Greenwood Health And Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenwood, Indiana.
- Location
- 937 Fry Rd, Greenwood, Indiana 46142
- CMS Provider Number
- 155412
- Inspections on file
- 28
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Greenwood Health And Living Community during CMS and state inspections, most recent first.
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
The facility did not develop or implement care plans for five residents with needs related to skin conditions, use of an electric wheelchair, and behavioral non-compliance. Observations and record reviews showed that residents with wounds, pressure ulcers, and cognitive impairments did not have individualized, measurable care plans in place, despite physician orders and staff awareness of their conditions and behaviors.
Narcotic medications prescribed for pain management were found missing for several residents with complex medical needs. An LPN removed controlled substances for destruction but failed to account for their whereabouts, and additional discrepancies in narcotic counts were identified. Facility policies for the handling and destruction of scheduled drugs were not consistently followed, resulting in the misappropriation of residents' medications.
A resident with severe cognitive impairment and right-sided paralysis was observed on multiple occasions without access to their call light, as the device was left hanging from the wall and out of reach. Staff interviews confirmed the expectation that call lights should be accessible, but acknowledged the resident sometimes tossed the device. The facility lacked a specific call light policy, and the resident was unaware of the call light's location during the observations.
A resident with type 2 diabetes mellitus and neuropathy was repeatedly observed with open areas and dried scabs on both legs, including an open area on the left knee, without the required dressing as ordered by the physician. The facility did not follow the prescribed treatment regimen for wound care, as confirmed by the DON.
A resident receiving tube feeding for dysphagia and heart disease was observed with unlabeled and undated feeding and water flush bags, as well as unlabeled tubing. Staff confirmed that labeling and dating were required but had not been completed, and the water flush bag was also found open at one point.
A resident with chronic respiratory and metabolic conditions was not provided a timely two-step tuberculin skin test upon admission, as required by facility policy. The resident received two first step TB skin tests over a month apart, with no documented timely second step, contrary to the policy that mandates a follow-up TST 1 to 3 weeks after the initial negative result.
A resident's controlled pain medication was found missing after an LPN administered a dose and later transferred the medication cart keys to the Unit Manager, who placed additional medication cards in the lock box without performing a count. The missing medication was discovered during the end-of-shift count, revealing a failure to protect the resident's property and to follow facility policy for controlled drug security.
The facility failed to develop a person-centered care plan for a resident with a hearing deficit who relies on an amplifier device system. Despite the resident's documented hearing needs and long-term use of the device, the clinical record lacked a specific care plan, which was confirmed by staff members.
The facility failed to date four opened Insulin Flex Pens in one of the medication carts. The Regional Nurse Consultant confirmed the pens should have been dated, and the Director of Nursing provided a policy indicating insulin should be dated when opened, retained for 28 days, and then discarded.
The facility failed to post the actual hours worked by nursing staff for three consecutive days. Observations on multiple days revealed that the posted nursing hours lacked the actual hours worked. The DON indicated that the hours had been posted, but the facility's policy was not followed.
The facility failed to ensure proper disposal of garbage and refuse, with observations showing open dumpster lids and surrounding debris. Staff confirmed that the area should be kept clean and lids closed, as per facility policy and sanitation requirements.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, as required, resulting in unmet needs related to skin conditions, use of assistive devices, and behavioral non-compliance. For one resident, multiple dried scabs and an open area on the left knee were observed, with a physician's order for wound care in place, but no corresponding care plan addressing either the skin condition or the use of an electric wheelchair, which had been removed due to safety concerns. The clinical record also lacked documentation of a care plan for the resident's wheelchair use, despite occupational therapy involvement and administrative acknowledgment of the omission. Another resident with vascular dementia and diabetes had an open area on the right heel, with a physician's order for wound care, but no care plan addressing the pressure ulcer. Similarly, a resident with severe cognitive impairment and a history of adjusting her bed to a high position was observed repeatedly with the bed elevated and the control within reach, yet there was no care plan addressing her non-compliance with keeping the bed in a low position, as confirmed by staff interviews and record review. Additional deficiencies included a resident with hemiplegia and severe cognitive impairment who was known to throw his call light out of reach, but lacked a care plan to address this behavior, and another resident with stage 2 and stage 3 pressure ulcers who was receiving wound care per physician orders, but whose clinical record did not contain a care plan for these skin conditions. In each case, the absence of individualized, measurable care plans was confirmed by administrative and nursing staff, and the facility's own policy requires such plans to be developed and updated as resident needs change.
Failure to Protect Residents from Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of property, specifically narcotic medications, for five residents. Clinical record reviews revealed that residents with various diagnoses, including chronic kidney disease, osteomyelitis, pneumonia, cerebral palsy, and diabetes, had physician orders for narcotic pain medications such as hydrocodone-acetaminophen, oxycodone-acetaminophen, and tramadol. These medications were found to be missing during routine checks and investigations. Interviews with the Director of Nursing (DON), Administrator, and nursing staff indicated discrepancies in the narcotic count, with specific instances where an LPN took possession of controlled substances for destruction but failed to account for their whereabouts. In one case, an LPN removed 30 tablets of hydrocodone-acetaminophen for destruction but could not explain their disappearance. Additional missing medications included oxycodone-acetaminophen, tramadol, and significant quantities of hydrocodone-acetaminophen from the narcotic lock box for multiple residents. The facility's investigation confirmed these losses, and the LPN involved was placed on leave and subsequently terminated. Facility policies required that discontinued controlled drugs be destroyed in the presence of the DON or a registered nurse, and that all scheduled drugs be counted at the beginning and end of each shift. However, the investigation and interviews revealed that these procedures were not consistently followed, leading to the unaccounted loss of narcotic medications prescribed to residents. The failure to adhere to established protocols resulted in the misappropriation of residents' property.
Failure to Ensure Call Light Accessibility for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency was identified when a resident with hemiplegia and hemiparesis following a stroke, who was also severely cognitively impaired and at risk for falls, was repeatedly observed without access to their call light. On two separate occasions, the resident was found either in bed or in a wheelchair with the call light cord and mechanism hanging from the wall and resting near the floor, approximately three feet away from the head of the bed and not within the resident's reach. The resident was unaware of the call light's location during both observations. Interviews with facility staff, including a scheduler and a unit manager, confirmed that the call light was supposed to be kept within reach of the resident, but noted that the resident sometimes tossed the call light away. The facility administrator stated there was no specific call light policy, but that the practice was for staff to ensure call lights were accessible to residents. Despite these expectations, the resident's call light was not made accessible, resulting in a failure to reasonably accommodate the resident's needs.
Failure to Follow Physician Orders for Skin Treatment
Penalty
Summary
The facility failed to provide care in accordance with the physician's orders for a resident with skin conditions. Over several days, the resident, who has a diagnosis of type 2 diabetes mellitus with neuropathy, was repeatedly observed in the hallway with multiple dried scabs and open areas on both legs, including an open area on the left knee, without the required dressing in place. The physician's order specified that the open scab on the left knee should be cleaned every other day with normal saline and covered with a border dressing every evening and as needed for soilage or dislodgement. Despite these orders, the resident was observed multiple times without the prescribed dressing, and the DON confirmed that the facility was expected to follow the physician's orders for treatment.
Failure to Label and Date Enteral Feeding Equipment
Penalty
Summary
A deficiency was identified when a resident with a history of atherosclerotic heart disease and unspecified dysphagia was observed receiving enteral tube feeding. The physician's orders specified the use of Osmolite 1.2 at a set rate and water flushes, both administered via an electronic pump. During multiple observations, the tube feeding container and the accompanying water flush bag were found to be unlabeled and undated, despite designated areas for staff to sign and date them. Additionally, the tubing itself was not labeled or dated, and at one point, the water flush bag was observed to be open at the top. Interviews with staff confirmed that the feeding container and water flush bag should have been labeled and that the flush bag should not have been left open. The LPN acknowledged the oversight and indicated that another nurse had started the feeding earlier. The DON and Administrator also confirmed that the tube feeding bag should have been signed and dated, indicating a failure to follow established protocols for labeling and dating enteral feeding equipment.
Failure to Provide Timely Two-Step TB Skin Test on Admission
Penalty
Summary
The facility failed to ensure that a resident was provided a two-step tuberculin skin test (TST) upon admission, as required by facility policy. The resident, who had diagnoses including chronic respiratory failure, chronic pulmonary edema, and type 2 diabetes mellitus, was admitted on 3/29/25. The clinical record showed that the resident received a first step TB skin test on 3/29/25 and another first step TB skin test on 4/30/25, with both tests read as negative. However, the two tests were administered 32 days apart, and both were labeled as first step TB skin tests, with no timely second step documented. Facility policy required that if the first TST is negative, a follow-up TST should be administered 1 to 3 weeks after the initial test is read, which was not followed in this case.
Failure to Protect Resident's Controlled Medication from Misappropriation
Penalty
Summary
A deficiency occurred when a resident's controlled pain medication, Oxycodone-acetaminophen 7.5-325 mg, went missing from the medication cart. The resident, who was cognitively intact and had diagnoses including diabetes mellitus, right tibia fracture, cellulitis, and right leg pain, was prescribed this medication both on a scheduled and as-needed basis. On the morning in question, an LPN administered a dose to the resident and confirmed that four tablets remained. During the shift, the LPN gave the medication cart keys to the Unit Manager, who, along with another LPN, placed additional medication cards in the lock box but did not perform a count of the controlled substances afterward. At the end of the day shift, during the routine medication count, it was discovered that the resident's Oxycodone-acetaminophen medication card was missing. The evening shift RN and the LPN confirmed the absence of the medication card during their count, and the incident was reported to the Director of Nursing. Facility policy required all Class II drugs to be stored under double lock at all times and for the environment to be free from misappropriation of resident property. The failure to properly secure and account for the controlled medication led to the misappropriation of the resident's property.
Failure to Develop Person-Centered Care Plan for Resident with Hearing Device
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with a hearing device. Resident 42, who has a hearing deficit and relies on an amplifier device system, was observed multiple times without a comprehensive care plan addressing her hearing needs. Despite being moderately cognitively intact and having a documented hearing deficit, the resident's clinical record lacked a specific care plan for the use of her amplifier device system. This omission was confirmed by the Regional Nurse Consultant and other staff members, who acknowledged that the care plan should have been initiated when the resident began using the device. Interviews with Resident 42 and various staff members, including the Staff Development Coordinator and a Qualified Medication Aide, revealed that the resident had been using the amplifier device system for several years. The facility's policy on comprehensive person-centered care plans, which requires the development of a care plan within seven days of the completion of the required comprehensive assessment (MDS), was not followed. This failure to develop and implement a care plan for Resident 42's hearing needs constitutes a deficiency in meeting the resident's physical, psychosocial, and functional needs.
Failure to Date Insulin Pens
Penalty
Summary
The facility failed to ensure medications were properly dated for one of the two medication carts observed. During a medication storage and labeling review, four opened Insulin Flex Pens were found in the 200 Hall Medication Cart without labels indicating the date they were opened. The Regional Nurse Consultant confirmed that the insulin pens should have been dated with an open date. The Director of Nursing provided an undated policy titled 'Insulin Packaging G-24,' which indicated that insulin bottles should be dated when activated, retained for 28 days, and then discarded. However, this policy was not followed for the insulin pens in question.
Failure to Post Actual Nursing Hours Worked
Penalty
Summary
The facility failed to ensure the actual hours worked by nursing staff were posted for three out of four days during the survey. On 5/8/24, 5/9/24, and 5/10/24, the posted nursing hours observed on the wall behind the nurses' station lacked the actual hours worked. During an interview on 5/10/24, the Director of Nursing (DON) indicated that they had posted the actual nursing hours. However, the policy provided by the DON, titled 'Posting Direct Care Daily Staffing Numbers,' was undated and indicated that the actual time worked during each shift of each category and type of nursing staff should be posted, which was not adhered to in this case.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a facility tour and follow-up observation. During the initial tour, one of the two top lids of the trash dumpster was not closed, and multiple filled trash bags were visible inside. Additionally, multiple broken-down boxes and one large unbroken-down box were leaning against the trash dumpster container. No staff were present in the area at the time of observation. The Regional Dietary Consultant confirmed that the dumpster area should be kept clean, free of debris, and the top lids should be kept closed when not in use. In a follow-up observation, both top lids of the recycle dumpster were found to be open, with multiple broken-down and unbroken-down boxes visible inside and hanging on the outside of the container. Again, no staff were observed in the area. The Regional Dietary Manager confirmed that the lids should be kept closed and all boxes should be broken down when placed into the recycle dumpster. The facility's policy on Food-Related Garbage and Rubbish Disposal, dated December 2008, and the Retail Food Establishment Sanitation Requirements were reviewed, both of which mandate that garbage and rubbish containers be kept closed and free of surrounding litter.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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