Bridgewater Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmel, Indiana.
- Location
- 14751 Carey Road, Carmel, Indiana 46033
- CMS Provider Number
- 155790
- Inspections on file
- 46
- Latest survey
- May 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Bridgewater Healthcare Center during CMS and state inspections, most recent first.
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.
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).
Two residents did not have their comprehensive care plans updated or developed by the interdisciplinary team to reflect current mental health diagnoses and treatments. One resident's care plan omitted a new depression diagnosis and antidepressant medication, while another's care plan failed to address PTSD and bipolar disorder, and lacked a trauma-informed assessment. Facility staff confirmed these omissions.
Two residents with complex cardiovascular conditions did not receive blood pressure medications according to physician orders. In both cases, staff failed to document or act on required blood pressure parameters before administering or withholding medications, resulting in missed or inappropriate doses. Facility policy required adherence to provider orders and documentation of vital signs prior to medication administration.
Staff did not consistently sign the controlled substance inventory tracker at shift changes for two medication carts, resulting in missing signatures and incomplete documentation as required by facility policy. Interviews confirmed that the reconciliation process was not followed every shift.
Surveyors found that multiple opened insulin vials and pens, as well as eye drops, were not dated upon opening in two medication carts and one medication refrigerator. Staff confirmed that insulin must be dated and not used after 30 days, and facility policy requires proper labeling and removal of outdated medications. However, undated and expired medications were observed in storage areas.
Surveyors observed that food items in two unit kitchen refrigerators were not dated as required by facility policy. Containers belonging to two residents and other undated food items were found, with staff confirming that all items should have been dated and that staff food should be stored separately.
Staff failed to follow infection control protocols for two residents, including not wearing required PPE during catheter care for a resident on EBP and improper wound cleaning technique by a wound nurse who reused gauze between clean and dirty areas. Both staff members acknowledged the lapses, and the facility lacked a specific policy on clean-to-dirty wound care technique.
A resident's modified cell phone holder went missing, and the facility failed to follow proper protocol for reporting and searching for the item. Despite the resident's request for assistance, the Head of Housekeeping did not file a grievance form or conduct a thorough search, leading to a deficiency in protecting the resident's personal property.
A facility failed to create a comprehensive care plan for a resident with CHF, despite the resident's medical history and a physician's order for daily weight monitoring. The care plan lacked specific interventions for CHF, which was confirmed by the Clinical Support Nurse. The facility's policy on resident-centered care planning was not followed in this instance.
A facility failed to provide effective communication for a resident whose primary language was Korean, leading to isolation and potential decline in psychosocial well-being. The resident's care plan lacked interventions for linguistic needs, and communication tools were in English, which the resident could not read. Staff interviews revealed a lack of resources and understanding to communicate effectively, and the facility lacked a policy for non-English speaking residents.
A resident with CHF, COPD, and hypertension experienced a significant weight loss from 149 to 141 pounds over seven days. Despite a physician's order for daily weights, the facility failed to document or notify the physician of this change until 17 days later. The facility's policy required weight loss concerns to be reported and discussed at weekly clinical meetings, which was not followed.
A resident with a history of trauma and multiple medical conditions was found hoarding moldy food and items in her room, but her care plan did not address this behavior. Staff were aware of the hoarding but lacked a formalized approach to manage it, contrary to the facility's behavior management policy.
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.
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 Update and Develop Comprehensive Care Plans for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that comprehensive care plans were properly reviewed, revised, and developed by the interdisciplinary team for two residents. For one resident with diagnoses including anxiety disorder and moderate recurrent depressive disorder, the care plan was not updated to reflect a new diagnosis of depression or the addition of an antidepressant medication. The care plan also lacked interventions to monitor the effectiveness or side effects of the medication, despite documentation in the clinical record and physician orders indicating the presence of depression and the use of antidepressants. The Clinical Support Nurse confirmed that these updates should have been made to the care plan. For another resident with a history of sexual abuse and diagnoses of bipolar II disorder, PTSD, and depression, the care plan did not include PTSD or bipolar disorder, and a trauma-informed care assessment was not completed upon admission. The resident was receiving virtual therapy for PTSD, and there was no physician's order for these psychiatric services in the record. Interviews with facility staff, including the DON and Social Service Director, confirmed that the care plan should have included these diagnoses and that a trauma/PTSD assessment should have been initiated. The facility also lacked a policy specifically addressing comprehensive care plans.
Failure to Administer Blood Pressure Medications per Physician Orders
Penalty
Summary
The facility failed to administer blood pressure medications according to physician orders for two residents with significant cardiovascular and respiratory diagnoses. For one resident with essential hypertension, COPD, and pulmonary fibrosis, the care plan identified a risk for unstable blood pressures and included a physician's order to administer Lasix daily, with instructions to hold the medication if the systolic blood pressure was less than 100. However, medication administration records showed that Lasix was given on multiple occasions without recording the systolic blood pressure, and on one occasion, it was administered when the systolic blood pressure was below the hold parameter. Interviews confirmed that blood pressure should have been checked and documented prior to administration, and the medication should have been held if parameters were not met. For another resident with hypertension, congestive heart failure, atrial fibrillation, and pulmonary edema, the care plan required administration of hydralazine as needed for systolic blood pressure greater than 160. Despite documented blood pressure readings above this threshold on several dates, the medication was not administered as ordered. Staff interviews confirmed that the as-needed medication should have been given and documented according to the physician's order. Facility policy also required medications to be administered only as prescribed and for pertinent information, such as blood pressure, to be recorded prior to administration.
Failure to Reconcile Controlled Medications per Policy
Penalty
Summary
Staff failed to follow facility policy and procedure for the reconciliation of controlled medications, as evidenced by missing signatures on the SHIFT CHANGE/CONTROLLED SUBSTANCE INVENTORY TRACKER documents for two medication carts. On multiple occasions, the required signatures from both off-going and on-coming nurses were absent, and in several instances, the date fields were not filled in. These omissions were observed during reviews of the narcotic reconciliation logs for the 3000-unit and 4000-unit medication carts. Interviews with staff confirmed that the narcotic inventory tracker was supposed to be signed every shift, in accordance with facility policy. The facility's policy, as provided by the Director of Nursing, requires that controlled drugs and their count sheets be reconciled and signed by both the nurse reporting off duty and the nurse reporting on duty at every shift change. Despite this, the logs reviewed showed missing signatures for several shifts, indicating that the reconciliation process was not consistently followed. No information was provided regarding the medical history or condition of any residents directly affected by this deficiency.
Failure to Properly Label and Remove Outdated Medications
Penalty
Summary
Surveyors observed that medications, including insulin vials and pens as well as eye drops, were found opened and not dated in two of four medication carts and one of two medication refrigerators. Specifically, on the 3000-unit medication cart, a bottle of latanoprost eye drops, a vial of Lantus insulin, and a Lantus insulin pen were all open without an open date. On the 4000-unit medication cart, a full Lantus insulin pen, a vial of Humalog insulin, a half-full Lantus insulin pen, and a lispro insulin pen were also open and not dated. Additionally, the 4000-unit medication storage refrigerator contained an opened Lantus insulin with an expiration date that had already passed. Interviews with staff confirmed that insulin is required to be dated upon opening and should not be used beyond 30 days after opening. The facility's policy, as provided by the Director of Nursing, states that all medications must be stored in their original pharmacy containers with proper labeling and that outdated medications are to be immediately removed and disposed of according to procedures. The observations and staff interviews indicated that these policies were not consistently followed, resulting in the presence of undated and expired medications in medication storage areas.
Undated Food Items Found in Unit Kitchen Refrigerators
Penalty
Summary
The facility failed to ensure that food items stored in the unit kitchen refrigerators were properly dated, as observed in two of four kitchenettes reviewed. In the 3000-unit kitchenette, two white Styrofoam containers belonging to two residents were found in the refrigerator without any dates indicating when the items were placed in storage. The Infection Preventionist confirmed that these items should have been dated. In the 4000-unit kitchenette, a clear container with a red lid, a bag of yogurt, and a container of fruit were found in the refrigerator without names or dates, and a container of spread for another resident was also undated. An RN confirmed that these items should have been dated and that staff food should be stored in the employee break room. The facility's policy requires staff to date containers when food or beverages are brought into the facility.
Failure to Follow Infection Control Protocols During Catheter and Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for two residents observed during survey. In one instance, a CNA provided catheter care to a resident on Enhanced Barrier Precautions (EBP) without donning a gown, despite clear signage and care plan instructions requiring gown use for close contact care. The resident had an indwelling Foley catheter and diagnoses including obstructive and reflux uropathy, urinary retention, and diabetes with chronic kidney disease. The CNA acknowledged that gowns were required for EBP, and the Infection Preventionist confirmed the omission. In a separate incident, a wound nurse performed wound care on another resident and failed to follow clean-to-dirty technique. The nurse used the same piece of gauze to clean both the inside and outside of a sacral wound multiple times, contrary to best practice standards and facility expectations. The nurse admitted this was not typical practice and should have used a new piece of gauze. Clinical support staff confirmed that staff should not move from clean to dirty areas with the same gauze, and the facility lacked a specific policy on clean-to-dirty technique.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a resident's personal property, specifically a cell phone holder, which was reported missing by Resident 16. The resident, who has diagnoses including generalized pain, major depressive disorder, dwarfism, and anxiety disorder, had modified the phone holder to fit his motorized wheelchair. Despite the resident's request for assistance in locating the item, the facility did not follow proper protocol for reporting and searching for the missing property. The resident initially asked the Head of Housekeeping to check the laundry, but the item was not found, and no grievance form was filed at that time. The facility's policy on misappropriation of property requires a report to be made if an item is determined to have existed in the facility but is not found during an initial search. However, this procedure was not followed, as evidenced by the lack of a grievance form until much later. Interviews with staff, including the Executive Director and Head of Housekeeping, revealed that the protocol was not adhered to, and the search for the missing phone holder was not conducted thoroughly or documented appropriately. This oversight led to a deficiency in honoring the resident's right to retain and use personal possessions.
Failure to Develop Comprehensive Care Plan for CHF
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with congestive heart failure (CHF). The resident, who also had chronic obstructive pulmonary disease (COPD) and hypertension, was admitted to the facility with a history of several medical conditions, including CHF. Despite the presence of a physician's order to weigh the resident daily, the care plan did not address the resident's CHF diagnosis or include any specific interventions related to managing CHF. During an interview, the Clinical Support Nurse confirmed the absence of a care plan for CHF. The facility's policy on care planning emphasizes the importance of providing resident-centered care that addresses the psychosocial, physical, and emotional needs of residents. However, the policy was not adhered to in this case, as the care plan failed to incorporate the resident's CHF diagnosis and necessary interventions.
Deficiency in Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure effective communication with a resident whose primary language was Korean, leading to a deficiency in providing resident-centered care. Resident 91, who was new to the facility, had a care plan indicating a potential for isolation and a need for social interaction and cognitive stimulation. However, the care plan did not address the resident's primary language needs, and interventions for cultural preferences and linguistic needs were not specified. The resident was observed lying in bed while other residents participated in activities, and communication tools in the resident's room were in English, which the resident could not read. Interviews with staff revealed a lack of understanding and resources to communicate effectively with the resident. LPN 3 indicated that communication was primarily through hand gestures, and the resident's room contained English-written materials. The Administrator and Clinical Support Nurse acknowledged the absence of a policy for communicating with residents whose primary language is not English. The resident's Brief Interview for Mental Status (BIMS) was conducted in English, resulting in a score indicating severe cognitive impairment, but it was unclear if this was due to a language barrier or other factors. The facility's policy on resident rights emphasized dignity, respect, and effective communication, but it did not provide specific guidance for non-English speaking residents. The lack of a communication system for the resident's primary language contributed to the resident's isolation and potential decline in psychosocial well-being. The facility did not have a method to ensure the resident could participate in activities or communicate needs effectively, as required by their policy.
Failure to Timely Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding a significant weight change for a resident with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and hypertension. The resident's weight decreased from 149 pounds to 141 pounds over a period of seven days, representing a weight loss of more than 5%. Despite a physician's order to weigh the resident daily starting on 6/27/24, there were no notes in the medical record addressing the weight loss until 17 days later. The Clinical Support Nurse confirmed the absence of documentation about the weight loss until much later, and the physician was only informed on 7/19/24, when they saw the resident for the significant weight change and CHF. The facility's policy indicated that weight loss concerns should be reported to the practitioner and discussed at weekly clinical meetings, which was not adhered to in this case.
Failure to Address Resident's Hoarding Behavior
Penalty
Summary
The facility failed to identify and treat a resident's behavior symptom of hoarding, which was observed during a survey. The resident, who had a history of trauma and was diagnosed with several medical conditions including acute respiratory failure and chronic obstructive pulmonary disease, was found with moldy fruit and piles of items in her room. Despite having care plans addressing mood problems and trauma-related symptoms, there was no mention of the resident's hoarding behavior or the collection of potentially hazardous food items. Interviews with staff revealed that the resident was known to hoard items and was protective of her food, yet this behavior was not documented in her care plan. The staff had to discreetly clean the resident's room when she was not present, indicating a lack of a formalized approach to managing her hoarding behavior. The facility's policy on behavior management emphasized the need for a resident-centered plan and documentation of behaviors, but these were not implemented for the resident's hoarding issue.
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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