Oak Grove Christian Retirement Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Demotte, Indiana.
- Location
- 221 W Division St, Demotte, Indiana 46310
- CMS Provider Number
- 155667
- Inspections on file
- 32
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Oak Grove Christian Retirement Village during CMS and state inspections, most recent first.
A resident with dementia, osteoporosis, impaired lower extremity function, and dependence for bed mobility was care planned and documented on the Kardex as requiring two-person assistance for bed mobility. An agency CNA, unaware of this requirement, performed incontinence care and rolled the resident in bed alone, during which the resident’s arm extended to the opposite side and the resident began sliding off the bed, resulting in a fall to the floor that the CNA partially controlled.
The facility failed to provide required medically-related social services follow-up after an abuse allegation by a resident with dementia, Alzheimer's disease, and anxiety. The resident reported that a CNA shoved her into a chair and threw her walker, and although no injuries were observed, a subsequent care plan documented a history of false allegations and called for Social Service involvement. However, there was no Social Service follow-up to monitor the resident’s psychosocial status, despite an abuse policy requiring increased monitoring and support after an allegation and the absence of a clear post–abuse allegation procedure while a staff member was filling in for the Social Service Director.
A resident with a history of stroke and vascular dementia had a UA obtained and sent to the lab without a Physician/NP order. An RN documented collecting the urine specimen and notifying the lab, and later stated that the DON had requested the UA and that the NP was notified. The resident was catheterized to obtain the urine sample. The DON reported she had only suggested they might want a UA and assumed the RN would obtain an NP order, but no such order was present in the record, resulting in lab services being performed without proper authorization.
A resident with dementia and Alzheimer’s disease reported that a CNA shoved her into a chair and threw her walker, with no injuries observed. Although this allegation was reported to the state health department, there was no documentation of the abuse allegation in the resident’s medical record, despite facility policy requiring that actions taken be documented. At the time of the allegation, a staff member was filling in for the Social Service Director.
A resident with COPD, heart failure, dementia, and other conditions, who was on oxygen therapy, developed a cough and later received a new order for albuterol nebulizer treatments twice daily for the cough. The medical record lacked documentation that the resident’s representative was informed of this change in condition and new medication order. In interview, an LPN confirmed she did not document any communication with the representative, and the DON stated that such communication and documentation should have occurred.
A resident with COPD and other comorbidities, who was on oxygen and cognitively impaired, developed a cough that led an LPN to contact a physician and obtain an order for albuterol nebulizer treatments twice daily. Although the treatments were administered as scheduled, the record contained no documentation of the respiratory assessment that prompted the new order and no pre- and post-treatment respiratory assessments, despite facility policy requiring baseline vital signs and respiratory assessments for nebulizer use. The LPN acknowledged not documenting her assessment, and the DON confirmed that required pre- and post-assessments were not found in the record.
A resident with Alzheimer's disease, heart failure, and hypertensive chronic kidney disease did not receive prescribed metoprolol as ordered. The medication was held on several occasions when blood pressure and heart rate were within the parameters for administration, or when no vital signs were recorded to justify withholding the dose. The DON could not provide further information regarding these decisions.
Two residents with cardiac and respiratory conditions did not receive necessary care and treatment related to oxygen therapy, including failures to monitor oxygen saturation, ensure oxygen tanks were filled, and document respiratory assessments as required by physician orders and facility policy.
The facility did not maintain complete and accurate clinical records for two residents, resulting in missing documentation for the administration of prescribed medications, oxygen therapy, and respiratory treatments. The MARs lacked entries for several scheduled doses and interventions, and the DON was unable to provide additional documentation to account for these omissions.
Two residents suffered serious injuries after staff failed to follow established care plans and safety protocols. One resident, dependent for transfers, was manually lifted by a CNA without using the required mechanical lift, resulting in leg and rib fractures. Another high fall-risk resident was left unattended in the bathroom and fell, sustaining a head laceration requiring staples.
A resident who returned from the ER with a fractured tibia and multiple rib fractures did not receive thorough or frequent nursing assessments as required. Documentation lacked detailed evaluation of the injuries, and follow-up assessments were not completed, despite ongoing pain and changes in condition. The DON confirmed that expected monitoring and documentation were missing.
The facility failed to ensure a sanitary kitchen environment due to inadequate dishwasher temperature monitoring. Observations revealed that the dishwasher's wash cycle temperature was below the required 180 degrees Fahrenheit, and the temperature logs showed frequent non-compliance with the required standards. The facility's policy on recording water temperatures before each meal was not consistently followed, potentially affecting all 52 residents receiving meals from the Main Kitchen.
A facility failed to maintain accurate documentation and accountability for narcotic medications, affecting a resident on a routine pain regimen. Discrepancies were found in the narcotic sign-out sheet, with missing doses and altered entries. An LPN reported the irregularities, leading to an investigation that revealed further documentation issues by a nurse who did not record administered medications in the MAR. The facility could not determine who was responsible for the missing medications.
A facility failed to notify a resident's Responsible Party in writing about a hospital transfer. The resident, with conditions like heart failure and diabetes, was significantly impaired in decision-making. Despite standard procedures, the State-approved transfer form was not completed, and the Responsible Party was not informed. Interviews confirmed the oversight.
A facility failed to provide a resident and their Responsible Party with the bed hold policy before and upon hospital transfer. The resident, with conditions including heart failure and diabetes, was significantly impaired in decision-making. Despite procedures to send the policy with the resident, documentation was missing, and the DON could not locate it.
A facility failed to update a resident's care plan to reflect the discontinuation of IV fluids. The resident, with a history of serious medical conditions, was observed without IV supplies and confirmed not receiving IV fluids since returning from the hospital. Despite this, the care plan still indicated a need for IV fluids, and there were no physician's orders for such treatment. The DON acknowledged the need for care plan modification.
A facility failed to establish parameters for physician notification regarding weight changes for a resident with CHF, diabetes, and fluid overload. The resident was weighed thrice weekly, but the physician's order lacked specific guidelines for notifying weight changes. The DON later received orders to notify the nurse practitioner if there was a five-pound increase in a week.
A facility failed to provide proper wound care for a resident with pressure ulcers, as the Wound Care Nurse did not follow hand hygiene protocols and was unaware of the daily treatment changes required by the physician's orders. The resident, who had multiple health issues and required assistance for mobility, did not receive the necessary treatment to promote healing, as the nurse did not adhere to the specified wound care regimen.
A resident with a history of infection had their urinary catheter bag improperly placed, uncovered, and hanging off a garbage can, contrary to care plan instructions. The resident, who was moderately cognitively impaired and required significant assistance, had a care plan that included specific catheter care instructions. Despite this, the catheter bag was not maintained properly, as observed by staff.
The facility failed to implement non-pharmacological interventions before administering anti-anxiety medication to a resident with Alzheimer's and depression, as documented in their medication administration record. Additionally, another resident with dementia and depression was not monitored for side effects of prescribed antidepressants, despite the care plan indicating a risk for adverse effects. The Director of Nursing confirmed the lack of documentation and monitoring, which is inconsistent with the facility's policy.
A facility failed to ensure complete and accurate clinical records for a resident's self-medication assessment. The resident, with moderate cognitive impairment and multiple medical conditions, was permitted to self-administer medication. However, the evaluation form lacked the resident's name, as the ADON mistakenly wrote her own name instead.
A Wound Care Nurse failed to follow infection control guidelines during a wound treatment for a resident, neglecting to perform hand hygiene and change gloves between tasks. The nurse also did not sanitize hands after reaching into her pocket during the procedure. The nurse later acknowledged the lapse in protocol, and the facility administrator could not provide further information or a policy.
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in oxygen equipment maintenance and administration. A resident with COPD had outdated respiratory equipment, while another resident's oxygen concentrator was set at an incorrect flow rate. A third resident also had outdated equipment, contrary to facility policy requiring weekly changes.
The facility failed to document oxygen administration and saturation levels for two residents with COPD and cognitive impairments. Resident B's records lacked documentation for specific shifts in July, despite a care plan requiring saturation checks every shift. Similarly, Resident C's records were incomplete for a specific shift. The DON confirmed the missing documentation, which violated the facility's policy on oxygen administration.
The facility failed to report an allegation of abuse/neglect to the Administrator and IDOH for a resident with reddened skin after spilling hot coffee. Despite the Responsible Party's accusation of neglect, the DON did not conduct an investigation or report the incident, violating the facility's abuse policy.
The facility failed to provide adequate supervision and follow care plan interventions, resulting in a fall for one resident and a hot coffee spill for another. Resident D, with dementia, was left alone in her room and fell, hitting her head. Resident C, with Alzheimer's, was served hot coffee in her room, leading to a spill and skin redness. Staff interviews confirmed that care plan interventions were not followed.
The facility failed to ensure a resident received necessary treatment and services after a fall. The resident, with Alzheimer's and fractures, was lowered to the floor during a transfer. Initial assessments were incomplete, and no further assessments were done until the next morning, revealing significant injuries. The DON confirmed that post-fall assessments should have been conducted for 72 hours, but this was not done.
Failure to Follow Two-Person Bed Mobility Care Plan Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a care-planned intervention requiring two staff members for bed mobility assistance, which resulted in a resident falling from the bed. The resident had diagnoses including dementia and osteoporosis, a moderately impaired cognitive status, impairment to one side of the lower extremities, and was documented as dependent for bed mobility with use of a pressure-reducing device. The resident’s Kardexes dated 7/7/25 and 3/22/26, as well as a care plan revised on 1/28/26, all indicated that two staff members were required for bed mobility. On the date of the incident, a post-fall evaluation and fall investigation documented that an agency CNA performed incontinence care and bed mobility alone, without a second staff member, contrary to the resident’s care plan and Kardex. The CNA rolled the resident toward herself while standing on one side of the bed; during this maneuver, the resident’s arm extended to the opposite side and the resident began sliding off the bed. The CNA then moved around the bed and was able to lower the resident to the floor. The CNA later reported being unaware that the resident required two-person assistance for bed mobility, despite this requirement being documented on the Kardex.
Failure to Provide Social Services Follow-Up After Abuse Allegation
Penalty
Summary
The facility failed to provide medically-related social services following an allegation of abuse for one resident. Resident D, who had dementia, Alzheimer's disease, moderately impaired cognition, and documented anxiety with fixation on staff, reported that a CNA had shoved her into a chair and thrown her walker; no injuries were observed. A care plan dated 8/29/25 identified anxiety and fixation on staff, with interventions for staff to assist the resident in developing more appropriate coping and interaction methods. After the abuse allegation was reported to the Indiana Department of Health on 2/3/26, a new care plan dated 2/4/26 documented that the resident had a history of making false allegations and exaggerations of the truth and specified that Social Service would be involved with the resident. Despite this care plan intervention, there was no documented Social Service follow-up after the allegation to monitor the resident’s psychosocial status. During interview, the Executive Director stated that at the time of the allegation a staff member was filling in for the Social Service Director and acknowledged there was no policy outlining procedures for post–abuse allegation care. The facility’s abuse policy indicated that after an allegation was voiced, the resident would receive increased monitoring and support, but this was not carried out through Social Service follow-up for Resident D.
Unauthorized Urinalysis Performed Without Practitioner Order
Penalty
Summary
The facility failed to ensure laboratory services were only completed when ordered by a Physician or NP, as evidenced by a urinalysis (UA) obtained for Resident B without a corresponding practitioner order. Resident B, who had diagnoses including stroke and vascular dementia, had a urine specimen collected and the lab company notified, as documented in a progress note dated 3/23/26 at 11:35 a.m. by RN 1. Record review showed there was no Physician/NP order for this urine specimen. In interview, RN 1 stated that the DON had requested the UA and that she notified the NP, and that the resident was catheterized to obtain the urine sample. In a separate interview, the DON reported she had only verbalized that they “may want to get a UA,” had not directly instructed RN 1 to obtain one, and had assumed RN 1 would notify the NP to obtain an order, resulting in the UA being performed without a valid practitioner order. This deficiency was cited under 410 IAC 16.2-3.1-49(f)(1).
Failure to Document Resident Abuse Allegation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident related to an allegation of abuse. Record review on 4/14/26 showed that Resident D, who had diagnoses including dementia and Alzheimer’s disease, had made a reported allegation on 2/3/26 that a CNA shoved her into a chair and threw her walker; no injuries were observed. This allegation was documented in an Indiana Department of Health reported incident form, but there was no corresponding documentation of the abuse allegation in the resident’s medical record. During interview, the Executive Director indicated that at the time of the allegation a staff member was filling in for the Social Service Director. The facility’s abuse policy dated 7/15/25 stated that actions taken would be documented, but this documentation was absent from the resident’s record.
Failure to Notify Resident Representative of Change in Condition and New Breathing Treatment
Penalty
Summary
The facility failed to ensure a resident’s representative was informed of a change in condition and new treatment order. A cognitively impaired resident with diagnoses including COPD, heart failure, hypertension, dementia, atrial fibrillation, and depression, and who was receiving oxygen therapy, was noted in a progress note on 12/21/25 at 6:22 a.m. to have slept well overnight, with staff noticing a cough and clear lung sounds. Later that day at 10:07 p.m., a progress note documented a physician’s order for albuterol sulfate nebulization twice daily for cough until 12/27/25, indicating a change in the resident’s condition and treatment. Record review showed no documentation that the resident’s representative was informed of this change in condition or the new breathing medication order. During interview, the LPN acknowledged she did not document that she spoke with the resident’s representative about the change in condition and new medication, and the DON stated the nurse should have documented that she spoke with the family regarding the change in condition and medication change.
Failure to Document Respiratory Assessments for Nebulizer Treatments
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not documenting a respiratory assessment when a resident experienced a change in condition and by not completing required pre- and post-nebulizer assessments. The resident had multiple diagnoses including COPD, heart failure, hypertension, dementia, atrial fibrillation, and depression, and was receiving oxygen therapy. A quarterly MDS indicated the resident was cognitively impaired. On one date, a progress note documented that the resident appeared to sleep well but staff noticed a cough, with lungs described as clear. Later that same day, a physician’s order was obtained to start albuterol sulfate nebulizer treatments twice daily for cough for a specified period, and the MAR showed the medication was administered as ordered. Despite the initiation and ongoing administration of nebulizer treatments, the clinical record lacked documentation of the respiratory assessment that led to the new breathing treatment order, as well as any pre- and post-respiratory assessments for each nebulizer treatment. In an interview, an LPN stated that a CNA had reported the resident’s cough, that she performed a respiratory assessment, and then contacted the physician who ordered the nebulizer, but she acknowledged she did not document her assessment and that pre- and post-assessments should have been completed. The DON confirmed that the nurse should have documented the respiratory assessment supporting the start of nebulizer therapy and that staff should have completed and documented pre- and post-assessments with each treatment, but she was unable to find any such documentation. The facility’s nebulizer policy required obtaining vital signs and performing respiratory assessments to establish a baseline.
Failure to Administer Medication as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Alzheimer's disease, heart failure, and hypertensive chronic kidney disease did not receive medication as ordered. The resident's care plan required administration of metoprolol tartrate 25 mg twice daily, with instructions to check blood pressure (BP) before administration and to hold the medication if BP was less than 100/50 or heart rate was less than 60. Review of the Medication Administration Records (MAR) for June, July, and August showed that the medication was held on several occasions when the resident's BP and heart rate were within the parameters to administer, or when no vital signs were recorded to justify holding the dose. Specifically, the medication was withheld on multiple dates despite recorded BP and heart rate readings that did not meet the criteria for holding the medication, and in some instances, there was no documentation of vital signs to support the decision to withhold. During an interview, the Director of Nursing was unable to provide further information regarding the rationale for holding the medication when the parameters were not met. This failure to administer medication as ordered constituted a deficiency in following physician orders and the resident's care plan.
Failure to Ensure Safe and Appropriate Respiratory Care and Oxygen Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with diagnoses including heart failure and chronic pulmonary edema, there were multiple incidents where the resident's portable oxygen tank was found empty, both in the morning and at dinner time, resulting in low oxygen saturation levels. Documentation did not show that a respiratory assessment was completed after the resident was found without oxygen, and there was a lack of consistent monitoring and documentation of oxygen saturation. The resident experienced episodes of respiratory distress and was ultimately sent to the hospital after her oxygen saturation dropped significantly despite interventions. Another resident with heart failure and atrial fibrillation was observed receiving continuous oxygen therapy via nasal cannula, although the physician's order specified oxygen as needed for shortness of breath to maintain saturation above 90%. The medication administration record did not indicate that oxygen had been administered as needed, and the last documented oxygen saturation was several days prior, showing the resident was on room air. There was no ongoing documentation of oxygen saturation monitoring as required by the physician's order and facility policy. Facility policy required that oxygen be administered per physician order, with initial and ongoing assessment and documentation of the resident's condition and response to therapy. The policy also required staff to check portable oxygen tanks for sufficient supply and to regularly monitor tanks while in use. These requirements were not consistently met, as evidenced by the lack of respiratory assessments, insufficient monitoring of oxygen saturation, and failure to ensure oxygen tanks were adequately filled for residents requiring oxygen therapy.
Incomplete Documentation of Medication and Oxygen Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents regarding the documentation of medications and oxygen administration. For one resident with diagnoses including heart failure, chronic pulmonary edema, and hypertension, the medical record review revealed missing documentation for the administration of BiPAP, oxygen therapy, and several prescribed medications on specific dates and times. The resident's care plan required continuous oxygen and BiPAP use at bedtime and during naps, with instructions to chart refusals, but the Medication Administration Records (MARs) lacked entries for these interventions. The Director of Nursing was unable to provide any additional documentation to account for the missing records. Another resident, diagnosed with Alzheimer's disease, COPD, and chronic respiratory failure with hypoxia, also had incomplete MARs. The records showed that prescribed inhalers and nebulizer treatments were not documented as administered on several occasions. The care plan required administration of aerosol or bronchodilators as ordered, but the MARs for June and July were missing entries for specific medications at scheduled times. The Director of Nursing confirmed that no further information was available to explain the missing documentation.
Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure that residents were protected from accident hazards and received adequate supervision to prevent accidents. In one incident, a CNA transferred a dependent resident with a history of traumatic brain injury, cognitive deficit, and peripheral vascular disease from bed to a chair without using the required mechanical lift and without the assistance of a second staff member, as specified in the resident's care plan. The CNA manually lifted the resident, resulting in the resident sustaining a nondisplaced spiral fracture of the right tibia and multiple left lower rib fractures. Documentation and staff statements confirmed that the mechanical lift was not used, and the transfer was not performed according to the resident's plan of care. Another incident involved a resident with a history of stroke, osteoporosis, severe cognitive impairment, and a high risk for falls. The resident required moderate to maximum assistance for transfers and was identified as a fall risk. While being assisted in the bathroom, the CNA left the resident unattended to retrieve socks, during which time the resident attempted to self-toilet and fell, resulting in a head laceration that required staples. The care plan and CNA care card indicated that the resident should not be left alone due to the high risk of falls, but this protocol was not followed at the time of the incident. Both incidents demonstrate a failure to follow established care plans and safety protocols for residents with significant physical and cognitive impairments. The lack of adherence to transfer and supervision requirements directly led to serious injuries, including fractures and a head laceration, for two residents who were dependent on staff for safe mobility and toileting.
Failure to Assess and Monitor Resident After Return with Fractures
Penalty
Summary
A resident with a history of peripheral vascular disease, traumatic brain injury, and cognitive deficit sustained a spiral fracture of the right tibia and multiple fractured ribs following a facility incident. Upon returning from the emergency room, the resident was assisted to bed with an immobilizer on the right lower leg and complained of pain. Documentation shows that while the immobilizer was noted to be in place, there was no thorough assessment of the right leg or the resident's overall status at that time. No nursing assessments were completed the following day, and subsequent notes focused on pain management without detailed evaluation of the injuries. Further documentation revealed that the resident experienced pain and distress, with pain medication being adjusted accordingly. Edema of the lower extremities was later observed, but again, no comprehensive assessment of the fractured leg or ribs was documented. The Director of Nursing confirmed that follow-up assessments were expected but not found in the records. The facility's acute condition change policy required monitoring and documentation of the resident's progress and response to treatment, which was not consistently followed in this case.
Dishwasher Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment due to issues with the dishwasher temperatures not reaching the required levels and a lack of consistent temperature monitoring for a high-temperature dish machine. During an initial kitchen tour, it was observed that the dishwasher's wash cycle temperature was only 105 degrees Fahrenheit, whereas it should have been 180 degrees. The rinse cycle was recorded at 191 degrees, but the Dietary Manager was unsure of the correct temperature for this cycle. A review of the Dish Machine Temperature Log for October 2024 revealed several instances where the recorded temperatures did not meet the required standards, with wash temperatures frequently falling below the necessary 160 degrees. Additionally, there were gaps in the temperature recordings for breakfast, lunch, and dinner throughout the month. The facility's policy on dishwasher temperatures mandates that water temperatures be measured and recorded before each meal or after the dishwasher is emptied or refilled for cleaning. However, this policy was not consistently followed, as evidenced by the incomplete temperature logs and the failure to maintain the required wash temperatures. This deficiency had the potential to affect all 52 residents who received meals from the Main Kitchen.
Deficiency in Narcotic Medication Documentation and Accountability
Penalty
Summary
The facility failed to maintain an accurate system for accounting, reconciling, and ensuring the disposition of controlled drugs, specifically narcotic medications, for one of the residents reviewed. This deficiency was identified during a review of Resident 211's records, who was cognitively intact and on a routine pain medication regimen that included opioids. The issue arose when discrepancies were found in the documentation of narcotic medications, with missing doses and altered narcotic count sheets. The investigation revealed that the narcotic sign-out sheet had been tampered with, using whiteout to conceal previous entries, and new documentation was written over it. The irregularities were first noticed by an LPN who reported them to the Director of Nursing (DON). Further investigation by the facility's administrator uncovered discrepancies in the Medication Administration Records (MAR) and narcotic count sheets, particularly involving a nurse who failed to document administered medications in the MAR. This nurse was also frequently responsible for administering as-needed narcotics. Despite the audits and investigation, the facility could not conclusively determine who was responsible for the missing medications or the alterations on the narcotic count sheet. The Director of Nursing admitted to not conducting any audits on narcotic medications prior to the incident.
Failure to Notify Resident's Responsible Party of Hospital Transfer
Penalty
Summary
The facility failed to ensure proper notification procedures were followed for a resident's transfer to the hospital. Resident 15, who had diagnoses including heart failure, diabetes mellitus, and fluid overload, was significantly impaired in daily decision-making. The resident was sent to the hospital and returned to the facility, but there was no documentation indicating that the State-approved transfer form was completed or that the resident's Responsible Party received written notification of the transfer. Interviews with RN 4 and the Director of Nursing revealed that while certain documents were typically sent with residents, the required State-approved transfer form could not be located.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that a resident and their Responsible Party were provided with the facility's bed hold and reserve bed payment policy before and upon transfer to the hospital. This deficiency was identified for one of the two residents reviewed for hospitalization. The resident in question had diagnoses including heart failure, diabetes mellitus, and fluid overload, and was significantly impaired in daily decision-making. The resident was transferred to the hospital and later returned to the facility, but there was no documentation indicating that the bed hold policy was completed and sent with the resident or that the Responsible Party received written notification of the policy. Interviews with facility staff revealed that while the procedure was to send the bed hold policy with the resident, the Director of Nursing was unable to locate the policy documentation.
Failure to Update Care Plan for IV Fluids
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect changes in the treatment of a resident, specifically regarding the administration of IV fluids. Resident D, who has a medical history including malignant neoplasm of the kidney, urinary tract infection, pathological fracture, bone cancer, paraplegia, and neuromuscular dysfunction of the bladder, was observed without IV supplies or equipment in her room. The resident confirmed that she had not received IV fluids since returning from the hospital. Despite this, her care plan, dated 9/14/24, indicated a need for IV fluids due to dehydration, with interventions such as administering IV fluids and monitoring the IV site. However, there were no physician's orders for IV fluids, and the Director of Nursing acknowledged that the care plan required modification.
Lack of Weight Monitoring Parameters for Resident with CHF
Penalty
Summary
The facility failed to establish parameters for physician notification concerning weight monitoring for a resident with congestive heart failure, diabetes mellitus, and fluid overload. The resident was significantly impaired in daily decision-making, as indicated by the Quarterly Minimum Data Set assessment. A physician's order required the resident to be weighed every Monday, Wednesday, and Friday due to congestive heart failure, but did not specify when to notify the physician of weight changes. The resident's Fluid Maintenance Care Plan highlighted the risk of fluid volume overload and included interventions such as monitoring electrolytes and assessing for edema. However, it lacked specific parameters for weight change notification. During an interview, the Director of Nursing acknowledged the absence of these parameters and noted that orders were later received to notify the nurse practitioner if there was a five-pound increase in a week.
Failure to Follow Wound Care Protocols for a Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate wound care for a resident with pressure ulcers, as evidenced by the observation of the Wound Care Nurse not following proper hand hygiene protocols and not adhering to the physician's orders for wound treatment. During the wound care observation, the nurse did not perform hand hygiene between glove changes and used a marker from her pocket without changing gloves, which could compromise the sterility of the wound care process. Additionally, the nurse was unaware of the daily treatment changes required by the physician's orders, indicating a lack of communication or understanding of the current treatment plan. The resident in question had multiple diagnoses, including cellulitis, acute kidney failure, and heart failure, and was significantly impaired in daily decision-making, requiring staff assistance for transfers and bed mobility. The physician's orders specified the application of medical-grade honey gel and bordered gauze on specific days, but the wound care progress report indicated a need for daily treatment changes. The discrepancy between the physician's orders and the nurse's actions highlights a failure to ensure the resident received the necessary treatment and services to promote healing of the pressure ulcers.
Improper Catheter Care for Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to a deficiency. On two separate occasions, the resident's catheter bag was observed uncovered and hanging off the top of a garbage can, with the bag touching the top and side of the can, which contained trash. This was noted during observations on the same day, first at 10:37 a.m. and later at 3:15 p.m., with the Assistant Director of Nursing confirming the improper placement of the catheter bag. The resident, identified as having a history of infection, was moderately cognitively impaired and required substantial assistance with daily activities. The care plan for the resident included catheter care with specific instructions to keep the catheter bag covered and below the waist, and to ensure the tubing did not touch the floor. Despite these orders, the catheter bag was not maintained according to the care plan, as evidenced by its placement on the garbage can. The resident had a recent history of a urinary tract infection, for which they were prescribed an antibiotic, Cipro, indicating the potential for infection was a known risk.
Failure to Implement Non-Pharmacological Interventions and Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering anti-anxiety medication to Resident 37, who had diagnoses including Alzheimer's dementia and depression. The resident's medication administration record indicated that alprazolam was given on multiple occasions without documentation of non-pharmacological interventions being attempted, except for two instances. The Director of Nursing confirmed the lack of documentation for the remaining days, which is contrary to the facility's policy requiring such interventions before administering psychotropic drugs. Additionally, the facility did not monitor Resident 48 for side effects of antidepressant medications, despite the resident's diagnoses of unspecified dementia and depression. The resident was prescribed sertraline and buproprion, and the care plan indicated a risk for adverse effects from these medications. However, there was no physician's order or documentation in the resident's record to indicate monitoring for side effects, which the Director of Nursing acknowledged should occur every shift. This oversight is inconsistent with the facility's policy that mandates monitoring for side effects and documenting the resident's response to psychotropic medications.
Incomplete Clinical Records for Self-Medication Assessment
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented, specifically regarding a self-medication administration assessment for a resident. The deficiency involved Resident 23, who had a range of medical conditions including repeated falls, hemiplegia due to a stroke, aphasia, hypertension, and right foot drop. The resident's Quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a need for assistance with daily activities. A physician's order allowed the resident to self-administer Econazole nitrate powder topically. However, the Self-Administration of Medication Evaluation form, dated the same day as the physician's order, did not include the resident's name. During an interview, the Assistant Director of Nursing (ADON) admitted to mistakenly writing her own name on the form instead of the resident's.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to infection control guidelines during a wound treatment procedure for a resident. The Wound Care Nurse was observed performing wound care on a resident's right heel, ankle, and lower leg without following proper hand hygiene and glove use protocols. After removing the old dressings, the nurse changed gloves without performing hand hygiene. She continued to clean each wound without changing gloves or sanitizing her hands between each wound care task. Additionally, the nurse reached into her pocket to retrieve a marker, wrote on a foam dressing, and continued the procedure without changing gloves or sanitizing her hands. During an interview, the Wound Care Nurse acknowledged that she should have performed hand hygiene between glove changes and should have changed gloves after reaching into her pocket. The facility administrator was unable to provide further information or a corresponding policy when requested. This incident highlights a deficiency in the facility's infection prevention and control practices, specifically regarding hand hygiene and glove use during wound care procedures.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, resulting in deficiencies related to the maintenance and administration of oxygen therapy. Resident B was observed with outdated respiratory equipment, including a humidification bottle and nebulizer mask dated 10/6/24, despite physician orders requiring weekly changes. Resident B, diagnosed with heart failure, respiratory failure, and COPD, was moderately cognitively impaired and dependent on supplemental oxygen. LPN 1 confirmed the equipment was outdated and should have been changed. Resident C, who had diagnoses including cancer, hypertension, depression, and COPD, was observed with an oxygen concentrator set at an incorrect flow rate of 2 to 2.5 liters, contrary to the physician's order of 3 liters continuously. The ADON confirmed the incorrect setting. Resident D, with diagnoses such as malignant neoplasm of the kidney and paraplegia, was found with an outdated water bottle in her oxygen concentrator, also dated 10/6/24. LPN 1 acknowledged the bottle should have been changed weekly. The facility's policy required weekly changes of oxygen equipment, which was not adhered to in these cases.
Incomplete Documentation of Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records related to oxygen administration and saturation levels for two residents. Resident B, who had diagnoses including COPD, hypertension, and dementia, was cognitively impaired and received oxygen therapy. The care plan required checking oxygen saturation every shift. However, documentation was missing for specific dates and shifts in July 2024, where the oxygen administration and saturation levels were not recorded. The Director of Nursing confirmed the lack of documentation during an interview. Similarly, Resident C, with diagnoses including COPD, diabetes mellitus, hypertension, and dementia, was moderately cognitively impaired and also received oxygen therapy. The care plan required continuous oxygen administration, but documentation was missing for a specific date and shift in July 2024. The Director of Nursing was unable to provide further information regarding the missing documentation. The facility's policy on oxygen administration required staff to document the initial and ongoing assessment of the resident's condition and response to oxygen therapy, which was not adhered to in these cases.
Failure to Report Allegation of Abuse/Neglect
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the Administrator and the Indiana Department of Health (IDOH) for a resident with an allegation of abuse/neglect voiced by a family member. The resident, who had diagnoses including Alzheimer's disease, dementia, and diabetes mellitus, was found with reddened skin on the upper abdomen and underneath the left breast after spilling hot coffee. The incident was reported to the Responsible Party, who accused the facility of willful and criminal neglect. However, the Director of Nursing (DON) did not conduct an investigation or report the allegation to the Administrator or IDOH, as required by the facility's abuse policy. The incident was documented in the Nurse's Progress Notes, and the Responsible Party was informed after multiple attempts to reach them. Despite the Responsible Party's accusation of neglect, the DON did not observe any redness when she checked the resident and did not consider it necessary to report the allegation. The facility's abuse policy mandates that all allegations of abuse, neglect, and exploitation be reported immediately to the Administrator and relevant authorities, but this protocol was not followed in this case.
Failure to Provide Adequate Supervision and Follow Care Plan Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to care plan interventions, resulting in two separate incidents involving residents. Resident D, who has dementia and is dependent on assistance for mobility, was left alone in her room while in a wheelchair, contrary to her care plan. This led to a fall where she hit her head, resulting in a laceration that required two staples. The incident occurred because the resident forgot to lock her wheelchair brakes and attempted to reach for a TV remote, causing her to slide out of the wheelchair. Staff interviews confirmed that the resident was left alone, and the care plan intervention to not leave her alone in her room was not followed. Resident C, who has Alzheimer's disease and dementia, was served hot coffee in her room despite a care plan intervention that prohibited hot drinks in her room or with meals. This led to the resident spilling the hot coffee on herself, causing reddened and tender skin on her upper abdomen and underneath her left breast. The incident was documented by an Agency LPN, and subsequent notes indicated that the redness and tenderness subsided with cold compresses. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that staff had access to the care plan, which included the intervention against serving hot drinks in the resident's room.
Failure to Conduct Timely Post-Fall Assessments
Penalty
Summary
The facility failed to ensure a resident received the necessary treatment and services after a fall. Resident B, who had diagnoses including Alzheimer's disease and fractures in the left knee and right ankle, was assisted by an Agency CNA during a transfer and was lowered to the floor in the bathroom. The initial assessment noted no injuries, and vital signs were within normal limits. However, the after-fall assessment was not thorough, lacking significant findings and actual vital signs. No further assessments were completed until the following morning, when significant swelling, bruising, and deformity were observed in the resident's right ankle, leading to a hospital transfer and diagnosis of a right tibia/fibula fracture. The Director of Nursing (DON) confirmed that post-fall assessments should have been conducted for 72 hours following the fall, but no assessments were documented until the morning after the incident. The facility's policy required observation for delayed complications for approximately 48 hours post-fall, with documentation of any signs or symptoms. The failure to conduct timely and thorough assessments after the fall resulted in a delay in identifying the resident's injuries and providing appropriate care.
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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