Serenity Spring Senior Living At Northwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Jasper, Indiana.
- Location
- 2515 Newton St, Jasper, Indiana 47547
- CMS Provider Number
- 155282
- Inspections on file
- 29
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Serenity Spring Senior Living At Northwood during CMS and state inspections, most recent first.
Surveyors found that hallway and common-area temperatures on three units were below the facility’s own comfort range, with readings as low as 64°F despite a policy requiring 71–81°F. A resident council meeting had previously documented concerns about building temperatures, and residents reported feeling cool or cold when in the Garden Ridge and Cedar Pointe hallways. Maintenance staff stated they aimed to keep temperatures between 72–74°F, but actual thermostat readings on multiple units did not meet this standard, resulting in an environment that was not consistently safe, sanitary, or homelike.
A resident with lack of coordination, muscle weakness, and a history of repeated falls had a care plan identifying fall risk and specifying interventions such as parking the wheelchair outside the room and using a fall mat only when the resident was in bed. Surveyors observed that the fall mat was left on the floor when the resident was up in a wheelchair and that the wheelchair was parked inside the room while the resident was in bed, contrary to the care plan. An RN confirmed these interventions were not followed and noted staff might need reminders, despite a facility policy requiring comprehensive, person-centered care plans to be implemented as written.
The facility did not hold or document required care plan conferences for four residents with various diagnoses, including anxiety, depression, dementia, and neurological disorders. Despite being cognitively intact in most cases, these residents' records showed significant gaps in care plan conference documentation over the past year, contrary to facility policy and staff expectations.
The facility did not document notification to family or resident representatives after falls involving several residents with severe cognitive impairments and complex medical histories. Despite policy requiring such notifications, clinical records and IDT notes lacked evidence that families or representatives were informed following these incidents.
Several residents with severe cognitive and physical impairments experienced repeated falls, and the facility did not consistently perform thorough post-fall assessments, update care plans, or implement timely interventions. Documentation often lacked neurological checks and falls assessments, and staff did not always follow care plan interventions or ensure assistive devices were accessible. Facility policies for post-fall care and care plan updates were not consistently followed.
A resident was discharged from Medicare services with benefit days remaining, but the facility did not have documentation showing that the required Notice of Medicare Non-Coverage (NOMNC) was provided prior to discharge. The Social Service Director reported that the notice was given, but no record of this was found in the clinical file, contrary to facility guidelines.
Two residents were affected by failures in medication management: one was given an antipsychotic injection without a current physician order, and another continued to receive antipsychotic and antianxiety medications without documented attempts at gradual dose reduction or physician-documented contraindications, contrary to facility policy and regulatory requirements.
Staff did not follow infection prevention protocols during incontinence care, including inadequate hand hygiene, improper glove changes, and incorrect handling of incontinence pads. Residents were not offered hand hygiene after toileting, and soiled briefs were not always changed, contrary to facility policy.
The facility failed to provide transfer or discharge notices to five residents or their representatives during hospitalizations. Clinical records lacked documentation of these notices, and the Administrator indicated that staff were not retaining copies in the records.
The facility failed to provide bed hold forms and policies to residents or their representatives during hospitalizations. This deficiency was identified for five residents, whose clinical records lacked documentation of receiving the necessary information. The Administrator acknowledged that staff might not be making copies of the forms for the records.
The facility failed to ensure the accuracy of MDS Assessments for 14 out of 26 resident records reviewed. Several residents were observed without bed rails, despite their assessments indicating daily use of bed rails as restraints. The MDS Coordinator admitted to errors in coding and training, leading to discrepancies between the residents' actual conditions and their documented assessments.
The facility failed to develop comprehensive person-centered care plans for four residents, including those on hospice care and those receiving specific medications. This oversight was confirmed by the MDS Coordinator and the DON, leading to deficiencies in addressing the residents' specific needs.
The facility failed to update care plans and conduct timely care plan conferences for several residents. One resident's care plan was not revised after moving from a locked dementia unit, and another resident's care plan was not updated after a change in sleep medication. Additionally, two residents did not receive care plan conferences within the required timeframe.
The facility failed to ensure residents were free from unnecessary medications, with five residents receiving psychotropic medications without proper diagnoses or exceeding the 14-day limit for PRN orders without documented rationale for extension. The facility's Psychotropic Medication Use Policy was not adhered to in these cases.
The facility failed to maintain safe and secure storage of medications in three medication carts and one medication storage room. Loose pills were found in the carts, and temperature logs for the refrigerators were incomplete. LPNs indicated inconsistencies in cleaning schedules, and medications for a discharged resident were improperly stored.
The facility failed to adhere to food service safety standards as staff were observed handling food and utensils with bare hands during meal services, contrary to the facility's policy requiring the use of gloves.
The facility failed to document influenza and pneumococcal vaccines being offered to three residents. Clinical records lacked consent/refusal dates, reasons for refusal, and dates education was provided. The Infection Preventionist acknowledged the documentation lapses, despite the facility's policy requiring such records.
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, with issues such as dusty vents, unlabeled personal care items, scuffed doors, sticky floors, loose grab bars, and exposed wires in the common area. Observations on two separate dates confirmed these issues were not addressed.
The facility failed to treat two residents with respect and dignity. A CNA was observed standing while assisting a resident with feeding, contrary to policy. Additionally, an LPN left a resident with a visible urine spot under her wheelchair without providing immediate care, violating the facility's dignity policy.
The facility failed to provide ice water to a resident when requested, despite the resident being cognitively intact and requiring extensive assistance. The facility's policies on hydration and accommodation of needs were not followed, as ice water was not routinely passed, and residents had to ask for it.
The facility failed to clarify a resident's code status, resulting in a discrepancy between the resident's DNR order and the physician's orders, which indicated CPR. Interviews confirmed the inconsistency, and the facility's policy was not followed.
The facility failed to ensure a resident's right to be free from physical restraints, as bed rails were used without proper documentation, informed consent, or evidence that the resident could remove the restraint herself. Staff interviews and observations confirmed the inappropriate use of bed rails to prevent falls, contrary to the facility's policy.
A resident reported that a CNA physically removed her fingers from a lift, but the facility failed to document or report the allegation immediately as required by their policy. The DON was aware but did not report it, and the CNA had a prior battery charge.
A facility failed to properly investigate an abuse allegation involving a resident who reported that a CNA physically removed her fingers from a sit-to-stand lift. The incident was not documented or followed up on, and the CNA had a prior battery charge. The facility's policy on abuse reporting and investigation was not followed.
The facility failed to ensure adequate supervision to prevent accidents for two residents reviewed for falls. Non-skid strips were not placed, care plans were not updated, and neurological checks were not consistently completed. The facility did not follow its policies on falls and neurological assessments, leading to multiple falls and injuries.
The facility failed to ensure a resident received appropriate care to prevent and treat UTIs, leading to recurrent infections, cognitive decline, and multiple falls. Delays in obtaining and processing urinalysis orders, misinterpretation of results, and inadequate infection control practices during incontinence care were observed.
The facility failed to provide consistent respiratory care for three residents, with observations of incorrect oxygen settings, uncleaned oxygen concentrator filters, and lack of adherence to physician orders and care plans. The DON confirmed that staff were not following the facility's policy on cleaning filters weekly.
The facility failed to follow proper infection control practices during incontinence care and blood glucose monitoring for three residents. Staff did not perform hand hygiene between glove changes and did not adequately clean a glucometer between uses, contrary to facility policies and expected protocols.
The facility did not post nurse staffing sheets daily during the survey period, missing updates on two specific days. The DON confirmed that the night shift is responsible for this task, and the facility's policy requires daily postings.
Failure to Maintain Comfortable Temperatures in Resident Hallways and Common Areas
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment by not ensuring comfortable temperatures in multiple unit hallways and common areas. Surveyors noted that in 3 of 6 unit halls, including the 100 unit, Garden Ridge unit, and Cedar Pointe unit, temperatures were below the facility’s own policy range of 71–81°F. During observations on consecutive days, the Garden Ridge hallway thermostat was recorded at 65°F and then 64°F, the 100 unit hallway at 70°F, and the Cedar Pointe hallway at 68°F. These readings were inconsistent with the maintenance staff’s stated goal of keeping temperatures between 72–74°F and with the written “Homelike environment” policy specifying comfortable and safe temperatures. Resident feedback and facility records further demonstrated concerns about the low temperatures. Minutes from a Resident Council meeting documented that facility temperature levels were a topic of concern. During interviews, one resident reported that the Garden Ridge unit felt cool, and another resident stated she felt cold when coming out of her room into the Cedar Pointe hallway. These observations, interviews, and record reviews collectively showed that the facility did not maintain temperatures within its defined comfort range in several resident-accessible hallways and common areas.
Failure to Implement Fall-Prevention Care Plan Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan for a resident with a history of repeated falls. Record review showed that the resident had diagnoses including lack of coordination, muscle weakness, and repeated falls, and the most recent quarterly MDS documented upper and lower extremity impairments bilaterally, use of a wheelchair for mobility, and two or more falls since the prior assessment. The resident’s care plan, last revised in January, identified risk for falls and included specific interventions such as parking the wheelchair outside the room to maximize space and safety and placing a fall mat beside the left side of the bed when the resident was in bed, with instructions not to leave the mat on the floor when the resident was up in the wheelchair. During observations, surveyors noted that these care plan interventions were not consistently implemented. When the resident was observed in the dining room in a wheelchair, a fall mat remained on the floor next to the bed in the resident’s room. On another observation, when the resident was in bed sleeping, the wheelchair was parked inside the room near the head of the bed rather than outside the room as specified in the care plan. In an interview, an RN confirmed that the fall mat should be removed from the floor when the resident was not in bed and that the wheelchair should be parked outside the room while the resident was in bed to create more space and provide a safer environment, and indicated CNAs might need reminders about the resident’s fall interventions. The facility’s written policy required development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables, and that services outlined in the care plan be provided by qualified persons.
Failure to Hold and Document Required Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were held and documented for four out of five residents reviewed for unnecessary medications. For each of these residents, clinical record reviews revealed significant gaps in the documentation of care plan conferences within the past year. Specifically, one resident with diagnoses including anxiety, osteoporosis, depression, and early-onset cerebellar ataxia, who was cognitively intact, had no documented care plan conference between May 2024 and February 2025. Another resident with anxiety, depression, and dementia with behaviors, also cognitively intact, lacked documentation of a care plan conference between August 2024 and May 2025. A third resident with dementia without behaviors, depression, epilepsy, and anxiety, who was severely cognitively impaired, had no documented care plan conference after September 2024. The fourth resident, diagnosed with psychotic disorder with hallucinations, vascular dementia with behaviors, and stroke, and who was cognitively intact, had no documented care plan conference after August 2024. Interviews with facility staff confirmed that care plan conferences are expected to occur quarterly and as needed, with documentation required in the clinical record. The facility's own Comprehensive Care Plan Policy, revised in March 2022, also specifies that care plan meetings should take place according to state regulations, including at admission, with changes in condition, quarterly, annually, or as requested by the resident, POA, or facility. Despite these requirements, the records for the identified residents did not contain evidence of timely care plan conferences, resulting in a failure to allow residents to participate in the development and implementation of their person-centered care plans.
Failure to Notify Family/Representatives After Resident Falls
Penalty
Summary
The facility failed to ensure timely notification of family members or resident representatives following a change in condition, specifically after resident falls, for four out of five residents reviewed. In each case, clinical records and interdisciplinary team notes documented the occurrence of falls, but lacked evidence that the family or resident representative was informed. The residents involved had significant cognitive impairments or diagnoses such as Parkinson's disease, dementia, Alzheimer's disease, schizophrenia, seizure disorder, and depression. Falls were documented in the residents' health status notes and reviewed by the interdisciplinary team, but there was no documentation of required notifications to families or representatives. The facility's policy, last revised in 2018, requires that both the physician and family be notified when a resident falls, and that this notification be recorded in the medical record. Despite this policy, the records for the affected residents did not include documentation of such notifications. The Assistant Director of Nursing confirmed that all provided information was part of the clinical record and that any additional internal documents were not included in the clinical record reviewed.
Failure to Provide Adequate Supervision and Post-Fall Assessment
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistive devices to prevent accidents for four out of five residents reviewed for falls. Multiple residents with significant cognitive and physical impairments experienced repeated falls, and the facility did not consistently perform thorough post-fall assessments, update care plans with each incident, or implement timely interventions. For example, one resident with Parkinson's disease and dementia had at least eight falls, with records frequently lacking post-fall neurological checks and falls assessments. Interventions such as anti-rollbacks for wheelchairs and reminders for staff to use gait belts were often delayed in being added to care plans, and some interventions were not implemented at the time of the falls. Another resident, who was legally blind and had a seizure disorder, experienced several falls, including unwitnessed incidents resulting in head injuries. Documentation showed that neurological checks were incomplete or missing after some falls, and falls assessments were not performed. Observations revealed that staff did not always follow care plan interventions, such as ensuring the call light was clipped to the resident's clothing for safety. Transfers were sometimes performed by a single staff member despite care plan requirements for two-person assistance. Additional residents with diagnoses such as Alzheimer's disease, dementia, and schizophrenia also experienced multiple falls. In several cases, the facility did not document interdisciplinary team reviews or update care plans with new interventions after falls. Neurological checks were inconsistently performed or not documented, and falls risk assessments were often omitted following incidents. Observations further indicated that assistive devices, such as call lights, were not always accessible to residents as required by their care plans. Facility policies required neurological assessments and care plan updates after falls, but these were not consistently followed.
Failure to Provide Required Medicare Non-Coverage Notice at Discharge
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to a resident who was being discharged from Medicare services, despite the resident having Medicare benefit days remaining at the time of discharge. Record review showed that there was no documentation in the clinical record indicating that the resident was notified of the end of Medicare coverage prior to discharge. During interviews, the Social Service Director stated that the NOMNC notice was given to the resident, but was unable to provide documentation to support this. Facility guidelines indicated that a NOMNC should have been issued in this scenario, but no such documentation was available in the resident's record.
Failure to Prevent Unnecessary Psychotropic Medication Use and Ensure Proper Documentation
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, resulting in two deficiencies involving two residents. In the first case, a resident with diagnoses including Parkinson's disease, dementia, anxiety, depression, and psychotic disorder was administered an antipsychotic medication (Haldol) via injection after the physician's order for the medication had already been discontinued earlier that day. Documentation in the clinical record confirmed the administration of the medication without a current physician's order, and the Medication Administration Record did not reflect that the medication was given on that date. Interviews with staff revealed a lack of recall regarding the incident and a delay in follow-up after the medication was administered. In the second case, another resident with anxiety, osteoporosis, depression, and early-onset cerebellar ataxia was receiving both an antipsychotic and an antianxiety medication. The clinical record showed ongoing administration of these medications, with care plans indicating the need to consult with the healthcare provider for possible dosage reduction. However, there was no documentation of a contraindication for a gradual dose reduction (GDR) or a rationale from the prescribing practitioner to continue the medications at the current dose. The facility's policy required attempts at GDR unless clinically contraindicated and documented by the physician, but such documentation was not present in the resident's record. Facility policies reviewed included requirements to verify physician orders before administering intramuscular injections and to attempt GDRs for psychotropic medications unless contraindicated and documented. Staff interviews confirmed that orders should be obtained and documented for such medications, and that the required documentation for GDR contraindications was not available in the clinical record for the resident in question.
Infection Control Lapses During Incontinence Care
Penalty
Summary
Staff failed to maintain a sanitary environment and adhere to infection prevention and control protocols during incontinence care for three residents. Observations revealed that hand hygiene was not performed correctly, with staff washing hands for less than the required 15 seconds and failing to perform hand hygiene between glove changes. In several instances, staff handled soiled incontinence pads improperly, such as holding a clean pad against their scrub pants and leaving a visibly soiled pad on a resident after toileting. Additionally, residents were not offered the opportunity to wash their hands after toileting, and staff did not always assess or change soiled briefs as needed. Interviews with staff and review of facility policies confirmed that proper hand hygiene should include at least 20 seconds of scrubbing, and gloves should be changed with hand hygiene performed between tasks. The facility's policy also specified that gloves do not replace handwashing and that hand hygiene is the final step after removing personal protective equipment. Despite these guidelines, staff actions did not align with policy requirements, resulting in multiple breaches of infection control practices during resident care.
Failure to Provide Transfer or Discharge Notices
Penalty
Summary
The facility failed to ensure that a notice of transfer or discharge was given to residents or their representatives for five residents who were hospitalized. The clinical records for these residents lacked documentation of the transfer or discharge notice, and the facility did not make copies of the forms to keep in the residents' clinical records. The Administrator indicated that staff were filling out the forms and sending them with the residents but were not retaining copies in the clinical records. Resident 38, who had severe cognitive impairment, was sent to the emergency room after a fall, but there was no documentation of a transfer notice. Resident 52, with unspecified intellectual disabilities, was sent to the hospital after a fall, but again, no transfer notice was documented. Resident 43, who was cognitively intact, was hospitalized for vomiting, but neither the resident nor the representative received a transfer notice. Resident 15, with moderate cognitive impairment, was hospitalized for hypotension and lethargy, but the transfer form provided later lacked essential information. Resident 46 was hospitalized and returned the next day, but there was no transfer notice documented in the clinical record.
Failure to Provide Bed Hold Information During Hospitalizations
Penalty
Summary
The facility failed to ensure that a bed hold form and policy were provided to residents or their representatives during hospitalizations. This deficiency was identified for five residents who were hospitalized. The clinical records for these residents lacked documentation that the bed hold form and policy were given at the time of hospitalization. For instance, Resident 38, who had severe cognitive impairment, was sent to the emergency room after a fall, but there was no documentation that the representative received the bed hold form and policy. Similarly, Resident 52, who had severe intellectual disabilities, was sent to the hospital after a fall, and the clinical record also lacked documentation of the representative receiving the bed hold form and policy. Resident 43, who was cognitively intact, was sent to the emergency room due to vomiting, but neither the resident nor the representative received the bed hold form and policy. Resident 46 was discharged to the hospital and returned the next day, but there was no documentation that bed hold information was provided. During an interview, the Administrator indicated that staff were likely filling out bed hold forms and giving them to residents but were not making copies to keep in the clinical records. The Director of Nursing provided a current Bed-Holds and Returns policy, which stated that all residents or their representatives should receive written information about the facility's bed-hold policies at least twice, including well in advance of any transfer and at the time of transfer. However, this policy was not followed, leading to the deficiency.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of assessments for 14 out of 26 resident records reviewed during the survey. The Minimum Data Set (MDS) Assessments did not accurately reflect the resident status. For instance, Resident 36's clinical record indicated the use of physical restraints in the form of bed rails, but there was no current physician order or care plan related to bed rails. Similarly, Resident 14's MDS Assessment indicated the use of an anticoagulant medication, but the clinical record lacked a current physician's order for such medication, while it did include orders for antiplatelet medications instead. Several residents were observed without bed rails, despite their MDS Assessments indicating daily use of bed rails as restraints. For example, Resident 48's clinical record lacked an order and care plan related to bed rails, and Resident 19's MDS Assessment incorrectly marked the presence of pneumonia and the use of bed rails. The MDS Coordinator admitted that pneumonia was marked in error and should have been removed from the assessment. Additionally, Resident 17, Resident 52, Resident 38, and Resident 41 were all observed without bed rails, contradicting their MDS Assessments which indicated daily use of bed rails as restraints. The MDS Coordinator acknowledged errors in coding and training, stating that bed rails were not used as physical restraints and that the assessments were marked incorrectly. The facility lacked a policy for MDS Assessments and relied on the Resident Assessment Instrument (RAI) Manual. The inaccuracies in the MDS Assessments were attributed to incorrect training and misunderstanding of the use of bed rails and physical restraints, leading to discrepancies between the residents' actual conditions and their documented assessments.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their specific needs. Resident 19, who was on hospice care due to atherosclerotic heart disease, did not have a hospice care plan in their clinical record. This oversight was confirmed by both the MDS Coordinator and the Director of Nursing (DON), who acknowledged that a hospice care plan should have been in place following the physician's order for hospice care. Additionally, Resident 48, who was receiving antianxiety and antidepressant medications, lacked care plans for these medications, which was also confirmed by the DON as a requirement that should have been fulfilled by the MDS Coordinator. Resident 5, diagnosed with Alzheimer's disease, bipolar disorder, and other conditions, was taking multiple medications, including antipsychotic, antianxiety, hypnotic, anticoagulant, antibiotic, and diuretic medications. However, the clinical records did not include care plans for the diuretic and anticoagulant use. The MDS Coordinator admitted that care plans, especially for medications with black box warnings like anticoagulants, should have been developed. Furthermore, Resident 45, who was on hospice and used a bedside table in the dining room, did not have care plans for hospice care or the use of the bedside table. The resident was observed eating alone at a bedside table, and the CNA indicated that this arrangement was due to the resident's preference and visual impairment. The facility's policy, as provided by the Dementia Care Coordinator, mandates the development and implementation of comprehensive, person-centered care plans with measurable objectives and timetables to meet each resident's needs. The DON confirmed that it is the facility's policy to follow physician's orders and care plan interventions. Despite this policy, the facility failed to ensure that care plans were developed and implemented for the residents reviewed, leading to deficiencies in their care.
Failure to Update Care Plans and Conduct Timely Care Plan Conferences
Penalty
Summary
The facility failed to ensure that residents had timely care plan conferences and that care plans were revised appropriately. Resident 38, who was diagnosed with dementia and had severe cognitive impairment, was moved from a locked dementia unit to another hall, but her care plan was not updated to reflect this change. The Director of Nursing acknowledged that the care plan should have been revised. Additionally, Resident 12, who had moderate cognitive impairment and multiple diagnoses including hypertension and diabetes, did not receive a care plan conference after a significant period. Similarly, Resident 48, who had dysphagia and muscle weakness, did not receive a care plan conference within the required timeframe, as confirmed by the Social Services Director (SSD) and facility policy, which mandates quarterly care plan conferences. Furthermore, Resident 5, who had Alzheimer's disease and other significant health issues, had a change in sleep medication from Ambien to Belsomra, but the care plan was not updated to reflect this change. The Director of Nursing indicated that care plans should be revised immediately after any changes occur. The facility's policy on comprehensive person-centered care plans, revised in March 2022, states that care plans should be revised as information about the residents and their conditions change. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications for five of six residents reviewed. Resident 48 was prescribed an antipsychotic medication, Seroquel, for dementia without behavioral, psychotic, mood, or anxiety disturbances, which is not an acceptable diagnosis for such medication. The Director of Nursing confirmed that dementia alone is not a valid reason for prescribing antipsychotics. Resident 12 had an as-needed order for Lorazepam, an anti-anxiety medication, which was prescribed for restlessness and had been in place since November 2022. The medication was administered on multiple occasions in April and May 2024, exceeding the 14-day limit for PRN orders without documented rationale for extension. Similarly, Resident 14 had an as-needed order for Ativan, another anti-anxiety medication, without a stop date, and it was prescribed for increased anxiety. Resident 3 and Resident 45 also had PRN orders for Lorazepam for anxiety and pain/restlessness, respectively, with no documented rationale for extending the use beyond 14 days. Resident 19, who was cognitively intact, had a PRN order for Lorazepam for anxiety, which was administered multiple times in April and May 2024. The facility's Psychotropic Medication Use Policy, revised in July 2022, states that PRN orders for psychotropic medications should be limited to 14 days unless a documented rationale for extension is provided, which was not adhered to in these cases.
Medication Storage and Temperature Log Deficiencies
Penalty
Summary
The facility failed to maintain safe and secure storage of medications in three out of four medication carts and one out of three medication storage rooms observed. Loose pills were found in the drawers of the medication carts on the PARF Hall, 300 Hall, and 200 Hall. Licensed Practical Nurses (LPNs) indicated that the night shift was responsible for cleaning the medication carts, but there was inconsistency in the cleaning process. Additionally, the pharmacy reviewed the carts only once a month. Specific loose pills were identified in each cart, including small oval white pills, oblong white pills, and round red pills with various imprints. The LPNs were unsure about the cleaning schedule and the process for maintaining the carts' cleanliness. In the medication room on the 300 Hall, the temperature logs for the supplement and medication refrigerators were incomplete for several days. Medications for a discharged resident were found sitting on the counter, and the LPN was unsure why they were there, indicating they needed to be destroyed. The facility's policies on medication storage and refrigerator temperature tracking were not followed, as evidenced by the missing temperature logs and the presence of loose pills in the medication carts. The Director of Nursing (DON) and Clinical Care Leader provided policies that were not adhered to, highlighting a lapse in maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to ensure food distribution and service were provided in accordance with professional standards for food service safety. During a lunch observation, a Qualified Medication Aide (QMA) and a Certified Nurse Aide (CNA) were seen handling cookies with bare hands before serving them to residents. In a separate meal service observation in the kitchen, a Dietary Aide was observed transferring coffee mugs and touching the inside lids of handled cups with bare hands. Additionally, during a breakfast observation, the same QMA was seen touching toast with bare hands while applying jelly. The Kitchen Manager confirmed that staff should not handle food or utensils with bare hands, and the facility's Food Preparation and Service policy prohibits bare hand contact with food, requiring gloves to be worn and changed between tasks.
Failure to Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to properly document influenza and pneumococcal vaccines being offered to residents for three of five residents reviewed. Clinical records for these residents lacked the vaccine consent/refusal date, the reason for refusal, and the date education was provided to the resident and/or resident representative. Specifically, Resident 19's record lacked documentation for the influenza vaccine, Resident 4's record lacked documentation for the pneumococcal vaccines, and Resident 36's record lacked documentation for both the influenza and pneumococcal vaccines. All three residents were cognitively intact and had various diagnoses, including anxiety, atherosclerotic heart disease, depression, and Parkinson's disease. During interviews, the Infection Preventionist (IP) indicated that newly admitted residents should be offered the vaccines at admission, and other residents should be offered them annually before the influenza season. The IP acknowledged that the residents had refused the vaccines, but the reasons and education provided were not clearly documented. The facility's current Resident Immunizations Policy requires documentation of education, consent, and screening prior to vaccine administration, but this was not followed in these cases.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents in two of the five halls observed and one common area. Specific deficiencies included bathroom vents caked with dust, unlabeled personal care items, scuff marks, and chipping on doors, sticky floors, loose grab bars, and exposed wires in the common area. Additionally, there were issues with call lights, with one room having only one call light cord wrapped around a bed and no call light for the other side of the room. Uncovered briefs and personal care items were also found inappropriately stored in bathrooms. The observations were made on two separate dates, confirming that the issues were not addressed in the interim. The Maintenance Director indicated that staff should report environmental issues or submit a work order, but the repeated observations suggest this process was not effectively followed. The facility's Homelike Environment policy, revised in February 2021, states that residents should be provided with a safe, clean, and comfortable environment, which was not upheld in these instances.
Failure to Ensure Resident Dignity and Proper Care
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by two specific observations. In the first instance, a Certified Nurse Aide (CNA) was observed standing while assisting Resident 27 with feeding, which is against the facility's policy that requires staff to sit next to residents during meal assistance. This policy is intended to ensure residents are fed with attention to safety, comfort, and dignity. The CNA's action of standing while feeding the resident did not align with these standards and compromised the resident's dignified dining experience. In the second instance, Resident 48 was observed with a large wet spot, identified as urine, under her wheelchair while eating in the dining room. A Licensed Practical Nurse (LPN) placed the resident's meal tray in front of her and walked away without addressing the wet spot. The Director of Nursing (DON) later indicated that staff are expected to bring residents back to their rooms and provide care if such a situation is observed, and then clean the wet spot and the chair. The failure to address the resident's condition promptly and appropriately also violated the facility's dignity policy, which emphasizes caring for residents in a manner that promotes their well-being and self-esteem.
Failure to Provide Requested Ice Water to Resident
Penalty
Summary
The facility failed to provide services based on resident preferences for one of the five residents reviewed. Specifically, the facility did not provide ice water to Resident 45 when requested. During an interview, Resident 45 indicated that she did not receive water unless she asked for it. On a subsequent observation, a CNA assisted Resident 45 and noted that her water cup had only a small amount of water, asking if she would like it filled. Despite Resident 45's affirmative response, the water cup was not filled upon a later observation. Resident 45's clinical records indicated she was cognitively intact and required extensive assistance for various activities, including bed mobility, transfers, and toilet use. She also used oxygen and was on hospice care. Further interviews revealed that ice water was not routinely passed to residents, and they had to request it. The LPN mentioned that she would fill up an empty cup if she saw one in a resident's room. The facility's current Resident Hydration and Prevention of Dehydration policy, revised in October 2017, stated that the facility would strive to provide adequate hydration and prevent dehydration. Additionally, the Accommodation of Needs policy, revised in March 2021, indicated that residents' individual needs and preferences should be accommodated to the extent possible, except when it would endanger the health and safety of the individual or other residents.
Failure to Clarify Resident's Code Status
Penalty
Summary
The facility failed to clarify a resident's code status, leading to a discrepancy between the resident's documented wishes and the physician's orders. Resident 18, who had diagnoses including end-stage renal disease and diabetes mellitus, was cognitively intact and had a signed Do Not Resuscitate (DNR) order dated [DATE]. However, the current physician's orders indicated that the resident was to be resuscitated (CPR). Additionally, the resident's care plans were inconsistent, with one indicating a DNR status and another indicating a CPR status. During interviews, an LPN confirmed that the computer system showed the resident's code status as CPR, and the Director of Nursing acknowledged that the resident should have been listed as DNR. The facility's Advance Directives policy stated that the plan of care should be consistent with the resident's documented treatment preferences, which was not the case for Resident 18. This inconsistency in the resident's code status could lead to actions contrary to the resident's wishes in an emergency situation.
Failure to Ensure Resident's Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure the resident's right to be free of physical restraints for one resident who was observed with bed rails used as a physical restraint. During multiple observations, the resident was seen with bed rails up, and both the resident and her family member indicated that the bed rails were used to prevent falls. The resident's clinical record lacked an order for the bed rails, documentation of informed consent, and evidence that the resident could remove the restraint herself. Additionally, there was no documentation of the restraint being removed every two hours as required. Interviews with staff revealed that the bed rails were used for mobility and to prevent the resident from climbing out of bed. The Director of Nursing and other staff members indicated that evaluations for restraints should be completed quarterly, but the clinical record lacked a restraint evaluation after a specific date. The facility's policy on the use of restraints, which was provided by the Dementia Care Director, indicated that restraints should only be used to treat medical symptoms and not for the prevention of falls, and that a pre-restraining assessment and written order from a physician are required. The facility did not adhere to these policies in the case of this resident.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who claimed that a CNA physically removed her fingers and hand from a sit-to-stand lift. The resident, who has diagnoses including anxiety and depression and is cognitively intact, reported the incident to surveyors. The resident's clinical record lacked documentation of the allegation, an assessment of her hand/fingers, and any follow-up actions. The facility's policy requires immediate reporting of suspected abuse, but this was not adhered to in this case. Interviews revealed that the Director of Nursing (DON) was aware of the situation but did not report it immediately. The Administrator confirmed that the allegation should have been reported as soon as it was discovered. Additionally, the CNA involved had a prior battery charge, which was known to the facility. The facility's policy on abuse, neglect, exploitation, or misappropriation, revised in September 2022, mandates that suspicions of abuse be reported immediately, defined as within 24 hours of the allegation.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to properly investigate an allegation of abuse involving a resident who reported that a Certified Nurse Aide (CNA) physically removed her fingers and hand from a sit-to-stand lift. The resident, who has diagnoses including anxiety and depression and is cognitively intact, indicated that the CNA used an abusive tone and pulled her fingers one by one off the lift. The clinical record lacked documentation of the allegation, assessment of the resident's hand/fingers, and any follow-up to the allegation. The facility's policy requires immediate reporting and thorough investigation of abuse allegations, which was not followed in this case. The Director of Nursing (DON) was aware of the situation but did not inform the Administrator when it happened. The Administrator later indicated that the allegation should have been properly investigated and the CNA should have been suspended. Additionally, the CNA had a prior battery charge on their criminal background check. The facility's failure to investigate the abuse allegation promptly and thoroughly constitutes a deficiency in their handling of abuse reports.
Failure to Prevent Falls and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for two residents reviewed for falls. For Resident 38, non-skid strips were not observed on the floor in front of the toilet in her bathroom, and her care plan was not updated with new interventions after falls. Neurological checks were not consistently completed after her falls, and interventions such as keeping Dycem in her chair and ensuring she wore appropriate footwear were not followed. Despite having multiple falls, her care plan was not adequately revised to address her high fall risk, and necessary safety measures were not implemented in her new room after she moved from the locked dementia unit to the 300 Hall. For Resident 52, the facility failed to lock his Broda chair, which led to multiple incidents where he attempted to scoot out of the chair, causing it to roll. His care plan included interventions such as placing a soft mat on the wall side of his bed and providing diversional activities, but these were not consistently followed. Neurological checks were not performed after some falls, and his care plan was not updated with new interventions after each fall. Despite being identified as a high fall risk, the facility did not adequately supervise him or ensure that his care plan was followed. The Director of Nursing (DON) acknowledged that both residents were high fall risks and that there should have been interdisciplinary team (IDT) meetings, new interventions placed, and care plans revised after each fall. The facility's policies on falls and neurological assessments were not consistently followed, leading to multiple falls and injuries for both residents. The DON also indicated that there was no specific policy for following orders and interventions, but it was expected that staff would do so.
Failure to Prevent and Treat UTIs and Maintain Infection Control
Penalty
Summary
The facility failed to ensure a resident received appropriate care to prevent and treat urinary tract infections (UTIs). Resident 36, who had diagnoses including Parkinson's Disease and dementia, experienced recurrent UTIs and exhibited cognitive changes and behavioral issues. Despite these symptoms, there were significant delays in obtaining and processing urinalysis orders, and the clinical record lacked timely documentation and follow-up from the physician. For instance, a urinalysis ordered on 1/23/24 was not obtained until 1/24/24 and not sent to the hospital until 1/25/24. Additionally, there were inconsistencies in the interpretation of urinalysis results, leading to inappropriate antibiotic treatments and further confusion about the resident's condition. The resident experienced multiple falls and increased confusion, which were often linked to UTIs. Despite these indicators, the facility's response was delayed and inadequate. For example, after a fall on 3/10/24, a urinalysis was not collected until 3/11/24, and the results were misinterpreted as clear despite the presence of bacteria. This led to further delays in appropriate treatment. The resident's condition continued to deteriorate, with increased confusion, hallucinations, and aggressive behavior, eventually leading to a diagnosis of dementia and relocation to a secured unit. In addition to the delays and mismanagement of UTIs, the facility also failed to maintain proper infection control practices during incontinence care. On 5/20/24, two CNAs were observed assisting the resident with toileting but did not follow proper hand hygiene protocols. They failed to wash their hands adequately, did not change gloves appropriately, and contaminated clean items with soiled gloves. These lapses in infection control practices further compromised the resident's care and increased the risk of infection.
Failure to Provide Consistent Respiratory Care
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with the residents' orders and care plans. Resident 14 was observed with oxygen set incorrectly at 2.5 liters per minute (lpm) instead of the ordered 3 lpm. Additionally, the oxygen concentrator filter was caked with dust and had not been cleaned as required. The Director of Nursing (DON) indicated that the order to change the filter was not properly integrated into the system, leading to the oversight. Furthermore, Resident 14 was seen without oxygen on another occasion, despite having a portable oxygen tank available, and later with oxygen set between 3.5 and 4 lpm, which was not in accordance with the physician's orders. The oxygen concentrator had not been serviced since 8/16/23, and staff were unsure about the cleaning responsibilities for the filters. Resident 28's oxygen filter was also observed to be caked with dust on multiple occasions, and the resident was using oxygen at 2 lpm. The clinical records indicated that the filter should be cleaned weekly, but this was not being done. The DON confirmed that the company servicing the oxygen machines had shown staff how to clean the filters, but the task was not being performed as required. Resident 45 was observed with oxygen set at 3.5 lpm, and the filter on the oxygen machine was similarly caked with dust. The humidification bottle was dated 4/29/24, and there were no orders in the clinical records to change the oxygen tubing or humidification bottle. The DON indicated that the company serviced the oxygen machines weekly and had instructed staff on cleaning the filters, but the filters remained uncleaned. The facility's policy on respiratory therapy and infection prevention, which required washing filters every seven days, was not being followed.
Infection Control Deficiencies in Incontinence Care and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper infection control practices during incontinence care and blood glucose monitoring for three residents. During an observation, a Qualified Medication Aide (QMA) did not adequately clean a glucometer after obtaining a blood glucose level for a resident, wiping it for less than two seconds before placing it back in the medication cart. The QMA indicated that the glucometer should air dry for at least two minutes, which was not followed. Additionally, during incontinence care for two residents, Certified Nurse Aides (CNAs) did not perform hand hygiene between glove changes. One CNA removed soiled briefs and applied cream without sanitizing hands between glove changes, while another CNA also failed to sanitize hands between glove changes during the incontinence care process. Interviews with the Infection Preventionist (IP) and Licensed Practical Nurse (LPN) confirmed that the expected protocol was not followed. The IP indicated that staff should sanitize their hands between glove changes during incontinence care. The LPN and QMA both confirmed that the glucometer should be cleaned thoroughly and allowed to air dry for at least two minutes between uses. The facility's policies on hand hygiene and blood glucose monitoring were not adhered to, leading to these deficiencies.
Failure to Post Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that nurse staffing sheets were posted daily during the survey period, specifically on May 18 and May 19. On May 20, it was observed that the posted nurse staffing sheet in the main lobby was dated May 17, indicating that the sheets were not updated over the weekend. During an interview, the Director of Nursing (DON) confirmed that the night shift is responsible for posting the nurse staffing sheet daily, including weekends. The facility's policy, revised in July 2016, mandates daily posting of staffing numbers for each shift.
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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