Autumn Ridge Rehabilitation Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Wabash, Indiana.
- Location
- 600 Washington Ave, Wabash, Indiana 46992
- CMS Provider Number
- 155162
- Inspections on file
- 25
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Autumn Ridge Rehabilitation Centre during CMS and state inspections, most recent first.
Surveyors found that required State Agency and Ombudsman contact information was not posted in an accessible manner for residents, including those using wheelchairs. During a Resident Council interview, several residents reported they did not know where to find Ombudsman or State Agency contact details. These residents lived on a floor where they could not independently access the area where the State Agency posting was located, as they were not given the elevator code and had to be accompanied by staff. Observations showed no required postings on their floor, and the only State Agency posting on another floor lacked Ombudsman information and was mounted at a height the AD acknowledged would be difficult for a wheelchair user to see. This conflicted with the facility’s Resident Rights policy and state requirements to post names, addresses, and phone numbers of pertinent State advocacy groups in a form and manner residents can access and understand.
The facility restricted cognitively intact residents on an upper floor from independently accessing the first floor and outdoor patio by using an elevator keypad code not shared with residents and a locked exterior patio door, requiring staff supervision for any movement off the unit. Three residents with diagnoses including anxiety, depression, vitamin D deficiency, heart failure, chronic pain, Parkinson’s disease, and psoriatic arthritis reported feeling like they were in a prison and expressed a strong desire to go outside for fresh air and to access common areas such as the lobby and aquarium. MDS assessments and care plans documented that it was very important for these residents to go outside when weather permitted and that they enjoyed outdoor time, yet the monthly activities calendar lacked outdoor activities. The AD and DON stated that residents could only go outside when staff were available to accompany them, citing corporate direction, elopement concerns for other residents, and a prior elopement, while the Administrator confirmed there was no specific policy for securing the floor or for residents going outside, despite a Resident Rights policy requiring that residents be able to exercise their rights without interference.
A resident who was cognitively intact, frequently incontinent, and required partial to moderate assistance with bathing reported not receiving a shower for over a week, despite having assigned shower days and being willing to bathe at any time. Observations noted greasy, disheveled hair and the same clothing on consecutive days. Facility shower sheets for the month showed missed or undocumented showers on scheduled days, and Point of Care records contained multiple entries for partial bed baths (PBB) and "activity did not occur" without clarity on whether full partial baths or only peri-care were provided. CNAs stated that peri-care was documented as PBB and that blank or incomplete shower sheets could mean missed showers or undocumented care. The DON confirmed that blank shower sheets indicated no shower occurred, and the Administrator acknowledged there was no specific facility policy on showering/bathing beyond a general resident rights policy.
A resident with Parkinson’s disease, dementia, chronic pain, and a documented history of frequent, severe pain repeatedly complained of intense mouth pain and a toothache during breakfast, grimacing, crying out, and declining to eat. An RN walked past without acknowledging the complaints, continued assisting another resident, and, when asked about a dental appointment, did not immediately assess the resident or check for pain interventions. Only after the resident’s distress escalated and the DON was called were Orajel and acetaminophen administered. The resident’s care plans and orders included scheduled and PRN pain medications and nonpharmacologic interventions, and the facility’s pain management policy required pain care based on reported intensity, but staff did not promptly implement these measures when the resident first reported pain.
A resident with multiple chronic conditions was left waiting over 14 minutes for assistance with bed mobility for toileting after requesting help from a CNA, who failed to return. Other residents also reported delays in call light responses, with staff sometimes turning off call lights without providing assistance. Staff and the DON acknowledged that such delays were not acceptable, and the facility lacked a policy on timely call light response.
A resident with upper extremity impairment and multiple medical conditions did not receive timely assistance with nail care, despite repeated requests and visible need. Staff interviews revealed inconsistent practices and lack of clear documentation or policy regarding nail care, resulting in the resident having long, jagged fingernails and struggling to manage personal grooming independently.
The facility did not consistently provide bedtime snacks to residents as ordered by physicians and required by policy. Several residents reported that snacks were only offered intermittently or not at all, with some being told that snacks were unavailable. Staff interviews and pantry observations confirmed that snack supplies were sometimes insufficient, and the process for delivering snacks did not ensure all residents received them as prescribed.
Surveyors observed that staff failed to perform hand hygiene during laundry delivery to multiple residents, despite handling clean laundry, room surfaces, and personal items. Additionally, an LPN did not use required enhanced barrier precautions (gown and gloves) while performing central line care for a resident with multiple infection risks, even though facility policy and signage indicated this was necessary. These lapses occurred despite staff awareness of infection control protocols and the presence of relevant policies and signage.
The facility failed to notify two residents of Medicare non-coverage, lacking the required SNF ABN forms. Staff interviews revealed that the Administrator could not find documentation of completed forms, and the Social Services Director was unaware of the requirement, leading to a gap in the notification process.
A facility failed to provide adequate grooming and dressing assistance to a resident with moderate cognitive impairment, who was observed with unkempt facial hair and clothing with holes. Another resident did not receive timely showers, resulting in greasy hair, despite needing substantial assistance with personal hygiene. Staff interviews revealed no documented refusals of care, indicating a failure in adhering to care plans and documentation practices.
The facility failed to ensure that only qualified staff assisted residents with eating, as an Activity Assistant without full CNA certification was observed assisting a resident. The facility's policy requires licensed and certified personnel for such tasks, and the DON was unaware of the extent of the Activity Assistant's involvement in resident feeding.
Failure to Provide Accessible Posting of State Agency and Ombudsman Contact Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required State Agency and Ombudsman contact information was prominently displayed in a location and manner accessible to residents, including those using wheelchairs. During a Resident Council group interview, three residents reported they did not know where to find information for the local Ombudsman or how to contact the State Agency with concerns. One resident stated he could ask the Activities Director for the information. These residents lived on the third floor, where residents were not allowed to access the first floor without staff supervision due to the presence of residents on the third floor who were considered elopement risks. An observation of the third floor revealed no visible postings of State Agency or Ombudsman information. Further observation on the first floor showed that the required State Agency information was posted on the wall next to the elevators, but the posting did not include the Ombudsman’s contact information. During an interview and observation with the Activities Director, the State Agency informational poster was measured at 58 inches from the ground, and the Activities Director acknowledged it would be difficult for a person in a wheelchair to see the information at that height. The Director of Nursing confirmed that residents on the third floor were not given the elevator code and had to be accompanied by staff to go downstairs. The facility’s Resident Rights policy stated that information must be provided to each resident in a form and manner the resident can access and understand, and that the facility must post the names, addresses, and telephone numbers of all pertinent State client advocacy groups, including the State survey and certification agency and the State ombudsman program, among others, as required by 410 IAC 16.23.1-4(j)(3).
Failure to Honor Cognitively Intact Residents’ Right to Free Movement and Outdoor Access
Penalty
Summary
The facility failed to honor residents' rights to self-determination and freedom of movement by restricting cognitively intact residents from independently accessing other areas of the building and the outdoors. During a Resident Council group interview, three residents living on the third floor reported they were prohibited from going to the first floor or the outdoor patio without staff supervision. Barriers included an elevator that required a keypad code, which was not shared with residents, and a locked exterior door to the patio. These restrictions prevented them from visiting common areas such as the first-floor aquarium, the lobby, and the outdoor seating area at will; one resident reported being prevented from going to the lobby to collect cups for coffee the previous evening. All three residents expressed a desire for independent access to facility amenities and the outdoors and stated the facility felt like a prison. Record review showed that each of the three residents was assessed as cognitively intact and without hallucinations, delusions, or behavioral issues. One resident had diagnoses of anxiety, depression, and vitamin D deficiency, and her MDS indicated it was very important for her to go outside for fresh air when weather permitted. Another resident had anxiety, vitamin D deficiency, and psoriatic arthritis, was able to transfer independently in her wheelchair, and her MDS also indicated it was very important for her to go outside for fresh air when weather permitted. The third resident had type 2 diabetes, insomnia, heart failure, chronic pain, and Parkinson's disease, was able to transfer independently in his wheelchair, and his MDS likewise documented that it was very important for him to go outside for fresh air when weather permitted. Care plans for all three residents documented that they enjoyed going outside in good weather and were to participate in activities of their choice, with assistance or reminders as needed. However, the March activities calendar for the third floor contained no scheduled outdoor activities. The AD stated that residents could go outside only when weather permitted and when a staff member was available to accompany them, and that some residents would be fine to go outside unsupervised but corporate required supervision. The DON confirmed that third-floor residents were not given the elevator code because some residents on that floor were elopement risks, that the outside patio door was locked due to a past elopement, and that aides did not have time to take residents downstairs or outside, so they were to contact the AD to do so. The Administrator acknowledged there was no policy for keeping the third floor secured, that residents were not allowed to have the elevator code, that residents had to be supervised to go outside, and that there was no policy for residents going outside, despite a facility Resident Rights policy stating residents must be able to exercise their rights without interference, coercion, discrimination, or reprisal.
Failure to Provide Bathing Assistance per Assessed Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance according to an identified resident’s assessed needs and stated preferences. During a lunch observation, the resident was seen with greasy, disheveled hair. In a Resident Council interview, the resident reported not receiving a shower for over a week, noted that her hair remained greasy and stringy, and that she was wearing the same clothes as the previous day. She stated that her scheduled shower days were Saturdays and Tuesdays, that she had not received showers on those days, that she was willing to shower at any time of day, and that she had never refused a shower. Record review showed the resident had diagnoses including anxiety, depression, and Vitamin D deficiency, and an annual MDS indicated she was cognitively intact, frequently incontinent of bowel and bladder, required partial to moderate assistance for bathing/showering, and that it was very important to her to choose between a shower, bed bath, or sponge bath. Facility shower sheets for March showed a shower on one Saturday and a complete bed bath with hair washed on one Tuesday, but the sheets for two subsequent scheduled shower days were blank except for the resident’s name and date. The DON stated that a blank shower sheet meant no shower had occurred. CNAs reported that blank sheets could mean refusal or that staff forgot to document, and that a sheet without a signature indicated a missed or ignored shower. Point of Care documentation for March showed frequent entries of partial bed baths (PBB) and multiple “activity did not occur” notations on various days, including on and around the resident’s scheduled shower days. CNAs explained that partial bed baths were used to document peri-care and that the electronic record only allowed peri-care to be recorded as a partial bed bath, making it unclear whether entries reflected full partial bed baths or only peri-care. One CNA described a partial bed bath as including face, armpits, and peri-area, while another described it as peri-area and legs, sometimes the back. The Administrator reported there was no facility policy specific to showering/bathing, and the only related written policy provided addressed general resident rights to dignity, well-being, and proper delivery of care.
Failure to Promptly Assess and Manage Resident’s Severe Mouth Pain
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess and manage a resident’s complaints of severe mouth pain during a breakfast meal service. During a dining room observation, the resident repeatedly stated she had a bad toothache, guarded her right lower jaw, grimaced, cried out that it hurt badly, and declined breakfast. An RN walked past the resident after the initial complaint without acknowledging the pain, then sat nearby to assist another resident. Over the next several minutes, the resident continued to vocalize significant pain and insist she needed to go to a dental appointment, while CNAs moved in and out of the dining room and the RN continued assisting another resident. When a CNA asked the RN about the timing of the resident’s dental appointment, the RN shrugged and stated she was not looking, and did not immediately assess the resident or check for available pain interventions. The resident’s crying out intensified, and only after this escalation did the RN ask a CNA to get the DON. The DON then informed the resident that her dental appointment was not that day and indicated staff would obtain Orajel. The RN left the dining room, and Orajel was administered on a disposable mouth sponge, followed by acetaminophen a few minutes later, after the DON propelled the resident toward her room while the resident continued to state she was in horrible pain. The resident’s clinical record showed diagnoses including Parkinson’s disease, dementia, seizures, anxiety, chronic pain, and a pain disorder related to psychological factors. Orders included scheduled and PRN acetaminophen, Tramadol, and PRN Orajel, and a recent MDS documented that the resident was moderately cognitively impaired, frequently in pain, and that pain frequently interfered with sleep and daily activities, with the resident describing her pain as severe. The care plans identified the resident as at risk for pain and called for administering pain medications as ordered, assessing and documenting effectiveness, notifying the physician if pain was unrelieved or worsening, and offering nonpharmacological interventions. Interviews with nursing staff and the DON confirmed that the RN should have assessed the resident when she first complained of mouth pain and that pain complaints should be addressed first, consistent with the facility’s pain management policy requiring necessary care and services to manage pain based on reported intensity.
Failure to Respond Timely to Resident Requests for Assistance with Bed Mobility and Toileting
Penalty
Summary
A deficiency occurred when staff failed to respond promptly to a resident's request for assistance with bed mobility related to toileting needs. During observation, a resident with multiple diagnoses, including COPD, heart failure, acute respiratory failure with hypoxia, hypertension, and type 2 diabetes, was seen attempting to use a urinal while lying in bed and requested help from a CNA to be repositioned. The CNA acknowledged the request but did not return, leaving the resident to manage alone for over 14 minutes until another CNA entered and provided the needed assistance. The resident's care plan indicated a need for assistance with activities of daily living, including bed mobility and toileting. Additional interviews revealed that other residents also experienced delays in having their call lights answered, with staff sometimes turning off call lights without providing assistance and returning only after a significant wait. Staff interviews confirmed that residents should not have to wait extended periods for assistance, and the DON stated that it was not acceptable for residents to wait 20 or more minutes for their call lights to be answered. The administrator indicated there was no policy regarding timely response to call lights.
Failure to Provide Timely Nail Care Assistance
Penalty
Summary
A deficiency was identified when a resident, admitted with a history of left femur fracture, muscle weakness, anxiety, depression, hypertension, and mood disorder, did not receive adequate assistance with nail care. The resident, who was cognitively intact but had upper extremity impairment on one side, reported that no one had offered to cut his fingernails since admission. Multiple observations over several days showed the resident with long, jagged, and sharp fingernails, and he repeatedly stated that he had requested assistance from staff, but his nails remained untrimmed. Interviews with CNAs and the DON revealed inconsistent practices regarding nail care, with staff indicating that nails were cut as needed or upon request, typically on shower days. Documentation of refusals was unclear, and there was no established policy on nail care or grooming. The resident ultimately received partial assistance but continued to struggle with nail care due to his impairment, and fingernail clippers were left at his bedside for self-use.
Failure to Consistently Provide Bedtime Snacks as Ordered
Penalty
Summary
The facility failed to consistently provide bedtime snacks to all residents as ordered by their physicians and as required by facility policy. During a resident council meeting, several residents reported that bedtime snacks were only offered about half the time. Individual interviews with residents revealed that some had never received a bedtime snack, while others received them only occasionally or when snacks were available. One resident specifically mentioned that staff told her they were out of snacks, and she had only received her snack once in two weeks. Another resident, who took medications at bedtime, stated he would like a snack but had never been offered one. Clinical record reviews showed that all six residents involved had current physician orders for bedtime snacks, and most were cognitively intact or only mildly impaired, requiring varying levels of assistance with eating and mobility. Diagnoses among these residents included conditions such as fractures, heart failure, diabetes, chronic obstructive pulmonary disease, stroke, cancer, and mental health disorders. Despite their medical needs and dietary orders, the residents did not consistently receive the prescribed bedtime snacks. Staff interviews indicated that snacks were supposed to be offered when residents were put to bed, but there had been instances where the third floor ran out of snacks. Observations of the snack pantry revealed a limited supply of items, such as Gatorade and fig cookie bars. The dietary manager and DON confirmed the process for delivering and storing snacks, but the practice did not ensure that all residents received their snacks as ordered. Facility policy required that snacks be available between meals and that a bedtime snack be offered to all residents according to their diet orders, which was not consistently followed.
Failure to Follow Infection Control Practices During Laundry Delivery and Central Line Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during the delivery of laundry services. Observations over several days revealed that a laundry aide repeatedly entered and exited multiple resident rooms, handling clean laundry, closet doors, drawers, and hangers without performing hand hygiene at any point during the process. The aide acknowledged in an interview that hand hygiene was required after touching surfaces such as knobs and dressers, and the facility's own policy specified that hand hygiene should be performed before removing or touching clean laundry. Supervisory staff confirmed that the majority of residents received laundry services from the facility, indicating the widespread potential for cross-contamination. Additionally, the facility failed to utilize enhanced barrier precautions (EBP) during care for a resident with a central line, who was at higher risk for infection. The resident's clinical record included diagnoses such as surgical aftercare, rectal abscess, malignant neoplasm of the cervix, and Enterococcus infection, and she was receiving regular central line flushes as ordered by a physician. Despite the presence of EBP signage and a PPE cart in the resident's room, and facility policy requiring gown and gloves for high-contact care activities involving central lines, an LPN performed a central line flush without donning the required PPE. The clinical record and care plan also lacked documentation of EBP interventions for this resident. Interviews with staff, including the LPN, DON, and other personnel, confirmed that EBP was required for residents with invasive devices such as central lines, and that signage and PPE carts were in place to support compliance. However, the observed failure to use PPE during high-contact care activities, as well as the lack of care plan interventions for EBP, demonstrated a breakdown in adherence to infection control protocols. Facility policies provided clear guidance on both hand hygiene and EBP, but these were not consistently followed during the observed events.
Failure to Provide Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to provide necessary notifications of Medicare non-coverage for two residents who were under Medicare Part A Skilled Services. Resident 24 was admitted to the facility and continued to stay beyond the last covered day of Part A services, which was on 5/24/24. Similarly, Resident 138 remained in the facility after the last covered day of Part A services on 1/16/24. In both cases, the clinical records lacked the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), indicating a failure to inform the residents or their representatives about the end of Medicare coverage and potential financial liability. Interviews with facility staff revealed gaps in the notification process. The Administrator was unable to find documentation that the SNF ABN forms were completed or mailed to the residents' representatives. The Social Services Director, who was responsible for notifying residents' representatives when skilled services were ending, was unaware of the requirement to fill out the SNF ABN form. Although she attempted to notify representatives by phone and mailed forms for their decision, she could not provide documentation of these discussions or proof of mailing. The facility also lacked a specific policy regarding Beneficiary Protection Notification, contributing to the oversight.
Deficiencies in Grooming and Showering Assistance
Penalty
Summary
The facility failed to provide adequate grooming and dressing assistance to a resident, identified as Resident 1, who was observed multiple times with unkempt facial hair and wearing clothing with holes that exposed her skin. Despite the resident's moderate cognitive impairment and need for assistance with activities of daily living (ADLs), as indicated in her care plan, staff did not document any refusals of care or make necessary adjustments to her clothing. Interviews with staff, including CNAs and the DON, revealed that there were no records of the resident refusing grooming or dressing assistance, and staff were expected to offer help with clothing adjustments and shaving as needed. Another resident, identified as Resident 26, did not receive timely showers, resulting in greasy hair over several days. The resident's care plan required substantial assistance with showering and personal hygiene, with a schedule of two showers per week. However, documentation showed gaps in showering and no records of refusals during these periods. Interviews with CNAs and the DON confirmed that there were no documented refusals or full bed baths provided during the time frames when showers were missed. The facility's failure to adhere to care plans and document refusals of care contributed to the deficiencies observed. The lack of proper grooming and timely showers for these residents highlights a failure in providing necessary assistance with ADLs, as required by their care plans. The facility's documentation practices and staff adherence to care protocols were insufficient to meet the residents' needs.
Unqualified Staff Assisting with Resident Feeding
Penalty
Summary
The facility failed to ensure that only qualified staff assisted residents with eating during mealtime observations. Specifically, an Activity Assistant, who had not yet passed the written portion of her CNA certification, was observed assisting a resident with eating. The facility's policy requires that only licensed and certified personnel are permitted to assist residents with eating, and the Activity Assistant had only passed her skills test, not the full certification. The Director of Nursing (DON) was uncertain about how long the Activity Assistant had been assisting residents with eating without full certification and was not generally present during mealtimes to monitor the situation. The facility's policy allows individuals who have completed a Nurse Aide Training Program to work as a Nurse Aide for up to 120 days without full certification, but the Activity Assistant's role in assisting with eating was not compliant with this policy. The facility's failure to adhere to its policy resulted in unqualified staff assisting residents with eating.
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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