Williamsport Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsport, Indiana.
- Location
- 200 Short St, Williamsport, Indiana 47993
- CMS Provider Number
- 155568
- Inspections on file
- 19
- Latest survey
- July 15, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Williamsport Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found the kitchen in unsanitary condition, with dirty equipment, floors, and food storage areas, and discovered that required cleaning logs had not been completed for several months. Interviews with dietary staff and the DON confirmed that cleaning schedules were not followed and documentation was missing, despite facility policy requiring comprehensive cleaning records.
Surveyors found that the facility did not provide palatable or properly heated food, with residents receiving repetitive meals and food served at incorrect temperatures. Several residents reported cold and unappetizing meals, and a test tray confirmed that both hot and cold items were not within required temperature ranges. The Dietary Manager acknowledged menu substitutions, insufficient caloric intake, and lack of insulated carts for meal delivery.
A resident with moderate cognitive impairment indicated a strong preference for daily morning showers, but was only scheduled for showers twice weekly in the evening. Despite documentation of these preferences and multiple refusals of the offered showers, there was no evidence that her preferences were reassessed or that the care plan was updated to reflect her wishes, resulting in a failure to support resident choice as required.
A resident's MDS assessment was inaccurately coded to indicate anticoagulant use during the look-back period, despite the MAR showing no such medication was administered at that time. The DON confirmed the resident was not on an anticoagulant during the relevant period, and the error was due to incorrect coding.
The facility did not consistently hold or document care plan meetings for two residents, both of whom were cognitively intact and could not recall attending such meetings, with records lacking evidence of required quarterly reviews. Additionally, a resident receiving long-term Macrobid for UTI prevention due to ESBL and recurrent UTIs did not have this therapy addressed in the care plan.
Two residents did not receive showers and shaving as scheduled or per their preferences, despite being dependent on staff for ADLs due to conditions such as hemiplegia and Parkinson's disease. Documentation showed that scheduled showers were frequently missed without evidence of resident refusal, and observations confirmed ongoing issues with grooming and hygiene. Staff interviews revealed uncertainty about grooming routines, and facility policies lacked specific guidance on shower administration.
Staff failed to follow medication administration and disposal protocols for two residents. In one case, a resident was found with multiple pills left at the bedside, contrary to facility policy. In another, an LPN disposed of refused medications in a sharps container instead of the required Drug Buster disposal system. Interviews confirmed that these actions did not align with established procedures.
A resident with a stress fracture and chronic kidney disease requested PRN tizanidine for muscle spasms but was asked by an LPN to wait due to concerns about blood pressure and fall risk, despite being non-weight bearing and in a wheelchair. The resident received Xanax instead, and the LPN did not return to reassess or offer the tizanidine, resulting in increased pain and no further doses documented for that day.
An opened vial of tuberculin solution was found in a medication storage room refrigerator without a date of opening. Both an LPN and the DON confirmed that facility policy requires medications to be dated when opened, and the facility's policy document supports this requirement. This resulted in a deficiency related to proper medication labeling and storage.
A resident with a diabetic foot ulcer experienced improper placement of a wound vac, leading to maceration of the periwound area. The facility had the necessary supplies, but they were not the original brand, causing concern for the resident's wife. The DNS placed the wound vac and was responsible for staff education, but documentation of training was lacking. The DNS re-educated an LPN on proper placement, but this was not documented, resulting in a deficiency.
The facility failed to maintain safe hot water temperatures, with several residents reporting excessively hot water that could cause burns. The new Maintenance Supervisor confirmed the high temperatures but was initially unable to locate temperature logs or calibrate the thermometer. The facility lacked a policy for monitoring water temperatures, and logs for a specific period were missing.
The facility failed to ensure proper food handling and hand sanitization during meal service, affecting all 50 residents who ate meals from the kitchen. Staff were observed placing the ice scoop back into the ice bucket and using ice meant only to keep drinks cold. Additionally, a CNA did not sanitize her hands between assisting two residents with their meals and repositioning them.
The facility failed to ensure a resident was treated with dignity during a dining observation. The SLP was observed standing while assisting the resident with eating and drinking, contrary to the standard practice of sitting down. The resident has multiple diagnoses and requires assistance with daily activities, including eating. Both the DON and SLP acknowledged that staff should sit while assisting residents, in line with the facility's policy on Resident Rights.
The facility failed to conduct quarterly care plan meetings for a resident with moderate cognitive impairment and did not implement an oxygen care plan for another resident with hypoxemia, type 2 diabetes, and obstructive sleep apnea. The resident's oxygen was repeatedly set incorrectly, and staff were unsure of the correct settings.
The facility failed to ensure proper catheter care and placement for a resident, who was observed multiple times with his catheter bag in contact with the floor and other surfaces. Despite specific medical orders and facility policies, the catheter bag was not consistently secured, leading to repeated instances of improper placement.
The facility failed to provide proper respiratory care for two residents. One resident did not receive the prescribed oxygen level, and another resident's nebulizer treatment was not properly administered or assessed. Facility policies for oxygen concentrators and nebulizer treatments were not followed.
The facility failed to provide necessary mental health services to a resident with severe dementia, depression, and a psychotic disorder. Despite exhibiting significant behavioral issues, the resident did not receive timely psychiatric consultation, and there was inadequate documentation of family discussions regarding psychiatric services.
The facility failed to maintain a medication error rate below 5%, with errors including an LPN administering Creon by touching the capsule with an ungloved finger and another LPN administering insulin lispro without ensuring the resident received their meal within the recommended 15-minute window.
Failure to Maintain Kitchen Sanitation and Cleaning Documentation
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition and did not ensure that cleaning logs were completed and up to date. During an initial kitchen tour, surveyors observed that the convention oven burners had dark, charred particles caked on them, and the grill had food particles around its rim. The piping and wall behind the oven were dirty with old grease, and the kitchen floor had food crumbs and pieces of paper towel scattered throughout. The walk-in freezer also contained food crumbs and particles on the floor and shelving. No food was being cooked at the time of observation. Interviews with the Dietary Corporate Consultant and the Dietary Manager revealed that the kitchen cleaning logs for April, May, and June were blank and had not been completed. The Dietary Manager, who had recently started, acknowledged that cleaning tasks were not being consistently performed and that staff were not following a daily or deep cleaning schedule. The Director of Nursing confirmed awareness of the incomplete cleaning logs and noted recent management changes in the kitchen. The facility's policy required a comprehensive cleaning schedule and maintenance of cleaning logs, but these procedures were not followed.
Failure to Provide Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at safe and appetizing temperatures, as observed during multiple meal services. On one occasion, residents were served a chicken salad sandwich, beets, and pears instead of the scheduled menu of tomato basil soup, hot tuna and cheese sandwich, pickled beets, and sliced pears. Residents expressed dissatisfaction with the repetitive menu and questioned the frequent serving of chicken. The Dietary Manager was unable to explain the menu substitution and acknowledged that the meal provided did not meet adequate caloric intake. Staff interviews confirmed that soup was omitted from the meal due to unavailability, and the Dietary Manager noted ongoing concerns about menu repetition and the lack of a functioning food council. Multiple residents reported that food was often cold, repetitive, and unpalatable, whether eaten in the dining room or delivered to their rooms. The Dietary Manager acknowledged awareness of complaints about cold food and noted the absence of insulated food carts for tray delivery. A test tray revealed that hot food items were below the required temperature, and cold items were above the required temperature, with potato wedges noted as undercooked. The facility's policy requires hot foods to be held at or above 135°F and cold foods at or below 41°F, but these standards were not met during the survey.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
A resident with moderate cognitive impairment expressed a preference to shower every day and to have showers in the morning, which was documented during an interview and in her admission assessment. The resident's preferences were also recorded in a customary routines and activities observation, indicating it was very important for her to choose the type of bath and that she preferred to be bathed more than twice per week in the morning. Despite this, the resident was scheduled for showers only twice weekly on the evening shift, contrary to her stated preferences. Shower reports showed that the resident was offered showers on various dates, with several refusals, but there was no documentation that her preferences were reassessed or that the timing of the showers matched her morning preference. Progress notes did not indicate that the resident was offered a shower daily or that her preferences were revisited after refusals. The care plan did note her preference for daily showers, but this was not reflected in the actual shower schedule or in follow-up actions. Interviews with facility staff, including the DNS, confirmed that the resident's preferences should have been communicated and implemented, but this did not occur. The facility's policy required that resident preferences be identified and shared with the interdisciplinary team, but there was no evidence this process was followed in this case.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accurate coding of a Minimum Data Set (MDS) assessment for one resident. A quarterly MDS assessment indicated that the resident received an anticoagulant medication during the look-back period. However, a review of the Medication Administration Record (MAR) for the same period showed no documentation that the resident received an anticoagulant. The Director of Nursing Services (DNS) confirmed that the resident was not on an anticoagulant during the look-back period, as it had been discontinued prior to that time. The MDS assessment was therefore coded in error, contrary to the requirements outlined in the CMS Resident Assessment Instrument (RAI) manual, which specifies that medication administration records should be reviewed for the 7-day look-back period to ensure accurate coding.
Failure to Document and Conduct Care Plan Meetings and Address Long-Term Antibiotic Use
Penalty
Summary
The facility failed to ensure that care plan meetings were held and properly documented for two residents, and did not develop a care plan for the long-term use of an antibiotic for another resident. One resident, who was cognitively intact, reported not remembering being invited to or attending care plan meetings regularly, and her record showed only two care plan meetings documented over a year, with no evidence of quarterly meetings as required. Another cognitively intact resident also did not recall having a care plan meeting, and her record lacked documentation of invitations being accepted or meetings being held, with only evidence that invitations were mailed. The Social Service Director confirmed that there was no documentation of responses to invitations or that meetings occurred. Additionally, a resident with a history of extended spectrum beta lactamase (ESBL) and recurrent urinary tract infections (UTIs) was prescribed long-term Macrobid therapy for UTI prevention. Despite this, the resident's comprehensive care plan did not include documentation addressing the long-term antibiotic use, nor the resident's history of UTIs and ESBL. The Director of Nursing Services acknowledged that a care plan should have been developed for the resident's long-term antibiotic use.
Failure to Provide Showers and Grooming per Resident Preference
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living (ADLs), specifically in administering showers and shaving, according to resident preferences for two residents. One resident, who was cognitively intact but required assistance due to hemiplegia and poor vision, reported not being regularly shaved or given scheduled showers. Documentation showed that out of 22 scheduled showers, only 10 were administered, with no record of the resident refusing care. Staff interviews revealed uncertainty about shaving frequency and reliance on shower days for shaving, while the Assistant Director of Nursing was unsure about the shaving schedule. Observations confirmed the resident had extensive facial hair and reported not being shaved as preferred. Another resident, dependent for all personal care due to Parkinson's disease and cognitive impairment, was observed multiple times with unshaven facial hair and brown debris under fingernails. Documentation indicated only 6 out of 22 scheduled showers were administered, again with no record of refusals. The facility's policies addressed AM care and fingernail cleaning but did not provide a specific policy for administering showers or bathing. The Director of Nursing confirmed the use of internal shower sheets, which were not retained as part of the medical record.
Failure to Follow Medication Administration and Disposal Protocols
Penalty
Summary
Facility staff failed to follow professional standards for medication administration and disposal for two residents. In one instance, a cognitively intact resident with multiple diagnoses, including COPD, alcoholic cirrhosis, diabetes, GERD, and heart failure, was found with two cups containing several pills left at her bedside. The resident reported that the nurse did not want to wake her and left the medications on her overbed table. The resident's care plan noted a history of rejecting and hiding medications. Interviews with nursing staff and the Director of Nursing confirmed that facility policy prohibits leaving medications at the bedside, and staff stated they do not leave medications with residents. In another instance, an LPN was observed disposing of non-narcotic medications refused by a resident into a sharps container rather than the designated Drug Buster disposal system, as required by facility policy. The LPN acknowledged the error during an interview. The DON provided the facility's medication pass procedure, which specifies that all wasted, dropped, or discarded medications must be disposed of in the Drug Buster disposal system. These actions demonstrate a failure to ensure medications were administered and disposed of according to professional standards.
Failure to Provide Timely PRN Pain Medication for Muscle Spasms
Penalty
Summary
A resident with a history of stress fracture of the right ankle and stage 3 chronic kidney disease requested a PRN dose of tizanidine for muscle spasms during the morning medication pass. The nurse, concerned about the risk of falls due to the medication's potential to lower blood pressure, asked the resident to wait until after lunch. The resident, who was non-weight bearing and used a wheelchair, expressed confusion about the fall risk but reluctantly agreed to wait and instead requested and received Xanax. The nurse did not return after lunch to check on the resident or offer the tizanidine, and the resident later reported increased spasms and pain, with observable signs of discomfort. Record review showed that the resident did not receive any further doses of tizanidine that day, and there was no documentation that the nurse followed up regarding the resident's need for the medication. The facility's pain management policy required pain medication to be given based on pain intensity and for the nurse to monitor the efficacy of pain management. The DON confirmed that the nurse should have followed up with the resident to see if the tizanidine was still needed, but this did not occur.
Failure to Date Opened Medication Vial in Storage Room
Penalty
Summary
Surveyors observed that in one of two medication storage rooms reviewed, an opened vial of tuberculin solution was found in the refrigerator without a date indicating when it was opened. During interviews, both an LPN and the Director of Nurses confirmed that facility policy requires medications to be dated when opened, especially when the medication has a shortened expiration date after opening. The facility's Medication Storage and Expiration policy, provided by the DON, also specifies that staff should record the date opened on the primary medication container. The failure to date the opened tuberculin solution constituted a deficiency in proper medication labeling and storage practices as required by facility policy and professional standards.
Improper Placement of Wound Vac Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper placement of a wound vacuum-assisted closure (vac) for a resident with a diabetic foot ulcer and other medical conditions, including acute osteomyelitis and type 2 diabetes. The resident's care plan required the use of a wound vac, and physician's orders specified the application and maintenance of the device. However, during a wound clinic visit, it was noted that the foam from the wound vac was improperly placed against the resident's skin, leading to maceration of the periwound area. The Medical Records Director acknowledged that the facility had all necessary supplies for the wound vac, although they were not the original brand, which concerned the resident's wife. The Director of Nursing Services (DNS) had placed the wound vac upon the resident's admission and was responsible for educating staff on its use. However, there was no specific documentation of education provided to the staff, and only one nurse was believed to have received training. The DNS checked the placement of the wound vac daily but was unsure if it had been placed improperly. The Executive Director was aware of the concerns regarding the supplies and the placement of the wound vac. The DNS re-educated a Licensed Practical Nurse (LPN) on proper placement following the concerns raised by the resident's wife, but this education was not documented. The facility's policy emphasized the importance of providing care consistent with professional standards to promote healing and prevent complications, but the improper placement of the wound vac foam led to a deficiency in the care provided to the resident.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure hot water temperatures were maintained within a safe range for five residents. During random observations, the water temperatures in the public bathroom and residents' sinks were found to be excessively high, reaching up to 134.4 degrees Fahrenheit. Several residents reported that the water was too hot to hold their hands under without burning their skin. The Maintenance Supervisor, who had just started, confirmed the high temperatures but was initially unable to locate temperature logs or calibrate the thermometer correctly. The Administrator acknowledged the issue and indicated that the water heater had been recently replaced. Further investigation revealed that the facility did not have a policy related to monitoring water temperatures or temperature guidelines. The Maintenance Supervisor later discovered that there were three hot water heaters in the building, each serving different resident wings. Temperature logs for the period between 4/23/24 and 5/9/24 were missing, and it was unclear how long the temperatures had been running high. The Administrator confirmed that no one had been checking the water temperatures after the former Maintenance Supervisor left until the new one started.
Failure to Ensure Proper Food Handling and Hand Sanitization
Penalty
Summary
The facility failed to ensure proper food handling and hand sanitization during meal service, which had the potential to affect all 50 residents who ate meals from the kitchen. During a dining observation, a CNA and the Housekeeping Supervisor were seen placing the ice scoop back into the ice bucket after use, which is against the facility's policy. Additionally, another CNA used ice from a container meant only to keep drinks cold, not for consumption. The Dietary Manager confirmed that staff had been educated on proper procedures, but the issue persisted. In another observation, a CNA failed to sanitize her hands between assisting two residents with their meals and repositioning them. This was observed during the noon meal service in the restorative dining room. Another CNA also failed to sanitize her hands before delivering a meal tray to a resident. The facility's Hand Hygiene Policy clearly states that hand sanitization should occur before and after resident contact, as well as after touching any resident belongings or environmental surfaces. Despite this policy, proper hand hygiene was not followed during the observed meal service.
Failure to Ensure Resident Dignity During Assistance with Eating
Penalty
Summary
The facility failed to ensure that Resident 4 was treated with dignity during a dining observation. The Speech Language Pathologist (SLP) was observed standing while assisting Resident 4 with eating and drinking, rather than sitting down, which is considered a more respectful and dignified approach. Resident 4 has multiple diagnoses, including paraplegia, lack of coordination, muscle contracture, abnormal posture, and mild cognitive impairment, and requires assistance with activities of daily living, including eating. During interviews, the Director of Nursing (DON) and the SLP both indicated that the standard practice is to sit while assisting residents with eating. The DON expressed that she hoped staff would sit in a chair while assisting residents, and the SLP confirmed that she usually sits down next to residents during evaluations. The facility's policy on Resident Rights, updated in 2017, emphasizes the right of residents to be treated with respect and dignity, including reasonable accommodation of their needs and preferences.
Failure to Conduct Quarterly Care Plan Meetings and Implement Oxygen Care Plan
Penalty
Summary
The facility failed to ensure care plan meetings were conducted quarterly for Resident 7 and did not implement an oxygen care plan for Resident 15. Resident 7, who had moderate cognitive impairment, indicated he did not remember attending a care plan meeting. His record showed only two care plan meetings in the past year, despite the requirement for quarterly meetings. The Social Service Director and the Director of Nursing confirmed the lack of quarterly care plan meetings for Resident 7. Resident 15, who had diagnoses including hypoxemia, type 2 diabetes mellitus with hyperglycemia, and obstructive sleep apnea, was observed multiple times with his oxygen meter set incorrectly at 2 liters instead of the prescribed 3 liters. The resident's record lacked a care plan for oxygen use, and staff were unsure of the correct oxygen settings. The Director of Nursing confirmed the oxygen should be set at 3 liters per nasal cannula, and the facility's policy required a comprehensive care plan, which was not followed for Resident 15.
Improper Catheter Care and Placement
Penalty
Summary
The facility failed to ensure proper catheter care and placement for Resident 15, who was observed multiple times with his catheter bag in contact with the floor and other surfaces. On several occasions, the catheter bag was seen touching the floor, the wheel of the wheelchair, and the resident's shoes. The dignity bag, meant to cover the urinary drainage bag, was not fully covering it, making the urine visible. Despite the resident's actions of pulling on the tubing and placing the bag in his lap, the staff did not consistently ensure the catheter bag was properly secured and off the floor until an LPN intervened briefly. The resident's medical records indicated a need for an indwelling urinary catheter due to a bladder/prostate mass, with specific orders to store the collection bag inside a protective dignity pouch and to ensure the tubing or any part of the drainage system did not touch the floor. The facility's policies on catheter care, including the use of a securement device and proper placement of the drainage bag, were not adhered to, as evidenced by the repeated observations of improper catheter bag placement. The Director of Nursing confirmed that the catheter bag and tubing should not touch the floor, yet this standard was not maintained for Resident 15.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in their treatment. Resident 15 was observed with a portable oxygen tank set at 2 liters per minute (LPM) instead of the prescribed 3 LPM. The resident reported not receiving any air, and a CNA removed the portable oxygen tank without placing the resident on an oxygen concentrator. The LPN was aware of the situation but did not immediately address it due to being busy with medication pass. The resident's medical record indicated a diagnosis of hypoxemia and other conditions requiring continuous oxygen at 3 LPM, but the care plan lacked documentation for oxygen use. Resident 8 was observed lying in bed with a nebulizer mask removed and placed on the bed. The LPN did not clean the medication chamber after the treatment and failed to assess the resident before or after the nebulizer treatment. The resident confirmed that nurses sometimes did not assess her lungs before or after treatments. The medical record for Resident 8 included diagnoses such as chronic obstructive pulmonary disease and pulmonary hypertension, with physician orders for regular nebulizer treatments and oxygen at 5 LPM. The care plan indicated the resident received continual oxygen and nebulizer treatments as ordered. The facility's policies for oxygen concentrators and nebulizer treatments were not followed. The oxygen concentrator policy required verification of the physician's order and adjustment of the flow meter to the prescribed setting. The nebulizer policy required the nurse to stay with the resident during the entire medication administration and to clean and dry the nebulizer equipment properly. These procedures were not adhered to, leading to deficiencies in the respiratory care provided to the residents.
Failure to Provide Necessary Mental Health Services
Penalty
Summary
The facility failed to provide necessary mental health services to Resident 48, who exhibited significant behavioral health issues. On 5/09/24, during an observation and interview, Resident 48 was found to be very confused, crying, and expressing a desire to leave the facility. The staff indicated that the resident was an elopement risk and had been trying to leave the facility. The resident's medical record, reviewed on 5/14/24, included diagnoses of severe dementia with behavioral disturbances, depression, and a psychotic disorder with delusions. Despite these diagnoses, the resident's care plan and physician orders did not adequately address her behavioral health needs, and there was a lack of documentation regarding consultation with the family about psychiatric services. The Social Services Director acknowledged the need for psychiatric services but noted that the family was reluctant to allow these services, and there was no documentation of discussions with the family about this issue. The facility's policy on behavioral health, provided by the Director of Nursing, indicated that residents should be assessed for behavioral health needs and referred to behavioral health providers when necessary. However, the facility did not follow this policy for Resident 48, as evidenced by the lack of timely psychiatric consultation and inadequate documentation of family discussions. The resident's medical record showed several entries of behaviors including agitation and exit-seeking, yet the quarterly Minimum Data Set (MDS) assessment did not reflect any behavioral symptoms during the look-back period. This discrepancy further highlights the facility's failure to provide appropriate mental health services to Resident 48, leading to the deficiency noted in the report.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in an observed error rate of 6.45%. One incident involved an LPN administering Creon to a resident with chronic pancreatitis by touching the capsule with an ungloved finger, which is against the facility's medication administration policy. The Director of Nursing confirmed that medications should not be administered if touched by bare hands, and the facility's policy documents corroborated this procedure requirement. Another incident involved an LPN administering 3 units of insulin lispro to a resident with type 2 diabetes and hyperosmolarity. The insulin was administered at 11:10 a.m., but the resident did not receive their lunch meal until 11:52 a.m., which is beyond the 15-minute window recommended by the manufacturer's guidelines for fast-acting insulin. The Director of Nursing confirmed that residents receiving fast-acting insulin should get their meal within 15 minutes of administration. These actions led to a medication error rate exceeding the acceptable threshold.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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