Newburgh Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Newburgh, Indiana.
- Location
- 10466 Pollack Ave, Newburgh, Indiana 47630
- CMS Provider Number
- 155354
- Inspections on file
- 37
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Newburgh Health And Rehab during CMS and state inspections, most recent first.
The facility failed to ensure the Dietary Manager met CDM qualification requirements. The Dietary Manager stated she did not have kitchen manager certification and was still enrolled in a class to obtain it. Her file showed she started work before earning CDM status, and her application noted she was not yet a CDM and was still in school for the certification.
Failure to Hold Required Care Plan Conferences: The facility did not conduct required care plan conferences for multiple residents with varying needs, including residents with HTN, CVA, dementia, Alzheimer’s disease, and CHF. Records showed recent MDS assessments with needs for assistance with toileting, bathing, dressing, transferring, and eating, but the last documented care conferences were months earlier or absent altogether. The SSD stated care plan conferences were not completed during a staffing transition, despite the facility policy calling for regularly scheduled conferences and discussion of the plan of care with the resident and/or representative.
Inaccurate MDS assessments were completed for several residents. One resident with cerebrovascular disease was not assessed for cognition even though the MDS indicated it should have been, another resident’s antianxiety medication use was not coded despite eMAR documentation, a third resident’s cognition section was left blank when it should have been assessed, and a fourth resident’s MDS failed to code an active right shin wound and related care needs.
Improper medication storage and labeling were found in multiple medication carts. Surveyors observed numerous loose pills and unlabeled bottles, including supplements and resident-labeled items without proper labels. An LPN stated loose pills should not be in the carts, and the DON stated supplement bottles should have labels and a physician order.
Food was found stored improperly in the kitchen, including sliced and shredded cheese left open to air, a coleslaw carton past its use-by date, and bulk sugar and oatmeal containers left open to air. The low-temp dish machine sanitization log was blank even though the DM stated staff were supposed to record sanitizer levels before each meal.
A resident with CHF and CKD had ordered weekly weights and provider notification parameters for weight gain, but staff did not fax weekly weights on multiple scheduled dates and did not notify NHT after the resident gained 9.3 lbs in one week. The record lacked documentation of provider notification, and the DON confirmed the notification did not occur.
PRN psychotropic orders were left open-ended for three residents. Two residents had lorazepam orders without a stop date, including one resident on hospice, and another resident had a hydroxyzine PRN order without a stop date. The DON stated non-hospice meds should have a 14-day stop date, and hospice orders should specify the duration of hospice; the facility policy also required PRN psychotropic orders to be limited to no more than 14 days unless the prescriber documented a rationale and specific duration.
The facility failed to complete MDS assessments timely for two residents. One resident with cerebrovascular disease was discharged to the hospital and did not return, but no Discharge MDS was completed. Another resident with osteoarthritis had an admission MDS that was completed late, even though the assessment documented cognitive intactness and dependence on staff for toileting, bathing, and transfers.
Late Quarterly MDS Assessment: A resident with kidney and ureter disorder and essential primary HTN had a Quarterly MDS that was not completed within the required 3-month interval. Record review showed the assessment was completed after the due timeframe, and the SS Director stated care plan conferences needed to occur every 3 months.
The facility failed to follow care plan interventions for two residents whose call lights were not kept within reach, despite care plans calling for the call system and bedside table to be in reach. One resident had dementia, anxiety, PTSD, and was dependent for transfers, while another was moderately cognitively impaired and dependent for multiple ADLs. The facility also had no current care plans for a cognitively intact resident receiving antianxiety and antidepressant meds, including sertraline, Klonopin, and clonazepam.
A resident with CHF and CKD had physician-ordered daily early morning weights to monitor fluid overload and weight fluctuations, but weights were missed on multiple days over several months. The chart also documented edema, pitting edema, significant weight gain/loss triggers, and repeated notes that daily weights were needed to monitor changes. The DON stated the weights were either not done or the resident was marked asleep, despite staff being expected to try again or pass it to the next shift.
The facility failed to ensure pharmacist medication recommendations were reviewed and acted upon by the physician for a resident receiving Eliquis for pulmonary embolism. A pharmacy new admission review noted the Eliquis dose was outside the typical dose and should be evaluated, but the clinical record lacked approval or rationale for denying the recommendation. The DON later stated the physician reviewed and accepted the recommendation, and the facility policy required staff to act upon medication regimen review irregularities.
Infection control practices were not followed during resident care and insulin administration. A resident with an order for EBP due to wounds was toileted, transferred, and moved without staff wearing gowns, and the resident was not offered hand hygiene. In a separate observation, an LPN administered Lantus and lispro insulin without wiping the pen’s rubber injectable port with alcohol before inserting the needle.
A resident dependent on staff for bathing was not showered on multiple scheduled days. The resident had cerebrovascular disease, required substantial to maximal assistance with bathing per the care plan, and was described as generally unkempt when transported to the ER. Shower documentation showed missed showers or bed baths, while the DON stated residents were to receive showers at least twice weekly and the resident’s assigned shower days were Tuesdays and Saturdays.
Staff failed to administer and document medications according to ordered times and facility policy. An LPN gave a resident’s morning medications but did not sign the EMAR, leaving the doses showing as not given. A QMA later prepared additional medications for that resident while unaware they had already been administered. The same QMA also prepared multiple scheduled 8:00 a.m. medications for two residents much later in the morning, outside the facility’s required one-hour window for medication timing.
The facility failed to ensure the Dietary Manager met required qualifications, as he did not have a certification and was not enrolled in a program. The policy required enrollment in a training course if not certified at hire. The dietician was contracted and present only once a week.
The facility did not complete or update a comprehensive facility-wide assessment since 2022, as required by their policy. The assessment, which should involve multiple staff members and be updated annually or when changes occur, was only completed by the Administrator and DON on the day it was requested. This oversight potentially affected the care of 59 residents.
The facility did not hold QAPI meetings quarterly as required, with the first meeting since April 2024 occurring in January 2025. The meeting lacked the presence of the Medical Director or a designee, as confirmed by the Administrator and DON. The facility's policy mandates monthly meetings with specific members, including the DON, Administrator, and a designated physician.
The facility failed to ensure proper hand hygiene and Enhanced Barrier Precautions (EBP) for two residents during care. A QMA and two nurses did not perform hand hygiene or wear gowns while administering medications through a PEG tube for a resident with cerebral palsy. Additionally, a CNA did not wash hands before donning gloves during a shower for another resident. The facility also did not conduct testing for legionella or other waterborne pathogens, despite having a policy for Legionella Surveillance and Detection.
The facility failed to designate a certified Infection Preventionist (IP) for its infection prevention and control program. The ADON, responsible for the program, lacked certification and dedicated only 12 hours weekly to the role. The ADON's file lacked a job description for IP duties, and the facility's policy required an IP specialist. The job description required nursing training and qualifications in infection control.
The facility failed to update care plans and implement new interventions to prevent falls for residents with a history of falls. Despite multiple falls experienced by residents with conditions such as Alzheimer's and dementia, care plans were not consistently updated, and fall reviews were often incomplete. This lack of action contributed to ongoing safety hazards for the residents.
The facility failed to conduct quarterly care plan conferences for two residents, one with Alzheimer's and another with chronic pain syndrome, as required by policy. Despite a significant change in condition for one resident and cognitive intactness for the other, no conferences were documented in the last three months, leading to a deficiency.
The facility failed to update care plans for two residents following new diagnoses and physician orders. One resident with pneumonia and congestive heart failure did not have timely updates to their care plan for weight monitoring and appetite stimulant use. Another resident with Alzheimer Disease did not have their care plan updated for a urinary tract infection and antibiotic treatment. The facility's policy required care plan revisions with changes in condition, which was not followed.
A facility failed to update a resident's care plan to reflect changes in the gastrostomy device. The resident, who has cerebral palsy and is not cognitively intact, was observed with a PEG tube instead of the expected Mic-Key gastro tube button. The MDS Coordinator confirmed the care plan should have listed the correct device, but it was not updated as required by the facility's policy.
The facility failed to properly label and manage oxygen equipment for three residents, leading to deficiencies in respiratory care. A resident with COPD had undated oxygen tubing despite orders to change it weekly. Another resident with congestive heart failure lacked a care plan for oxygen use, and the oxygen concentrator was set incorrectly. A third resident with COPD had undated tubing and aides improperly adjusting oxygen flow, contrary to facility policy.
The facility exceeded the acceptable medication error rate of 5%, reaching 8% due to errors in insulin administration for two residents. An RN failed to prime the insulin pen before administering 14 units of insulin lispro, and an LPN did not prime the pen needle before administering 18 units. Both incidents were contrary to physician orders and facility policy.
The facility failed to maintain safe and sanitary hallway floors, with observations of sticky and soiled conditions persisting over two days. Interviews revealed that hallways were not mopped daily, despite the facility's policy requiring regular floor care to ensure resident safety.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure the Dietary Manager was certified for 1 of 1 Dietary Manager Qualifications reviewed. During an interview, the Dietary Manager stated that she did not have kitchen manager certification and was enrolled in a class to obtain it. Review of her employee file showed that she began employment with the facility on 3/5/26 and had been enrolled in a Certified Dietary Manager (CDM) course on 2/17/26. Her job application indicated that she was not a CDM and was still in school to obtain the certification. The Administrator later provided a current CDM Job Description policy dated 2025 stating that the position required graduation from a foodservice manager training program or a 2-year or 4-year foodservice management or nutrition program, along with successful completion of the CDM Credentialing Exam and active CDM, CFPP certification status.
Failure to Hold Required Care Plan Conferences
Penalty
Summary
The facility failed to ensure quarterly care conferences were conducted for multiple residents as part of their person-centered plan of care. Resident 8, admitted with hypertension, had a Significant Change MDS dated 3/13/26 showing cognition not assessed, partial assistance needed for toileting, and substantial staff assistance for bathing, but the clinical record lacked a care plan conference since admission. Resident 7, with diagnoses including nontraumatic intracerebral hemorrhage and bipolar disorder, had a Quarterly MDS dated 2/11/26 showing intact cognition and dependence on staff for toileting and bathing, but the last care plan conference was on 11/25/25 and was attended by family. Resident C, with cerebrovascular disease, had a Quarterly MDS dated 3/4/26 showing cognition not assessed, setup assistance for transferring and eating, and substantial to maximal assistance for toileting, but the last care plan conference was on 10/14/25. Resident 25, with wedge compression fracture of L2, unspecified dementia, and Alzheimer’s disease, had a current Significant Change MDS showing intact cognition, set-up help for eating, partial to moderate assistance for dressing, hygiene, and toileting, and substantial to maximum assistance for transferring, but the last care conference was on 7/22/25. Resident 38, with muscle weakness and chronic combined systolic and diastolic heart failure, had a current Quarterly MDS showing intact cognition, set-up assistance for eating, substantial to maximum assistance for hygiene and dressing, and dependence for transferring, but the last care conference was on 12/23/25. The SSD stated in interview that care plan conferences were not completed during the period between the prior SSD leaving and his starting in the position. The facility policy stated the plan of care would be discussed with the resident and/or representative at regularly scheduled care plan conferences, initially, at routine intervals, and after significant changes.
Inaccurate MDS Assessments for Cognition, Medication Use, and Skin Conditions
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for residents reviewed for skin conditions, cognition, medication use, and falls-related functional status. Resident C, who had cerebrovascular disease, had a quarterly MDS dated 3/4/26 that indicated cognitive impairment should have been assessed, but the assessment was not completed. During interview, the MDS Coordinator stated Resident C could have been assessed for cognitive impairment but was not because staff were not available to administer the test when it was due, and the Administrator stated corporate MDS staff completed assessments during the period when the facility did not have an in-house MDS Coordinator, while in-house nursing staff were responsible for the cognitive assessments. Resident 7’s quarterly MDS dated 2/11/26 coded the resident as cognitively intact and indicated no antianxiety medication use during the 7-day lookback period, even though the eMAR showed hydroxyzine 25 mg three times daily from 2/5/26 through 2/11/26 and the medication was ordered for anxiety. Resident 8’s significant change MDS indicated cognition should be assessed, but the cognition section was left unassessed. Resident 49’s admission MDS dated 3/19/26 coded the resident as cognitively intact, dependent on staff for toileting, bathing, and transfers, and having no skin conditions, despite a physician order for treatment of a right lateral shin wound that had started on 3/17/26; the MDS Coordinator stated the wound should have been coded on the assessment.
Improper Medication Storage and Labeling in Multiple Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 4 of 4 medication carts observed. During observation, surveyors found numerous loose pills in the Front Hall medication cart, including multiple white, brown, pink, blue, and oval tablets and capsules with various markings, all stored without proper identification. Similar loose pills were also observed in the Back Hall, Front East Hall, and Back East Hall medication carts, including tablets and capsules with markings such as L 16, 725, 913, 346, PRIMA 36, 564, PH 320, 111, EP127, PH 020, H39, and UL 125. Surveyors also found unlabeled bottles in the carts, including a bottle of fiber pills with a resident's name but no label, several supplements with another resident's name but no labels, and bottles of Baby Aspirin and Fiber with a resident's name but no label. During interview, an LPN stated there should be no loose pills in the carts and that she destroys pills in a drug buster solution. The DON stated the supplement bottles should have a label and a physician's order. The Administrator later provided the facility's Medication Storage policy, which stated that discontinued, outdated, defective, or deteriorated medications are destroyed.
Food Storage and Dish Machine Sanitization Deficiencies
Penalty
Summary
Food was not stored under sanitary conditions and the low-temperature chemical dishwasher sanitization log was left blank during the initial tour of the kitchen. The Dietary Manager stated that staff should be filling in the dishwasher log each time they tested the dishwasher for sanitization levels, and that the dishwasher was tested before each meal. The blank April 2026 log was hanging on the wall across from the dishwasher at the time of observation. In the walk-in dairy refrigerator, sliced cheese was open to air with no date and shredded cheese was open to air. In the walk-in vegetable refrigerator, a carton of coleslaw had a use-by date of 4/9/26. In the dry storage room, a bulk sugar container and a bulk oatmeal container were both open to air. The Administrator later provided policies stating that refrigerated foods must be labeled, dated, covered or kept in tight containers, bulk items must be stored in approved containers, expired items must be discarded, and dish machine sanitizer levels must be tested and logged before washing dishes from each meal.
Failure to Notify Provider of Significant Weight Gain
Penalty
Summary
The facility failed to notify the provider of a significant weight gain outside of ordered parameters for Resident 5. The resident had diagnoses including congestive heart failure and chronic kidney disease. The most current MDS, dated 3/10/26, indicated the resident’s memory was OK, he was independent in making decisions about his daily life, required supervision for transferring, and partial to moderate assistance for toileting. His weight was documented as 226 lbs with no weight loss. His care plan included interventions to monitor weights as ordered and to weigh as scheduled. Physician orders directed staff to fax weekly weights to Nursing Home Triage every Tuesday day shift related to congestive heart failure and to notify Nursing Home Triage if the resident gained three pounds in 24 hours or five pounds in one week. The eMAR showed weekly weights were not faxed on 1/13/26, 2/10/26, and 2/24/26. The weight summary showed the resident weighed 215.6 lbs on 2/24/26 and 224.9 lbs on 3/2/26, a gain of 9.3 lbs in one week. The clinical record lacked documentation that the provider was notified of the weight gain, and the DON confirmed that notification did not occur after the resident gained over five pounds in a week.
PRN Psychotropic Orders Lacked Required Stop Dates
Penalty
Summary
The facility failed to ensure that PRN anti-anxiety medications had a specific duration or stop date for three residents reviewed. Resident 4 had Alzheimer's disease and was dependent on staff for eating, bathing, toileting, and transfers; the physician order for lorazepam 0.5 mg every 30 minutes as needed for anxiety/restlessness, started 3/15/26, did not include a stop date. Resident 48 had heart failure, was on hospice services, and had severe cognitive impairment; the order for lorazepam 0.5 mg, give half a tablet every two hours as needed for anxiety/restlessness while receiving hospice services, dated 3/20/25, also lacked a stop date. In both residents' eMARs, the PRN lorazepam was not administered during the reviewed periods. Resident 7 had bipolar disorder and was cognitively intact; the order for hydroxyzine 10 mg every 12 hours as needed for itching, dated 12/4/25, did not include a stop date. The eMAR showed the resident received PRN hydroxyzine on multiple occasions between January and March 2026. During interview, the DON stated that if a resident was not receiving hospice services, medications should have a 14-day stop date, and if a resident was receiving hospice services, the order should specify the duration of hospice. The facility policy provided by the Administrator stated PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days unless the prescriber documents the rationale for extending the order and indicates a specific duration.
Late and Missing MDS Assessments
Penalty
Summary
The facility failed to ensure comprehensive MDS assessments were completed timely for two residents. One resident with diagnoses including cerebrovascular disease was discharged to the hospital and did not return to the facility, but a Discharge MDS Assessment was not completed. The resident’s most recent Quarterly MDS, dated 3/4/26, indicated the resident was not assessed for cognitive impairment and required substantial to maximal assistance for toileting. During interview, the MDS Coordinator stated the previous MDS Coordinator did not complete the resident’s Discharge MDS Assessment. For another resident with osteoarthritis, the admission MDS Assessment was completed late. The admission MDS, dated 3/19/26, indicated the resident was cognitively intact and dependent on staff for toileting, bathing, and transfers, but the assessment itself was not completed until 4/13/26. During interview, the MDS Coordinator acknowledged the admission MDS Assessment was completed late. The facility policy provided by the Administrator stated that accurate assessment requires qualified health professionals to correctly document the resident’s medical, functional, and psychosocial problems using the appropriate Resident Assessment Instrument.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed no less than once every 3 months for 1 of 1 residents reviewed for resident assessment. Resident 6 had diagnoses including disorder of the kidney and ureter and essential primary hypertension. On 4/6 at 11:26 A.M., the resident's clinical record was reviewed and the most recent Quarterly MDS assessment was found to be dated [DATE] but was not completed until 4/10/26. During an interview on 4/17/26 at 10:35 A.M., the Social Services Director stated care plan conferences needed to be done every 3 months. On 4/17/26 at 10:40 A.M., the Administrator provided the current Care Planning policy dated 2/2026, which stated the facility will discuss the care plan with the resident and/or representative at regularly scheduled care plan conferences, initially, at routine intervals, and after significant changes.
Failure to Implement Call Light Interventions and Develop Medication Care Plans
Penalty
Summary
The facility failed to implement care plan interventions for Resident 3 and Resident 2 related to call lights being within reach. Resident 3 was observed during multiple observations with the call light under the bed, on the floor under the foot of the bed, or hung over the foot of the bed while the resident was in bed or being transferred. Resident 3’s record showed diagnoses including dementia with behavioral disturbances, anxiety, and post traumatic stress disorder, and the most recent discharge MDS indicated the resident required partial assistance for toileting and was dependent on staff for transfers. The care plan identified the resident as at risk for falls and included interventions for the call system and bedside table to be in reach, but those interventions were not consistently in place during the observations. Resident 2 was also observed with the call light wrapped around the headboard post while the resident was in a wheelchair at the end of the bed. The record showed a diagnosis of dysphagia, and the annual MDS indicated the resident was moderately cognitively impaired and dependent on staff for eating, toileting, bathing, and transfers. The care plan identified the resident as at risk for falls and included the intervention that the call system and bedside table be in reach, but the observed condition did not match that intervention. In addition, Resident 38’s record showed current orders for sertraline, Klonopin, and clonazepam, and the MDS indicated use of antianxiety and antidepressant medications during the look-back period, but there were no current care plans for antianxiety and antidepressant drugs.
Failure to Obtain Ordered Daily Weights
Penalty
Summary
The facility failed to ensure that a resident with congestive heart failure and chronic kidney disease was monitored according to physician orders for daily early morning weights. The resident’s record showed that daily weights were ordered related to CHF, and care plans identified weight monitoring as an intervention for nutritional risk and fluid overload. Dietary notes documented edema, anticipated weight fluctuations due to CHF and diuretic therapy, pitting edema, significant weight gain and loss triggers, and repeated references that daily weights were ordered to monitor changes. Record review showed that a daily morning weight was not obtained on 18 listed days across December 2025 through April 2026. During interview, the DON stated the weights were either not done or the resident was marked asleep, and staff were expected to try again or pass it along to the next shift if the resident needed to be weighed and was asleep. The facility’s weight monitoring policy stated that weights should be recorded at the time obtained and that daily monitoring should occur if clinically indicated.
Pharmacist Recommendation Not Addressed for Anticoagulant Order
Penalty
Summary
The facility failed to ensure that pharmacist medication recommendations were reviewed and acted upon by the physician for 1 of 5 residents reviewed for unnecessary medications, Resident 8. Resident 8 was admitted with a diagnosis that included pulmonary embolism, and the most recent Significant Change MDS indicated the resident’s cognition was not assessed, the resident required partial assistance with toileting, substantial assistance with bathing, and received anticoagulant medication during the lookback period. Physician orders included Eliquis 2.5 mg by mouth in the morning related to pulmonary embolism, with a start date of 3/13/26. A pharmacy document titled New admission Review, dated 3/13/26, indicated the pharmacist recommended that Resident 8’s Eliquis be evaluated because it was outside the typical dose. The clinical record lacked approval or rationale for denying the pharmacist recommendation. During interview, the DON stated the physician reviewed the pharmacy recommendation on 4/16/26 and accepted it. The facility policy titled Medication Regimen Review stated the pharmacist shall communicate irregularities to the attending physician, DON, and/or staff, and that facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.
Infection Control and Enhanced Barrier Precautions Not Followed
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were implemented during care and transfer of a resident with an order for Enhanced Barrier Precaution due to wounds. During an observation, a CNA and QMA entered the resident’s bathroom, cleaned the resident after toileting, assisted the resident off the toilet and onto a sit-to-stand lift, and moved the resident from the bathroom to a wheelchair in the bedroom. The resident was not offered hand hygiene, and the CNA and QMA wore gloves but did not wear gowns during the care and transfer. The resident’s clinical record showed diagnoses including dementia with behavioral disturbances, anxiety, and post traumatic stress disorder, and the most recent discharge MDS indicated the resident required partial assistance for toileting and was dependent on staff for transfers. The facility also failed to follow infection control practices during insulin administration. During a medication pass, an LPN administered Lantus and lispro insulin to a resident without using an alcohol swab to prepare the rubber injectable port of the insulin pen before inserting the needle. The LPN stated she should have prepped the pen stopper with alcohol before placing the needle, and the DON stated the nurse should have cleaned the rubber injectable port before administration. The lispro Kwik Pen insert reviewed by surveyors indicated the rubber seal should be wiped with an alcohol swab.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident dependent on staff for ADLs was showered as scheduled. Resident C, who had diagnoses including cerebrovascular disease, was assessed on the most recent Quarterly MDS as requiring partial to moderate assistance with bathing, and the care plan indicated substantial to maximal assistance for bathing. An anonymous interview stated that Resident C was transported to the hospital from the facility and appeared generally unkempt upon arrival in the emergency room. Review of March 2026 shower documentation showed that Resident C did not receive and did not refuse a shower or complete bed bath on multiple scheduled days, including 3/10/26, 3/14/26, 3/17/26, and 3/24/26. The DON stated that residents received showers at least twice weekly and identified Resident C's assigned shower days as Tuesdays and Saturdays, while the facility policy stated residents would be provided showers according to request or facility schedule protocols and based on resident safety.
Late Medication Administration and Incomplete EMAR Documentation
Penalty
Summary
The facility failed to ensure medications were administered at the ordered times and properly documented on the Electronic Medication Administration Record (EMAR) for multiple residents during the morning medication pass. On 2/9/26 at 10:58 a.m., a Qualified Medication Aide (QMA 2) was observed preparing aspirin 81 mg and ferrous sulfate 325 mg for Resident D and searching for Lasix 40 mg in the medication cart. A Licensed Practical Nurse (LPN 3) then reported she had already given Resident D her morning medications but had not yet signed them off on the EMAR, which still showed the medications in red as not given. LPN 3 indicated she had been passing morning medications and had been called away to do other tasks, after which QMA 2 took over the medication pass. Later that same morning, QMA 2 was observed preparing multiple medications for Resident B, including clonazepam 0.5 mg, escitalopram oxalate 10 mg and 20 mg, glimepiride 1 mg, tamsulosin 0.4 mg, metformin 500 mg, and meclizine 25 mg, and then preparing medications for Resident C, including aspirin 81 mg, Tylenol 325 mg (two tablets), atenolol 25 mg, citalopram 10 mg, celecoxib 100 mg, docusate sodium 100 mg, Refresh Tears ophthalmic solution (one drop in both eyes), and a cranberry capsule 500 mg. These medications for Residents B and C were scheduled on the EMAR for 8:00 a.m., but were being prepared and administered significantly later than the facility’s policy requirement of within one hour before or after the prescribed time. The facility’s medication administration policy also required the individual administering medications to initial the MAR after giving each medication and before administering the next ones, which did not occur for Resident D’s morning medications.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the required qualifications. During an interview, the Dietary Manager admitted to not having a dietary manager certification and not being enrolled in a certification program. A review of the Dietary Manager's employee file revealed that he began employment as a dietary cook and later signed a job description for the role of Dietary Manager. The facility's policy indicated that completion of an approved dietary manager training course is preferred, and employees are required to enroll and complete the course if not certified at the time of hire. Additionally, the facility's dietician worked through a contract and was only present in the facility approximately once a week.
Failure to Update Facility Assessment
Penalty
Summary
The facility failed to comprehensively complete and implement a facility-wide assessment to determine the necessary care and resources for resident care. During an entrance conference, the Administrator was unable to provide a current facility assessment, revealing that the last assessment was completed in 2022. The Administrator and Director of Nursing only completed the assessment on the day it was requested, indicating a lack of regular updates. The facility's policy, dated 8/18/17, requires annual updates or updates whenever changes occur that would necessitate modifications to the assessment. The policy also specifies that the assessment should involve various staff members, including the administrator, a representative of the governing body, the medical director, and the director of nursing, among others. However, this comprehensive approach was not followed, potentially affecting the care of 59 residents in the facility.
Inconsistent QAPI Meetings and Missing Medical Director
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings were held quarterly with the required staff present. During an interview, the Administrator confirmed that the facility had 59 residents and acknowledged that the QAPI meeting on January 15, 2025, was the first since her employment began on April 17, 2024. The sign-in sheet for this meeting lacked documentation of the Medical Director or a designee's presence. The Director of Nursing also indicated that the QAPI committee had not been meeting consistently. The facility's policy requires the QAPI committee to include the Director of Nursing, the Administrator, at least two other staff members, and a designated physician, and to meet monthly to review monitoring activities and action plans.
Inadequate Infection Control and Waterborne Pathogen Testing
Penalty
Summary
The facility failed to implement proper hand hygiene and Enhanced Barrier Precautions (EBP) for two residents during care. In one instance, a Qualified Medication Aide (QMA) and two nurses did not perform hand hygiene or wear gowns while administering medications through a percutaneous endoscopic gastrostomy (PEG) tube for a resident with cerebral palsy who was dependent on staff for mobility and had an enteral feeding tube. Despite the presence of an EBP sign on the resident's door and physician orders for EBP due to the feeding tube, these precautions were not followed. Additionally, a Licensed Practical Nurse (LPN) was observed administering tube feeding to the same resident without wearing a gown. In another instance, a Certified Nurse Aide (CNA) did not wash her hands before donning gloves while performing a shower for a resident. The CNA removed a used brief, changed gloves without washing hands, and continued with the resident's care, including cleaning the perineal area and dressing the resident, without removing gloves. Furthermore, the facility did not conduct testing for legionella or other waterborne pathogens, despite having a policy for Legionella Surveillance and Detection. The Assistant Director of Nursing was unaware of any testing being performed, and the Maintenance Director confirmed the absence of mapping or testing for legionella. Six residents had been diagnosed with pneumonia in the past year, but none were tested for legionellosis.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The Assistant Director of Nursing (ADON) was identified as responsible for the program but lacked a current Infection Preventionist certification and was only able to dedicate approximately 12 hours per week to the role. The ADON's employee file did not contain any job description or roles related to infection preventionist duties. Additionally, the facility's policy, revised in October 2018, required the infection prevention and control program to be coordinated by an infection preventionist specialist. The job description provided by the Administrator indicated that the IP should have primary professional training in nursing and be qualified by education, training, experience, or certification in infection control.
Failure to Update Care Plans and Prevent Falls
Penalty
Summary
The facility failed to ensure that residents had appropriate interventions in place to prevent accidents, specifically falls, for four residents reviewed. The care plans for these residents were not updated with new interventions following falls, and fall reviews were not consistently completed. For instance, Resident 6, who had a history of Alzheimer's Disease and a type 4 fracture of the sacrum, experienced seven falls over several months. Despite these incidents, the care plan was not updated with new interventions after each fall, and there was a lack of documentation indicating that the Interdisciplinary Team (IDT) reviewed the falls. Similarly, Resident 34, diagnosed with Alzheimer's Disease and general weakness, experienced eleven falls over a year. The care plan was not updated with new interventions after most of these falls, and there was a lack of documentation indicating that the IDT reviewed the falls. In some cases, the clinical record lacked documentation of post-fall assessments, and there was no evidence that the physician and family were notified of the falls. Resident 36, with dementia and major depression, had seven falls, and the care plan was not updated with new interventions after these incidents. The IDT notes indicated new interventions, but these were not added to the care plan. Resident 27, who had dementia, experienced multiple falls, and the care plan was not updated after each fall. Additionally, observations revealed that the resident's bed was not in the lowest position, contrary to the care plan's interventions. The facility's failure to update care plans and conduct thorough fall reviews contributed to the deficiency in preventing accidents.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to conduct quarterly care plan conferences for two residents, leading to a deficiency in ensuring resident participation in their person-centered care plans. Resident 6, diagnosed with Alzheimer's Disease and a type 4 sacrum fracture, had a significant change in their Minimum Data Set (MDS) assessment indicating mild cognitive impairment and required substantial to maximal assistance for daily activities. Despite a letter being sent to invite the resident's family to a care plan conference, there was no documentation of a conference being held since July 2024. Similarly, Resident 13, who is cognitively intact but dependent on staff for toileting and bathing, had their last care plan conference in October 2024. The Social Services Director acknowledged that care plan conferences were not scheduled for these residents in the last three months, contrary to the facility's policy requiring quarterly meetings. The lack of timely care plan conferences for these residents was identified as a deficiency during the survey.
Failure to Update Care Plans for New Diagnoses and Treatments
Penalty
Summary
The facility failed to develop and implement care plans for two residents following new diagnoses and physician orders. Resident 43, who had diagnoses including pneumonia and congestive heart failure, was noted to have significant cognitive impairment and required assistance with daily activities. Despite a recommendation from the Registered Dietician on 1/16/25 to trial an appetite stimulant due to inadequate meal intake and weight loss, the stimulant was not ordered until 1/27/25. Additionally, there were missing weight records on specific dates, and the care plan did not reflect the new physician orders for weight monitoring. Resident 46, diagnosed with Alzheimer Disease, was prescribed an antibiotic for a urinary tract infection on 2/3/25. However, the care plan was not updated to include this new diagnosis and treatment between 2/3/25 and 2/8/25. The MDS Coordinator confirmed that a new care plan should have been created with each new infection and antibiotic order. The facility's policy required care plans to be revised as changes in the resident's condition dictated, but this was not adhered to in these cases.
Failure to Revise Care Plan for Gastrostomy Device
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident 41, to reflect changes in the resident's gastrostomy device. The resident, who has cerebral palsy and is not cognitively intact, relies on staff for all bed mobility and has an enteral feeding tube. A Quarterly Minimum Data Set (MDS) Assessment indicated the resident's dependency and the presence of an enteral feeding tube. However, the clinical record did not include an order for a Mic-Key gastro tube button, which was supposed to be part of the resident's care plan. During an observation, it was noted that Resident 41 had an intact PEG tube, but a Mic-Key gastro tube button was not observed. The MDS Coordinator confirmed that the care plan should have listed the appropriate tube feeding device. The facility's policy requires care plans to be revised as needed when there are changes in the resident's condition, including changes in physician orders. Despite this policy, the care plan was not updated to reflect the correct gastrostomy device, leading to the deficiency.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper labeling and management of oxygen equipment for three residents, leading to deficiencies in respiratory care. Resident 25 was observed multiple times with oxygen tubing that was not dated, despite having a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and physician orders to change the tubing weekly. The resident's care plan included interventions to change the oxygen tubing per facility protocol, but this was not adhered to, as evidenced by the undated tubing observed over several days. Resident 16, diagnosed with congestive heart failure, was observed using oxygen via nasal cannula without the tubing being labeled with a date. The resident's clinical record lacked a current care plan for oxygen use, and the oxygen concentrator was set to an incorrect flow rate of 3.5 liters per minute, contrary to the physician's order of four liters per minute. The LPN responsible was unsure of the correct setting, indicating a lack of adherence to professional standards and facility protocols. Resident 13, who also had COPD, was observed receiving oxygen via face mask with undated tubing and a humidification bottle that was not changed as per the facility's protocol. The resident's care plan included instructions to change the oxygen mask and tubing weekly, but these were not followed. Interviews revealed that aides were improperly adjusting the oxygen flow, which was against the facility's policy. The DON confirmed that aides should not be handling oxygen adjustments, highlighting a failure in staff training and protocol adherence.
Medication Error Rate Exceeds 5% Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in an observed error rate of 8 percent during a medication pass for two residents. The first incident involved a Registered Nurse (RN) who prepared an insulin injection for a resident but attempted to prime the insulin pen without the needle attached. Despite this error, the RN administered 14 units of insulin lispro into the resident's upper right arm. The resident's physician orders required the administration of 14 units of Admelog (insulin lispro) subcutaneously in the afternoon. The second incident involved a Licensed Practical Nurse (LPN) who prepared an insulin injection for another resident but failed to prime the insulin pen needle before administration. The LPN administered 18 units of insulin lispro into the resident's lower left quadrant of the stomach. The physician orders for this resident specified the administration of 18 units of Admelog subcutaneously with meals, with specific instructions to administer after eating if the blood glucose level was below 100. The facility's policy on insulin administration, as well as the manufacturer's instructions, emphasized the importance of priming the insulin pen needle to ensure proper dosage and functionality.
Failure to Maintain Safe and Sanitary Hallway Floors
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of sticky and soiled hallway floors. During an initial walkthrough, a large red sticky substance with smaller drip marks was noted outside a specific room, and a large black substance was observed between other rooms. These conditions persisted during a reinspection later the same day. The following day, the same red sticky substance and black substance were observed in the same locations, along with muddy footprints outside the main dining area. Interviews revealed that the facility did not mop the hallways daily, as indicated by an anonymous source. Housekeeper 5 confirmed that only one person was responsible for floor care, which was scheduled from Monday to Friday. The facility's Floor Care Procedures policy, dated March 10, 2021, stated that floors should be maintained to ensure resident safety, with spills cleaned promptly and hallways dust mopped and mopped regularly. This deficiency was related to a specific complaint, IN00449014.
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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