Brickyard Healthcare - Twelfth Street Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mishawaka, Indiana.
- Location
- 811 E 12th Street, Mishawaka, Indiana 46544
- CMS Provider Number
- 155109
- Inspections on file
- 28
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Brickyard Healthcare - Twelfth Street Care Center during CMS and state inspections, most recent first.
A resident with a complex medical history experienced a decline in consciousness and refused medications for several days. The facility failed to notify the physician in a timely manner after the resident was given medication in the incorrect form and continued to refuse medications. The resident was eventually sent to the hospital after the family insisted, highlighting a lapse in following the facility's notification policy.
A facility failed to develop comprehensive care plans for a resident with multiple diagnoses, including type 2 diabetes and congestive heart failure. Despite being on high-risk medications, no care plans were in place to address these conditions. The MDS nurse confirmed the absence of care plans, which should have been established upon admission and when medications were prescribed, as per facility policy.
A facility failed to have Physician Orders for hypoglycemia management for a diabetic resident, leading to a critical low blood glucose event. The resident, with a history of multiple health issues, was found unresponsive and later diagnosed with hypoglycemia at the hospital. Staff interviews revealed a lack of timely assessment and monitoring of the resident's blood sugar levels, despite facility policy requirements.
A resident with Type 2 diabetes had multiple instances of elevated blood glucose levels exceeding 400 mg/dL, but the facility failed to notify the physician as required by the physician's order. Despite the facility's policy on notifying changes, there was no documentation in the nursing progress notes or triage binders indicating that the physician or Nurse Practitioner was informed of these elevated levels.
A resident with hemiplegia and hemiparesis filed a grievance requesting therapy services, which was not addressed in a timely manner by the facility. Despite the resident's request and a grievance filed on 8/5/2024, therapy services were not initiated until a physician's order was made on 9/21/2024. The facility's policy required prompt resolution of grievances, but the delay was attributed to issues with Medicaid funding and staffing for restorative programs.
The facility failed to complete Significant Change MDS assessments within the required 14 days for two residents receiving hospice services. One resident with multiple diagnoses, including COPD and traumatic brain injury, had a delayed assessment after hospice initiation. Another resident with conditions like epilepsy and diabetes also experienced a delay in assessment following hospice service commencement. The Regional MDS Nurse confirmed the assessments should have been completed within the specified timeframe.
The facility failed to maintain grooming for three residents, leading to deficiencies in their ADLs. A resident was observed with long nails and a dark substance underneath, despite requiring assistance. Another resident expressed that staff had not offered to shave him, and observations confirmed increased facial hair growth and long nails. A third resident was found with long fingernails and a dark substance underneath, with no documentation of refusals for care. Interviews with CNAs indicated they provided general ADL care but did not specifically address grooming needs.
A resident with a pressure ulcer on the back of his left upper thigh did not receive adequate treatment and monitoring. Despite reporting the sore weeks prior, the dressing was inconsistently changed, and staff were unaware of the wound care needs. The resident's medical history included chronic venous hypertension and peripheral vascular disease. Facility policies on wound care were not followed, resulting in inadequate management of the pressure ulcer.
A resident with Medicaid was not provided equal access to rehabilitation services at the facility. Despite having a physician's order for therapy, the resident experienced a delay in receiving an evaluation and therapy services due to the facility's policy requiring Administrator approval for Medicaid admissions. The resident, who had significant medical conditions affecting mobility, had requested therapy but did not receive it until later, highlighting a failure to adhere to the facility's policy on specialized rehabilitation services.
Failure to Notify Physician of Medication Errors and Resident Decline
Penalty
Summary
The facility failed to ensure timely notification of a physician when a resident, identified as Resident B, was given medication in the incorrect form, refused all medications for six consecutive medication passes, and experienced a decline in level of consciousness. Resident B had a complex medical history including stroke, seizures, heart failure, hypertension, diabetes, and dementia. The resident's Medication Administration Record (MAR) indicated that from March 1 to March 3, 2025, the resident did not receive any prescribed medications due to refusals and incorrect administration. On March 2, 2025, the resident's medications were not administered due to charted nausea and vomiting, although it was later clarified that the resident had refused the medications. On March 3, 2025, the resident continued to refuse medications and meals, and was noted to be very difficult to arouse. Despite these significant changes in condition, there was no documentation of physician notification until the resident's representative requested medical attention. The resident was eventually sent to the hospital for evaluation and treatment after the family insisted. Interviews with facility staff revealed that the resident's Depakote ER was crushed, which is against proper administration guidelines, and that the resident's lack of responsiveness and medication refusals were not promptly communicated to the physician. The facility's policy on notification of changes was not followed, as significant changes in the resident's condition were not reported in a timely manner, leading to a delay in appropriate medical intervention.
Lack of Comprehensive Care Plans for Resident with Multiple Diagnoses
Penalty
Summary
The facility failed to ensure comprehensive care plans were in place for a resident with multiple medical conditions, including type 2 diabetes, seizures, bipolar disorder, congestive heart failure, and anxiety. Upon review of Resident B's medical records, it was found that despite being admitted in September 2024 with these diagnoses, there were no care plans addressing these conditions or the medications prescribed for them. The resident was on several high-risk medications, including antipsychotics, antidepressants, and a diuretic, yet the necessary care plans to manage these conditions and medications were absent. During an interview, the MDS nurse confirmed that Resident B did not have care plans for the listed diagnoses and medications, which should have been established upon admission and when the medications were prescribed. The facility's policy mandates the development and implementation of comprehensive, person-centered care plans that include measurable objectives and timeframes to meet the resident's needs. However, this policy was not adhered to in the case of Resident B, leading to the deficiency cited in the report.
Failure to Manage Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to ensure that Physician Orders were in place for the treatment of low blood glucose and did not assess hypoglycemia in a timely manner for Resident B, who was one of three residents reviewed for diabetic treatment. Resident B had a history of stroke, seizures, heart failure, hypertension, diabetes, hyperlipidemia, dementia, and chronic obstructive pulmonary disease. Despite being severely cognitively impaired, Resident B was sometimes able to communicate his needs. The resident was on multiple medications for type 2 diabetes, but there were no orders for hypoglycemia management or a plan of care addressing the diabetes diagnosis. On a specific day, Resident B was reported to be very difficult to arouse and had not taken his medications due to lack of alertness. The resident's family requested hospital evaluation due to his unresponsiveness. The Emergency Department noted a critically low blood glucose level of 18 mm/dl, indicating hypoglycemia and altered mental status. Interviews with facility staff revealed that the resident's condition had been declining, and although vital signs were checked, blood sugar levels were not monitored. The facility's policy required glucose monitoring and treatment orders for residents at risk of hypoglycemia, which were not in place for Resident B.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of significantly elevated blood glucose levels for a resident diagnosed with Type 2 diabetes. The physician's order required notification if the resident's blood glucose levels were below 60 mg/dL or above 400 mg/dL. However, the facility did not document any notification to the physician when the resident's blood glucose levels exceeded 400 mg/dL on multiple occasions. Specifically, the resident's blood glucose levels were recorded as 420 mg/dL, 433 mg/dL, 450 mg/dL, and 416 mg/dL on different dates, yet there was no evidence that the physician was informed of these elevated levels. Interviews with facility staff, including the Administrator, Director of Nursing (DON), and RN 5, revealed that the elevated blood glucose levels should have been documented in a nursing progress note or the triage book. However, a review of the triage binders on both the resident's previous and current halls showed no notes indicating that the Nurse Practitioner (NP) was contacted regarding the resident's out-of-range blood glucose levels. The facility's policy on Notification of Changes, which was undated, stated that the facility should promptly inform the resident, consult the physician, and notify the resident's representative when there is a change requiring notification. Despite this policy, the required notifications were not made in this case.
Delayed Response to Resident's Grievance for Therapy Services
Penalty
Summary
The facility failed to respond to a resident's grievance in a timely manner, specifically regarding the request for therapy services. Resident L, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, expressed during an interview that he had not received the therapy he sought upon admission. He had filed a grievance on 8/5/2024, expressing concerns about the wait time for colostomy care and the need for therapy. The grievance form indicated a resolution on the same day, but the resident did not receive therapy services until a physician's order was made on 9/21/2024. The Director of Rehab noted that she could not evaluate new admissions with Medicaid funding without the Administrator's permission, and the Administrator confirmed that the facility did not offer a restorative program due to staffing and reimbursement issues. Despite the resident's request and the grievance filed, the Administrator did not provide a satisfactory explanation for the delay in addressing the grievance. The facility's policy required prompt efforts to resolve grievances, but the resolution for Resident L's request for therapy was delayed significantly.
Failure to Timely Complete Significant Change MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment in a timely manner for two residents who were receiving hospice services. Resident 16, with diagnoses including chronic obstructive pulmonary disease, traumatic brain injury, depression, bipolar disorder, and anxiety disorder, had a hospice contract initiated on March 28, 2024. However, the Significant Change MDS assessment was not completed until June 19, 2024, which was not within the required 14 days after the initiation of hospice services. The Regional MDS Nurse confirmed that the assessment should have been completed within 14 days of the hospice services initiation. Similarly, Resident 28, who had diagnoses including epilepsy, type 2 diabetes mellitus, Crohn's disease, dysphagia, spinal stenosis, and benign prostatic hyperplasia, had a hospice agreement dated August 2, 2024, with hospice services starting on August 12, 2024. The facility failed to complete a Significant Change MDS assessment within 14 days of the hospice order. The Regional MDS Nurse acknowledged that the assessment should have been completed within the specified timeframe. The facility does not have a specific policy for MDS assessments but follows the Resident Assessment Instrument (RAI) manual.
Deficiency in Grooming and ADL Care for Residents
Penalty
Summary
The facility failed to maintain proper grooming for three residents, leading to deficiencies in their activities of daily living (ADLs). Resident 15 was observed multiple times with long nails and a dark substance underneath them. Despite having a care plan indicating a self-care deficit and requiring assistance, there was no documentation of any refusals for nail care. Interviews with CNAs revealed that while they provided various aspects of ADL care, there was no mention of addressing nail care specifically. Resident L expressed that staff had not offered to shave him, despite his preference for a closer shave with a razor. His care plan required assistance with personal hygiene, including shaving, due to limited movement in his left arm. Observations confirmed increased facial hair growth and long nails with a brown substance underneath, with no documentation of refusals for care. Interviews with CNAs indicated they provided general ADL care but did not specifically address shaving or nail care. Resident 21 was also found with long fingernails and a dark substance underneath them. His care plan required staff assistance for grooming, but there was no documentation of refusals for hygiene or grooming assistance. Interviews with CNAs indicated they provided comprehensive personal care, including nail care, but there was no evidence of this being done for Resident 21. The facility's policy on ADLs included grooming, but the observations and interviews suggest a lack of adherence to this policy.
Inadequate Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide adequate treatment and monitoring for a pressure ulcer for Resident 37, who had a sore on the back of his left upper thigh. The resident reported the sore to the nursing staff 3-4 weeks prior, and it was attributed to his wheelchair cushion. Despite receiving a new cushion, the resident indicated that the dressing on the sore was only replaced every couple of days upon his request. Observations revealed that the dressing was undated, uninitialed, and showed visible drainage, indicating inadequate wound care management. The resident's medical history included chronic venous hypertension with ulcer of bilateral lower extremity and peripheral vascular disease. A significant MDS assessment indicated normal cognition. Progress notes from the wound care office detailed the wound's measurements and treatment plan, which included cleansing with soap and water, daily dressing changes with Medihoney Gel, and offloading with a cushion for pressure relief. However, interviews with nursing staff revealed a lack of awareness and documentation regarding the resident's wound care needs, with some staff indicating no wounds were being monitored or treated. The facility's policies on notification of changes, skin assessment, and clean dressing change were not adhered to, as evidenced by the lack of consistent documentation and communication regarding the resident's wound care. The DON indicated that wounds should be measured weekly, and new wounds should be documented, with treatment orders obtained. However, the resident's wound care was inconsistent, and staff failed to follow the established protocols, leading to inadequate treatment and monitoring of the pressure ulcer.
Failure to Provide Equal Access to Rehab Services for Medicaid Resident
Penalty
Summary
The facility failed to provide equal access to rehabilitation services for a resident with Medicaid as a payer source. Resident L, who had been admitted to the facility with the expectation of receiving therapy, reported that he had not received any range of motion exercises or therapy since his admission. Despite having a physician's order for physical therapy, the resident experienced a delay in receiving an evaluation and therapy services. The Director of Rehab indicated that she was unable to evaluate new admissions with Medicaid without the Administrator's permission, which contributed to the delay in Resident L's therapy evaluation and services. Resident L had significant medical conditions, including hemiplegia and hemiparesis following a cerebral infarction, which affected his left side. His admission Minimum Data Set assessment indicated he required assistance with personal hygiene, bathing, and transfers, and had impaired range of motion on his left side. A baseline care plan outlined the need for physical and occupational therapy to improve his functional status and minimize decline. However, the therapy services were not initiated until after the Administrator approved them, despite the resident's requests and the Director of Rehab's belief that he would benefit from therapy. The Administrator acknowledged that the facility did not offer a restorative program and that they did not receive reimbursement for therapy services for residents with Medicaid. This financial consideration appeared to influence the delay in providing therapy services to Resident L. The Administrator confirmed that Resident L had requested therapy and that his request was addressed in a written grievance. The facility's policy on specialized rehabilitation services indicated that such services are considered a facility service and should not be charged to Medicaid recipients, yet the delay in providing these services suggests a failure to adhere to this policy.
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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