Majestic Care Of Bedford
Inspection history, citations, penalties and survey trends for this long-term care facility in Bedford, Indiana.
- Location
- 2111 Norton Ln, Bedford, Indiana 47421
- CMS Provider Number
- 155100
- Inspections on file
- 28
- Latest survey
- May 13, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Majestic Care Of Bedford during CMS and state inspections, most recent first.
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 cerebral palsy, severe intellectual disability, and muscular dystrophy was found with a pillowcase draped over the face while two CNAs were preparing a transfer. The SSD entered the room after hearing the resident yelling, directed staff to remove the pillowcase, and was told by a CNA that the measure was taken because the resident had spit at staff. Another CNA reported witnessing the pillowcase over the resident’s face and demonstrated that it was draped from the forehead to below the chin. These staff actions violated the resident’s right to be free from abuse under the facility’s abuse policy.
Staff failed to use appropriate behavioral interventions for a resident with cerebral palsy, severe intellectual disability, and muscular dystrophy whose care plan identified behaviors such as hitting, kicking, and spitting during care. Instead of following the care-planned approach to postpone care and re-approach when the resident became resistive or combative, two CNAs attempted a bed-to-wheelchair transfer while the resident’s face was covered with a pillowcase to avoid being spit on. Leadership later stated that the CNAs had access to the resident’s cardex with the correct interventions and should have followed those person-centered strategies in accordance with the facility’s behavior management policy.
A severely cognitively impaired male resident with a history of aggressive behavior physically assaulted three other residents, causing injuries such as scratches, pain, and a corneal abrasion that required hospital care. Despite one-on-one supervision, the resident was able to grab hair, scratch faces, and poke another resident in the eye, with staff needing to intervene multiple times. The affected residents had significant cognitive and physical disabilities, and staff interviews confirmed repeated incidents of aggression and injury.
A resident with severe cognitive and physical impairments and a history of neurogenic bladder was left sitting in a wheelchair with urine visibly streaming onto the floor. Staff present did not provide incontinence care, citing that CNAs were busy and the resident required a mechanical lift, and instead prioritized cleaning the floor. The facility could not produce a policy on incontinence care when asked.
Surveyors found that food was not stored in a sanitary manner, including a container of salad dressing that was not discarded by its discard date and an open box of cheddar biscuits stored directly under a condenser fan with ice accumulation above. The Dietary Manager confirmed these practices were not in line with facility policy, potentially affecting a large number of residents served by the kitchen.
A resident with dementia and other conditions experienced a fall, but the facility did not document new interventions or update the care plan until several days later. The fall was not promptly documented or reported to the DON, and an IDT meeting was delayed, contrary to facility policy requiring immediate assessment, documentation, and care plan review after such incidents.
The facility failed to provide written notification of transfer and discharge to residents and their representatives in three cases involving hospitalization. A resident with lymphedema and a femur fracture, another with heart failure and atrial fibrillation, and a third with epileptic spasms and intellectual disabilities were all transferred to the hospital without the required documentation. The facility's policy did not mandate sending a written copy of the Transfer and Discharge form, and the administrator confirmed this omission.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon hospital transfer. This deficiency was noted for three residents, including one with lymphedema and a femur fracture, another with heart failure and atrial fibrillation, and a third with epileptic spasms and intellectual disabilities. The Administrator admitted that the facility did not provide the notification forms in writing, contrary to the facility's policy.
A facility failed to transmit a resident's Discharge MDS assessment to CMS within the required 14-day period. The resident, diagnosed with chronic respiratory failure and anemia, had their assessment completed but not transmitted on time. This issue was confirmed by the MDS Coordinator during a review.
The facility failed to ensure accurate MDS assessments for two residents. One resident with anxiety and depression was incorrectly assessed as not having an anxiety diagnosis, despite being prescribed lorazepam. Another resident's discharge assessment inaccurately stated they were sent to a hospital, while they were actually discharged to another skilled nursing facility. The MDS Coordinator confirmed both assessments were coded incorrectly.
A resident with an anxiety disorder exhibited frequent behaviors such as yelling and attempting to stand from a recliner, yet the facility failed to develop a comprehensive care plan to address these behaviors. Despite staff attempts to redirect and reassure the resident, no formal care plan was in place, as confirmed by facility staff.
The facility failed to provide necessary range of motion services for three residents, leading to a decline in their mobility. A resident with a stroke, another with a traumatic brain injury, and a third with a broken leg did not receive recommended restorative programs after therapy discharge. Observations and staff interviews confirmed the absence of such programs, despite the facility's policy on preventing decline in range of motion.
A facility failed to label an open vial of Humalog insulin with an open date for a resident with type 2 Diabetes Mellitus. During medication administration, an RN administered 2 units of insulin from a vial without an open date. The RN acknowledged the insulin should have been labeled, as it is good for 90 days after opening. The facility's policy requires multi-use vials to include the date they were initially opened.
A facility failed to provide timely laboratory services for a resident with an order for a blood draw every six months due to hypertension and congestive heart failure. A lab technician was unable to obtain a sample, and no second attempt was documented. The Nurse Practitioner confirmed the lab service did not return to complete the draw, despite the facility's policy stating responsibility for timely services.
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.
Pillowcase Placed Over Resident’s Face During Care
Penalty
Summary
The deficiency involves staff placing a pillowcase over a resident’s face during care, constituting mental abuse. The resident involved had diagnoses including cerebral palsy, severe intellectual disability, and muscular dystrophy. During an interview, a CNA stated that staff should not have placed a pillowcase over the resident’s face and that appropriate action would have been to stop the behavior, remove the pillowcase, ensure the resident was okay, remove the staff from resident care areas, and report the incident to the Administrator as abuse. The facility’s abuse policy in effect at the time stated that residents have the right to be free from abuse. The Social Service Director reported that she entered the resident’s room after hearing the resident yelling and observed two CNAs preparing to transfer the resident from bed to wheelchair, with the resident’s entire face covered by a pillowcase, though the head was not inside the pillowcase. She instructed the CNAs to stop and remove the pillowcase, which one CNA did before completing the transfer. One CNA told the Social Service Director that the resident had spit at staff and she did not want to be spit on. Another CNA later reported witnessing a pillowcase over the resident’s face and demonstrated to the Administrator that it had been draped from the top of the forehead to below the chin. These observations and statements formed the basis for the finding that the resident was not protected from mental abuse by staff.
Improper Use of Pillowcase to Manage Resident Behavioral Symptoms
Penalty
Summary
The deficiency involves staff failing to demonstrate appropriate skills and competencies to meet a resident’s behavioral health needs. Resident B had diagnoses including cerebral palsy, severe intellectual disability, and muscular dystrophy, and a care plan dated 11/4/25 documented behavioral symptoms of hitting, kicking, and spitting at staff during care. The care plan interventions, initiated 11/4/24, directed staff that if the resident became resistive to care or combative, they were to postpone care and re-approach rather than continue in a confrontational manner. During an observation described by the Social Service Director (SSD), she entered Resident B’s room and saw CNA 2 and CNA 3 preparing to transfer the resident from bed to wheelchair while the resident’s entire face was covered with a pillowcase, though the head was not in the pillowcase. The SSD instructed the CNAs to stop and remove the pillowcase, after which they completed the transfer. CNA 2 told the SSD that the resident had spit at staff and she did not want to be spit on. The DON stated that CNA 2 and CNA 3 had access to the resident’s cardex with the appropriate interventions and should have known to use those interventions instead of covering the resident’s face with a pillowcase, contrary to the facility’s Behavior Management policy that calls for supportive, person-centered interventions for behavioral needs.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when a severely cognitively impaired male resident engaged in multiple aggressive incidents toward other residents. The male resident, who had diagnoses including chorea, cerebral palsy, anxiety disorder, and autistic disorder, was documented as having displayed verbal and physical behavioral symptoms directed toward others. Despite being assigned one-on-one supervision, he was able to grab a female resident by the hair on two separate occasions, causing pain and a scratch, and required intervention by multiple staff members to be separated from the victim. Further incidents involved the same male resident physically aggressing toward two additional residents. In one case, he scratched a resident under the eye while attempting to adjust her glasses, and in another, he entered a resident's room and pressed his thumbs into the resident's eyes, resulting in a corneal abrasion that required hospital treatment. The affected residents had significant cognitive and physical impairments, including spastic quadriplegic cerebral palsy, muscular dystrophy, and dependence for all activities of daily living. Staff interviews and clinical documentation confirmed that the male resident's aggressive behaviors were witnessed on multiple occasions, and that the victims experienced pain, injury, and emotional distress. The facility's policy stated that residents have the right to be free from abuse, but the documented events show that the facility did not effectively prevent or intervene to stop repeated physical abuse among residents.
Failure to Provide Timely Incontinence Care and Lack of Policy
Penalty
Summary
A resident with diagnoses including neurogenic bladder, aphasia, cerebral palsy, seizure disorder, and anxiety disorder, who was severely cognitively impaired and always incontinent of bladder, was observed sitting in a wheelchair with urine visibly streaming from the seat onto the floor, creating a large puddle. Staff, including a Qualified Medication Aide (QMA) and an LPN, were present but did not provide incontinence care at the time, with the QMA stating that CNAs were busy and the resident required a mechanical lift. Instead, the area was cleaned by housekeeping while the resident remained in the soiled condition. The facility was unable to provide a policy regarding incontinence care when requested.
Unsanitary Food Storage and Failure to Discard Expired Items
Penalty
Summary
Surveyors observed that the facility failed to store food in a sanitary manner during a kitchen inspection. Specifically, a container of liquid salad dressing in the walk-in refrigerator was found with an open date of 1/12/25 and a discard date of 2/12/25, but had not been discarded as required. Additionally, an open box of cheddar biscuits was stored directly under the condenser fan in the walk-in freezer, with ice accumulation noted on the fan above the box and the biscuits covered only by a plastic bag inside the opened box. The Dietary Manager confirmed that opened containers should be discarded after 30 days and that food should not be stored under the condenser fan to prevent contamination, in accordance with facility policy. These findings were observed during a follow-up kitchen tour and confirmed through staff interviews and policy review. No specific residents were directly involved in the deficiency, but 85 of 102 residents who were served food from the kitchen had the potential to be affected by these unsanitary food storage practices.
Failure to Update Fall Interventions and Timely Documentation After Resident Fall
Penalty
Summary
The facility failed to document and implement new interventions to prevent falls for one resident following a fall incident. The resident, who had diagnoses including dementia, rheumatoid arthritis, and peripheral neuropathy, experienced a fall on 3/16/25. Although neurological checks and monitoring were documented in the days following the fall, there was no documentation of new interventions or updates to the care plan until 3/24/25. The care plan had existing fall prevention measures, but no new strategies were added in response to the incident. Additionally, the fall was not documented in the clinical record at the time of the event, nor was it reported to the DON until much later. An interdisciplinary team meeting to review the incident and update the care plan was not conducted until 3/27/25. The facility's fall prevention policy requires assessment, post-fall assessment, incident reporting, notification of physician and family, care plan review and update, and documentation of all actions, but these steps were not followed in a timely manner after the resident's fall.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide the required written notification for transfer and discharge to residents and their representatives in three cases involving hospitalization. Resident 67, diagnosed with lymphedema and a femur fracture, was sent to the hospital on February 19, 2024, without documented evidence of a written Notice of Transfer and Discharge being provided. Similarly, Resident 94, with diagnoses including heart failure and atrial fibrillation, was hospitalized on March 16, 2024, due to a critical digoxin lab result, but there was no documentation of the required written notice being given. Additionally, Resident 15, who had epileptic spasms and unspecified intellectual disabilities, was transferred to the hospital on May 1, 2024, without written notification to the resident or their representative. The facility's policy on holding bed space did not include a requirement to send a written copy of the Transfer and Discharge form to the resident and their representative. The facility administrator confirmed during an interview that the transfer/discharge form was not provided in writing for hospital transfers.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required. This deficiency was identified for three residents who were reviewed for hospitalization. Resident 67, diagnosed with lymphedema and a femur fracture, was sent to the hospital on February 19, 2024, but there was no documentation of the bed-hold policy being communicated in writing. Similarly, Resident 94, with diagnoses including heart failure and atrial fibrillation, was transferred to the hospital on March 16, 2024, due to a critical digoxin lab result, yet the clinical record lacked evidence of written notification of the bed-hold policy. Additionally, Resident 15, who has epileptic spasms and unspecified intellectual disabilities, was transferred to the hospital on May 1, 2024, without documented written notification of the bed-hold policy. During an interview, the Administrator acknowledged that the facility did not provide the bed-hold notification forms in writing to the residents or their representatives, instead sending the forms with the residents upon transfer. The facility's policy, as provided by the Administrator, indicated that the business office was responsible for providing this information upon admission and when a resident is transferred for hospitalization or therapeutic leave.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was electronically transmitted to the Center for Medicare and Medicaid Services (CMS) system within the required timeframe. Specifically, the Discharge MDS assessment for Resident 12, who had diagnoses including chronic respiratory failure and anemia, was completed on 12/31/23 but was not transmitted within 14 days of the completion date. This deficiency was identified during a record review on 6/13/24, and confirmed in an interview with the MDS Coordinator, who acknowledged the failure to transmit the assessment within the mandated period.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. Resident 67, diagnosed with anxiety and depression, had a Quarterly MDS assessment dated 4/24/24 that incorrectly indicated the absence of an anxiety diagnosis. However, the resident's current orders from June 2024 showed a prescription for lorazepam, an anti-anxiety medication, prescribed on 4/10/24. The MDS Coordinator confirmed the assessment was coded incorrectly. Resident 92, with diagnoses including congestive heart failure and hypertension, had a Discharge MDS assessment dated 5/18/24 that inaccurately stated the resident was discharged to a critical access hospital. A nursing note from the same date indicated the resident was actually discharged to a different skilled nursing facility. The MDS Coordinator acknowledged the incorrect coding in the assessment.
Failure to Develop Comprehensive Care Plan for Resident with Behaviors
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident exhibiting behaviors, specifically for a resident diagnosed with an anxiety disorder. The resident, identified as Resident 60, was observed multiple times over several days attempting to stand up from a recliner and yelling phrases such as "I'm gonna die" and "help me, I will die." These observations occurred in both the dayroom and dining room, indicating a pattern of behavior that was not addressed in the resident's care plan. Despite the resident's behaviors being documented in the Admission Minimum Data Set (MDS) assessment as occurring daily, there was no care plan in place to manage these behaviors. Interviews with facility staff, including an RN and the Social Services Assistant, confirmed that Resident 60 exhibited these behaviors regularly and that attempts were made to redirect and reassure the resident. However, the absence of a formal care plan for these behaviors was acknowledged by the Social Services Assistant, indicating a deficiency in the facility's care planning process.
Failure to Provide Range of Motion Services
Penalty
Summary
The facility failed to provide necessary treatment or services to prevent further decrease in range of motion for three residents. Resident 29, who had a stroke affecting her left side, was discharged from therapy with recommendations for a restorative range of motion program. However, the facility did not have such a program in place, and her care plan lacked documentation of any services to prevent further decline in her range of motion. Observations confirmed her left hand and wrist were contracted, and interviews with staff indicated the absence of a restorative program. Resident 63, who suffered a traumatic brain injury and was quadriplegic, also did not receive a range of motion restorative program after being discharged from therapy. His care plan did not include any active or passive range of motion services, and observations showed his wife assisting him with exercises. Interviews with staff confirmed that the facility lacked a restorative program, which would have benefited Resident 63. Resident 79, who had a broken leg, was no longer receiving therapy and did not have a restorative program to maintain her range of motion. Her care plan lacked documentation of any services to prevent further decline, and interviews with staff confirmed the absence of a restorative program. The facility's policy on preventing decline in range of motion was reviewed, but it did not appear to be effectively implemented, as evidenced by the lack of appropriate services for these residents.
Insulin Vial Lacking Open Date
Penalty
Summary
The facility failed to ensure that an open vial of insulin was labeled with an open date for a resident receiving insulin during medication administration. During an observation of medication administration, a registered nurse was seen removing an open vial of Humalog insulin from the medication cart and administering 2 units to a resident without an open date on the vial. The resident's clinical record indicated a diagnosis of type 2 Diabetes Mellitus, and physician orders specified the use of Humalog insulin per a sliding scale. The registered nurse acknowledged that the insulin should have been labeled with an open date, as it is considered good for 90 days after opening. The facility's policy on labeling medications and biologicals, which was provided by the administrator, also required that multi-use vials include the date they were initially opened or accessed.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to ensure laboratory services were provided for a resident who had an order for a blood draw every six months. The resident, who had diagnoses including lymphedema and a femur fracture, was supposed to have a complete blood count (CBC) with differential and a basic metabolic panel (BMP) due to hypertension and congestive heart failure. On 5/16/24, a lab technician attempted to obtain a blood sample but was unsuccessful, and the clinical record did not document a second attempt by another phlebotomist. The Nurse Practitioner confirmed that the lab service company did not return to complete the blood draw, which was part of the admission follow-up labs. The facility's policy indicated that it was responsible for the timeliness of laboratory services.
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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