Miller's Merry Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Logansport, Indiana.
- Location
- 200 26th St, Logansport, Indiana 46947
- CMS Provider Number
- 155235
- Inspections on file
- 32
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Miller's Merry Manor during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
A resident with Alzheimer’s disease and depression exhibited intermittent delusional statements, refusals of medications and care, and occasional yelling or suspiciousness toward staff over several months. Nursing notes documented these behaviors but did not show a comprehensive psychiatric assessment or evidence of a sustained major mood episode. A psychiatric NP subsequently added diagnoses of schizoaffective disorder, borderline personality disorder, and delusions, and ordered Seroquel, despite no prior history of schizoaffective disorder and no detailed evaluation in the record to support the new diagnosis. The resident’s representative reported no known mental health history or hospitalizations and was unaware of the schizoaffective disorder diagnosis, and the DON indicated there was no specific facility policy for schizoaffective disorder.
A resident with DM and dementia, ordered for twice-daily blood glucose checks, had their blood sugar taken by an RN using a glucometer that was not disinfected before or after use and was placed directly on a medication cart without a clean barrier. Interviews with the RN, an LPN, and the Clinical Support Nurse confirmed that facility policy required glucometers to be cleaned with commercial disinfectant wipes before and after each use, following manufacturer contact time and air-dry instructions, but this procedure was not followed during the observed blood glucose check.
Three residents with chronic conditions did not receive care according to physician orders, including failure to document required blood pressure readings before administering antihypertensive medication, failure to administer PRN diuretics or notify the physician after significant weight gains, and missed daily weights without documentation. Facility staff and policies confirmed these actions were required but not completed.
A resident with severe cognitive impairment and a history of wandering was identified as being at risk for elopement and was observed wearing a wanderguard bracelet. Despite care plan and facility policy requirements for daily function and placement checks, there was no physician's order for the device, and no documentation of checks was found for most of the month. Staff interviews confirmed that required orders and documentation were missing, and the facility's policy for monitoring at-risk residents was not followed.
A facility failed to hold a relocation planning conference with a resident's POA before transferring the resident from a memory care unit to a skilled nursing unit due to inappropriate behaviors. The POA was not informed of the move and did not waive the required two-day notice. The facility's policy required notification and a relocation plan, but the necessary documentation and communication were lacking.
The facility failed to manage infection control data accurately during a COVID outbreak, affecting all residents. Conflicting reports on the number of COVID cases were noted, and the Infection Control Preventionist struggled to complete data entry due to other responsibilities. The facility's policy required comprehensive tracking and reporting of infections, but incomplete data collection hindered effective infection management.
The facility failed to update the elopement alarm status for a resident who was no longer at risk for elopement. Despite a re-evaluation indicating the wander guard was unnecessary, the care plan and physician orders were not updated, and the wander guard was still being checked off daily. An observation confirmed the wander guard was still on the resident's wheelchair.
The facility failed to provide personalized trauma-informed care for a resident with PTSD, dementia, depression, and anxiety. The care plan did not address PTSD, and staff were unaware of the resident's traumatic history and specific triggers, leading to the deficiency.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
Unsubstantiated Schizoaffective Disorder Diagnosis and Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality when assigning a new diagnosis of schizoaffective disorder and initiating an antipsychotic medication for one resident without adequate supporting assessment or documentation. The resident’s clinical record showed existing diagnoses of Alzheimer’s disease, depression, borderline personality disorder, and delusional disorder, with prior PASSAR and admission MDS assessments reflecting depression and dementia/Alzheimer’s disease, and treatment with an antidepressant. Nursing progress notes over several months documented episodes of the resident reporting men causing trouble, believing a man was in her room, and talking about a man wanting to marry her and yelling through the walls, as well as frequent refusals of medications, blood sugar checks, blood pressure checks, insulin, and hygiene care. Additional nursing documentation described the resident as sometimes yelling at staff, being visibly upset by a room move, being leery of staff and asking to see name badges, and making statements that housekeeping had not cleaned her room or that she had not received medications when records indicated that she had. Despite these behaviors and delusional-type statements, there were no other documented behaviors in the nursing progress notes between late April and mid-July beyond refusals of care, expressions of dissatisfaction, and intermittent suspiciousness. The record did not contain a comprehensive psychiatric evaluation establishing that the resident had experienced a major mood episode of uninterrupted duration or otherwise met the diagnostic criteria for schizoaffective disorder. On a psychiatric NP visit for initial psychotropic medication management, the NP added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusions, and ordered Seroquel 25 mg. The resident had no prior history of schizoaffective disorder, and the clinical record lacked an assessment to substantiate this new diagnosis. There was also no documentation that the resident’s mental health history was reviewed with the resident’s representative or that the delusional symptoms were evaluated as a possible progression of Alzheimer’s disease. The resident’s representative later reported that the resident had no known history of mental health disorders or psychiatric hospitalization and was unaware of the schizoaffective disorder diagnosis. The DON stated there was no facility policy specific to schizoaffective disorder and that the facility followed federal regulations.
Failure to Disinfect Glucometer Between Resident Uses
Penalty
Summary
The deficiency involves the facility’s failure to sanitize a glucometer in accordance with its infection prevention and control policy for one resident. During an observation, an RN removed a glucometer from the third-floor medication cart and placed it directly on top of the cart without a clean barrier. Without cleaning the glucometer, the RN took it, along with an alcohol pad and lancet, into the resident’s room, obtained a blood glucose reading, and then returned the glucometer to the medication cart without disinfecting it before or after use. The resident’s record showed diagnoses including diabetes mellitus and dementia, with a physician’s order to check blood glucose twice daily. In interviews, the RN stated she should have used a disinfectant wipe to clean the glucometer and acknowledged that facility policy required staff to use wipes before and after blood sugars were taken to ensure the device was clean for the next resident, and that failure to clean it could cause an infection control problem. An LPN and the Clinical Support Nurse both confirmed that facility policy required glucometers to be cleaned with disinfectant wipes stored in each medication cart before and after each resident use. The written policy titled “Cleaning Of Glucometer” specified that the glucometer would be disinfected after completing a blood sugar using a commercial disinfectant wipe, kept visibly wet for the manufacturer’s required contact time, placed in a covered container during this period, and allowed to air dry before reuse.
Failure to Follow Physician Orders and Document Required Assessments
Penalty
Summary
The facility failed to follow physician orders and ensure appropriate documentation and notification for three residents with complex medical conditions. For one resident with vascular dementia and hypertension, staff administered lisinopril daily as ordered, but did not record the required blood pressure readings at the time of administration, as specified by the physician's parameters. Interviews with the DON and unit manager confirmed that blood pressures were not documented on the MAR and should have been obtained prior to medication administration. Another resident with chronic heart failure, fluid overload, and severe kidney disease had physician orders for daily weights and as-needed furosemide based on specific weight gain thresholds, with instructions to notify the physician for certain weight increases. Despite documented weight gains exceeding the parameters, there was no evidence that the PRN diuretic was administered or that the physician was notified, as required by the orders. The DON confirmed that staff should have followed the orders for medication administration and physician notification, and documented these actions. A third resident with hypertension, dementia, and diabetes had orders for daily weights and PRN torsemide for weight gains meeting specific criteria. The MAR showed missed daily weights without documentation of refusal or unavailability, and instances where significant weight gains occurred but the PRN medication was not administered. There was also no documentation of physician notification for these events. Facility policies required necessary assessments before medication administration and physician notification for values outside ordered parameters, but these were not followed in the cited cases.
Failure to Ensure Wanderguard Function and Documentation for At-Risk Resident
Penalty
Summary
A dependent resident with severe cognitive impairment and a history of wandering was observed wearing a wanderguard bracelet on her right ankle. The resident was independently mobile, had diagnoses including dementia, and was assessed as being at risk for elopement. The care plan specified that the function and placement of the wanderguard sensor should be checked daily. However, there was no physician's order for the use of the wanderguard, and no documentation was found indicating that the placement or function of the wanderguard was checked between the beginning and end of the month. The MAR only reflected an order for the wanderguard starting late in the month, with checks not documented until several days after the order. Interviews with staff revealed a lack of awareness regarding the presence of residents with wanderguard bracelets, and staff confirmed that an order and regular checks should have been in place and documented. The facility's policy required that residents at risk for elopement have interventions such as a wanderguard applied, with nursing staff responsible for checking placement each shift and function daily, documenting these checks on the treatment record. These required checks and documentation were not completed as outlined in the policy.
Failure to Conduct Relocation Planning Conference for Resident Transfer
Penalty
Summary
The facility failed to conduct a relocation planning conference with the resident's Power of Attorney (POA) and the Administrator before transferring Resident B from the memory care unit to the skilled nursing unit. This deficiency was identified during an interview and record review, where it was found that the transfer was made due to Resident B's inappropriate sexual behaviors. The facility's Executive Director (ED) indicated that the transfer was necessary because the women in the memory care unit could not voice concerns if assaulted, unlike those in the skilled care unit. Resident B's clinical record showed diagnoses including Alzheimer's disease, severe dementia with anxiety, chronic kidney disease, anxiety disorder, post-traumatic stress disorder, and depression. A social service progress note indicated that the resident and his son were informed about the potential room change, and the son agreed to waive the 48-hour notice. However, the POA later stated he was not notified of the move and did not waive the two-day notification. He discovered the transfer when visiting the facility and found Resident B in a new room on the skilled care side. The facility's policy required notifying the resident, family, and legal representative before a move, with a two-day notice unless waived. The policy also mandated a relocation plan and conference, which could be waived with a signed waiver. However, the intrafacility transfer form lacked the POA's signature, and the relocation planning conference box was unchecked. The POA was unaware of his rights to request a copy of the transfer form or appeal the move, indicating a failure in communication and adherence to policy.
Inadequate Infection Control Data Management During COVID Outbreak
Penalty
Summary
The facility failed to adhere to its Infection Control Surveillance Program policy, resulting in incomplete and inaccurate data collection regarding infections. This deficiency was observed during a survey when the facility was experiencing a COVID outbreak. An unidentified receptionist confirmed the outbreak, and the Executive Director (ED) reported that 19 residents and one staff member had tested positive for COVID. However, an agency nurse provided conflicting information, indicating that 20 residents on the third floor had COVID, and there were additional staff members out sick. The facility's Infection Surveillance Data Collection Form was incomplete, with no forms available for June 2024. The Infection Control Preventionist was in the process of entering data into the system but had not completed it. The Director of Nursing (DON) was unable to trace the source of the COVID outbreak or determine the extent of exposure among residents and staff. The Infection Control Preventionist was also responsible for other duties, such as wound care and staff education, which hindered her ability to focus on infection control tasks. The facility's policy required the Infection Control Coordinator to track each resident's infection status until symptoms resolved and to compile monthly summaries for the QAPI committee. However, the Infection Control Preventionist was unable to complete these tasks due to being frequently pulled away for other responsibilities. The lack of complete and accurate infection data collection and analysis compromised the facility's ability to effectively manage and prevent infections, as outlined in their policy.
Failure to Update Elopement Alarm Status for Resident
Penalty
Summary
The facility failed to ensure that an elopement alarm was followed for a resident. Resident 77, who had a diagnosis of unspecified intracranial injury with loss of consciousness, was initially assessed to require a wander/elopement alarm daily. A physician order dated 12/13/23 indicated that the wander guard function should be checked daily and placed on the resident's wheelchair. However, a subsequent nursing-supplemental elopement risk assessment indicated that Resident 77 was no longer at risk for elopement, and the care plan and physician orders were not updated to reflect this change. Despite this, the Treatment Administration Record (TAR) for January, February, and March 2024 showed that the wander guard was still being checked off as being on the wheelchair daily, indicating a failure to update the care plan and physician orders accordingly. An observation on 03/20/24 confirmed that the wander guard was still visible on Resident 77's wheelchair. In an interview, the Director of Nursing stated that Resident 77 had been re-evaluated and it was decided that the wander guard was no longer necessary, and it should have been removed from the wheelchair and physician orders on 1/5/24. The facility's policy on Elopement Risk Assessment, dated 6/3/14, was provided, which indicated the need to assess residents for potential elopement and ensure they are always free from harm. The failure to update the care plan and physician orders led to the deficiency in following the appropriate treatment and care for Resident 77 according to the updated assessment and orders.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure personalized trauma-informed care for a resident diagnosed with dementia, PTSD, depression, and anxiety. The resident's care plan did not include any focus, goals, interventions, or triggers for PTSD, despite the resident having a history of traumatic experiences. The care plan only addressed anxiety and yelling out, with interventions such as administering psych medication, monitoring side effects, and documenting mood behavior. Trauma screenings indicated the resident denied any trauma, but the resident's son, who is the POA, revealed that the resident had several traumatic experiences, including growing up in an abusive home and witnessing the violent death of a sibling. During interviews, staff members, including a CNA and the unit manager, were unaware of the resident's PTSD diagnosis or any specific triggers. The CNA's pocket care sheet did not include instructions regarding behaviors or triggers for PTSD. The facility's policy on trauma-informed care stated that residents with PTSD should receive person-centered and individualized treatment, but this was not implemented for the resident in question. The lack of personalized trauma-informed care led to the deficiency identified in the report.
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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