Majestic Care Of New Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in New Haven, Indiana.
- Location
- 1201 Daly Drive, New Haven, Indiana 46774
- CMS Provider Number
- 155207
- Inspections on file
- 43
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Majestic Care Of New Haven during CMS and state inspections, most recent first.
A resident with dementia and a history of physical and verbal aggression took adhesive wipe packets from the nurse station and refused to return them despite calm redirection and an offer of a snack from an LPN. An RN observing the interaction approached from behind and sprayed wound cleanser toward the resident’s face without speaking, causing the resident to drop the packets, startle, and wipe his face and eye. A housekeeper witnessed the RN’s actions, and both the LPN and the housekeeper did not immediately report the incident, initially not recognizing it as abuse. The event was later reported to leadership and confirmed on video, and clinical notes documented that the resident had no recollection of the incident and no acute medical concerns.
Dining staff did not consistently follow meal tickets, resulting in several residents not receiving menu items such as broccoli salad and garlic bread, with no substitutions provided. Grievances and interviews confirmed that staff failed to reference meal tickets as required by facility policy.
Dietary staff did not consistently temperature-test pureed meals for four residents on pureed diets. Observations and interviews revealed that food was sometimes served below the required temperature, and food temperature logs showed multiple days with missing records for pureed meals, contrary to the facility's safe food handling policy.
A multiple dose liquid medication bottle was found on a medication cart without an open date, despite being marked 'NOT OPEN' and having been used, with a punctured seal and residue present. The medication had been discontinued and was not on the active MAR. An LPN was observed handling the bottle, and the DON confirmed there was no current improvement plan for medication storage, despite a history of similar citations and ongoing audits reported in QAPI meetings.
A resident with a history of heart disease and other conditions was transferred to the ER for chest pain, but the facility did not notify the resident's emergency contact. Documentation did not show that the resident declined such notification, and the care plan indicated family involvement. Staff interviews provided conflicting explanations, and facility policy on notification was not followed.
A resident was subjected to inappropriate verbal comments by the Rehabilitation Director during a discussion about room conditions, including a reference to prison and a remark about being 'outnumbered' in the presence of staff and the resident, all of whom were black except the RD. The resident, who was cognitively intact, became visibly upset by the comments, which were corroborated by other staff present. The facility's policy on verbal abuse was not followed in this incident.
A resident with chronic pain conditions received oxycodone-acetaminophen for pain levels below the physician-ordered threshold, and there was no documentation that nonpharmacological pain interventions were provided as outlined in the care plan. The DON confirmed the medication was administered outside of the prescribed parameters without justification.
A resident with end stage renal disease requiring dialysis did not consistently have pre-dialysis vital signs and communication forms completed by facility staff before appointments. The dialysis center RN reported that the communication sheets were often blank and no separate facility assessment was provided, despite facility policy requiring this documentation. The DON could not verify that the necessary paperwork was sent with the resident.
A bottle of Guaifenesin liquid was found in a medication cart with 'NOT OPEN' written on the label, but the inner seal was punctured and some medication had been used. The bottle lacked an open date, and a resident did not have an active order for this medication. The DON confirmed the absence of a current order, and facility policies did not clearly address required labeling practices.
A facility failed to properly label and store medications on a medication cart, affecting three residents with respiratory conditions. Observations revealed inhalers without open or expiration dates, contrary to facility policy. The DON confirmed the inhalers should have been removed, highlighting a lapse in adherence to medication administration protocols.
A facility failed to properly assess and care plan for a resident with recurrent head lice. Despite a history of lice after leave of absences, the resident's care plan did not address the condition, and there were no documented protocols or assessments during isolation. Treatment was ordered, but no additional orders or staff education on lice protocols were documented. The facility's policies on lice and isolation precautions were not followed, contributing to the deficiency.
A facility failed to ensure residents were not given psychotropic medications without specific targeted behaviors identified and non-pharmacological interventions in place. A resident with dementia and depression was administered Haloperidol without documented behaviors or follow-up, while another resident with COPD and depression was prescribed Xanax without clear indication or behavior monitoring. The facility did not adhere to its policies requiring behavior monitoring and non-pharmacological interventions before psychotropic medication use.
Failure to Protect Resident From Physical Abuse and Delayed Reporting by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by staff when a nurse sprayed a liquid wound cleanser toward the resident’s face during an interaction over facility supplies. The resident, who had dementia and moderately impaired cognition, used a wheelchair and had a care plan noting episodes of physical and verbal aggression, including hitting, pushing, yelling, antagonizing others, and blocking hallways. Interventions in the care plan directed staff to approach him calmly, explain tasks before initiating them, offer distractions, remove him from situations, and, if he became combative or resistive, to postpone care and re-approach later. On the day of the incident, the resident took two packets of adhesive wipes from the nurse’s station counter and refused to return them when asked by an LPN, who also attempted to trade a snack for the packets. The resident yelled and refused, and an RN observing from behind the nurse’s station then approached and sprayed wound cleanser near the resident’s face without speaking, causing him to drop the packets. A housekeeper in the hallway observed the LPN calmly trying to coax the items from the resident while he yelled, then saw the RN approach from behind and beside the resident and spray something toward his face, after which the resident startled, looked at the nurse, and began wiping his face and rubbing his eye. The RN then looked down the hall, saw the housekeeper watching, and walked away. The LPN and the housekeeper did not immediately report the incident at the time it occurred because they did not initially recognize it as abuse. The incident was later reported to facility leadership, who reviewed video footage confirming the event. Subsequent clinical notes documented that the resident had no recollection of the incident, no acute concerns, no breathing issues, and mentation at baseline, but the deficiency centered on the willful act of spraying wound cleanser toward the resident’s face and the failure of staff who witnessed the event to promptly report it as required by the facility’s abuse policy.
Failure to Follow Resident Meal Tickets and Menu Postings
Penalty
Summary
The facility failed to ensure that dining staff followed resident meal tickets for four residents, resulting in residents not receiving items listed on their menus. During dining observations, two residents were not served broccoli salad as indicated on their meal tickets, and one resident reported not receiving garlic bread, with no substitutions provided. Review of posted menus confirmed that these items were scheduled to be served, and the postings were not updated to reflect any changes or substitutions. Additionally, grievances from two residents documented ongoing issues with meal trays, specifically that dining staff were not referencing meal tickets and were omitting food items. Interviews with facility leadership confirmed that staff are expected to review meal tickets to ensure residents receive appropriate items and avoid serving restricted foods. The facility's policy requires menus to be followed and to accommodate resident preferences, but observations and records indicated this was not consistently practiced.
Failure to Consistently Temperature-Test Pureed Meals
Penalty
Summary
The facility failed to ensure that pureed meals were consistently temperature-tested for four residents who required pureed diets. During an observation, dietary staff was seen checking the temperature of pureed broccoli, which registered at 130°F. A staff member acknowledged that the food was below the required temperature and indicated that she would reheat it. Interviews confirmed that on multiple occasions, food was not at the appropriate temperature before being served. A review of food temperature logs for December revealed that there were numerous days when no temperature records were documented for breakfast, lunch, or dinner pureed meals, despite four residents being on pureed diets during those times. The facility's policy on safe food handling, which aims to reduce the risk of foodborne illness, was not followed as evidenced by the lack of temperature documentation and inconsistent temperature checks for pureed meals.
Recurring Medication Storage Deficiency Due to Inadequate Labeling and Oversight
Penalty
Summary
The facility failed to maintain an effective process to prevent recurring medication storage issues, as evidenced by the observation of a multiple dose liquid medication bottle on a medication cart that was not properly labeled with an open date. The bottle, marked 'NOT OPEN' in black marker, was found to have been opened and used, with a punctured inner seal and visible red liquid residue. Review of the resident's record revealed that the medication had been discontinued and did not have an active order. This incident was cited under F0761 for improper labeling and storage of drugs and biologicals. Additionally, the facility had a history of similar citations for the same deficiency on multiple previous survey dates. During an interview, the DON confirmed that there was no current improvement plan specifically addressing medication storage, although routine audits were being conducted and results reported in QAPI meetings.
Failure to Notify Emergency Contact of Resident Transfer
Penalty
Summary
The facility failed to notify the emergency contact of a resident who was transferred to the emergency room for chest pain that was not relieved by Nitroglycerin and at the resident's request. Record review showed no documentation that the resident's emergency contact, his brother, was notified of the transfer. There was also no documentation indicating that the resident did not want his emergency contact notified. The resident's care plan indicated family involvement in the last 14 days and did not specify any wishes to exclude the brother from notification in emergencies. Interviews with facility staff revealed conflicting information. The DON stated that the resident did not wish for his brother to be notified and that this was reflected in the care plan, but review of the care plan did not support this claim. The Regional Nurse Consultant indicated that the brother was not notified because the resident was his own responsible party. Facility policy allows for disclosure of information to individuals involved in the resident's care or for notification purposes, but there was no evidence that this policy was followed in this instance.
Verbal Abuse Involving Inappropriate and Racially Charged Comments by Staff
Penalty
Summary
A deficiency occurred when a resident was subjected to inappropriate and potentially racially charged verbal comments by the Rehabilitation Director (RD) in the presence of other staff members. The incident took place during a discussion about the condition of the resident's room, specifically the walls being only half painted. The RD responded to the resident's complaint by making a comment referencing prison, which the resident found offensive, especially as he stated he had never been to prison and that prison was no place for an educated black man. The RD then remarked that she was 'outnumbered' and left the room, a statement interpreted by those present as referring to the racial makeup of the group. The resident was visibly upset during subsequent interviews, raising his voice and appearing emotional when recounting the incident. Multiple staff members, including an LPN and a QMA who were present, corroborated the resident's account of the RD's comments. The facility's investigation included statements from those involved, confirming the sequence of events and the nature of the remarks made. The resident was found to be cognitively intact, with a BIMS score of 15, and was able to clearly articulate his experience. The facility's policy defines verbal abuse as the use of disparaging or derogatory language toward residents, which was not adhered to in this instance.
Failure to Follow Pain Management Orders and Document Nonpharmacological Interventions
Penalty
Summary
A resident with multiple pain-related diagnoses, including arthritis, lupus, and sciatica, had physician orders for oxycodone-acetaminophen to be administered every 8 hours as needed for severe pain greater than 7 on the pain scale. However, the medication was administered on several occasions when the resident reported pain levels below the threshold specified in the order, with documented pain scores of 4 and 6. There was no documented justification for administering the medication outside the prescribed parameters. Additionally, the resident's care plan included interventions for nonpharmacological pain management, such as position changes, relaxation, a quiet environment, back rubs, and diversional activities. Despite this, there was no documentation in the progress notes that these nonpharmacological interventions were provided on the dates when the medication was administered for pain levels below 7. The DON confirmed that the medication should not have been given for pain less than 7 and could not provide a reason for the deviation from the physician's order.
Failure to Ensure Proper Dialysis Communication and Collaboration
Penalty
Summary
The facility failed to ensure proper collaboration with an off-site dialysis center for a resident diagnosed with end stage renal disease and dependent on renal dialysis. Review of the resident's dialysis communication records revealed that the pre-dialysis section, which should include vital signs, was incomplete or missing on multiple dates. The resident reported that the facility did not always complete the required communication form that he took to dialysis appointments, which contained his medications and the dialysis communication sheet. Interviews with facility staff and the dialysis center RN confirmed that the facility often sent the dialysis communication sheet blank and did not provide a separate facility assessment with the resident. The DON stated that the facility conducted its own assessments and sent them in a packet with the resident, but could not provide evidence that these assessments were actually sent, as no folder was maintained and the information was not tracked. The facility's policy required continued assessment and appropriate paperwork to be sent with the resident to the off-site dialysis center, which was not consistently followed.
Failure to Properly Label and Store Medications in Medication Cart
Penalty
Summary
The facility failed to ensure that only current medications with appropriate labeling were present in medication carts, as observed during a review of one out of three carts. A bottle of Guaifenesin liquid labeled for a specific resident was found with the words 'NOT OPEN' written on it, but the inner seal was punctured and some medication had been used, indicating it had been opened. There was no open date on the bottle, and the resident did not have an active order for this medication at the time of the review. The Director of Nursing confirmed that the resident should have had an order but did not currently have one. The facility's medication storage policy did not specify labeling practices, while the labeling policy required multidose vials to be labeled with the date opened or accessed.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on one of the two medication carts reviewed. During an observation, it was found that an inhaler for a resident with chronic obstructive pulmonary disease had no open date labeled, and another resident's inhaler had an open date but no expiration date. Additionally, a third resident's inhaler had neither an open date nor an expiration date. These labeling deficiencies were identified during a review of the medication cart in the 200 Hall, and the Qualified Medical Assistant indicated that staff usually checked the cart to ensure proper labeling and discarded any medications that were not labeled or expired. The Director of Nursing confirmed that the inhalers should have been removed from the cart. The residents involved had various respiratory conditions, including chronic obstructive pulmonary disease and asthma, and had specific physician orders for their inhalers. The facility's policy on medication administration required the disposal of medications that were not securely closed, outdated, contaminated, or deteriorated, and emphasized the timely removal of such medications from stock. However, the facility did not adhere to this policy, resulting in the observed deficiencies.
Failure to Assess and Care Plan for Resident with Head Lice
Penalty
Summary
The facility failed to ensure proper assessment and care planning for a resident with a known contagious condition, specifically head lice. Resident E, who had a history of recurrent head lice after returning from leave of absences, was not adequately assessed or care planned for this condition. The Director of Nursing indicated that Resident E was to be checked for lice upon return to the facility, and treatment orders were to be obtained and communicated to staff. However, Resident E's care plan did not address lice infestation, and there were no documented protocols or assessments conducted during her isolation period. Resident E's medical record indicated she had been seen by a nurse practitioner for head lice, and treatment was ordered. Despite this, there were no additional treatment orders or documentation of staff education on lice protocols. Progress notes revealed that Resident E had been isolated in her room for approximately four weeks due to lice, but there was no formal documentation of when the isolation began or ended. Additionally, there was no evidence that other residents sharing her bathroom were checked for lice. The facility's policies on head lice and isolation precautions were not followed, as there was no documentation of assessments, treatment regimens, or decontamination procedures. The Director of Nursing was unable to find any orders for isolation or documentation of staff education on lice protocols. This lack of adherence to policies and procedures contributed to the deficiency in providing appropriate treatment and care for Resident E.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were not given psychotropic medications without specific targeted behaviors identified and non-pharmacological interventions in place. Resident D, who had diagnoses including dementia, chronic pain, generalized anxiety disorder, sleep disorder, and major depressive disorder, was hospitalized for a change in condition. Upon her return to the facility, she was administered Haloperidol Lactate for anxiety/agitation without documentation of behaviors requiring its use, notification to the provider, or follow-up documentation after administration. The care plans for Resident D included non-pharmacological interventions, but there was no evidence that these were implemented prior to the administration of the psychotropic medication. Resident J, diagnosed with chronic obstructive pulmonary disease and major depressive disorder, was also given psychotropic medication without proper documentation of behaviors or non-pharmacological interventions. Despite having no documented symptoms of anxiety, Resident J was prescribed Xanax, an anti-anxiety medication, without a clear indication for its use. The facility's records did not include a care plan or behavior monitoring for the use of Xanax, nor did they document potential adverse effects due to its use alongside other sedating medications. The facility's policies on Mood and Behavior Management and Psychotropic Management require that residents receiving psychotropic medications have a supporting diagnosis, appropriate indication for use, and a behavior monitoring program in place. However, these requirements were not met for Residents D and J, as there was a lack of documentation and implementation of non-pharmacological interventions and behavior monitoring. This deficiency was identified during a survey, which included interviews and record reviews, revealing the facility's failure to adhere to its own policies and regulatory requirements.
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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