Saint Anthony
Inspection history, citations, penalties and survey trends for this long-term care facility in Crown Point, Indiana.
- Location
- 203 Franciscan Dr, Crown Point, Indiana 46307
- CMS Provider Number
- 155214
- Inspections on file
- 43
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Saint Anthony during CMS and state inspections, most recent first.
A nurse failed to follow professional standards of medication administration when an LPN, who admitted to smoking marijuana before work, attempted to give a resident a blue pill later identified as finasteride 5 mg taken from another resident’s card, instead of the ordered famotidine 20 mg for GERD. The resident’s family noticed the discrepancy, questioned the pills in the cup, and retained a photo of the medication, which was confirmed through record review and drug references to be a drug not ordered for the resident. Facility records showed the resident was cognitively intact, had GERD, and had no orders for finasteride, while the facility’s own medication pass guidelines required verification of the correct drug against the MAR and prohibited borrowing medications, which were not followed in this incident.
An RN was observed twice leaving an unlocked medication cart unattended and out of sight during a med pass. In each instance, the RN removed medications from the cart, prepared pills in a medication cup (including a Miralax dose in one case), and entered a resident's room to administer the meds while the cart remained unlocked in the hallway. In a subsequent interview, the RN acknowledged she was required to lock the cart whenever stepping away, and facility policy confirmed that all drugs and biologicals must be stored in locked compartments or remain under direct observation during administration.
Two residents with diabetes did not receive insulin and blood sugar monitoring as ordered by their physicians. Multiple scheduled doses of insulin, including Lispro, Lantus, and Glargine, were missed or not administered according to sliding scale protocols, and blood sugar checks were not consistently performed. Facility leadership acknowledged the missed doses but provided no further explanation.
A resident with Alzheimer's disease, asthma, and GERD was observed keeping and self-administering Tums and an inhaler at the bedside without documented physician orders for self-administration or completed assessments to determine their ability to do so. The facility did not have a care plan or required documentation in place, despite policy requirements.
Two residents did not have their MDS assessments accurately completed regarding antianxiety and antiplatelet medication use. One resident with psychiatric and neurological diagnoses was documented as not receiving antianxiety medication on the MDS, despite physician orders and MAR showing regular administration of clonazepam. Another resident with cardiovascular and renal conditions was similarly documented as not receiving antiplatelet medication, although ticagrelor was administered as ordered. The MDS Coordinator confirmed both errors.
Two residents who were dependent on staff for ADLs did not consistently receive scheduled showers or nail care. One resident missed several scheduled showers, and another had long toenails with no documentation of nail care, despite both having care plans requiring these services. The DON was unable to provide further documentation for the missed care.
A resident with multiple medical conditions, including dementia and on anticoagulant therapy, was observed with a dark purple discoloration on the hand. Despite care plan interventions to monitor for bruising, there was no documentation of assessment or monitoring of the area, and the wound nurse was unaware of the issue.
Two residents with a history of falls and injuries did not have required fall prevention interventions in place, including accessible call lights, non-skid strips, and Dycem mats, as specified in their care plans. Observations confirmed that these interventions were missing at the time of review, despite recent falls resulting in injuries and hospitalizations.
A resident with severe cognitive impairment and respiratory conditions was observed receiving oxygen at 5 lpm instead of the physician-ordered 3 lpm. The incorrect oxygen flow was identified during observations and confirmed by record review and staff interview.
A QMA left a medication cart drawer partially open and unattended with medications visible while administering medications to a resident. The QMA was unaware the drawer was not fully closed, which was not in accordance with facility policy requiring all medications to be secured in locked storage areas.
A staff member in a Memory Care Unit used foul language in the presence of residents after an altercation with a resident diagnosed with Alzheimer's disease. The employee, Terminated Employee 1, reacted to having her hair pulled by Resident G by yelling profanity, which was heard by other residents. The facility's investigation found no staff-to-resident abuse, but the incident was considered disrespectful and undignified.
A facility failed to implement care-planned fall prevention interventions for a resident with dementia and a history of falls. The resident was observed in a wheelchair without a non-slip pad, and a floor mat was not placed next to the bed as required. Staff were unsure about the interventions, and care cards were not up to date, leading to the deficiency.
The facility did not maintain up-to-date Nurse Staffing information, as observed when the posted information was outdated by several days. The Administrator stated that either the Scheduler or the Nursing Supervisor was responsible for updating this information daily. This issue was linked to specific complaints.
A facility failed to implement fall interventions for a resident with a history of falls. Despite a care plan requiring non-skid strips in the bathroom, they were not in place, increasing the resident's fall risk. The resident, with severe cognitive impairment and a history of self-transferring, was found on the bathroom floor, highlighting the need for the intervention.
The facility failed to document meal consumption for two residents with a history of weight loss. One resident, who was cognitively intact, experienced significant weight loss and had numerous undocumented meals. Another resident, who was cognitively impaired, also had missing meal documentation and experienced weight loss. The DON was unable to provide documentation for the missing records.
A facility failed to monitor a resident's pulse before administering metoprolol succinate, as required by the physician's order. The resident, with multiple health conditions, was given the medication on several occasions without documented pulse checks. The DON confirmed the absence of documentation.
The facility failed to provide adequate ADL care for several residents, including those with cognitive impairments and physical disabilities. Observations revealed issues such as greasy hair, unshaven facial hair, and soiled linens, indicating neglect in personal hygiene and toileting care. Documentation inconsistencies and missing records further highlighted the facility's failure to adhere to care plans requiring scheduled showers and grooming.
The facility failed to properly store medications in four out of five medication carts, with loose pills found scattered in the drawers. Nurses acknowledged their responsibility for cleaning the carts, and the DON confirmed that all nursing staff were accountable for this task.
A resident was observed with a medication cup containing multiple pills, which she stated were left by nurses for her to take after breakfast. Despite an IDT note indicating the resident was capable of self-administering medications, there were no physician orders authorizing this. The resident's diagnoses included dementia, heart disease, and anxiety disorder, and she had been taking various medications, including antidepressants and opioids.
The facility failed to notify families of significant weight loss and new dietary orders for two residents. One resident with dementia lost 12.5% of their weight since admission, and another with Alzheimer's lost 6.45% over four months. Despite these changes, families were not informed, contrary to facility policy.
A facility failed to ensure a clean and homelike environment for a resident, as evidenced by stained and dirty bed linens. The resident was observed with a dark reddish-brown stain on the bottom sheet and a large brown stain on the pillowcase over two days. Despite care being provided, the stains remained until the Administrator acknowledged the issue and changed the linens.
The facility failed to monitor and document skin discolorations for three residents. A resident had scabbed areas and discolorations on his forearms without documentation, despite being at risk for skin breakdown. Another resident had dark purple discolorations on her hands, not documented despite her care plan noting a risk for bruising due to aspirin therapy. A third resident had discolorations on his legs, a reddened neck, and a swollen arm, with no documentation or awareness from the Wound Nurse.
A resident with cognitive impairment and a history of hemiplegia and vascular dementia was observed with broken glasses, which were not addressed in a timely manner. The resident's record lacked documentation of the issue or optometry appointments. A CNA noted the glasses had been broken for several days, but it was unclear if the nurse or Unit Manager had been informed. The Social Service Director was unaware of the problem but planned to investigate.
The facility failed to provide adequate pressure ulcer care for two residents. One resident developed a stage 3 pressure ulcer on the left hip, with a lack of documented treatment orders and a data entry error by the Wound Nurse. Another resident was observed without pressure offloading boots, despite orders for their use, and there was no documentation of refusal or intolerance. These deficiencies highlight a failure in ensuring necessary treatment and preventative care.
The facility failed to apply hand splints as ordered for three residents, affecting their range of motion and mobility. A resident with hemiplegia was observed without a prescribed splint, and staff were unaware of the order. Another resident with severe cognitive impairment and cellulitis was not wearing a required splint, and a third resident with a hand contracture reported not receiving assistance with splint application. There were no care plans or documentation of refusals for the splints.
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. One resident was observed without prescribed floor mats, and another was without non-skid footwear, both contrary to their care plans. The DON was informed but provided no further information.
A facility failed to document urinary output for a resident with a catheter as per the care plan. The resident, who was cognitively intact and dependent on staff for toileting, reported that staff did not regularly empty the catheter bag. The care plan required documentation of catheter output every shift, but records showed multiple instances of missing documentation. The DON confirmed the requirement for documentation every shift.
The facility failed to implement interventions for residents with significant weight loss and did not complete food consumption logs or weekly weights as ordered. A resident with Lewy body dementia lost 29 pounds without receiving nutritional supplements, and their food intake was not consistently recorded. Another resident with diabetes and osteoarthritis lost significant weight, with numerous undocumented meals despite care plan interventions. A third resident with heart failure and kidney disease experienced weight loss, and weekly weights were not obtained as ordered.
A facility failed to provide appropriate care for a resident with a g-tube by not performing a required 30 ml water flush before administering medication. An RN was observed administering Tylenol via the g-tube without the pre-medication water flush, contrary to the physician's orders. The RN acknowledged forgetting this step during an interview.
A facility failed to provide trauma-informed care for a resident with PTSD, dementia, and other mental health issues. Despite care plans outlining interventions like room visits and relaxation techniques, these were not effectively implemented. Staff interviews revealed a lack of awareness and communication regarding the resident's needs and triggers, contributing to the deficiency.
A facility failed to accurately document the administration of antibiotics for a resident with a history of septicemia and a urinary tract infection. Despite a physician's order for piperacillin-tazobactam to be given intravenously every 8 hours, the MAR showed missing signatures for several doses. The DON confirmed the absence of antibiotics in storage, suggesting they were administered but not recorded.
An RN improperly disposed of a used lancet in a resident's garbage can instead of a sharps container during a blood sugar check, violating the facility's infection control guidelines.
Improper Medication Administration and Impairment Concerns During Med Pass
Penalty
Summary
The deficiency involves a failure to ensure professional standards of quality in medication administration when a nurse attempted to administer the wrong medication to a resident and admitted to having used marijuana before work. A family member of Resident B reported that the nurse assigned to the resident smelled like marijuana and had brought a medicine cup containing the wrong medications, including a blue round pill marked "F5," to administer to the resident. The family questioned the pills, took the cup, and later provided a picture of the medication. The nurse initially stated there were no issues with the resident or family during the shift, but later acknowledged bringing the medication cup into the room and that the family questioned the blue pills. Record review showed that Resident B had a diagnosis of GERD and a physician’s order for famotidine 20 mg tablets, to be given twice daily, with no orders for finasteride. The care plan for Resident B included an intervention to administer medications as ordered for GERD. The blue pill in the medicine cup photographed by the family was identified as finasteride 5 mg, a medication prescribed for benign prostatic hyperplasia in men, and it was determined that this medication belonged to another resident (Resident E). The nurse reported that, because Resident B’s medications had not yet been delivered, she took what she believed to be famotidine from the cart, but the pill was actually finasteride. Interviews documented in the investigation indicated that the Executive Director and DNS were informed that the family believed the nurse appeared impaired and that the wrong medication had been prepared for Resident B. While the Executive Director did not personally observe signs of impairment or smell of substances when assessing the nurse at the end of the shift, the nurse admitted during the investigation to smoking marijuana before coming to work, though she later retracted this statement. The facility’s medication pass guidelines required verification of the correct medication, strength, and directions against the MAR and prohibited borrowing medications, but the nurse’s actions in pulling finasteride from another resident’s supply and attempting to administer it as famotidine to Resident B did not comply with these professional standards of medication administration.
Unlocked Medication Cart During Med Pass
Penalty
Summary
Surveyors identified a deficiency related to medication security when an RN failed to keep a medication cart locked during a medication pass. On 4/8/26 at 9:32 a.m., the RN was observed preparing medications for a resident by retrieving medications from the cart, popping pills into a medication cup, and preparing a dose of Miralax in water. She then walked into the resident's room to administer the medications, leaving the medication cart unlocked and out of her sight. After administering the medications, she returned to the cart and prepared the next resident's medications. A second similar incident was observed on the same date at 9:41 a.m., when the RN again retrieved medications from the cart, popped the pills into a medication cup, and went into another resident's room to administer the medications, leaving the cart unlocked and out of sight. During an interview at 9:51 a.m., the RN acknowledged she was supposed to lock the cart any time she stepped away from it. The facility's current "Medication Storage" policy stated that all drugs and biologicals must be stored in locked compartments and that during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area or cart. The Executive Director was notified of the RN leaving the cart unlocked and provided no further information.
Failure to Administer Insulin and Monitor Blood Sugar as Ordered
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the administration of insulin and monitoring of blood sugar levels for two residents with diabetes mellitus. For one resident, multiple instances were identified where blood sugar checks were not performed and prescribed insulin doses, including Lispro, Lantus, and Glargine, were not administered as ordered by the physician. Documentation showed missed insulin doses at various scheduled times, and in some cases, insulin was administered even when blood sugar levels were below the threshold specified in the physician's order. The Executive Director acknowledged the missed doses during an interview but provided no further information. For another resident, similar deficiencies were observed, including failure to administer sliding scale Lispro insulin when blood sugar readings indicated it was required, and missed doses of Glargine insulin at bedtime. The resident's care plan and physician's orders clearly outlined the need for insulin administration based on blood sugar results, but the Medication Administration Records revealed several occasions where insulin was not given as ordered. The Administrator confirmed the missed dosages and had no additional information regarding these omissions. The facility's medication administration policy required medications to be given as ordered by the physician.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, asthma, and gastroesophageal reflux disease (GERD) was observed on multiple occasions with Tums (calcium carbonate) and an inhaler at the bedside. The resident reported self-administering Tums as needed for heartburn, and the inhaler was also kept at the bedside. Review of the resident's medical record showed that while there were physician's orders for the use of albuterol sulfate and calcium carbonate as needed, there were no specific orders permitting self-administration of these medications. Additionally, there was no documented assessment to determine the resident's ability to safely self-administer medications, nor was there a care plan addressing self-administration. The facility's policy required both a clinical assessment and a specific skill assessment to determine appropriateness for self-administration, but these steps were not completed for this resident. The DON was unable to provide further information regarding the lack of documentation.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed for two residents regarding their receipt of antianxiety and antiplatelet medications. For one resident with diagnoses including schizoaffective disorder, general anxiety disorder, and dementia with behavioral disturbance, multiple quarterly MDS assessments indicated that the resident had not received any antianxiety medications. However, the care plan and physician's orders documented ongoing administration of clonazepam, an antianxiety medication, which was also confirmed by the Medication Administration Record (MAR). The MDS Coordinator acknowledged that the medication had been incorrectly coded as an anticonvulsant due to the classification in the computer charting system. For another resident with a history of stroke, congestive heart failure, and chronic kidney disease, the admission MDS assessment indicated no receipt of antiplatelet medications in the past seven days. Contrarily, the physician's order summary and MAR showed that the resident had been receiving ticagrelor, an antiplatelet medication, twice daily. The MDS Coordinator confirmed that the MDS assessment was incorrect and required modification.
Failure to Provide Scheduled Showers and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for dependent residents, specifically regarding twice weekly showers and nail care. One resident, who was cognitively intact and dependent on staff for bathing and other ADLs due to conditions including heart failure, chronic kidney disease, and a stage 3 pressure ulcer, reported not always receiving scheduled showers. Record review confirmed missed showers on multiple scheduled dates, and the Director of Nursing was unable to provide documentation for these missed showers. Facility policy required showers to be provided per schedule or resident request, but this was not consistently followed. Another resident, also cognitively intact and dependent on staff for personal hygiene due to diagnoses including edema and type 2 diabetes mellitus, reported that her toenails had not been cut despite requests. Observation confirmed long toenails, and record review showed no documentation of nail care being performed during the review period, despite care plan interventions specifying nail care on bath days and as needed. The Director of Nursing had no additional information regarding the lack of nail care documentation.
Failure to Assess and Monitor Skin Discoloration in Resident on Anticoagulant Therapy
Penalty
Summary
A resident with diagnoses including anemia, atrial fibrillation, heart failure, hypertension, and dementia was observed on two separate occasions to have a dark purple discoloration on the top of his right hand. The resident was cognitively impaired, required substantial assistance with mobility and dressing, and was receiving anticoagulant therapy (Eliquis) for atrial fibrillation. The care plan indicated the resident was at risk for abnormal bleeding due to anticoagulant use and included interventions to inspect the skin for bruising and notify nursing staff of abnormal findings. Despite these interventions, there was no documentation in the medical record that the discoloration had been assessed or monitored. The weekly skin assessment did not note any new skin concerns, and the wound nurse was unaware of the discoloration until interviewed by surveyors. The facility did not provide a policy regarding the assessment or monitoring of skin discolorations.
Failure to Implement Fall Prevention Interventions for Residents with History of Falls
Penalty
Summary
The facility failed to ensure that residents with a history of falls and injuries had appropriate fall prevention interventions in place. One resident, who had diagnoses including Alzheimer's disease and dementia, was observed twice with her call light not within reach, despite her care plan specifying that the call light and personal items should be accessible. This resident had recently fallen while attempting to reach for something from her nightstand, resulting in visible injuries, and was unable to locate her call light during both observations. Documentation confirmed her cognitive intactness and dependence on staff for mobility and transfers. Another resident, with a history of a left humerus fracture and other medical conditions, was observed without required non-skid strips near his recliner and without a Dycem mat in his wheelchair, as ordered in his care plan. The resident had recently fallen while trying to pull up his pants from the recliner, resulting in a fracture and hospitalization. Observations confirmed the absence of these fall prevention interventions, and staff interviews indicated that the resident was frequently noncompliant with the Dycem and that the recliner may have been moved, leading to the non-skid strips not being in the correct location.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, asthma, and chronic obstructive respiratory disease did not receive oxygen therapy as ordered by the physician. The resident, who had severe cognitive impairment and was dependent for bed mobility, transfers, and toileting, was observed on two separate occasions with oxygen administered at 5 liters per minute (lpm) via nasal cannula, instead of the prescribed 3 lpm continuously. The discrepancy between the physician's order and the actual oxygen flow rate was confirmed through record review and staff interview.
Medication Cart Left Unsecured While Unattended
Penalty
Summary
A medication cart was observed with a bottom drawer not fully closed and medications visible while unattended. The Qualified Medication Aide (QMA) had prepared medications for a resident, locked the cart, and entered the resident's room, but the drawer remained partially open from 9:12 a.m. to 9:18 a.m. The QMA was unaware that the drawer was not completely closed. The Director of Nursing was informed of the incident, and the facility's policy was reviewed, which requires all medications to be secured in locked storage areas accessible only to authorized personnel.
Staff Use of Foul Language in Memory Care Unit
Penalty
Summary
The facility failed to ensure that residents on the Memory Care Unit were treated with respect and dignity. This deficiency arose from an incident involving a staff member, Terminated Employee 1, who used foul language in the presence of residents. The incident occurred when Resident G, who has a diagnosis of Alzheimer's disease and/or dementia, grabbed the hair of Terminated Employee 1. In response to the pain, the employee began to yell profanity, including calling RN 1 derogatory names when instructed to leave the facility. This altercation was audible to residents in the hallway and common area, potentially affecting all residents on the Memory Care Unit. The facility's investigation into the incident, reported to the Indiana Department of Health, concluded that staff-to-resident abuse had not occurred. However, it was noted that Terminated Employee 1 admitted to using profanity in front of the residents. During interviews, RN 1 confirmed that the employee's reaction was not violent towards the resident but was a response to the situation. Despite this, the use of foul language in a setting with residents who have cognitive impairments was deemed disrespectful and undignified, leading to the deficiency finding.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care-planned interventions to prevent injuries from falls for a resident with a history of falls and dementia. On multiple observations, the resident was seen sitting in a wheelchair without a non-slip pad, which was a specified intervention in the care plan. Additionally, when the resident was assisted to bed, a floor mat intended to be placed next to the bed was not used, as it was left leaning against the wall. Staff members, including a QMA and a CNA, were unsure about the requirement for the non-slip pad and did not place it under the resident in the wheelchair. During an interview, a CNA indicated that care cards, which contain interventions to prevent falls, were available but not always up to date. A review of the care card confirmed the requirement for a non-slip pad on the wheelchair, but the floor mat was not listed. The resident's care plan, however, included both interventions, with the non-slip pad added in November 2024 and the floor mat in March 2020. The deficiency was identified during a complaint investigation related to the resident's risk for falls and history of falls.
Outdated Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted Nurse Staffing information was up-to-date and current, which had the potential to affect all residents in the facility. The Nurse Staffing Information was observed to be outdated, as it was dated 1/8/25, while the observation took place on 1/13/25. During an interview, the Administrator indicated that either the Scheduler or the Nursing Supervisor was responsible for posting the current Nurse Staffing Information daily. This deficiency was related to Complaints IN00449509 and IN00450162.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident with a history of falls, identified as Resident D. On October 8, 2024, it was observed that there were no non-skid strips on the bathroom floor of Resident D's room, despite a care plan intervention dated September 23, 2024, which required these strips to be placed near the toilet. Resident D's medical history includes Alzheimer's disease, hypertensive chronic kidney disease, type 2 diabetes mellitus, osteoarthritis, dementia, and repeated falls. The resident was assessed as severely cognitively impaired and required substantial assistance with activities of daily living. The facility's records indicate that Resident D had a history of behaviors such as hitting, punching, and kicking walls, and self-transferring without assistance, which contributed to her fall risk. An incident on September 23, 2024, involved the resident being found on her bathroom floor, prompting the recommendation for non-skid strips. However, these strips were not in place at the time of the survey. Interviews with staff confirmed the absence of the non-skid strips, and the facility's fall management policy required fall risks to be assessed and interventions discussed by the interdisciplinary team after each fall.
Failure to Document Meal Consumption for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for residents with a history of weight loss, specifically for Residents F and C. Resident F, who was cognitively intact and required partial assistance with eating, experienced a significant weight loss from 227 pounds to 203 pounds over a short period. The resident's meal intakes had declined due to depression, yet the facility did not document meal consumption for numerous dates across breakfast, lunch, and dinner. The Director of Nursing (DON) was unable to provide any documentation for the missing meal consumption logs. Resident C, who was cognitively impaired and required substantial assistance with eating, also had missing meal consumption documentation. The resident's weight decreased from 170 pounds to 154 pounds, and there were multiple instances where meal consumption was not documented. Despite being informed of the missing documentation, the DON did not provide further information. This deficiency was related to a specific complaint, indicating a failure in maintaining accurate records of food and fluid intake for residents at nutritional risk.
Failure to Monitor Pulse Before Administering Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was properly managed and monitored, specifically regarding the administration of metoprolol succinate, a blood pressure medication. The deficiency involved not monitoring the resident's pulse as ordered before administering the medication. The resident, who was cognitively intact, had multiple diagnoses including atrial fibrillation, heart failure, hypertension, Cushing's syndrome, diabetes mellitus, and end-stage renal disease. The physician's order required holding the medication if the heart rate was less than 60. However, the medication was administered on multiple dates without any documentation of pulse monitoring prior to administration. The Director of Nursing confirmed the lack of documentation during an interview.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for several residents, as evidenced by observations, record reviews, and interviews. Resident 76, who has hemiplegia and vascular dementia, was observed with greasy hair and food debris in his beard, indicating a lack of proper hygiene care. The resident's care plan required total assistance for bathing, yet records showed only bed baths were given instead of scheduled showers, with no documentation of refusals on certain dates. Similarly, Resident 121, who requires total assistance for bathing due to dementia, reported not receiving showers as scheduled, with missing documentation for several dates. Resident 52, who is cognitively intact but dependent on staff for personal hygiene, was observed with long facial hair, indicating a lack of grooming care. The care plan required weekly shaving, but staff interviews revealed this was not consistently done. Resident C, who is severely cognitively impaired and dependent on staff for toileting, was found in bed with soiled linens and no brief, suggesting neglect in personal hygiene and toileting care. The documentation for Resident C's showers was incomplete, with refusals noted but no further information provided. Resident 45, who has schizoaffective disorder and requires substantial assistance for showering, reported not receiving showers twice a week as scheduled. Although the shower sheets indicated some showers were given, there were inconsistencies in the documentation. Interviews with the Director of Nursing and other staff members revealed a lack of additional shower sheets and no further information to address the discrepancies. These findings highlight the facility's failure to ensure dependent residents received the necessary ADL care, as required by their care plans.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in four out of five medication carts observed. During observations on May 20, 2024, it was noted that the 1A, 2C, 2B, and 3D Medication Carts contained loose pills of various sizes and colors scattered throughout the bottoms of the drawers. The nurses responsible for these carts acknowledged that it was their duty to ensure the medication carts were cleaned and organized. In an interview conducted on the same day, the Director of Nursing confirmed that all nursing staff were responsible for maintaining the cleanliness and organization of the medication carts. This deficiency indicates a lapse in the facility's adherence to proper medication storage protocols, as required by professional principles and regulations.
Lack of Physician Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident had physician's orders for self-administration of medications. On May 14, 2024, a resident was observed in her room with a medication cup containing multiple pills on the table next to her. The resident stated that nurses routinely left her morning medications for her to take after breakfast. The resident's medical record, reviewed on May 15, 2024, indicated diagnoses including dementia, heart disease, and anxiety disorder. An MDS assessment dated April 5, 2024, showed the resident was cognitively intact for daily decision-making and had been taking various medications, including antidepressants and opioids, in the past week. An IDT note from May 14, 2024, documented that the team determined the resident was capable of self-administering her prescribed medications, which included furosemide, l-methylfolate, levothyroxine, and others. However, there were no physician orders authorizing the resident to self-administer these medications. During an interview on May 16, 2024, the Administrator acknowledged that there should have been an order for self-administration.
Failure to Notify Family of Significant Weight Loss and Dietary Changes
Penalty
Summary
The facility failed to notify the family or representative of significant weight loss and a new nutritional supplement order for two residents. Resident 59, diagnosed with Lewy body dementia, psychotic disorder, depressive disorder, and diabetes mellitus, experienced a significant weight loss of 15 pounds, or 5%, within one month, followed by an additional 14-pound loss, totaling a 12.5% weight loss since admission. Despite these changes, there was no documentation that the family was informed. A family member confirmed they were only notified of the weight loss on 5/16/24, and the Director of Nursing acknowledged the lack of documentation regarding family notification. Similarly, Resident 143, with Alzheimer's dementia, iron deficiency, and chronic lymphocytic leukemia, lost eight pounds, or 6.45%, over four months. A new physician's order for a health shake was issued due to the weight loss, but there was no documentation that the family was informed. A family member was unaware of the weight loss and the new dietary order. The Administrator confirmed the absence of documentation for family notification. The facility's policy requires notifying the resident's physician and family/guardian of any significant weight change, which was not adhered to in these cases.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Resident B, as evidenced by stained and dirty bed linens. On two consecutive days, Resident B was observed lying in bed with a dark reddish-brown stain on the bottom sheet and a large brown stain on the pillowcase. Despite care being provided by a CNA, the stains remained on the linens. During an interview, the Administrator acknowledged that the linens were likely already stained when placed on the bed and subsequently changed them. This deficiency was identified during a complaint investigation.
Failure to Monitor and Document Skin Discolorations
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services related to the monitoring and assessment of skin discolorations. Resident B was observed with scabbed areas and multiple purple discolorations on his forearms, yet the most recent Weekly Nursing Summary indicated no current skin issues. Despite being at risk for skin breakdown, as noted in his care plan, there was no documentation of these skin conditions, and the Director of Nursing indicated that the Wound Nurse would assess the resident's skin, but no further information was provided. Resident 66 was observed with dark purple discolorations on the tops of both hands, which were not documented in the Weekly Nursing Summary. Her care plan noted a risk for increased bruising due to aspirin therapy, but there was no documentation of these findings, and the Administrator was made aware of the discolorations without further action. Resident 10 had discolorations on his lower legs, a reddened area on his neck, and a swollen right arm, but there was no documentation of these conditions in his record. The Wound Nurse was unaware of these issues, indicating a lack of proper monitoring and assessment.
Failure to Address Resident's Broken Glasses
Penalty
Summary
The facility failed to ensure a resident received the necessary assistive device to maintain vision, as evidenced by the broken glasses of a resident not being addressed in a timely manner. The resident, who has a history of hemiplegia, hemiparesis following a cerebral vascular accident, diabetes mellitus, and vascular dementia, was observed on multiple occasions with broken glasses on the overbed table. The resident indicated that the glasses were used for reading. A review of the resident's record showed no documentation regarding the broken glasses or any optometry appointments. A CNA mentioned that the glasses had been broken for several days, but she was unsure if the nurse or Unit Manager had been informed, as she had been off work. The Social Service Director was also unaware of the issue but indicated she would investigate further.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for pressure ulcers for two residents. Resident D, who was admitted with a risk for pressure ulcers, developed a stage 3 pressure ulcer on the left hip. Despite a care plan indicating wound treatments as ordered, there was a lack of documented treatment orders for the left hip in the Physician's Orders Summary. The Wound Nurse made a data entry error, incorrectly documenting treatment for the left buttock instead of the left hip, and continued using a previous treatment without documenting the deviation from the Wound Nurse Practitioner's recommendation. Resident E, diagnosed with Alzheimer's disease and type 2 diabetes mellitus, was observed without pressure offloading boots, which were found on the floor behind his recliner. Despite a Physician's Order for bilateral heel offloading boots every shift, the Medication Administration Record indicated the boots were signed off every shift. The Director of Nursing was unable to provide documentation of the resident refusing or not tolerating the boots, highlighting a failure to ensure the resident's preventative care was consistently applied.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to ensure proper positioning and application of hand splints for three residents, leading to deficiencies in maintaining or improving their range of motion and mobility. Resident 76, diagnosed with hemiplegia and hemiparesis following a cerebral vascular accident, was observed multiple times without the prescribed left hand splint, which was ordered to be worn 6-8 hours daily. The Treatment Administration Record did not reflect this order, and staff were unaware of the requirement, resulting in the resident's left hand remaining contracted. Resident 10, with severe cognitive impairment and a diagnosis of cellulitis of the right upper limb, was observed without the necessary right hand splint, despite a physician's order for its use and circulation checks every shift. Similarly, Resident 125, who had a contracture in the left hand, was not provided with a splint as ordered, and there was no care plan addressing the contracture. The resident reported that staff had not assisted with the splint in a long time, and there was no documentation of refusals or care plans related to the splinting device.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to ensure fall interventions were in place for two residents, leading to deficiencies in accident prevention. Resident B was observed on two separate occasions lying in bed without the prescribed floor mats in place, which were instead found leaning against the wall. The resident's care plan, updated in March 2024, indicated the need for a mat beside the bed due to the resident's cognitive impairment and requirement for substantial assistance with mobility. Despite this, the intervention was not implemented, and the Director of Nursing (DON) was made aware of the oversight but provided no further information. Similarly, Resident 91 was observed twice seated in a Broda chair without wearing socks, contrary to the care plan's intervention to encourage and assist the resident in wearing appropriate non-skid footwear. The resident, who was cognitively impaired and had a history of falls, was at risk due to the lack of adherence to the care plan. The DON acknowledged the situation and indicated uncertainty about the resident's preference for not wearing socks, suggesting a potential update to the care plan might be necessary.
Failure to Document Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to ensure that urinary output was recorded as per the plan of care for a resident with a urinary catheter. Resident 89, who was cognitively intact and dependent on staff for toileting, was observed with a urinary catheter that had not been emptied regularly. The resident reported having to remind staff multiple times a day to empty the catheter bag. A review of the resident's care plan indicated a requirement to document catheter output every shift, but records showed multiple instances where this documentation was missing across various shifts. The Director of Nursing confirmed that staff should have documented the urinary output every shift.
Failure to Monitor and Document Nutritional Intake
Penalty
Summary
The facility failed to implement necessary interventions for residents experiencing significant weight loss and did not complete food consumption logs or weekly weights as ordered. Resident 59, diagnosed with conditions including Lewy body dementia and diabetes mellitus, experienced a weight loss of 29 pounds since admission, with no documentation of interventions or nutritional supplements provided. The resident's food consumption was not consistently recorded, and the significant weight loss was not identified until surveyors pointed it out. Resident 91, with diagnoses including type 2 diabetes mellitus and osteoarthritis, also experienced significant weight loss, dropping from 137 pounds to 119 pounds over a few months. Despite a care plan intervention to serve diet and supplements as ordered and record consumption, there were numerous instances where meal consumption was not documented. The lack of documentation was brought to the attention of the facility's administrator, but no further information was provided. Resident 158, who has congestive heart failure and chronic kidney disease, was also affected by the facility's failure to monitor nutrition properly. The resident's weight dropped from 175 pounds to 162 pounds, and a physician's order for weekly weights was not followed. Additionally, there were multiple instances where the resident's meal consumption was not recorded. The Director of Nursing had no further information to provide regarding these deficiencies.
Failure to Perform Pre-Medication Water Flush for G-Tube Administration
Penalty
Summary
The facility failed to ensure appropriate treatment for a resident with a gastronomy tube (g-tube) during medication administration. On May 16, 2024, RN 1 was observed preparing and administering medication to Resident 115 via a g-tube. The nurse crushed Tylenol 325 mg tablets, mixed them with water, and administered the mixture through the g-tube. However, RN 1 did not perform the required water flush of 30 ml before administering the medication, as ordered by the physician. This omission was confirmed during an interview with RN 1, who acknowledged forgetting to flush the g-tube with water prior to medication administration. The physician's order specifically required a 30 ml water flush before and after medication administration via the g-tube.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD, dementia, psychosis, major depressive disorder, and generalized anxiety disorder. The resident, who was severely cognitively impaired, exhibited behaviors such as yelling out, anxiety, restlessness, and irritability. Despite having care plans in place that included interventions like room visits, sensory stimulation, and relaxation techniques, these were not effectively implemented or updated to address the resident's PTSD-related needs. Observations noted the resident yelling out in various settings, indicating a lack of adherence to the care plan interventions designed to manage his symptoms. Interviews with facility staff revealed gaps in the execution of the care plan. The Activity Director was unaware of any one-to-one activities being conducted with the resident, despite care plan requirements. Additionally, the Social Services Director admitted to not reaching out to the resident's family to identify potential triggers for the resident's flashbacks and yelling episodes. The family had been invited to care plan meetings but had not attended, leaving the facility without crucial insights into the resident's needs and triggers. This lack of communication and failure to follow through on care plan interventions contributed to the deficiency in providing appropriate care for the resident's PTSD and related behaviors.
Incomplete Documentation of Antibiotic Administration
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented regarding medication administration for a resident being treated with antibiotics. The resident, who was cognitively intact, had a history of septicemia and a urinary tract infection. A physician's order was in place for the administration of piperacillin-tazobactam intravenously every 8 hours for 7 days to treat sepsis due to pseudomonas. However, the Medication Administration Record (MAR) for the month indicated that the antibiotic was not signed off as administered on several occasions, specifically at 6 a.m. on two dates, 2 p.m. on three dates, and 10 p.m. on one date. During an interview, the Director of Nursing confirmed that there were no antibiotics left in the medication storage room and believed the medication had been administered as ordered but not documented in the MAR.
Improper Disposal of Lancet During Blood Sugar Check
Penalty
Summary
The facility failed to adhere to infection control guidelines during a blood sugar check for a resident. An RN was observed performing a blood sugar test on a resident, during which she followed proper hand hygiene and glove use. However, after obtaining the blood sample, the RN improperly disposed of the used lancet in the resident's garbage can instead of the designated sharps container. This action was contrary to the facility's policy on sharps disposal, which mandates that contaminated sharps be discarded into appropriately labeled or color-coded containers. The RN acknowledged the error during an interview following the observation.
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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