Harrison's Crossing Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Terre Haute, Indiana.
- Location
- 395 8th Avenue, Terre Haute, Indiana 47804
- CMS Provider Number
- 155830
- Inspections on file
- 30
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Harrison's Crossing Health Campus during CMS and state inspections, most recent first.
Surveyors found that prescribers failed to document individualized clinical rationales and to sign and date consultant pharmacist recommendations when declining suggested changes to psychotropic medications for three residents with dementia, anxiety, depression, insomnia, and psychotic disturbance. In each case, the pharmacist recommended gradual dose reductions or dose adjustments of antipsychotic, antianxiety, or sedative medications, but the declinations lacked written justification on the recommendation forms, and in two instances the forms were not signed or dated by the prescriber, despite facility policy requiring an explanation when rejecting pharmacist suggestions.
A resident with a history of neuromuscular bladder dysfunction and a coccyx wound had an indwelling Foley catheter ordered for neurogenic bladder, but the medical record lacked physician clarification or valid justification for its continued use. Hospital records indicated the catheter was originally placed for an unstageable coccyx wound, not neurogenic bladder, and there was no subsequent physician assessment documenting the clinical reason to maintain the catheter. The resident’s husband reported the resident had no prior urinary issues, did not know why the catheter remained in place, and stated he had requested its removal without receiving an explanation. The resident, who was cognitively impaired per MDS, could not recall urinary issues or discussions about the catheter. The Regional Nurse Consultant cited wound protection as the rationale but acknowledged the absence of physician documentation, and the facility’s own catheter policy requiring valid medical justification, supporting diagnoses, and informing the resident/representative of risks and benefits was not followed.
A resident with Parkinson's, Alzheimer's, and dysphagia was observed eating without a clothing protector, resulting in food spills. Despite CNA 20's acknowledgment of the need for a protector, it was not provided until CNA 13 intervened. The resident, requiring assistance and not cognitively intact, was reassured after expressing apologies.
A resident did not receive showers as scheduled due to cold water in her room, and staff failed to offer alternative shower options. Despite being cognitively intact and requiring assistance, the resident went almost two weeks without a shower. Facility staff acknowledged the oversight, noting available alternatives like a spa area or unoccupied rooms.
A resident experienced a 19.5% weight loss in less than 30 days, but the facility failed to notify the physician of this significant change. The resident, who was on Lasix for edema, had their dosage adjusted by an NP, yet there was no documentation of a plan to address the weight loss or notification to the attending physician. The facility's policy on physician notification was not adhered to, as there was no record of attempts to notify the physician or their response.
A resident with a urostomy catheter bag was observed multiple times with the bag in contact with the floor, contrary to facility policy. The resident, who had a history of UTIs and kidney issues, developed a UTI after admission. Staff interviews confirmed the bag should not have been on the floor, and the care plan lacked measures to prevent this.
A facility failed to ensure proper medication administration and competent handling of a PICC line for two residents. One resident received alprazolam outside the prescribed timeframe without physician notification, while another had a PICC line improperly handled by an LPN, leading to removal without a physician's order or RN assessment. The facility's policies were not followed, resulting in deficiencies in care.
A facility failed to justify the long-term use of antibiotics for a resident with a history of UTIs and chronic kidney disease. The resident was prescribed doxycycline hyclate for UTI prophylaxis without a discontinue date, and the last documented UTI was months prior. The Medical Director, who initially prescribed the antibiotic, was unaware of best practices for antibiotic stewardship, and the new physician continued the medication without documented justification. The facility's policy on antibiotic stewardship was not adhered to in this case.
The facility failed to conduct AIMS assessments for three residents on antipsychotic medications, despite policy requirements and pharmacy recommendations. The Clinical Support nurse confirmed the absence of these assessments, which were necessary to monitor for involuntary movements in residents with dementia and other conditions.
The facility failed to ensure proper hand hygiene during meal service and did not maintain sanitary measures while obtaining food temperature readings. Staff were observed not sanitizing hands between serving residents and not sanitizing the food temperature measuring device between uses. Hand sanitizer and wipes were available, but not utilized appropriately.
The facility failed to properly store and handle clean and soiled linens in the laundry area. Clean laundry was found on the floor, and soiled linen barrels were uncovered. Laundry staff were observed not following proper procedures, including not wearing gloves while handling soiled linen. The Director of Health Services acknowledged these practices were incorrect.
Lack of Documented Rationale for Declined Psychotropic Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that prescribers documented individualized clinical rationales when declining consultant pharmacist recommendations for gradual dose reductions or dose changes of psychotropic medications, and failure to sign and date those recommendations. For one resident with unspecified dementia, anxiety, and depression who had severe cognitive impairment and was receiving aripiprazole, the pharmacist recommended a dose reduction of 5 mg daily. The recommendation form was marked as denied but contained no documented rationale explaining why the physician declined the gradual dose reduction, and the electronic health record also lacked any physician explanation. The Regional Clinical Support Nurse confirmed that no physician rationale could be provided and acknowledged that such documentation should have been present. For another resident with insomnia and unspecified Alzheimer’s disease, who had severe cognitive deficit and was receiving trazodone 50 mg at bedtime, the pharmacist recommended changing the dose to 25 mg at bedtime PRN for 14 days with reevaluation of need. The physician declined this recommendation, but the recommendation form did not include any justification for the declination. Psychiatry and behavioral health progress notes from the same period documented that the resident reported eating and sleeping well and denied sleep issues, and staff reported the resident was stable and functioning at baseline. Despite this, there was no documented physician rationale on the pharmacy recommendation form explaining the decision to continue the existing trazodone regimen. For a third resident with unspecified dementia with psychotic disturbance, severe cognitive deficit, and receiving both antipsychotic and antianxiety medications, the pharmacist recommended a dose reduction of quetiapine from 100 mg twice daily to 50 mg in the morning and 100 mg at bedtime. The physician declined, noting only that the resident was on hospice, without further individualized justification. Additionally, this recommendation form lacked the physician’s signature and date. A separate pharmacist recommendation to reduce alprazolam from 0.25 mg three times daily to twice daily was also declined without a documented rationale, and that form likewise lacked the physician’s signature and date. Behavior tracking reports from the same period showed the resident continued to experience anxiety-related behaviors. The facility’s own policy required that prescribers either accept pharmacist suggestions or reject them with an explanation, which was not followed in these cases.
Lack of Physician Justification and Resident/Representative Information for Indwelling Foley Catheter Use
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document valid medical justification from the attending physician for the continued use of an indwelling Foley catheter for a resident. The resident was admitted with diagnoses including surgical aftercare following clot evacuation, hemiplegia and hemiparesis after intracerebral hemorrhage, and neuromuscular dysfunction of the bladder, unspecified. A physician order dated 11/19/25 indicated use of an indwelling urinary catheter for neurogenic bladder, and the care plan documented Foley catheter use with interventions for catheter care and changes per physician orders. However, review of the hospital discharge records and discharge summary from admission showed the catheter had been placed for an unstageable coccyx wound and did not include a diagnosis of neurogenic bladder. The current medical record lacked clarification or justification by the physician for ongoing Foley catheter use. During interviews, the resident’s husband reported that the catheter was placed in the hospital, that the resident had no urination issues prior to hospitalization, and that he did not know why the catheter was still in place despite having requested its removal and not being informed of the reason for its continued use. The resident, who was documented as cognitively impaired on a quarterly MDS and noted to have an indwelling Foley catheter during the assessment period, could not recall urinary issues prior to hospitalization or whether staff had discussed the catheter with her. The Regional Nurse Consultant stated that the justification for the Foley catheter was the resident’s wound on her bottom and the concern that removal would contaminate the wound, but acknowledged there was no physician assessment documenting the clinical reason for maintaining the catheter. The facility’s policy on indwelling catheters required valid medical justification, supporting diagnoses, and that residents/representatives be informed of risks and benefits, but the documentation and interviews showed these requirements were not met for this resident.
Resident Dignity Compromised During Meal Service
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner during a meal service observation. Resident 8, who has diagnoses including Parkinson's disease, Alzheimer's disease, and dysphagia, was observed eating at the nurses' station table without a clothing protector, resulting in food spilling over their clothing. Despite the presence of CNA 20, who acknowledged the need for a clothing protector, the CNA did not provide one, allowing the resident to continue spilling food on themselves. Later, CNA 13 intervened by cleaning the resident's clothing with a washcloth and applying a clothing protector. The resident, who required assistance with eating and was not cognitively intact, expressed apologies for spilling food, and CNA 13 reassured them. The facility's policy on resident rights emphasizes treating residents with dignity and respect, which was not upheld in this instance.
Failure to Provide Resident with Preferred Shower Schedule
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact and required two-person assistance for transfers, received showers as per her preference and schedule. The resident was scheduled to receive showers three times a week, but due to the cold water issue in her room, she had not received a shower for almost two weeks. Despite the resident's refusal to shower due to the cold water, the staff did not document offering her an alternative shower option. Interviews with the resident and facility staff revealed that the resident was not offered an alternative shower location, such as the spa area or an unoccupied room, even though these options were available. The facility's policy on resident rights emphasized the importance of treating residents with dignity and respect, which was not upheld in this case. The Clinical Support Nurse and the Director of Health Services acknowledged that the resident should have been offered an alternative shower option.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for a resident, identified as Resident 15, who experienced a 19.5% weight loss, equating to 37.5 pounds, in less than 30 days. The resident was admitted with multiple diagnoses, including a fracture of the right femur, cardiomyopathy, type 2 diabetes, lymphedema, and edema. The resident was on a diuretic medication, Lasix, to manage edema, which was initially prescribed at 40 mg twice daily and later reduced to 40 mg once daily. Despite the significant weight loss, there was no documentation of physician notification regarding this change in the resident's condition. The medical record review revealed that the Nurse Practitioner (NP) had seen the resident and adjusted the Lasix dosage, but there was no indication of a plan to address the weight loss or notification to the attending physician. The physician acknowledged not being aware of the weight loss until a later date and confirmed the lack of documentation regarding the notification of the weight loss. The facility's policy on physician notification was not followed, as there was no record of attempts to notify the physician or their response documented in the resident's electronic health record.
Improper Handling of Urostomy Catheter Bag
Penalty
Summary
The facility failed to ensure proper care for a resident with a urostomy catheter bag, as it was repeatedly observed in contact with the floor. During multiple observations, the resident's urinary catheter bag was seen dragging on the floor while she was in her wheelchair, both during meal service and while moving around the facility. The resident's medical history included a personal history of urinary tract infections and a disorder of the kidney and ureter. Despite these conditions, the care plan did not include measures to prevent the catheter bag from touching the floor. The facility's policy, titled 'Preserving Dignity with Indwelling Catheter,' explicitly stated that urinary drainage bags and catheter tubing should not touch the floor. Interviews with staff, including a Certified Resident Care Assistant and the Clinical Support nurse, confirmed that the catheter bag should not have been in contact with the floor. An event document indicated that the resident developed a urinary tract infection after admission, which was not present upon her arrival, suggesting a potential link to the improper handling of the catheter bag.
Medication Administration and PICC Line Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper administration of scheduled medication and competent handling of a PICC line for two residents. Resident 14, diagnosed with Alzheimer's disease and anxiety disorder, was prescribed alprazolam to be administered four times a day at specific times. However, the medication was repeatedly administered outside the prescribed timeframe by an LPN, without notifying the physician or documenting any resident request for early administration. Interviews with nursing staff revealed uncertainty about the policy for administering medication outside the designated timeframe, and the facility was unaware of the deviations from the prescribed schedule. Resident 20, admitted with multiple diagnoses including MRSA and osteomyelitis, required IV medication through a PICC line. The facility failed to document the measurement of the PICC line as ordered by the physician. An incident occurred where the resident removed the dressing, causing the PICC line to be pulled out and bleed. An LPN removed the PICC line without a physician's order or proper documentation, and there was no assessment by an RN before or after the removal. Additionally, blood was drawn from the PICC line without a physician's order or RN involvement, and the dressing was not changed as scheduled, leading to a soiled dressing. The facility's policies on medication administration and PICC line care were not followed, resulting in improper medication administration and handling of the PICC line. The lack of documentation and failure to notify physicians of changes or incidents contributed to the deficiencies. Interviews with staff highlighted a lack of awareness and adherence to the facility's procedural guidelines, indicating a need for improved competency and communication among the nursing staff.
Failure to Justify Long-term Antibiotic Use
Penalty
Summary
The facility failed to ensure justification for the long-term use of antibiotics for a resident diagnosed with urinary tract infection (UTI) and chronic kidney disease stage 3. The resident's record indicated a physician order for doxycycline hyclate, an antibiotic, to be administered daily for UTI prophylaxis without a discontinue date. The last documented UTI for the resident was noted in December 2024, yet the antibiotic prescription dated back to June 2023. The facility's Clinical Support Nurse was unable to provide documentation justifying the long-term use of the antibiotic. Interviews revealed that the Medical Director, who initially prescribed the antibiotic, was no longer the resident's primary care doctor and had not been informed of best practices regarding antibiotic stewardship. The new physician continued the medication without documented justification. The facility's policy on antibiotic stewardship aimed to optimize infection treatment and reduce adverse events from unnecessary antibiotic use, but there was no evidence of adherence to this policy in the resident's case. The Clinical Support Nurse was unable to contact the resident's current primary care doctor to obtain justification for the continued use of the antibiotic.
Failure to Conduct AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to conduct Abnormal Involuntary Movement Scale (AIMS) assessments for three residents who were receiving antipsychotic medications. Resident 31, diagnosed with unspecified dementia with psychotic disturbance, was on a routine antipsychotic medication regimen. Despite a pharmacy recommendation in July 2024 to complete an AIMS assessment, the facility did not document any such assessment. The Clinical Support nurse confirmed the absence of the AIMS assessment during an interview. Resident 5, also diagnosed with unspecified dementia with psychotic disturbance, was receiving antipsychotic medication as per a physician's order. The resident's care plan included monitoring for adverse side effects of the medication. However, the facility did not document an AIMS assessment for this resident either. The Clinical Support nurse acknowledged the lack of documentation during an interview. Resident 15, with diagnoses including dementia with agitation and Alzheimer's disease, was receiving antipsychotic medication following post-operative hallucinations. The care plan required observation for adverse side effects, yet no AIMS assessment was documented. The Clinical Support nurse confirmed the absence of the assessment. The facility's policy required AIMS assessments for residents on antipsychotic medications every six months or as needed, but this was not adhered to for the three residents.
Deficiencies in Hand Hygiene and Food Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper hand hygiene during meal service, as observed during one of two dining observations. Dietary Assistant 18 was seen assisting a resident by repositioning her wheelchair and then serving food to another resident without sanitizing his hands in between. Additionally, several employees were observed entering the kitchen by touching the door handle and not sanitizing their hands before serving meals to residents. Certified Nurse Aide (CNA) 19 also served food to residents without sanitizing hands between residents and entered the kitchen multiple times without sanitizing hands after touching the door handle. Hand sanitizer was available in the dining area, and a handwashing sink was accessible in the kitchen service area. The Clinical Nurse Consultant confirmed that employees should sanitize their hands between serving residents and that the kitchen door had a push bar, eliminating the need to touch the door handle. The facility also failed to maintain sanitary measures while obtaining temperature readings of prepared food. During an observation, Dietary Employee 22 tested the temperature of various food items using a food temperature measuring device but only wiped the device on a napkin instead of sanitizing it between uses. The employee acknowledged the oversight and mentioned the lack of available wipes. The Dietary Manager confirmed that the device should have been sanitized between each food item and that wipes were available in the main kitchen. The facility's policy indicated that equipment and utensils should be cleaned between uses with different food items, including potentially hazardous foods.
Improper Storage and Handling of Linens in Laundry Area
Penalty
Summary
The facility failed to ensure proper storage and handling of clean and soiled linens in the laundry area. During a tour with the Director of Health Services (DHS), who also served as the Infection Preventionist, clean laundry was observed lying on the floor, with personal items and gowns in bags also on the floor. Unbagged clean laundry was found on top of and next to these bags, and clean gowns and lift pads were partially on the floor. In the soiled laundry area, several barrels of soiled linen were uncovered. Additionally, Laundry Staff 17 was seen transferring bagged soiled linen without wearing gloves and placing the soiled linen on the floor in front of the washer. Interviews with Laundry Staff 18 and Laundry Staff 17 revealed a lack of proper training and adherence to procedures. Laundry Staff 18 indicated that the items in the clean laundry area were clean but acknowledged that the lift pads might need labeling and washing. Laundry Staff 17, who was new, admitted to being unsure of their duties and confirmed that the soiled area contained soiled linen. The DHS acknowledged that the observed practices were incorrect. The facility's policy, provided by the Executive Director, required PPE to be worn and carts to be covered at all times, but no policy for handling clean linen was provided.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
