Edgewater Woods
Inspection history, citations, penalties and survey trends for this long-term care facility in Anderson, Indiana.
- Location
- 1809 N Madison Ave, Anderson, Indiana 46011
- CMS Provider Number
- 155066
- Inspections on file
- 31
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Edgewater Woods during CMS and state inspections, most recent first.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy: A resident with liver cancer, altered mental status, and malnutrition was sent to the ER after being found lethargic and difficult to rouse, then admitted to the hospital. The record lacked documentation that the resident or representative received written transfer/discharge notice and the bed hold policy, and the notice provided during survey did not include the bed hold policy.
PASRR screening was not updated after a resident received a new major mental health diagnosis. The resident had schizoaffective disorder, bipolar type, with behavioral symptoms documented in the care plan, but the SSD confirmed the last PASRR Level I submission did not include the diagnosis and no later screen was provided after the new diagnosis was received.
Failure to review dialysis communications led to a duplicate pneumococcal vaccination for a resident receiving dialysis. The resident had CKD with heart failure, acute kidney failure, and hypertensive heart disease, and dialysis records showed Prevnar 20 was given at dialysis, but the facility later documented another Prevnar 20 in the resident’s chart. Staff interviews indicated the dialysis binder was not being consistently reviewed by the UM, IP, or bedside nursing staff, and the resident’s immunization history was not available in the clinical record.
The facility failed to complete pharmacy recommendations in a timely manner for several residents. A pharmacist identified irregularities involving PRN meds, daily cetirizine use, and cyclobenzaprine, and also noted that a resident on amiodarone lacked ongoing TSH monitoring in the chart. The DON said she was new to the pharmacy review process and that recommendations were routed to the provider by email and paper, while the corporate nurse consultant said the goal was 30 days or by the next review, with some items taking longer based on urgency.
A resident with hypertensive heart disease, CKD with HF, and AKI received Prevnar 20 at dialysis, but the facility later documented another Prevnar 20 dose in the resident’s chart. The record lacked prior immunization history, and interviews showed the dialysis communication binder was not consistently reviewed by the UM, IP, or clinical staff before the vaccine was documented, leading to duplicate pneumococcal vaccination documentation.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, and that catheter care and UTI prevention measures were inadequate. These failures resulted in a deficiency related to resident care.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
The facility did not ensure that representatives of two cognitively impaired residents were invited to participate in care plan meetings, as required by policy. Documentation and staff interviews confirmed that invitations were not consistently sent or recorded, and a resident's representative reported not being invited. Both residents had severe cognitive impairment and required representative involvement in care planning.
A resident with multiple chronic conditions missed a scheduled stent placement procedure because the facility's transport driver did not report to work and there was no backup transportation plan in place. Staff were unable to arrange alternative transport in time, resulting in the appointment being missed and rescheduled.
The facility failed to follow infection prevention and control practices during laundry delivery and for residents requiring enhanced barrier precautions (EBP). Laundry attendants did not perform hand hygiene, and staff did not adhere to EBP protocols for residents with indwelling catheters or feeding tubes. This affected multiple residents and posed a risk of infection transmission.
A facility failed to monitor and report urinary output and abnormalities for a resident with a urinary catheter. The resident, with a history of dementia and chronic kidney disease, had cloudy and thick urine, which was not reported to the provider. The facility did not consistently document urinary output as ordered, and a CNA was observed improperly handling the catheter drainage bag. The DON confirmed the lack of documentation and policy on urinary catheter maintenance.
The facility failed to ensure proper infection control practices during medication administration. An RN was observed preparing medications with bare hands and not sanitizing her hands between administrations. Facility policies on medication administration and infection prevention were not followed.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy
Penalty
Summary
The facility failed to provide written notice of transfer/discharge and the bed hold policy to the resident and/or the resident's representative for one resident reviewed for hospitalization. The resident had diagnoses including liver cancer, altered mental status, and malnutrition. On 1/29/26, a nurse's note documented that a Nurse Practitioner found the resident lethargic and difficult to rouse and ordered the resident sent to the emergency room. Later that day, another nurse's note documented that the resident was admitted to the hospital. A transfer/discharge notice dated 1/29/26 was provided by the DON during the survey, but it lacked an attached bed hold policy. The clinical record did not contain documentation that the resident and/or representative was given a written copy of the transfer/discharge form or the bed hold policy. During interviews, RN 7 stated that when a resident is sent to the ER, paperwork including the notice of transfer/discharge with bed hold policy is provided to the resident before leaving, or reviewed and signed by the representative if the resident is unstable or not cognitively intact, with documentation entered in a progress note. The DON stated that residents sent to the ER are sent with a face sheet, continuing care document, and bed hold policy, and if admitted, the paperwork is mailed to the family.
PASRR Screening Not Updated After New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a required PASRR Level I screening assessment to determine whether a Level II assessment was needed after a resident received a new major mental illness diagnosis. Resident 11’s record showed a diagnosis of schizoaffective disorder, bipolar type, added in July 2024, while a prior PASRR Level I outcome from 6/6/24 stated that a Level II assessment was not required and that a new screen must be submitted if changes occurred or new information refuted the findings. The resident’s care plan, initiated 7/11/24, documented behavioral symptoms including delusions, tangential thoughts, agitation, grandiose thoughts, restlessness, and impulsivity related to schizoaffective disorder. A 4/13/26 quarterly MDS assessment indicated the resident was cognitively intact and listed schizophrenia among active diagnoses. During interview, the Social Services Director stated she was responsible for PASRR submissions and confirmed the last screening was submitted on 6/6/24 without the major mental diagnosis; she was unable to provide any later PASRR submission after the schizoaffective disorder diagnosis was received and believed it had been overlooked.
Failure to Review Dialysis Communications Led to Duplicate Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure communications with the dialysis provider were reviewed to prevent duplicate pneumococcal vaccinations and to maintain continuity of care for a resident receiving dialysis. The resident had diagnoses including hypertensive heart disease, chronic kidney disease with heart failure, and acute kidney failure, and had an order for dialysis on Monday, Wednesday, and Friday. The resident’s March 2026 dialysis communication binder showed that Prevnar 20 was given at dialysis in the left deltoid, but the facility’s clinical record also showed a Prevnar 20 vaccination was administered in the facility later that month in the left deltoid. The clinical record lacked historical data of previous immunizations, and the resident’s quarterly MDS indicated moderate cognitive impairment. During interviews, the DON stated the dialysis communication binder was supposed to be reviewed by the UM or IP, but there was a time when the facility had neither position filled. The Corporate Nurse Consultant stated the clinical staff should have reviewed the communication binder and documented the Prevnar 20 given at dialysis in the resident’s clinical record. RN 4 stated that when a resident returned from dialysis, the nurse assigned to the hall should review the communication binder and document important information in the resident’s record. The IP stated the resident’s clinical record should be reviewed before giving any vaccination, and the facility followed CDC guidelines for all vaccinations. The facility policy on Dialysis Care stated the nurse in charge at time of return will review paperwork for new orders and/or notes accompanying the resident and that the facility will use a method of communication between the facility and the dialysis center to relay changes in condition and response to treatment.
Delayed Follow-Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure pharmacy recommendations were completed in a timely manner and in accordance with facility policy for 3 of 5 residents reviewed for unnecessary medications. The record review showed that a licensed pharmacist completed monthly medication regimen reviews and identified irregularities, but the recommendations were not consistently acted on within the time frame described in the facility policy. The policy stated that pharmacy recommendations should be reviewed with physician follow-up within 30 days of the facility receiving them. For one resident with COPD, type 2 diabetes mellitus, and morbid obesity, discontinued PRN orders included ipratropium-albuterol, ondansetron, and polyethylene glycol 3350. The pharmacy review dated 1/7/26 recommended discontinuing these PRN medications because they had not been used within the previous 60 days. The provider signed the recommendation on 3/10/26 and indicated to discontinue the PRN orders. For another resident with COPD, coronary artery disease, and peripheral vascular disease, cetirizine 10 mg daily was discontinued on 4/14/26 after the pharmacy review dated 1/7/26 recommended discontinuation because daily long-term use should be limited to the allergy season to avoid adverse events. For a third resident with chronic atrial fibrillation, hypertensive heart disease with heart failure, and hemiplegia and hemiparesis following cerebrovascular disease, the record showed current amiodarone 100 mg daily and a TSH order once on 3/12/26, but no future TSH orders every 6 months were present in the chart. The pharmacy review dated 1/7/26 recommended discontinuing cyclobenzaprine due to lack of use within the previous 60 days and also recommended monitoring TSH every six months because amiodarone may affect thyroid function. The provider signed the recommendation on 3/10/26 and ordered a TSH for 3/12/26. During interview, the DON stated she was new to the pharmacy review process, received recommendations by email, printed them, and handed them to the provider, while the corporate nurse consultant stated the facility aimed for 30 days or by the next review per regulation, with some recommendations taking longer depending on urgency.
Duplicate Pneumococcal Vaccination Documentation
Penalty
Summary
The facility failed to ensure pneumococcal vaccinations were provided in accordance with CDC guidelines and facility policy to prevent duplication of administration for 1 of 6 residents reviewed for immunizations. Resident 2 had diagnoses including hypertensive heart disease, chronic kidney disease with heart failure, and acute kidney failure. The resident’s dialysis communication binder showed that Prevnar 20 was administered in the left deltoid at dialysis on 3/2/26, but the facility’s clinical record also documented a Prevnar 20 vaccination in the left deltoid on 3/26/26. The clinical record lacked historical data of any previous immunizations, and the resident’s quarterly MDS indicated moderate cognitive impairment. During interviews, the DON stated the Unit Manager or Infection Preventionist was responsible for reviewing the dialysis communication binder, but there was a period when the facility had neither position filled. The Corporate Nurse Consultant stated there was no UM or IP to review the binder when the resident would have received the vaccine at dialysis, and the clinical staff should have reviewed the binder and documented the dialysis vaccination in the resident’s record. RN 4 stated that when a resident returned from dialysis, the nurse assigned to the hall should review the communication binder. The IP (Float) stated the resident’s clinical record should be reviewed before giving any vaccination.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for this resident, indicating that the required services were not adequately provided as needed.
Failure to Notify Resident Representatives for Care Plan Meetings
Penalty
Summary
The facility failed to ensure that resident representatives of cognitively impaired residents were invited to participate in the care plan process for two out of three residents reviewed. Both residents had diagnoses including severe cognitive impairment, as indicated by their quarterly MDS assessments. For each care plan meeting reviewed, documentation showed that the residents were listed as attending, but there was no evidence that their representatives were invited or present. Progress notes for both residents lacked any record of notification or invitation to the responsible parties for care plan meetings over several months. Interviews with facility staff confirmed that the process for inviting resident representatives was not consistently followed or documented. The Social Services Director stated that invitations were documented in progress notes and that representatives were contacted by phone if not sent a written invitation, but this was not reflected in the records. The Director of Nursing acknowledged that there should be documentation of notification or attendance by the resident representative, especially for residents who are cognitively impaired. Additionally, a resident's representative reported not being invited to any care plan meetings. Facility policy requires that residents or their representatives be invited to care plan reviews, but this procedure was not followed in these cases.
Missed Medical Appointment Due to Lack of Transportation Backup
Penalty
Summary
The facility failed to provide transportation for a resident to attend a scheduled medical procedure, resulting in the resident missing the appointment. The resident, who had multiple diagnoses including emphysema, hemiplegia, atherosclerotic heart disease, diabetes with neuropathy, peripheral vascular disease with arterial ulcers, and hypertension, was cognitively intact and required substantial to maximum assistance with mobility and personal care. The resident was scheduled for a stent placement to treat peripheral vascular disease, with transportation to be provided by the facility bus. On the day of the appointment, the assigned transport driver did not report to work or notify the facility, and multiple attempts to contact the driver were unsuccessful. The facility did not have a backup transportation plan in place, and staff were unable to arrange alternative transportation in time for the appointment. As a result, the resident missed the scheduled procedure and the appointment had to be rescheduled for a later date. Facility policy indicated that transportation should be provided for residents to medical appointments when no other option is available, but in this instance, the lack of a backup driver led to the deficiency.
Infection Control Deficiencies in Laundry and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to utilize proper infection prevention and control practices during laundry delivery, affecting 69 of 70 residents who received facility laundry services. Observations revealed that laundry attendants did not perform hand hygiene when entering and exiting residents' rooms while delivering clean laundry. This was confirmed by interviews with the laundry attendants, the Infection Preventionist, and the Laundry Supervisor, who all acknowledged the requirement for hand hygiene during the laundry delivery process. The lack of hand hygiene posed a potential risk for the transmission of infections, especially given the presence of residents with COVID-19, Influenza A, and Clostridium difficile. The facility also failed to implement enhanced barrier precautions (EBP) for residents at higher risk of infection due to indwelling urinary catheters or feeding tubes. For instance, Resident 8, who had a suprapubic catheter, did not receive proper catheter care as the spigot of the urinary catheter drainage bag was not cleansed after touching the urinal. Additionally, the CNA did not wear a gown during high-contact care activities, despite the presence of an EBP sign. Similar deficiencies were observed with Resident 10, whose urinary catheter bag was allowed to touch the floor, and Resident 9, where a nurse administered medication via a feeding tube without donning a gown. Interviews with staff, including CNAs and the Infection Preventionist, revealed a lack of understanding and adherence to EBP protocols. The facility's policies and procedures for infection prevention and control, including hand hygiene and EBP, were not consistently followed, leading to potential risks of infection transmission among residents. The facility was unable to provide a policy regarding urinary catheter maintenance, further highlighting the gaps in infection control practices.
Failure to Monitor and Report Urinary Output and Abnormalities
Penalty
Summary
The facility failed to ensure proper monitoring and reporting of urinary output for a resident with a urinary catheter. The resident, who had a history of dementia, neuromuscular dysfunction of the bladder, and chronic kidney disease, was observed with milky-white and cloudy yellow urine in the catheter drainage tube on multiple occasions. Despite the presence of cloudy and thick urine, which are potential signs of a urinary tract infection, these abnormalities were not reported to the provider as required. The resident's care plan indicated a risk for infection due to a supra-pubic urinary catheter and required staff to report signs of urinary tract infections. However, the facility did not consistently document urinary output every shift as ordered by the physician. Specific dates in January and February were noted where urinary output was not recorded, and there was no documentation of any diagnostic urine testing during the period of observed abnormalities. During observations, a CNA was seen improperly handling the catheter drainage bag, allowing the spigot tip to touch the urinal walls without cleansing it afterward. The CNA acknowledged the requirement to report urine abnormalities to the nurse, but failed to do so. The DON confirmed the lack of documentation and was unable to provide a policy on urinary catheter maintenance or outputs, highlighting a systemic issue in monitoring and reporting urinary conditions.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration on the [NAME] Lane Unit. During an observation, RN 2 was seen preparing medications by punching six capsules from the medication card into her bare hand and opening each capsule with bare hands before emptying the contents into a medication cup. RN 2 did not sanitize her hands following the administration of these medications. Additionally, RN 2 prepared and administered an as-needed pain pill to a resident without sanitizing her hands. It was only after a conversation with LPN 3 that RN 2 performed hand hygiene using an alcohol-based hand rub. The facility's current policies on medication administration and infection prevention and control, revised in 2023, were not followed by RN 2. The policies clearly state that medications should be opened without contamination and that an infection prevention and control program should be maintained to provide a safe and sanitary environment. RN 2 acknowledged that she should have sanitized her hands between preparing medications and that gloves should have been worn when opening capsules to administer medications ordered to be crushed.
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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