Brickyard Healthcare - Fountainview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mishawaka, Indiana.
- Location
- 609 W Tanglewood Ln, Mishawaka, Indiana 46545
- CMS Provider Number
- 155178
- Inspections on file
- 33
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brickyard Healthcare - Fountainview Care Center during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities remained on a full liquid diet carried over from a hospital stay, even though the liquid diet had been ordered for nutritional reasons rather than swallowing issues and the resident was observed eating without difficulty. The resident’s POA and family repeatedly requested a change to a soft/mechanical diet, reporting they had safely fed the resident soft foods such as mashed potatoes and cottage cheese, but facility staff stated they would not change the order and discussed requiring a legal waiver if the family fed foods outside the ordered diet. Therapy and nursing leadership indicated that, because the resident could not follow commands, they believed she did not meet criteria for a diet change and did not ensure a timely, thorough swallow evaluation, resulting in the facility not honoring the resident representative’s diet preferences despite a policy supporting resident self-determination.
A resident with dementia, acute kidney failure, and documented concerns about food and fluid intake was repeatedly observed in common areas and in her room without fluids available and without being offered fluids between meals. A CNA confirmed that no fluids were given between breakfast and lunch, and the resident’s family reported that staff did not "push fluids," which they associated with a recent hospitalization for severe dehydration and abnormal lab values requiring IV fluids. The resident’s care plan identified risk for dehydration, and the facility’s hydration policy required offering sufficient fluids to maintain hydration, but these measures were not implemented for this resident.
A resident who was on antiplatelet therapy and had a history of falls sustained a head injury during a transfer with a mechanical lift, resulting in significant bruising and a large hematoma. Although a physician ordered a CAT scan of the head and face due to the trauma, facility records and staff interviews confirmed that the scan was never completed as ordered.
The facility did not notify the LTC Ombudsman in a timely manner about the discharges of three residents, including one who was discharged home after therapy and two who were sent to the hospital and not readmitted. Record reviews and interviews confirmed that required notifications were not sent, despite facility policy requiring documentation of such notifications.
The facility did not maintain a safe and sanitary environment in several rooms, as evidenced by gouged walls, broken closet doors, and damaged or non-functional window blinds. The Area Maintenance Director confirmed that these issues should have been identified and addressed through regular room tours and the facility's maintenance reporting system.
A resident with a Foley catheter experienced new, significant pain and bleeding at the catheter site, but staff did not promptly notify the physician or hospice provider as required. Despite repeated complaints and visible symptoms, the pain was not assessed or addressed in a timely manner, and documentation of notification was lacking. The facility's pain management policy requiring practitioner notification for uncontrolled pain was not followed.
The facility did not provide two residents with timely SNF-ABN and NOMNC forms after the end of their Medicare skilled services. Required notifications were either undated or not given at least 48 hours before therapy ended, and staff interviews confirmed a lack of awareness of these requirements.
A resident with severe cognitive impairment and multiple medical conditions required substantial assistance with ADLs, including bathing. The care plan documented the need for staff assistance but did not include the resident's preferences for type and frequency of bathing, as required by facility policy. The DON confirmed this omission during interview.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall resulting in a head injury. Although interventions such as a fall mat and low bed were implemented after the incident, the care plan was not promptly updated to reflect these changes, with the fall mat added much later and the low bed not documented at all.
A resident with multiple serious diagnoses, including dysphagia and malnutrition, did not receive a physician-ordered health shake with lunch on several observed occasions, even though documentation indicated it was provided. Staff interviews confirmed the supplement was not served and highlighted a breakdown in communication between dietary and nursing staff regarding responsibility for ensuring the supplement was delivered and documented.
A resident experienced significant pain related to a Foley catheter, with staff failing to promptly assess, document, and communicate the new pain to the physician or Hospice provider. Despite repeated complaints and visible signs of discomfort, no PRN pain medication was ordered or administered, and catheter care was continued without proper pain management or reassessment, contrary to facility policy.
A Unit Manager failed to wear a gown, as required by Enhanced Barrier Precautions, while providing Foley catheter care to a resident with an indwelling urinary catheter. Although gloves were used, the omission of a gown was inconsistent with the facility's policy and a physician's order for high-contact care activities involving medical devices.
The facility failed to respond promptly to grievances from four residents, who reported issues such as long wait times for care and missing personal items. Despite grievances being reviewed and resolved, residents did not receive any written or verbal responses, contrary to the facility's policy.
The facility failed to follow physician's orders and document wounds for several residents. A resident with a fluid restriction was given excess water due to staff unawareness. Another resident's wounds were not documented or assessed, and post-operative treatment orders for a third resident were delayed. Additionally, a new admission did not have treatment orders obtained, and dressings were not dated, indicating lapses in care and documentation.
The facility did not ensure the Medical Director or their designee attended quarterly QAPI meetings over the past year. The Administrator acknowledged the absence and mentioned reviewing meetings with the Medical Director or sending minutes via email. The Nurse Practitioner attended some meetings but was not recorded in the QAPI signature log. The facility's policy mandates an interdisciplinary QAA Committee, including the Medical Director, to meet quarterly.
The facility failed to inform two residents of the bed hold policy upon their transfer to a hospital. One resident, with type 2 diabetes and anxiety disorder, was hospitalized for a staph infection, while another, with leg amputations and diabetes, was transferred for congestive heart failure. In both cases, the families were notified of the transfers, but there was no documentation that the bed hold policy was communicated or provided. Interviews with staff confirmed the lack of documentation.
The facility failed to provide adequate nail care for three residents who were dependent on staff for activities of daily living. One resident, severely cognitively impaired, was observed with long, curled fingernails, and there was no documentation of nail care being offered after refusals of baths or showers. Another resident, with moderate cognitive impairment, had long fingernails with dark matter underneath, and the care plan lacked reference to nail care. A third resident, requiring substantial assistance, was observed with very long fingernails and dark matter, with no documentation of nail care provided.
A resident with a urinary catheter did not receive a catheter strap to prevent excessive tension, despite multiple requests. The resident, who had conditions such as paraplegia and pressure ulcers, was observed without a catheter strap on two occasions. The care plan included an intervention to anchor the catheter, but this was not followed. An LPN confirmed the need for securing the catheter, and the facility's policy also required it, yet it was not implemented.
A facility failed to follow physician orders for a resident's tube feeding, as observed when the resident had 350 mL of Jevity 1.5 remaining in the feeding bag, contrary to the order of 1050 mL daily. The resident, with severe cognitive impairment and multiple diagnoses, was dependent on tube feeding. Despite the Medication Administration Record indicating full compliance, the Unit Manager confirmed the resident did not receive the full prescribed amount, violating the facility's policy on feeding tube care.
A facility failed to follow physician orders for a resident's PICC line dressing changes, leading to a deficiency. The resident reported infrequent dressing changes, with discrepancies noted in the Medication Administration Records. The Infection Preventionist Nurse confirmed inaccuracies and lack of documentation for an initial dressing change upon admission, contrary to the facility's policy.
The facility failed to reconcile controlled drugs for three medication carts, resulting in missing signatures on narcotic reconciliation sheets over several weeks. An LPN and a QMA confirmed that narcotics should be counted and signed off by both the off-going and oncoming nurses every shift. The facility's policy requires all controlled substances to be accounted for to prevent loss or diversion.
The facility failed to store medications properly in the C-Wing Hall 1 medication cart. An unopened bottle of Lantus insulin for a resident was found unrefrigerated, contrary to its label instructions. Additionally, two opened bottles of eye drops for another resident were undated. The facility's policy requires refrigerated storage for certain medications.
The facility failed to dispose of leftovers in the kitchen's walk-in cooler in a timely manner, potentially affecting two residents with altered diets. During a kitchen tour, it was found that trays containing thickened drinks for residents were dated beyond the three-day limit for leftovers. The Regional Certified Dietary Manager confirmed that prepared food should have a made-on date and a discard date, and provided a policy indicating that refrigerated foods should be labeled and discarded within the allowed days.
An LPN failed to follow infection control protocols during a PICC line dressing change for a resident. The LPN placed the dressing kit on an uncleaned nightstand, did not change gloves or perform hand hygiene between steps, and did not offer the resident a mask or ask them to turn their head away from the insertion site. These actions were contrary to the facility's infection control policy.
The facility did not document declination forms for COVID-19 immunizations for three residents. A record review showed missing signed declination forms, and the Infection Prevention Nurse confirmed the absence of these forms, despite the facility's policy requiring such documentation for residents who refuse or have contraindications for the vaccine.
A facility failed to maintain a temperature log for a resident's personal refrigerator, as required by its policy. During a survey, it was observed that a resident's refrigerator lacked both a thermometer and a temperature log. The Unit Manager confirmed the absence of these items, which are necessary for compliance with the facility's policy. The policy requires weekly temperature recordings and the presence of a calibrated thermometer, along with regular cleaning and adherence to safe food handling practices.
The facility failed to report a resident's abnormal vital signs to the physician. The resident had a significant drop in blood pressure and an irregular pulse, which were not communicated to the Nurse Practitioner, contrary to the facility's policy. This oversight was identified during a review of the resident's clinical records and an interview with the Nurse Practitioner.
The facility failed to create a wound vac care plan for a resident admitted with multiple pressure ulcers and a wound vac to the right buttock. Despite the resident's extensive medical needs and the facility's policy on comprehensive care plans, no care plan was developed for the wound vac intervention.
The facility failed to reassess a resident after a significant drop in blood pressure and an elevated irregular pulse. Despite these abnormal vital signs, no further readings were documented, and the resident was later admitted to the ER for confusion and a possible infection. The LPN did not document follow-up vital signs, and the NP was not informed of the abnormalities.
Failure to Honor Resident Representative’s Diet Preferences and Fully Evaluate Diet Needs
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s request to change a resident’s diet from full liquid to a soft/mechanical consistency, despite evidence the resident could tolerate soft foods and that the liquid diet was not ordered for swallowing concerns. Surveyors observed the resident being fed full liquid meals, including broth, yogurt, supplements, pudding, and juice, which she took via spoon and straw without difficulty. A CNA who frequently assisted with meals reported the resident ate well and did not exhibit choking, coughing, or other eating concerns. The resident’s diagnoses included Alzheimer’s disease, dementia, COPD, acute kidney failure, and issues concerning food and fluid intake, and a prior hospital nutrition note documented that the full liquid diet was intended to promote nutritional intake due to hypernatremia and poor intake, not because of dysphagia. The resident’s POA reported that before a recent hospitalization for dehydration and malnutrition, the resident had been on soft foods and that the family had continued to feed her soft items such as mashed potatoes and cottage cheese without any swallowing difficulty. The POA stated the family had repeatedly requested a change from a liquid diet to a mechanical soft diet but were told by the facility that the diet order would not be changed. In a care plan meeting, the family reported being able to feed the resident cottage cheese, pudding, and yogurt in the hospital without problems, and were informed by the Administrator that a legal waiver would be needed if the family chose to feed foods outside the liquid diet ordered from the hospital. Interviews with facility staff showed that the facility continued the full liquid diet order from the hospital and did not ensure a timely, thorough evaluation of the resident’s swallowing capabilities upon readmission. The Therapy Department Manager and DON stated that because the resident could not follow commands, she did not meet criteria for a diet change and that a swallow study could not be performed, and it was unclear why physical therapy was involved in decisions about swallow testing. The DON also stated that the facility had to follow the physician’s full liquid diet order and referenced multiple meetings with the family about their desire for a soft diet and the family’s refusal to sign a waiver. A subsequent swallow study by Speech Therapy, observed by surveyors, confirmed the resident had previously been on a soft mechanical diet and that the hospital’s liquid diet was for nutritional reasons, after which Speech Therapy initiated a pureed diet; however, the deficiency centers on the period when the facility did not act on the family’s requests or fully evaluate the resident’s diet needs in accordance with her rights to self-determination as outlined in the facility’s Resident Rights policy.
Failure to Provide Adequate Fluids to Dependent Resident
Penalty
Summary
Surveyors identified that the facility failed to provide adequate fluids to maintain hydration for one dependent resident. Over multiple observations on consecutive days, the resident was repeatedly seen seated in a reclining wheelchair in the common area and in her room without any fluids available nearby. During the morning hours, no water or other fluids had been passed to the resident in her room or in the common area, and by late morning the resident remained without access to fluids. During a lunch dining observation, a CNA fed the resident a liquid diet meal that included broth, yogurt, a magic cup, a mighty shake, pudding, and juice, and the resident’s family took over feeding during the meal. The CNA reported that she had not given the resident any fluids between breakfast and lunch. The resident’s family member reported that staff had not “pushed fluids,” which they believed led to a recent hospitalization for dehydration and elevated sodium levels, and that family members came daily to feed the resident because staff did not feed or offer enough fluids. The family member stated that when they were unable to visit due to illness, the resident became dehydrated, and that the facility continued not to offer fluids even after the resident returned from the hospital. Record review showed the resident had multiple diagnoses including Alzheimer’s disease, dementia, acute kidney failure, and signs and symptoms concerning food and fluid intake. A recent ED note documented that the resident was admitted with severe dehydration, dry oral cavity, and significantly abnormal labs, including sodium of 170 and potassium of 3.0, and was treated with IV fluids. The resident’s care plan identified dehydration or potential for fluid deficit related to diuretic use, with an expectation that the resident would be free of dehydration symptoms, and the facility’s hydration policy required offering sufficient fluids to maintain proper hydration and health.
Failure to Complete Physician-Ordered CAT Scan After Resident Injury
Penalty
Summary
A physician order for a CAT scan was not completed for a resident who had sustained direct trauma to the forehead during a transfer with a mechanical lift. The resident, who had a history of falls and a fractured right femur, was on antiplatelet therapy and was observed with faded bruising around her right eye and a dark red/purple bruise on her right cheekbone. Documentation indicated that the resident was struck on the forehead by the lift's weight mechanism, resulting in a large hematoma and periorbital ecchymosis. A physician subsequently ordered a CAT scan of the head and face due to these injuries. Record review did not show any results for the ordered CAT scan, and interviews with facility staff confirmed that the scan had not been completed as ordered. The facility's policy required timely submission and scheduling of physician-ordered diagnostic tests, but this process was not followed in this instance, resulting in the failure to provide the ordered diagnostic service.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman in a timely manner regarding resident discharges for three out of five residents reviewed. Specifically, one resident was discharged to home after completing therapy, but the discharge notification for that month was not sent to the Ombudsman as required. The Executive Director (ED) confirmed that the discharge notifications for April had not been sent, despite being due at the beginning of the following month. Additionally, two other residents were sent to the hospital and subsequently discharged, but their names were not included on the Ombudsman notification lists for their respective months. Record reviews and interviews with the ED confirmed that these residents' discharges were omitted from the required notifications. The facility's policy states that evidence of notification to the Ombudsman should be maintained, but this was not followed in these cases.
Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
The facility failed to provide a safe and sanitary environment for residents, staff, and the public in 7 out of 19 rooms reviewed. Observations on the 100 Unit revealed multiple instances of environmental disrepair, including gouges in the walls near the baseboard behind a resident's bed, several basketball-sized gouges on a room's north wall, broken and partially missing window blind slats, and multiple rooms with broken closet doors and non-functional window blinds. During interviews, the Area Maintenance Director confirmed that 24 rooms are toured monthly to identify issues and that a technological system (TELS) is used for submitting maintenance work orders, with all staff expected to report problems. The Director acknowledged that the damaged and disrepaired items required repair. The DON provided the facility's maintenance policy, which states that maintenance should attempt to repair items as soon as possible.
Failure to Notify Physician of New Catheter-Related Pain
Penalty
Summary
A deficiency occurred when staff failed to notify the physician of a resident's new pain associated with a Foley catheter. The resident, who had diagnoses including neurogenic bladder, schizophrenia, anxiety disorder, dysphagia, and major depressive disorder, reported significant pain (rated 7-8 out of 10) and visible blood at the catheter site. Despite the resident's repeated complaints of pain and the presence of blood, there was no documentation that the physician or hospice provider was notified of the new pain on the day it was first reported. Observations and interviews revealed that the unit manager was aware of the resident's pain and had requested a PRN pain medication from hospice, but no order was received, and the pain was not addressed promptly. The resident continued to experience pain, and staff proceeded with catheter care without reassessing or addressing the pain. Communication lapses were evident, as the pain was reported to a nurse not assigned to the resident, and the assigned nurse did not assess the pain before continuing care. Further review showed that hospice staff were not informed of the new pain until days after the initial complaint, and there was no record of calls or notes from the facility to hospice regarding the pain on the day it began. The facility's pain management policy required staff to notify the practitioner if pain was not controlled, but this was not followed, resulting in the resident experiencing ongoing pain without timely intervention or notification to the appropriate medical providers.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) and Notice of Medicare Non-Coverage (NOMNC) forms to two residents following the end of their Medicare skilled services. For both residents, documentation showed that Medicare coverage had ended, but the NOMNC forms provided were undated, and there was no evidence indicating when the residents were informed. Additionally, the required SNF-ABN forms were not given to the residents at least 48 hours before the end of their therapy, as required by facility policy and federal regulations. Interviews with the Business Office Manager revealed a lack of awareness regarding the requirement to provide these notices in a timely manner. The Director of Nursing provided an undated policy that specified the need to give residents or their representatives at least two days' notice before the end of Medicare Part A coverage, but this policy was not followed in the cases reviewed. The deficiency was identified through record review and staff interviews, confirming that the necessary notifications were not provided as required.
Failure to Individualize ADL Care Plan for Resident with Self-Care Deficits
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with significant ADL self-care performance deficits. The resident, who had diagnoses including local skin infection, falls, anxiety, depression, hypertension, bipolar disorder, sepsis, and dysphagia, was assessed as severely cognitively impaired and requiring substantial assistance with multiple ADLs such as dressing, hygiene, toileting, and bathing. The care plan in place noted the need for assistance by one staff member but did not specify the resident's preferences regarding the type and frequency of bathing. During interviews, the DON confirmed that care plans were created using an interdisciplinary approach and acknowledged that the omission of the resident's bathing preferences was a deficiency. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes based on the resident's assessment, but this was not fully implemented for the resident in question.
Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan with new interventions following a fall incident involving a resident with severe cognitive impairment, acute and chronic respiratory failure with hypoxia, and depression. The resident, who was dependent for toileting, bed mobility, and transfers, experienced a fall from bed resulting in a head injury. Although a post-fall evaluation was conducted and interventions such as placing a fall mat and using a low bed were implemented, these changes were not promptly reflected in the resident's care plan. The fall mat was not added to the care plan until over a month later, and the low bed intervention was never documented in the care plan, contrary to facility policy requiring timely care plan updates after status changes.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to follow a physician's order to provide a health shake as a nutritional supplement at lunch and dinner for a resident with diagnoses including dysphagia, rhabdomyolysis, protein-calorie malnutrition, starvation, and a sacral pressure ulcer. During meal observations on three consecutive days, the resident did not receive the prescribed health shake with lunch, despite the medication administration record indicating it had been given. Interviews with staff revealed that the kitchen was responsible for providing the health shake, while nursing staff were responsible for documenting intake, and that if the supplement was missing, the nurse should have contacted the kitchen. The facility's policy required providing nutritional supplements consistent with residents' assessed needs.
Failure to Timely Address and Manage Resident's Catheter-Related Pain
Penalty
Summary
A resident with a Foley catheter reported significant pain, rating it as 7 to 8 out of 10, and was observed to have a catheter leg strap stuck to the tip of his penis with a small amount of blood present. Despite the resident's repeated complaints of pain, the only pain medication available was a scheduled dose, with no PRN (as needed) pain medication ordered for breakthrough pain. The Unit Manager acknowledged that a request for PRN pain medication had been made to the Hospice provider, but no order had been received, and there was no documentation that the physician or Hospice had been contacted regarding the new pain on the day it was first reported. The resident's pain persisted over multiple days, and staff continued to provide catheter care without reassessing the resident's pain or obtaining appropriate pain management interventions. Communication lapses were evident, as the pain was reported to a nurse who was not assigned to the resident, and the nurse responsible did not assess the pain before proceeding with care. The Hospice nurse and Director of Operations confirmed that no calls or requests for PRN pain medication were received from the facility prior to the day the deficiency was identified, and the Hospice nurse only became aware of the pain after a subsequent visit. The facility's pain management policy required staff to evaluate and report new or uncontrolled pain to the practitioner, but this was not followed in the resident's case. Documentation was lacking regarding timely notification to the physician or Hospice, and staff failed to ensure the resident's pain was addressed before continuing with catheter care. The deficiency was substantiated by interviews, observations, and record reviews showing a delay in both assessment and intervention for the resident's pain.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency occurred when the Unit Manager (UM) failed to follow Enhanced Barrier Precautions (EBP) while providing care to a resident with an indwelling urinary catheter. During an observed care activity, the UM wore gloves but did not don a gown as required by the facility's EBP policy, despite a visible EBP sign and available PPE supplies outside the resident's room. The resident had multiple diagnoses, including neurogenic bladder and an indwelling catheter, and a current physician's order specified the need for both gown and gloves during high-contact care. The UM later acknowledged not wearing a gown during the procedure, which was inconsistent with the facility's policy for residents with indwelling medical devices.
Failure to Respond to Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were responded to promptly and acted upon, affecting four out of 21 residents reviewed. Resident 52 reported waiting an hour on every shift for care, with staff turning off his call light without providing assistance. He filed a grievance on June 7, 2024, regarding a 40-minute wait for bathroom assistance, which was reviewed and resolved by the Executive Director on June 10, 2024, but he did not receive any response or outcome. Similarly, Resident 30 experienced a two-hour wait for care, with staff turning off his call light without returning. He filed a grievance on June 30, 2024, about the care received on June 29, 2024, which was resolved on July 13, 2024, but he was not informed of the outcome. Resident 70 reported a 20-minute wait for her call light to be answered, with staff turning it off and not returning. Her significant other filed a grievance on June 8, 2024, which was resolved on June 10, 2024, but she did not receive any response or outcome. Resident 128 reported missing $20 from his wallet, with a grievance filed on June 27, 2024. The Admissions Director was assigned to investigate but did not follow up or inform the resident of any outcome. The facility's policy required written responses to grievances, but the Administrator admitted that residents were not provided with written responses, indicating a failure to adhere to the grievance policy.
Failure to Follow Physician's Orders and Document Wounds
Penalty
Summary
The facility failed to adhere to physician's orders for several residents, leading to deficiencies in care. Resident 11, who had a fluid restriction order of 1800 mL per day due to conditions such as chronic kidney disease and hypertension, was observed with swollen legs and feet and was given more water than prescribed. The staff, including CNA 2, were unaware of the fluid restriction as it was not listed in the kitchenette, resulting in the resident receiving full cups of water exceeding the allowed amount. Resident 5, who had peripheral venous insufficiency and diabetes, was found to have wounds on his toes that were not documented or assessed during weekly skin inspections. The Unit Manager and LPN 4 were unaware of these wounds, indicating a failure in the facility's skin assessment process. The policy required weekly skin inspections, but the wounds were not noted, leading to a lack of appropriate wound care. Resident 63 returned from a post-operative appointment with treatment orders that were not initiated until two days later, delaying necessary wound care. Additionally, Resident 127, who had a surgical site on the hip and a skin tear on the wrist, did not have treatment orders obtained upon admission, and dressings were not dated as required. The Wound Nurse confirmed that treatment orders should have been obtained and dressings dated, but this was not done, indicating a lapse in following the facility's wound treatment management policy.
Failure to Ensure Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director or their designee attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings during the past year. During an interview, the Administrator admitted that the Medical Director had not attended these meetings, although she reviewed them with him or sent the meeting minutes via email. The Nurse Practitioner attended some facility meetings, but the QAPI signature log did not show her attendance at any QAPI meetings over the past year. The facility's policy on Quality Assurance and Performance Improvement, which was undated but indicated as current, requires the QAA Committee to be interdisciplinary. It must include, at a minimum, the Director of Nursing Services, the Medical Director or their designee, at least three other staff members (including the Administrator, Owner, a Board Member, or another individual in a leadership role), and the Infection Preventionist. The committee is required to meet at least quarterly to coordinate and evaluate activities under the QAPI program.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that residents were informed of the bed hold policy upon transfer to a hospital, as evidenced by the cases of two residents. Resident 28, who had diagnoses including type 2 diabetes mellitus and anxiety disorder, was admitted to the hospital due to a methicillin-resistant staph aureus infection. Although the family was notified of the hospital transfer, there was no documentation indicating that the bed hold policy was explained or a copy provided to the resident or their family. Similarly, Resident 64, with diagnoses including acquired absence of both legs below the knee and type 2 diabetes mellitus, was transferred to the hospital for congestive heart failure. The family was informed of the transfer, but there was no record of the bed hold policy being communicated or a copy given to the resident or their family. Interviews with facility staff, including an LPN and the Executive Director, confirmed the absence of documentation regarding the provision of the bed hold policy to these residents. The facility's policy required that a notice of transfer and the bed hold policy be provided to the resident and their representative.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for three residents who were dependent on staff for activities of daily living. Resident 35, who was severely cognitively impaired and dependent on staff for personal hygiene, was observed multiple times with long, curled fingernails. Despite being given bed baths and showers, there was no documentation indicating that nail care was offered after the resident refused baths or showers. Additionally, there was no current care plan addressing the resident's rejection of care, and the Unit Manager could not provide documentation explaining the lack of nail care. Resident 5, with moderate cognitive impairment and dependent on staff for bathing and personal hygiene, was observed with long fingernails and dark matter underneath them. Although his toenails were trimmed, his fingernails remained unkempt. The care plan and facility documentation did not reference nail care, and a Qualified Medication Aide (QMA) confirmed that the resident's fingernails should have been clean and trimmed. Resident 28, who required substantial assistance for personal hygiene, was observed with very long fingernails and dark matter underneath them. The care plan and facility documentation lacked any reference to nail care. A Certified Nursing Assistant (CNA) indicated that nail care should be part of shower routines, especially for diabetic residents, but there was no documentation of such care being provided. The Unit Manager acknowledged that fingernails should be cleaned and trimmed, particularly for diabetic residents.
Failure to Provide Catheter Strap for Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, specifically by not providing a catheter strap to prevent excessive tension on the catheter. Resident 128, who had diagnoses including paraplegia, osteomyelitis, and pressure ulcers, reported asking for a catheter strap multiple times over several days on all three shifts. Despite these requests, observations on two separate days confirmed that no catheter strap was in place. The resident expressed concern about blood in the catheter and the risk of it being pulled out. The resident's care plan, dated 7/3/2024, included an intervention to anchor the catheter to avoid excessive tugging during transfers and care. However, this intervention was not implemented. An LPN acknowledged that the catheter should be secured to prevent trauma, although the physician's orders did not specifically mention catheter straps. The facility's policy on indwelling catheter use also emphasized the importance of keeping the catheter anchored to prevent urethral tears or dislodgement, yet this was not adhered to in the case of Resident 128.
Failure to Follow Tube Feeding Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding tube feeding for a resident identified as Resident 35. During an observation, it was noted that Resident 35 had a container of Jevity 1.5 with 350 mL of formula remaining, and the feeding tube pump was turned off. This observation was inconsistent with the physician's order, which specified that the resident should receive 1050 mL of Jevity 1.5 daily. Despite this, the Medication Administration Record for July 2024 inaccurately indicated that the resident had received the full prescribed amount of Jevity 1.5 on the day of the observation. Resident 35's medical history included severe cognitive impairment, conversion disorder with seizures, diabetes insipidus, bipolar disorder, dysphagia, anxiety, and dementia. The resident was dependent on tube feeding, with care plan goals to prevent undesirable weight changes, discomfort, and dehydration. The facility's policy on the care and treatment of feeding tubes required that enteral nutrition administration be consistent with practitioner orders. However, during an interview, the Unit Manager confirmed that Resident 35 did not receive the full prescribed tube feeding on the observed day, indicating a failure to follow the established care plan and physician orders.
Failure to Follow PICC Line Dressing Change Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely changing of a PICC line dressing for a resident. The resident, who had a diagnosis including paraplegia and osteomyelitis, reported that his PICC line dressing had only been changed once since admission, with the last recorded change on 6/29. The physician's order specified that the dressing should be changed upon admission, then weekly and as needed, specifically on the night shift every Sunday. However, the Medication Administration Records indicated discrepancies, showing changes on 6/23, 6/30, and 7/7, with the latter being inaccurately signed according to the Infection Preventionist Nurse. During interviews, it was revealed that the dressing had been reinforced with tape, which was not appropriate, and there was no documentation of a dressing change upon the resident's admission. The facility's policy required weekly dressing changes or when soiled, but the Infection Preventionist Nurse could not find documentation supporting the initial change upon admission. This oversight in following the physician's orders and facility policy led to a deficiency in the safe administration of IV fluids for the resident.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to ensure proper reconciliation of controlled drugs for three medication carts, leading to a deficiency in pharmaceutical services. During an observation of the B-Wing Hall 1 medication cart, it was found that the narcotic reconciliation sheets were missing signatures between June 17, 2024, and July 11, 2024. An LPN confirmed that narcotics should be counted by both the off-going and oncoming nurses, with both required to sign the reconciliation sheet every shift. Similarly, the C-Wing Hall 1 medication cart was observed to have missing signatures on the narcotic reconciliation sheets between June 13, 2024, and July 11, 2024. A QMA indicated that the reconciliation should occur every shift with signatures from both nurses. Additionally, the C-Wing Hall 2 medication cart had missing signatures from May 30, 2024, to June 12, 2024. The Infection Preventionist Nurse confirmed that both the off-going and oncoming nurses should sign the sheets after counting the narcotics. The facility's policy on controlled substance administration and accountability was provided, indicating that all controlled substances should be accounted for to prevent loss or diversion.
Improper Medication Storage in C-Wing Hall 1 Cart
Penalty
Summary
The facility failed to properly store medications in one of the three medication carts reviewed, specifically the C-Wing Hall 1 medication cart. During an observation, an unopened bottle of Lantus insulin for a resident was found in the cart, despite the label indicating it should be refrigerated until opened. The IP nurse confirmed that the insulin should have been stored in the refrigerator. Additionally, two bottles of eye drops, Timolol and Brimonidine, for another resident were found opened but undated. A QMA acknowledged that the eye drops should have been dated when opened. The facility's policy on medication storage, provided by the Regional Nurse Consultant, stated that all medications requiring refrigeration should be stored in designated refrigerators.
Failure to Timely Dispose of Leftovers in Kitchen
Penalty
Summary
The facility failed to dispose of leftovers in a timely manner in the walk-in cooler of the kitchen, which could potentially affect two residents with altered diets who received their meals from the kitchen. During a kitchen tour with the Registered Dietician (RD), it was observed that three trays dated 7/2/2024 were in the refrigerator, containing thickened drinks for residents with altered liquid diet orders. The drinks included 8 glasses of milk, 2 glasses of water, 3 glasses of cranberry juice, and 2 glasses of orange juice. The RD confirmed that the date on the tray was the preparation date of the drinks. In an interview, the Regional Certified Dietary Manager (RCDM) stated that leftovers were considered good for three days and that prepared food should have a made-on date and a discard date. The RCDM later provided an undated policy titled 'Storage of Refrigerated Foods,' which indicated that refrigerated foods should be labeled with a use-by date and discarded within the allowed days per manufacturer directions. Recipe-prepared items should be discarded three days from preparation if not used.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change procedure for a resident with a peripheral inserted central catheter (PICC) line. During the observation, the Licensed Practical Nurse (LPN) placed the dressing kit on the resident's nightstand without using a barrier or disinfecting the surface. The LPN then donned sterile gloves and removed the old dressing. Without changing gloves, she cleaned the area below the insertion site and around it with an antimicrobial sponge disk, applied skin prep, and patted it with gauze before applying a transparent dressing. The resident was not offered a mask, nor was he asked to turn his head away from the insertion site, and he continued talking to the nurse during the procedure. The LPN indicated in an interview that she believed a barrier was unnecessary since the items were inside the packet and did not think it was necessary to change gloves or perform hand hygiene before cleaning the site and applying a new dressing. The facility's policy, provided by the Infection Preventionist Nurse, outlined specific steps for hand hygiene, mask usage, and setting up a clean field, which were not followed during the procedure. The policy also specified the need for the resident to turn their head away from the insertion site or wear a mask, which was not adhered to in this instance.
Failure to Document COVID-19 Vaccine Declination Forms
Penalty
Summary
The facility failed to document declination forms for COVID-19 immunizations for three residents. During a record review, it was found that the medical records for these residents lacked signed declination forms for the COVID-19 vaccine. An interview with the Infection Prevention Nurse revealed that she did not have the signed declination forms for these residents, although she acknowledged that she should have obtained them. The facility's policy on COVID vaccination, as provided by the Regional Nurse, requires that the resident's medical record include documentation if the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal.
Failure to Maintain Temperature Log for Resident's Refrigerator
Penalty
Summary
The facility failed to maintain a temperature log for a resident's personal refrigerator, as observed during a survey. Specifically, Resident 9's personal refrigerator lacked both a thermometer and a temperature log, which are required by the facility's policy. This deficiency was confirmed during an interview with the Unit Manager, who acknowledged that there should have been a thermometer and a temperature log in place. The facility's policy, provided by the Administrator, mandates that staff record refrigerator temperatures weekly and ensure a thermometer is present and calibrated. Additionally, the policy requires that nursing or housekeeping staff clean the refrigerator weekly and discard any non-compliant foods, while residents and staff must adhere to safe food handling and storage principles.
Failure to Report Abnormal Vital Signs to Physician
Penalty
Summary
The facility failed to ensure that a resident's abnormal vital signs were reported to the physician. Resident B, who was admitted with diagnoses including toxic encephalopathy, anemia, atrial fibrillation, heart failure, hypertension, orthostatic hypotension, and paraplegia, had abnormal vital signs recorded on 3/7/24. Specifically, the resident's blood pressure was 76/42 and the pulse was 108 and irregular at 9:17 A.M. These abnormal readings were not reported to the Nurse Practitioner, who was unaware of the irregular pulse and low blood pressure at that time. The Nurse Practitioner had ordered routine labs and started the resident on an antibiotic for a suspected urinary tract infection but was not informed of the abnormal vital signs that could have indicated a significant change in the resident's condition. The facility's policy titled 'Notification of Change' requires prompt consultation with the resident's physician when there is a significant change in the resident's physical status. Despite this policy, the abnormal vital signs were not communicated to the Nurse Practitioner, leading to a failure in addressing the resident's potentially critical condition. This deficiency was identified during a review of Resident B's clinical records and an interview with the Nurse Practitioner, who confirmed that the abnormal vital signs should have been reported immediately.
Failure to Create Wound Vac Care Plan
Penalty
Summary
The facility failed to ensure a wound vac care plan was created for Resident B, who was admitted with multiple pressure ulcers and a wound vac to the right buttock. The resident's clinical record indicated no care plan had been created for the wound vac intervention. The resident was admitted with diagnoses including toxic encephalopathy, anemia, atrial fibrillation, heart failure, hypertension, orthostatic hypotension, and paraplegia. An admission assessment noted the resident required extensive assistance with most activities of daily living, utilized an indwelling catheter, and required a wheelchair for locomotion. Despite these needs, the facility did not develop a care plan for the wound vac intervention, as confirmed by the MDS nurse during an interview. The facility's policy on comprehensive care plans, which mandates the development and implementation of a person-centered care plan for each resident, was not followed in this case.
Failure to Reassess Resident After Change in Condition
Penalty
Summary
The facility failed to reassess a resident after a change in condition. Resident B, who was admitted with multiple diagnoses including toxic encephalopathy, anemia, atrial fibrillation, heart failure, hypertension, orthostatic hypotension, and paraplegia, experienced a significant drop in blood pressure and an elevated irregular pulse on 3/7/24. Despite these abnormal vital signs, there were no further vital sign readings documented for the rest of the day. The resident was later admitted to the emergency room for confusion and a possible infection. The LPN responsible for Resident B on that day did not document any follow-up vital signs and did not return to work to complete a late entry in the resident's electronic medical record. The Director of Nursing confirmed that the vital signs should have been monitored throughout the day, but the facility lacked a policy to address the monitoring of abnormal vital signs. The Nurse Practitioner, who was present in the facility on the morning of 3/7/24, was unaware of the abnormal blood pressure and irregular pulse. She had ordered routine labs and started the resident on an antibiotic for a suspected urinary tract infection but was not informed of the abnormal vital signs. The NP indicated that she would have expected the nurse to repeat and monitor the abnormal vital signs. The facility's failure to reassess and monitor the resident's condition after the initial abnormal readings led to the deficiency cited in the report.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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