Creasy Springs Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Indiana.
- Location
- 1750 S Creasy Ln, Lafayette, Indiana 47905
- CMS Provider Number
- 155777
- Inspections on file
- 25
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Creasy Springs Health Campus during CMS and state inspections, most recent first.
A resident was administered multiple medications in error after admission due to a failure in the medication transcription and verification process. An LPN transcribed the wrong medication orders, and the required second nurse check was not performed, resulting in the resident receiving 23 doses of 11 different medications not prescribed for him over several days. The error was discovered only after a review of records, despite concerns raised by the resident's family.
A resident with dementia and Alzheimer's disease, who was not identified as exit-seeking, was allowed to leave a secured unit unsupervised after a CNA mistook the individual for a visitor and opened a secured door. The resident was later found walking outside by another staff member and returned to the facility. The facility was unaware of the elopement until notified by the staff member who found the resident.
A facility failed to maintain a resident's dignity during meal service when a CNA stood while assisting a resident with feeding, contrary to facility policy. The resident, with multiple diagnoses including Alzheimer's and dementia, had a care plan addressing significant weight loss. Staff interviews confirmed that standing while feeding could intimidate residents, and the facility's guidelines emphasized the importance of promoting dignity during dining.
The facility failed to promptly implement DNR orders for two residents, despite their advance directive wishes. One resident had a signed advance directive and POST form indicating DNR, but a physician's order initially indicated full code status. Similarly, another resident's DNR status was delayed in being reflected in a physician's order. The facility's policy required review of advance directives at admission, but there were delays in updating physician orders to match residents' wishes.
A facility failed to update a resident's PASARR Level I to reflect current mental health diagnoses and medications, despite physician's orders for antidepressant and anxiety medications. The Social Service Director confirmed the oversight, which was inconsistent with the facility's policy requiring updates for severe mental illness or psychiatric medication regimens.
A resident with hypertension and chronic kidney disease received lisinopril despite physician orders to hold the medication if systolic blood pressure was below 110. The MAR showed multiple instances of administration with blood pressure readings below this threshold. Facility policies require reviewing orders and vital signs before medication administration, but these were not followed.
The facility failed to obtain a physician's order for oxygen administration for two residents, leading to a deficiency in respiratory care. One resident with pulmonary fibrosis and another with multiple health issues were both placed on oxygen without timely physician orders, contrary to facility policy.
A resident with pneumonia and impaired kidney function received double doses of Augmentin due to the facility's failure to discontinue an initial order when a new one was issued. The resident, with a GFR of 24, was administered both 500 mg and 875 mg doses from 1/27/25 to 2/2/25. The facility's MAR did not automatically update with the pharmacy's system, requiring manual discontinuation of the previous order, which was not done.
The facility failed to manage medications properly, with a compromised lorazepam card found on the 200-hall cart and an unopened insulin pen improperly stored on the 300-hall cart. Additionally, drinking cups were stored under the sink in the 200-medication room, violating facility policy.
Two residents in a LTC facility received incorrect meal consistencies due to failures in implementing hospital discharge diet orders. One resident with dysphagia was served a regular meal instead of a mechanical soft diet, while another with multiple health issues received a regular diet instead of a soft and bite-sized consistency. Staff interviews revealed communication lapses and reliance on electronic systems for diet updates, leading to these deficiencies.
A facility failed to follow infection control protocols when a QMA handled a pain pill without gloves for a resident with multiple health conditions. The QMA picked the pill from a cup with bare hands and placed it in the resident's mouth after it fell on his shirt, contrary to the facility's policy requiring gloves for handling medications.
A resident with chronic kidney disease received duplicate doses of Augmentin due to a failure in the facility's antibiotic stewardship program. The resident was prescribed two different dosages without discontinuing the initial order, leading to inappropriate medication administration. The oversight was not identified by the clinical team or the pharmacy, despite daily reviews of new antibiotic orders.
A resident with multiple health conditions did not receive an influenza vaccination in a timely manner despite signing a consent form. The facility's process involved educating the resident and ordering the vaccine, but the administration was delayed, deviating from the policy that residents receive immunizations per their request.
A resident with multiple health conditions signed a consent form for a COVID-19 vaccine, but the facility failed to administer the vaccine in a timely manner, resulting in a delay of several months. The facility's policy required timely vaccination upon consent, but the process of batching vaccines led to a significant delay.
Medication Transcription Error on Admission Leads to Multiple Medication Errors
Penalty
Summary
The facility failed to ensure that medications were transcribed correctly upon admission for a resident, resulting in significant medication errors. Upon admission, a staff member transcribed medication orders for the resident, but the orders entered into the resident's record were actually those intended for another resident. This error was not identified because the required second nurse check, as outlined in facility policy, was not completed. As a result, the resident received multiple medications that were not prescribed for him over several days. The resident's family member noticed that a staff member attempted to administer unfamiliar medications and raised concerns with the staff. Despite this, the resident continued to receive incorrect medications for several days. The clinical record review confirmed that 11 medications not ordered by the transferring hospital were administered in error, with a total of 23 incorrect doses given over four days. The medications included drugs for Alzheimer's disease, overactive bladder, anxiety, high blood pressure, diarrhea, stomach acid, potassium supplementation, pain, depression, nausea, and constipation. The facility's own policies required that all new admission orders be double-checked by a second nurse and that the five rights of medication administration be followed. However, these procedures were not followed in this case, leading to the administration of multiple incorrect medications. The error was only discovered after several days when a review of the records was conducted, confirming that the resident had received medications intended for another individual.
Resident with Dementia Allowed to Exit Secured Unit Unsupervised
Penalty
Summary
A resident with dementia and Alzheimer's disease, newly admitted to the secured locked unit, was able to leave the facility unsupervised. The resident was not identified as exit-seeking and had no history of elopement according to the admission assessment. On the day of the incident, a CNA responded to a door alarm and, after interacting with the resident who requested to go outside, allowed the resident to exit through a secured door by entering the code. The CNA mistook the resident for a visitor and did not provide supervision as the resident left the building. The resident was later observed by another staff member walking on a sidewalk away from the facility and was subsequently escorted back. The facility was unaware of the resident's elopement until notified by the staff member who found the resident. Documentation confirmed that the door alarm functioned as intended, but staff failed to follow elopement prevention protocols, resulting in the resident being unsupervised outside the facility for a period of time.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity during meal service. During an observation, a Certified Nursing Assistant (CNA) was seen standing while assisting a resident with feeding in the dining room. The CNA remained standing for the entirety of the meal, which is against the facility's policy that requires staff to sit at eye level with residents while assisting them with eating. This action was observed despite the facility's guidelines emphasizing the importance of promoting resident independence and dignity during dining. The resident involved had a clinical record indicating diagnoses such as Alzheimer's, hypertensive, anxiety disorder, tachycardia, dementia, and acute kidney failure. The care plan for the resident, who had experienced significant weight loss, included interventions like offering encouragement and assistance with eating. Interviews with staff revealed that standing while feeding residents could make them feel intimidated, and it was acknowledged by the CNA involved that this practice was not appropriate. The facility's documents and policies clearly outlined the expectation for staff to treat residents with dignity and respect, including during meal times.
Failure to Implement DNR Orders Promptly
Penalty
Summary
The facility failed to promptly implement a do not resuscitate (DNR) order for two residents, despite their advance directive wishes. Resident 152 had a signed Indiana advance directive form and a Physician Orders for Scope of Treatment (POST) form indicating a DNR status, yet a physician's order dated 1/23/25 indicated full code status. It was not until 1/24/25 that a physician's order reflected the resident's DNR status. The Legacy Director confirmed that the facility's process involved meeting with residents and their representatives to discuss code status, ensuring paperwork was signed, and updating the electronic medical record. However, there was a delay in aligning the physician's order with the resident's advance directive. Similarly, Resident 160 had a signed State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order on 1/9/25, but a physician's order on 1/7/25 indicated full code status. The resident's DNR status was not reflected in a physician's order until 1/17/25. The facility's policy required that advance directives be reviewed at admission and that nursing staff obtain an order from the attending physician for the desired code status. Despite this policy, there was a delay in updating the physician's order to match the resident's advance directive, as confirmed by interviews with facility staff.
Failure to Update PASARR for Resident's Mental Health Diagnoses and Medications
Penalty
Summary
The facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) Level I was submitted to reflect a resident's current diagnoses and medications. The clinical record for a resident was reviewed, revealing diagnoses of anxiety, depression, and adjustment disorder with mixed anxiety and depressed mood. However, the PASARR Level I, dated 1/7/25, indicated no known or suspected mental health diagnoses and no mental health medications being prescribed. This was inconsistent with the physician's orders dated 1/6/25 and 1/7/25, which included prescriptions for trazodone, sertraline, and buspirone, all medications related to mental health conditions. During an interview, the Social Service Director acknowledged that a new Level I PASARR was not completed to reflect the resident's mental health diagnoses and medications. The facility's policy, as provided by the Director of Nursing, indicated that certain conditions, such as severe mental illness or a psychiatric diagnosis and medication regimen, would trigger a Level II PASARR. The failure to update the PASARR to include the resident's mental health diagnoses and medications represents a deficiency in the facility's compliance with the PASARR requirements.
Failure to Hold Medication as Ordered for Blood Pressure Parameters
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of lisinopril for a resident with essential primary hypertension, hypertensive chronic kidney disease, and type 2 diabetes mellitus. The physician's order specified that lisinopril should be held if the resident's systolic blood pressure was less than 110. However, the Medication Administration Records (MAR) from July to October 2024 indicated that lisinopril was administered multiple times when the resident's systolic blood pressure was below the specified threshold, with readings as low as 97. An interview with a nurse confirmed that medications should be held if a resident's blood pressure is outside the hold parameters, and such instances should be documented on the MAR. The facility's policies on medication administration, which were reviewed and confirmed by the Director of Nursing and a Clinical Support nurse, emphasize the importance of reviewing and confirming medication orders and checking vital signs before administering medications. Despite these guidelines, the facility did not comply with the physician's order, leading to the administration of unnecessary medication to the resident.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for two residents, leading to a deficiency in respiratory care. Resident 150 was observed wearing 2 liters of oxygen via nasal cannula without a prior physician's order. The resident's clinical record indicated a history of pulmonary fibrosis, chronic obstructive pulmonary disease, and other significant health issues. Despite the resident using oxygen at night in the hospital before arriving at the facility, a physician's order for oxygen was not obtained until after the resident had already been receiving oxygen at the facility. Similarly, Resident 156 was placed on oxygen due to low O2 saturations, but a physician's order was not obtained until several days later. The resident's clinical record showed a history of hemiplegia, diabetes, heart failure, and asthma. Nursing progress notes documented the resident's oxygen use, but the order for oxygen administration was delayed. The facility's policy allowed for emergency oxygen administration as a nursing intervention, but a physician's order was required thereafter, which was not promptly obtained in these cases.
Failure to Discontinue Duplicate Antibiotic Order Leads to Double Dosing
Penalty
Summary
The facility failed to ensure the discontinuation of an order for Augmentin 500 mg when a new order for Augmentin 875 mg was received, resulting in double dosing of the antibiotic for a resident with pneumonia. The resident, who had a history of hemiplegia, type 2 diabetes, chronic kidney disease, and other conditions, was administered both doses from 1/27/25 to 2/2/25. The resident's GFR was low at 24, indicating impaired kidney function, which necessitated a lower dose of Augmentin. Despite the pharmacy's usual practice of canceling duplicate orders, the facility did not send a discontinue order for the initial dose, leading to both doses being administered. Interviews with the Assistant Director of Nursing/Infection Preventionist and a pharmacist revealed that the facility's MAR did not automatically update with the pharmacy's system, requiring manual discontinuation of the previous order. The pharmacist noted that the resident should not have received the 875 mg dose due to her impaired renal function. An LPN indicated that she would verify doctor's orders and consult with a pharmacist if she encountered duplicate medications on the MAR, although she was not involved in administering the medications during the double dosing period. A Medication Error Event progress note confirmed the occurrence of the medication error due to the duplicate order.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, leading to several deficiencies. On the 200-hall medication cart, a compromised controlled substance card of lorazepam for a resident was found with taped slots, indicating improper handling. The lorazepam tablets had expired, and there was no current order for them in the Electronic Health Record. The Licensed Practical Nurse on duty did not notice the tape during the narcotics count, and the Assistant Director of Nursing confirmed that the pills needed to be destroyed by two nurses. Additionally, on the 300-hall medication cart, an unopened Humalog insulin pen for another resident was improperly stored outside of the refrigerator, contrary to the storage instructions. The Director of Nursing confirmed that the insulin pen should have been refrigerated until needed and should be destroyed if not stored correctly. Furthermore, in the 200-medication room, drinking cups were improperly stored under the sink, which was against facility policy. The Assistant Director of Nursing acknowledged that nothing should be stored under the sink, and the cups needed to be destroyed.
Dietary Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to accurately initiate the correct diet orders upon admission for two residents, leading to inappropriate meal consistencies being served. Resident 151, who had a history of cerebrovascular accident, Alzheimer's dementia, and dysphagia, was observed receiving a regular consistency meal instead of the prescribed mechanical soft diet. The resident's hospital discharge summary recommended a Level 5 Minced and Moist diet, but due to a series of miscommunications and errors in updating the diet orders, the resident was initially served inappropriate food items. The Speech Therapist intervened, and the meal was corrected, but not before the resident had already started eating the incorrect meal. Resident 156, who had multiple health issues including hemiplegia, diabetes, and heart failure, was also affected by incorrect diet orders. The hospital discharge summary indicated a Level 6 Soft and Bite-Sized diet, but the facility ordered a regular consistency diet instead. This oversight was compounded by the resident's ongoing health issues, including pneumonia and a productive cough, which raised concerns about potential aspiration. The facility's failure to recognize and implement the correct diet order from the hospital discharge summary contributed to the resident's risk of aspiration. Interviews with facility staff revealed systemic issues in the communication and implementation of diet orders. The Director of Dining Services noted reliance on the electronic medical record system for diet order updates, which failed to capture last-minute changes. Additionally, the Clinical Support Nurse admitted to not seeing the correct diet order on the hospital discharge summary, leading to the incorrect diet being ordered. These lapses in communication and procedure resulted in the residents receiving inappropriate meals, highlighting deficiencies in the facility's dietary management processes.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident. During an observation, a Qualified Medication Aide (QMA) was seen handling a pain pill without wearing gloves. The resident, who had multiple diagnoses including end-stage renal disease and chronic heart failure, requested only the pain pill from a cup containing multiple medications. The QMA picked the pill out with bare hands and handed it to the resident, who then dropped it onto his shirt. The QMA subsequently picked the pill up from the resident's shirt and placed it in his mouth without donning gloves. The facility's policy on oral medication administration requires staff to avoid touching medications unless wearing gloves, which was not followed in this instance.
Failure in Antibiotic Stewardship Leads to Duplicate Dosing
Penalty
Summary
The facility failed to ensure proper monitoring of antibiotic use under its antibiotic stewardship program, resulting in a resident receiving duplicate doses of the same antibiotic. Resident 156, who had a history of hemiplegia, diabetes, heart failure, and chronic kidney disease, was prescribed Augmentin for pneumonia. Initially, a dose of 500-125 mg was ordered, but a subsequent order increased the dosage to 875-125 mg without discontinuing the initial order. This led to the resident receiving both dosages concurrently, which was inappropriate given her renal function. The Assistant Director of Nursing/Infection Preventionist was unaware of the duplicate dosing and did not investigate the higher dosage. The pharmacy did not receive a discontinue order for the initial dose, resulting in both dosages appearing on the facility's Medication Administration Record. Despite daily reviews of new antibiotic orders, the clinical team failed to identify and address the duplicate dosing. The facility's policy on antibiotic stewardship was not effectively implemented, as evidenced by the lack of action to prevent the medication error that occurred.
Failure to Administer Timely Influenza Vaccination
Penalty
Summary
The facility failed to provide an influenza vaccination during the current influenza season for a resident who had requested it with a signed consent form. The resident, who had multiple health conditions including type 2 diabetes mellitus, chronic obstructive pulmonary disease, and Alzheimer's disease, signed a consent form for the influenza vaccine on January 2, 2024. However, the resident's medical record did not show any influenza vaccination administered between the date of the signed consent and the administration of the vaccine on October 4, 2024. Interviews with the Clinical Support Nurse and the Assistant Director of Nursing revealed that the facility's process involved educating the resident or family after consent was signed and then ordering the vaccine. The Assistant Director of Nursing mentioned that vaccines were occasionally batched but were typically administered within a few days to a week. Despite this process, the resident did not receive the influenza vaccine in a timely manner as per their request, which was a deviation from the facility's policy that stated residents would receive immunizations per their request.
Failure to Timely Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to provide a COVID-19 vaccination to a resident who had requested it and signed a consent form. Resident 13, who had multiple health conditions including type 2 diabetes, chronic kidney disease, and Alzheimer's disease, signed a consent form for the COVID-19 vaccine on January 2, 2024. However, the resident's medical record did not show any vaccination administered between the date of consent and October 4, 2024, when the vaccine was finally given. Interviews with the Clinical Support Nurse and the Assistant Director of Nursing revealed that the facility's process involved educating the resident or family and then ordering the vaccine, which could sometimes be batched and administered within a few days to a week. Despite this procedure, there was a significant delay in administering the vaccine to Resident 13, which was not in accordance with the facility's policy that required residents to receive immunizations per their request upon signing the consent form.
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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