Harbor Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in East Chicago, Indiana.
- Location
- 5025 Mccook Ave, East Chicago, Indiana 46312
- CMS Provider Number
- 155653
- Inspections on file
- 35
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Harbor Health & Rehab during CMS and state inspections, most recent first.
The facility failed to keep care plans current and comprehensive for several residents with dementia, schizophrenia, behavioral issues, fall risk, and abuse/neglect risk. One resident with Alzheimer’s and psychotic disorder had incidents involving other residents, including a verbal altercation that led to pain and hospital transfer, yet elopement, abuse/neglect, and fall care plan interventions had not been revised for many months. Another resident with schizophrenia and multiple comorbidities had repeated verbally aggressive behaviors, was placed on frequent safety checks, and was twice sent to the hospital, but behavior care plan interventions were not updated to reflect these events until much later. Additional residents with suicidal ideation, psychotic disorder, paranoid schizophrenia, and hemiplegia were involved in aggressive or maladaptive interactions, while their abuse/neglect and behavior-related care plan interventions remained outdated despite later revision dates on the care plans themselves.
A resident with Alzheimer’s disease, psychotic disorder, HTN, depression, anemia, and COPD, who was documented as cognitively impaired for daily decision making on the MDS, experienced a change in roommate. A nurse’s progress note indicated the resident was adjusting well to the new roommate, confirming the change occurred, but there was no documentation that the resident’s Responsible Party was notified. During interview, the DON acknowledged that the Responsible Party had not been informed of the roommate change, as she believed notification was only required for a room change.
A resident with Alzheimer's disease, psychotic disorder, HTN, depression, anemia, and COPD, identified on the MDS as cognitively impaired for daily decision making, did not have ongoing care plan meetings conducted and documented as required. A social services note showed that a care plan meeting was arranged with the resident's daughter and held on the same day, but records indicated this was the last documented care plan meeting, with no further meetings recorded. During interview, a nurse consultant confirmed there was no documentation of any subsequent scheduled or rescheduled care plan meetings, despite the expectation that any cancelled meetings be documented as rescheduled.
A resident with schizophrenia, dementia, depression, anxiety, HIV, alcohol abuse, and a history of verbal and physical aggression exhibited escalating behaviors, including unprovoked verbal abuse and striking staff and another resident, leading to multiple hospital and psychiatric evaluations. Despite physician orders for 15‑minute safety checks and a behavior care plan citing aggression toward staff and peers, the record lacked required safety check documentation over an extended period, and behavior interventions were not updated for many months despite repeated aggressive incidents. Staff interviews confirmed the resident’s unpredictable aggression, absence of effective de‑escalation techniques, and that ordered close monitoring was not consistently implemented after returns from behavioral health hospitalizations.
A resident with multiple psychiatric, cognitive, and medical diagnoses, including schizophrenia, dementia, depression, anxiety, HIV, and alcohol abuse, had a physician’s order for 15-minute safety checks every shift. Review of safety logs showed that the ordered 15-minute checks were not signed out for a one-hour period. An LPN reported that the checks had been done but not yet charted, and the DON stated that staff are expected to complete all ordered 15-minute checks and sign off each time, acknowledging that the documentation for that hour should have been completed.
A resident with COPD and other medical conditions was observed receiving oxygen therapy at a flow rate below the physician-ordered 2 liters per minute on multiple occasions. The nasal cannula was not always properly positioned, and an LPN initially failed to verify the correct flow rate before adjusting it. The care plan and physician's orders specified the need for 2 liters of oxygen via nasal cannula as needed, but this was not consistently provided as required.
A resident, dependent on staff for mobility, fell and fractured her leg during a Hoyer lift transfer when only one staff member assisted, contrary to the facility's two-person policy. The resident, with a history of osteoporosis and neuromuscular weakness, was transferred by a CNA who could not find additional help. The CNA attempted to prevent the fall, but the resident's leg was injured during the incident.
The facility's first floor had several environmental deficiencies, including marred walls, loose baseboards, and missing bolts around toilets, affecting multiple residents. The Maintenance Director confirmed the need for repairs.
A cognitively impaired resident was repeatedly observed wearing a hospital gown during the day, with no care plan indicating this preference. The resident, with multiple health conditions, had an incomplete Activity Assessment and lacked a care plan addressing clothing needs. The DON confirmed the absence of personal clothes and a related care plan.
Two residents in the facility did not receive adequate assistance with ADLs, including nail care, oral hygiene, and mobility. One resident had long, dirty fingernails and expressed a need for nail care, which had not been performed since late July. Another resident was observed with long fingernails and dried mucous around the lips, indicating a lack of oral care, and was not assisted out of bed despite no bed rest order. Staff interviews confirmed these deficiencies, and the DON acknowledged that care tasks should have been completed as needed.
The facility failed to provide personalized activity programs for two cognitively impaired residents. One resident, in a persistent vegetative state, received minimal engagement despite a care plan for 1:1 visits and music stimulation. Another resident, with multiple diagnoses, was observed in bed without access to activities or proper stimulation, and the care plan did not reflect the resident's current status. The Activity Director and DON acknowledged these deficiencies.
The facility failed to provide appropriate treatment and documentation for two residents with non-pressure related skin conditions. One resident did not receive consistent treatment for a finger wound as ordered, and another resident's arm discoloration was not documented or communicated among staff. The facility's Wound Management policy was not effectively followed.
The facility failed to provide necessary vision and hearing services to residents. A resident with diabetes and renal disease did not receive new glasses recommended after an eye exam, and another resident with hearing loss did not receive a hearing aid despite a recommendation. Additionally, a third resident with chronic conditions did not receive glasses as advised. The Social Service Director was unaware of these issues, and Medicaid coverage was a barrier for one resident's glasses.
A resident with multiple health conditions, including a pressure ulcer, did not receive the necessary treatment as ordered by the physician, leading to a deficiency in care. Observations revealed the absence of a bandage on the ulcer, which had worsened with necrotic tissue. Staff interviews indicated a lack of adherence to the treatment plan, and the Wound Nurse confirmed the treatment was not completed as ordered, resulting in the wound's deterioration.
A resident with a suprapubic catheter did not receive the required catheter care, as evidenced by an outdated bandage with dried blood. The resident, who has multiple medical conditions, was assessed to need assistance with personal hygiene. Despite physician orders for catheter care every shift, the facility failed to comply, as confirmed by the DON.
A resident with a PEG tube was improperly positioned during enteral feeding, contrary to the care plan requiring the head of the bed to be elevated 30-45 degrees. CNAs lowered the bed and put the feeding on hold, which was not allowed. The resident had multiple health issues and was dependent on staff for care.
A resident with COPD and other health conditions was observed receiving oxygen at 1.5 liters instead of the prescribed 2 liters. The care plan and physician orders both indicated the need for a 2-liter flow rate, but this was not followed, as confirmed by the DON.
A facility failed to maintain accurate documentation for narcotic medications, leading to a suspected diversion by a nurse. A resident prescribed Morphine Sulfate had discrepancies in the narcotic log, with doses inaccurately recorded. The issue was not reported until later, despite the medication being signed out as given twice daily. The nurse involved refused a drug screen and terminated employment.
A facility failed to document blood pressure readings for a resident receiving Hydralazine, despite a physician's order to hold the medication if systolic blood pressure was below 110. Staff interviews revealed that blood pressures were checked but not documented due to system limitations, and nursing leadership acknowledged the oversight.
A resident with Alzheimer's disease was prescribed Seroquel for behavior management without adequate documentation of its necessity or an attempt at gradual dose reduction. The resident's care plan included antipsychotic medication, but there was no approved diagnosis for its use, and the resident had not been seen by the behavioral health NP. Seroquel is not FDA-approved for dementia-related psychosis, and there is a black box warning about increased mortality in such cases.
A resident with decayed and broken teeth did not receive routine dental services due to a lack of follow-up after a dental exam in April 2024. The exam indicated non-restorable teeth and inflamed gums, but no care plan was documented. The MDS Coordinator was unaware of the issues, and the resident had not seen a dentist since the facility changed providers. The resident was reluctant to restart the dental process with the new provider.
The facility did not follow recipes for pureed diets, affecting two residents. A cook prepared pureed barbeque chicken and broccoli without using additional ingredients as specified in the recipes, such as sauce and margarine. The Dietary Manager confirmed that the recipes should have been followed, indicating a failure to adhere to dietary protocols.
The facility failed to maintain accurate clinical records for two residents. A resident with end-stage renal disease had inconsistent documentation of their dialysis access site condition, while another resident, who was NPO, had incorrect medication administration routes documented as oral instead of via peg tube. The DON and ADON acknowledged these documentation errors.
The facility failed to address a repeated deficiency related to pest control, specifically gnats in resident rooms, affecting all 60 residents. Despite regular meetings of the QAA Committee, no action plans or Performance Improvement Plans were developed. The Administrator was aware of the issue and engaged pest control services weekly, but treatments did not always target gnats.
A resident with pressure ulcers was found in a room infested with gnats, which were observed on their bed linen and wound dressing. The Wound Nurse confirmed the presence of gnats during wound care, despite pest control measures being in place for other pests. The facility's pest control program did not address gnats, contrary to its policy of maintaining a pest-free environment.
A resident with a history of falls was observed with a low bed and floor mat, but these interventions were not documented in the care plan. Despite a previous fall, the care plan only included a reach assist bar and lacked specific interventions like the low bed and mat. The DON confirmed the care plan update post-fall but acknowledged the missing documentation.
A facility failed to notify a physician of a resident's elevated blood glucose levels, despite multiple readings above 400 mg/dL. The resident, who was receiving insulin for diabetes, had no specific parameters in place for physician notification. Interviews with staff confirmed the expectation to notify physicians of such levels, but documentation was lacking.
Failure to Maintain Current, Comprehensive Care Plans for Residents With Behaviors, Falls, and Abuse Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and update comprehensive, measurable care plans with current interventions for multiple residents with behaviors, falls, schizophrenia, and abuse/neglect risk. For one resident with Alzheimer’s disease, psychotic disorder, depression, COPD, and cognitive impairment, the record showed two facility-reported incidents: a candy-related interaction with another resident where no injuries occurred, and a later verbal altercation with a different resident that resulted in the resident being found on the floor with right leg and hip pain and being sent to the hospital. Despite these events and existing care plans for elopement/wandering, abuse/neglect risk, and falls, the interventions within these care plans had not been revised for many months, with the elopement/wandering interventions last revised in June of the prior year, the abuse/neglect interventions unchanged since May of the prior year, and the fall interventions last updated in July of the prior year. Another resident with schizophrenia, dementia, dysphagia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse had multiple documented episodes of verbally aggressive behavior toward staff and residents over several dates. Nursing notes documented the use of 30‑minute checks and later 15‑minute safety checks, as well as two separate hospital transfers for evaluation and behavioral health care. The resident had a behavior care plan that included interventions such as praising progress, protecting the rights and safety of others, minimizing disruptive behaviors, and 15‑minute safety checks. However, the interventions in this behavior care plan were not updated after the series of aggressive behaviors and hospitalizations in December and January; the last intervention prior to the February incident was from September of the previous year, and the care plan interventions were only updated after a later psychiatric hospitalization. A third resident with suicidal ideations, dementia, anxiety, hypertension, major depressive disorder, and psychotic disorder was involved in the candy-related incident when another resident offered candy and this resident swatted at it, knocking it to the floor, with no injuries noted. This resident had an abuse/neglect risk care plan and a separate care plan for socially inappropriate and maladaptive behavior, but the interventions for abuse/neglect had not been revised since early August of the prior year, and the socially inappropriate/maladaptive behavior interventions had not been revised since mid‑September of the prior year. A fourth resident with hemiplegia, hypotension, paranoid schizophrenia, aphasia, epilepsy, dysphagia, and a right hand contracture was involved in an aggressive incident toward the third resident, after which both residents were assessed and one was sent to the hospital. This fourth resident had an abuse/neglect risk care plan and a schizophrenia care plan, but the abuse/neglect interventions had not been revised since May of the prior year, and the schizophrenia care plan interventions had not been updated since early May of the prior year, despite the later aggressive incident and subsequent care plan revision dates that did not include updated interventions.
Failure to Notify Responsible Party of Roommate Change
Penalty
Summary
The facility failed to notify a resident’s Responsible Party of a change in roommate, as required for situations that affect the resident. Resident B’s record, reviewed on 2/23/26, showed multiple diagnoses including Alzheimer’s disease, psychotic disorder, hypertension, depression, anemia, and COPD, and a Quarterly MDS dated 11/4/25 documented that the resident was cognitively impaired for daily decision making. A nurse’s progress note dated 1/22/26 at 12:46 a.m. stated that the resident appeared to be adjusting well to a new roommate, confirming that a roommate change had occurred. However, there was no documentation that the resident’s Responsible Party had been notified of this new roommate, and during interview the DON acknowledged that the Responsible Party was not notified of the roommate change, as she believed notification was only required for a room change. This deficiency was cited under 3.1-5(b)(1) and related to Intake 2739564.
Failure to Conduct and Document Ongoing Care Plan Meetings
Penalty
Summary
The facility failed to ensure required care plan meetings were conducted and documented for a resident, as mandated to be developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by an interdisciplinary team. Record review for Resident B, who had diagnoses including Alzheimer's disease, psychotic disorder, hypertension, depression, anemia, and COPD, showed that a Quarterly MDS dated 11/4/25 identified the resident as cognitively impaired for daily decision making. A Social Services note dated 9/23/25 documented that the Social Service Director contacted the resident's daughter to schedule a care plan meeting, and the daughter agreed to have the meeting when she arrived at the facility that day, with the SSD indicating availability to conduct it. The record showed the last care plan meeting occurred on 9/23/25, with no documentation of any subsequent care plan meetings after that date. During interview, the Nurse Consultant reported contacting the previous social worker and confirmed there was no documentation of a scheduled or rescheduled care plan meeting, and stated that any cancelled meeting should have been documented as rescheduled. This citation relates to Intake 2739564 and regulatory reference 3.1-35.
Failure to Provide Adequate Behavioral Health Interventions and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services to a resident with a history of significant psychiatric and behavioral issues. The resident’s diagnoses included schizophrenia, dementia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, alcohol abuse, and dysphagia. A quarterly MDS showed the resident was cognitively intact for daily decision-making but had worsening verbal behaviors. On one day, multiple behavior notes documented verbal aggression toward staff and residents, and the resident was placed on 30‑minute safety checks for 72 hours. Subsequently, the resident was sent to the hospital for evaluation and later returned to the facility. Following the resident’s return, a physician ordered 15‑minute safety checks every shift with completion of a safety log, and nursing documentation indicated the resident was verbally aggressive and placed on 15‑minute checks before being sent again to a hospital behavioral health unit. However, the record lacked documentation of 15‑minute safety checks from late December through early February, despite ongoing behavior issues. During this period, multiple nurse’s notes documented repeated verbally aggressive behaviors on numerous dates. The behavior care plan, which identified aggression toward staff and residents related to mental illness, contained general interventions such as administering medications, assessing coping skills, and assessing understanding of the situation, but behavior interventions were not updated after the December incidents and hospitalizations. On a later date in February, nurse’s notes documented verbal and physical aggression toward staff and another resident, leading to the resident being isolated from others and sent to the hospital for psychological evaluation. A facility‑reported incident described staff overhearing a verbal altercation between two residents, after which one resident was found on the floor with pain in the leg and hip and was sent to the hospital, while the aggressive resident was sent for psychiatric evaluation. A physician again ordered 15‑minute safety checks for 72 hours. The behavior care plan, originally dated in 2023 and revised in early February 2026, noted a history of verbal and physical aggression and included interventions such as praising progress, protecting the rights and safety of others, and placing the resident on 15‑minute safety checks, but the interventions had not been updated between September 2024 and mid‑February 2026 despite multiple aggressive incidents and hospitalizations. Interviews with the ADON, CNAs, and DON confirmed the resident’s unpredictable, unprovoked verbal and physical aggression, the lack of effective de‑escalation techniques, and that the resident was not on 15‑minute safety checks when returning from earlier psychological evaluations.
Failure to Accurately Document 15-Minute Safety Checks
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical records for a resident on physician-ordered 15-minute safety checks. Resident C had multiple diagnoses, including schizophrenia, dementia, dysphagia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse. A Quarterly MDS dated 11/4/25 documented that the resident was cognitively intact for daily decision-making and exhibited verbal behaviors that were worse than on the previous assessment. A physician’s order dated 2/16/26 directed staff to initiate 15-minute safety checks every shift for monitoring. On 2/24/26, review of the safety logs on the second floor showed that the 15-minute safety checks for Resident C were not signed out from 3:00 p.m. to 4:00 p.m. During interview, an LPN stated she should have charted the 15-minute checks after performing them but had not yet done so. In a separate interview, the DON stated she expected nursing staff to complete all ordered 15-minute safety checks and sign off in the logs each time, and acknowledged that the checks for the previous hour should have been signed off.
Failure to Ensure Correct Oxygen Flow Rate for Resident
Penalty
Summary
A deficiency was identified when a resident requiring oxygen therapy for conditions including COPD, heart failure, and dementia was observed with their oxygen flow rate set incorrectly on multiple occasions. On two separate days, the oxygen flow meter was set slightly above 1.5 liters per minute, rather than the physician-ordered 2 liters per minute via nasal cannula. During one observation, the nasal cannula tubing was not properly positioned under the resident's nose. An LPN, when questioned, initially stated the oxygen was set at 2 liters but upon verification, acknowledged the flow rate was incorrect and adjusted it to the prescribed level. The resident's care plan specified oxygen therapy as needed for shortness of breath, with instructions to administer oxygen as ordered by the physician. The resident's medical record confirmed the order for 2 liters of oxygen via nasal cannula as needed. The DON confirmed that nursing staff had been previously in-serviced on the correct method for checking oxygen flow rates, which involves viewing the flow meter at eye level to ensure accuracy. Despite these instructions, the oxygen was not set at the correct rate as ordered.
Inadequate Supervision During Hoyer Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate assistance and supervision during a mechanical lift transfer, resulting in a fall and injury for a dependent resident. The incident involved a single staff member assisting the resident during a Hoyer lift transfer, contrary to the facility's policy and the manufacturer's recommendation of requiring two staff members. This lapse in protocol led to the resident falling and sustaining a fracture to her leg. The resident involved in the incident was cognitively intact but dependent on staff for mobility and transfers. She had a history of conditions that increased her risk for falls, including osteoporosis and neuromuscular weakness. Despite these risk factors, the resident was transferred by only one staff member, which was insufficient to ensure her safety during the transfer process. The incident was witnessed by a CNA who admitted to transferring the resident alone because she could not find another staff member to assist, and the resident was insistent on being moved. The CNA attempted to prevent the fall by getting under the resident, but the resident's leg may have hit the lift, contributing to the injury. The facility's failure to adhere to the two-person transfer policy directly led to the resident's fall and subsequent injury.
Environmental Deficiencies on First Floor
Penalty
Summary
The facility failed to maintain a safe and well-maintained environment for residents on the first floor, as observed during an environmental tour. Several deficiencies were noted, including marred walls, loose baseboards, and missing bolts around toilets in multiple rooms. Specifically, the cove base was pulling away from the wall near the entrance of one room, and the walls were marred under the chair rail. Another room had a marred and gouged wall behind the bed. In a different room, the door frame was marred by the closet, and the cove base was loose in the entryway. Additionally, the bathroom walls were marred. In another instance, the bathroom door frame was marred, and the paint on the walls was chipped, with exposed bolts at the base of the toilet. These conditions affected several residents who shared these rooms and bathrooms. The Maintenance Director acknowledged the need for repairs during the interview.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a cognitively impaired resident, identified as Resident 58, who was observed wearing a hospital gown during the day on multiple occasions. The resident, who was moderately impaired in daily decision-making due to conditions such as stroke, obesity, dysphagia, type 2 diabetes, high blood pressure, heart disease, and restlessness, did not have a care plan indicating a preference for wearing a hospital gown. Additionally, an Activity Assessment for the resident was incomplete, lacking information on recreation interests, habits, and preferences. During an interview, the Director of Nursing acknowledged that the resident had no clothes but confirmed there was no care plan addressing this issue.
Deficiency in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, specifically in the areas of nail care, oral hygiene, and mobility. Resident 45 was observed multiple times with long and dirty fingernails, despite expressing a need for nail care. The resident's care plan indicated a need for assistance with personal hygiene, but nail care had not been performed since 7/29/24. Interviews with staff revealed that nail care was not provided as needed, and the Director of Nursing confirmed that nail care should be done as required. Resident 58 was also observed with long fingernails and dried mucous around the lips, indicating a lack of oral care. The resident was dependent on staff for personal hygiene and oral care due to a recent stroke, as noted in the care plan. Despite this, there was no documentation of oral care being performed daily. Additionally, the resident was not being assisted out of bed, although there was no physician's order for bed rest. Staff interviews confirmed the lack of oral care and mobility assistance, and the Director of Nursing acknowledged that these care tasks should have been completed as needed.
Failure to Provide Personalized Activity Programs for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide a personalized activity program for two residents, both of whom were cognitively impaired and dependent. Resident 24, diagnosed with conditions including stroke and major depressive disorder, was observed multiple times over several days in a persistent vegetative state, lying in bed with no television or radio present for stimulation. The resident's care plan indicated the need for 1:1 visits and music stimulation, yet the resident only received minimal engagement, such as listening to music on two occasions and being read a story twice in early August. The Activity Director acknowledged the lack of ongoing stimulation and the absence of a radio in the resident's room. Resident 58, who had diagnoses including stroke and diabetes, was observed in bed with the television turned off and positioned in a way that the resident could not see it. The resident's care plan required encouragement for activities, but the resident had not participated in any group activities since June and had limited 1:1 visits. The Activity Director noted that the care plan did not reflect the resident's current status, and there was no radio for continuous music. The Director of Nursing mentioned that the resident was not being moved out of bed due to restlessness, although there was no care plan or physician's order for bed rest.
Failure to Provide Proper Skin Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents with non-pressure related skin conditions. Resident 13, who has multiple diagnoses including COPD, diabetes, and heart disease, was observed with dry, flaky skin on her feet and an open area on her right ring finger that was not covered. The resident reported that the treatment for her finger was last done on a previous Friday and was supposed to be done every Monday, Wednesday, and Friday. However, the treatment was not completed as scheduled on 8/6/24. The Wound Physician had ordered daily treatment with betadine, but the Treatment Administration Record indicated it was not consistently administered. The Wound Nurse acknowledged the treatment was to be done daily, and the Director of Nursing confirmed the treatment should have been completed as ordered. Resident 57, who has Alzheimer's disease and other conditions, was observed with a large red and purple discoloration on his left forearm. Despite this visible condition, there was no documentation in the clinical record regarding the discoloration from 8/1-8/7/24. Staff members, including an LPN and an RN, were unaware of the discoloration, and the Director of Nursing only assessed it after being informed. The resident mentioned that such discolorations occur frequently. The facility's Wound Management policy was intended to assist in the care and documentation of wounds, but it was not effectively implemented in this case.
Failure to Provide Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that residents received necessary vision and hearing services as ordered. Resident 2, who has diagnoses including type 2 diabetes and end-stage renal disease, reported needing new glasses, which were recommended after an eye exam on 12/19/23. Despite being cognitively intact and having a care plan that included arranging consultations with an eye care practitioner, there was no documentation indicating that the resident received the new glasses. The Social Service Director, who had been employed for 95 days, acknowledged the issue and noted that Medicaid would not cover the cost of the glasses, leaving the resident with a $215 out-of-pocket expense. Resident 45, with multiple diagnoses including spinal cord infarction and major depressive disorder, indicated he had been fitted for a hearing aid months ago but had not received any follow-up. An audiology exam from 9/6/23 recommended a hearing aid due to moderate to severe sensorineural hearing loss, but there was no care plan addressing hearing difficulties, and the Social Service Director was unaware of the need for a hearing aid. Similarly, Resident 34, with diagnoses including chronic kidney disease and depressive disorder, had an eye exam on 12/19/23 recommending new glasses, but had not received them. The Social Service Director confirmed that the resident should have received glasses following the recommendation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure sore, leading to a deficiency in care. During an observation, it was noted that a resident with a pressure ulcer did not have a bandage covering the affected area, and the ulcer showed signs of necrotic tissue. The resident, who was dependent on staff for repositioning and had multiple health conditions including stroke and diabetes, was observed with several ulcers on the buttocks and sacral area, which were not properly treated as per the physician's orders. The treatment plan included the application of a hydrocolloid dressing three times a week, but this was not adhered to, resulting in the deterioration of the wound. Interviews with staff revealed a lack of awareness and execution of the prescribed treatment plan. A CNA indicated the resident was last changed hours before the observation, and an LPN was unsure of the treatment required. The Wound Nurse confirmed that the treatment was not completed as ordered, and the wound had worsened since the last assessment. The resident's condition had declined, with the wound evolving into an unstageable pressure ulcer, and additional new wounds were noted. The Director of Nursing acknowledged that the treatment should have been completed as ordered.
Failure to Provide Adequate Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic foley catheter, as observed during a survey. Resident 45, who has a suprapubic catheter, was found with a bandage around the stoma that was dated three days prior and had dried brown blood on it. This observation was made during a random check while the resident was in bed. The resident's medical history includes conditions such as infarction of the spinal cord, heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, urine retention, and neuromuscular issues of the bladder. The resident was assessed to be cognitively intact and required partial to moderate assistance with personal hygiene. The care plan for the resident, revised in July, indicated that the resident was attention-seeking regarding catheter care, with an approach to provide catheter care as ordered. However, the physician's orders from July required catheter care every shift, which was not adhered to, as evidenced by the outdated bandage. The facility's policy on suprapubic site care, dated February 2021, outlines the procedure to decrease the risk of infection, including cleaning the area around the stoma and evaluating it for any signs of infection. Despite these guidelines, the facility did not ensure that the resident received the necessary catheter care, as confirmed by the Director of Nursing, who had no additional information to provide.
Improper Positioning During Enteral Feeding
Penalty
Summary
The facility failed to ensure proper positioning of a resident during enteral feeding, which is a deficiency in care. During an observation, two CNAs were asked to reposition a resident with a PEG tube to examine a pressure ulcer. One of the CNAs lowered the head of the bed to 5 degrees while the enteral feeding was infusing, which is against the care plan that requires the head of the bed to be elevated 30-45 degrees during and thirty minutes after tube feeding. The CNA then put the feeding on hold, claiming that nurses allowed them to do so, which was not appropriate according to the Director of Nursing. The resident involved had a history of stroke, obesity, dysphagia, type 2 diabetes, high blood pressure, heart disease, restlessness, and agitation, and was dependent on staff for various activities. The resident was moderately impaired in daily decision-making and received more than half of their nutrition through the PEG tube. The physician's orders specified that the resident was NPO and required enteral feeding at specific times. The deficiency was identified through observation, record review, and interviews, highlighting a lapse in following the care plan and physician's orders.
Failure to Maintain Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen was set at the correct flow rate for a resident requiring respiratory care. During observations on multiple occasions, the resident was seen wearing oxygen via nasal cannula at 1.5 liters, despite physician orders specifying a flow rate of 2 liters. The resident's medical record indicated a history of chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and other significant health conditions. The care plan, revised on two separate occasions, also specified the need for oxygen therapy at 2 liters. However, the observed flow rate did not align with these orders, as confirmed by the Director of Nursing during an interview.
Narcotic Documentation Discrepancy and Diversion Investigation
Penalty
Summary
The facility failed to maintain an accurate system for accounting, reconciling, and ensuring the disposition of controlled drugs, specifically narcotics, for a resident. This deficiency was identified during an investigation into a suspected narcotic diversion involving a previously employed nurse. The investigation revealed discrepancies in the documentation of narcotic medications for a resident who was prescribed Morphine Sulfate for pain and shortness of breath. The narcotic log showed inconsistencies in the recorded remaining doses, particularly on 7/6/24, where the remaining dose was inaccurately documented as higher than expected. This discrepancy was not reported until 7/31/24, despite the medication administration record indicating the medication was signed out as given twice daily throughout July. The resident involved had multiple diagnoses, including hemiplegia, a stage 4 sacral wound, and anxiety, and was using hospice services. The care plan highlighted the risks associated with opioid use, such as constipation and respiratory failure. During interviews, it was revealed that the nurse who administered the morphine on 7/6/24 did not report the discrepancy to the Director of Nursing or the Administrator. The nurse consultant acknowledged that a diversion issue likely existed before the report was filed. The nurse involved in the discrepancy refused a drug screen and subsequently signed a voluntary termination.
Failure to Document Blood Pressure Monitoring for Medication Administration
Penalty
Summary
The facility failed to appropriately monitor and document blood pressures for a resident receiving Hydralazine, a medication used to lower blood pressure. The resident, who was admitted with multiple diagnoses including stroke, obesity, type 2 diabetes, and high blood pressure, had a physician's order to hold Hydralazine if the systolic blood pressure was less than 110. However, the Medication Administration Record (MAR) for July and August 2024 showed no documented blood pressure readings prior to the administration of the medication, with the last recorded blood pressure being on July 28, 2024. Interviews with facility staff revealed that blood pressures were checked but not documented due to a lack of a designated place in the computer system. The LPN responsible for administering the medication confirmed that she checked the blood pressure but did not document it. Both the Assistant Director of Nursing and the Director of Nursing acknowledged that blood pressures should have been recorded in the clinical record before administering Hydralazine, indicating a lapse in following proper documentation protocols.
Inadequate Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to document an adequate indication for the use of an antipsychotic medication for a resident diagnosed with Alzheimer's disease, high blood pressure, anemia, and osteoarthritis. The resident, who was moderately impaired in daily decision-making and exhibited wandering behavior, was prescribed Seroquel, an antipsychotic medication, for behavior management without a documented attempt at gradual dose reduction (GDR). The resident's care plan indicated the use of antipsychotic medication, but there was no documentation of behaviors or an adequate indication for its use in the clinical record. The resident was initially prescribed Seroquel 25 mg at bedtime for insomnia, which was later increased to 50 mg at bedtime and 25 mg in the morning for restlessness. Despite these changes, there was no approved diagnosis for the use of Seroquel, and the resident had not been seen by the contracted behavioral health Nurse Practitioner. The FDA-approved uses for Seroquel do not include treatment for dementia-related psychosis, and there is a black box warning about increased mortality in elderly patients with dementia-related psychosis treated with antipsychotic drugs.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident with decayed and broken teeth. The resident, who was cognitively intact and required assistance with personal hygiene, had not received dental care since a dental exam in April 2024. This exam revealed root tips, non-restorable teeth, and inflamed gums, with recommendations for further x-rays and a treatment plan. However, no care plan for dental issues was documented, and the resident had not been seen by a dentist since the facility switched dental providers. Interviews revealed that the MDS Coordinator was unaware of the resident's dental issues, relying on the MDS look-back assessment rather than direct observation. The Social Service Director confirmed the resident had not seen a dentist since April 2024, despite visits from a new dental company in June and August 2024. The resident expressed reluctance to see the new dentist, not wanting to restart the process. This lack of follow-up and coordination resulted in the resident's continued dental issues.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that food was prepared in a form to meet individual needs, specifically for residents on a pureed diet. During an observation, it was noted that a cook prepared pureed barbeque chicken and broccoli without following the provided recipes. The cook did not use any additional ingredients as specified in the recipes, such as sauce for the chicken or margarine for the broccoli, resulting in a mixture that was pudding thick and even, but not prepared according to the guidelines. The Dietary Manager confirmed that the recipes should have been followed, indicating a lapse in adherence to dietary protocols.
Documentation Errors in Dialysis and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in documentation. For Resident 2, who had diagnoses including type 2 diabetes and end-stage renal disease, the facility did not correctly document the condition of the resident's dialysis access site. The care plan required the site to be assessed every shift for signs of infection, with abnormalities noted using specific symbols. However, the July Medication Administration Record (MAR) showed both positive and negative symbols documented on several dates, indicating inconsistencies in recording the site's condition. The Director of Nursing confirmed that the MAR should have been coded correctly. For Resident 58, who had multiple diagnoses including stroke, obesity, and dysphagia, the facility failed to accurately document the administration route for medications. Despite the resident being NPO and receiving nutrition through a peg tube, the physician's orders incorrectly indicated that medications were to be given by mouth. An LPN acknowledged awareness of the resident's NPO status but was unsure why the orders specified oral administration. The Assistant Director of Nursing confirmed that the orders should have reflected administration through the peg tube.
Failure to Address Repeated Pest Control Deficiency
Penalty
Summary
The facility failed to address unresolved quality deficiencies related to pest control, specifically concerning gnats in resident rooms. This issue was previously cited in an annual survey, indicating a repeated deficiency. The Quality Assessment and Assurance (QAA) Committee, which includes various key personnel such as the Medical Director, Administrator, and Director of Nursing, met regularly but did not develop or implement action plans to address the pest control issue. The lack of a Performance Improvement Plan (PIP) for the prevention of gnats was noted, despite the Administrator's awareness of the problem and the engagement of a pest control company. The deficiency had the potential to affect all 60 residents residing in the facility. During an interview, the Administrator acknowledged the ongoing gnat problem and mentioned that pest control services were being utilized weekly, although they did not always treat for gnats. The Administrator was in the process of reviewing the pest control contract to make necessary revisions. However, there was no evidence of continuous monitoring or corrective actions being taken to resolve the issue effectively.
Facility Fails to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of gnats in a resident's room. On the morning of August 5, 2024, a resident was observed in bed with gnats flying around the room and landing on their bed linen and wound dressing. The Wound Nurse, upon entering the room to perform wound care, noted gnats in the air, on the resident's gown, and within the bandages covering the resident's open ulcerations on the right lower leg. The Wound Nurse acknowledged the presence of gnats and mentioned that a work order had been submitted for pest treatment. Despite the presence of gnat strips in the room, the gnats continued to be a problem during the wound care process. The resident's medical record indicated diagnoses of pressure ulcers and hemiplegia following a cerebral infarction, with hospice services being provided. A review of the facility's pest control documentation revealed that while fruit flies, bed bugs, and cockroaches had been treated in various areas of the facility, gnats had not been addressed. The facility's policy on maintaining a safe environment stated that the facility should be free of pests and rodents, yet this was not achieved in the case of the resident's room. The Administrator later confirmed that the resident was moved to a different room, and the original room was deep cleaned.
Failure to Document Fall Interventions in Care Plan
Penalty
Summary
The facility failed to ensure that fall interventions were adequately care planned for a resident with a history of falls. Resident E, who was admitted with diagnoses including dysphagia, Diabetes Mellitus, and hypertension, was observed in bed with the bed in a low position and a mat on the floor next to him. Despite these observations, the resident's care plan did not include these specific interventions. The resident had previously fallen on 6/8/24 while trying to reach for something, although no injury occurred. The care plan was updated to include a reach assist bar, but it lacked the interventions of a low bed and a mat on the floor. The Director of Nursing confirmed during an interview that the care plan had been updated post-fall to include a grabbing tool, but it still did not reflect the use of a low bed or floor mat as interventions. This oversight was identified during a review of the resident's care plan, which indicated the resident was at risk for injury related to falls. The care plan included general interventions such as continuing existing interventions, educating the resident and caregivers about safety, a pharmacy consult, and physical therapy evaluation, but failed to document the specific interventions observed during the survey.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to provide necessary care and services for a resident with diabetes by not having blood glucose parameters in place and failing to notify the physician of elevated blood glucose levels. The resident, who was cognitively intact and diagnosed with Diabetes Mellitus, heart failure, and hypertension, was receiving insulin as per physician orders. However, there were no specific parameters set for when to notify the physician of abnormal blood glucose levels. Despite having several instances of blood glucose levels exceeding 400 mg/dL, there was no documentation indicating that the physician had been notified. Interviews with the RN and the Director of Nursing revealed that the general rule was to notify the physician if blood glucose levels were less than 60 or above 400, in the absence of specific physician orders. The facility's policy on Diabetes Mellitus Guidelines also required that abnormal lab or blood glucose results be communicated to the physician and recorded in the nurse's notes. The deficiency was identified during a complaint investigation, highlighting a lapse in following the facility's policy and ensuring proper communication with the physician regarding the resident's elevated blood glucose levels.
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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