Robin Run Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 6370 Robin Run W, Indianapolis, Indiana 46268
- CMS Provider Number
- 155505
- Inspections on file
- 30
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Robin Run Health Center during CMS and state inspections, most recent first.
The facility failed to prevent serious falls and injuries for two residents by not following established care plans and fall‑prevention practices. One resident with dementia, severe mobility deficits, and a documented need for a mechanical lift and two‑person assistance was instead manually transferred by a single CNA, was "lowered" to the floor without use of a lift, and later was found to have multiple fractures of the left hip and pelvis. Staff did not initially treat or document this as a fall, and there was a delay before an RN was informed of the resident’s pain. In a separate incident, another fully ADL‑dependent resident with high fall risk and limited, uncontrolled arm movement fell from bed while trying to reach a personal cell phone that had been placed on a bedside table positioned parallel to the bed rather than safely within reach on an over‑bed table, resulting in a head injury and bilateral subdural hematomas.
Surveyors found that the facility failed to notify the Ombudsman and provide required bed-hold notices when two residents with dementia-related diagnoses and other conditions were transferred to the ER. In one case, a resident with dysphasia, dementia, and anxiety was sent to the ER per NP orders without any documented Ombudsman notification or bed-hold notice to the resident or representative. In another case, a resident with Pick’s disease, aphasia, and repeated falls was found on the floor with a head laceration, assessed, and sent by ambulance to the ER, with the DON, physician, and family notified, but again without Ombudsman notification or a bed-hold notice to the resident or representative. The DON reported that the Social Worker did not notify the Ombudsman and that bed-hold information was not provided to residents or families.
A resident admitted for LTC services with diagnoses including bipolar disorder and HTN did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. Record review showed the absence of any baseline care plan documentation, and the DON confirmed that facility policy mandates a baseline plan of care to address immediate health and safety needs for all new admissions within the 48-hour timeframe.
A resident with an enterocutaneous fistula was admitted with hospital instructions for ongoing meticulous wound care until surgical repair, but the facility did not obtain specific physician or NP orders for treatment of the fistula or surrounding moisture-associated skin damage. The care plan only noted use of an ostomy appliance to manage output and lacked detailed treatment instructions. Repeated NP notes directed staff to continue an ostomy bag over the open wound and change as able, yet these were not converted into formal treatment orders, and skin assessments documented dermatitis and redness without any corresponding treatments on the MARs or TARs. The DON later confirmed there were no treatment orders in place for the fistula despite the need for ongoing care.
Two residents with significant mobility and skin integrity risks did not receive adequate pressure ulcer prevention and treatment. One resident with a documented left heel SDTI and black eschar had a heel protector left unused, was observed with her heels pressing against wheelchair foot pedals and leg rests, and had a care plan that omitted heel off-loading interventions. Another resident at risk for skin breakdown was on a LAL mattress set at a firm setting, but the care plan did not include the use of the LAL mattress as an intervention, and staff could not provide complete manufacturer guidelines for setting the mattress based on the resident’s weight.
A resident with hypertension and type 2 diabetes was admitted without a documented code status order in their chart, despite hospital records and the resident's verbal confirmation indicating a full code preference. An LPN was aware of the resident's wishes and had prepared a POST form for the family, but did not obtain the necessary documentation during the family's visit, resulting in noncompliance with facility policy on advanced directives.
Surveyors found that the facility did not update care plans for three residents after incidents such as bruising, an allegation of sexual abuse, and injury following suctioning. Despite changes in condition and new events, care plans were not revised as required by facility policy.
Staff failed to initiate and document appropriate care for a newly admitted resident with complex needs, including missing orders for catheter and oxygen use, lack of adherence to dietary recommendations, and incomplete documentation. Another resident with CHF and edema was not properly monitored for weight changes as ordered by the physician, with significant weight gain not reported. These deficiencies reflect failures in following physician orders and providing individualized care.
A resident with a pressure ulcer and indwelling catheter, who was under Enhanced Barrier Precautions, did not have appropriate signage or a PPE cart at the room. Multiple staff members provided care while only wearing gloves, without gowns, contrary to EBP requirements. The facility's infection control policy did not address EBP, and staff interviews revealed inconsistent understanding of required precautions.
The facility did not ensure the timely return of personal funds to multiple residents after discharge, with several individuals not reimbursed within the required 30-day period. Funds owed ranged from small to substantial amounts, and the issue persisted for months in some cases. The process for managing and refunding resident money, handled by a third-party system and overseen by the BOM, did not comply with facility policy or regulatory timelines.
Four residents dependent on staff for ADL assistance did not receive scheduled showers, with some going over a month without bathing. Observations noted strong urine odors and unkempt appearances, and documentation failed to show completed showers or refusals. Care plans did not address bathing preferences or refusals, and facility policy requirements for documentation and supervisor notification were not met.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident with pressure ulcers did not consistently receive required interventions to promote healing, and preventive measures for at-risk residents were not adequately implemented, including lapses in repositioning, skin assessments, and use of pressure-relieving devices.
Two residents did not receive respiratory care in line with professional standards when QMAs administered nebulizer treatments, left residents unattended, and failed to assess or monitor respiratory status before, during, or after treatments. Facility records lacked care plans and documentation of required assessments, and staff were unclear about QMA scope of practice regarding nebulizer administration.
A resident with a history of falls and multiple diagnoses, including Alzheimer's and pancreatic cancer, experienced a fall resulting in a hip fracture. Despite being in obvious pain, the resident only received routine pain medication, as staff awaited hospice arrival. The hospice nurse arrived hours later, and the family eventually decided to transport the resident to a hospital. The facility's pain management policy was not effectively followed, leading to inadequate pain relief for the resident.
A facility failed to ensure proper supervision and care for a resident with a history of falls, leading to a fall in the shower room and multiple fractures. The care plan did not reflect the need for two-person assistance, and post-fall procedures were not followed. Additionally, cleaning chemicals were not stored securely, allowing a resident on the memory care unit to access a poisonous substance. The resident's record lacked documentation of physician notification or follow-up care for the potential ingestion.
The facility failed to conduct a significant change MDS assessment for two residents admitted to hospice. One resident with pancreatic cancer and Alzheimer's, and another with dementia, did not receive the required assessment within 14 days of hospice admission, as confirmed by the MDS Coordinator.
The facility failed to comply with its food storage and temperature logging policies. In the main kitchen, several food items were found without proper labeling of arrival or expiration dates. Additionally, the facility did not maintain complete temperature logs for its refrigerators and freezers across multiple locations, missing entries for both opening and closing temperatures on various dates. These deficiencies indicate a lack of compliance with the facility's policies on food safety standards.
The facility inaccurately coded the MDS for three residents, leading to deficiencies in their assessments. A resident with schizoaffective disorder and another with paranoid schizophrenia had Level II assessments completed, but their MDS inaccurately indicated they did not require them. Another resident admitted with hospice services had an MDS that failed to reflect her hospice status. Attempts to interview the MDS coordinator were unsuccessful.
A resident with a history of falls and medical conditions such as myocardial infarction and hypertension was admitted to the facility without a documented fall care plan. Despite the facility's policy requiring a comprehensive care plan, no interventions were documented to address the resident's fall risk. The DON confirmed the absence of the care plan, citing the resident's short stay as a factor.
The facility failed to provide comprehensive nutritional assessments and services for two residents. One resident, at risk for malnutrition, consistently left meals untouched without timely alternative options, and lacked a comprehensive care plan. Another resident, unable to consume oral nutrition, experienced significant weight loss due to a disconnected feeding pump, with no adjustments made to the feeding plan. Facility policies on care planning and nutritional services were not followed, leading to deficiencies in care.
The facility failed to reconcile medications upon discharge for two residents, leading to a deficiency in pharmaceutical services. One resident, with a history of myocardial infarction and other conditions, was discharged without a record of medication reconciliation for twelve medications. Another resident, who passed away, also had five medications not reconciled. The facility's policy on discharge medications was not followed.
A facility failed to label a vial of tuberculin serum with the date it was opened, as observed in the medication room. The DON confirmed that the serum should be dated and refrigerated when not in use. The facility's policy requires labels to include necessary information such as the drug's name, strength, lot number, expiration date, and cautionary statements.
The facility failed to document insulin administration and blood sugar levels for two residents, leading to a deficiency in maintaining accurate medical records. One resident with type 2 diabetes and other health issues had multiple instances of undocumented insulin administration. Another resident with similar conditions also experienced omissions in documenting insulin and blood sugar levels. The DON acknowledged the omissions, attributing them to staff forgetting to document after administering medication.
The facility failed to ensure dietary staff covered facial hair during food preparation, maintained clean and sanitary conditions in the kitchen and pantry, and stored food at proper temperatures. Observations revealed kitchen staff without beard covers, a dirty pantry refrigerator at 54°F, and an opened, undated gallon of milk left out. Confidential interviews indicated issues with snack availability and improper storage of personal food in the resident refrigerator.
The facility failed to care for a resident in a manner that preserved his dignity and rights. Despite the family's request and the care plan agreement to have the resident out of bed daily, observations showed that the resident remained in bed for several days, not dressed appropriately, and not participating in activities. Staff interviews revealed inconsistencies in the care provided, and the resident expressed a preference to be out of bed daily.
The facility failed to ensure call lights were within reach for three dependent residents, leading to a deficiency. Despite staff passing by, call lights were observed unplugged or out of reach for residents with severe impairments and a history of falls, contrary to their care plans and facility policy.
The facility failed to address resident grievances regarding missing clothing and hearing aids for multiple residents. Interviews revealed frequent issues with missing laundry and a lack of response from management. Grievance logs did not document these concerns, and staff were unaware of the grievance process.
The facility failed to provide personalized activities for two residents, one dependent and one with dementia. Despite care plans and family requests, the residents were often left in bed or alone without meaningful engagement. Staff inconsistencies and lack of alternative hearing devices further hindered their participation in activities.
The facility failed to ensure fall follow-up and care plan updates for two residents. One resident had several falls with no documented root causes or follow-up assessments, and another resident experienced a witnessed fall with no 72-hour follow-up or care plan. Staff interviews revealed inconsistent adherence to fall follow-up procedures.
The facility failed to properly elevate the head of the bed for a resident with a g-tube and a history of aspiration pneumonia. Observations showed the resident lying on his back with the HOB elevated less than 30 degrees while tube feeding was infusing, and the feeding bags were not labeled as required. Despite family complaints, the issue remained unresolved.
The facility failed to post the Ombudsman's contact information, affecting all 44 residents and their representatives. Staff interviews and observations revealed that the information was missing, and the facility had no specific policy for posting it.
Failure to Prevent Falls and Use Safe Transfer and Positioning Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and provide adequate supervision and appropriate transfer methods, resulting in serious injuries to two residents. For Resident H, who had vertigo, a prior left femur fracture, dementia with impaired safety awareness, muscle weakness, and a history of falls, the care plan specified that she required extensive assistance with toileting by 1–2 staff, total assistance of two staff with transfers using a mechanical lift, and use of a wheelchair. Her fall‑risk care plan also included interventions such as encouraging her to lie down after breakfast and between meals, assisting her to bed if restless or tired, and promptly responding to all requests for assistance. Despite these documented needs and interventions, she was transferred without a mechanical lift and without the required number of staff. On the morning in question, CNA 10 reported that Resident H was still in bed and that, while attempting to get her up before breakfast, the resident fell backwards into the bed. CNA 10 then attempted to transfer the resident to a chair; during this attempt, the resident went down to the floor and was “lowered” there by CNA 10, who then called QMA 11 for help to get the resident off the floor. QMA 11 confirmed that she was called to help lift the resident from the floor and that they lifted the resident by placing their arms under the resident’s armpits and pulling her up by her pants, rather than using a mechanical lift. CNA 10 stated she did not know the resident was having problems standing and believed QMA 11 was a nurse. The DON later indicated that the resident was a Hoyer‑lift transfer and that she had been lifted by one person when she should have been transferred with a mechanical lift, and also stated that a resident “lowered to the floor” was not considered a fall. Following this event, Resident H began to exhibit pain. CNA 10 reported that later in the shift, the resident started to complain of leg pain, and this was reported to RN 9, although RN 9 stated she was not informed of pain on that date and only became aware of the resident’s pain two days later, when staff reported it to her. When RN 9 assessed the resident, she noted guarding of the leg and pain with movement, and the resident screamed when her leg was lifted. Imaging revealed a fracture of the neck of the left femur with an acute impacted intertrochanteric fracture and an acute nondisplaced left superior pubic ramus fracture. The facility reported the event as an injury of unknown origin, but staff statements and interviews showed that the resident had been transferred contrary to her care plan and without appropriate equipment or staffing, and that the event in which she was “lowered to the floor” was not treated or documented as a fall. For Resident C, the deficiency involved failure to ensure personal items were kept within safe reach, consistent with the resident’s care plan and standard fall precautions. Resident C was dependent on staff for all ADLs and had a care plan identifying them as high risk for falls, with interventions including anticipating and meeting needs, ensuring personal items were within reach, and placing a fall mat next to the bed. LPN 5 and RN 6 described standard fall precautions as keeping residents’ personal items on a bedside table within reach, and, for residents with limited range of motion, placing items on an over‑bed table directly in front of them. The DON agreed with this description of standard fall precautions and the requirement to keep personal items within reach. On the day of Resident C’s fall, a CNA had been in the room getting the resident situated and then left to assist another resident. Shortly afterward, the roommate yelled for Resident C to stop moving around in bed or they would fall, and the CNA called for LPN 5. When LPN 5 arrived, Resident C was found face down on the floor beside the bed, between the bed and the bedside table. LPN 5 indicated that the bedside table appeared to be parallel to the bed rather than positioned over it, and Resident C stated they had flipped off the bed while trying to reach their personal cell phone on the bedside table. LPN 5 described Resident C as having recently gained some range of motion in the lower arms but with very poor control, comparing the arm movements from the elbows down to a “fish out of water,” floppy and uncontrolled. The resident was observed with a knot on the forehead and was immediately sent to the hospital, where they were diagnosed with an acute head injury and bilateral subdural hematomas. The record lacked documentation of the resident’s subsequent status or plans to return to the facility. The facility’s own Falls and Fall Risk policy defined a fall as unintentionally coming to rest on the ground, floor, or other lower level, including episodes where a resident would have fallen if not caught or lowered, and stated that when a resident is found on the floor, a fall is considered to have occurred unless there is evidence otherwise. Despite this, the DON stated that a resident lowered to the floor was not considered a fall. In both residents’ cases, the facility did not follow its own fall‑risk policy and resident‑specific care plans: Resident H was transferred without the required mechanical lift and staffing, and the event in which she was lowered to the floor was not treated as a fall, while Resident C’s personal items were not maintained within safe reach, contributing to the resident’s attempt to reach a cell phone and subsequent fall from bed.
Failure to Notify Ombudsman and Provide Bed-Hold Notices for Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required notifications related to resident discharges and bed-hold policies for two residents sent to the emergency room. For Resident H, who had diagnoses including dysphasia, dementia, and anxiety, a progress note dated 3/9/26 at 11:38 a.m. documented that she was seen by the Nurse Practitioner and new orders were received to send her to the emergency room. Record review showed that there was no documentation that the Ombudsman was notified of this discharge, and no bed-hold notice was provided to the resident or her family representative. For Resident F, who had diagnoses including Pick’s disease, aphasia, and a history of repeated falls, a progress note dated 3/1/26 at 7:45 a.m. indicated he was found on the floor in his room with a bleeding gash above his left eyebrow. He was alert and awake, able to move all extremities, and no other trauma was noted after assessment. He was assisted to his wheelchair, vital signs were obtained, and an ambulance was notified to transfer him to the emergency room; the DON, primary physician, and family were notified. However, the record lacked documentation that the Ombudsman was notified of the discharge, and no bed-hold notice was given to the resident or his family representative. The DON later indicated that the Social Worker did not notify the Ombudsman and that bed-hold notices were not sent with residents or communicated to family representatives.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident, as required by facility policy and regulation. Record review showed that the resident, admitted on 3/28/26 with diagnoses including bipolar disorder and hypertension, had no documented baseline care plans in the medical record when reviewed on 4/1/26. The Director of Nursing stated in an interview that it was facility policy for a baseline care plan to be put in place for all new admissions within 48 hours, and the written policy titled “Care Plans- Baseline” confirmed that a baseline plan of care to meet the resident’s immediate health and safety needs must be developed within forty-eight hours of admission. This deficiency was cited under 410 IAC 16.2-3.1-30(a) and related to Intake 2799346, based on the lack of a required, preliminary baseline care plan for the resident’s immediate needs between admission and the development of a comprehensive care plan.
Lack of Physician Orders and Wound Care for Enterocutaneous Fistula
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders and provide ordered treatment and care for an enterocutaneous fistula and associated moisture-related skin damage for one resident. The resident was admitted with a diagnosis that included an intestinal fistula and had a documented history of an enterocutaneous fistula requiring wound care and surgical intervention. Hospital discharge documentation specified the need for ongoing meticulous wound care for the fistula until surgery. On admission, the assessment noted moisture-associated skin damage on the abdomen around the stoma area, and the care plan identified an alteration in intestinal status due to the fistula with an intervention to use an ostomy appliance to manage fistula output. However, the care plan did not include specific treatment orders or instructions for when and how to treat the fistula and surrounding skin. Multiple NP progress notes over several weeks directed staff to continue using an ostomy bag over the open wound, to change it as able, and to follow up for a surgical consult, but these notes did not include specific parameters or instructions for treatment of the fistula. Skin assessments documented incontinence-associated dermatitis and redness around the stoma and fistula sites related to moisture-associated dermatitis, yet there was no documentation of any treatment ordered or provided for these conditions. Throughout this period, there was no evidence that the NP notes were translated into formal physician or NP orders with clear treatment protocols. Review of physician orders, MARs, and TARs for the relevant time frame showed no orders or documentation of treatment, care, or monitoring for the fistula or the moisture-associated skin damage on the abdomen. During interviews, the DON confirmed that the resident had a fistula rather than a surgically created ostomy and that an ostomy bag was used because the area oozed constantly and required surgical intervention. The DON acknowledged that there were no physician orders for treatment of the fistula, that such orders should have been obtained at admission, and that she was unsure how this was missed. The facility’s existing colostomy/ileostomy care policy described documentation expectations for skin condition and care but there was no evidence these procedures were implemented for this resident’s fistula and associated skin damage.
Failure to Off-Load Heels and Integrate Pressure-Relief Devices Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent pressure on bony prominences for two residents. For one resident with a history of left femur fracture, dementia, and anxiety, staff documented on readmission from the hospital that the left heel was mushy with a possible deep tissue injury (DTI). Subsequent notes described the left heel as a new unstageable wound presenting as a DTI, initially measuring 3.13 cm by 2.78 cm, with an order for betadine to be applied three times daily and instructions for continuous off-loading when in bed. Later assessment documented the wound as an unstageable/SDTI measuring 4.5 cm by 4.3 cm, with 60% light pink/normal skin color and 40% black color, and indicated that an off-loading boot was replaced to the left foot and the right foot was off-loaded with a pillow. Despite these documented needs and orders, observations showed that this resident had a regular mattress and a heel protector sitting unused on a fall mat next to the bed. When the resident was observed in a wheelchair, her feet were resting on the foot pedals, and the left heel, which had a hard black eschar approximately 5 cm by 5 cm, was not protected. An RN wheeled the resident out of the room without protecting the heel from pushing into the wheelchair leg rest. The resident’s care plan, dated 3/16/26, identified a documented pressure ulcer and a goal to prevent future pressure ulcers but did not include any intervention to off-load the resident’s heels. For a second resident with diagnoses including age-related physical debility, hyperlipidemia, dysphagia, major depressive disorder, respiratory failure, and generalized weakness, observations showed the resident in bed on a low air loss (LAL) mattress that was set to the firmest setting and later at a setting of approximately 160. The resident’s care plan, initiated due to risk for impaired skin integrity from decreased mobility, friction and shear, moisture, impaired sensory perception, enteral nutrition, and bilateral buttock shearing, included an intervention to use a draw sheet to avoid shearing and a goal for bilateral buttock shearing to heal. However, the care plan did not include an intervention for the use of the LAL mattress. During interview, the ADON stated that the mattress settings should be based on resident weight, but the manufacturer’s guidelines supporting this were not available in full at the time of survey.
Failure to Document Resident Code Status Upon Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident had a documented code status order in their medical record. Record review showed that the resident, who had diagnoses including hypertension and type 2 diabetes and was their own responsible party, did not have a code status order in their chart. Hospital records indicated the resident was a full code during their hospital stay, and the resident verbally confirmed their wish to be a full code and to have all interventions in place. However, this preference was not formally documented in the facility's records. An LPN acknowledged awareness of the resident's full code status from hospital records and stated that a POST form was prepared for the resident's family to complete. Although the family visited the facility, the LPN did not have time to have them fill out the necessary paperwork during their visit. Facility policy requires inquiry about advanced directives prior to or upon admission and assessment of decision-making capacity, but these steps were not completed as required, resulting in the absence of a documented code status for the resident.
Failure to Update Care Plans After Incidents and Allegations
Penalty
Summary
The facility failed to update or revise care plans for three residents following significant incidents or allegations, as required by policy. For one resident, visible bruising over the bridge of the nose and both eyes was observed, but the care plan was not updated to reflect this new condition, despite the resident's history of wandering, falls, and anticoagulant therapy. Another resident made an allegation of sexual abuse, which led to an investigation and subsequent treatment for a urinary tract infection, but the care plan was not revised to address the new allegation or related behavioral changes. A third resident was noted to have bruising on the right jawline after being suctioned, yet there was no care plan addressing this injury. These deficiencies were identified through observation, record review, and interviews. The facility's policy requires ongoing assessment and revision of care plans as residents' conditions change, but this was not followed in the cases reviewed. The lack of timely care plan updates after incidents or allegations was confirmed by the administrator during the survey.
Failure to Provide Resident-Specific Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide resident-specific care and follow physician orders for two residents, resulting in deficiencies related to quality of care. For one newly admitted resident with diagnoses including dysphagia, functional quadriplegia, and weakness, staff did not initiate appropriate care or document necessary orders for critical aspects such as catheter use, catheter care, oxygen use, respiratory care, and code status. Observations revealed the resident was left in discomfort, unable to access their call light or television, and was not provided with their personal clothing or dentures. Staff were unaware of the resident's needs and failed to follow hospital speech therapy recommendations regarding diet and liquid consistency, resulting in the resident receiving inappropriate meal trays with thin liquids despite a recommendation for thickened liquids. Documentation in the resident's medical record was inconsistent and incomplete, with conflicting information about the resident's catheter size, oxygen use, and level of independence with oral care. Staff interviews revealed a lack of awareness regarding the resident's care needs and orders, with some staff admitting to confusion due to multiple admissions and others not realizing required standing orders were missing. The admitting nurse did not enter necessary orders for the resident's indwelling catheter, oxygen, or code status, and this was not corrected by subsequent shifts. The facility's policies required complete and accurate documentation and timely initiation of care plans and orders, which were not followed in this case. For another resident with congestive heart failure and edema, the facility failed to follow physician orders for daily weight monitoring and notification of significant weight gain. The resident experienced a weight increase of over 6 pounds in 24 hours, but there was no documentation that the physician was notified as required. Additionally, a weight was omitted on a subsequent date, further indicating a lack of adherence to monitoring protocols. These failures demonstrate lapses in following physician orders and ensuring quality of care for residents with complex medical needs.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for a resident who was under Enhanced Barrier Precautions (EBP). Observations revealed that the resident, who had a pressure ulcer on the coccyx and an indwelling urinary catheter, did not have an EBP sign posted on or around her door during multiple checks. Staff members, including a CNA, a physical therapy assistant, a QMA, and an RN, were observed providing care to the resident while only wearing gloves, without donning gowns as required for high-contact care under EBP. Additionally, there was no PPE cart located next to the resident's room, and the resident's catheter bag was observed lying on the ground next to the bed. Interviews with staff indicated a lack of consistent understanding regarding the reasons for EBP and the required PPE. The infection prevention nurse confirmed that both gloves and gowns should be worn for high-contact care, but this was not followed in practice. Review of the facility's infection control policy showed that EBP was not addressed, and no other relevant policy was provided. These failures resulted in the facility not maintaining proper infection control practices for the resident on EBP.
Failure to Timely Return Resident Personal Funds After Discharge
Penalty
Summary
The facility failed to maintain a system for the proper management and timely return of resident personal funds for 8 out of 11 residents reviewed. Anonymous concerns were raised during the survey process regarding mismanagement of residents' personal money by management. Record review revealed that several residents had not been reimbursed their personal funds within 30 days of discharge, with some cases dating back several months. Specific amounts owed to discharged residents ranged from $16.18 to $7,480.00, and in some instances, the non-return of funds dated back to residents who had left the facility as early as December 2023. Interviews with the Business Office Manager (BOM) indicated that resident funds were managed by a third-party system at the corporate office, with the BOM responsible for daily census updates and submitting refund requests after resident discharge. Despite the facility's policy requiring the return of personal funds and a final accounting within 30 days of discharge, eviction, or death, this process was not followed for multiple residents. The deficiency was identified through both interviews and record reviews, confirming that the facility did not adhere to its own policy or regulatory requirements regarding the timely conveyance of resident funds.
Failure to Provide Scheduled Bathing and Showering Assistance
Penalty
Summary
The facility failed to provide necessary assistance with bathing and showering for four residents who were dependent on staff for activities of daily living. Observations and interviews revealed that these residents had not received showers as scheduled, with some going over a month without a shower. For example, one resident reported receiving only one shower since admission several weeks prior, and another was last documented as having a shower nearly a month before the survey. In multiple cases, there were strong urine odors present in residents' rooms, and residents appeared disheveled or unkempt. Documentation in the Point of Care system showed missed scheduled showers, and there was no evidence that residents had refused care or that their preferences or refusals were addressed in their care plans. Record reviews confirmed the lack of documentation for completed showers or refusals, and the facility's own policy required detailed documentation of bathing, including refusals and interventions taken. The policy also required notification of supervisors if a resident refused a shower, but there was no documentation to support that this process was followed. The deficiency was identified through observation, interview, and review of both electronic and handwritten records, which consistently showed a lack of compliance with scheduled bathing and documentation requirements for the affected residents.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and goals of the resident. Specific details regarding the resident’s medical history and condition at the time of the deficiency were not provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents with existing pressure ulcers did not consistently receive the necessary interventions to promote healing. Additionally, preventive strategies to protect residents at risk for developing pressure ulcers were not adequately carried out, as evidenced by lapses in repositioning, skin assessments, and use of pressure-relieving devices.
Failure to Provide Safe and Appropriate Respiratory Care During Nebulizer Treatments
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for two residents who required nebulizer treatments. During a medication administration observation, a Qualified Medication Aide (QMA) prepared and administered a nebulizer treatment to a resident, left the resident unattended, and did not assess the resident's respiratory status before or after the treatment. The resident was not monitored during the treatment, and there was no documentation of respiratory assessments or monitoring by a licensed professional. Additionally, the facility's records for both residents lacked care plans related to their respiratory conditions and did not include interventions for nebulized treatments. Review of medication administration records showed that the majority of nebulizer treatments were administered by QMAs, despite state guidelines prohibiting QMAs from administering nebulizer treatments. Interviews with staff revealed confusion regarding the scope of practice for QMAs, with some staff unaware of the restrictions. The facility did not have a policy outlining the QMA scope of practice, and the job description and competency evaluations for QMAs did not address nebulizer treatments. The facility's own policy required licensed staff to assess and monitor residents during nebulizer treatments, but this was not followed.
Failure to Manage Pain for Resident After Fall
Penalty
Summary
The facility failed to manage pain for a resident, identified as Resident B, who had a history of falls and was experiencing pain related to a fall that resulted in a fracture of her left hip. Resident B had multiple diagnoses, including osteoarthritis, pancreatic cancer, Alzheimer's disease, and major depressive disorder. Her care plan indicated she was at risk for falls due to confusion, dementia, and impaired safety awareness. Despite these risks, Resident B attempted to self-ambulate and fell while trying to self-toilet, resulting in a head laceration and a fractured femur. Following the fall, Resident B was found with a bruise and cut on her head, and she was in obvious pain, crying out and wincing. Although she had orders for pain medications, including tramadol and acetaminophen, she was only administered her routine doses at 8:30 a.m. The nursing staff, including RN 7, did not administer additional pain medication despite recognizing her pain, as they were waiting for hospice to arrive. The hospice nurse did not arrive until around 12:30 p.m., and by that time, the family had decided to transport Resident B to a hospital for further evaluation and treatment. The facility's policy on pain management emphasizes the importance of alleviating pain based on clinical assessment and treatment goals. However, the staff failed to provide timely pain relief for Resident B after her fall, as evidenced by the delay in administering additional pain medication and the reliance on hospice for pain management. The Executive Director was unaware of the hospice nurse's order for pain medication, indicating a lack of communication and coordination in managing Resident B's pain effectively.
Deficiencies in Resident Supervision and Chemical Storage
Penalty
Summary
The facility failed to ensure that a resident with a history of fall-related fractures was transferred with two staff persons as per the care plan, leading to a fall in the shower room. This incident resulted in the resident sustaining fractures of two left ribs, the spine, and the sacrum. The resident's care plan did not reflect the need for extensive assistance of two persons for transfers, and post-fall procedures were not followed, as there was no documentation of the fall, root cause analysis, or follow-up assessments in the resident's record. Additionally, the facility failed to store cleaning chemicals securely, allowing a resident on the secured memory care unit to access and potentially ingest a poisonous substance. The resident was observed with a bottle of Faboloso cleaner, and although staff did not witness the resident ingesting the cleaner, poison control was contacted. The resident's record lacked documentation of physician notification, follow-up orders, or a care plan addressing the ingestion of a poisonous chemical. The report highlights deficiencies in both the supervision and care of residents, as well as the storage and management of hazardous materials. These failures resulted in significant risks to resident safety and well-being, as evidenced by the incidents involving falls and potential chemical ingestion.
Failure to Conduct Significant Change MDS Assessment for Hospice Admissions
Penalty
Summary
The facility failed to conduct a Minimum Data Set (MDS) significant change assessment for three residents who experienced a change in condition due to hospice admission. Resident 14 was admitted to hospice on June 22, 2024, but a significant change MDS assessment was not completed following this admission. Resident 14's medical history included malignant neoplasm of the pancreas, Alzheimer's disease, and a history of breast cancer. Despite the hospice and cancer care plans indicating her terminal prognosis and hospice status, the required MDS assessment was not performed. Similarly, Resident 49, residing in a secured memory care unit with dementia, was admitted to hospice on March 15, 2024. However, no significant change MDS assessment was initiated following his hospice admission. The MDS Coordinator confirmed that the facility's protocol required a significant change assessment when a resident was admitted to hospice. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a significant change MDS must be completed within 14 days of hospice election, which was not adhered to in these cases.
Food Storage and Temperature Logging Deficiencies
Penalty
Summary
The facility failed to adhere to its food storage and temperature logging policies, as observed during a survey. In the main kitchen, several food items, including fresh herbs, pepperoni, whipped cream, and feta cheese, were found without proper labeling of arrival or expiration dates. Additionally, the walk-in freezer contained undated items such as crumbled sausage, impossible burgers, and a lemon meringue pie. These observations indicate a lack of compliance with the facility's policy that requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated. Furthermore, the facility did not maintain complete temperature logs for its refrigerators and freezers across multiple locations, including the main kitchen, satellite kitchenette, and Memory Care pantry. The logs were missing entries for both opening and closing temperatures on various dates throughout August. This failure to document temperatures as per the facility's policy, which mandates monthly tracking sheets for all refrigerators and freezers, suggests a systemic issue in monitoring and ensuring food safety standards.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in their assessments. Resident 11, diagnosed with schizoaffective disorder, diabetes mellitus type 2, anxiety disorder, and chronic kidney disease, had a Level II assessment completed in October 2021 due to her mental health condition. However, her MDS inaccurately indicated that she did not require a Level II assessment. Similarly, Resident 1, with diagnoses including paranoid schizophrenia, major depression, heart failure, insomnia, and unspecified dementia, had a Level II assessment completed in January 2024, but her MDS also incorrectly stated that she did not require it. Additionally, Resident 211, who was admitted with hospice services and had diagnoses such as hypertension, anxiety, diabetes mellitus, and degenerative disease of the nervous system, had an MDS that failed to reflect her hospice status. Attempts to interview the MDS coordinator were unsuccessful, and the facility's policy on resident assessments, provided by the Administrator, mandates the use of the MDS form as per federal and state regulations.
Failure to Implement Fall Care Plan for Resident
Penalty
Summary
The facility failed to implement a fall care plan for a resident with a history of falls. During a record review, it was found that Resident 60, who had been admitted with diagnoses including myocardial infarction, hypertension, and vitamin D deficiency, did not have a documented care plan addressing his risk for falls. Despite his history of falls, there were no interventions documented to prevent future falls. The Director of Nursing confirmed the absence of a fall care plan during an interview, noting that the resident had only been at the facility for a short time. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, which was not adhered to in this case.
Deficiencies in Nutritional Care and Assessment
Penalty
Summary
The facility failed to ensure comprehensive nutritional assessments and services for Resident 43, who was at risk for malnutrition and had a history of poor food intake. Observations revealed that Resident 43 consistently left meals untouched, and alternative food options were not offered in a timely manner. Despite being identified as a picky eater and having difficulty expressing preferences due to dementia, the facility did not develop a comprehensive nutritional care plan or notify the dietician of the resident's poor intake. The resident's weight decreased over time, and her nutritional assessment was overdue. Resident 53, who was unable to consume oral nutrition due to dysphagia, experienced significant weight loss over a four-month period. The resident had a prescribed feeding regimen via a gastrostomy tube, but observations showed that the feeding pump was disconnected for three hours, contrary to the physician's orders. The Assistant Director of Nursing was unaware of the weight loss, and the Registered Dietician did not adjust the feeding plan despite the resident's weight loss, citing a recent slight weight gain. The facility's policies on care planning and nutritional services were not adhered to, as evidenced by the lack of timely assessments and interventions for both residents. The interdisciplinary team failed to effectively monitor and address the nutritional needs and weight changes of the residents, leading to deficiencies in providing adequate nutrition and care.
Failure to Reconcile Medications Upon Discharge
Penalty
Summary
The facility failed to reconcile medications upon discharge for two residents, leading to a deficiency in pharmaceutical services. Resident 60, who had a history of myocardial infarction, hypertension, type 2 diabetes mellitus, and other conditions, was discharged to home without a record of medication reconciliation. The medications not reconciled included aspirin, atorvastatin, Crestor, and several others, totaling twelve different medications. This lack of reconciliation was identified during a record review conducted on August 20, 2024. Similarly, Resident 58, who had diagnoses including the presence of an artificial hip, chronic kidney disease, and osteoporosis, passed away without a record of medication reconciliation. The medications not reconciled for this resident included aspirin, Miralax, paroxetine sodium, and others, totaling five medications. The Director of Nursing indicated that all available information regarding the residents' discharge medications was provided, but the facility's policy on discharge medications, which requires a complete medication disposition record, was not followed.
Failure to Label Tuberculin Serum Appropriately
Penalty
Summary
The facility failed to appropriately label tuberculin serum in the medication room, as observed during a survey. On the specified date, a vial of tuberculin serum was found at the north nurse's station without a date indicating when it was opened. This observation was made in the presence of the Assistant Director of Nursing (ADON). During a subsequent interview, the Director of Nursing (DON) confirmed that tuberculin serum should be dated upon opening and stored in the refrigerator when not in use. The facility's policy, dated April 2019, requires that labels for stock medications include necessary information such as the name and strength of the drug, lot or control number, expiration date, and appropriate accessory and cautionary statements and directions for use.
Failure to Document Insulin Administration and Blood Sugar Levels
Penalty
Summary
The facility failed to document the administration of insulin and blood sugar levels for two residents, leading to a deficiency in maintaining accurate medical records. Resident 20, who had diagnoses including hypertension, type 2 diabetes mellitus, unspecified dementia, and chronic kidney disease, had multiple instances where insulin administration was not documented on the Medication Administration Record (MAR). The omissions occurred at various times, including before meals and at bedtime, despite having a care plan that required monitoring and documenting the effectiveness of diabetes medication. Similarly, Resident 11, diagnosed with schizoaffective disorder, muscle weakness, type 2 diabetes mellitus, and difficulty walking, also experienced multiple omissions in documenting insulin administration and blood sugar levels on the MAR. The resident's care plan included goals to prevent complications related to diabetes, yet the documentation was incomplete on several occasions. The Director of Nursing acknowledged the omissions, attributing them to staff forgetting to document after administering the medication, despite a policy requiring immediate documentation post-administration.
Failure to Maintain Sanitary Conditions and Proper Food Storage
Penalty
Summary
The facility failed to ensure dietary staff covered facial hair during food preparation, maintained clean and sanitary conditions in the kitchen, pantry, and pantry refrigerator, and stored food at proper temperatures. During an observation, two kitchen staff members with full beards were seen prepping raw chicken without beard covers. The kitchen floors had a buildup of grease, debris, and trash. The pantry refrigerator was found to be at 54 degrees Fahrenheit, with food debris and dried liquid substances inside, and a broken rubber seal on the door. Additionally, an opened, undated gallon of milk was left out without a lid on a utility cart in the hallway. Confidential interviews revealed that the pantry on the unit was frequently filthy and smelled, and that extra food was immediately thrown away after meal trays were passed, leaving residents without the option for more food. Snacks were not consistently offered outside of mealtimes, especially for diabetic residents, and nursing staff did not have access to juice off-hours in case of a diabetic emergency. The Director of Dietary confirmed ongoing issues with nursing staff storing their food in the resident refrigerator and acknowledged that dietary staff were responsible for cleaning the pantry refrigerator. The Administrator observed that staff members were not supposed to store personal food among resident food and that resident food should have been discarded due to the refrigerator not being cool enough. The facility's policies on sanitization and food preparation were provided, indicating that food service areas should be maintained in a clean and sanitary manner and that food and nutrition services staff should wear hair restraints. No policy regarding resident snacks was obtained during the survey process.
Failure to Preserve Resident's Dignity and Rights
Penalty
Summary
The facility failed to care for Resident K in a manner that preserved his dignity and rights. Despite the family's request and the care plan agreement to have Resident K out of bed daily from around 11:00 a.m. to 3:00 p.m., observations showed that the resident remained in bed for several days. On multiple occasions, Resident K was found lying in bed, wearing only a hospital gown, and not participating in any activities. The resident expressed a preference to be out of bed daily and mentioned that it had been three days since he was last gotten up. Staff interviews revealed inconsistencies in the care provided, with some staff unable to explain why the resident had not been out of bed as scheduled. Resident K's medical history includes hemiplegia, hemiparesis on the left non-dominant side, and dysphagia. The resident enjoyed attending social events, bingo, movies, exercise, and art, and his family had provided thermal clothing to keep him warm. Despite these preferences and the care plan interventions, the resident was repeatedly observed in bed, not dressed appropriately, and not engaged in activities. The Nurse Practitioner also confirmed that she had not seen Resident K out of bed in the past week, noting that he enjoyed social interactions and cared about his appearance.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for three dependent residents, leading to a deficiency. Resident M was observed multiple times with her call light unplugged and out of reach while sitting in a wheelchair. Despite staff members, including CNAs, an RN, and the DON, passing by her room, none addressed the issue. Resident M's medical history includes severe vision impairment, moderate cognitive impairment, and a need for extensive assistance with mobility and transfers. Her care plan specifically required that her call light be within reach to prevent falls and ensure timely assistance. Resident P was found lying in bed with her call light tucked under her shoulder and out of sight. Although capable of using the call light, she was unable to transfer or ambulate independently. Her medical history includes severe vision impairment, severe cognitive impairment, and a history of falls. Her care plan also emphasized the importance of having the call light within reach to prevent falls and ensure prompt assistance. Resident Q was observed sitting in a wheelchair with her call light under the bedding and out of reach. She indicated that she would use the call light to call for assistance but was unable to locate it. Resident Q's medical history includes hemiplegia, hemiparesis, and dementia, and she is totally dependent on assistance for mobility and transfers. Her care plan required that the call light be within reach to prevent falls and ensure timely assistance. The facility's policy on answering call lights, which mandates that call lights be plugged in and within easy reach, was not followed in these instances.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address resident grievances regarding missing clothing and hearing aids for multiple residents. Confidential interviews revealed that patient laundry was frequently missing, and there were multiple complaints by family members about the missing clothes. Concerns about resident care and the quality of care were reported to the nursing staff and receptionist, but there was no response from management. Grievance logs from January to April 2024 indicated only a few documented concerns, none of which related to the missing clothing or hearing aids. Resident C's record lacked documentation of clothing or missing clothing, and there was no inventory of personal effects completed. Resident J's family reported multiple missing items, including hearing aids and clothing, but no grievance forms were filled out, and the items were not found or replaced. Resident Q's family also reported missing clothing, but there was no documentation in the grievance logs, and the inventory list was outdated. Interviews with staff revealed a lack of knowledge about the grievance process and the location of grievance forms. The Social Services Director (SSD) acknowledged the problem with staff not filling out grievance forms and indicated there was no current process in place for handling grievances. The facility's grievance policy was provided, but it was not being followed, as evidenced by the lack of documentation and follow-up on reported grievances.
Failure to Provide Personalized Activities for Residents
Penalty
Summary
The facility failed to provide personalized activities to a dependent resident, Resident K, who was incapable of self-initiated activities. Despite the family's request for the resident to be out of bed daily from around 11:00 a.m. to 3:00 p.m. to attend activities, observations showed that Resident K was frequently left in bed, often in a hospital gown, and not engaged in any activities. Staff interviews revealed inconsistencies in getting the resident out of bed, with some staff unable to explain why the resident had not been up during the day shift. The resident's care plan indicated a need for support in activity participation, but this was not consistently provided, as evidenced by multiple observations of the resident lying in bed without engagement in activities over several days. Resident J, who had dementia, also did not receive consistent activity engagement. The resident had moved from a secured memory care unit to a room in the health center due to the busy atmosphere of the former. Despite the resident's need for hearing aids, which were lost, no alternative hearing devices were provided, making it difficult for her to engage in activities or hear the TV without disturbing others. Observations showed Resident J often sitting alone, either in her room or in the hallway, without meaningful engagement. The resident's record lacked documentation of care plans for activity preferences or personal preferences for care. Interviews with staff, including the Director of Life Enrichment, revealed that while activity calendars and participation tracking were in place, they were not effectively implemented for Residents K and J. The facility's documentation did not provide specific details on the activities attended by the residents or their level of engagement. This lack of personalized activity planning and execution led to the residents not receiving the cognitive, social, and emotional stimulation they needed, as outlined in their care plans.
Failure to Ensure Fall Follow-Up and Care Plan Updates
Penalty
Summary
The facility failed to ensure fall follow-up was completed for two residents, Resident C and Resident K, who were reviewed for falls. Resident C had several falls due to muscle weakness and cognitive impairment, but the facility did not document root causes, follow-up assessments, or care plan updates for incidents on 3/9/24 and 3/13/24. Additionally, there was a discrepancy in the reported location of a fall that led to hospitalization on 4/11/24, and the resident was not listed on the fall tracking log during her admission period. Resident K, who had hemiplegia and dysphagia, experienced a witnessed fall on 3/1/24. The facility did not document 72-hour follow-up assessments, family notifications, or a fall care plan. Observations on 4/24/24 revealed the resident lying in bed with a fall mat on the floor, but no care plan was found despite a high fall risk score. Interviews with staff indicated that proper fall follow-up procedures, including head-to-toe assessments, vital signs, and neuro checks for unwitnessed falls, were not consistently followed. The facility's policy on managing falls, dated March 2018, was not adequately implemented, leading to deficiencies in fall prevention and follow-up care for the residents involved.
Failure to Properly Elevate Head of Bed for Resident with G-Tube
Penalty
Summary
The facility failed to properly elevate the head of the bed (HOB) for a resident receiving nutrients via a gastroscopy tube (g-tube) who had a known history of aspiration pneumonia. Multiple observations revealed that the resident was frequently lying on his back with the HOB elevated less than 30 degrees while the tube feeding formula was infusing at 70 ml/hr. Additionally, the bags of tube feeding formula and water were not labeled with the date, time, nurse's name, or physician's order, as required by the facility's policy. Despite the family member's concerns and complaints to the facility management, the issue remained unresolved, posing a risk to the resident's health. The resident's medical record indicated diagnoses including a history of pneumonitis due to inhalation of food and vomit, hemiplegia, hemiparesis, dysphagia, and gastro-esophageal reflux disorder (GERD). Physician's orders and the care plan specified that the HOB should be elevated 30-45 degrees during feeding and at least one hour post-feeding. However, observations on multiple occasions showed non-compliance with these orders. The facility's policy on enteral feedings also emphasized the importance of preventing aspiration by elevating the HOB at least 30 degrees during and after tube feeding, which was not adhered to in this case.
Failure to Post Ombudsman Contact Information
Penalty
Summary
The facility failed to publicly post the name, address, and telephone number of the area Ombudsman, affecting all 44 residents and their representatives. During a confidential interview, a resident expressed a desire for regular visits from the Ombudsman but noted the absence of posted contact information. Observations on 4/25/24 confirmed that there was no Ombudsman contact information posted at the front entrance or common areas of the health center. Interviews with staff, including a Registered Nurse, the Assistant Director of Nursing, the Director of Nursing, and the receptionist, revealed that none of them knew where the Ombudsman information was posted. The receptionist mentioned that the information had been in a frame that broke and was subsequently misplaced. The Administrator acknowledged that the signs had been stolen and indicated plans to make new ones. Further observations on 4/25/24 showed the receptionist retrieving the broken frame that had previously contained the Ombudsman contact information. On 4/29/24, the Administrator confirmed that the facility had no specific policy regarding the posting of Ombudsman information. This lack of posted information and the absence of a policy directly contributed to the deficiency, leaving residents and their representatives without easy access to the Ombudsman’s contact details.
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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