Brickyard Healthcare - Willow Springs Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 2002 West 86th Street, Indianapolis, Indiana 46260
- CMS Provider Number
- 155834
- Inspections on file
- 35
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brickyard Healthcare - Willow Springs Care Center during CMS and state inspections, most recent first.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to proper transition planning.
A resident with complex behavioral and psychiatric needs was re-admitted multiple times from psychiatric hospital stays, but the IDT did not review or update the care plan to reflect new or modified interventions as required by facility policy. The clinical record lacked documentation of team discussions or care plan revisions following each re-admission.
A resident with a history of stroke, hemiplegia, and bladder incontinence was found without access to a call light, despite being alert and able to voice needs. The call light was discovered out of reach, and staff confirmed it should have been accessible according to facility policy and the resident's care plan.
The facility did not accurately code MDS assessments for three residents, including failing to document dialysis treatment for a resident with end stage renal disease and omitting bed rail use for two residents who were observed using them. Care plans for these residents also lacked interventions related to bed rail use, despite confirmation from staff and resident interviews.
A resident with serious mental health diagnoses remained in the facility beyond the 60-day temporary PASARR approval period without a new Level I PASARR being completed, as required. Staff interviews confirmed the oversight, and facility policy mandates were not followed regarding timely rescreening for continued stay.
A resident with epilepsy and a history of stroke, who was prescribed multiple anti-seizure medications, did not have a seizure care plan in their current record. The DON confirmed the care plan was missing from the current system, despite facility policy requiring comprehensive, person-centered care plans for all identified needs.
A resident with a history of frequent elopement was not properly assessed for elopement risk upon admission, despite documentation from a caregiver and hospital records indicating prior incidents. The elopement assessment was completed incorrectly by a nurse, resulting in the resident not being included in the facility's elopement monitoring system, contrary to facility policy.
Staff did not consistently follow facility policy for controlled substance reconciliation, as evidenced by missing required nurse signatures on shift change count records for two medication carts. Despite policy requiring two licensed nurses to count and sign for narcotics at each shift change, documentation showed repeated omissions of signatures, indicating lapses in controlled substance accountability.
Two residents prescribed antipsychotic medications did not receive baseline AIMS assessments as required by facility policy. Both had care plans and physician orders indicating the need to monitor for adverse reactions, but documentation showed that AIMS testing was not completed. The DON confirmed the assessments were missed upon admission.
Surveyors found that medications on two medication carts were not properly stored or labeled, with missing open dates, loose pills in drawers, and discontinued or resident-specific medications not removed after discharge. Staff confirmed these practices did not follow facility policy, which requires proper labeling and timely removal of unused or expired medications.
Staff failed to follow enhanced barrier precautions and infection control protocols for three residents, including not posting EBP signs, not wearing required PPE during wound care, and handling medications in an unsanitary manner. Residents with wounds did not have appropriate care plans or timely implementation of EBP, and staff were unaware of required procedures.
The facility did not document that bed hold policy information was provided to three residents with complex medical needs when they were transferred to the hospital, and failed to notify the ombudsman after a resident's discharge. Staff interviews confirmed that while forms were reportedly sent with residents, there was no documentation in the health record or on notification lists to verify compliance with required procedures.
Two residents were found wearing hospital gowns due to missing personal clothing, violating their rights to dignity and respect. Resident 46's clothes were missing from the laundry, and Resident 42's shirts were lost shortly after admission. The facility's policy on personal belongings was not followed, leading to inadequate inventory management and prolonged periods without personal clothing.
A facility failed to update a resident's code status after hospitalization, leading to a discrepancy between the hospital discharge summary and a previous POST form. The resident, with multiple health conditions, was listed as a full code upon return, despite expressing a desire to be a no code. The facility did not follow its policy to review and clarify advance directives during care planning.
A facility failed to notify the ombudsman when a resident with multiple health issues, including respiratory failure and pressure ulcers, was transferred to the hospital and later discharged. The facility's policy required notification to the ombudsman for emergency transfers and discharges, but no such notice was found in the resident's records. The Clinical Support Nurse confirmed the omission during an interview.
The facility failed to provide the bed hold policy to two residents during their transfer to a hospital. One resident with respiratory failure and other conditions was not given the policy upon transfer or discharge. Another resident with dementia and pneumonia was also not provided the policy during their hospital transfer. The Clinical Support Nurse confirmed the absence of the required documents in both cases.
A facility failed to monitor blood sugar levels for a diabetic resident due to the absence of a glucose monitoring sensor. The resident, who had a periprosthetic fracture, a stage 4 pressure ulcer, and type 2 diabetes, reported that her sensor had not been in place for over a week, and no staff had checked her blood sugar. The facility's policy required routine glucose monitoring and maintaining an adequate supply of sensors, but these were not followed, as confirmed by staff interviews and record reviews.
A resident with a colostomy experienced a delay in care after their colostomy bag ruptured, leaving them in discomfort and with a stool-stained shirt. Despite the resident's repeated calls for help, the LPN delayed assistance, and the CNA was occupied with another resident. The resident, who required assistance from two staff members for transfers, was not attended to for 42 minutes. The facility lacked a formal incontinence program policy.
A resident with chronic respiratory failure and other health issues did not receive the prescribed continuous oxygen therapy due to an empty portable tank and disconnected tubing. Staff interviews revealed a lack of adherence to the physician's order for 2 liters of oxygen per nasal cannula, with a CNA noting the resident received only 1.5 liters. A nurse also failed to notice the disconnection of the oxygen supply, contrary to the facility's policy on oxygen administration.
The facility failed to complete side rail assessments and obtain consents for two residents before using side rails, leading to a deficiency. One resident had raised side rails without a physician's order or consent, and the Clinical Support Nurse suggested possible bed switching by staff. Another resident also had raised side rails without documentation, despite having a care plan for multiple conditions. The facility's policy required informed consent and a physician's order, which were not followed.
A facility failed to provide a clinical rationale for declining a gradual dose reduction of an antipsychotic medication for a resident with multiple health conditions. Despite a pharmacist's recommendation for dose reduction, the form only noted contraindication by a nurse practitioner without supporting documentation, contrary to the facility's policy requiring clinical justification.
The facility failed to properly label and store medications on the second and third-floor carts. Observations revealed open bottles of amantadine, Nystatin, diazepam, Tussin, and morphine sulfate without open dates, and some with illegible labels or expired. The DON and LPNs confirmed that medications should be dated when opened and expired medications should be removed, as per facility policy.
A resident with multiple health issues requested dental services, including extractions and dentures, but the facility failed to follow up on dental recommendations. The care plans did not address the resident's oral care needs or her request for extractions, and the Social Services Designee was unaware of the dentist's advice. The facility's policy required documentation of dental care needs, which was not done, leading to a deficiency.
The facility failed to ensure accurate documentation in the MAR/TAR for two residents. One resident's G-tube orders were signed off as completed despite the tube being dislodged, with LPNs citing reasons such as not wanting to go against the MAR and moving too fast. Another resident had missing documentation for several medications on specific dates. The facility's policy emphasizes timely and accurate documentation.
A facility failed to properly transcribe and communicate a hospice medication order, leading to a resident receiving excessive morphine doses. The hospice provider ordered morphine every 6 hours, but the facility's MAR indicated every 2 hours, resulting in four doses within 10.5 hours. Additionally, the facility did not document or communicate a potential fall incident when the resident was found deceased on the floor. Interviews revealed a lack of communication and awareness among staff regarding the transcription error and the resident's condition.
The facility failed to monitor and maintain refrigerator temperatures below 41°F for two out of three kitchen refrigerators. One refrigerator was at 48°F, and another lacked an internal thermometer and was warm. Temperature logs were missing for several days. The Dietary Manager and Dietitian confirmed issues with the refrigerators, which contradicted the facility's food safety policy requiring daily monitoring.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident-centered care and safe transition planning.
Failure to Update Care Plan After Resident's Psychiatric Re-admissions
Penalty
Summary
The facility failed to ensure that a person-centered, comprehensive care plan was reviewed and updated by the Interdisciplinary Team (IDT) to reflect the behavioral care needs of a resident with multiple diagnoses, including Parkinson's disease, dementia, metabolic encephalopathy, and bipolar disorder. The resident exhibited behavioral symptoms such as racial slurs, derogatory comments, verbal and physical aggression, throwing items, and refusing care. The care plan included various interventions to address these behaviors, such as administering medications, providing care in pairs, and monitoring behavior episodes. Despite multiple re-admissions from psychiatric hospital stays, the clinical record lacked documentation of IDT progress notes after each re-admission to indicate that the care plan had been reviewed and revised with new or modified interventions. Facility policy required the care plan to be reviewed and updated upon a resident's status change, with team discussions documented in the nursing progress notes. However, this process was not followed for the resident in question, as evidenced by the absence of updated care plan documentation after each hospital re-admission.
Failure to Ensure Call Light Accessibility for Resident with Mobility Impairment
Penalty
Summary
The facility failed to ensure that the call system was within reach for a resident who required assistance, as observed and confirmed during interviews and record review. The resident, who had a history of hypertension, weakness, and left-sided hemiplegia and hemiparesis following a stroke, reported being left wet and not changed as often as needed. During an observation, the resident was found sitting in her wheelchair, alert and able to voice her needs, but without the call light in view or within reach. The call light was later found behind the resident and out of reach by a CNA, who acknowledged that it should have been accessible. The resident's care plan indicated a communication problem and specified that the call light should be left within reach, but the care plan for bladder incontinence did not address call light accessibility. Facility policy required staff to ensure the call light was within reach and secured as needed.
Inaccurate MDS Assessments and Omitted Bed Rail Documentation
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents. For one resident with diagnoses including hypertension, end stage renal disease, and hyperlipidemia, the MDS assessment did not indicate that the resident received dialysis, despite nursing documentation and staff interview confirming that dialysis was provided. The MDS Coordinator acknowledged that the assessment should have reflected the resident's dialysis treatment. Additionally, two residents were observed using bilateral bed rails, but their MDS assessments did not indicate the use of bed rails. Both residents' care plans also lacked interventions related to bed rail use, despite observations and resident interviews confirming their use for mobility and support. The Director of Nursing stated that care plans should indicate bed rail use, but this was not documented. The facility did not ensure that staff had the requisite knowledge to complete accurate assessments as required.
Failure to Complete Timely PASARR Rescreening After Temporary Approval Expired
Penalty
Summary
A deficiency occurred when the facility failed to ensure a new Pre-Admission Screening and Resident Review (PASARR) was completed after the expiration of the approved 60-day period for a resident with diagnoses including bipolar disorder, post-traumatic stress disorder (PTSD), and autistic disorder. The clinical record showed that the initial PASARR Level I screen outcome provided only a temporary approval for 60 days, with clear instructions that a new Level I screen must be submitted if the resident's stay exceeded the approved period. Interviews with facility staff, including the Social Services Director and the MDS Coordinator, confirmed that a new PASARR was not completed after the initial approval expired. Additionally, a PASARR help desk staff member clarified that the expired Level I PASARR was no longer valid and required resubmission. The facility's policy also required all applicants to be screened in accordance with state Medicaid rules, but this was not followed in this instance.
Failure to Develop and Implement Comprehensive Seizure Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with epilepsy and other neurological conditions. The resident's clinical record showed diagnoses including epilepsy with status epilepticus, aphasia following a stroke, and hemiplegia/hemiparesis. The resident was prescribed multiple anti-seizure medications, including Depakote Sprinkles, lacosamide, and levetiracetam, as indicated by physician orders. Despite these diagnoses and treatments, there was no seizure care plan found in the resident's current record. During an interview, the Director of Nursing confirmed that a seizure care plan previously existed in the facility's old system but was not present in the current system. The facility's policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes for all identified needs. The absence of a seizure care plan for this resident constituted a failure to meet this policy and regulatory requirement.
Failure to Accurately Assess and Monitor Elopement Risk
Penalty
Summary
The facility failed to accurately complete an elopement assessment for a resident with a history of frequent elopement from home, as documented by both a hospital discharge report and a caregiver statement. Despite clear evidence that the resident had previously eloped and was missing for several days prior to admission, the facility's elopement assessment incorrectly indicated no such history. The Social Services Director confirmed that the resident was not included in the elopement monitoring system due to this error, and the nurse responsible for the assessment did not document the resident's known elopement risk. Facility policy required that all residents be assessed for elopement risk upon admission and throughout their stay, but this was not followed in this case.
Failure to Consistently Reconcile and Document Controlled Substances at Shift Change
Penalty
Summary
The facility failed to ensure staff followed established policy and procedure for the reconciliation of controlled substances on two of six medication carts reviewed. During observations of medication storage, multiple instances were identified where the required signatures of on-coming and off-going nurses were missing from the Controlled Substance Shift Change Count Records for the South and Southwest medication carts. These missing signatures occurred across several dates in February, April, and May, indicating that the process for jointly counting and signing for controlled substances at shift changes was not consistently followed. Interviews with staff confirmed that the expectation was for two licensed nurses to count narcotics together and sign the log at each shift change, as outlined in facility policy. The reviewed policy documents also specified that two licensed nurses must account for all controlled substances and access keys at the end of each shift. Despite these requirements, the observed documentation showed repeated failures to obtain the necessary signatures, demonstrating noncompliance with the facility's controlled substance accountability procedures.
Failure to Complete Baseline AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to complete baseline Abnormal Involuntary Movement Scale (AIMS) assessments for two residents who were prescribed antipsychotic medications. For one resident with diagnoses including acute and chronic respiratory failure with hypoxia and major depressive disorder, Latuda was ordered, and the care plan included monitoring for adverse reactions such as tardive dyskinesia. However, no baseline AIMS assessment was documented from the time of the antipsychotic prescription through the review period. Similarly, another resident with diagnoses of insomnia and major depressive disorder was prescribed Aripiprazole, with orders and care plans specifying monitoring for side effects, including extrapyramidal symptoms. Despite these directives, no baseline AIMS assessment was completed for this resident during the relevant timeframe. The DON confirmed that AIMS assessments were not performed upon admission for either resident. Facility policy required AIMS testing for residents receiving antipsychotic medications, but this was not followed in these cases.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of medications on two of three medication carts reviewed. Specifically, medications were not stored in their original packaging, open dates were missing on several medications, and discontinued medications were not removed from the carts. On the 200-unit cart, there was a bottle of latanoprost eye drops without an open date, a bottle of liquid protein without a resident's name that belonged to a discharged resident, and 19 loose pills found in the drawers. Staff interviews confirmed that the eye drops should have been dated when opened, the liquid protein should have been discarded or given to the discharged resident, and loose pills should not be present in the cart. On the 300-unit north cart, similar issues were found, including multiple bottles of eye drops and other medications without open dates, a medication for a discharged resident that had not been removed, a discontinued medication still present, and 16 loose pills in the drawers. Staff interviews confirmed that open dates were required on medications and that discontinued or resident-specific medications should have been removed from the cart. Facility policies reviewed indicated requirements for proper labeling and disposal of unused, contaminated, or expired medications.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices for residents requiring enhanced barrier precautions (EBP) and during medication administration. For one resident with a pressure wound, an LPN performed wound care without wearing a gown, did not follow correct wound cleaning technique by reusing the same gauze on the wound bed, and used a towel from the bedside table to pat the wound dry. There was no EBP sign posted outside the resident's room, and the care plan did not address the use of EBP, despite a physician's order requiring these precautions. The LPN was unaware of the required PPE for EBP, and the Director of Nursing confirmed the absence of the sign and staff awareness. In another instance, an RN was observed preparing medications and, after dropping a tablet onto the medication cart, picked it up with her fingers and placed it into the medication cup, contrary to infection control procedures and facility policy, which prohibit touching medications with bare hands. The RN acknowledged this was not the correct procedure and that the medication should have been replaced. Additionally, a resident with wounds on the vagina and buttocks had wound care supplies stored on top of the dresser in her room. The resident reported that staff only wore gloves, not gowns, during wound care. There was no EBP sign on the door or PPE available outside the room, despite a physician's order for EBP. The care plan did not include EBP at the time wound care was initiated, and the order for EBP was delayed. Interviews with staff confirmed that EBP should have been implemented earlier and that proper signage and PPE availability were lacking.
Failure to Document Bed Hold Policy and Notify Ombudsman After Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required documentation and notifications related to bed hold policies and ombudsman notification for three residents who were hospitalized or discharged. For one resident with cognitive communication deficit and muscle weakness, there was no documentation that bed hold information was provided at the time of transfer to the hospital following an acute episode. Similarly, another resident with respiratory failure and hemiplegia was transferred to the hospital without documentation of bed hold information being given, and a completed transfer form was not found in the record. Additionally, a resident with chronic respiratory failure and end stage renal disease was discharged and later returned, but the ombudsman was not notified of the discharge as required, and there was no documentation that the bed hold policy was provided during a subsequent hospital transfer. Interviews with staff confirmed that while transfer forms and bed hold policies were reportedly sent with residents, there was no documentation in the electronic health record to verify this, and the ombudsman notification list did not include the resident in question. Facility policies require written information on bed hold practices to be provided and documented, and for the ombudsman to be notified of transfers and discharges, but these procedures were not followed for the residents reviewed.
Failure to Maintain Resident Clothing Inventory
Penalty
Summary
The facility failed to ensure that residents were dressed in their own clothing instead of hospital gowns, which violated their rights to be treated with respect and dignity. Resident 46 was observed wearing a hospital gown because his clothes were missing from the laundry. The Social Services Designee was unaware of this situation, and the resident's personal inventory list was not updated in the electronic health record. The Director of Nursing later found clothes that did not belong to any resident and provided them to Resident 46, who had been without his own clothes for a long time. Resident 42 also experienced a similar issue, as he was observed wearing a hospital gown due to missing shirts. His clothing was labeled upon admission, but many items went missing shortly after. The resident's mother had to start doing his laundry to prevent further loss. Despite efforts to locate the missing items, most of his shirts remained unaccounted for until the facility found all but two shirts and completed a new inventory sheet. The facility's policy on resident personal belongings emphasizes the protection of residents' rights to possess personal items and the responsibility to maintain an inventory of these belongings. However, the facility failed to adhere to this policy, resulting in the loss of personal clothing for the residents. The lack of proper labeling and inventory management contributed to the deficiency, as residents were left without their personal clothing for extended periods.
Failure to Update Resident's Code Status Post-Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's code status was reviewed and updated after returning from an inpatient hospitalization. The clinical record for a resident, who had multiple diagnoses including muscle atrophy, type 2 diabetes mellitus, and various mental health disorders, was reviewed. A hospital discharge summary indicated the resident was a full code, while a previous POST form indicated the resident was a no code. The resident's face sheet also showed the resident as a full code. During an interview, the Director of Nursing indicated that the resident was listed as a full code upon returning from the hospital, and there was no documentation in the electronic health record to show that the resident's code status and POST form were reviewed after hospitalization. The resident expressed a desire to be a no code, consistent with the POST form dated prior to hospitalization. The facility's policy on residents' rights regarding treatment and advance directives was not followed, as it requires the review and clarification of advance directives during the care planning process.
Failure to Notify Ombudsman of Resident Transfer and Discharge
Penalty
Summary
The facility failed to notify the ombudsman when a resident was hospitalized and subsequently discharged. Resident 254, who had diagnoses including respiratory failure with hypoxia, an unstageable pressure ulcer, anxiety disorder, depression, bradycardia, and anemia, was transferred to the hospital. A nursing progress note documented the transfer, and the Nurse Practitioner and Director of Nursing were informed. However, the electronic medical record lacked evidence of notification to the Office of the State Long-Term Care Ombudsman at the time of the transfer or upon discharge. During an interview, the Clinical Support Nurse confirmed that no notice to the ombudsman was found or provided. The facility's policy required that copies of notices for emergency transfers be sent to the ombudsman, and in cases where the facility decided to discharge a resident while hospitalized, a discharge notice should also be sent to the ombudsman.
Failure to Provide Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide the bed hold policy to two residents during their transfer to a hospital, which is a requirement during such events. Resident 254, who had multiple diagnoses including respiratory failure and an unstageable pressure ulcer, was transferred to the hospital on June 14, 2024. However, the facility did not provide the bed hold policy to the resident or their representative at the time of transfer or upon discharge. This was confirmed during an interview with the Clinical Support Nurse, who indicated that the necessary paperwork, including the bed hold policy, was not found in the resident's records. Similarly, Resident 154, who had conditions such as dementia, diabetes with foot ulcer, and pneumonia, was sent to the emergency room on June 7, 2024, and later returned to the facility. The facility again failed to provide the bed hold policy to the resident or their representative. The Clinical Support Nurse confirmed that no transfer documents or bed hold policy were found in the electronic health record. The facility's current policy requires that a notice of transfer and the bed hold policy be provided to residents and their representatives, but this was not adhered to in these cases.
Failure to Monitor Blood Sugar in Diabetic Resident
Penalty
Summary
The facility failed to ensure routine blood sugar monitoring for an insulin-dependent diabetic resident, identified as Resident 260. The resident reported that her glucose monitoring system sensor had not been in place for over a week, and no staff had been checking her blood sugar levels. The clinical record review revealed that the resident had a periprosthetic fracture, a stage 4 pressure ulcer, and type 2 diabetes mellitus. Physician's orders included the application of a continuous blood glucose monitoring sensor every 14 days, insulin injections, and oral diabetes medication. However, the electronic medical record showed only two blood sugar readings for the month of June, indicating a lack of routine monitoring. Interviews with facility staff, including the Unit Manager and Clinical Support Nurse, confirmed the absence of routine glucose checks and the lack of documentation regarding the unavailability of the sensor. The Unit Manager was unaware of the sensor's absence and acknowledged that staff should have used the facility glucometer to monitor the resident's blood sugar in the interim. The Clinical Support Nurse found no orders for routine glucose checks or documentation of physician notification about the sensor issue. The facility's policy on continuous glucose monitors emphasized the need for recording glucose values as part of daily vital signs and maintaining an adequate supply of sensors, which was not adhered to in this case.
Delayed Colostomy Care for Resident
Penalty
Summary
The facility failed to provide timely colostomy care for a resident, identified as Resident 42, who returned from therapy with a ruptured colostomy bag. The resident was observed in a wheelchair with a stool-stained shirt and expressed discomfort and urgency for assistance. Despite acknowledging the situation, LPN 8 delayed attending to the resident, indicating she would return once a CNA was available. The resident continued to call for help, but LPN 8 remained at the nurse's station, and CNA 9 was occupied with another resident. It was not until 42 minutes later that CNA 9 attended to the resident with the necessary equipment. Resident 42's clinical record revealed multiple health issues, including anoxic brain damage, a stage 4 pressure ulcer, diabetes with neuropathy, and a colostomy. The resident was dependent on staff for transfers and hygiene, requiring assistance from two staff members with a mechanical lift. The care plan specified regular and as-needed ostomy care, but the facility lacked a formal incontinence program policy. Interviews indicated that staff were often too busy to respond promptly, although additional help could be summoned from other units if necessary.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 10, who required continuous oxygen therapy. During an observation, the resident was found with an empty portable oxygen tank while sitting in her wheelchair, and on another occasion, the oxygen tubing was disconnected and lying on the floor while the resident was in bed. The resident's clinical record indicated a physician's order for continuous oxygen at 2 liters per nasal cannula, with instructions to contact the physician if oxygen saturation fell below 90%. Interviews with staff revealed a lack of awareness and adherence to the prescribed oxygen flow, as a CNA noted the tank was empty and the resident was receiving only 1.5 liters, contrary to the physician's order. Additionally, a nurse failed to notice the disconnection of the oxygen supply during her visit to the resident's room. The facility's policy on oxygen administration requires adherence to physician orders, except in emergencies, which was not followed in this case.
Failure to Obtain Consent and Assessment for Bed Rail Use
Penalty
Summary
The facility failed to complete side rail assessments and obtain consents before using side rails for two residents, leading to a deficiency in ensuring safety and compliance with policies. Resident 46 was observed with raised side rails, despite not having a physician's order or documented consent for their use. The resident's clinical record, which included diagnoses such as generalized anxiety disorder and cerebral infarction, lacked any side rail assessment or consent documentation. The Clinical Support Nurse acknowledged the absence of consent and assessment, attributing the situation to possible bed switching by staff, although she was uncertain about the exact cause. Similarly, Resident 22 was observed with raised side rails on multiple occasions without a corresponding physician's order or consent in the electronic medical record. The resident's care plan, which included conditions like a fracture of the left femur, dementia, and a history of traumatic brain injury, did not mention side rails. The Clinical Support Nurse confirmed the lack of a signed consent or order for the bed rails. The facility's policy on the proper use of bed rails emphasized the need for informed consent and a physician's order, which were not adhered to in these cases.
Lack of Clinical Rationale for Antipsychotic Dose Reduction Decline
Penalty
Summary
The facility failed to provide a clinical rationale for declining a gradual dose reduction of an antipsychotic medication for a resident. The resident, who had multiple diagnoses including malignant neoplasm of the prostate, type 2 diabetes with kidney complications, dysphagia, dementia with anxiety and behavioral disturbances, bilateral osteoarthritis of the hip, and depression, was prescribed Seroquel (quetiapine) 25 mg twice daily. A pharmacist recommended a dose reduction, and the report was provided to the Medical Director and DON. However, the form only contained a handwritten note indicating the dose reduction was contraindicated per a nurse practitioner, without any clinical rationale provided. Upon review of the resident's clinical record and during an interview with the Clinical Support Nurse, it was confirmed that there were no progress notes or documentation to support the contraindication of the dosage reduction. The facility's policy on the use of psychotropic medication stated that residents should receive gradual dose reductions unless clinically contraindicated, but in this case, the necessary clinical justification was absent.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on the second and third-floor medication carts. During an observation, an open bottle of amantadine was found without an open date, and the Director of Nursing subsequently dated it as opened on 6/1/24. Additionally, an open bottle of Nystatin was found without an open date. The Director of Nursing confirmed that liquid medications should be dated when opened. On the third-floor north cart, a bottle of diazepam was found opened without a date and with an illegible label. The resident associated with this medication had been discharged on 5/29/24, and the LPN acknowledged that the bottle should have been labeled with an open date. Further observations on the third-floor west medication cart revealed an open bottle of Tussin without an open date and a bottle of morphine sulfate with an expired manufacturer's date of 1/14/24. Another sealed bottle of morphine sulfate was found with an expiration date of 6/11/24. The LPN confirmed that open bottles should be labeled with an open date and expired medications should be removed. The facility's policy on medication storage, revised in 2/24, indicated that discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels should be destroyed according to the Destruction of Unused Drugs Policy.
Failure to Follow Up on Dental Recommendations
Penalty
Summary
The facility failed to follow up with dental recommendations for a resident who had requested dental services, including the extraction of teeth and the provision of dentures. The resident, who had a history of type 2 diabetes mellitus, depressive disorder, agoraphobia, and diabetic polyneuropathy, expressed her desire to have her teeth pulled and replaced with dentures supported by implants. Despite the resident's request and the presence of dental issues such as missing teeth, a fractured tooth with an abscess, and poor oral hygiene, the care plans did not address her need for assistance with oral care or her request for extractions. Additionally, the resident experienced pain while chewing, which was not documented in the care plans. The Social Services Designee (SSD) was unaware of the dentist's recommendations against full mouth extraction and did not follow up on the dental notes after the resident's appointment. The Director of Nursing (DON) indicated that she would have ensured a dental appointment if she had known about the resident's request for extractions. The facility's policy on dental services required documentation of oral and denture care needs in the resident's plan of care, but this was not done. The lack of follow-up and documentation led to the deficiency in providing appropriate dental care for the resident.
Inaccurate MAR/TAR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the Medication and Treatment Administration Record (MAR/TAR) for two residents. For Resident 6, despite the G-tube being dislodged on 6/17/24, the MAR indicated that the G-tube related physician's orders were signed off as completed from 6/18/24 through 6/24/24. Interviews with LPNs revealed that they signed off on the MAR/TAR without verifying the presence of the G-tube, citing reasons such as not wanting to go against the MAR and moving too fast. The Nurse Practitioner did not discontinue the G-tube orders as she was unaware of them. For Resident 45, there was a lack of documentation for the administration of several medications on 6/18/24, including Melatonin, Tamsulosin, Trazadone, acetaminophen, and oxycodone. Additionally, there was no documentation for the administration of oxycodone on 6/19/24 at 10:00 p.m. The Corporate Support Nurse indicated that medication should be documented after administration unless an urgent issue arises, but it still needs to be documented. The facility's policy on documentation emphasizes that it should be completed at the time of service or no later than the shift in which the care service occurred, and false information should not be documented.
Failure in Transcription and Communication of Hospice Orders
Penalty
Summary
The facility failed to ensure proper transcription and communication of a hospice medication order for a resident receiving end-of-life care. The hospice provider had ordered morphine concentrate 20 mg/ml, 15 mg every 6 hours as needed for pain, but the facility's medication administration record (MAR) incorrectly indicated the medication should be given every 2 hours. As a result, the resident received four doses of morphine within a 10.5-hour period, exceeding the prescribed amount. This discrepancy was identified during a hospice visit, and new orders were communicated to the facility. Additionally, the facility did not effectively communicate or document a potential fall incident involving the resident. The resident was found deceased on the floor next to her bed, but the facility's progress note did not specify the position in which the resident was found or whether it was a result of a fall. The hospice note also failed to mention that the resident was found on the floor, and the hospice nurse was not informed of a potential fall during the report of the resident's death. Interviews with facility and hospice staff revealed a lack of communication regarding the resident's condition and the transcription error. The hospice nurse and clinical manager were unaware of the resident being found on the floor, and the facility's LPN confirmed the transcription error in the morphine order. The facility's policy on coordination of hospice services emphasizes the importance of communication and coordination between the facility and hospice provider, which was not adequately followed in this case.
Refrigerator Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that refrigerator temperatures were monitored and maintained below 41 degrees Fahrenheit for two out of three refrigerators in the kitchen. During an observation, one refrigerator across from the walk-in refrigerator was found to have a temperature of 48 degrees Fahrenheit. Another refrigerator, located across from the dishwasher area and used for storing drinks, lacked an internal thermometer and was warm to the touch. Temperature logs for these refrigerators showed missing entries for several consecutive days, from June 19 to June 24, 2024. In an interview, the Dietary Manager and Dietitian confirmed that the drinks had been removed from the malfunctioning refrigerator, which was also noted to have a pan collecting a clear fluid underneath it. The facility's current policy on food safety requirements, dated 2024, mandates that staff inspect all food and beverages for safe transport and quality upon delivery and ensure timely and proper storage. It also requires monitoring food temperatures and the functioning of refrigeration equipment daily and at routine intervals during all hours of operation.
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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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