Majestic Care Of Avon
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon, Indiana.
- Location
- 445 S County Road 525 E, Avon, Indiana 46123
- CMS Provider Number
- 155338
- Inspections on file
- 35
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Majestic Care Of Avon during CMS and state inspections, most recent first.
A CNA was observed passing lunch trays alone, and food temperatures on the 600 hall were found to be below required standards, with items such as chicken and vegetables measured well under the facility's policy for hot food holding. Fourteen residents receiving room tray service were potentially affected.
A resident with multiple medical conditions, including weight loss, was not served her physician-ordered diet, which required double portions and a magic cup at lunch. The omission was observed and confirmed by a CNA, who subsequently provided the missing items.
The facility failed to address ongoing Resident Council Grievance concerns about call light wait and response times, affecting 5 of 82 residents. Despite repeated complaints documented in meeting minutes, the issue persisted, with residents experiencing long wait times and accidents. Interviews revealed that grievance responses were inconsistent, and the facility's policy on prompt grievance resolution was not effectively implemented.
The facility failed to enforce its non-smoking policy, allowing residents with various health conditions to smoke on the premises and keep smoking materials in their rooms. Despite being a non-smoking facility, residents were observed smoking on the grounds, and some admitted to storing cigarettes and lighters in their rooms. The facility lacked smoking assessments for these residents, contributing to the deficiency.
The facility failed to label and date medications when opened and did not remove expired medications from use, as observed in three medication carts and one refrigerator. Medications for several residents, including inhalers, insulin pens, and nasal sprays, were found without opening dates or were expired. Additionally, a vial of tuberculin and a bottle of aplisol in the medication room refrigerators were improperly dated or expired.
A facility failed to complete necessary assessments for a resident self-administering medications. The resident had fluticasone nasal spray, carboxymethylcellulose eye drops, and metronidazole lotion in her room, but the facility's documentation was incomplete. The Medication Self-Administration Safety Screen and care plan lacked proper assessments and specific listings for these medications, contrary to the facility's policy requiring interdisciplinary team assessments.
A resident with Alzheimer's in the Memory Care unit fell and fractured her hip after being found in another resident's bed. The fall was not accurately coded in the MDS assessments, initially marked as no falls and later not indicating the fracture. The facility's policy on accurate assessment was not followed.
The facility failed to provide sufficient licensed nurse coverage on weekends, affecting all 82 residents. The CASPER report highlighted staffing concerns in the second quarter of 2024. A review of the May 2024 schedule showed a downward trend in licensed staff per-patient-per-day (PPD), with several days not meeting the minimum required PPD. The Executive Director acknowledged the issue and noted that leadership staff were mainly scheduled for weekdays, suggesting a potential rearrangement to cover weekends. The Facility Assessment Tool indicated the required minimum PPD, which was not met.
The facility failed to provide appropriate assessments and person-centered care for two residents with dementia who wished to have a relationship. Despite family approval, the care plans and assessments did not reflect the residents' preferences and behaviors, leading to a deficiency in care.
The facility failed to provide person-centered care, supervision, and engaging activities in the secured memory care unit, leading to multiple resident-to-resident altercations and injuries. Residents frequently wandered into each other's rooms, causing distress and physical altercations. The facility lacked adequate supervision and activities to redirect residents, especially during the night shift.
A facility failed to protect a non-verbal, cognitively impaired resident from abuse. A video showed a CNA hitting the resident during care while a QMA did not intervene. Family members, watching live through a web camera, reported the incident. Interviews and records revealed the resident's cognitive impairments and the facility's ongoing abuse investigation.
The facility failed to ensure staff immediately reported witnessed abuse by another staff member to a resident. During care, a CNA hit a resident, and the QMA did not intervene or report the incident immediately. The Administrator received reports later in the morning, but the QMA did not follow the facility's policy for immediate reporting.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
During a lunch service observation, a CNA was found to be passing trays alone on the 600 hall. Temperatures of the food items on the lunch trays were checked and found to be below the facility's required holding temperature of greater than 135 degrees Fahrenheit, with chicken measured at 122 degrees, mashed potatoes at 122.7 degrees, and mixed vegetables at 117 degrees. The facility's policy, provided by the Executive Director, specifies that hot foods must be held at appropriate temperatures, with poultry and stuffed foods requiring a minimum of 165 degrees Fahrenheit and all foods held above 135 degrees Fahrenheit. Fourteen residents who had their trays delivered to their rooms on the 600 hall were potentially affected by this deficiency.
Failure to Provide Prescribed Therapeutic Diet to Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including weakness, hypertension, and weight loss did not receive her prescribed diet as ordered by the physician. The resident's orders specified a regular diet with ground meat, double portions, and a magic cup at lunch. During observation, the resident was served lunch without the double portions or the magic cup. This was confirmed by a CNA, who then retrieved the missing items. No facility policy was provided at the time of the survey exit.
Failure to Address Call Light Response Concerns
Penalty
Summary
The facility failed to address Resident Council Grievance concerns regarding call light wait and response times in a timely and effective manner. This issue affected 5 of 82 residents who attended the Resident Council Meeting and complained on behalf of all 82 residents residing in the facility. The Executive Director (ED) was unable to locate Resident Council Minutes from October 2023 through February 2024, but provided minutes from March 2024 to July 2024. These minutes consistently documented complaints about overnight staff not responding to call lights for 1-2 hours and staff using phones during resident care. Despite these ongoing complaints, the facility did not effectively resolve the issue, as evidenced by repeated grievances and lack of improvement in call light response times. Interviews with residents and staff revealed that the problem persisted, with residents experiencing long wait times for assistance, leading to accidents in their briefs. The Activity Director (AD) confirmed that call light response times and inappropriate phone use by staff were major concerns. Although grievance forms were submitted, responses were inconsistent, and some grievances related to call light issues were not addressed. The Assistant Director of Nursing (ADON) reported conducting night shift observations without finding concerns, and staff had been educated multiple times. However, the facility's policy on grievances, which mandates prompt resolution efforts, was not effectively implemented, resulting in ongoing resident dissatisfaction.
Non-Smoking Policy Violation in LTC Facility
Penalty
Summary
The facility failed to adhere to its non-smoking policy, allowing residents who had not been assessed for smoking to smoke on the premises and keep smoking materials in their rooms. This deficiency was observed in six residents, all of whom had various medical conditions that could be exacerbated by smoking. Despite the facility's policy stating it was a non-smoking environment, residents were found smoking on the grounds, and some admitted to keeping cigarettes and lighters in their rooms. Resident 6, who had chronic obstructive pulmonary disease (COPD) and other health issues, was observed smoking in the parking lot. His care plan indicated he was a smoker and should comply with the facility's smoking policy, but there was no documentation of a smoking assessment in his records. Similarly, Resident 22, with schizoaffective disorder and COPD, kept cigarettes in her room, contrary to the policy. Resident 7, who also had COPD, admitted to smoking on the facility grounds and keeping smoking materials in his car. Other residents, such as Resident 67 with schizophrenia and dementia, and Resident 77 with dementia and PTSD, were also found to be non-compliant with the smoking policy. They kept smoking materials in their rooms and smoked on the premises. Resident 26, with dementia and anxiety, was observed smoking with the help of another resident, despite having a behavioral contract prohibiting smoking on facility grounds. The facility's Executive Director and staff acknowledged the lack of smoking assessments and the failure to enforce the non-smoking policy, contributing to the deficiency.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to properly label and date medications when opened and did not remove expired medications from use, as observed in three of five medication carts and one of two refrigerators. On the 600 hall medication cart, an albuterol inhaler and a trelegy ellipta inhaler for a resident, as well as a fluticasone nasal spray for another resident, were found without dates indicating when they were opened. On the 700 hall medication cart, expired Humalog insulin pens for two residents and a glargine insulin pen for another resident were found, along with a carboxymethyl solution without an opening date. On the 800 hall medication cart, insulin pens and a nasal spray for two residents were also found without opening dates. Additionally, the medication room refrigerators on the 600, 700, and 800 halls contained a vial of tuberculin that had expired and a bottle of aplisol with an unclear date. These observations indicate a failure to adhere to the facility's policy of ensuring medications are stored according to manufacturer's recommendations, which includes proper labeling, dating, and removal of expired medications.
Failure to Complete Resident Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that resident assessments were completed for a resident who self-administers medications. Resident 15 was observed to have medications in her room, including fluticasone nasal spray, carboxymethylcellulose eye drops, and metronidazole lotion. The physician's orders allowed Resident 15 to self-administer these medications, but the facility's documentation was incomplete. The Medication Self-Administration Safety Screen dated 1/3/24 only assessed the fluticasone nasal spray, while the eye drops and topical creams were not considered applicable. Furthermore, the resident's electronic medical record lacked documentation of quarterly self-administration assessments for all three medications. A new Medication Self-Administration Safety Screen dated 8/5/24 assessed only the carboxymethylcellulose eye drops, omitting the fluticasone and metronidazole. The medication care plan dated 4/4/24 indicated that Resident 15 could self-administer eye medication and face cream, but did not specifically list the metronidazole lotion. During an interview, Resident 15 mentioned that the facility staff had taken away her rosacea medication, which she had previously been allowed to keep in her room. The facility's policy on self-administration of medications requires an interdisciplinary team assessment, which was not adequately documented in this case.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to accurately code falls on the Minimum Data Set (MDS) for a resident in the Memory Care unit. The resident, who had Alzheimer's disease, experienced a fall on her right hip after being found in another resident's bed and was escorted back to her room. This incident resulted in an acute, impacted, nondisplaced right subcapital femoral neck fracture, which required surgical repair. However, the significant change MDS assessment initially indicated no falls since admission or prior assessment, and a subsequent assessment failed to note the fracture resulting from the fall. The facility's policy on accurate assessment, effective at the time, was not adhered to, as the resident's status was not accurately reflected in the MDS assessments.
Insufficient Weekend Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure sufficient licensed nurse coverage on weekends during one of the four quarters reviewed, potentially affecting all 82 residents. The CASPER report indicated staffing concerns were triggered in the second quarter of 2024 due to low weekend staffing. Upon reviewing the licensed nursing schedule for May 2024, it was found that the licensed staff per-patient-per-day (PPD) trended down throughout the month, with several days not meeting the minimum required PPD. Specific days, including Thursdays and weekends, showed PPDs below the minimum threshold, with the lowest being 0.19 on a Sunday. During an interview, the Executive Director (ED) acknowledged the staffing issues and noted that leadership staff, such as the Medical Records Coordinator and the Assistant Director of Nursing, were primarily scheduled for weekday office hours. The ED suggested that some of these hours could be rearranged to cover weekends. The Facility Assessment Tool, dated May 20, 2024, indicated the required minimum PPD for RNs and LPNs, which was not met according to the schedule review. The ED confirmed that the Facility Assessment Tool served as the policy for staffing requirements.
Deficiency in Person-Centered Care for Residents with Dementia
Penalty
Summary
The facility failed to ensure that two cognitively impaired residents, who wished to have a relationship and resided on the secured memory care unit, had appropriate assessments, ongoing supervision, and person-centered goals and interventions. The report highlights that the facility did not adequately document or revise care plans to reflect the residents' preferences and behaviors, particularly regarding their relationship. This lack of documentation and revision in care plans contributed to the deficiency. Resident 53, who was severely cognitively impaired with a BIMS score of 3 out of 15, had a history of wandering and seeking affection from male residents. Despite her family's approval of her relationship with Resident 55, the facility did not update her care plan to include her preference for companionship with him. Additionally, her behavioral assessments lacked documentation of her seeking affection, and her activity assessments did not reflect her meaningful relationship with Resident 55. Resident 55, who was moderately cognitively impaired with a BIMS score of 10 out of 15, also had a care plan that did not address his relationship with Resident 53. His behavioral assessments did not document his feelings towards her, and his activity assessments lacked information about his preference for companionship. The facility's failure to incorporate these aspects into their care plans and assessments resulted in a deficiency in providing person-centered care for these residents.
Failure to Provide Person-Centered Care and Supervision in Memory Care Unit
Penalty
Summary
The facility failed to ensure the secured memory care unit provided person-centered care, supervision, and engaging activities to prevent resident-to-resident altercations and/or accidents. This deficiency affected all 30 residents in the secured memory care unit. Observations, interviews, and record reviews revealed that residents frequently wandered into each other's rooms, leading to altercations and injuries. For instance, Resident L, who had a history of verbal and physical aggression, pushed Resident B, causing him to fall and sustain severe head injuries. Resident B had been agitated and wandering the halls, and staff attempts to put him to bed only increased his agitation. The facility lacked adequate supervision and activities to redirect residents, especially during the night shift when the activity room was closed and no materials for redirection were available. Resident L's family member reported that she had experienced a decline in cognitive abilities and an increase in aggression, leading to her transfer to the facility. Despite being placed in a room near the activity room, Resident L was frequently disturbed by other residents wandering into her room, which agitated her further. The facility's attempts to use a Velcro stop-sign to prevent other residents from entering her room were ineffective. Resident L's care plan lacked person-centered interventions to address her history of aggression and need for personal space. The facility also failed to provide adequate supervision and engaging activities for other residents, leading to multiple resident-to-resident altercations. For example, Resident EE wandered into Resident GG's room, resulting in an altercation where Resident EE sustained an abrasion. Similarly, Resident X wandered into Resident M's room, leading to an altercation where Resident X sustained a skin tear and bruising. Observations during the survey period showed continuous unsafe and unsupervised wandering by several residents, with no staff intervention or redirection. The care plans for these residents lacked person-centered, specialized interventions for dementia care and intrusive wandering.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a non-verbal, cognitively impaired resident was free from abuse. During the survey, a video provided by the family showed Qualified Medication Aide (QMA) 11 and Certified Nurse Aide (CNA) 12 providing incontinence care to Resident B. The video captured CNA 12 hitting Resident B on the left arm and upper abdomen with both open hands and yelling at the resident. QMA 11 did not intervene to stop the abuse and did not reposition Resident B's legs or reassure her during the incident. Family members, who were watching the care live through a web camera, voiced their concerns to the staff during the incident. The facility's grievance log indicated that a grievance was filed by the family on the same day, and an abuse investigation was ongoing. Interviews with staff and family members revealed that Resident B had a history of cognitive impairment and required assistance with activities of daily living. QMA 11 and CNA 12 were providing care when the incident occurred. QMA 11 admitted to witnessing CNA 12 hit Resident B and reported the incident to the oncoming nurse. Family members had previously installed a web camera in Resident B's room due to concerns about her care. The family provided the video evidence to the facility and filed a grievance. The facility's Director of Nursing (DON) confirmed that the abuse prevention policy was in place, which included training staff to manage residents' verbal or physical aggression and monitoring staff behavior. Resident B's medical records indicated diagnoses of Pick's disease, general anxiety disorder, depression, and psychotic disorder with delusions. The care plans for Resident B included interventions for cognitive impairment, impulsivity, and communication difficulties. The records lacked documentation of the incident, and focused charting on the day of the incident did not indicate any signs of emotional distress or changes in Resident B's condition. The facility's policy emphasized the residents' right to be free from abuse and the importance of staff training and monitoring to prevent such incidents.
Failure to Immediately Report and Intervene in Resident Abuse
Penalty
Summary
The facility failed to ensure staff immediately reported to the Administrator witnessed abuse by another staff member to a resident. The incident involved Resident B, who was being cared for by a Qualified Medication Aide (QMA) and a Certified Nurse Aide (CNA). During the care, the CNA hit Resident B on the left arm and upper abdomen, and yelled at the resident. The QMA did not intervene or stop the abuse and did not reposition Resident B's legs or reassure her. The incident was witnessed by Resident B's family members through a web camera, who voiced their concerns during the event. The QMA attempted to call the Administrator but did not receive a response and did not make further attempts to report the incident immediately. The Administrator received multiple calls reporting the abuse allegation later in the morning from other staff members and Resident B's family. The QMA provided a handwritten statement the following day, indicating she had called the Administrator but did not receive a response. The Administrator's call log showed no missed calls from the QMA. The facility's policy required immediate reporting of abuse to the Administrator or the Director of Nursing (DON) if the Administrator was unavailable. The QMA did not follow up with additional calls or notify the DON as required by the policy. Resident B's medical records indicated she had diagnoses including Pick's disease, general anxiety disorder, depression, and psychotic disorder with delusions. The resident had adequate hearing and vision, was not comatose, and sometimes understood others. The facility's policy on abuse prevention emphasized the importance of immediate reporting of any suspected abuse to facility management. The failure to report the abuse immediately and the lack of intervention during the incident led to the deficiency cited in the report.
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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