Great Lakes Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dyer, Indiana.
- Location
- 2300 Great Lakes Dr, Dyer, Indiana 46311
- CMS Provider Number
- 155218
- Inspections on file
- 50
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Great Lakes Healthcare Center during CMS and state inspections, most recent first.
Surveyors found widespread failures in following treatment orders and monitoring residents’ conditions, including several residents with very dry, scaly skin and documented NP recommendations for daily emollients who had no corresponding moisturizer orders and persistent dry, flaky skin. A resident with a buttock abscess did not receive ordered daily wound care on multiple days, and another with a biliary drain lacked early orders for drain care and had missing documentation of drain output after orders were written. One resident’s abrasions and scabbed areas were not assessed or monitored despite a care plan for impaired skin integrity. Multiple residents experienced inappropriate medication management: blood pressure medications were held without ordered parameters or given outside ordered BP ranges, a diabetic resident with frequent diarrhea and an order for PRN Loperamide had no doses documented despite notes stating it was given, and the same resident had numerous missed doses of long-acting, mixed, and sliding-scale insulins even when blood glucose readings met criteria for administration. Another resident with an arterial foot/heel ulcer had daily wound care ordered, but documentation of wound care was absent on several dates.
Failure to Provide Needed ADL Assistance: Surveyors found that dependent residents did not consistently receive needed help with showers, oral care, grooming, and nail care. Residents were observed with greasy hair, body odor, dirty fingernails, uncombed hair, and an untrimmed beard, and one resident with fractured arms reported staff were not helping with meals, oral care, or morning care. Records showed care plans calling for ADL assistance and shower documentation that did not reflect consistent completion.
Improper Labeling of Medications and Topicals: An observation of the East Unit med cart found an OTC pain relief bottle labeled only with a resident's name and room number, without directions for use or the physician's name. A separate observation of the treatment cart found seven opened creams and ointments, including Zinc Oxide, Calmoseptine, and Voltaren gel, with no resident name or label on them. Staff stated the items should have been properly labeled.
A resident with diabetes and need for assistance with personal care said CNAs routinely did not bring snacks when requested, and the record lacked documentation that snacks were offered or provided. In the Resident Council, three residents reported snack trays were left at the end of the hall, staff did not deliver them, and they were told no snacks were available even though snacks were visible in the kitchenette; the Kitchen Manager said snacks were always available on the nursing units and CNAs should deliver them.
Uncovered food and beverages were passed down hallways during meal distribution on the East Unit. During lunch, staff pushed a tray cart down the hall and passed room trays with uncovered desserts to residents' rooms. During breakfast, staff poured coffee into uncovered cups and walked the trays down the hallway to residents' rooms, with no lids available. The meal distribution policy stated that food transported to dining areas not adjacent to the kitchen was to be covered.
Dirty and Uncontained Resident Room Items: Surveyors observed dirty floors, ceiling vents, bed rails, tables, enteral feeding poles, and heavily soiled chairs across multiple units, along with torn or missing privacy curtain hooks and stained or peeling bathroom surfaces. They also found uncontained wash basins, urinals, and clear plastic cylinders left on bathroom floors or toilets, and one resident had personal items stored in a bed pan on a closet shelf. The Administrator acknowledged the areas needed cleaning and/or repair, and the RN consultant stated there was no policy for storing wash basins, cylinders, and urinals.
Surveyors found that three residents with pressure ulcers did not consistently receive wound care as ordered by physicians and a wound NP. One resident with a sacral ulcer present on admission had orders for cleansing and Zinc Oxide every shift, but TARs showed treatment only on day shift, and observation revealed an open, bloody coccyx wound without visible cream or dressing. Another resident with a new Stage 2 buttock ulcer had multiple missed or undocumented Zinc Oxide treatments across shifts, and later developed an additional open area on the opposite buttock. A third resident with a right hip pressure injury and contractures had evolving wound orders, including collagen and later Dakin’s with collagen-silver, yet TARs showed several dates where daily treatments were left blank. The wound nurse acknowledged treatments were to be done as ordered, and the DON provided no further explanation.
A resident with a history of stroke, severe protein malnutrition, seizures, pressure ulcer, and a documented right lower extremity contracture was admitted with limited ROM in both legs and was dependent for ADLs. PT was ordered to address decreased strength, impaired balance, and functional mobility, including a goal for use of a knee orthotic to inhibit abnormal positioning. However, the initial PT evaluation did not document lower extremity strength, degree of contracture, or specific functional limitations, and subsequent PT notes showed only assisted ROM and gentle stretching, with the resident unable to perform ROM independently. The right knee orthotic was briefly trialed but removed after short periods due to pain, and there was no further documented use or clinical rationale for discontinuation, despite recertified plans that continued to reference possible orthotic management. Staff interviews confirmed lack of clear documentation regarding the orthotic’s ordering, fitting, and discontinuation, and the restorative nurse reported the right knee contracture remained unchanged at the time of review.
A resident who was cognitively intact and required maximal ADL assistance reported that meal trays were brought to her room and, when she requested an alternate meal, aides often did not bring it, leaving her without eating. The Kitchen Manager said alternate meals were always available and should be communicated through the aides, while another resident reported he had to notify the kitchen himself because aides would not bring the alternate meal.
A resident with quadriplegia had a physician order for oxygen at 2 L/min via NC and was repeatedly observed wearing oxygen, and an LPN said the resident always wore oxygen. However, the quarterly MDS did not code oxygen use, and the MDS nurse said she relied on progress notes stating oxygen was not required without recalling a visual observation. The RD of Clinical Operations stated a visual observation should have been completed.
A CNA placed a PEG tube feeding on hold before repositioning a resident during a wound care observation, even though the Wound Nurse stated the CNA was not supposed to turn off or place the tube feeding on hold. The resident had stroke, dysphagia, and a PEG tube, was cognitively intact, and received most of his calories through enteral feeding.
A resident with stroke, HTN, ESRD, and DM had a signed POST form indicating DNR, but the chart also contained a CPR order. When the resident was found unresponsive with no pulse, staff applied oxygen, initiated CPR, and called 911; CPR continued until the resident could not be revived. The RD of Clinical Ops stated the physician's orders were not updated because the POST form was not dated by the physician, and staff should have clarified the form before the resident's death.
Missing Urinary Output Documentation for Residents with Indwelling Catheters: Two residents with indwelling urinary catheters had physician orders to measure and record output every shift, but TARs showed multiple missed documentation entries across day, evening, and night shifts. One resident was cognitively intact and dependent for bed mobility, transfers, and toileting hygiene; the other was cognitively impaired and required substantial maximal assistance with toileting hygiene. Facility leadership could not provide documentation that the ordered urinary output had been recorded.
A resident with cancer, severe malnutrition, dysphagia, and fluid balance disorder had an order for NS 0.9% IV fluids at 50 ml/hr for dehydration, but surveyors observed the same one-liter bag hanging and infusing by gravity over multiple days. The resident, who was on a mechanical diet and had poor intake with repeated meal refusals, was seen in bed with the same dated IV bag still infusing into a chest port, and the UM stated she was unaware it was the same bag from two days prior.
An LPN improperly administered a bolus enteral feeding for a resident with a G-tube, dysphagia, protein calorie malnutrition, and severe cognitive impairment. During observation, the LPN flushed the tube and delivered the formula and water by plunging a syringe rather than allowing the feeding to flow by gravity, which was inconsistent with the facility’s tube feeding policy.
A resident was observed receiving oxygen via nasal cannula at 1 lpm even though the physician's order directed 2 lpm. An LPN acknowledged the flow rate should have been 2 lpm and did not know why it was not set correctly. The resident had quadriplegia, severe cognitive impairment, and was dependent in ADLs, and could not change the flow rate independently.
Failure to care plan resident grief and mood symptoms: A resident with bipolar disorder, depression, schizophrenia, and anxiety reported severe grief after his mother’s death, including sadness, hopelessness, paranoia, anxiety, crying, and insomnia. Records showed treatment refusal tied to depression, a psychiatry note identifying significant grief-related symptoms, and limited social service documentation, but no care plan with specific interventions to monitor or address his mood and behavior.
A resident with atrial fibrillation, HTN, and hypotension was ordered metoprolol tartrate 50 mg BID with instructions to hold the dose if SBP was below 100 or HR was below 60. However, the MARs did not include a place to document HR before PM doses, and there was no documentation that HR was monitored before administering the medication.
Ombudsman contact information was not posted for public view in the facility. A resident reported trying to reach the ombudsman and said he only had the prior ombudsman’s contact information, while front desk staff stated the updated information was taped on her side of the desk rather than posted where residents and visitors could see it.
A resident with Parkinson’s disease, diabetes, and morbid obesity experienced significant, ongoing weight loss that was not identified or addressed because ordered weekly weights were not consistently documented and weight data were not entered into the record. Although the care plan called for monitoring nutritional status and weights, and the RD documented stable intakes and goals to maintain weight, multiple weights obtained by staff were never recorded, so the RD, physician, NP, and responsible party were not informed of the resident’s substantial weight decline. The resident’s expressed desire to lose weight was also not incorporated into the care plan or communicated to the care team, contrary to the facility’s own weight policy requiring timely documentation and reporting of weight changes.
A resident with chronic kidney disease, a history of UTIs, and a nephrostomy catheter did not receive timely and valid UA and urine culture testing as ordered. Multiple urine specimens were collected, but one set of results was reported after an extended delay and marked invalid, another specimen was rejected due to urine stability lapsing, and results for a later ordered UA were not found in the record. The Corporate RN Consultant acknowledged the delays and missing results and confirmed there was no policy addressing timeliness of lab results, while the lab company reported having no results for the most recent ordered test.
A resident with hemiplegia, stroke, and Parkinson's who required maximal assistance with ADLs and was frequently incontinent did not have incontinence care documented on multiple shifts as required by their care plan. The resident reported staff did not consistently check or respond to requests for incontinence care, and the DON confirmed care should have been performed and documented each shift.
The facility's kitchen was found to be in poor condition, with issues such as a dark substance on the oven door, dirt on ceiling fixtures and vents, a sticky substance on a sugar bin handle, and dust under storage shelves. The Kitchen Manager acknowledged the need for deep cleaning and possible maintenance intervention.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in documenting pressure ulcers and medication use. A resident was incorrectly documented as having pressure ulcers on admission, while another was inaccurately recorded as not receiving antiplatelet medication. Additionally, a resident was wrongly noted as not receiving scheduled antipsychotics, and another was incorrectly marked as receiving insulin instead of Trulicity.
The facility failed to provide adequate personal hygiene care for several residents, resulting in long, dirty fingernails, greasy hair, and unshaven faces. Despite being dependent on staff for assistance, residents expressed dissatisfaction with the lack of regular showers and grooming. The facility's records lacked documentation of nail care or any indication of residents refusing such care, indicating a systemic issue in the provision and documentation of personal hygiene assistance.
The facility failed to administer medications per prescribed parameters and inadequately monitored residents' conditions, leading to potential health risks. A resident with hypertension received Midodrine despite high blood pressure, while another with heart failure did not receive Midodrine when needed. A resident with COPD was not properly assessed before and after nebulizer treatments, leading to hospitalization. Additionally, two residents with edema and skin conditions were not monitored or treated appropriately.
The facility failed to properly store and label medications, including insulin pens and multi-dose vials, which were found without opening or expiration dates. Observations on two units revealed loose pills in medication carts and expired insulin vials and pens. Staff interviews indicated a lack of awareness and adherence to protocols for medication storage and labeling, despite existing policies requiring such measures.
The facility failed to implement proper infection control practices, including handling medications with bare hands, improper disposal of sharps, and not adhering to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Staff were observed not wearing appropriate PPE and improperly storing medical supplies, contrary to facility policies.
The facility was found deficient in maintaining a clean and well-repaired environment. Observations included dirty equipment, stained curtains, overflowing garbage, and non-functional clocks across two units. The Administrator acknowledged the need for cleaning and repair. This relates to Complaint IN00443889.
A resident with severe cognitive impairment was observed wearing a hospital gown during the day, compromising his dignity. Despite requiring substantial assistance with dressing, there was no care plan addressing this issue. The DON acknowledged the situation and the resident's limited clothing.
Two residents were observed self-administering medications without proper assessments or physician's orders. One resident took antacids for stomach upset, while another applied Lidocaine cream before dialysis. Both residents were cognitively intact but lacked documented authorization for self-administration, contrary to facility policy.
A facility failed to provide a bed long enough for a resident, resulting in his feet touching the footboard. The resident, with a height of 73 inches and multiple health conditions, was observed in this position multiple times, indicating the bed was too short. Despite his need for assistance with movement, the facility did not accommodate his height, leading to discomfort. An LPN and the Assistant Director of Nursing acknowledged the issue.
A facility failed to provide a resident's medical records to the family in a timely manner. Despite a request logged in early September, the records were not released until late October and were only sent to the family in December. Interviews indicated that the records should have been provided more promptly, highlighting a failure to adhere to the facility's policy for handling medical record requests.
A facility failed to maintain professional standards when an LPN borrowed Tylenol from another resident's medication card during a medication pass for a resident who requested it for pain. The LPN admitted to the practice, which was against the facility's policy, and the Director of Nursing confirmed the breach. The facility's policy prohibits sharing or borrowing medications and touching them directly.
A resident with multiple medical conditions, including COPD and hypertension, reported that staff did not consistently perform treatments for her Stage 3 pressure ulcers. The care plan required daily treatments, but the Treatment Administration Records showed several instances where treatments were not documented as completed. The DON confirmed that treatments should have been completed as ordered.
A resident with limited range of motion did not receive the prescribed intervention of placing a washcloth in his right hand to prevent further decline. Despite observations showing the resident's wrist in a hyperextended position and contracted fingers, there was no documentation of the intervention being carried out. The resident had severe cognitive impairment and required significant assistance with daily activities.
A facility failed to secure smoking materials for a resident with a history of respiratory issues and nicotine dependence. The resident admitted to keeping cigarettes and a lighter in his coat pocket instead of locking them in a designated mailbox, as required by the facility's smoking guidelines. The guidelines stated that staff should store smoking materials securely when not in use, but this was not followed, leading to a deficiency.
A facility failed to maintain proper catheter care and documentation for a resident with an indwelling Foley catheter. The catheter collection bag was found on the floor, contrary to policy, and urinary output was not consistently documented as required. The resident had a history of prostate cancer, end-stage renal disease, and obstructive uropathy. The DON confirmed the lack of documentation and the need for proper catheter care.
The facility failed to document meal consumption for two residents with a history of weight loss. One resident, with conditions including COPD and anxiety, lost significant weight despite a care plan to monitor meal intake. Another resident, with a history of stroke and depression, also experienced weight loss, and meal logs were incomplete. The DON confirmed the lack of documentation.
The facility failed to properly administer medications and water flushes via a gastrostomy tube for two residents. An LPN was observed plunging medications and water instead of using gravity for Resident 147, contrary to facility policy. Additionally, Resident 58's enteral feeding was not started on time due to a shift change oversight, despite the resident's dependence on staff for nutrition and a specified feeding schedule.
A resident with COPD and other conditions was observed receiving oxygen at three liters per minute, contrary to the physician's order for two liters. This discrepancy was noted over several days, with both portable oxygen tanks and concentrators set incorrectly. The issue was confirmed by facility staff, highlighting a failure to follow prescribed oxygen therapy.
A resident with chronic pain conditions, including multiple sclerosis and quadriplegia, was inadequately managed for pain, receiving only over-the-counter Tylenol despite reporting significant pain levels. The facility failed to provide alternative pain relief options or conduct detailed pain assessments, leading to a delay in prescribing stronger medication. Staff interviews revealed a lack of awareness of the resident's pain needs until the issue was escalated to the NP, who then prescribed Tramadol.
A facility failed to monitor a resident's perma cath for infection signs, despite care plan and physician's orders. The resident, with multiple diagnoses including end stage renal disease, had no documented checks of the dialysis site for three months. The DON had no additional information.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. An LPN administered insulin incorrectly by not priming the needle for a resident with diabetes, and another LPN improperly administered medications via a gastrostomy tube, including giving Lansoprazole at the wrong time. Both errors were acknowledged by the staff involved.
A resident with type 2 diabetes did not receive sliding scale insulin as prescribed due to a computer entry error marking it as PRN, leading to missed doses when blood sugar levels were high. An LPN administered insulin incorrectly during a medication pass, and the error was confirmed by the DON.
A resident who had undergone open heart surgery was observed during a physical therapy session where the therapist instructed him to pull his upper body using his arms, despite having sternal precautions in place that prohibited such movements. The therapy care plan included these precautions, but there was no documentation or physician's orders indicating they were not to be followed. The physical therapist's actions were questioned, and the Therapy Manager and Administrator were informed, but no further information was provided.
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in medication and tube feeding documentation. One resident's MAR showed discrepancies in medication administration without proper documentation, while another resident's eMAR contained inconsistent entries for tube feeding intake. The DON acknowledged the need for staff education on documentation practices.
A facility failed to accurately report a resident-to-resident altercation to the IDOH. Two residents were involved in an incident where one fell and sustained injuries after attempting to hit the other. The initial report contained inaccuracies regarding the location, circumstances, and diagnoses of the residents. The follow-up report omitted investigation findings, which clarified that no physical contact occurred and that one resident was intoxicated. The facility's abuse policy required detailed reporting, which was not met.
A facility failed to maintain a current smoking assessment for a resident with alcohol dependency who smoked independently. The last assessment was conducted over a year ago, and no updated assessment was available. A social service staff member confirmed the lack of a current assessment, despite the facility's policy requiring regular evaluations.
A resident with a history of alcohol dependency was inadequately monitored by the facility, leading to intoxication and an altercation with another resident. Despite signing a Behavioral Contract, the resident frequently left the facility without proper monitoring, resulting in further incidents. Interviews revealed a lack of behavior monitoring records and care plans, contributing to the deficiency.
Widespread Failures in Skin, Wound, Diarrhea, and Medication Management
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders and residents’ needs, particularly for skin conditions, wound care, diarrhea management, and medication administration. One resident with stroke, PEG tube, Alzheimer’s disease, and peripheral vascular disease was repeatedly observed with very dry, scaly skin on the arms and legs and without a pressure-relieving cushion in the wheelchair, despite a care plan identifying risk for impaired skin integrity and physician orders for zinc oxide to the buttocks and ammonium lactate lotion to the feet every shift. Treatment records showed missed applications on several dates, and a wound NP had recommended Triad cream to the sacrum/buttocks, arm protectors, and daily emollient to the lower extremities, yet the resident’s creams were not available on the treatment cart and the dry, flaky skin persisted. Another resident with an abscess on the right inner buttock had a dressing dated several days earlier and the wound nurse acknowledged not performing the ordered daily treatment since the initial dressing change, with the TAR showing missed treatments on two dates. Additional failures were identified in the management of other residents’ skin and wound conditions. One resident with multiple cancers and a left biliary drain had no initial orders to empty and record drain output or clean the site until mid-March, and once ordered, drain output documentation was missing for specific shifts. Another resident with stroke and PEG tube was repeatedly observed with extremely dry, flaky, scaly skin on the lower extremities and feet, with large flakes on the floor, despite a wound NP recommendation for daily emollient to legs and feet and no corresponding physician orders for moisturizing cream. A further resident with diabetes, severe protein malnutrition, stroke, and pressure ulcer risk had extremely dry, scaly skin on both legs and feet, and although a wound NP had recommended routine moisturizer, there were no orders for any skin moisturizer and the wound nurse confirmed the absence of such orders. A resident with Parkinson’s disease and functional decline had reddened, scabbed areas on both hands and abrasions on the right elbow and upper arm that were not reflected in weekly skin checks, shower documentation, or any assessment or monitoring notes, despite a care plan for risk of impaired skin integrity. The survey also identified multiple medication-related deficiencies, including holding or administering medications without appropriate parameters and failing to administer ordered medications. One resident with diabetes and chronic kidney disease had Lisinopril held on numerous occasions when blood pressures were documented, with nursing notes citing lack of high blood pressure or low blood pressure per physician orders, yet there were no physician-ordered parameters to hold the medication. Another resident with atrial fibrillation, hypertension, and hypotension received metoprolol and midodrine outside of ordered blood pressure parameters on multiple dates, with no documentation explaining why medications were given when blood pressures were out of range. A resident with acute cor pulmonale and hypertension had metoprolol held repeatedly without any ordered parameters, and an LPN stated she would hold blood pressure medications if systolic blood pressure was less than 120 even when no parameters were ordered. A diabetic resident who reported frequent diarrhea and believed she received anti-diarrheal medication had multiple episodes of watery stools documented and an alert note stating Loperamide was given, but the MAR showed no doses administered. The same resident had multiple instances where long-acting, mixed, and fast-acting insulins, including sliding-scale Humalog for significantly elevated blood sugars, were not administered despite standing orders and no hold parameters, with no documentation of administration on numerous dates when blood glucose readings met criteria for dosing. Another resident with quadriplegia, diabetes, and peripheral vascular disease had an arterial ulcer on the right foot/heel with daily wound care ordered, yet documentation of wound care was missing on several specified dates, with no record of completion or refusal.
Failure to Provide Needed ADL Assistance
Penalty
Summary
The facility failed to ensure dependent residents received needed assistance with activities of daily living, including showers, oral care, grooming, and nail care. Surveyors observed and reviewed records for five residents who were dependent on staff for personal care and found concerns related to missed or inconsistent showers, greasy hair, body odor, dirty fingernails, uncombed hair, and an untrimmed beard. The deficiency was supported by observations, resident interviews, record review, and staff interviews. One resident with stroke, depression, and need for substantial to maximum assistance with bathing and personal hygiene stated he did not always get two showers per week. His care plan identified refusal of showers as a behavior problem, and shower documentation showed many scheduled shower dates with only some marked accepted. Another resident with fractures to both arms reported needing help with eating, tray setup, oral care, and morning care, but staff were not observed assisting him with breakfast and there was no documentation that oral care was provided on one of the reviewed days. The resident’s care plan called for assistance with ADLs. Three additional residents were observed with unmet personal care needs. One resident with Parkinson’s disease and hypertension had long fingernails with dark debris underneath them and was dependent on staff for personal hygiene. Another resident with stroke, hemiplegia, and dementia had long dirty fingernails, uncombed hair, and a long unkempt beard while dependent on staff for personal hygiene. A third resident with hemiplegia due to stroke had greasy hair and body odor and stated she had not had a shower in two weeks, despite being scheduled for showers twice weekly and not refusing care. Facility leadership acknowledged the findings but provided no additional information.
Improper Labeling of Medications and Topicals
Penalty
Summary
The facility failed to ensure over-the-counter medications and creams were labeled in accordance with accepted professional principles. During an observation of the East Unit medication cart, an over-the-counter bottle of Extra Strength pain relief medication was found labeled only with a resident's name and room number, with no directions for use or physician name on the bottle. During a separate observation of the East Unit treatment cart, seven opened creams and ointments from the pharmacy were found with no resident name or label on them, including Zinc Oxide, Calmoseptine, and Voltaren gel. The Assistant DON stated the pain relief bottle should have included directions for use, and the Divisional Director of Clinical Operations stated the creams and ointments should not have been in the cart without a resident's name on them. The facility's storage of medications policy indicated medications dispensed by the pharmacy were to be stored in a container with the pharmacy label.
Snacks Not Delivered to Residents Who Requested Them
Penalty
Summary
The facility failed to deliver snacks to residents who requested them and did not ensure snacks were provided at times consistent with resident needs, preferences, and requests. Resident L, who had diagnoses including diabetes and needed assistance with personal care, stated during interview that when she asked for snacks, CNAs routinely did not bring them to her. Her care plan, updated in March 2025, identified a behavior problem of not wanting to get out of bed and included offering snacks as an intervention, and a later care plan update in October 2025 included offering fluids and snacks as part of non-pharmacological measures for acute and chronic pain. The resident’s record lacked documentation that snacks were provided or offered. During the Resident Council meeting, Residents 44, 86, and 121 stated that trays of snacks were left at the end of the hall and staff did not deliver them to residents. All three said they had asked for snacks several times and were told there were no snacks available. Resident 44 later reported that a CNA again told him there were no snacks available, even though he could see a tray of snacks in the kitchenette when he wheeled himself down the hall. The Kitchen Manager stated snacks were always available on the nursing units and that CNAs should deliver them to residents who wanted them.
Uncovered Food and Beverages Passed in Hallways
Penalty
Summary
Food was not served under sanitary conditions during meal distribution on the East Unit. During the lunch meal observation, a dietary employee brought a covered cart with lunch trays to the unit, but staff took the cart and pushed it down the hallway while passing room trays to residents instead of pushing the cart door to door. The dessert on the lunch trays was uncovered, and staff continued passing trays down all three hallways until the cart was empty, with none of the trays having the dessert covered. During the breakfast meal observation on the East Unit, staff were observed passing breakfast trays from a covered cart parked in the hallway. Staff pulled trays from the cart, poured coffee from the beverage cart into cups, and walked down the hallway with the meal trays to residents' rooms. The coffee cups were uncovered because there were no lids available, and staff continued passing trays with uncovered coffee cups for all of the trays. The Regional Director of Clinical Operations was informed of the issue and provided the meal tray passing policy, which stated that food transported to dining areas not adjacent to the kitchen was to be covered.
Dirty and Uncontained Resident Room Items
Penalty
Summary
The facility failed to ensure resident areas were clean and in good repair in the South, West, and East units. During an environmental tour with the Administrator, Maintenance Director, Housekeeping Director, and District Manager of Housekeeping, surveyors observed dirty return ceiling vents, dirty floors, dried enteral feeding on the base of tube feeding poles, dirty overbed tables, cracked and dirty bed rail padding, food crumbs in a bed, dirty storage bins, stained bathroom floors, peeling flooring by a heat register, and heavily soiled white cloth chairs with brown stains. Privacy curtains were also observed falling off hooks, ripped in several areas, or not on some of the hooks. Surveyors also observed multiple items left uncontained in resident bathrooms and rooms, including pink wash basins, clear plastic cylinders, and urinals on the floor or on the back of toilets. In one room, a resident had personal items stored in a bed pan on a closet shelf. The Administrator stated that the observed conditions were in need of cleaning and/or repair. The Regional Nurse Consultant stated the facility had no policy for storing wash basins, cylinders, and urinals, and that multi-use equipment should have been stored off the floor and contained in a plastic bag.
Failure to Provide Ordered Pressure Ulcer Treatments for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care as ordered by physicians for three residents with existing pressure injuries. For one resident with severe protein malnutrition, adult failure to thrive, dysphagia, and a sacral pressure ulcer present on admission, the care plan and wound NP notes specified cleansing the sacrum/buttocks with soap and water, patting dry, and applying Zinc Oxide and collagen particles every shift, leaving the area open to air. Although the wound initially improved in size and remained 100% epithelial tissue, the Treatment Administration Records (TARs) for two consecutive months showed the treatment was documented only on the day shift instead of every shift as ordered. During observation, the resident was found on his side with an open, bloody coccyx wound and no visible cream or bandage. A later wound NP note documented that the Stage 2 ulcer had worsened significantly in size and was described as a Kennedy terminal ulcer, with treatment changed to a collagen silicone bordered foam dressing three times weekly. A second resident, cognitively intact with a history of stroke, dysphagia, and PEG tube, developed a new Stage 2 pressure ulcer to the right buttock. The wound NP ordered cleansing with soap and water and application of Zinc Oxide every shift, to be left open to air, and a physician’s order mirrored this. The TAR for the month showed blanks where the treatment was not signed out as completed on specific day and evening shifts. A subsequent NP note showed the ulcer had increased in size, and a later physician’s order changed the regimen to cleansing both buttocks with soap and water and applying Zinc Oxide every day shift. The TAR for the following month again contained multiple blank entries on day, evening, and midnight shifts where the buttock treatment was not documented as completed. Later NP documentation noted the right buttock ulcer measurements and identified a new open area, described as an abrasion, on the left inner buttock, with treatment changed to a collagen with silver dressing and silicone bordered gauze. A third resident with type 2 diabetes, severe protein malnutrition, stroke, contracture of the right lower leg, and an existing right hip wound was care planned as being at risk for pressure ulcers, with approaches including administering treatments as ordered. The wound began as an abrasion to the right hip and progressed to a full-thickness wound with slough, then to an unstageable pressure injury with increased depth and slough. The wound NP repeatedly adjusted the treatment orders, including cleansing with wound cleanser, then Honey Hydrogel Sheet Dressing, and later collagen with daily and PRN changes. The TAR for one month showed missed documentation of the daily collagen and bordered gauze treatment on two dates. After the wound was noted with undermining and malodor, the NP changed the treatment to cleansing with 0.25% Dakin’s solution, applying collagen with silver, and covering with bordered gauze daily and PRN, and a physician’s order reflected daily shift care. The TAR for the end of that month and into the next again showed blank entries on specific dates where the Dakin’s and collagen with silver treatment was not documented as completed. Throughout interviews, the wound nurse stated that treatments were supposed to be completed as ordered, and the DON had no additional information.
Failure to Provide Consistent ROM Treatment and Orthotic Management for Contracted Right Leg
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to maintain or improve range of motion (ROM) for a resident admitted with limited ROM and a right leg contracture. The resident had diagnoses including severe protein malnutrition, stroke, pressure ulcer, contracture of the right lower leg, and seizures, and MDS assessments documented limited ROM in both lower extremities and dependence on staff for ADLs. On observation, the resident’s right leg was found to be severely contracted and completely bent, with inability to fully extend. The care plan identified an alteration in musculoskeletal status related to the right leg contracture, and physician orders and PT documentation showed that the resident was to receive PT services, including evaluation for and use of an orthotic device to inhibit abnormal positions. PT documentation showed that the initial PT evaluation did not include objective measurements of lower extremity strength, degree of contracture, or specific functional limitations of the lower extremities. PT notes over time documented active assist ROM and gentle manual stretching to the bilateral lower extremities and specifically to the right lower extremity, but consistently indicated the resident could not return ROM demonstrations independently. A goal was established for the resident to safely wear the least restrictive splinting/orthotic device one hour on and one hour off without skin irritation. The orthotic device for the right knee was introduced and applied on several documented dates, but the resident was only able to tolerate about 15 minutes of wear due to pain, and there was no further documentation of the device being used after a short trial period. Subsequent PT recertifications continued to reference therapeutic exercises, gentle manual stretching, and that treatment to prevent further decline "may include" orthotic management and training, but there was no documentation explaining why the orthotic device was not continued or re-trialed after its initial brief use. Interviews with PT staff and the Director of Rehabilitation revealed that the therapist who performed the initial evaluation worked PRN and was unavailable, that staff were unaware when the orthotic was ordered or why it was discontinued, and that there was no documentation of initial lower extremity strength or functional ROM. The restorative nurse reported that the right knee contracture appeared the same at the time of interview as at PT discharge, and that the resident sometimes refused interventions due to pain. Overall, the record lacked adequate assessment data and documentation of consistent orthotic use or clinical rationale for discontinuing the orthotic device, despite the resident’s known right leg contracture and limited ROM.
Failure to Provide Requested Alternate Meals
Penalty
Summary
The facility failed to ensure a dependent resident received the alternate meal choice she requested. Resident L stated during interview that she did not get to choose what she ate, that meal trays were brought to her room by an aide, and that when she did not want what was brought she would request the alternate meal. She reported that more than half the time the aides did not bring the alternate meal and she would not eat. The resident’s record showed diagnoses including diabetes and need for assistance with personal care, and the Quarterly MDS indicated she was cognitively intact for daily decision making and required maximal assistance with ADLs. The Kitchen Manager stated alternate meals were always available and that aides were supposed to tell him when a resident wanted one. During Resident Council, another resident stated he had to notify the kitchen himself if he wanted the alternate meal because aides would not bring it to him.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident related to oxygen use. Resident M, who had diagnoses including quadriplegia and a physician’s order for oxygen at 2 liters per minute via nasal cannula, was observed wearing oxygen during multiple random observations. An LPN stated the resident always wore oxygen. However, the Quarterly MDS dated 3/7/26 did not indicate that the resident was on oxygen, and there was no care plan for oxygen. During interview, the MDS nurse said she coded the resident as not using oxygen because she found two progress notes stating supplemental oxygen was not required, but she could not recall whether she visually observed the resident. The Regional Director of Clinical Operations stated that a visual observation should have been completed when the MDS was done.
CNA Placed PEG Tube Feeding on Hold During Repositioning
Penalty
Summary
The facility failed to maintain professional standards of quality when a CNA placed an enteral tube feeding on hold before repositioning a resident. During a pressure ulcer treatment observation, the resident was lying in bed with a PEG tube feeding infusing and the head of the bed elevated to 45 degrees. When the Wound Nurse told the CNAs they could turn the resident onto his right side, CNA 3 went to the feeding pump and placed it on hold, then lowered the head of the bed to a flat position while both CNAs repositioned the resident. Resident E had diagnoses including stroke, dysphagia, and a PEG tube. The quarterly MDS indicated the resident was cognitively intact for daily decision making, had coughing while eating, and received 51% or more of total calories through the PEG tube. The Physician's Order directed Jevity 1.2 at 85 ml per hour, and the Wound Nurse stated the CNA was not supposed to turn off or place the PEG tube on hold. The DON had no additional information to provide.
CPR Initiated Despite Signed DNR/POST Form
Penalty
Summary
The facility failed to ensure CPR was not initiated for a resident who had a signed DNR/POST form. Resident 119 had diagnoses including stroke, hypertension, end stage renal disease, and diabetes mellitus, and the admission MDS indicated the resident was cognitively intact. The Indiana Physician Orders for Scope of Treatment form showed the CPR section was not checked and the DNR section was checked, and the form was signed and name printed by the resident and also signed by the treating physician. However, a physician's order dated in the record indicated CPR. During the night, staff found the resident unresponsive with no carotid pulse. A sternum chest rub produced no response, vital signs could not be obtained, oxygen was applied, CPR was initiated, and 911 was called. When 911 arrived, CPR was continued until the resident could not be revived. The Regional Director of Clinical Operations stated the physician's orders were not updated to include the DNR status because the physician did not date the POST form after signing it, and staff should have clarified the POST form with the physician before the resident's death.
Missing Urinary Output Documentation for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling urinary catheters received the ordered treatment and services related to measuring and recording urinary output every shift. For Resident D, whose diagnoses included atrial fibrillation, hypertension, and hypotension, the admission MDS dated 2/1/26 indicated the resident was cognitively intact, dependent on staff for bed mobility, transfers, and toileting hygiene, and had an indwelling urinary catheter. A physician’s order dated 1/28/26 directed staff to measure and record catheter output every shift, but the February and March 2026 TARs did not document urinary output on multiple day, evening, and night shifts, and the record lacked any documentation that the output amounts were recorded on those dates. A similar issue occurred for Resident 53, whose diagnoses included end stage renal disease and obstructive uropathy. The admission MDS dated 1/18/26 indicated the resident was cognitively impaired, required substantial maximal assistance with toileting hygiene, and had an indwelling urinary catheter. The March 2026 POS ordered staff to measure and record catheter output every shift, but the February and March 2026 TARs showed missing urinary output documentation on multiple day, evening, and night shifts. During interviews, the Divisional Director of Clinical Services and the Regional Director of Clinical Operations were unable to provide documentation that the urinary output had been recorded on the identified dates and shifts.
Failure to Provide Ordered IV Fluids
Penalty
Summary
The facility failed to ensure a resident with a physician's order for IV fluids received the correct amount over a 24-hour period. Resident F was admitted with diagnoses including colon, liver, rectal and large intestine cancer, severe protein malnutrition, adult failure to thrive, obstruction of bile duct, dysphagia, a sacral pressure ulcer, and an electrolyte and fluid balance disorder. The modified MDS dated 3/3/26 indicated the resident was moderately impaired for daily decision making, had coughing or choking while swallowing, complained of difficulty or pain when swallowing, weighed 72 pounds, received parenteral/IV fluids, and was on a mechanical diet. The care plan identified the resident as at risk for dehydration or potential fluid deficit related to malnutrition and metastatic colon and liver cancer, and noted he was receiving IV fluids for hydration for three days. A physician's order dated 3/14/26 directed Sodium Chloride 0.9% at 50 ml per hour intravenously every shift for dehydration for three days. During observations on 3/16/26, 3/17/26, and 3/18/26, the resident was seen in bed with the same one-liter bag of 0.9% Normal Saline dated 3/16/26 still hanging and infusing by gravity into a port in the right chest. The bag remained in place across multiple observations, including when it was almost empty on 3/18/26, and the resident later had a new bag dated 3/18/26 infusing by gravity. Nursing notes dated 3/14, 3/16, and 3/17/26 indicated the resident refused to eat after several attempts. During interview, the East Unit Manager stated she was aware the resident had an IV but was unaware it was the same bag from two days prior. The DON had no additional information to provide.
Improper Bolus Tube Feeding Administration
Penalty
Summary
The facility failed to ensure a bolus enteral feeding was administered correctly for Resident K, who had diagnoses including dysphagia, gastrostomy, and protein calorie malnutrition. The Quarterly MDS dated 1/20/26 indicated the resident had severe cognitive impairment, required maximal assistance with ADLs, and received all nutrition via a feeding tube. During observation of a bolus tube feeding administration, an LPN flushed the feeding tube with water by plunging a syringe, administered 237 ml of tube feeding formula by plunging it through a syringe, and then gave another plunged water flush. The LPN stated she administered all feeding tube bolus feedings, flushes, and medications by plunging with a syringe rather than by gravity. The facility policy received from the Regional Director of Clinical Operations stated to pour the prescribed bolus amount slowly into the 60cc piston syringe, allowing the formula to flow through the G-tube or PEG tube, and to not force the solution with the plunger.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure supplemental oxygen was set at the correct flow rate for Resident M. During observations, the resident was seen wearing oxygen via nasal cannula at 1 lpm on two occasions, even though a physician's order dated 2/17/26 directed oxygen at 2 liters per minute per nasal cannula. During interview, an LPN stated the resident should have been set at 2 lpm and did not know why it was not. Resident M had diagnoses including quadriplegia, and the quarterly MDS dated 3/7/26 indicated severe cognitive impairment and dependence in ADLs. The resident was unable to change the flow rate independently.
Failure to Care Plan Resident Grief and Mood Symptoms
Penalty
Summary
The facility failed to create and follow a care plan with specific interventions to address the mental health needs of a resident who recently lost his mother. The resident had diagnoses including bipolar disorder, depression, schizophrenia, and anxiety. During interviews, he stated that his mother had died two weeks earlier, that he felt very sad, hopeless, paranoid, and anxious, that he had been crying a lot, and that he was unable to sleep. He also said that listening to the radio his mother gave him or drinking soda sometimes helped him feel a little better, and he was not aware of any different staff actions to help with his grief. The record showed a Medication Administration Note documenting that the resident refused treatments due to depression related to the loss of his mother, with the only intervention noted as the nurse practitioner being aware of the consequences. A psychiatry note documented significant grief-related symptoms and added grief as a diagnosis. A Social Service Note documented that a family member called requesting help arranging transportation for the resident to attend his mother's funeral, but the record lacked other social service notes regarding his mental health and grief. The record also lacked a care plan to monitor or treat the resident's grief, and the Social Service Director stated she had been checking on the resident more frequently and should have updated the care plan with specific interventions to address and monitor his mood and behavior related to the loss.
Failure to Monitor Heart Rate Before Metoprolol Administration
Penalty
Summary
The facility failed to ensure adequate monitoring of a resident's heart rate before administering metoprolol tartrate, a blood pressure medication, as ordered by the physician. Resident D had diagnoses including atrial fibrillation, hypertension, and hypotension. A physician's order dated 1/26/26 directed staff to give metoprolol tartrate 50 mg twice daily for hypertension and to hold the medication if systolic blood pressure was less than 100 or heart rate was less than 60. Review of the January, February, and March 2026 MARs showed no section to document the resident's heart rate before the PM doses, and the heart rate was not monitored on the PM administrations prior to giving metoprolol during those months. During interview, the Divisional Director of Clinical Services stated she could not provide documentation showing the resident's heart rate was monitored before the PM doses and said she would fix the order on the MAR to include heart rate.
Ombudsman Contact Information Not Posted
Penalty
Summary
The facility failed to post the State Long-Term Care Ombudsman's contact information. During a Resident Council meeting, a resident stated he had been trying to contact the ombudsman and wanted them to attend a resident council meeting, but he only had the contact information for the previous area ombudsman and was not aware there was a new ombudsman. He also stated there was no ombudsman information posted in the facility. Later that day, no ombudsman information was observed at the front desk, and front desk staff stated she had the ombudsman information taped on her side of the desk, but it was not posted for public view. The finding was discussed with the Regional Nurse Consultant, and no additional information was received.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to identify and address significant weight loss for a resident with multiple comorbidities, including Parkinson’s disease, diabetes mellitus, and morbid obesity. A Significant Change MDS dated 12/14/25 documented the resident’s weight at 294 pounds with no significant weight loss or gain and noted that she was on a therapeutic diet and hypoglycemic medication. The care plan, revised on 12/23/25, identified a nutritional problem related to a BMI over 40, therapeutic diet, and prior weight gain, with a goal to maintain adequate nutritional status and stable weight. Interventions included monitoring meal intake, obtaining a nutritional consult on admission, quarterly and as needed, obtaining weekly weights if unplanned weight loss was identified, and providing meals per physician orders. Weight records showed the resident’s weight fluctuated from 296.6 pounds in early July 2025 to 293.5 pounds in November 2025. The resident was hospitalized for shortness of breath on 11/29/25 and readmitted on 12/3/25. A physician’s order dated 12/6/25 required weekly weights for four weeks, but the MAR for 12/2025 showed only one documented weight on 12/12/25 at 293.5 pounds, with no further weekly weights recorded until 2/3/26. An RD assessment on 12/15/25 referenced a weight of 293.5 pounds, noted dietary intakes of 75–100%, and estimated calorie needs of 1850–2200, with goals to maintain adequate nutritional status and stable weight. The resident expressed a desire to lose weight, but there were no care plan interventions or documentation that staff, the physician, or the responsible party were notified of this request. Subsequent information revealed undocumented weights and unrecognized significant weight loss. A weight on 2/3/26 was 259.3 pounds, representing an 11.6% loss from the 12/12/25 documented weight and a 14.5% loss over six months, while intake records for 12/2025 through 2/2026 showed average meal intakes of 76–100%. The RD’s 2/5/26 note identified a 10% loss in 180 days and questioned weight accuracy, requesting a re-weight. During interview, the Corporate RN Consultant reported that weights of 272.1 pounds on 12/8/25 and 264.6 pounds on 1/5/26 had been obtained but not documented in the record, resulting in staff and the RD being unaware of the ongoing weight loss, and the physician, NP, RD, and responsible party not being notified. The Restorative Aide stated she weighed residents, wrote weights on paper, and gave them to the Unit Manager for entry, and she was unaware the resident required weekly weights. The facility’s weight policy required admission weights, weekly weights for four weeks, and documentation of weights and any concerns in the record, but these requirements were not followed for this resident, leading to the failure to identify and address her significant weight loss.
Failure to Ensure Timely and Valid Urine Laboratory Testing
Penalty
Summary
The facility failed to ensure timely and valid laboratory services for urinalysis (UA) and urine culture and sensitivity testing for a resident with significant urinary and renal conditions. The resident had diagnoses including stage 3 chronic kidney disease, a history of UTIs, and a left nephrostomy catheter, with a care plan directing monitoring for UTI signs and symptoms. A nurse’s note documented that a urine sample was collected for testing, and lab records showed a UA with culture and sensitivity was collected on 12/10/25. However, the results were not reported until 11 days later and were marked invalid. A subsequent nurse practitioner note documented the nephrostomy tube status and included an order for another UA with culture and sensitivity. A nurse’s note later indicated another urine sample was collected on 12/26/25, and lab records showed the UA with culture and sensitivity was reported five days after collection, with the specimen rejected due to urine stability lapsing, rendering the results invalid. A physician’s order dated 1/9/26 directed that another UA be completed, but no results for this test were found in the resident’s record. During interview, the Corporate RN Consultant stated that the delay in results from the 12/10/25 UA had only come to their attention on 1/13/26, acknowledged that the 12/26/25 UA had not been completed, and confirmed there was no facility policy addressing timeliness of lab results. The lab company reported having no results yet for the UA ordered on 1/9/26.
Failure to Document and Provide Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when the facility failed to document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who had diagnoses including hemiplegia, stroke, and Parkinson's disease, was cognitively intact but required maximal assistance with ADLs and was frequently incontinent of bowel and bladder. The resident's care plan required staff to check for incontinence every two hours and as needed. However, a review of the Point of Service documentation for the month showed multiple shifts across several days where incontinence care was not documented as provided. During interviews, the resident reported that staff did not check on him at least once per shift for incontinence care and that, when he used the call light to request assistance, staff sometimes failed to return, resulting in him being left in a soiled brief for hours. The DON confirmed that incontinence care should be performed and documented each shift and was unable to explain the missing documentation for the identified dates and shifts.
Kitchen Cleanliness and Maintenance Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and proper repair in the kitchen, as observed during an Initial Kitchen Sanitation Tour. Specific issues included a dark, dripping substance on the bottom of the oven door, dirt accumulation on the edges of ceiling light fixtures and vents above the food preparation area, a tan, sticky substance on the handle of the sugar storage bin, and dust and debris under the shelves in the dry storage room. During an interview, the Kitchen Manager acknowledged the need for deep cleaning and indicated that maintenance might be required to clean the light fixtures and vents. The facility's policy, as provided by the Administrator, mandates that all food preparation, service, and dining areas be maintained in a clean and sanitary condition.
Inaccurate MDS Assessments for Pressure Ulcers and Medications
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the documentation of pressure ulcers and medication use. Resident 59, who was cognitively intact, was documented as having two Stage 3 pressure ulcers present on admission, but a Skin and Wound Note indicated these ulcers developed in the facility. Resident 86, with moderate cognitive impairment, was documented as not receiving antiplatelet medication, despite physician orders and medication administration records showing daily administration of Plavix. Resident D, with moderate cognitive impairment, was incorrectly documented as not receiving scheduled antipsychotic medication, despite physician orders for daily Risperidone. Resident F, who was cognitively intact, was incorrectly documented as receiving insulin, although the medication administered was Trulicity, a GLP-1 agonist for diabetes, which should have been marked under hypoglycemic medication. These inaccuracies in MDS assessments highlight the facility's failure to ensure accurate resident assessments, impacting the documentation of care provided.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for dependent residents, specifically in relation to personal hygiene tasks such as shaving, washing hair, providing showers, and nail care. This deficiency was observed in six residents, who were found with long, dirty fingernails, greasy hair, and unshaven faces. The residents expressed their dissatisfaction with the lack of personal care, indicating that they did not always receive the necessary assistance with bathing and grooming. Resident E, who was cognitively intact but physically dependent due to multiple sclerosis and quadriplegia, was observed multiple times with long, dirty fingernails and greasy hair. Despite being scheduled for showers twice a week, there was a lack of documentation indicating that these were consistently provided. Similarly, Resident D, who required assistance due to Parkinson's disease and other health issues, was found with long, dirty fingernails and unshaven, despite expressing a desire for regular showers and grooming. Other residents, such as Resident C, who had contracted fingers, and Resident F, who required maximal assistance due to Parkinson's disease, were also observed with inadequate nail care. Resident L, who had severe cognitive impairment, was found with long, dirty fingernails that were indenting into his face, and an unshaven appearance. The facility's records lacked documentation of nail care or any indication that residents refused such care, highlighting a systemic issue in the provision and documentation of personal hygiene assistance.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer medications according to prescribed parameters for several residents, leading to potential health risks. Resident 59, who had a history of hypertension and other cardiovascular issues, was prescribed Midodrine HCl to be held if systolic blood pressure exceeded 100. However, the medication was not held on multiple occasions despite blood pressure readings above the specified threshold. Similarly, Resident M, with conditions including end-stage renal disease and heart failure, did not receive Midodrine when systolic blood pressure was below 100, and Metoprolol was administered when it should have been held due to low blood pressure readings. In another case, Resident 65, who had COPD and other respiratory issues, was not adequately monitored before and after receiving nebulizer treatments. The resident's oxygen saturation levels were critically low, yet there was a lack of documentation of pre and post-treatment assessments. This oversight contributed to the resident's eventual hospitalization for acute hypoxic respiratory failure. Additionally, Resident 87 had a large discoloration on his hand that was not assessed or monitored, despite being at risk for abnormal bleeding due to aspirin use. The facility also failed to address and monitor edema and skin conditions in other residents. Resident 75 exhibited swelling in the right arm and hand, and scaly skin on the feet, but there was no care plan or treatment in place. Similarly, Resident 24 had swollen legs with socks indenting into the skin, yet there was no care plan to monitor or treat the edema. These deficiencies highlight a pattern of inadequate assessment and monitoring of residents' conditions, leading to potential health risks.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper medication storage, specifically concerning insulin pens and multi-dose vials, which were not labeled with opening or expiration dates. During an observation on the [NAME] unit, eight loose pills were found in the medication drawers, and an opened multi-dose vial of Aplisol was discovered in the refrigerator without a date indicating when it was opened. The Assistant Director of Nursing (ADON) mentioned that the pharmacy was responsible for cleaning the carts and checking the medication rooms weekly. On the East unit, similar issues were observed. A medication cart contained 22 loose pills, and insulin vials and pens were found without proper discard dates. LPN 2 was unaware of the frequency of cart cleaning by the pharmacy. Another observation on the East unit revealed four loose pills and insulin vials and pens with expired discard dates. RN 1 admitted to checking the dates but failed to notice expired items. The Director of Nursing (DON) confirmed that protocols existed for cleaning medication carts and dating opened insulin pens and vials, but these were not followed. The facility's Storage of Medications policy required medications to be dated when opened and checked for expiration before administration, which was not adhered to in these instances.
Infection Control Deficiencies in Medication Handling and Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during medication administration and resident care. During a medication pass, an LPN was observed handling medications with bare hands and failing to disinfect a glucometer immediately after use. The LPN also improperly disposed of a used lancet by placing it in her shirt pocket instead of a sharps container. The Director of Nursing confirmed that these actions were against the facility's policies, which require immediate disinfection of glucometers and proper disposal of sharps. Another LPN was observed improperly disposing of a used lancet by placing it inside rolled-up gloves and then into a regular trash can instead of a sharps container. The LPN admitted to setting the gloves aside temporarily but failed to follow through with proper disposal. The Director of Nursing reiterated that used lancets should be disposed of in a sharps container, as per the facility's policy. Additionally, staff failed to adhere to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. An LPN stored gloves and alcohol wipes in her shirt pocket, which is not allowed under EBP. Furthermore, two CNAs did not wear gowns while providing direct care to a resident on EBP, despite the presence of a sign indicating the requirement. The CNAs admitted to not wearing gowns, with one citing a lack of availability. The Director of Nursing confirmed that gowns and gloves should have been worn during the care of residents under EBP.
Environmental Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents, as observed during an Environmental Tour. In the East Unit, a resident's bed handrails were found with a buildup of a dark brown substance. In the [NAME] Unit, multiple deficiencies were noted: a tube feeding pole had spillage on the floor and the pole itself, a Broda chair had dried brown substance, and clothing was piled on boxes and a wheelchair. Additionally, window curtains were stained, and emesis basins containing personal hygiene items were not properly contained. Further observations in the [NAME] Unit revealed overflowing garbage bins, crumbs and food spills on the floor, and uncontained briefs in the bathroom. Washcloths and hygiene items were improperly placed on the toilet seat. In another room, two clocks were not functioning, and a resident was unsure about the ownership of items in a bag on the floor. These findings were confirmed by the Administrator, who acknowledged the need for cleaning and repair in these areas. This citation is related to Complaint IN00443889.
Resident Dignity Compromised by Inappropriate Attire
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident L, by allowing him to wear a hospital gown during the day instead of regular clothing. Observations on multiple occasions revealed that Resident L was seen in the dining room and in his room wearing a hospital gown. The resident's medical record indicated severe cognitive impairment and a need for substantial assistance with dressing. However, there was no care plan addressing the use of a hospital gown during the day. The Director of Nursing acknowledged awareness of the situation and noted the resident's limited clothing, but confirmed that this should have been included in a care plan.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and had physician's orders to self-administer medications. Resident 83 was observed with a medicine cup containing chewable antacids on his bedside table, which he took as needed for stomach upset. Although the resident was cognitively intact and required set-up assistance for activities of daily living, there was no documented self-administration assessment or physician's order allowing him to self-administer the medication. The Director of Nursing (DON) had no additional information regarding this oversight. Similarly, Resident G was observed holding a tube of Lidocaine cream, which he applied himself to his AV fistula site before dialysis sessions. Despite being cognitively intact and requiring assistance with activities of daily living, there was no self-administration assessment or physician's order for this practice. The DON acknowledged awareness of the resident's self-administration but admitted that an order should have been in place. The facility's policy requires a skill assessment for residents who self-administer medications, which was not conducted in these cases.
Facility Fails to Provide Adequate Bed for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs, specifically regarding the length of the bed. Resident D, who has a height of 73 inches, was observed multiple times with his feet touching the footboard of his bed, indicating that the bed was too short for him. This was noted during several observations over a period of days, where the resident was consistently positioned high up in the bed with his feet touching the footboard. The resident, who has a history of Parkinson's disease, falls, depressive disorder, anxiety disorder, epilepsy, heart disease, kidney disorder, and stroke, indicated that he stayed in bed most of the time and required assistance to reposition himself. The resident's condition was further complicated by his moderate impairment in daily decision-making and his need for partial to moderate assistance with movement, as indicated in his Quarterly Minimum Data Set assessment. Despite these needs, the facility did not provide a bed that accommodated his height, leading to discomfort and potential risk. The issue was acknowledged by LPN 5, who observed the resident's feet touching the footboard and stated that the bed was too short. The Assistant Director of Nursing also confirmed that the resident's feet should not be touching the footboard, highlighting the facility's failure to meet the resident's needs for appropriate bed accommodations.
Delayed Release of Medical Records to Resident's Family
Penalty
Summary
The facility failed to ensure that a resident's family received the resident's medical records in a timely manner. Resident H, who had diagnoses including multiple sclerosis, respiratory failure, type 2 diabetes, pressure ulcers, and anxiety, was admitted to the facility and later discharged home. The resident's family requested the medical records, but there was a significant delay in providing them. The request for the medical records was initially logged on 9/6/24, but the records were not released by corporate until 10/30/24 and were only sent electronically to the family on 12/2/24. Interviews with the Medical Records Supervisor and the Administrator revealed that the records should have been provided more promptly. The facility's Medical Record Request Guide policy outlines a process for handling such requests, including ensuring HIPAA compliance and determining the necessary documentation. However, the delay in releasing the records indicates a failure to adhere to this policy, resulting in the deficiency noted in the report.
Medication Borrowing Breach During Medication Pass
Penalty
Summary
The facility failed to maintain professional standards of quality during a medication pass involving Resident C and LPN 1. During the medication pass, LPN 1 was observed removing medications from Resident C's punch cards and administering them. When Resident C requested Tylenol for pain, LPN 1 returned to the medication cart and took two Tylenol tablets from another resident's medication card, placing them into a medication cup with her bare hands. Upon questioning, LPN 1 admitted to borrowing the Tylenol from another resident because Resident C did not have any available, despite being aware that this practice was against policy. The review of Resident C's records confirmed a physician's order for Acetaminophen 325 mg, to be given as needed. During an interview, the Director of Nursing acknowledged that the nurse should not have taken medication from another resident's punch card. The facility's current Medication Administration policy explicitly states that medications should not be shared or borrowed from others, and that medications should not be touched directly. This incident highlights a breach in the facility's medication administration protocol.
Failure to Complete Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that treatments for pressure ulcers were completed as ordered for a resident with multiple medical conditions, including chronic obstructive pulmonary disease, chronic kidney disease, and hypertension. The resident, who was cognitively intact, reported that staff did not always perform the necessary treatments for her pressure ulcers. The resident had two Stage 3 pressure ulcers on her left buttock and sacrum, which were identified as having developed in the facility. The care plan required treatments to be administered as ordered by the medical provider. The treatment administration records indicated multiple instances where the prescribed treatments were not documented as completed. Specifically, the January 2025 Treatment Administration Record (TAR) showed that treatments were not signed out on four occasions, and the February 2025 TAR indicated missed treatments on two occasions. During an interview, the Director of Nursing acknowledged that the treatments should have been completed as ordered, highlighting a failure in adhering to the prescribed care plan for the resident's pressure ulcers.
Failure to Implement Range of Motion Intervention for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, identified as Resident L, to increase or prevent further decrease in range of motion. Observations over several days revealed that Resident L consistently had his right wrist fixed in a hyperextended position, supporting his head, with contracted fingers and nothing in his right hand. The resident's care plan, revised on 10/18/23, specified that a washcloth should be placed in his right hand for 4-6 hours a day, up to 7 days a week, to address his condition. However, there was no documentation in the treatment record indicating that this intervention was being implemented. Resident L's diagnoses included dementia, type 2 diabetes, and adult failure to thrive, and he required substantial to maximum assistance with activities of daily living. During an interview, the Director of Nursing acknowledged the findings but did not provide further information.
Failure to Secure Smoking Materials for Resident
Penalty
Summary
The facility failed to ensure that smoking materials were secured for a resident who was reviewed for smoking. The resident, who was cognitively intact and had a history of respiratory failure, tracheostomy status, sleep apnea, and nicotine dependence, indicated during interviews that he was supposed to lock up his cigarettes and lighter in a mailbox located across from the smoking area after smoking. However, he admitted to rarely locking them up because he had previously lost the key, which made him nervous. Instead, he kept his cigarettes and lighter in his coat pocket, although he was aware that he should not smoke in his room. The facility's Resident Smoking Guidelines, which were identified as current, stated that facility staff would store smoking materials in a secure area when not in use by the resident, regardless of whether the resident was an independent or supervised smoker. Smoking materials were to be returned to the facility staff upon completion of smoking. The Administrator confirmed that smoking materials were to be left in the locked mailboxes outside of the smoking area, and residents were not to keep their smoking materials. This failure to adhere to the guidelines resulted in a deficiency related to accident hazards and supervision.
Deficiency in Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and documentation for a resident with an indwelling Foley catheter. On two separate occasions, the resident's catheter collection bag was observed lying on the floor next to the bed, which is against the facility's policy. During an interview, a registered nurse acknowledged that the catheter bag should not have been on the floor and took corrective action by hanging it properly. The resident, who was moderately cognitively impaired, had a history of prostate cancer, end-stage renal disease, and obstructive uropathy, necessitating the use of an indwelling urinary catheter. Additionally, the facility did not consistently document the resident's urinary output as required by the physician's orders. The Treatment Administration Records for January and February 2025 showed missing documentation of urinary output on several dates and shifts. The Director of Nursing confirmed that staff should have documented the urinary output every shift but could not provide evidence that this was done on the specified dates. The facility's policy on catheter care emphasizes the importance of ensuring the collection bag is not on the floor and that any adverse findings are documented and reported.
Failure to Document Meal Consumption for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure proper documentation of food consumption logs for two residents with a history of weight loss. Resident 65, who was admitted with diagnoses including COPD, high blood pressure, anxiety, dehydration, and alcohol abuse, experienced a significant weight loss from 91 pounds to 85 pounds within a month. Despite a care plan that included monitoring meal intake and a physician's order for a specific diet to promote weight gain, the meal consumption logs lacked documentation for several meals over a period of days. The Director of Nursing confirmed that meal consumptions were supposed to be documented after each meal. Similarly, Resident 67, who had a history of stroke, heart failure, hypertension, seizure disorder, and depression, also experienced weight loss, dropping from 136.8 pounds to 127.6 pounds over six months. The resident required supervision for eating, and the care plan included monitoring meal intake. However, the Task Nutrition-Amount Eaten Logs were missing documentation for numerous meals over the last 30 days. The Director of Nursing was unable to provide any documentation related to the resident's meal consumption for the specified dates.
Improper Administration of Gastrostomy Tube Medications and Delayed Enteral Feeding
Penalty
Summary
The facility failed to ensure proper administration of medications and water flushes via a gastrostomy tube for two residents. For Resident 147, an LPN was observed administering medications and water flushes by plunging them through the gastrostomy tube instead of using gravity, as required by the facility's policy. The LPN acknowledged awareness of the correct procedure but did not follow it. The Director of Nursing confirmed that the medications and water should be administered via gravity, aligning with the facility's Enteral Tube Medication Administration policy. For Resident 58, the facility did not start the enteral feeding at the scheduled time. The resident, who had a history of stroke, diabetes mellitus, and adult failure to thrive, was observed in bed with the feeding pump machine not connected and turned off. An RN admitted to being unaware that the resident's tube feeding had not been started after a shift change. The resident's care plan indicated total dependence on staff for eating, and the physician's order specified the feeding schedule, which was not adhered to, resulting in a delay in the resident's nutritional intake.
Oxygen Flow Rate Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered at the correct flow rate as prescribed by the physician. Resident 59, who has diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension, was observed multiple times over several days with her oxygen set at three liters per minute, despite a physician's order indicating it should be set at two liters per minute. This discrepancy was noted during observations on various dates, both when the resident was using a portable oxygen tank and an oxygen concentrator. The resident's care plan, which was intended to address her ineffective gas exchange, specified the need for oxygen therapy. However, the facility staff, including an LPN and the Director of Nursing, confirmed that the oxygen was consistently set higher than the prescribed two liters. This oversight was identified during a review of the resident's records and through direct observation, indicating a failure to adhere to the physician's orders for oxygen administration.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to adequately manage the pain of a resident, identified as Resident E, who was observed crying out in pain and reported a consistent pain level of five to six out of ten. Despite her complaints, the resident was only provided with over-the-counter Tylenol and had previously stopped using Lidoderm patches due to skin irritation. The resident expressed a desire for stronger pain relief, but no alternative topical creams or stronger medications were offered until later. The resident's care plan included monitoring for pain and providing medication as ordered, but these measures were insufficient to address her chronic pain effectively. The resident's medical history included multiple sclerosis, quadriplegia, chronic pain, anxiety disorder, and low back pain. Despite being cognitively intact and able to communicate her pain levels, the facility's records showed a lack of detailed pain assessments, with the last comprehensive pain observation assessment dated nearly a year prior. Interviews with staff revealed a lack of awareness regarding the resident's pain levels and needs, leading to a delay in adjusting her pain management plan. It was only after the resident's continued complaints that the facility's Nurse Practitioner was informed, resulting in the prescription of Tramadol to better manage her pain.
Failure to Monitor Dialysis Site for Infection
Penalty
Summary
The facility failed to monitor for signs and symptoms of infection in a resident's perma cath used for dialysis. Resident M, who has diagnoses including end stage renal disease, type 2 diabetes, stroke, and high blood pressure, was observed with a clear bandage over the perma cath on the right upper chest. The care plan required evaluation for infection signs such as redness, tenderness, swelling, pain, and drainage, with visual inspection each shift. A physician's order also mandated checking the dialysis site for infection signs every shift. However, there was no documentation of these checks in the Medication or Treatment Administration Records for December 2024, January 2025, and February 2025. The Director of Nursing had no additional information to provide during an interview.
Medication Administration Errors Result in 7.14% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.14% error rate during medication administration for two residents. The first incident involved a Licensed Practical Nurse (LPN) administering insulin to a resident with type 2 diabetes. The LPN failed to prime the second needle before administering the remaining 3 units of insulin after initially administering 30 units. This was contrary to the physician's order, which required 33 units of insulin to be administered subcutaneously before meals. The LPN acknowledged the mistake during an interview, and the Director of Nursing confirmed the need for priming the insulin pen before administration. The second incident involved another LPN administering medications via a gastrostomy tube to a resident with a history of stroke and dysphagia. The LPN administered Lansoprazole, Atorvastatin, and Metoprolol by pushing the medications with a plunger rather than allowing them to flow by gravity, as is standard practice. Additionally, the Lansoprazole was administered at 4:30 p.m., which was not in accordance with the physician's order for bedtime administration. The LPN admitted to the error, and the Director of Nursing confirmed that the administration time was incorrect.
Failure to Administer Sliding Scale Insulin Correctly
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of sliding scale insulin. During a medication pass, an LPN was observed administering insulin to a resident with a blood sugar level of 335. The LPN attempted to administer 33 units of Lispro Insulin as per the physician's order but was only able to administer 30 units initially due to the insulin pen's limitation. The LPN then administered the remaining 3 units separately. However, the resident did not receive any additional insulin as per the sliding scale order. The resident's medical record indicated a diagnosis of type 2 diabetes, with a physician's order for Humalog insulin to be administered according to a sliding scale. The sliding scale insulin was incorrectly entered into the computer system as a PRN order, which prevented it from appearing on the MAR for routine administration. Consequently, the resident did not receive the prescribed sliding scale insulin on numerous occasions when their blood sugar was above 200. Interviews with the LPN and the Director of Nursing confirmed the error in the computer system entry, which led to the oversight in administering the sliding scale insulin.
Failure to Follow Sternal Precautions in Physical Therapy
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for a resident, identified as Resident G, who was observed during a physical therapy session. Resident G, who had undergone open heart surgery and had an aortic valve replacement, pulmonic valve replacement, and tricuspid valve annuloplasty, was observed in bed with a dressing on his left upper arm AV fistula and a large gauze wrap on his left forearm with visible bleeding. Despite having sternal precautions in place, which included no pushing or pulling with the arms for 6 to 8 weeks, the physical therapist instructed Resident G to pull his upper body using his arms, which was contrary to the hospital's physical therapy notes that emphasized the importance of following these precautions. The therapy care plan included various precautions, but there was no documentation or physician's orders indicating that sternal precautions were not to be followed during physical therapy. The physical therapist's actions were questioned, and the Therapy Manager and Administrator were informed of the findings. However, there was no further information provided, and the Administrator suggested that the physical therapist might not have considered the need for sternal precautions. This lack of adherence to the prescribed precautions and absence of communication with the physician regarding safety measures for the resident led to the deficiency.
Deficiencies in Medication and Tube Feeding Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in medication documentation and tube feeding records. For one resident, identified as Resident F, the Medication Administration Record (MAR) for February 2025 showed discrepancies in the administration of Metoprolol Succinate ER and Glimepiride. Specifically, there were missing entries and unexplained codes indicating the need to refer to nurse's notes, which were not available. The Director of Nursing (DON) was unable to provide documentation confirming whether the medications were administered on the specified dates, suggesting a lack of proper record-keeping. For another resident, identified as Resident 75, the facility failed to accurately document the percentage of tube feeding intake. The electronic Medication Administration Record (eMAR) contained inconsistent and nonsensical entries for the resident's enteral feeding intake, which did not reflect the actual percentage of intake as required. The DON acknowledged the discrepancies and indicated that the staff required further education on proper documentation practices. These failures highlight significant lapses in maintaining accurate and complete medical records for residents receiving critical medications and nutritional support.
Failure to Accurately Report Resident Altercation
Penalty
Summary
The facility failed to accurately and thoroughly report an allegation of resident-to-resident abuse to the Indiana Department of Health (IDOH). The incident involved two residents, C and D, who had a physical altercation resulting in Resident C falling to the ground and Resident D receiving a scratch to his left eye. The initial report to IDOH did not accurately describe the location of the altercation, the circumstances, or the correct diagnoses of the residents involved. Specifically, Resident C was incorrectly reported to have a diagnosis of bipolar disorder, whereas the record indicated alcohol dependency. Additionally, the injury was misreported as a hematoma to the back of the head instead of bruising to the left eye/brow. The follow-up report failed to include the investigation's findings, which clarified that there was no physical contact between the residents and that Resident C was intoxicated at the time of the incident. The investigation revealed that the altercation occurred outside the building in the smoking area at 3:30 a.m., and Resident C was intoxicated, having consumed alcohol obtained from a liquor store. Witness statements indicated that Resident C attempted to hit Resident D, who stepped aside, causing Resident C to fall and hit his face on the concrete. The facility's follow-up report to IDOH did not include these details or the conclusion that no physical contact had occurred. The facility's abuse policy required that the initial incident report provide sufficient information to describe the alleged violation and that the results of the investigation be reported within five working days, which was not adequately done in this case.
Failure to Maintain Current Smoking Assessment for Resident
Penalty
Summary
The facility failed to maintain a current smoking assessment for a resident who smoked independently. The resident, identified as having a diagnosis of alcohol dependency, had their last smoking assessment completed on September 20, 2023, which indicated they were capable of smoking independently. However, as of September 17, 2024, no updated assessment had been conducted. During an interview, a social service staff member confirmed the absence of a current smoking assessment. The facility's smoking policy, provided by the Director of Nursing, stated that residents should be assessed for smoking assistance upon admission, quarterly, and with any significant change in condition.
Failure to Monitor Resident with Alcohol Dependency
Penalty
Summary
The facility failed to adequately monitor a resident with a history of alcohol dependency, leading to an incident where the resident became intoxicated and had an altercation with another resident. The resident, identified as having alcohol dependency, was allowed to leave the facility on a pass and was later found intoxicated by a store employee. Despite being treated at a hospital for intoxication and a thumb fracture, the facility did not implement a comprehensive behavioral management plan to monitor the resident's alcohol use. Following the initial incident, the resident signed a Behavioral Contract agreeing to refrain from excessive alcohol consumption. However, the facility did not establish a care plan or behavior management plan to monitor the resident's alcohol use or behaviors related to alcohol consumption. The resident continued to sign out of the facility frequently without adequate monitoring for alcohol use, leading to another incident where the resident was involved in an altercation while intoxicated, resulting in physical injuries. Interviews with facility staff, including the Administrator and Director of Nursing, revealed that there were no behavior monitoring records or care plans in place for the resident's alcohol use. The facility's behavioral management policy required a resident-centered behavior management plan, but this was not implemented for the resident in question. The lack of monitoring and documentation of the resident's alcohol use and behaviors contributed to the deficiency identified in the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
