Brookside Care Strategies
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 505 N Gavin St, Muncie, Indiana 47303
- CMS Provider Number
- 15E064
- Inspections on file
- 47
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Brookside Care Strategies during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia was at the nurse’s station holding a QMA’s hand when a CNA approached and made a derogatory remark implying the QMA should bleach or disinfect her hands after contact with the resident. The comment was made within the resident’s hearing and in the resident’s presence, and the QMA perceived it as disrespectful and undignified. In interviews, the CNA acknowledged making the statement while the resident was nearby, though she claimed she did not intend for the resident to hear it or view it as demeaning. Facility leadership, including the DON and Administrator, identified the remark as disrespectful, undignified, and a form of verbal abuse that violated the resident’s right to dignity and respectful treatment.
The facility failed to report an allegation of abuse to the state agency after a resident told a CNA during personal care that a housekeeper had kissed her on the lips multiple times and had been communicating with her via social media for about a week. The CNA documented the disclosure and notified facility management, and a subsequent statement indicated the resident said the kiss was wanted and that she did not want the housekeeper to get into trouble. The housekeeper denied kissing the resident but admitted to social media messaging, and the resident later recanted her original statement, saying she made it up to get closer to him. The Administrator, aware of these details and of the facility’s abuse policy requiring reporting of alleged violations to the Department of Health when required by law or regulation, chose not to report the allegation to the state agency.
A resident with multiple chronic conditions was subjected to verbal abuse by an Activity Assistant during a smoke break, where both parties exchanged insults and the staff member made inappropriate remarks about the resident's health. Staff witnesses confirmed the incident, and the facility's abuse prevention policy was not followed despite regular staff education.
A cognitively impaired resident who required substantial assistance and frequent redirection was subjected to verbal abuse by a maintenance staff member. The staff member made threatening and intimidating statements, including threats of physical harm, in response to the resident's behaviors. Multiple staff witnessed the incident, and the facility's investigation confirmed that the staff member's actions constituted verbal and mental abuse.
The facility did not provide quarterly funds statements to two residents whose personal funds were managed by the facility, as required by policy. Staff acknowledged that statements were not given to residents without a responsible party, resulting in the deficiency.
The facility did not maintain a surety bond sufficient to cover all resident funds it managed, as required by policy. On multiple occasions, the balance of resident funds exceeded the bond amount, and the Business Office Manager confirmed that no reviews were conducted to ensure adequate coverage.
A resident with multiple medical conditions experienced a significant change in condition, including symptoms such as tachycardia, hypertension, and refusal of medication and fluids. Staff failed to notify the resident's representative of these changes as required, only informing them after the resident was ordered to be transferred to the ER. Facility policy and staff interviews confirmed that notification should have occurred at the time of the initial change.
The facility did not provide necessary social services to two residents requiring assistance with financial management. One resident's cash was stored in the Social Service office without documentation or a care plan, and the family was not informed. Another resident, with significant cognitive impairment, had funds exceeding Medicaid limits, but there was no evidence of assistance or care planning to help spend down resources, and the resident was unaware of the available funds.
A facility failed to sanitize a multi-use blood glucose monitoring device per manufacturer's guidelines. A QMA used an alcohol swab to clean the device between testing two residents, which was insufficient according to the manufacturer's policy. The DON confirmed the inadequacy of the sanitization method used.
The facility failed to administer insulin as prescribed for three residents, resulting in missed doses and inadequate documentation. A resident with type 2 diabetes did not receive Lantus and Lispro as ordered, while another with type 1 diabetes missed Novolog doses. A third resident with diabetes and hypoglycemia also had missed Humalog doses. The DON noted staff were not signing off on the eMAR, leading to documentation gaps.
A facility failed to suspend an employee accused of abuse, as required by its policy, when a resident alleged that the employee kicked his foot intentionally. Despite the resident's request for further action and his wish to avoid interaction with the employee, the accused was not suspended during the investigation. The facility's policy mandates suspension of the accused until a full investigation is completed, but this was not followed, leading to a deficiency.
The facility failed to maintain safe food temperatures in its refrigerators, impacting all residents. A refrigerator was found at 48°F, with logs showing missing entries and no guidance on acceptable ranges. Despite being informed, the Dietary Manager did not verify temperatures, relying on staff reports. The facility policy required storage below 41°F, which was not followed.
The facility failed to implement an effective QAPI program, resulting in repeat deficiencies related to improperly labeled medications and incomplete narcotic reconciliation sheets. The Administrator admitted to not having a recent QAPI plan and lacked record-keeping of meeting minutes. An audit tool for pharmacy services was insufficiently detailed, and the QAPI plan provided was outdated, contributing to the facility's inability to address and prevent repeat deficiencies.
The facility failed to maintain a functional call light system, impacting all 34 residents. Instead, residents were given manual bells, which were often out of reach and inadequate, especially for those with physical limitations. The call light system had been inoperable for months, and management was aware but had not yet arranged for its repair or replacement. Residents had to resort to yelling or using personal phones to summon help, and staff found it challenging to identify which resident needed assistance.
The facility did not ensure that the most recent survey results were accessible to residents and their representatives. The survey binder, located behind the nurse's station, only contained surveys dated before 11/27/23, despite complaint surveys being conducted after this date. The Administrator was unaware that complaint surveys needed to be included, contrary to facility policy.
The facility failed to follow its grievance policy, as the Social Services Director resolved complaints immediately without documentation, contrary to the policy requiring written responses and reports. The last recorded grievance was several months ago, indicating a lack of adherence to the established grievance process.
The facility did not effectively implement an infection control program, as evidenced by the lack of prior tracking and trending of resident infections. The Infection Preventionist, new to the position and splitting time between locations, was unaware of previous infection control measures and only recently completed the Infection Log using antibiotic orders. The facility's policy required an infection control program, but it was not effectively executed.
The facility failed to provide chairs in resident rooms, affecting all 34 residents. Residents expressed a need for chairs during confidential interviews, with some having to sit on beds or tables. Observations confirmed the absence of chairs in multiple rooms. The Administrator was unaware of the requirement, citing space issues, and the DON confirmed no policy on room furniture.
A facility failed to create a baseline care plan for a resident at risk for pressure ulcers upon admission. The resident, with a history of chronic kidney disease and other conditions, did not receive a Braden Scale risk assessment, which is essential for pressure ulcer prevention. The DON confirmed the absence of a baseline care plan, violating the facility's policy.
A resident at risk for pressure ulcers was not assessed upon admission, leading to the development of heel wounds. Despite physician orders for interventions, the facility failed to consistently implement and document preventative measures, such as pressure relief boots and repositioning schedules. Observations showed the resident often in bed with heels against the mattress, and staff interviews revealed a lack of awareness of the resident's care needs.
A resident with severe cognitive impairment and multiple mental health diagnoses exhibited disruptive behaviors in a common area. Despite having a care plan with specific interventions, staff failed to implement these measures, resulting in a deficiency. The resident's actions included pounding on walls and throwing furniture, causing fear among peers. Staff did not attempt to de-escalate the situation or document interventions, and security cameras were not functioning properly during the incident.
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for two medication carts. Observations revealed missing narcotic card counts and reconciliation signatures for numerous dates in August and September 2024. Interviews with QMAs indicated that the narcotic count was supposed to be completed during shift changes, but this was not consistently done. The DON confirmed that the expectation was for staff to complete the narcotic count sheet at the start and end of each shift, as per facility policy.
The facility failed to properly label and store medications, as observed in two medication carts. A Levemir insulin vial was not discarded after 30 days, and lidocaine patches lacked resident identifiers. A Humalog insulin Kwikpen was found without an open date. Facility policies require proper labeling and storage, which was not followed.
A resident reported an allegation of inappropriate touching by another resident, which the facility investigated and deemed unsubstantiated. However, the facility failed to report the incident to the Indiana Department of Health as required by their policy and state guidelines, leading to a deficiency finding.
A facility failed to thoroughly investigate an alleged sexual abuse incident involving a resident who reported inappropriate touching by another resident. The investigation lacked essential details, such as specific times and comprehensive interviews with staff and other residents. Despite the facility's policy requiring a detailed investigation, the process was halted due to insufficient evidence from limited surveillance footage.
The facility did not post nurse staffing information in a clear and accessible format for three consecutive days. Observations showed no staffing numbers were posted, and interviews with the DON and Administrator revealed reliance on a schedule book kept at the nurse station, which did not meet the policy requirement for prominent posting.
A facility failed to honor a resident's right to return after an ER visit following an altercation. Despite no significant behavioral changes noted at the hospital, the facility discharged the resident to a distant homeless shelter without proper notice or appeal opportunity. The resident was later found by police and hospitalized for dehydration and acute kidney injury.
A resident with a history of cognitive and behavioral issues was improperly discharged from a facility after a hospital visit. The facility failed to provide a 30-day notice or allow an appeal, instead leaving the resident at a hotel without proper documentation. This led to the resident's hospitalization for dehydration and acute kidney injury.
A cognitively impaired resident was physically abused by another resident with a history of aggression. Despite care plans and interventions, the aggressive resident's behaviors persisted, leading to an incident where the impaired resident was found with a head laceration after entering the aggressive resident's room. The facility's failure to adequately supervise and protect the wandering resident resulted in this altercation.
The facility failed to ensure proper labeling of medications for a resident, as observed during a medication administration. Two bottles of oral Nystatin lacked resident identifiers and instructions, and the RN was unable to identify the prescribed resident. The DON also did not know how the medication was received without appropriate labels, violating the facility's policy on medication labeling.
Derogatory Staff Comment in Resident’s Presence Violates Dignity and Abuse Protections
Penalty
Summary
The deficiency involves a failure to protect a resident’s right to be treated with respect and dignity when a staff member made a derogatory statement about the resident within the resident’s hearing. The resident involved had diagnoses including moderate dementia with mood disturbance and a cognitive communication deficit, and an admission MDS assessment indicated the resident was severely cognitively impaired. A progress note documented that a staff member made an inappropriate statement about the resident to another staff member in front of the resident, and although the resident later stated he did not hear the statement and denied psychosocial distress, the incident was recognized as a concern for the resident’s psychosocial well-being. During interviews, a QMA reported that she had been at the nurse’s station holding the resident’s hand when a CNA approached and stated that the QMA should probably bleach her hands because she was holding the resident’s hand. This comment was made in front of the resident, who was next to the QMA and talking at the time, and the QMA perceived the statement as disrespectful and undignified. The QMA noted that, although the resident was cognitively impaired and might not have processed the remark, it was made within a distance that the resident could have heard it, and that if the resident had been cognitively intact, the statement would have hurt his feelings. In a separate interview, the CNA acknowledged that she had walked up to the nurse’s station and, seeing the resident touching the QMA’s hands and arms, muttered that she would use bleach wipes afterward, referring to the resident’s contact. She admitted the resident was within hearing distance when she made the remark but stated she did not intend for the resident to hear it and did not believe her statement was humiliating or demeaning. The DON and Administrator both indicated that the remark was made in the presence of the resident, was disrespectful and undignified, and had the potential to hurt the resident’s feelings, constituting verbal abuse and a violation of the resident’s right to a dignified existence and to be treated with respect.
Failure to Report Allegation of Staff-Resident Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the state agency as required by policy and regulation. An anonymous report to the Indiana Department of Health alleged that a staff member was having an affair with a resident and that facility management failed to act on the allegation. During an interview, the Administrator stated that while a CNA was assisting a resident with a shower, the resident disclosed that she and a housekeeper had kissed. The CNA reported this allegation to management. Written statements from the CNA indicated the resident reported that when she was sad, the housekeeper asked what he could do to make her feel better, she requested a kiss, and he kissed her on the lips three times. The CNA documented that the resident asked her not to tell anyone because she did not want to get anyone in trouble. A typed statement indicated that the Infection Prevention Nurse and Business Office Manager were informed that the housekeeper had been in the resident’s room and kissed the resident, and that the resident stated the kiss was wanted and she did not want the housekeeper to get into trouble. The statement also documented that the interaction had been occurring for about a week and that the resident and housekeeper had been messaging each other through a social media platform. The Administrator reported that the housekeeper denied kissing the resident but admitted to messaging the resident on social media. The Administrator further indicated that, after the resident initially confirmed the kissing, she later recanted and said she made up the story to get closer to the housekeeper. Based on the resident’s later recantation, the Administrator decided not to report the allegation to the state agency, despite the facility’s abuse policy requiring that alleged violations of abuse be reported immediately to the Administrator or designee and, when required by law or regulation, to the Department of Health.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident with diagnoses including schizophrenia, chronic pneumothorax, muscle wasting and atrophy, and depressive disorder was involved in a verbal altercation with an Activity Assistant. The resident, who was noted to refuse care daily, called the Activity Assistant a derogatory name after expressing frustration about the timing of receiving a cigarette during a smoke break. In response, the Activity Assistant made disparaging remarks about the resident's health condition and returned the insult, engaging in further disrespectful comments. Multiple staff statements confirmed that the Activity Assistant responded to the resident's insult with additional derogatory remarks, referencing the resident's use of oxygen and choice to smoke. The facility's investigation included written statements from staff who witnessed the incident, all of whom confirmed the exchange of verbal insults. The facility's abuse prevention policy defines verbal abuse as inappropriate oral, written, or gestured communication directed at residents. Despite routine abuse education provided to staff, the Activity Assistant's conduct constituted verbal abuse, as it involved inappropriate and disrespectful communication towards the resident.
Staff-to-Resident Verbal Abuse of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including Asperger's syndrome, altered mental status, malignant neoplasm of the parotid gland, and generalized anxiety disorder was involved in a verbal altercation with a maintenance staff member. The resident was noted to be severely cognitively impaired, requiring substantial assistance with daily activities and frequent redirection due to repetitive vocalizations and behaviors. On the morning of the incident, the resident was near the medication cart, engaging in his usual repetitive verbalizations and behaviors, when a maintenance staff member approached and engaged in a verbal exchange. Multiple staff statements and interviews confirmed that the maintenance staff member responded to the resident's behaviors by making threatening and intimidating statements, including telling the resident, "If you touch me, I will put you on the ground," and provoking the resident to approach him. The staff member also made disparaging remarks about the resident in front of other staff. Witnesses described the staff member's actions as antagonizing, intimidating, and threatening, with one LPN specifically identifying the behavior as verbal and mental abuse. The resident, upon hearing the threat, quickly left the area. The facility's investigation substantiated the allegation of verbal abuse, with the maintenance staff member admitting that his statements were inappropriate and acknowledging that, according to facility education, it was abusive to humiliate, intimidate, or threaten residents. The facility's policy clearly states that all residents have the right to be free from abuse, including verbal and mental abuse by staff. The incident was reported and documented by staff, and the facility's investigation confirmed the occurrence of staff-to-resident verbal abuse.
Failure to Provide Quarterly Funds Statements to Residents
Penalty
Summary
The facility failed to provide quarterly funds statements to residents for whom it managed personal funds, specifically for two out of three residents reviewed. Record review showed that the facility managed funds for 32 residents, and quarterly statements were requested for three of these residents. However, two residents did not have quarterly statements available for review. During interviews, the Administrator and Business Office Manager acknowledged that quarterly statements had not been given to residents who did not have a responsible party, which was an error, as the residents themselves should have received the statements. Facility policy requires that residents be provided with a confidential quarterly statement of funds on deposit.
Insufficient Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to provide a surety bond in an amount sufficient to safeguard all resident funds managed by the facility. Record review showed that the facility managed funds for 32 residents, and the surety bond in place covered only $30,000.00. However, bank statements for May, June, and July 2025 revealed that on 23 separate days, the daily ledger balance of resident funds exceeded the bond amount, with balances reaching as high as $48,374.65. During an interview, the Business Office Manager confirmed that the facility did not conduct reviews to ensure the surety bond was adequate for the actual balance of resident funds, as this responsibility was handled by the home office. The facility's policy required it to act as a fiduciary and safeguard resident funds, but this was not met due to the insufficient bond coverage.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative regarding a significant change in condition for one resident. The resident, who had diagnoses including paranoid schizophrenia, hypertension, and gastro-esophageal reflux disease, was noted to be mildly cognitively impaired. On the day in question, the resident was found to be cool, clammy, tachycardic, and hypertensive, and refused both blood pressure medication and fluids. Nursing notes from this period did not document any notification to the resident's family or representative about these changes in condition. Later that day, the resident continued to exhibit symptoms such as excessive sweating, tachycardia, hypertension, and tachypnea, and again refused medications and fluids. The nurse practitioner was contacted and ordered the resident to be sent to the emergency room, at which point the resident's representative was informed of the transfer. Interviews with staff confirmed that the expectation was to notify the resident's representative when a change in condition was identified, and that this should be documented in the progress notes. However, the initial significant change in the resident's condition was not communicated to the representative as required by facility policy.
Failure to Provide Social Services for Resident Financial Management
Penalty
Summary
The facility failed to provide appropriate social services related to financial management for two residents who required assistance with managing their funds and maintaining Medicaid eligibility. For one resident with paranoid schizophrenia and moderate cognitive impairment, the Social Services Director stored $900 in cash in a locked file cabinet in her office without any documentation, receipts, or care plan regarding the funds. The resident's family was not informed about the storage or management of the money, and there was no method to account for expenditures. At discharge, $700 was returned to the family, who questioned the amount, and the Administrator was unaware that the funds had been kept in the Social Service office. For another resident with hypertension, diabetes, major depressive disorder, and unspecified dementia, the facility acted as representative payee and held a balance exceeding Medicaid asset limits. Although the resident received multiple written notifications about the excess funds, there was no documentation that the information was verbally shared or that assistance was offered to help spend down the resources. The resident, who was moderately cognitively impaired and required decision-making assistance, was unaware of the excess funds and expressed interest in using money for personal items. The clinical record lacked a care plan or documentation of actions taken to assist with financial management to maintain Medicaid eligibility.
Improper Sanitization of Blood Glucose Monitoring Device
Penalty
Summary
The facility failed to properly sanitize a multi-use blood glucose monitoring device according to the manufacturer's guidelines during a random observation of blood glucose testing. On the specified date, a Qualified Medication Aide (QMA) was observed using an alcohol swab to clean the device between testing two residents, which was not in compliance with the manufacturer's instructions. The QMA used the same device for multiple residents, wiping it with an alcohol swab after each use, and then returned it to the medication cart. During interviews, the QMA confirmed that an alcohol swab was used for sanitizing the device between residents, and it was the only device available on the medication cart. The Director of Nursing (DON) acknowledged that using an alcohol wipe was insufficient for sanitizing the multi-use glucose monitoring device. The manufacturer's policy, provided by the Scheduler, specified that only certain EPA-registered wipes should be used, and the device surfaces must remain wet for the contact time specified by the wipe manufacturer to prevent the transmission of bloodborne pathogens.
Failure in Insulin Administration and Documentation
Penalty
Summary
The facility failed to ensure proper insulin administration for three residents, leading to multiple missed doses and lack of documentation. Resident B, diagnosed with type 2 diabetes mellitus, had several instances where insulin was not administered as per physician's orders. Specifically, Lantus was not given in the morning as prescribed, and Lispro was not administered before meals on certain dates. Additionally, there was a failure to document blood sugar readings and missed doses in the progress notes. Resident C, with type one diabetes mellitus, also experienced missed doses of Novolog, both as a regular dose and per sliding scale, on consecutive days. Similarly, Resident D, diagnosed with type two diabetes mellitus and hypoglycemia, had missed doses of Humalog on specified dates. The Director of Nursing acknowledged that staff were not signing off on medication administration, resulting in blank spaces on the electronic medication administration record (eMAR).
Failure to Suspend Employee Accused of Abuse
Penalty
Summary
The facility failed to implement its abuse prohibition policy effectively when an employee accused of abuse was allowed to remain in the facility during the investigation. Resident B, who was cognitively intact, alleged that a Care Specialist (CS 1) kicked his foot intentionally. Despite the resident's request for the Administrator to contact the State Agency, police, and ombudsman, and his wish for CS 1 to avoid any interaction with him, the employee was not suspended during the investigation. Instead, CS 1 was merely instructed to stay away from Resident B. The facility's current policy, dated December 1, 2021, clearly states that if an employee is suspected of abuse, they should be suspended until the incident is fully investigated. However, the Administrator did not follow this procedure, as he believed the incident had already been resolved. This failure to adhere to the policy resulted in a deficiency, as the accused employee was not suspended, potentially compromising the safety and well-being of Resident B.
Refrigerator Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that refrigerators were functioning at a level to maintain safe food temperatures, potentially impacting all 34 residents. During an initial kitchen tour, a standard white refrigerator was found to be at 48 degrees Fahrenheit, containing pre-poured drinks and sliced cheeses. The dietary staff member acknowledged that the refrigerator should be between 36 to 38 degrees Fahrenheit and suspected the door had been left open too long. However, the refrigerator temperature logs for September 2024 showed that temperatures had not been recorded for several days, with the white refrigerator and freezer missing entries since 9/18/24, and the silver units since 9/19/24. The logs also lacked guidance on acceptable temperature ranges. Further observations during lunch meal preparation revealed the white refrigerator at 50 degrees Fahrenheit, with orange juice inside registering at 57.6 degrees Fahrenheit. Despite being informed of the issue, the Dietary Manager had not checked the refrigerator temperature since the initial concern was raised, relying instead on staff reports that temperatures were 40 degrees Fahrenheit or less. The facility's policy stated that refrigerated foods must be stored below 41 degrees Fahrenheit, which was not adhered to, as evidenced by the consistent temperature issues and lack of proper monitoring.
Facility Lacks Effective QAPI Program Leading to Repeat Deficiencies
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program effectively, leading to repeat deficiencies. During the last annual recertification and licensure survey, deficiencies were identified related to improperly labeled medications and incomplete shift-to-shift narcotic reconciliation sheets. Despite the plan of correction indicating that ongoing corrective action would be monitored through the facility's QAPI program, the facility did not have a formal QAPI plan in place. The Administrator admitted to not having a recent QAPI plan and lacked record-keeping of meeting minutes, which are essential for tracking and addressing deficiencies. The Administrator's focus was primarily on environmental issues, such as cleaning and pest control, rather than on the systemic issues identified in the survey. An audit tool for pharmacy services was provided, but it lacked specific details about the audits conducted, such as which medication or treatment cart was audited. Additionally, a document titled "BROOKSIDE CARE STRATEGIES 2022 QAPI PLAN" was outdated and did not reflect current practices. This lack of a structured and effective QAPI plan contributed to the facility's inability to address and prevent repeat deficiencies.
Deficient Call Light System in Facility
Penalty
Summary
The facility failed to provide a fully functional call light system for all resident rooms and bathrooms, affecting all 34 residents. Observations revealed that instead of a working call light system, residents were given hand bells or tabletop bells, which were often placed out of reach. Confidential interviews with residents and staff confirmed that the call light system had been inoperable for four to six months, and management was aware of the issue. Residents expressed difficulty in summoning assistance, with some having to yell or use personal telephones to call the facility for help. Employees also noted the challenge in identifying which resident needed assistance when a bell rang, as there was no light indicator. The report highlights that the facility's management was aware of the call light system's failure and had not yet signed a contract for its replacement or repair, despite being informed that the system was completely down and needed replacement. The facility's policy, revised in January 2023, emphasized the importance of providing residents access to a call light and ensuring the system's proper functioning. However, the facility's inaction in addressing the broken call light system led to residents relying on inadequate manual bells, which were not suitable for all residents, particularly those with physical limitations.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible to residents and their representatives. During a review of the facility's survey binder, it was found that the most recent survey included was dated 11/27/23, and all other surveys were dated prior to this. The binder was located behind the nurse's station, and signage indicated that individuals should ask for the survey binder. The Administrator, during an interview, stated that he believed only annual surveys needed to be included in the binder and was unaware that complaint surveys were also required. However, records from the Indiana Department of Health showed that complaint surveys were conducted on several dates after 11/27/23, which were not included in the binder. The facility's policy indicated that a copy of the most recent standard survey, including any subsequent surveys and follow-up reports, should be maintained in a location frequented by residents, such as the main lobby or resident activity center.
Failure to Implement Grievance Process According to Policy
Penalty
Summary
The facility failed to implement a grievance process according to its policy for resident and resident representative concerns. During a record review, it was found that the most recent grievance was filed several months prior, indicating a lack of documentation for any grievances or complaints since that time. The Social Services Director (SSD), who was identified as the grievance official, stated that any complaints or concerns were resolved immediately, and therefore, there was no need to document them on a grievance form. The facility's current policy, revised in April 2017, requires that all grievances, complaints, or recommendations concerning resident care be considered and responded to in writing. The policy also mandates that upon receipt of a grievance, the Grievance Officer must review and investigate the allegations and submit a written report to the Administrator within five working days. However, the SSD's practice of resolving issues immediately without documentation contradicts the facility's policy, leading to a deficiency in the grievance process.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to develop and implement an effective infection control program. During a record review, it was found that the Infection Control Binder's Infection Log and color-coded mapping were only completed using the antibiotic Order Listing Report, which was not printed until after the survey began. This report was printed for several months, from March to September 2024, indicating a lack of prior tracking and trending of resident infections. The Infection Preventionist, who had only been in the position since early September and was splitting her time between two locations, was unaware of who held the position before her and had only recently filled out the Infection Log pages based on the antibiotic orders. The facility's policy on infection prevention and control was undated and indicated the need for an infection control program to prevent and control infections, but this was not effectively implemented.
Facility Fails to Provide Chairs in Resident Rooms
Penalty
Summary
The facility failed to provide safe and comfortable chairs in resident rooms, impacting all 34 residents. During confidential interviews, several residents expressed a desire for chairs in their rooms, indicating they often had to sit on their beds or tables. Observations confirmed the absence of chairs in multiple resident rooms on different dates. One resident mentioned the difficulty of bringing a chair from the dining room, while another expressed the need for a chair for guests, who otherwise had to sit on the bed with the resident. The facility's Administrator was unaware of the need to provide chairs in resident rooms and cited a lack of space as a reason for their absence. The Director of Nursing (DON) confirmed that the facility did not have a policy regarding furniture in resident rooms. This lack of awareness and policy contributed to the deficiency, as residents had not explicitly requested chairs, and the facility had not proactively addressed this need.
Failure to Develop Baseline Care Plan for Pressure Ulcer Risk
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident who was admitted with a risk for pressure ulcers. The resident, who had diagnoses including pain in the right lower leg, alcohol abuse in remission, and stage 3 chronic kidney disease, was admitted to the facility, but her clinical record lacked a baseline care plan. During interviews, it was revealed that a Braden Scale risk assessment, which is crucial for determining pressure ulcer prevention interventions, was not completed upon admission. The Director of Nursing confirmed that a baseline care plan was not developed for the resident at the time of admission, which is a requirement according to the facility's policy on pressure ulcer/wound care.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to assess a resident for pressure ulcer risk upon admission and did not implement timely interventions to prevent pressure ulcers. Resident 31, who was admitted with no skin issues, was not assessed using the Braden Scale until seven weeks after admission, despite being at risk for pressure ulcers. The resident required substantial assistance for various activities of daily living and was dependent on staff for repositioning, yet the facility did not have a consistent plan in place to manage this risk. Observations revealed that the resident was often found in bed on her back, with her heels resting against the mattress, which contributed to the development of deep tissue injuries on both heels. The facility's records showed a lack of weekly skin assessments and documentation of the resident's heel wounds, which were first noted by a Nurse Practitioner on 7/2/24. Despite physician orders for interventions such as skin preparation wipes, floating heels, and the use of a low air loss bed, these measures were not consistently documented or observed in practice. Interviews with staff indicated a lack of awareness and implementation of a turn and reposition schedule for the resident. The resident was cooperative with care but was not consistently provided with pressure relief boots, which were only introduced after the development of pressure ulcers. The facility's policy required documentation of preventative measures and equipment used, but this was not adhered to, contributing to the resident's condition worsening over time.
Failure to Implement Behavioral Interventions for Resident
Penalty
Summary
The facility failed to implement care plan interventions for a resident, identified as Resident 13, who was experiencing behavioral difficulties in a common area. Resident 13, diagnosed with schizophrenia, profound intellectual disability, generalized anxiety disorder, and borderline personality disorder, exhibited severe cognitive impairment and displayed physical behavioral symptoms. The care plan for Resident 13 included interventions such as ensuring space for the resident, offering to take the resident to a quiet area, and assisting with removing peers from the area during behavioral episodes. However, these interventions were not implemented during an incident where Resident 13 became out of control, causing fear among other residents. On the evening of the incident, Resident 13 engaged in disruptive behaviors, including pounding on walls, throwing furniture, and punching holes in the wall. Despite the care plan's directives, staff did not attempt to remove Resident 13 or his peers from the area, nor were any behavioral interventions documented in the clinical record. Interviews with staff members, including RN 17 and CNA 18, revealed that they witnessed the resident's aggressive actions but did not take steps to de-escalate the situation or ensure the safety of other residents. The facility's security cameras, which could have provided additional oversight, were reportedly not functioning properly during the incident. The facility's failure to follow the established care plan and implement appropriate behavioral interventions resulted in a deficiency. The lack of action by staff members during Resident 13's behavioral episode, combined with the absence of documented interventions, highlights a significant oversight in managing the resident's care. The facility's policy on behavior management emphasizes the need for appropriate intervention and treatment plans, which were not adhered to in this case.
Failure in Narcotic Count and Reconciliation
Penalty
Summary
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for two medication carts, the West cart and the East cart. During a medication storage observation, it was found that the Narcotic Count Sheet for the West cart lacked shift-to-shift count and reconciliation signatures for numerous dates in August and September 2024. Specifically, there were missing narcotic card counts and reconciliation signatures for various shifts, indicating a failure to document the transfer of controlled medications between staff members. Interviews with QMA 6 revealed that the narcotic count was supposed to be completed when the medication cart was transferred from one employee to the next. Similarly, the East medication cart also showed deficiencies in narcotic count and reconciliation. The Narcotic Count Sheet for this cart lacked signatures for several dates in August and September 2024. Interviews with QMA 5 confirmed that the narcotic count sheet was intended to be completed by both the oncoming and off-going nurses at shift change. The Director of Nursing indicated that the expectation was for staff to complete the narcotic count sheet in full at the start and end of each shift. The facility's policy on controlled substances required a physical inventory of controlled medications at each shift change, conducted by two licensed clinicians and documented on an audit record.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during a survey of two medication carts. On the West medication cart, a Levemir insulin vial was found with an open date, but it was not discarded after the 30-day period as indicated by the Director of Nursing (DON). Additionally, 66 single packets of 4% lidocaine patches were found without resident identifiers or manufacturer container information. The Qualified Medication Aide (QMA) accompanying the surveyor was not insulin certified and unaware of the insulin's shelf life. The DON confirmed that opened insulin should be discarded after 30 days. On the East medication cart, a Humalog insulin Kwikpen was found without an open date, contrary to the facility's policy that requires insulin to be dated upon opening and discarded after 28 days. Interviews revealed that the lidocaine patches were stock medications ordered from a supply company and not individually labeled for residents, as only two residents used them. The facility's policies require medications to be stored in their original containers with clear labeling, including expiration dates and resident information, which was not adhered to in these instances.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the Indiana Department of Health concerning a resident, identified as Resident C, who reported being touched inappropriately by another resident, Resident D, in a common area. The incident was reported to the facility's Administrator on the same day it occurred. The Administrator conducted an investigation, which included reviewing video surveillance, and concluded that the allegation was unsubstantiated. Despite the facility's investigation, the alleged abuse was not reported to the Indiana Department of Health as required. The Administrator believed that the allegation did not need to be reported due to Resident C's history of making false allegations and the results of the facility's investigation. However, the facility's policy on abuse prevention and prohibition, as well as the Indiana Department of Health's guidelines, require that any incident involving unwanted sexual contact be reported to the appropriate authorities. The failure to report this incident was identified as a deficiency during the survey.
Inadequate Investigation of Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an alleged sexual abuse incident involving Resident C, who reported that a male resident, Resident D, touched her breast without consent. The incident was reported to the Social Services Director (SSD) and the Administrator, but the facility's investigation was found lacking. The investigation did not include essential details such as the time the information was reported, the time the alleged event occurred, and the time the follow-up was completed. Additionally, the investigation did not include a skin assessment of Resident C or interviews with other staff or residents who might have witnessed the event. Resident C's clinical record indicated diagnoses of general anxiety, moderate major depressive disorder, and post-traumatic stress disorder. Despite being cognitively intact, the record lacked documentation of the alleged sexual abuse during the specified period. Resident D's clinical record showed diagnoses of major depressive disorder, generalized anxiety disorder, and bipolar disorder, with a care plan addressing hypersexuality and allegations of inappropriate touching. However, the facility's investigation did not include interviews with other residents or staff, which could have provided additional insights into the incident. The facility's policy on abuse prevention and prohibition required a thorough investigation of any abuse allegations, including documenting the time, date, place, individuals present, and a description of the event. However, the investigation was halted due to a lack of evidence from the limited surveillance footage provided by the corporate office. The Administrator believed the facility followed state guidelines, but the investigation did not meet the facility's policy requirements, as it lacked comprehensive interviews and documentation.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information in a readily accessible and readable format for residents and visitors over a period of three consecutive days. Observations on 9/22/24, 9/23/24, and 9/24/24 revealed that no direct care staffing numbers were posted. During an interview on 9/24/24, the Director of Nursing (DON) indicated that the schedule book, which contained handwritten staff schedules, was kept at the nurse station and used for staff posting. However, this did not meet the requirement of posting staffing numbers in a prominent location. The Administrator was unaware of the missing staff posting and also referred to the schedule book for daily staff schedules. The facility's policy, revised in July 2016, required that staffing numbers be posted within two hours of each shift's start in a clear and accessible manner, which was not adhered to during the survey period.
Facility Fails to Honor Resident's Right to Return After ER Visit
Penalty
Summary
The facility failed to honor a resident's right to return to the facility after an emergency room visit following a resident-to-resident altercation. The resident, who had a history of mild cognitive impairment, mood disorder, and other health issues, was involved in a physical altercation where he stomped on another resident's head. Despite undergoing psychiatric and social work evaluations at the hospital, which noted no significant behavioral changes, the facility refused to accept the resident back, citing discomfort with his behaviors. The facility discharged the resident to a homeless shelter located 61 miles away without providing a thirty-day written notice or an opportunity for the resident to appeal the transfer. The resident was given his belongings, medications, and a small amount of cash, but the shelter had no record of his admission. The facility's actions did not align with their discharge policy, which requires documentation of the resident's needs not being met or the resident posing an immediate danger to others. The resident was later found by police on a sidewalk in the same city as the facility and was hospitalized for dehydration and acute kidney injury. The facility's failure to provide a safe discharge plan and to document the necessity of the discharge placed the resident at risk of harm, as evidenced by his subsequent hospitalization.
Improper Discharge of Resident Following Hospital Visit
Penalty
Summary
The facility failed to adhere to its policies regarding the return of a resident following a hospital visit, resulting in a deficiency. Resident C, who had a history of mild cognitive impairment, alcohol use, cerebral infarction, mood disorder, cocaine abuse, and epileptic syndrome, was involved in a physical altercation with another resident. Following this incident, the police were called, and Resident C was taken to the emergency department for evaluation. Despite the hospital's assessment that the resident could return to the facility, the facility refused to accept him back, citing concerns about his behavior. The facility did not provide Resident C with a thirty-day written notice of discharge, nor did it offer him the opportunity to appeal the discharge decision. Instead, the Administrator arranged for the resident to be taken to a homeless shelter, which was later found to have no record of his admission. The resident was subsequently left at a hotel 26 miles away from the facility, without proper documentation or consideration of his needs and choices. This action was taken without ensuring a safe and appropriate discharge location, as required by the facility's policies. The failure to follow proper discharge procedures and provide adequate notice placed Resident C at risk, as evidenced by his subsequent hospitalization for dehydration and acute kidney injury after being found on a sidewalk. The facility's actions were inconsistent with its own policies, which require a documented reason for discharge and consideration of the resident's best interests in determining a discharge location.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident, Resident D, from physical abuse by another resident, Resident C, who was known to have a history of aggressive behavior. On the evening of August 15, 2024, Resident D was found on the floor of Resident C's room with a head laceration and bruising, requiring emergency treatment and six sutures. Resident C admitted to stomping on Resident D's head multiple times after being woken up by him. This incident was reported to the Indiana Department of Health and involved local police intervention. Resident C had a documented history of verbal and physical aggression, with care plans indicating potential triggers and interventions to manage his behavior. Despite these measures, Resident C's aggressive tendencies persisted, as evidenced by multiple incidents of verbal and physical behaviors recorded in a Behavior Management Monthly Review. Staff interviews revealed that Resident C was often agitated by noise and proximity to others, and while some interventions were in place, they were not always effective in preventing aggressive outbursts. Resident D, on the other hand, was known to wander due to impaired safety awareness and severe cognitive deficits. His care plan included interventions to redirect him from wandering and entering other residents' rooms, but these measures were insufficient to prevent the incident with Resident C. Staff interviews confirmed that Resident D frequently wandered into other rooms and was easily redirected, yet there was a lack of supervision to ensure his safety, ultimately leading to the altercation with Resident C.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications received from the contracted pharmaceutical company were labeled appropriately for one of the nine residents reviewed for medication use. During a medication administration observation, two bottles of oral Nystatin were found in the medication cart without proper labeling, including missing resident identifiers and instructions. Specifically, one bottle lacked the resident's name, dosage, and time/frequency for administration, and had a sticker with an opened date. The second bottle also lacked the resident's name, dosage, and time/frequency for administration. The RN present during the observation was unable to identify to whom the medications were prescribed, noting that two residents were currently prescribed Nystatin, and no other bottles were available in the cart. The Director of Nursing (DON) was also interviewed and indicated a lack of knowledge regarding to whom the medication was prescribed and how it was received from the pharmacy without appropriate labels. The facility's current policy, titled Provider Pharmacy Requirements, mandates that all prescription medications have labels with specific information, including the resident's name and directions for use. This deficiency was related to a specific complaint, highlighting a failure in adhering to the facility's established procedures for medication labeling.
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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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