Hickory Creek At Crawfordsville
Inspection history, citations, penalties and survey trends for this long-term care facility in Crawfordsville, Indiana.
- Location
- 817 N Whitlock Ave, Crawfordsville, Indiana 47933
- CMS Provider Number
- 155419
- Inspections on file
- 23
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Hickory Creek At Crawfordsville during CMS and state inspections, most recent first.
A QMA repeatedly failed to perform required hand hygiene while administering and preparing medications for multiple residents during meal service. The QMA handled personal items such as hair, removed food from a resident’s clothing, and touched another resident’s shirt between direct resident contacts and medication passes, without washing or sanitizing hands as required by facility policy. The facility’s medication policy required appropriate hand hygiene before and after direct resident contact, but these practices were not followed.
Surveyors found that a QMA routinely crushed and mixed multiple oral medications in applesauce for two residents, including memantine, aspirin EC, and potassium ER, despite pharmacy guidance and reference materials indicating these products should not be crushed. One resident had vascular dementia and swallowing difficulties, while the other had a history of stroke and vascular dementia without a swallowing disorder. The QMA reported she always crushed all medications for these residents, either due to swallowing problems or to improve acceptance. Although the facility had a General Dose Preparation and Medication policy requiring adherence to pharmacy guidelines and a pharmacy-supplied “do not crush” list, there was no formal, specific policy on crushing medications, and the listed non-crush medications were still altered during administration.
The facility did not ensure RN coverage for at least 8 consecutive hours on multiple days, as shown by staffing records and PBJ data. The Executive Director confirmed awareness of these lapses and acknowledged the regulatory requirement.
A resident with COPD and respiratory failure was observed multiple times with their nebulizer mask left un-bagged on the bedside table, contrary to facility policy requiring sanitary storage of respiratory equipment. Staff confirmed the expectation for proper storage, but the mask was not maintained in a safe and sanitary manner after use.
An LPN was observed placing a shared glucometer directly on a medication cart without a barrier and cleaning it with a hand sanitizing wipe instead of the approved disinfectant. The DON confirmed that facility policy requires the use of specific germicidal wipes and a clean barrier for glucometer disinfection, which was not followed in this instance.
The facility failed to ensure a Registered Nurse (RN) was present for 8 consecutive hours during a 24-hour period on multiple occasions in the first quarter of 2024. The Regional Director of Clinical Services (RDCS) confirmed the lack of RN coverage on specified dates and noted the absence of a Director of Nursing Services (DNS) and a related policy.
The facility failed to ensure proper labeling and disposal of medications for two medication carts. An undated eye drop solution and two insulin pens, one undated and one expired, were found. Staff were unsure of the policies regarding medication expiration.
The facility failed to ensure that personal funds were available on weekends for a resident who was cognitively intact. Interviews revealed that the Business Office Manager was unaware of the weekend procedure, and neither the LPN nor the RN knew of any money bag or cash box for weekend access. The facility had not had consistent business office staff, and both staff and residents needed education on the procedure for obtaining personal funds on weekends.
The facility failed to ensure that two dependent residents were shaved due to a shortage of razors, despite their care plans requiring assistance with personal hygiene. Staff interviews revealed issues with the ordering process, and the facility lacked a specific policy on maintaining an adequate supply of razors.
The facility failed to ensure dining meal service was completed in a sanitary manner. An RN and a CNA were observed assisting two residents by cutting their sandwiches with ungloved hands. The Regional Director of Clinical Services confirmed that this practice was inappropriate and against Indiana retail food guidelines.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure hand hygiene was completed according to infection control practices during medication administration for five of six residents reviewed. On 1/13/26 at 7:50 a.m., a Qualified Medication Aide (QMA 10) was observed passing medications during breakfast in the main dining room. After handing one resident a cup of medications and while waiting for the resident to swallow, QMA 10 removed a piece of bacon from another resident’s shirt, lifted her long hair from her neck, scratched her head, and ran her fingers through her hair. When the resident finished taking the medications, QMA 10 returned to the medication cart and began setting up medications for another resident without washing or sanitizing her hands. At 8:11 a.m., QMA 10 spoon-fed a resident crushed medications in applesauce and, while walking back to the medication cart, tweaked another resident’s shirt as she joked with her, again without performing hand hygiene before setting up medications for the next resident. At 8:21 a.m., QMA 10 administered medications to another resident and returned to the medication cart without washing or sanitizing her hands before preparing medications for yet another resident. At 8:27 a.m., QMA 10 administered medications to that resident and did not wash or sanitize her hands before starting to set up the next medication. The facility’s General Dose Preparation and Medication policy, revised 11/15/24, indicated that appropriate hand hygiene should be performed before and after direct resident contact, which was not followed in these observed instances.
Improper Crushing of Non-Crush Medications During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to manufacturer specifications, specifically by improperly crushing medications that should not be altered. During a morning medication pass in the main dining room, a QMA crushed and spoon-fed memantine tablets mixed in applesauce to a resident with vascular dementia, severe cognitive impairment, and documented swallowing difficulties. The physician’s orders allowed crushing of appropriate medications, but memantine was listed by the contracted pharmacy on a “do not crush” list, and a medication reference from the Mayo Clinic indicated memantine tablets should not be crushed, chewed, or divided because crushing can cause the drug to release too quickly into the body. In a separate observation, the same QMA crushed and spoon-fed aspirin EC (enteric coated), Jardiance (empagliflozin), and potassium chloride ER (extended release) mixed together in applesauce to another resident with a history of stroke and vascular dementia, who had severe cognitive impairment but no signs or symptoms of a swallowing disorder. The physician’s orders also allowed crushing of appropriate medications, but aspirin EC and potassium ER were on the pharmacy’s “do not crush” list. ISMP guidance indicated enteric-coated and ER medications should not be crushed or dissolved, and FDA information described potassium chloride ER as a formulation intended to slow potassium release. The QMA stated she always crushed all medications for these residents and administered them mixed together in applesauce, doing so for one resident due to swallowing problems and for the other because she took them better that way. The Regional Nurse Consultant indicated there was no formal facility policy for crushing medications, although a pharmacy-provided list of medications that should not be crushed was available, and the facility’s General Dose Preparation and Medication policy required staff to crush oral medications only in accordance with pharmacy guidelines and/or facility policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours each day, as required by regulation. Review of the Payroll Based Journal (PBJ) report during the entrance conference revealed that on multiple dates within one quarter, there was no documentation of RN coverage for any shift. Specifically, the staffing sheets for eight separate dates lacked evidence of an RN working in the facility. During an interview, the Executive Director confirmed awareness of the lack of RN coverage on the identified dates and acknowledged the expectation to comply with the regulation. The deficiency was based on both the PBJ report and the absence of RN documentation on the facility's staffing sheets for the specified dates.
Nebulizer Mask Not Stored Safely After Use
Penalty
Summary
A deficiency was identified when a resident's nebulizer mask was repeatedly observed left un-bagged on the bedside table during multiple random observations throughout the day. The nebulizer mask was not stored in a safe and sanitary manner as required by facility policy, which specifies that nebulizer equipment should be placed in a plastic bag when not in use. These observations were made despite the resident having recently received a nebulizer treatment, as documented in the medication administration record. The resident involved had diagnoses including chronic obstructive pulmonary disease (COPD) and both acute and chronic respiratory failure with hypercapnia, requiring regular nebulizer treatments as ordered by a physician. Interviews with the Assistant Director of Nursing confirmed the expectation that nebulizer masks should be stored in a bag when not in use, and the Director of Nursing provided the facility's policy supporting this procedure. The failure to properly store the nebulizer mask constituted a lapse in maintaining safe and sanitary respiratory care for the resident.
Failure to Follow Infection Control Procedures for Shared Glucometer
Penalty
Summary
A Licensed Practical Nurse (LPN) was observed performing a blood glucose assessment for a resident using a shared glucometer. After completing the assessment, the LPN placed the glucometer directly on top of the medication cart without using a barrier, contrary to facility policy. The LPN then used a hand sanitizing wipe, rather than the approved disinfecting wipe, to clean the glucometer and wrapped it in the wipe before placing it into a plastic cup. During an interview, the LPN confirmed that hand sanitizing wipes were used for cleaning the glucometer after use. The Director of Nursing (DON) later clarified that the facility's policy requires the use of specific germicidal wipes for disinfecting shared glucometers and mandates the use of a clean barrier when placing the device on solid surfaces. The DON confirmed that the hand sanitizing wipes used by the LPN were not the approved type for disinfecting glucometers. The facility's policy also specifies that the glucometer should remain wet with the disinfectant for the recommended contact time and be allowed to air dry on a clean barrier before reuse. These procedures were not followed during the observed incident.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was present for 8 consecutive hours during a 24-hour period on multiple occasions in the first quarter of 2024. Specifically, the Payroll-Based Journal (PBJ) Staffing report indicated that there was no RN coverage on 10/23, 10/29, 12/3, 12/9, 12/10, 12/14, 12/16, 12/17, 12/23, 12/24, 12/25, and 12/30. This was confirmed by the Regional Director of Clinical Services (RDCS) during an interview, who reviewed the PBJ data and staffing schedules and acknowledged the lack of RN coverage on the specified dates. The RDCS also noted that the facility did not have a Director of Nursing Services (DNS) at the time, and a float DNS was not present on those days. The RDCS further indicated that the facility did not have a policy related to RN coverage. This lack of policy and the absence of a DNS contributed to the failure to maintain the required RN coverage. The deficiency was identified through record reviews and interviews conducted on 5/22/24, where it was confirmed that the facility did not meet the regulatory requirement of having an RN on duty for 8 consecutive hours each day for the specified dates.
Improper Medication Labeling and Disposal
Penalty
Summary
The facility failed to ensure medications were labeled properly and expired medications were disposed of appropriately for two medication carts reviewed. On one occasion, an undated and opened bottle of eye drop solution for a resident was found in the front hall medication cart. The Qualified Medication Aide (QMA) confirmed that eye drops should be dated when opened and are good for 28 days. The resident's physician order indicated the use of the eye drops twice a day. In another instance, an undated and opened insulin pen for a resident was found in the back hall medication cart. Additionally, another insulin pen with an open date far exceeding the 28-day limit was also found in the same cart. The Licensed Practical Nurse (LPN) was unsure of the policy regarding the duration insulin pens are good for once opened. The Regional Director of Clinical Services confirmed that insulin pens should be discarded after 28 days. The residents involved had diagnoses including type 2 diabetes mellitus with complications such as diabetic neuropathy.
Failure to Ensure Weekend Access to Personal Funds
Penalty
Summary
The facility failed to ensure that personal funds were available on the weekends for Resident 19, who was cognitively intact according to a quarterly Minimum Data Set (MDS) assessment. During an interview, Resident 19 indicated she had not been able to access her money on weekends for a while. The Business Office Manager (BOM) confirmed that residents could only obtain their money Monday through Friday and was unaware of the weekend procedure. The Corporate Business Office Specialist mentioned that a money bag should be kept at the nurse's station for weekend access, but was unsure of its exact location at this facility. Additionally, the facility had not had consistent business office staff for some time, and both staff and residents needed education on the procedure for obtaining personal funds on weekends. Further interviews revealed that neither the Licensed Practical Nurse (LPN) nor the Registered Nurse (RN) were aware of any money bag or cash box being available for personal funds on weekends. The RN mentioned that the Director of Nursing had recently purchased a cash box, but staff had not yet been educated on its use. The Regional Director of Clinical Services provided an undated document titled 'Resident Trust Overview,' which indicated that funds should be available to residents 24/7 and that a method for distributing funds after hours and on weekends must be established. However, this policy was not being followed at the time of the survey.
Failure to Ensure Residents Were Shaved
Penalty
Summary
The facility failed to ensure that dependent residents were shaved, leading to deficiencies in personal hygiene for two residents. Resident 30, who had a seizure disorder and was on anticoagulant medication, was observed with long facial hair on multiple occasions. The resident expressed that he had not been shaved for quite a while due to the facility running out of razors. His care plan indicated he required assistance with ADLs, including shaving during showers, but records showed he had not been shaved for several days in May 2024. Similarly, Resident 17, who had hypertensive heart disease, chronic kidney disease, and diabetes, was also observed with long facial hair. The resident indicated he had not been shaved for several days and depended on staff for shaving during showers or bed baths. Despite his care plan requiring assistance with ADLs, including shaving, records showed he had not been shaved for several days in May 2024. The resident was finally shaved after the facility received a new supply of razors. Interviews with staff, including the Regional Director of Clinical Services, a CNA, and the Administrator, revealed that the facility had issues with the ordering process, leading to a shortage of razors. The Administrator acknowledged that the facility could have purchased razors locally to meet the residents' needs. The facility lacked a specific policy on maintaining an adequate supply of razors, although the expectation was to always have enough supplies on hand to meet residents' needs.
Unsanitary Dining Meal Service
Penalty
Summary
The facility failed to ensure dining meal service was completed in a sanitary manner. During an observation, a Registered Nurse (RN) was seen assisting a resident by cutting her sandwich while holding it with her ungloved left index finger. Similarly, a Certified Nursing Assistant (CNA) was observed assisting another resident by pushing down on the resident's sandwich with her ungloved hand while cutting it. The Regional Director of Clinical Services confirmed that it was inappropriate for staff to touch resident food items with ungloved hands, and the facility was expected to follow the Indiana retail food guidelines, which mandate minimizing bare hand contact with exposed food.
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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