Brickyard Healthcare - Laporte Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in La Porte, Indiana.
- Location
- 1700 I Street, La Porte, Indiana 46350
- CMS Provider Number
- 155062
- Inspections on file
- 24
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Brickyard Healthcare - Laporte Care Center during CMS and state inspections, most recent first.
Surveyors found that the main kitchen had unsanitary conditions, including dried grease on cooking equipment, dirty oven hood vents, accumulated food spillage on PVC pipes under the dish machine, a dirty floor, and rusted ceiling vents in the dish room. The Dietary Food Manager confirmed these areas needed cleaning.
Several residents were found with medications at their bedside and self-administering them without current physician orders or up-to-date assessments. Medications included throat lozenges, eye drops, nebulizer treatments, topical pain medication, and nasal sprays. In some cases, residents were cognitively impaired or had not been assessed for self-administration capability as required by facility policy.
A resident dependent on staff for dressing and with multiple medical conditions was consistently kept in a hospital gown during the day without documented preference, and was not routinely offered pleasure foods at meals despite no NPO order. Staff only provided pleasure foods if requested, and there was no care plan supporting these practices.
A resident's representative raised multiple concerns about the resident's care, including allegations of a bug and bite marks, but staff failed to initiate grievance forms, document specific concerns, or thoroughly investigate and resolve the complaints as required by facility policy.
Three dependent residents with significant medical conditions were repeatedly observed with unshaven facial hair and, in one case, matted hair, despite being reliant on staff for personal hygiene. Documentation did not show that shaving or hair washing was provided as needed, and staff interviews confirmed these care tasks were not consistently performed.
The facility did not ensure timely assessment and treatment for constipation, bruising, and edema in three residents. One resident with severe cognitive impairment and a history of heart failure did not receive PRN bowel medications as ordered despite multiple days without a bowel movement. Another resident on anticoagulants had visible bruising that was not assessed or documented as required. A third resident with chronic kidney disease and heart disease had persistent hand swelling and pitting edema, but there was no ongoing assessment or care plan intervention for the condition.
A resident with multiple medical conditions, severe cognitive impairment, and dependent on staff for personal hygiene was observed multiple times with very long toenails. Despite being on hospice care and receiving regular visits from hospice staff, the resident had not received podiatry services, and staff were aware of the issue but did not ensure toenail care was provided.
A resident with a history of Alzheimer's, stroke, and right side hemiplegia was repeatedly observed in a wheelchair without the required right shoulder arm tray, despite physician orders and care plan directives for its use to support the upper extremity. Staff interviews confirmed the tray was not consistently in place, and there was no documentation of refusals.
Two residents with significant cognitive and physical impairments did not have required fall prevention interventions in place, including keeping the bed in the lowest position and ensuring a floor mat was present as ordered. Despite care plans and physician orders specifying these measures, staff failed to consistently implement them, as confirmed by the DON.
The facility did not consistently document food consumption for three residents with a history of weight loss, despite care plans and physician orders requiring monitoring due to conditions such as cognitive impairment, failure to thrive, malnutrition, and dietary restrictions. Food intake logs were found to have missing entries for multiple meals, and the DON confirmed that documentation should have occurred for each meal.
A resident with a PEG tube and multiple medical conditions was found lying flat in bed while receiving enteral feeding, contrary to care plan and physician orders requiring the head of the bed to be elevated to at least 45 degrees. Staff reported the resident often adjusted the bed position, but the required elevation was not maintained during the feeding.
A resident with a history of amputation, COPD, and acute respiratory failure was observed experiencing significant pain and reported only receiving Tylenol for relief. Despite physician orders for pain management and a care plan requiring detailed pain assessments, there was no documentation of regular pain assessments in the record. The DON confirmed that pain assessments were not being documented due to the removal of the pain assessment form from the EMR system.
A resident with end-stage renal disease and an AV fistula for dialysis did not have their access site assessed and documented every shift as ordered by the physician and required by facility policy. Review of records showed multiple missed assessments over several months, and the DON confirmed that monitoring should have occurred every shift.
Surveyors found that two residents received unnecessary and excessive medications: one received prolonged and overlapping antibiotic therapy despite being on hospice, and another, who was nonverbal and dependent, was given Lorazepam and Morphine Sulfate together on multiple occasions for pain and anxiety. Staff interviews and record reviews confirmed that medication regimens were not adequately monitored or reviewed, resulting in unnecessary drug use.
Medications were left unattended on a medication cart by an LPN, and a resident with COPD and other conditions was found storing and self-administering his own pharmacy-supplied Albuterol and Fluticasone without physician orders or facility evaluation. These actions did not comply with facility policies requiring locked storage and proper authorization for self-administration.
Staff did not follow infection control protocols for two residents, including not wearing required PPE during high-contact care for a resident with a feeding tube under enhanced barrier precautions, and failing to clean multi-use scissors between wound care procedures for a resident with pressure ulcers. Facility policies required these infection prevention measures, but they were not implemented as observed and confirmed by leadership.
The facility failed to maintain sanitary conditions in food preparation and storage areas. A deep fryer was found greasy with food crumbs, and refrigerators in the A-Wing and C-Wing pantries had dried beverage spillage and improperly labeled items. Staff were unaware of the ownership of some items and did not follow labeling policies.
The facility failed to maintain an effective infection control program, with incomplete documentation and mapping of infections, and improper glove use during insulin administration. The Infection Preventionist and an LPN both demonstrated lapses in following established protocols.
A resident with hemiparesis and other medical conditions waited over 30 minutes for assistance because the call light was not within reach. The DON observed the issue and moved the resident's bed to allow access to the call light.
A staff nurse inappropriately used a resident's insulin pen for personal use, violating the resident's right to be free from misappropriation of medication. The incident was reported by a QMA after being witnessed by two CNAs. The resident had type 2 diabetes mellitus and required insulin. The facility suspended the nurse, removed the insulin pen, and conducted an investigation, leading to the nurse's termination.
The facility failed to provide adequate ADL assistance to dependent residents, specifically in nail care and facial hair removal. Multiple residents were observed with unshaven faces and dirty, untrimmed fingernails despite care plans indicating the need for assistance with personal hygiene.
A facility failed to assess and provide devices for a resident with limited range of motion. The resident was observed with her left hand clenched and lying against her chest, and the Director of Nursing was unaware of the limitation. An OT screen confirmed limited range of motion, and the resident was scheduled for therapy.
The facility failed to monitor meal consumption for a resident with a history of weight loss and nutritional risk. The resident experienced significant weight loss, and meal logs showed multiple undocumented meals. The DON confirmed that meal intakes should be documented after every meal.
The facility failed to ensure a newly hired CNA was certified within 120 days of employment. The employee continued to work past the 120-day period without certification due to a misunderstanding by the Payroll Coordinator, who thought the requirement was 120 shifts instead of 120 days.
The facility failed to accurately document weekly skin assessments and nutritional supplements for two residents. One resident had scabs and a rash that were not properly recorded, while another resident received an incorrect dosage of Ensure due to duplicate physician's orders.
Unsanitary Kitchen Conditions Due to Unclean Equipment and Surfaces
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the main kitchen, as evidenced by multiple instances of unclean food equipment and areas. Specifically, there was a large amount of dried grease on top of and on the sides of the deep fryer, as well as on the side of the stove and steamer, with additional food crumbs and dust under the steamer. The oven hood vents were found to be dirty and greasy. The white PVC pipes under the dish machine had a significant accumulation of dried food spillage, and the floor beneath the dish machine was dirty with adhered dirt against the wall. Additionally, two rusted ceiling vents were noted in the dish room. During an interview, the Dietary Food Manager acknowledged that all of these areas required cleaning.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and had physician's orders to self-administer medications for four residents reviewed. Multiple observations revealed that medications, including throat lozenges, eye drops, nebulizer treatments, topical pain medication, and nasal sprays, were found in residents' rooms and accessible for self-administration without appropriate documentation or current physician orders. In several cases, medications were left at the bedside or in personal storage, and residents reported using them independently as needed. For one resident with COPD and chronic respiratory failure, a bag of throat lozenges was observed in the room without a physician's order, and the last self-administration assessment was over a year old. Another resident with neurocognitive disorder and cerebral aneurysm had eye drops at the bedside, but there was no order or assessment for self-administration, and the resident was cognitively impaired. A third resident, who was cognitively intact but required partial assistance with ADLs, had a nebulizer, Biofreeze, and Fluticasone in his room, with no orders for self-administration or for the medications to be kept at the bedside, and the assessment did not document capability for topical medication administration. A fourth resident, also cognitively intact but requiring substantial assistance with ADLs, had a nasal spray and topical steroid on the bedside table, with the most recent self-administration assessment being nearly a year old. The facility's policy required interdisciplinary team assessment and physician orders for self-administration, but these procedures were not followed for the residents involved.
Failure to Maintain Resident Dignity and Offer Pleasure Foods
Penalty
Summary
A resident with a history of stroke, hemiplegia, dysphagia, chronic kidney disease, heart failure, and a PEG tube was repeatedly observed wearing a hospital gown during the day, with no documentation indicating this was the resident's preference. The resident was dependent on staff for dressing and personal hygiene and was not cognitively intact for daily decision making, according to the MDS assessment. Despite this, staff consistently dressed the resident in a hospital gown, and there was no care plan addressing this practice or indicating resident preference. Additionally, the resident was not consistently offered pleasure foods during meal times, even though there was no physician's order for nothing by mouth. Observations showed that while the resident's roommate received meal trays, the resident was not offered any food or pleasure items unless specifically requested. Interviews with staff confirmed that pleasure foods were only provided upon request, and the dietary manager stated that food was not routinely sent unless asked for. The DON acknowledged that pleasure foods should be offered at every meal, and there was no care plan supporting the use of a hospital gown during the day.
Failure to Document and Investigate Resident Grievances
Penalty
Summary
The facility failed to properly document, investigate, and resolve grievances raised by a resident's representative regarding the care of a resident with diagnoses including diabetes, a sacral pressure ulcer, colon cancer, and dementia. The resident was cognitively intact and required maximum assistance with activities of daily living and transfers. On two separate occasions, the resident's representative voiced concerns and made accusations about the resident's care, including the presence of a bug and bite marks found during a wound clinic visit. Although these concerns were discussed in meetings and documented in social service notes, there was no documentation of the specific concerns, investigation, or resolution, and a grievance form was not initiated as required by facility policy. During interviews, the Social Services Director acknowledged that no grievance forms had been completed for the concerns raised, despite regular meetings and documentation in progress notes. The facility's policy required staff to record grievances on a designated form and for the Grievance Official to document actions taken toward resolution. The lack of formal grievance documentation and investigation constituted a failure to honor the resident's right to voice grievances without discrimination or reprisal, as well as a failure to follow the facility's established grievance policy.
Failure to Provide Assistance with Shaving and Hair Washing for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three dependent residents, specifically regarding shaving and hair washing. Observations over several days revealed that one resident remained in bed wearing a hospital gown and consistently had a moderate amount of facial hair on her chin. Her records indicated she was not cognitively intact and was dependent on staff for personal hygiene due to a stroke, yet there was no documentation of assistance with facial hair removal. Another resident, who was dependent on staff for personal hygiene due to Parkinson's and Alzheimer's disease, was repeatedly observed with a large amount of facial hair, and there was no documentation that he had been shaved despite regular showers. A third resident, also dependent on staff for personal hygiene, was observed with a large amount of facial hair and matted, knotted hair. Documentation showed he received showers or bed baths twice weekly, but there was no record of shaving or hair washing during this period. Interviews with staff, including the Director of Nursing, confirmed that these residents should have been shaved and had their hair washed as needed, but this care was not consistently provided or documented. The residents involved had significant medical conditions, including stroke, hemiplegia, dysphagia, Parkinson's disease, Alzheimer's disease, and limited mobility, all of which contributed to their dependence on staff for personal hygiene. The lack of assistance with shaving and hair washing for these dependent residents constituted a failure to meet their ADL needs as required.
Failure to Provide Timely Assessment and Treatment for Constipation, Bruising, and Edema
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in several instances. One resident with a history of acute respiratory failure, heart disease, and severe cognitive impairment was at risk for constipation and had physician orders for bowel management, including a PRN bisacodyl suppository. Despite multiple documented periods of no bowel movement, the PRN suppository was not administered, and there was no facility policy for constipation management. The Director of Nursing confirmed that staff should administer PRN medications after three days without a bowel movement or contact the physician if no PRN orders were available. Another resident on anticoagulant therapy with a history of heart failure and diabetes was observed with bruising on the shins and right knee over several days. The care plan required monitoring and documentation of bruising, and physician orders directed staff to observe for signs of bleeding every shift. However, the record lacked documentation of assessments for the bruised areas. Additionally, a resident with chronic kidney disease and heart disease was observed with persistent hand swelling and pitting edema, but the record contained only one assessment and lacked care plan interventions for edema monitoring or treatment. Nursing staff were unaware of the swelling, and the DON acknowledged that regular assessment and documentation were required but not completed.
Failure to Provide Appropriate Foot Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for personal hygiene and was receiving hospice care was repeatedly observed with very long toenails over several days. The resident, who had diagnoses including acute respiratory failure, anxiety, heart disease, osteoarthritis, and heart failure, was severely impaired for decision making and was never or rarely understood, according to the Minimum Data Set assessment. Despite being under hospice care, there was no documentation of podiatrist visits since admission, and hospice had previously determined that podiatry services were not necessary for this resident. Staff, including a QMA and the Wound Nurse, were made aware of the resident's long toenails, and the Director of Nursing confirmed that hospice staff provided regular care, during which the toenails should have been observed.
Failure to Ensure Prescribed Arm Tray Was in Place for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of Alzheimer's disease, stroke, right side hemiplegia, and limited range of motion was observed multiple times sitting in a wheelchair without the prescribed right shoulder arm tray in place. Instead, the resident's right arm was elevated on a small bed pillow. The care plan and physician's order both specified that the resident was to use a right shoulder arm tray to support the right upper extremity while upright in the wheelchair for joint protection and proximal support. Documentation in the Medication Administration Records indicated that the tray was signed out as being on the wheelchair every day shift, with no documented refusals. Interviews with staff revealed that the arm tray was stored between the dresser and nightstand and was supposed to be attached to the wheelchair whenever the resident was up. Staff also noted that the resident's daughter might sometimes request its removal, but there was no documentation of such refusals. The Director of Nursing confirmed that the tray was to be on the resident's wheelchair, indicating a failure to ensure the assistive device was consistently in place as ordered and care planned.
Failure to Implement Fall Prevention Measures for At-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents with a history or risk of falls. For one resident with diagnoses including Parkinson's disease, Alzheimer's disease, and other significant conditions, observations revealed that the bed was not kept in the lowest position as required by the care plan, despite the resident being dependent on staff for transfers and bed mobility. Documentation showed that this resident had previously been found on the floor mat next to the bed, and the Director of Nursing confirmed that the bed should have been in the lowest position. For another resident with multiple diagnoses and severe cognitive impairment, observations showed that a floor mat was not present next to the bed while the resident was in bed, contrary to both the care plan and a physician's order. This resident had a documented history of falls from the bed, and the care plan specifically required a floor mat to be in place at all times while the resident was in bed. The Director of Nursing acknowledged that the mat should have been present. These failures demonstrate that the facility did not ensure required fall prevention measures were consistently implemented for residents at risk.
Failure to Document Food Intake for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were consistently completed for residents with a history of weight loss. For three out of four residents reviewed for nutrition, there were multiple instances where meal intake was not documented as required. This deficiency was identified through observation, record review, and staff interviews. One resident with diagnoses including mild cognitive impairment, adult failure to thrive, and dysphagia had a significant weight loss of 27% over six months. Despite care plans and physician orders addressing her nutritional needs, her food consumption logs had missing entries for several meals throughout the month. Another resident, who had a history of stroke, congestive heart failure, and dependence on renal dialysis, experienced a 12% weight loss in one month following hospitalization. His care plan required monitoring due to dietary restrictions and fluctuating intake, yet his dinner intake was not documented on multiple occasions. A third resident, diagnosed with neurocognitive disorder, protein-calorie malnutrition, and dysphagia, was also identified as being at nutritional risk. Her care plan included interventions to monitor and record meal intake at every meal, but her logs showed missing documentation for several lunches and dinners. In each case, the DON confirmed that food consumption should have been documented for every meal, but this was not consistently done.
Failure to Maintain Proper Bed Elevation During Tube Feeding
Penalty
Summary
A deficiency occurred when a resident receiving enteral nutrition via a PEG tube was observed lying completely flat in bed while tube feeding was actively infusing at 55 cc per hour. The head of the bed was not elevated to at least 45 degrees as required by the resident's care plan and physician's orders. Staff interviews revealed that the resident frequently adjusted the bed position using the remote control, and the head of the bed had been elevated earlier during medication administration, but was found flat during the observation. The resident involved had a history of stroke, hemiplegia, dysphagia, chronic kidney disease, heart failure, and a cardiac pacemaker, and was not cognitively intact for daily decision making. The care plan specifically directed staff to maintain the head of the bed at a minimum 45-degree elevation during tube feeding. Facility policy also required staff to follow care plan directives regarding resident positioning during enteral feeding. Despite these directives, the required positioning was not maintained at the time of observation.
Failure to Assess and Document Pain Management per Care Plan
Penalty
Summary
A resident with a history of left leg amputation, COPD, and acute respiratory failure with hypoxia was observed wincing in pain while moving in bed and reported daily pain in the shoulder and hip, rating it between 5 and 8 out of 10. The resident stated that only Tylenol was being provided for pain and was unaware of the reason for this approach. Review of the resident's medical record revealed physician orders for both topical Biofreeze and oral acetaminophen for hip pain, as well as a care plan that required monitoring and recording of pain characteristics such as quality, severity, location, onset, duration, aggravating, and relieving factors. Despite these orders and care plan interventions, the record lacked documentation of regular pain assessments. During an interview, the DON acknowledged that pain should be assessed and documented for residents experiencing pain or receiving pain medication, but noted that the facility's EMR system had removed the pain assessment form, leaving them without a current method for documentation. The facility's pain management policy required recognition and management of pain consistent with the comprehensive assessment and plan of care, which was not followed in this instance.
Failure to Consistently Assess and Document Dialysis Access Site
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident requiring dialysis had their dialysis access site assessed and monitored as ordered. The resident, who had diagnoses including stroke, congestive heart failure, and dependence on renal dialysis, had a physician's order for their arteriovenous (AV) fistula to be assessed for patency, audible bruit, and palpable thrill every shift. The care plan also required monitoring and documentation of signs and symptoms of infection at the access site. However, review of the Treatment Administration Records (TAR) for January, February, and March revealed multiple shifts where there was no documentation that the AV fistula was assessed as required. During an interview, the Director of Nursing confirmed that the resident's fistula should have been monitored every shift, in accordance with the facility's hemodialysis policy. The policy specified that the dialysis access site should be checked before and after dialysis treatments and every shift for patency by auscultation and palpation. The lack of documentation on several shifts indicated that the required assessments were not consistently performed or recorded, resulting in noncompliance with physician orders and facility policy.
Failure to Prevent Unnecessary Drug Use and Excessive Medication Regimens
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs, specifically regarding the use of antibiotics and the administration of medications for pain and anxiety. For one resident with a history of ESBL, neurogenic bladder, sepsis, and recurrent UTIs, records showed prolonged and overlapping use of multiple antibiotics, including Macrobid, Zyvox, Meropenem, Levaquin, and Imipenem-Cilastatin. Despite the discontinuation of a Foley catheter and multiple courses of IV antibiotics, the resident continued to receive oral Macrobid concurrently. The Director of Nursing acknowledged that the resident had received numerous rounds of antibiotics and questioned the ongoing effectiveness of the oral antibiotic, especially as the resident was also on hospice care. Another resident, who was severely cognitively impaired, dependent for mobility, and receiving hospice care for multiple diagnoses including acute respiratory failure and heart failure, was administered both opioid and anti-anxiety medications. Medication administration records indicated that Lorazepam and Morphine Sulfate were frequently given simultaneously or within minutes of each other on numerous occasions over several months. Staff relied on nonverbal pain assessment tools due to the resident's inability to communicate pain levels, and the DON confirmed that the two medications should not have been administered together. These findings demonstrate that the facility did not adequately monitor or review the necessity, duration, and dosing of medications for these residents, resulting in the use of unnecessary drugs and potentially excessive medication regimens. The deficiencies were identified through record review and staff interviews, highlighting lapses in medication management and oversight for residents with complex medical needs.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for two residents. In one instance, an LPN was observed preparing medications for a resident and left a medication cup containing two pills and a packaged Tamsulosin tablet on top of the medication cart while entering the resident's room, leaving the cart and medications unattended and out of view. The facility's policy requires all drugs and biologicals to be stored in locked compartments, but this was not followed during the medication administration process. In another case, a resident with a history of COPD, amputation, and acute respiratory failure was found to have a bag in his closet containing multiple boxes of Albuterol and Fluticasone, which he obtained from his own pharmacy and used as he felt necessary. There were no physician orders for the resident to use his own medications or to keep them at bedside, and the facility's policy requires evaluation and specific orders for self-administration and bedside storage. The Director of Nursing was unaware of the resident's possession and use of these medications.
Failure to Implement Infection Control Practices for EBP and Wound Care
Penalty
Summary
Staff failed to implement proper infection control practices for residents under enhanced barrier precautions (EBP) and during wound care procedures. In one instance, a resident with a feeding tube, who had an order for EBP, was observed being repositioned and receiving a bed bath by staff who wore gloves but did not don required isolation gowns. The resident's medical record indicated multiple complex diagnoses, including stroke, hemiplegia, dysphagia, and a PEG tube, and the facility's policy required both gowns and gloves for high-contact care activities for residents with feeding tubes. Despite this, staff did not follow the policy, as confirmed by the absence of used gowns in the room and acknowledgment from facility leadership. In a separate incident, a wound nurse was observed using the same pair of scissors to remove and apply bandages to a resident's pressure ulcers on both feet without cleaning the scissors between uses. The nurse admitted to not cleaning the scissors between dirty and clean bandages or between different wound sites. The resident involved had significant cognitive impairment and two unhealed Stage 2 pressure ulcers. Facility policy required that multi-use equipment be cleaned and disinfected after each use, but this was not followed, as confirmed by the Director of Nursing.
Sanitation Issues in Kitchen and Pantries
Penalty
Summary
The facility failed to ensure food was prepared and stored under sanitary conditions. During a kitchen sanitation tour, a deep fryer was observed to be greasy with many food crumbs, and the grease extended to the side of the convection oven. The Dietary Food Manager indicated that the deep fryer was cleaned weekly. In the A-Wing pantry refrigerator, there was a heavy accumulation of dried pink, orange, and red beverage spillage, and the refrigerator housed residents' food and other beverages. An LPN present during the observation had no comment regarding the spillage. In the C-Wing pantry refrigerator, an open bottle of orange Gatorade with no open date or label was found. An LPN indicated she did not know whose Gatorade it was and speculated it might belong to a resident who recently had a colonoscopy. The facility's policy required food or beverages brought in from outside to be labeled with the resident's name, room number, and the date the item was brought in.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by incomplete documentation and mapping of infections, and improper glove use during insulin administration. The Infection Control Logs for January through April 2024 lacked documentation of diagnostic lab or x-ray results and did not confirm if criteria for a true infection were met. Additionally, several entries lacked documentation of signs or symptoms associated with the infections. The Infection Preventionist admitted to not including infection criteria or diagnostic results on the Infection Log, as she believed the information was available elsewhere in the record. Furthermore, the January and March 2024 infection maps did not accurately reflect the number of residents with urinary tract and respiratory infections, respectively, due to missed entries and carryovers from previous months. This inconsistency was acknowledged by the IP nurse during an interview. Additionally, an LPN was observed administering insulin to a resident without donning gloves, contrary to the facility's policy. The LPN indicated she was unaware that gloves were required during insulin administration. The facility's current policy on insulin pen use clearly states that gloves should be worn during the procedure. This lapse in protocol was observed during a medication pass and highlights a gap in adherence to infection control practices among the staff.
Failure to Ensure Resident Could Reach Call Light
Penalty
Summary
The facility failed to ensure a resident who required staff assistance for activities of daily living (ADLs) received necessary services related to having the ability to reach the call light when ADL care was needed. Resident 32, who had diagnoses including hemiparesis following cerebral infarction, chronic kidney disease, and diverticulosis, indicated he had waited over 30 minutes to get help off the stool and could not reach the call light. Observations confirmed that the call light was not within reach, and the resident smelled of feces. The Director of Nursing (DON) observed the situation and moved the resident's bed to allow the resident to reach the call light. The resident's record indicated he was dependent for toilet assistance and required partial to moderate assistance for toilet transferring.
Misappropriation of Resident's Medication by Staff Nurse
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of medication when a staff nurse used the resident's insulin pen for her personal use. The incident was reported by a Qualified Medication Aide (QMA) to the Director of Nursing (DON) and the Administrator after two Certified Nursing Assistants (CNAs) witnessed the Licensed Practical Nurse (LPN) using the resident's insulin pen on herself. The resident involved had a diagnosis of type 2 diabetes mellitus with diabetic neuropathy and required insulin usage as indicated in their care plan and medication orders. The insulin pen was prescribed to be administered subcutaneously every 12 hours. The facility's policy on abuse, neglect, and exploitation was violated when the LPN used the resident's insulin pen. Immediate action was taken by the facility, including suspending the LPN and removing the insulin pen from the medication cart. The incident was thoroughly investigated, and the LPN was found guilty of misappropriation of medication and subsequently terminated. The facility also conducted staff interviews and reviewed the resident's care plan and medication orders to confirm the deficiency.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate ADL assistance to dependent residents, specifically in the areas of nail care and facial hair removal. Resident 23, who had diagnoses including dementia, high blood pressure, and heart disease, was observed multiple times over several days to be unshaven. Despite receiving hospice services and bed baths twice a week, there was no documentation indicating that the resident had been shaved. The care plan for Resident 23 indicated a need for substantial assistance with personal hygiene, which was not adequately provided as evidenced by the resident's unshaven state during the observations. Resident 45, diagnosed with Alzheimer's dementia and other conditions, was observed with long and dirty fingernails on multiple occasions. The resident's care plan indicated a need for partial to moderate assistance with personal hygiene, and her shower documentation showed she received showers twice a week. However, there was no documentation that her nails were trimmed during these showers. Similarly, Resident 11, who had hemiplegia and mild cognitive impairment, was observed with long and dirty fingernails despite indicating a preference for well-groomed nails. The resident's care plan required dependent assistance for bathing and toileting, yet her nails remained unkempt even after receiving a shower. These observations and records indicate a failure by the facility to provide necessary ADL assistance to these residents.
Failure to Assess and Provide Devices for Limited Range of Motion
Penalty
Summary
The facility failed to ensure an assessment was completed and devices were in place for a resident with limited range of motion. Resident 45 was observed multiple times with her left hand clenched and lying against her chest while sitting in a wheelchair. The Director of Nursing was unaware of the resident's range of motion limitations and no anti-contracture device was in place for the left hand. The resident's record indicated diagnoses including Alzheimer's dementia, high blood pressure, depression, psychotic disorder, and traumatic subdural hemorrhage encounter. The Quarterly Minimum Data Set (MDS) assessment indicated no impairment to her upper extremities, but a Functional and Abilities Assessment showed impairment to one side for both upper and lower extremities. An Occupational Therapy (OT) Plan and Treatment indicated impaired left upper extremity strength, but the shoulder, elbow/forearm, and wrist were within normal limits. On 5/13/24, the Director of Nursing assessed the resident's left hand and found limited extension of the middle finger. The Physician was notified, and a new order was received for OT to evaluate and treat. An OT screen completed the same day indicated a 70-degree flexion at the knuckle with pain indicated by facial expressions and sounds, although the resident denied pain when asked. The Certified Occupational Therapist Assistant confirmed the limited range of motion and indicated the resident would be picked up by OT for therapy.
Failure to Monitor Meal Consumption for Resident at Nutritional Risk
Penalty
Summary
The facility failed to ensure meal consumption was monitored for a resident with a history of weight loss and nutritional risk. Resident 51, who had diagnoses including pneumonia, diabetes, anemia, acute pancreatitis, and anxiety, was noted to have an 8.25% weight loss over 30 days. The resident's care plan indicated the need to observe meal intakes, but meal consumption logs showed multiple instances where meals were not documented. Specifically, breakfast was not documented on two occasions, lunch on five occasions, and dinner on nine occasions. The Director of Nursing confirmed that meal consumption should be documented after every meal.
Failure to Ensure CNA Certification Within 120 Days
Penalty
Summary
The facility failed to ensure that a newly hired Certified Nursing Assistant (CNA) was certified within 120 days of employment. Employee 1 was hired on January 10, 2024, and their 120th day of employment was on May 8, 2024. However, the employee continued to work as a CNA on May 9, 13, and 14, 2024, without the required certification. During an interview, the Payroll Coordinator revealed a misunderstanding, believing the requirement was 120 shifts instead of 120 days. Employee 1 was still working on the floor as a CNA on May 14, 2024, despite not being certified past the 120-day period.
Inaccurate Documentation of Skin Assessments and Nutritional Supplements
Penalty
Summary
The facility failed to ensure clinical records were accurately documented for weekly skin assessments and nutritional supplements for two residents. Resident 16 was observed with many bloody and dried scabs on his upper body, arms, and trunk. Despite this, the weekly skin reviews inaccurately documented his skin as intact on multiple occasions. The Director of Nursing indicated that the nurses might have misunderstood the assessment criteria, leading to incorrect documentation of the resident's skin condition. Resident 51 experienced significant weight loss, dropping from 204 pounds to 189 pounds within 30 days. The resident had physician's orders for Ensure nutritional supplements, but the Medication Administration Record indicated that the resident received four cans of Ensure daily instead of the prescribed two cans. The Director of Nursing acknowledged that nursing staff should have discontinued one of the orders to avoid confusion, resulting in the resident receiving an incorrect dosage of nutritional supplements.
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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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