessment was documented. The ADON was unaware of the condition, and no treatment for itching was ordered, nor was Hospice notified. The facility's policy on skin alterations was not followed, and the care plan did not address the itching issue.
A facility failed to obtain an admission weight and weekly weights for a newly admitted resident, leading to an undetermined weight loss. The resident, with multiple diagnoses including Alzheimer's and abnormal weight loss, was not weighed upon admission, and the facility relied on hospital discharge paperwork for initial weight records. Subsequent weight assessments showed a significant decrease, but there was no documentation of physician or family notification. The facility's policy required weekly weights for new admissions, which was not followed.
A facility failed to follow physician's orders for a resident with a G-tube, resulting in incomplete administration of enteral feedings and water flushes. Observations showed that bottles of Jevity 1.5 were left with significant amounts remaining, and the LPN did not document the actual amount given. The resident, with multiple diagnoses including malnutrition, did not receive the prescribed water flushes, and the physician was not notified of these deficiencies.
A facility failed to properly store a CPAP machine and its components for a resident with obstructive sleep apnea. The CPAP mask was found under bed covers or on the bed, and the sterile water used was unsealed and partially used. Additionally, the physician's order for CPAP settings was incomplete. The facility's policy did not specify storage or maintenance procedures for the equipment.
A newly admitted resident did not receive the influenza vaccine despite signing a consent form. The facility's process involved the IP confirming vaccine history and consent, but the vaccine was not administered, and no documentation explained the oversight. The facility's policy required offering the vaccine to all residents unless contraindicated or already immunized, which was not followed in this instance.
A resident with severe cognitive impairment and mobility issues fell in the bathroom, sustaining injuries. The incident was reported to the state, but the facility failed to submit the required 5-day follow-up report on time, as acknowledged by the Executive Director.
Failure to Accurately Carry Out Ordered Treatments and Document Care
Penalty
Summary
The facility failed to ensure staff accurately administered physician-ordered medications and treatments for 2 of 2 residents reviewed. For one resident with chronic obstructive pulmonary disease and emphysema, an observation found the oxygen concentrator dirty and dusty, with dust clinging to the filter. The resident’s orders required the oxygen tubing, humidity, concentrator, and filter to be cleaned on Sundays, and the MAR showed staff initials documenting those tasks as completed on multiple Sundays, including the most recent Sunday before the observation. The Unit Manager confirmed the concentrator and filter should have been cleaned weekly on Sundays, and the DON stated staff should not initial tasks until after they were completed. For another resident with Parkinson’s disease, cellulitis, urinary tract infection, lymphedema, neuromuscular bladder dysfunction, muscle weakness, hypertension, pemphigus foliaceous, and moderate cognitive impairment, physician orders initiated for Eucerin lotion and hydrocortisone ointment required scheduled application to dry skin and to the face, legs, and lower abdomen for redness. The MAR documented both treatments as administered starting on the day the orders were initiated, but the resident stated he had not received the medicated creams or Eucerin lotion and had asked several times without receiving them. He also stated staff had been applying the facility brand lotion instead of Eucerin because of his dermatologist’s recommendation. During observation, three unopened tubes of hydrocortisone ointment with the resident’s name were found in the treatment cart without open dates, and the Eucerin lotion had an open date later than the order date. The resident later stated he had only recently begun receiving the Eucerin lotion and was still waiting for the hydrocortisone cream to be applied. At the time of skin observation, he had reddened and excoriated skin to the entire lower half of his abdomen. The Executive Director stated the facility did not have a policy for following physician orders or for accurate records.
Failure to Administer Ordered Skin Treatments
Penalty
Summary
The facility failed to ensure ordered treatments were administered for a resident with Parkinson's disease, cellulitis of the right lower limb, lymphedema, muscle weakness, hypertension, pemphigus foliaceous, and other diagnoses. A Significant Change MDS dated 1/11/26 indicated the resident was moderately cognitively impaired. Physician orders dated 3/25/2026 directed Eucerin Original lotion to be applied twice daily to dry skin and Hydrocortisone Ointment 2.5% to be applied twice daily to the face, legs, and lower abdomen for redness. Although the March 2026 MAR showed both treatments as started on 3/25/2026, the resident stated on 3/26/2026 and again on 3/30/2026 that he had not received the medicated creams or the Eucerin lotion and had asked several times for them. During observation on 3/30/2026, three unopened tubes of hydrocortisone ointment with the resident's name were found in the medication room, each without an open date, and the Eucerin lotion bottle had an opened date of 3/27/2026 even though documentation indicated it had been applied before that date. On 3/31/2026, the resident stated he had only recently begun receiving the Eucerin lotion and would receive the hydrocortisone cream after lunch. A skin observation that day showed reddened and excoriated skin to the entire lower half of his abdomen. The Executive Director stated the facility did not have a policy for following physician orders or for accurate records.
Oxygen Equipment Not Maintained per Orders
Penalty
Summary
The facility failed to provide oxygen according to standards of practice for 2 residents receiving respiratory care. For Resident 1, who had diagnoses including chronic obstructive pulmonary disease and emphysema, an observation found the oxygen concentrator dirty and dusty, with a clump of dust on the filter at the back of the unit. The record showed physician orders for oxygen at 2 liters per minute every shift, with oxygen tubing, humidity, the concentrator, and the filter to be cleaned once a day on Sundays. The medication administration record indicated the tubing and concentrator/filters were cleaned on several Sundays in 2026, but the Unit Manager confirmed during interview that the concentrator and filter were dusty and should have been cleaned most recently on Sunday and weekly thereafter. For Resident 61, who had multiple diagnoses including COPD, acute on chronic respiratory failure, CHF, CKD, OSA, pulmonary hypertension, and PVD, an observation found undated oxygen tubing connected to the nasal cannula and portable oxygen tank behind the wheelchair, with an empty clear plastic bag dated and hanging behind the wheelchair. The clinical record included an order to change oxygen tubing and humidity and to clean the concentrator and filter once a day on Sunday during the night shift. During interview, the Regional Nurse Consultant stated she had checked for expired oxygen tubing in the resident's room. The facility also provided policies stating that concentrators and filters should be maintained for optimal function, nasal cannula tubing should be changed weekly and as needed, and the air inlet filter should be cleaned weekly and as needed.
Failure to Complete Ordered Laboratory Monitoring
Penalty
Summary
The facility failed to follow through on monitoring laboratory orders for Resident 3, whose record was reviewed on 3/27/2026. Resident 3 had diagnoses including dementia, major depressive disorder, morbid obesity, congestive heart failure, hypothyroidism, and type 2 diabetes mellitus, and was receiving diabetic medications including Freestyle insulin 5 units three times a day, Jardiance 10 mg daily, and Insulin Glargine 20 units daily, as well as Levothyroxine 100 mcg daily for thyroid issues. A physician's order dated 3/20/2026 required hemoglobin A1C and thyroid-stimulating hormone testing, but the resident's record lacked documentation that these laboratory orders had been completed. During interview, the DON stated the laboratory orders had not been completed and that the facility processes laboratory orders daily, but Resident 3's order had not been completed timely. The ED provided the facility policy titled, Guidelines for Lab and Radiology Tracking, which indicated to confirm that each lab and/or radiology test due has been obtained.
Oral Surgery Cancelled After Medication Hold Order Was Not Transcribed
Penalty
Summary
The facility failed to ensure an order for oral surgery was transcribed timely and followed timely for one resident who was scheduled for oral extractions. The resident had diagnoses including dementia, major depressive disorder, morbid obesity, congestive heart failure, and type 2 diabetes mellitus. A pre-surgical instruction sheet from the oral surgery center indicated the facility was to hold the resident’s scheduled doses of Jardiance four days before the procedure, and the resident had a current physician’s order for Jardiance 10 mg daily. Review of the March 2026 MAR showed the resident received Jardiance on March 21, 22, 23, and 24. A nursing note documented that the oral extractions were cancelled because the Jardiance had not been held prior to the procedure. The Unit Manager stated the facility had received a fax from the oral surgery center with instructions to hold Jardiance, but those orders had not been transcribed into the resident’s EMR. The Regional Nurse Consultant stated the facility did not have a policy for following physician’s orders.
Failure to Secure Controlled Narcotic Medication
Penalty
Summary
The facility failed to ensure that a controlled narcotic medication was either secured in a locked environment or under direct observation of the staff member administering the medication. During an observation, Resident D was found with a breakfast tray and a disposable cup of medications on his bedside table. The resident indicated that the pills were always left on his table, including a pain pill. An LPN later confirmed that Resident D had refused his medication and planned to return later to check if the resident had taken them. The medications left at the bedside included Eliquis, tamsulosin, lexapro, daily-vite, hydrocodone-acetaminophen, and mucinex. The LPN acknowledged that the medications should not have been left at the bedside. The facility's medication administration procedure, revised in July 2023, stated that medications should be observed being taken and not left at the bedside.
Failure to Provide Activities According to Resident Preferences
Penalty
Summary
The facility failed to provide individual and group activities according to the preferences of a resident, identified as Resident 11, who was reviewed for activities. Observations over several days showed that Resident 11 was often seated in a reclining gerichair in front of a television, but she was not engaged with the television or any other activity. On one occasion, she was observed lying in bed looking at the television. Despite having a care plan that included encouraging activities such as people-watching, musical activities, and watching specific types of TV shows, there was no evidence that these activities were being provided. Resident 11 had a history of severe cognitive impairment, dementia, and other medical conditions such as hypertension and diabetes. Her activity preferences, as indicated in her MDS assessments, included listening to music, reading, being around pets, and participating in religious practices. However, the Activities Director confirmed that there was no documentation of activity participation for Resident 11 for several months, despite being scheduled for one-to-one activities. Additionally, the facility lacked an activity program policy, which contributed to the deficiency in meeting the resident's activity needs.
Failure to Assess and Report Resident's Skin Condition
Penalty
Summary
The facility failed to assess a resident's skin condition and notify the physician in a timely manner for a resident with multiple scratches on the head. Observations on three separate dates revealed that the resident had scratches in various stages of healing, with some covered by thick scabs. The resident, who had a history of chronic obstructive pulmonary disease, heart failure, cerebral palsy, schizophrenia, dysphagia, and major depressive disorder, was known to refuse nail care, which was preferred to be provided by the family. Despite these observations, the resident's record lacked documentation of a weekly skin assessment by a nurse. The Assistant Director of Nursing (ADON) was unaware of the scratches until informed on a later date and confirmed that no treatment for itching was ordered, nor was Hospice notified of the resident's excessive scratching. The facility's policy required that any skin alterations be reported to a licensed nurse for further assessment, but this was not followed. The resident's care plan did not address the issue of excessive itching or scratching, indicating a lapse in the facility's adherence to its skin management program.
Failure to Monitor Resident's Weight Upon Admission
Penalty
Summary
The facility failed to obtain an admission weight and weekly weights for a newly admitted resident, resulting in an undetermined weight loss. Resident 62, who was admitted with diagnoses including a fracture of the left femur, Alzheimer's disease, dementia, anxiety, hypertension, and abnormal weight loss, was not weighed upon admission. The Admission Minimum Data Set (MDS) assessment indicated the resident weighed 125 pounds, but this weight was based on hospital discharge paperwork, not an actual measurement taken by the facility. The Registered Dietician noted on 11/29/2024 that the resident had not been weighed by the facility, and the weight used for dietary recommendations was from the hospital's records. The resident's weight was not assessed until 12/2/2024, showing a weight of 117 pounds, and further decreased to 116.4 pounds by 12/15/2024, indicating a 6.7 percent weight loss in less than 30 days. The facility's care plan, dated 11/29/2024, identified the resident as at risk for weight loss and required monitoring of weight with notifications to the physician and family for significant changes. However, there was no documentation that the physician or family had been informed of the weight loss. The Director of Nursing confirmed the failure to weigh the resident upon admission and acknowledged the facility's inability to determine if a significant weight loss had occurred due to reliance on hospital discharge weights.
Failure to Administer Prescribed Enteral Feedings and Water Flushes
Penalty
Summary
The facility failed to adhere to physician's orders regarding enteral feedings and water flushes for a resident with a gastronomy tube (G-tube). Observations revealed that bottles of Jevity 1.5, an enteral feeding formula, were consistently left with significant amounts of the formula remaining, indicating that the resident did not receive the full prescribed amount. The Licensed Practical Nurse (LPN) responsible for the resident's care did not document the actual amount of Jevity 1.5 administered and was unsure if the resident received the necessary calories as recommended by the dietician. Furthermore, the physician was not notified when the resident did not receive the full amount of ordered enteral feedings. The resident's medical record indicated multiple diagnoses, including moderate protein-calorie malnutrition and dysphagia, necessitating careful monitoring of nutritional intake. Despite a care plan intervention to administer tube feedings and water flushes as ordered, the Treatment Administration Record (TAR) showed numerous instances where the resident did not receive the prescribed 225 mLs of water flushes. The Regional Clinical Nurse confirmed that the resident had not received water flushes as ordered, and the facility's policy required licensed nurses to monitor and implement physician orders for enteral therapy, which was not followed in this case.
Improper Storage and Incomplete Orders for CPAP Machine
Penalty
Summary
The facility failed to ensure proper storage and maintenance of a CPAP machine and its components for a resident diagnosed with obstructive sleep apnea, anxiety disorder, and major depressive disorder. During multiple observations, the CPAP storage bag was found on the floor, and the mask was not stored in the bag but rather under bed covers or on the bed. Additionally, the sterile water used for the CPAP machine was from a concentrator bubbler, which was unsealed and partially used, contrary to the resident's usual practice of using distilled water at home. The facility also failed to complete the physician's order regarding the CPAP settings, as the section for pressure settings was left blank. An interview with RN 2 confirmed that the CPAP tubing and mask should have been stored in a bag when not in use, and any remaining water from the concentrator bubbler should have been discarded after opening. The facility's policy on CPAP therapy did not specify how the equipment should be stored or maintained, contributing to the deficiency.
Failure to Administer Influenza Vaccine to Consenting Resident
Penalty
Summary
The facility failed to administer the influenza vaccine to a newly admitted resident, despite the resident having signed a consent form indicating her wish to receive the vaccine. During a record review, it was found that the consent form was completed on 1/6/2025, but the Medication Administration Record (MAR) showed that the vaccine had not been administered. Interviews with the Admissions Director and the Director of Nursing (DON) revealed that the process for administering vaccines involved the Infection Preventionist (IP) confirming the resident's vaccine history and consent, but there was no documentation or explanation for the failure to administer the vaccine to the resident. The facility's policy, as provided by the Administrator, stated that all current and newly admitted residents should be offered the influenza vaccine unless contraindicated or already immunized. However, the policy did not seem to be followed in this case, as there was no indication of contraindication or prior immunization for the resident. The lack of action in administering the vaccine after consent was obtained represents a deficiency in the facility's adherence to its vaccination policy.
Failure to Submit Timely Follow-Up Report for Resident Fall
Penalty
Summary
The facility failed to complete and submit a timely 5-day follow-up report regarding a fall investigation for a resident. The resident, who had diagnoses including atrial fibrillation, metabolic encephalopathy, dementia, and a fracture of the right pubis, was found on the bathroom floor with injuries after a fall. The incident was initially reported to the Indiana State Department of Health, but the required follow-up investigation report was not submitted within the mandated five-day period. The resident was severely cognitively impaired and required assistance for transfers, using a front-wheeled walker for mobility. At the time of the fall, the resident was attempting to use the bathroom independently, resulting in a fall that caused skin tears and a fracture. The facility's Executive Director acknowledged the failure to submit the follow-up report on time, which was a requirement according to the facility's policy on incident reporting.
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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