West River Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 714 S Eickhoff Rd, Evansville, Indiana 47712
- CMS Provider Number
- 155785
- Inspections on file
- 33
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at West River Health Campus during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and frequent incontinence had a physician's order for a urinalysis and culture due to suspected UTI. Over five days, only two documented attempts were made to obtain the urine sample, with no consistent documentation or timely physician notification when unsuccessful. The sample was eventually collected via in-and-out catheterization after a new order, resulting in delayed diagnosis and treatment.
A resident with severe cognitive impairment and a history of needing staff assistance for transfers and toileting was left without required support, leading to a fall. Documentation and interviews confirmed that staff did not follow the care plan, despite the resident's increased confusion and fall risk due to a UTI.
A resident with multiple neurological diagnoses was discharged without complete documentation, as required by facility policy. The discharge form lacked a selected reason for transfer, and the physician's order did not provide sufficient detail regarding the discharge. Staff interviews confirmed that required documentation fields were left blank or incomplete.
A resident with an indwelling urinary catheter developed a CAUTI, septic shock, and pneumonia due to inadequate care at the facility. The resident, who was cognitively impaired and dependent on staff, showed signs of complications like blood in the urine, but there was no documented assessment or physician notification. A catheter flush was performed without proper documentation or physician notification, and the resident was later hospitalized with severe health issues. The facility lacked a catheter assessment tool and comprehensive policy for CAUTI prevention.
The facility failed to provide adequate bathing care for residents dependent on staff for ADLs. A resident with cognitive impairment received only a few showers over two months, while another resident received none since admission. A cognitively intact resident reported not receiving scheduled showers and was not offered alternatives. The facility's policy required bathing at least twice a week, which was not followed.
The facility failed to maintain sanitary food service practices, with unlabeled food items observed in the kitchen and dementia unit refrigerator. The kitchen had soiled equipment and debris build-up, and the facility's food labeling policy was not followed.
The facility failed to ensure proper hand hygiene and sanitation practices during resident care. An LPN and a CNA did not perform hand hygiene after glove removal and before other tasks. An RN washed hands for only nine seconds after wound care. A sit-to-stand lift used by CNAs was dirty and had a peeling grip mat, indicating poor equipment sanitation.
Two residents in an LTC facility experienced deficiencies in supervision and intervention. A resident with a history of falls did not have updated care plans or necessary safety measures, leading to multiple falls. Another resident, on a puree diet due to dysphagia, was given inappropriate food during an activity, resulting in choking and hospitalization. The facility lacked effective implementation of care policies and supervision, contributing to these incidents.
A resident with Parkinson's, dementia, and dysphagia experienced significant weight loss due to the facility's failure to address nutritional needs and follow dietary recommendations. Despite orders for weekly weight monitoring and supplements, weights were inconsistently recorded, and improper weighing techniques were used. The facility's guidelines for weight tracking were not followed, leading to a deficiency.
A resident was observed receiving 5 liters of oxygen instead of the prescribed 3 liters, with an empty and undated humidification bottle and tubing. The staff was unclear about responsibilities for changing oxygen equipment, and the facility lacked a specific policy for following physician orders, although staff were expected to adhere to them.
A cognitively impaired resident experienced an unwitnessed fall resulting in a clavicle fracture due to the failure of staff to follow the care plan, which required the bed to be in a low position with a fall mat. The incident occurred after CNAs assisted the resident and left the bed in its highest position without the fall mat.
Delayed Urine Sample Collection and Physician Notification for Suspected UTI
Penalty
Summary
The facility failed to complete a physician's order to obtain a urine sample in a timely manner for a resident with diagnoses including Alzheimer's disease, dementia, and a disorder of the kidney and ureter. The resident, who had severe cognitive impairment and was frequently incontinent of bladder and bowel, had a physician's order for a urinalysis and culture due to suspected urinary tract infection (UTI). Documentation showed that after the initial order was placed, there were only two documented attempts to obtain the urine sample over a five-day period, with one refusal by the resident and one unsuccessful attempt to collect the sample. No further documented attempts were made until a new order for in-and-out catheterization was received and completed. The resident's clinical record indicated that staff did not consistently document attempts to obtain the urine sample as required, nor did they promptly notify the physician when the sample could not be obtained. The Assistant Director of Nursing confirmed that staff should document each attempt and notify the physician if unsuccessful, but this was not done. The Medication Administration Record and Treatment Administration Record also lacked documentation of ongoing attempts between the initial order and the eventual catheterization. As a result, the urine sample was not obtained until five days after the initial order, delaying the diagnosis and treatment of the resident's UTI.
Failure to Follow Care Plan for Transfer Assistance Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan by not providing the required assistance during transfers and toileting. The resident, who had diagnoses including dementia and was severely cognitively impaired, was assessed as needing partial staff assistance for bathing and toileting, and supervision for transfers. Despite this, on the day of the fall, documentation indicated that the resident was left to transfer and toilet independently, with no staff setup or physical help provided. This lack of assistance was confirmed by point of care records and an anonymous interview, which revealed that the resident's family observed the fall via a camera and had to notify staff. Further review of the resident's clinical record and interviews with staff confirmed that the care plan accurately reflected the resident's need for assistance, especially during periods of illness such as a urinary tract infection (UTI), which was present at the time of the incident. Previous nursing notes and event reports documented the resident's difficulty with transfers and increased confusion and falls associated with the UTI. Despite these documented needs and care plan directives, staff failed to provide the necessary support, resulting in a fall.
Incomplete Discharge Documentation for Resident Transfer
Penalty
Summary
The facility failed to complete the required discharge documentation for a resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, aphasia, and dysphagia. The resident was admitted with intact cognition and had a care plan to return to their previous living environment after rehabilitation. Upon review, the transfer/discharge documentation was found to be incomplete, with key sections left blank. Specifically, the 'Reason for Transfer or Discharge' was not selected from the provided options, and instead, 'Resident Request' was handwritten. The physician's order indicated approval for discharge but did not provide further details regarding the discharge reason. Additionally, the clinical record lacked comprehensive documentation from the physician related to the discharge, aside from the order to discharge. The facility's policy requires recording the reasons, effective date, and location of transfer or discharge in the medical record and on the discharge form, as well as physician documentation of medical reasons for transfer or discharge. These requirements were not met, as confirmed by staff interviews and record review, resulting in incomplete discharge documentation for the resident.
Inadequate Catheter Care Leads to CAUTI and Hospitalization
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling urinary catheter, leading to the development of a catheter-associated urinary tract infection (CAUTI) and subsequent septic shock and pneumonia. The resident, who was significantly cognitively impaired and completely dependent on staff for daily activities, had an indwelling catheter due to obstructive uropathy. The clinical record lacked current orders for catheter care and documentation of physician notification for catheter use. Despite the resident showing signs of complications, such as blood in the urine, there was no documented assessment or physician notification. On one occasion, a catheter flush was performed without specific documentation of the technique or physician notification. The resident was later found with abnormal vital signs and was sent to the hospital, where they were diagnosed with septic shock secondary to a urinary tract infection and pneumonia. The facility's policy on catheter care did not address flushing or CAUTI prevention, and there was no catheter assessment tool in place. The lack of proper documentation, assessment, and physician notification contributed to the resident's severe health decline.
Failure to Provide Adequate Bathing Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADL) received adequate bathing care. Four residents, identified as Resident 11, Resident 32, Resident 148, and Resident 6, were not bathed according to their care plans. Resident 32, who was significantly cognitively impaired and completely dependent on staff, received only four showers or complete bed baths in July and one in August, despite the care plan indicating showers per schedule. Similarly, Resident 11, who was moderately cognitively impaired and completely dependent on staff, received only two showers or complete bed baths in July and none in August. No shower schedule was available for review for either resident. Resident 148, who lacked a completed MDS assessment, had not received any showers or complete bed baths since admission. Resident 6, who was cognitively intact and required substantial assistance, reported not receiving showers as scheduled and was not offered a bed bath as an alternative when refusing a shower. The facility's policy indicated that bathing should occur at least twice a week, but this was not adhered to, as evidenced by the Point of Care History report and observations of Resident 6's condition.
Deficiency in Food Service Safety and Sanitation
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety. During observations in the kitchen, surveyors noted that food items such as lunch meat and cookies in the walk-in cooler and freezer were not labeled. Additionally, the kitchen had soiled shelves under the grill and steamer, sides of the stove were dirty, and there was debris build-up on the floors under equipment and storage racks. The dishwasher area, edges of walls, and sides of the ice machine had calcium build-up, and vents were dusty. Further observations on the locked dementia unit revealed a refrigerator containing unlabeled food items, including a bowl of purple pureed food, muffins, macaroni salad, and orange pureed food. The Dietary Manager acknowledged that the pork chops delivered the previous week should have been labeled and explained that food was typically labeled after being opened and placed in a two-gallon bag. The facility had a policy on food labeling and dating, revised in 2019, which required labeling of any food product removed from its original container or with a broken seal, including the item name, date and time of labeling, use-by date, and initials of the person labeling the item.
Inadequate Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to ensure proper hand hygiene and sanitation practices were followed by staff during care activities for several residents. An LPN was observed not performing hand hygiene after removing gloves and before engaging in other tasks, such as assisting another staff member and charting on the computer. Similarly, a CNA did not perform hand hygiene after removing gloves and handling various items and tasks, including giving a resident a drink, stripping bed linens, and disposing of trash, before eventually washing hands after leaving the room. Additionally, during a wound care observation, an RN was noted to have washed hands for only nine seconds after removing gloves and gown, which is below the recommended duration. Furthermore, a sit-to-stand lift used by two CNAs to transfer a resident was found to have dirty buildup and a peeling grip mat, indicating a lack of proper equipment sanitation. The facility's policies on hand hygiene and standard precautions were provided, highlighting the expectations for hand hygiene before and after resident contact and the proper handling of potentially contaminated equipment.
Inadequate Supervision and Intervention for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent accidents for two residents. Resident 30, who was admitted following left hip surgery and had a history of Alzheimer's disease and muscle weakness, experienced multiple falls. Despite being at high risk for falls, the care plan interventions were not consistently updated or implemented effectively. For instance, nonskid strips were not placed in front of the toilet as required, and the resident had fallen 10 times since admission, often while attempting to self-toilet. The facility's failure to maintain a safe environment and provide necessary assistance contributed to these repeated incidents. Resident 32, diagnosed with Parkinson's disease, dementia, and dysphagia, required a modified diet and assistance with eating. However, during a group activity, the resident was given banana bread by another resident, despite being on a puree diet. This led to choking, requiring the Heimlich maneuver and subsequent hospitalization for aspiration and pneumonia. The facility lacked a policy on resident supervision during activities and failed to ensure staff followed diet orders, resulting in a serious health incident for Resident 32. The facility's policies on falls management and comprehensive care plans were not effectively implemented. The interdisciplinary team was expected to update care plans with new interventions following incidents, but this was not consistently done. The lack of adherence to these policies and the absence of a supervision policy contributed to the deficiencies observed in the care of Residents 30 and 32.
Failure to Address Nutritional Decline and Weight Monitoring
Penalty
Summary
The facility failed to address a resident's decline in nutritional status and follow dietary recommendations, leading to a significant weight loss for a resident with Parkinson's disease, dementia, and dysphagia. The resident required moderate assistance with eating and was on a modified diet due to swallowing difficulties. Despite physician orders for weekly weight monitoring and dietary supplements, there were inconsistencies in weight documentation, and several weekly weights were not recorded. The resident's weight fluctuated significantly, with a notable drop from 231 pounds to 175.4 pounds within a short period. The registered dietitian noted that some weight records were likely errors and recommended re-weighing the resident, but this was not consistently done. The assistant director of nursing acknowledged that the weight fluctuations were due to incorrect weighing practices and issues with the weight machine, which required calibration. Interviews with facility staff revealed that the weight discrepancies were attributed to improper weighing techniques and potential equipment malfunctions. The clinical record lacked thorough documentation of the resident's condition and the weight loss, and there was no evidence of diarrhea or edema during the period of weight loss, despite claims to the contrary. The facility's guidelines for weight tracking were not adequately followed, contributing to the deficiency.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring that oxygen equipment was properly labeled and that oxygen services were provided according to the physician's order. Resident 6 was observed receiving 5 liters of oxygen via nasal cannula, despite the physician's order indicating 3 liters. Additionally, the humidification bottle was empty and not dated, and the tubing was also not dated. Resident 6, who was cognitively intact, expressed uncertainty about the discrepancy in the oxygen level she was receiving. Further investigation revealed a lack of clarity among the staff regarding the responsibility for changing oxygen tubing and humidification bottles. An LPN was unsure about who was responsible for these tasks, and the ADON indicated that the night shift nursing staff was expected to change them according to the physician's order or as needed. However, the facility did not have a specific policy for following physician orders, although staff were expected to adhere to them. The Respiratory Equipment policy provided by Clinical Support 5 stated that sterile distilled water should be used for humidification over 4 liters per minute and that oxygen cannula and tubing should be changed monthly and as necessary.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure effective supervision for a cognitively impaired, dependent resident, resulting in an unwitnessed fall and a left clavicle fracture. Resident B, who had severe cognitive impairment and required substantial assistance for bed mobility, was found on the floor beside his bed with a skin tear on his left elbow. The care plan for Resident B included the use of a low bed with a fall mat, but these interventions were not in place at the time of the fall. On the day of the incident, CNA 1 and CNA 2 assisted Resident B with a check and change. After completing the task, CNA 1 left the bed in its highest position without placing the fall mat, contrary to the care plan. Approximately 20-30 minutes later, Resident B was found on the floor by CNA 1, who then called the nurse for an assessment. The Director of Nursing (DON) confirmed that the bed was not in the low position with a fall mat immediately after the fall. The facility's policies required that care plan interventions be communicated to the nursing staff and implemented to address the resident's risk factors. However, the failure to follow these protocols led to Resident B's fall and subsequent injury. The incident was documented in progress notes and a state reportable incident, and interviews with the involved CNAs corroborated the findings.
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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