Majestic Care Of Connersville
Inspection history, citations, penalties and survey trends for this long-term care facility in Connersville, Indiana.
- Location
- 1029 E 5th Street, Connersville, Indiana 47331
- CMS Provider Number
- 155491
- Inspections on file
- 49
- Latest survey
- October 29, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Majestic Care Of Connersville during CMS and state inspections, most recent first.
A male resident with severe cognitive impairment and a history of sexually inappropriate behavior was reported and observed to have inappropriately touched female residents on multiple occasions, including during smoke breaks and while assisting with wheelchairs. Staff and other residents reported these incidents, but there was a lack of thorough documentation, investigation, and consistent staff awareness regarding the reasons for increased supervision. The facility did not fully implement its abuse prevention policy, resulting in residents experiencing anxiety and fear.
The facility did not thoroughly investigate or ensure protection following multiple allegations of sexual abuse involving a resident with severe cognitive impairment and two other residents with moderate cognitive impairment. Despite reports and witness accounts of inappropriate touching during smoke breaks, the facility failed to interview all involved parties or document the reasons for safety interventions, resulting in repeated incidents and ongoing distress for the affected residents.
Two residents with cognitive impairments were involved in an incident where one resident was alleged to have sexually acted out toward another. Despite staff awareness and facility policy requiring notification, the DON and Administrator did not report the abuse allegation to the state health department, and there was a lack of documentation regarding the incident and follow-up with the affected resident.
A resident with severe cognitive impairment and dementia repeatedly engaged in sexually inappropriate behaviors toward female residents, including inappropriate touching. Staff documentation and communication about these behaviors were inconsistent, and some staff were unaware of the resident's history. Other residents reported distress and fear, and incidents were not always thoroughly investigated or documented, resulting in a failure to provide individualized interventions and protect residents.
A resident with severe cognitive impairment and a history of constipation did not receive PRN laxatives as ordered due to inaccurate EMR documentation and lack of staff follow-up. The EMR failed to generate alerts for no bowel movement, and staff did not notify the physician or administer PRN medications, resulting in a failure to provide care according to physician orders.
The facility failed to maintain the kitchen door in the west building, allowing rodents to enter. Despite monthly pest control visits, the door lacked a proper seal and was often propped open by staff, leading to an ongoing mouse problem. The issue affected 42 residents, with multiple mice caught in traps over several months. Staff interviews and pest control reports highlighted the need for door repairs, which had not been effectively addressed.
The facility failed to maintain a homelike environment for several residents, as observed during a survey. A resident's room was bare with a broken clock, while another expressed dissatisfaction with the lack of personal items. Additional issues included broken blinds, malfunctioning lights, and bathroom damage. The facility's policy emphasizes a homelike environment, which was not upheld.
The facility failed to administer medications and treatments as ordered for several residents. A resident with renal disease did not receive prescribed Midodrine before dialysis, and another with heart failure experienced unreported weight gains, leading to unadjusted medication. A resident's gastrointestinal tube removal was delayed due to incomplete orders, and another resident did not have compression stockings applied as required.
The facility failed to provide accessible fluids to three residents, leading to a deficiency in hydration care. A resident with a history of urinary tract infections had fluids placed out of reach, while another resident was observed without fluids multiple times. A third resident reported receiving only one cup of ice water a day. The facility's hydration policy was not followed, as fluids were not consistently available to these residents.
A facility failed to provide a resident with in-room self-initiated activities, despite the resident's preference for independent activities and a care plan emphasizing their importance. The resident, who had multiple medical conditions, was observed lying in bed without access to activities like music or reading materials. The facility's policy required an ongoing activity program, but the responsibility to ensure activities were available was not met.
A facility failed to maintain proper hygiene standards for a resident's urinary catheter, as the drainage bag and tubing were observed in contact with the floor. The resident, who required extensive assistance and had an indwelling catheter for obstructive uropathy, was at risk for infection due to this oversight. A CNA confirmed the issue and was unaware of how to prevent it, despite the facility's policy requiring adherence to standard practices.
A resident with chronic pain syndrome did not receive four doses of prescribed tramadol over two days, leading to elevated pain levels. The facility's medication records confirmed the missed doses, and there was a lack of documented pain assessments during this period, contrary to the facility's pain management policy.
A resident with osteoarthritis and end-stage renal disease did not have a timely follow-up for a CT scan appointment. Despite a physician's order and referral sent to a local provider, there was no documentation of a scheduled appointment or follow-up actions. The DON confirmed that the process involved contacting the provider, but a diagnosis code needed for scheduling was not provided until later, delaying the appointment.
A resident, who was cognitively intact and had multiple health conditions, was observed to have no teeth and expressed difficulty eating due to the lack of dentures. The resident had not seen a dentist since impressions were made in June 2023, as the dentures were not completed due to a lack of communication from the POA. Social Services did not follow up adequately, resulting in the resident being without dentures.
A facility failed to document treatments and enteral feeding for a resident with complex medical needs, including chronic respiratory failure and quadriplegia. The May 2024 TAR showed missing documentation for various wound care treatments and g-tube feeding, which were neither recorded as completed nor refused. The Corporate Director of Respiratory confirmed these omissions, highlighting a breach in the facility's documentation policy.
Failure to Protect Residents from Sexual Abuse by a Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving a male resident with severe cognitive impairment and a history of sexually inappropriate behaviors. This resident, diagnosed with vascular dementia, depression, and anxiety, was observed and reported to have inappropriately touched female residents on multiple occasions. Documentation shows that the resident was found with his hand inside a female resident's shirt, physically moving his hand around her breast, and was later reported to have touched another female resident's chest during a smoke break. Despite these incidents, there was a lack of clear documentation and follow-up regarding the behaviors that led to increased monitoring, and staff were often unaware of the reasons for the interventions being implemented. Interviews with staff and residents revealed that the incidents were witnessed by other residents, who reported the behaviors to nursing staff. One female resident expressed anxiety and fear following the incidents, stating she was uncomfortable and worried about her safety at night. Another female resident described similar inappropriate contact and indicated that such behaviors had occurred repeatedly, particularly during transitions from the smoking area. Despite these reports, there was no evidence that management conducted thorough interviews or investigations with all involved parties, including witnesses and victims. The facility's documentation and response to the allegations were inconsistent. Staff members, including nurses and CNAs, were often unaware of the specific reasons for increased supervision or 15-minute checks. The Director of Nursing and Administrator acknowledged receiving reports of inappropriate behavior but did not ensure comprehensive documentation or investigation. The facility's policy on abuse prevention required identification, correction, and intervention in situations where abuse was likely, as well as protection of residents, but these measures were not fully implemented in response to the incidents described.
Failure to Investigate and Protect Residents from Repeated Sexual Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation and ensure protection from further allegations of sexual abuse involving three residents. Resident C, who had diagnoses including vascular dementia, depression, and severe cognitive impairment, was placed on 15-minute safety checks for sexually acting out, but there was no documentation explaining the behaviors that led to this intervention. On two separate occasions, Resident C was reported to have inappropriately touched female residents during or after smoke breaks. Despite these reports, the facility did not complete comprehensive interviews or investigations with all involved residents and witnesses. Resident B, who was moderately cognitively impaired and had a history of anxiety and depression, reported being touched inappropriately by Resident C while being wheeled inside after a smoke break. Another resident witnessed the incident and corroborated the report. Resident B expressed feeling uncomfortable, upset, and fearful that Resident C might enter her room at night. Similarly, Resident G, also moderately cognitively impaired, reported that Resident C had touched her inappropriately on more than one occasion and that she had informed staff, but could not recall their names. Resident G stated that these behaviors continued to occur, particularly during transitions from the smoking area, and that management had not interviewed her about the incidents. Interviews with staff, including the DON, LPN, and RN, revealed uncertainty about the reasons for Resident C's monitoring and a lack of follow-up on the initial and subsequent allegations. The facility's abuse policy required a thorough investigation, including interviews with all involved parties and witnesses, but this was not completed. The lack of comprehensive investigation and failure to ensure resident protection resulted in repeated incidents and ongoing anxiety and fear among the affected residents.
Failure to Report Sexual Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the Indiana Department of Health (IDOH) involving two residents. Resident C, who had diagnoses including vascular dementia and was severely cognitively impaired, was placed on 15-minute safety checks for sexually acting out, but there was no documentation in the clinical record explaining the behaviors that led to this intervention. Staff, including a registered nurse and the Director of Nursing (DON), were unable to provide documentation or clear details about the incident, and the DON confirmed that the incident was not reported to IDOH. The Administrator was also aware of the allegation via text from the DON but did not report it to the state agency. Resident G, who had moderate cognitive impairment and diagnoses including diabetes and anxiety, reported that Resident C had inappropriately touched her while she was in her wheelchair. Resident G stated she informed several staff members but could not recall their names, and indicated that similar behaviors had occurred previously. The DON had not spoken with Resident G about the event, and there was no evidence that the required abuse reporting policy was followed. The facility's own policy required the Administrator to notify IDOH in the event of an abuse allegation, which was not done in these cases.
Failure to Implement Individualized Interventions for Sexually Inappropriate Behaviors in Dementia Resident
Penalty
Summary
The facility failed to implement individualized interventions for a resident with dementia who exhibited sexually inappropriate behaviors towards female residents. One resident, diagnosed with vascular dementia and severe cognitive impairment, was documented on multiple occasions to have inappropriately touched female residents, including incidents where he placed his hand inside a female resident's shirt and touched her breast, and another where he touched a female resident's chest while returning from a smoke break. Despite these incidents, documentation in the clinical record was inconsistent, with gaps in recording the behaviors that prompted safety checks and a lack of clear communication to staff regarding the resident's history of sexually inappropriate actions. Interviews with staff revealed uncertainty and lack of awareness about the reasons for safety checks and the resident's behavioral history. Some staff members were unaware of the resident's sexually inappropriate behaviors, and the Kardex did not contain alerts or documentation about these behaviors. The care plan did include some interventions, such as supervision during smoke breaks and one-on-one supervision, but these were not consistently communicated or documented in a way that ensured all staff were informed and able to implement them effectively. Other residents reported feeling uncomfortable, upset, and fearful as a result of the inappropriate behaviors, and there was evidence that incidents were not always thoroughly investigated or followed up with the affected residents. The facility's dementia care policy required individualized care plans and ongoing monitoring of interventions, but the observed deficiencies indicated a failure to consistently identify, document, and address the resident's sexually inappropriate behaviors, as well as to protect other residents from further incidents.
Failure to Document and Address Resident Constipation per Physician Orders
Penalty
Summary
The facility failed to ensure accurate documentation and appropriate follow-through regarding a resident's lack of bowel movements, which resulted in not administering physician-ordered PRN medications for constipation. The resident in question had multiple diagnoses, including unspecified dementia, COPD, a recent hip fracture, and a history of constipation. He was severely cognitively impaired, non-ambulatory, and dependent on staff for all activities of daily living. After returning from a hospital stay, he was prescribed routine stool softeners and had PRN orders for additional laxatives if no bowel movement occurred within three days. However, the electronic medical record (EMR) did not accurately reflect the absence of bowel movements, as staff selected 'Response Not Required' instead of 'No bowel movement,' and no alert was generated to notify staff of the issue. During the period in question, there was no documentation in the progress notes regarding the lack of stooling, nor was the physician or nurse practitioner notified of the resident's constipation. As a result, the PRN medications ordered for constipation were not administered. The DON confirmed that the facility did not have a specific bowel protocol policy and that the EMR system failed to alert staff to the resident's condition. The resident did not display symptoms of abdominal discomfort during this time, but the lack of accurate documentation and follow-up led to a failure to provide care as ordered.
Rodent Entry Due to Faulty Kitchen Door
Penalty
Summary
The facility failed to maintain the entry door into the main kitchen of the west building, which resulted in rodents entering the building. This deficiency was observed during a survey where mice traps were set in both the west and east kitchens. The Dietary Manager confirmed that a pest control company serviced the facility monthly, but there was an ongoing issue with mice in the west building. The kitchen door to the outside was observed to be shut but lacked a proper seal, allowing rodents to enter. Additionally, staff were found to prop the door open with a brick, as the door would lock when closed, making it difficult for dietary staff to re-enter. Interviews with various staff members, including an LPN and the Pest Control Technician, revealed that the problem had been ongoing, with mice sightings reported in resident rooms and traps catching multiple mice over several months. The Maintenance Director acknowledged attempts to fix the door but stated it needed replacement. Pest control reports from May to September indicated repeated recommendations to keep the door shut or fix it to prevent pest entry, yet the door was often found slightly open or propped open. The facility's pest control policy aimed to eradicate and contain rodents, but the deficiency persisted, affecting the 42 residents in the west building.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for several residents, as observed during a survey. Resident 18's room was noted to be bare, lacking personal belongings and pictures, with a broken clock on the wall. Despite the care plan indicating the need for a homelike environment, these conditions persisted over multiple observations. Similarly, Resident 1's room was devoid of personal items, and the resident expressed dissatisfaction with the room's lack of homeliness. The Social Service Director acknowledged the issue, noting that it was the responsibility of Social Services, Nursing, and Marketing to ensure a homelike environment. Additional deficiencies were observed in the rooms of other residents. Resident 75 reported broken blinds that had not been repaired, while Resident 38 experienced issues with malfunctioning lights, which had been reported to staff but remained unfixed. Resident 64's bathroom had unmatched paint and holes in the drywall. The facility administrator was unaware of these issues until the survey and committed to addressing them. The facility's policy on resident rights emphasizes the importance of a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Medication and Treatment Administration Failures
Penalty
Summary
The facility failed to administer medications as ordered for Resident 52, who had diagnoses including end-stage renal disease and hypotension. The resident required hemodialysis three times a week, with a physician's order to administer Midodrine before dialysis sessions. However, the medication was not administered on two occasions, and there was no documentation of blood pressure readings on non-dialysis days to justify the non-administration of as-needed Midodrine. The Director of Nursing was unsure of the correct orders and acknowledged the lack of blood pressure monitoring. Resident 64, diagnosed with congestive heart failure and edema, experienced significant weight gains that were not reported to the physician as required. The resident's care plan included daily weight monitoring and notification of the physician for weight gains over three pounds in a day. Despite several instances of weight gain exceeding this threshold, there was no evidence of physician notification, and a verbal order to increase the dosage of Metolazone was not implemented. Resident 45 had a physician's order for the removal of a gastrointestinal tube, which was not followed through due to incomplete information in the initial order. The facility failed to ensure the order was processed correctly, resulting in a delay. Additionally, Resident 14, who required compression stockings for edema, did not have them applied as ordered. The resident reported discomfort due to swelling, and observations confirmed the absence of compression stockings, despite documentation indicating they were administered.
Failure to Provide Accessible Fluids to Residents
Penalty
Summary
The facility failed to provide fresh fluids and keep fluids within reach for three residents, leading to a deficiency in hydration care. Resident 54 was observed multiple times without water or any fluids within reach, despite having a history of urinary tract infections and being ordered thin liquids. Observations revealed that the resident's fluids were either absent or placed across the room, out of reach, on several occasions. Similarly, Resident 18 was observed without any fluids available in the room on multiple occasions, despite being ordered thin liquids. Resident 1 was also found without fluids in her room during observations, and she reported receiving only one cup of ice water a day. The facility's hydration policy, which mandates the provision and encouragement of bedside fluids, was not adhered to, as evidenced by the lack of fluids available to these residents.
Failure to Provide In-Room Activities for Resident
Penalty
Summary
The facility failed to provide in-room self-initiated activities for a resident who was observed lying in bed, awake, and staring at the ceiling on multiple occasions. The resident's television was unplugged, and there were no available activities such as music, books, magazines, puzzles, or a daily chronicle. The resident expressed dissatisfaction with her room and indicated a preference for staying to herself rather than participating in group activities. Despite being cognitively intact and having a care plan that emphasized the importance of independent activities, the resident was not provided with the necessary resources to engage in such activities. The resident's medical history included Parkinson's disease, chronic obstructive pulmonary disease, dementia, diabetes, atherosclerotic heart disease, major depressive disorder, paranoid personality disorder, and conversion disorder with seizures. The facility's activity policy stated that an ongoing activity program should support residents' choices and interests, yet the responsibility to ensure the resident had self-initiated activities available was not fulfilled. The Activity Director acknowledged that it was the Activity Aides' responsibility to provide these activities, highlighting a lapse in the implementation of the facility's policy.
Failure to Maintain Catheter Hygiene Standards
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag and tubing remained free of contact with the floor, which is a standard practice to prevent infection. Resident 33, who was mildly cognitively impaired and required extensive assistance for toileting needs, had an indwelling urinary catheter due to obstructive uropathy. Observations on two separate occasions revealed that the catheter tubing and drainage bag were in contact with the floor, which poses a risk for infection. During an interview, a Certified Nursing Assistant (CNA) confirmed that the catheter bag was contacting the floor and admitted to not knowing how to prevent this. The Regional Nurse Consultant also confirmed that keeping the catheter tubing and drainage bag off the floor is the current standard of practice. The facility's policy on the appropriate use of indwelling catheters aligns with this standard, indicating a failure in adherence to the policy.
Failure to Administer and Assess Pain Medication
Penalty
Summary
The facility failed to routinely assess and administer narcotic pain medication for a resident with chronic pain. Resident 12, who was cognitively intact and diagnosed with chronic pain syndrome, was supposed to receive tramadol 50 mg three times a day and Tylenol 650 mg every six hours for pain management. However, the resident did not receive four doses of tramadol over two days, which led to elevated pain levels, although it did not prevent her from performing her usual routine. The resident and her family member reported that the facility staff mentioned an outage as the reason for the missed medication. The facility's July 2024 medication administration record confirmed the missed doses of tramadol, while Tylenol was administered as ordered. Additionally, there was a lack of documented pain assessments between the evening of 7/18/2024 and the morning of 7/20/2024, despite the facility's pain management policy requiring residents receiving routine pain medications to be assessed each shift. This oversight in pain management and documentation contributed to the deficiency identified during the survey.
Failure to Timely Schedule CT Scan for Resident
Penalty
Summary
The facility failed to timely follow up on scheduling a CT scan for a resident with skin conditions, identified as Resident 52. The resident's clinical record was reviewed, revealing diagnoses of osteoarthritis and end-stage renal disease. A physician's order for a CT scan of the spine without contrast was issued on 7/10/24, including the cervical, lumbar, and thoracic spine, with a referral sent to a local hospital provider. However, there was no documentation in the clinical record indicating that an appointment was scheduled or any follow-up actions were taken after the referral was sent. An interview with the Director of Nursing (DON) revealed that the process for scheduling CT scans involved calling the local provider and sending the order, after which the provider would respond with an appointment or request additional information. Despite the staff's initial call to schedule the appointment, there was no verification of follow-up until the DON contacted the provider on 7/26/24. The provider indicated they needed a diagnosis code to proceed, which was not provided until the day of the interview, delaying the scheduling of the CT scan for Resident 52.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure a resident received routine dental services, as evidenced by the case of a resident who was observed to have no upper or lower teeth and expressed difficulty eating due to the lack of dentures. The resident, who was cognitively intact and had multiple diagnoses including Parkinsonism, COPD, dementia, and diabetes, had not seen a dentist since June 2023. At that time, impressions for dentures were made, but the dentures were not completed because the dentist did not receive communication from the resident's Power of Attorney (POA). Social Services, responsible for following up with the POA and dentist, had not ensured the completion of the dental services, resulting in the resident being without dentures for an extended period.
Failure to Document Treatments and Enteral Feeding
Penalty
Summary
The facility failed to properly document treatments and enteral feeding for Resident C, who has complex medical conditions including chronic respiratory failure with hypoxia, quadriplegia, and dependence on a ventilator. The Treatment Administration Record (TAR) for May 2024 showed multiple instances where treatments were neither documented as completed nor refused. These treatments included the application of Dakins solution to the buttocks, wound care for the right lateral foot, right lateral leg, right elbow, coccyx, and buttocks, as well as enteral feeding via a gastrostomy tube. The Corporate Director of Respiratory confirmed the lack of documentation during an interview. The facility's documentation policy requires accurate and timely records of residents' experiences, which was not adhered to in this case. The absence of documentation for specific dates and shifts indicates a significant lapse in maintaining accurate medical records for Resident C, as required by professional standards.
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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