Majestic Care Of Goshen
Inspection history, citations, penalties and survey trends for this long-term care facility in Goshen, Indiana.
- Location
- 2400 College Ave, Goshen, Indiana 46528
- CMS Provider Number
- 155689
- Inspections on file
- 39
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Majestic Care Of Goshen during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities experienced two separate incidents in which other residents entered her room and engaged in inappropriate and intrusive behavior, including exposure, physical contact, and getting into bed with her while undressed. The resident’s responsible party reported both incidents to facility leadership via email and the facility had an abuse policy requiring immediate reporting of alleged violations to the Administrator and the Department of Health within defined time frames. However, the prior administrator did not submit required reports for these allegations, and the current administrator later acknowledged he had assumed they had been reported when they had not, resulting in a failure to timely report suspected abuse as required.
A resident with severe cognitive impairment and multiple comorbidities had a care plan including video monitoring and a STOP sign at her doorway. A male resident entered her room on more than one occasion, including an incident captured on family-installed cameras where he approached her bed while she slept, opened his robe, and ultimately sat on her chest and shoulder, causing her to cry out in pain before staff removed him. The resident’s representative reported this allegation to the Administrator by email, but the facility did not complete a thorough abuse investigation as required by its policy to investigate all alleged violations reported by residents or relatives.
Two cognitively intact residents who required substantial assistance with bathing did not receive scheduled twice-weekly showers as care planned and per facility policy. One resident with a femur fracture, cerebral palsy, and bipolar disorder received only a few documented showers despite a set Tuesday/Friday schedule, and the spouse reported repeated complaints to staff and disputed claims that the resident had refused showers, with no refusal documentation found. Another resident with neuromuscular bladder dysfunction, BPH, stroke, and anxiety reported going weeks without a shower and being told by staff they would provide one only if they could "fit it in," and he declined to sign a shower refusal sheet because he had not refused. Record reviews showed minimal shower documentation and no recorded refusals, while an LPN and the DON described expectations that showers and any refusals be documented according to the facility’s shower policy.
Surveyors found that the facility failed to follow physician orders for medication administration for a resident with exocrine pancreatic insufficiency and hypertension, including giving pancrelipase at times not aligned with meals, missing multiple doses without notifying the provider, and administering metoprolol despite heart rates below ordered hold parameters. In addition, the facility did not ensure a neurologist appointment was scheduled for a cognitively intact resident with multiple sclerosis and trigeminal neuralgia, despite a physician order, repeated resident requests, a grievance stating prior unmet requests, and documentation of severe pain, while the transportation director reported no appointments had been scheduled or completed for this resident.
A resident with a chronic Foley catheter and multiple comorbidities experienced inadequate monitoring and care when an order to record urinary output each shift was discontinued and staff did not continue to obtain or document outputs. Over subsequent days, the resident reported severe penile pain and pus at the meatus, and staff noted ongoing pain, abnormal drainage, and later fever, shaking, and gray discoloration before sending the resident to the hospital. In the ED, the Foley was found displaced with the balloon in the penile shaft, and the resident was diagnosed with a UTI and early sepsis related to a displaced catheter, while the facility’s own policy required ongoing catheter care and monitoring for catheter-associated UTI.
The facility did not ensure catheter care and urinary output documentation were completed as ordered for three residents with indwelling catheters. Review of records showed multiple shifts with missing documentation, and staff interviews confirmed there was no way to verify care was provided when documentation was absent. Family and resident interviews raised concerns about catheter care and urinary tract infections.
The facility failed to maintain sanitary conditions in the kitchen, affecting food safety for all 101 residents. Observations revealed improperly sealed food items in the freezer and a lack of open dates on dry storage items. Additionally, kitchen utensils and equipment were found with dried food and grease, despite being stored as clean. The Dietary Manager acknowledged these issues, which were contrary to the facility's sanitation policies.
The facility failed to follow infection control practices, including improper glove use and handwashing during resident care, and did not adhere to Enhanced Barrier Precautions for residents with wounds and catheters. Additionally, an illness outbreak was not reported to the State Department of Health, and medication was handled without gloves. These deficiencies potentially affected all residents.
The facility failed to notify physicians of abnormal conditions for residents, including elevated blood glucose levels and insulin refusals for two residents with diabetes, and new skin issues for another resident. Despite care plans and policies requiring physician notification, documentation was lacking, and staff interviews confirmed the deficiencies.
The facility failed to resolve resident grievances regarding long call light response times and incomplete shower schedules. Residents reported ineffective alternative alert methods and inconsistent grievance handling. Grievance forms were not accessible for anonymous submission, and the facility's grievance policy was inadequately implemented.
A facility failed to update a Level One PASARR assessment for a resident who received a new diagnosis of psychotic disorder with delusions and was prescribed antipsychotic medications. The initial PASARR form did not accurately reflect the resident's current mental health status or medications, and a new assessment was not conducted as required by facility policy.
A resident with multiple health conditions developed a stage 3 pressure ulcer due to the facility's failure to implement timely preventative measures. Despite being at risk for pressure sores, the resident's care plan interventions, such as turning and repositioning and the use of a prevalon boot, were not consistently documented or implemented. The facility delayed obtaining the recommended boot, and staff interviews confirmed the resident did not receive it until weeks after the recommendation.
A resident with nephrostomy tubes did not receive appropriate dressing changes, as staff were unfamiliar with the procedure and there were no physician orders specifying the frequency of changes. Observations showed dirty dressings, and an RN confirmed that daily changes were necessary, highlighting a deficiency in catheter care.
The facility failed to schedule timely specialty appointments for two residents, leading to a deficiency. A resident with a history of cervical cancer waited over eleven weeks for a gynecological oncology appointment after a mass was found in her uterus. Another resident with chronic kidney disease and anemia had no documented specialty referrals scheduled despite physician orders. The facility's policy on change in condition and physician notification was not effectively followed.
The facility failed to document clinical contraindications for declining gradual dose reductions (GDR) for two residents. One resident, with multiple diagnoses including PTSD, was on Haloperidol and Trazadone, while another resident with anxiety and depression was on Alprazolam PRN. Despite pharmacy recommendations to reduce dosages or evaluate the need for continued medication use, the facility did not provide adequate documentation to justify the decisions to maintain current dosages. The Director of Nursing acknowledged the lack of documentation, which was contrary to the facility's policy on managing unnecessary drugs.
The facility was found deficient in medication storage and labeling practices. Observations revealed unlabeled and improperly stored medications, including loose pills and topical creams stored with oral medications. Staff interviews confirmed these practices were against facility policy, and a policy on labeling was not provided during the survey.
A resident with diabetes and a stage 3 pressure ulcer did not receive timely laboratory testing as ordered by their physician. The facility failed to conduct a Hemoglobin A1c test and delayed other tests ordered by a wound center, despite having a policy for prompt action and communication. Interviews with staff revealed lapses in executing lab orders, even though the lab visited the facility regularly.
Two residents in the facility did not receive adequate bathing and oral care as per their care plans. One resident with quadriplegia reported not receiving scheduled showers and had difficulty shaving, while another resident with cervical spina bifida did not receive showers on preferred days, affecting her social activities. The facility's policy on ADLs was not followed, despite previous concerns raised by the Resident Council.
A resident with Alzheimer's and dementia, identified as high risk for falls, experienced multiple falls due to the facility's failure to implement a prescribed non-slip pad on her wheelchair. Despite a care plan update following a previous fall, the intervention was not in place, leading to further incidents and family concern.
The facility failed to manage urinary catheters properly for three residents, leading to deficiencies in catheter care and documentation. A resident with multiple health issues was found with a full catheter collection meter, and staff failed to document urine output as required. Another resident expressed concerns about infrequent catheter emptying, with records showing multiple instances of undocumented output. The facility's policy on catheter care was not followed, resulting in these deficiencies.
A resident with a history of fractures and chronic conditions was not administered prescribed stool softener upon admission to the facility, leading to constipation. The facility failed to input physician's orders into the EMR, delaying medication administration. The bowel movement protocol was not initiated, and a required assessment was not completed, causing the resident discomfort.
A facility failed to provide timely care to prevent a pressure wound for a resident admitted with a right femur fracture and other conditions. The resident, who was severely cognitively impaired and at risk for skin breakdown, did not receive a skin assessment upon admission. A pressure wound was later identified, which was not documented by the hospital at discharge. Delays in entering physician's orders into the EMR and implementing a pressure-reducing mattress contributed to the deficiency.
A resident with severe cognitive impairment and multiple fractures experienced unmanaged pain due to the facility's failure to conduct a pain assessment and administer pain medication upon admission. Despite hospital orders for pain management, the resident did not receive medication until over 16 hours after the last hospital dose, as the facility did not enter physician's orders into the EMR or utilize the Pyxis system. This oversight led to a significant delay in pain relief and was contrary to the facility's policies.
A resident with specific medical needs and preferences for showering was not accommodated by the facility, missing 11 out of 26 scheduled showers. The resident's care plan indicated a preference for showers on Mondays, Thursdays, and Saturdays, but the facility altered the schedule, affecting her social participation. Resident Council Minutes also noted similar concerns from other residents.
A facility failed to develop a comprehensive care plan for a resident with a urostomy, as required by its policies. The resident, who was cognitively intact and required significant assistance, reported that their urostomy bag was not emptied regularly. Despite a physician's order to empty the bag every shift, the care plan lacked specific interventions for urostomy care, management, or monitoring, leading to a deficiency identified during a complaint investigation.
The facility failed to provide scheduled showers for several residents, including those with cognitive impairments and physical disabilities, leading to a deficiency in resident rights. Residents missed numerous scheduled showers, with no refusals documented, indicating a systemic issue in adhering to care plans and personal preferences. Complaints were noted in Resident Council minutes, and the facility's policy on resident showers was not followed.
A facility failed to provide proper urostomy care for a resident, resulting in the urostomy bag not being emptied regularly. The resident, who required substantial assistance due to conditions like spina bifida and paraplegia, reported that her catheter bag was often not emptied during the day shift. The issue arose after a new medical director was hired, and the necessary urostomy orders were not entered into the EMR system, leading to a lack of documentation and compliance with care standards.
The facility failed to conduct follow-up assessments for UTIs in three residents, leading to inadequate documentation and management of symptoms. One resident was discharged to the hospital with hematuria, another showed increased confusion and refused medication, and the third experienced confusion and falls. Despite care plans outlining necessary interventions, these were not properly executed or documented.
Failure to Timely Report Multiple Allegations of Resident Abuse
Penalty
Summary
The facility failed to timely report two separate allegations of abuse involving a cognitively impaired resident, Resident C, in accordance with its abuse, mistreatment, neglect, and exploitation policy. Resident C had diagnoses including Alzheimer's disease, dementia, seizures, weakness, and depression, with a quarterly MDS showing severe cognitive impairment and dependence on substantial assistance for most ADLs. Her care plan noted a preference for video recording in her room and a STOP sign across the door frame, with interventions to protect privacy. On one occasion, an incident report (Facility Incident #236) was submitted for an event in which a male resident entered Resident C's room and sat on her bed; however, the facility's later review revealed that an earlier, more serious incident involving the same resident entering her room, exposing himself, and sitting on her chest and shoulder had been reported by the responsible party via email but was not reported to the State Agency as required. The record further showed that another incident (Facility Incident #254) involving a different resident, Resident D, climbing into bed with Resident C after undressing and wiping her genital area with Resident C's blanket was also not reported to the State Agency at the time it occurred. The responsible party had emailed the previous administrator about this event as well, but no report was filed until months later, when the current Administrator became aware that the prior incident had never been reported. The facility’s abuse policy required that all alleged violations reported by residents, relatives, or care plan members be immediately reported to the Administrator and to the Department of Health within specified time frames (2 hours for alleged abuse and no later than 24 hours for all other allegations). The Administrator acknowledged awareness of the allegations from September and October and stated he had assumed the previous administrator had reported them, but they had not been reported in accordance with the policy and regulatory requirements.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation policy after an allegation of abuse involving a cognitively impaired resident. Resident C had diagnoses including Alzheimer’s disease, dementia, seizures, weakness, and depression, and required substantial assistance with most activities of daily living. Her care plan documented a preference for video recording in her room and a STOP sign across the door frame, with interventions to protect privacy. On one reported incident date, a male resident entered her room and sat on her bed; the facility’s incident report documented that Resident C reported no physical contact and that a head‑to‑toe assessment showed no findings. However, Resident C’s responsible party later provided an email describing an earlier incident captured on family-installed room cameras in which the same male resident entered Resident C’s room while she was asleep, attempted to sit on the bed, opened and closed his robe, and then sat in a chair. The email further described that the male resident then moved back to the bed, sat on the bed, and then sat directly on Resident C’s chest and left shoulder, causing her to groan and call out in pain, before he sat on the floor next to the bed and fell asleep until staff found him and escorted him out. This allegation was reported by the responsible party to the previous Administrator via email as a follow-up to an incident she had already reported. The current Administrator later acknowledged awareness of this abuse allegation and that a thorough investigation had not been completed by the previous Administrator. The facility’s written policy required that all alleged violations reported by residents or relatives be immediately reported to the Administrator and the Department of Health and that, once notified, an investigation of the alleged violation be conducted. Surveyors determined that the facility failed to implement this policy by not conducting a thorough investigation into the abuse allegation involving Resident C.
Failure to Provide Scheduled Showers and Document Bathing Care
Penalty
Summary
The facility failed to provide scheduled showers and assistance with activities of daily living for two residents who required substantial assistance with bathing. One resident with diagnoses including intertrochanteric fracture of the right femur, cerebral palsy, and bipolar disorder was cognitively intact and care planned to receive showers twice weekly, on Tuesdays and Fridays, with the goal of having daily care needs met. From admission through discharge, this resident received only three documented showers despite the schedule, and there was no documentation in the medical record of any shower refusals. The resident’s wife reported she had raised concerns with the facility about missed showers and was told the resident had signed refusal documentation, but she stated he would not have continued to request showers if he had refused them. She further reported that the social worker attempted to convince the resident he had signed refusal paperwork, but the alleged refusal documentation could not be located. The Interim Director of Nursing later indicated that shower sheets were not used during the relevant month and that showers and refusals should have been documented in the medical record and nursing progress notes. Another cognitively intact resident with diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hypertrophy, cerebrovascular accident, and anxiety disorder was also care planned to receive showers twice weekly on second shift, on Tuesdays and Fridays, with a goal of having daily care needs met. This resident reported he was supposed to receive showers on that schedule but had not had a shower in a while, stating that when he requested a shower, staff responded that they would provide one “if we can fit you in,” and that he had gone weeks without a shower. He also reported that the Director of Nursing asked if he had been refusing showers and that he refused to sign a shower sheet because he had not refused. Record review showed only one documented shower during the review period, with several shower sheets completed but no documentation of any refusals in the medical record. An LPN stated that residents should receive showers twice weekly and that refusals should be documented with a resident signature on a shower sheet and in nursing progress notes. The facility’s shower policy stated that residents would be provided showers per request or facility schedule protocols and based on resident safety.
Failure to Follow Medication Orders and Arrange Specialist Consultation
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for medication administration for one resident and to schedule a specialized physician appointment for another resident. For Resident C, who had diagnoses including exocrine pancreatic insufficiency, cerebral palsy, and type 2 diabetes mellitus and was cognitively intact, hospital discharge instructions ordered pancrelipase (Creon) 36,000 units three times daily with meals and snacks. A physician’s order dated 8/29/2025 directed Creon 36,000–114,000 units one capsule three times daily for exocrine pancreatic insufficiency, but the MAR for late August and early September showed the medication was administered at 6:00 A.M., 2:00 P.M., and 6:00 P.M., which were outside the facility’s scheduled mealtimes. The MAR also showed multiple missed doses on specific dates and times, with no evidence that the physician or nurse practitioner was notified of these missed administrations. A care plan conference note documented that the family had concerns about ensuring the resident received medications before every meal. Additionally, a physician’s order for metoprolol succinate ER 25 mg daily included parameters to hold the medication for systolic blood pressure less than 100 mmHg and heart rate less than 60 bpm, yet the MAR showed the medication was administered on two dates when the resident’s heart rate was below 60 bpm. For Resident E, who had diagnoses including trigeminal neuralgia and multiple sclerosis and was cognitively intact, the facility failed to ensure a neurological consultation was scheduled as ordered. A physician’s order dated 8/10/2025 directed that a neurological consultation be scheduled. The resident reported having asked staff for over two months to make an appointment with her neurologist due to new symptoms related to multiple sclerosis, and she stated the facility would not make the appointment. A grievance form submitted by the resident on 10/9/2025 requested an appointment with a neurologist and noted a previous request without follow-up; the grievance response stated an appointment had been made, but there was no evidence an appointment was actually scheduled. A nurse practitioner’s note documented that the resident was experiencing uncontrollable trigeminal neuralgia, was screaming out in pain especially in the evenings, had requested to return to her neurologist, and that a referral had already been ordered and the facility was working on setting up the appointment. The transportation director later reported that all outside appointments were to be scheduled through her, that she had not transported this resident to any appointments, and that she had not scheduled any appointments for the resident.
Failure to Monitor Foley Catheter Output and Respond to Catheter-Related Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and care of an indwelling urinary catheter for one resident. The resident had diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hypertrophy, cerebrovascular accident, and anxiety disorder, and had a chronic Foley catheter with substantial assistance needed for toileting and hygiene. A physician’s order had directed staff to monitor urinary catheter output every shift, but this order was discontinued in mid-December, and nursing staff did not continue to obtain or document urinary outputs each shift. An LPN later indicated it was unclear why the order had been discontinued and why staff had not monitored urinary output as expected. The facility’s own catheter policy required ongoing care, monitoring of the resident’s response to catheter use, and monitoring for changes in condition related to potential catheter-associated UTIs. In the days following discontinuation of the urinary output order, nursing notes documented that the resident complained of penile pain, with pus coming from the head of the penis, and requested removal of the Foley catheter. Staff documented severe pain throughout the evening, treated with Tylenol and lubricant applied to the penis. The next day, the Foley catheter was changed and a urine sample was obtained via clean catch through the new catheter. The following day, the resident was found with an elevated temperature, shaking, gray discoloration of hands and lips, pain with the Foley catheter, and white drainage from the penis around the catheter, leading to a verbal order to send him to the hospital. In the emergency room, the Foley catheter was found displaced with the balloon in the penile shaft, and the resident was diagnosed with a UTI and early sepsis with borderline shock related to a UTI due to the displaced Foley catheter. The resident and his sister reported that the catheter had been dislodged or incorrectly placed, with bloody and purulent urine in the tubing and another catheter being inserted, and that he had recently been hospitalized for sepsis.
Failure to Document and Complete Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that catheter care and documentation of urinary output were completed as ordered for three residents with indwelling catheters. For one resident with obstructive and reflux uropathy, physician orders required catheter care and output documentation every shift, but review of the Medication Administration Record (MAR) revealed multiple shifts across three months with missing documentation. Nursing notes confirmed the resident experienced urinary tract infections during this period, and there was no additional documentation to verify catheter care or output. Another resident with neuromuscular dysfunction of the bladder also had orders for output documentation every shift, but the MAR showed several shifts without documentation, and no other records were available. A third resident with similar diagnoses had orders for catheter care and output documentation every shift, but the MAR again showed multiple shifts with missing entries and no other supporting documentation. Interviews with staff, including a unit manager, RN, and the DON, confirmed that there was no other documentation available to verify that catheter care or output documentation was completed as ordered for these residents. The RN and DON both stated that catheter care was performed each shift and that output was documented on the MAR, but acknowledged that when documentation was missing, there was no way to confirm the care was provided. Family and resident interviews also indicated concerns about catheter care and a history of urinary tract infections. Facility policy required catheter care to be completed as ordered to prevent infection, but the lack of documentation indicated noncompliance with these requirements.
Sanitation Deficiencies in Kitchen Affecting Food Safety
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 101 residents receiving food from this kitchen. During a kitchen tour, it was observed that several food items in the walk-in freezer, including bags of green beans, corn, sausage patties, and eggs, were not sealed appropriately. Additionally, a bag of cream soup base in the dry storage area was found without an open date. The Dietician confirmed that these items should have been sealed properly and labeled with an open date. Further inspection revealed unsanitary conditions with kitchen equipment and utensils. A can opener, spatula, measuring cup, knife, and measuring spoon, all stored as clean, were found with dried food and grease on them. The utensils drawer also had dried food on the bottom. The Dietary Manager acknowledged that the kitchen utensils and drawer should have been cleaned. The facility's policies on kitchen sanitation and labeling and dating guidelines were provided, indicating that the Dietary Manager is responsible for ensuring safe food handling practices and regular inspections.
Infection Control and Reporting Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices, particularly in the use of gloves and handwashing during perineal and catheter care for several residents. Certified Nursing Assistants (CNAs) were observed not changing gloves or washing hands between tasks, such as after cleaning a resident's perineal area and before applying a clean brief. This was noted during care for multiple residents, including those with catheters and nephrostomy tubes, where CNAs continued to handle clean items and resident belongings without changing gloves or performing hand hygiene. Additionally, the facility did not follow its policy on Enhanced Barrier Precautions (EBP) for residents with wounds and catheters. Observations revealed that residents who required EBP were not placed in isolation, and there was a lack of signage and personal protective equipment (PPE) to indicate EBP status. This was evident in the care of residents with pressure ulcers and other wounds, where staff failed to use appropriate PPE or follow isolation protocols. The facility also neglected to report an outbreak of illness to the State Department of Health. Despite multiple residents experiencing symptoms such as nausea, vomiting, and diarrhea, the cases were not reported as required. The facility's infection surveillance report was incomplete, missing several affected residents. Furthermore, during medication administration, a Registered Nurse (RN) was observed handling medication without gloves, contrary to the facility's policy. These deficiencies potentially impacted all residents in the facility.
Failure to Notify Physician of Abnormal Conditions
Penalty
Summary
The facility failed to notify the physician of abnormal blood sugar levels and insulin refusals for two residents with diabetes. Resident 4 had multiple instances of blood glucose levels exceeding 400 mg/dl, as per the physician's order, but there was no documentation indicating that the physician was notified. Interviews with the RN and the Administrator confirmed the lack of documentation regarding the elevated blood glucose levels. Resident 5 had new skin issues that were not documented or reported to the physician. The resident's family noticed discoloration on the resident's arm, but there was no explanation provided. An LPN was unaware of the skin issues, and the facility's records lacked documentation of the abnormal skin findings. The Director of Nursing acknowledged that a new skin evaluation should have been completed and the physician notified, but this was not done. Resident 96, who had multiple health conditions including diabetes, refused insulin medication numerous times over several months. The facility's records did not show that the physician or nurse practitioner was notified of these refusals, despite the resident's care plan indicating that the physician should be notified as needed. Interviews with facility staff revealed that there was no documentation of communication with the physician regarding the resident's refusals, and the Director of Nursing confirmed that a conversation with the physician should have occurred due to the excessive refusals.
Inadequate Response to Resident Grievances on Call Light and Shower Issues
Penalty
Summary
The facility failed to adequately address grievances raised by residents regarding long call light response times and incomplete shower schedules. During a resident/surveyor meeting, several residents expressed that their grievances, although acknowledged, remained unresolved. Residents reported that call lights were not illuminating outside their rooms, and alternative methods such as bells and whistles were provided, which were ineffective. Some residents, including one who was left on the toilet for 30-45 minutes, indicated that the best way to receive assistance was to physically find a staff member. The review of Resident Council Meeting Notes from February to December 2024 revealed ongoing concerns about call light response times and shower schedules. Despite documented responses and attempts to address these issues, such as hiring a shower aide and revamping shower schedules, residents continued to report inconsistencies and unresolved grievances. The facility's responses often lacked follow-through, and some responses were undated or not provided at all. Additionally, the facility failed to provide residents with accessible and anonymous grievance forms. Residents were unaware of where to find these forms, and they were not placed in a location that allowed for anonymous submission. Interviews with facility staff revealed that grievance forms were kept in locations not easily accessible to residents, particularly those who were wheelchair-bound. The facility's grievance policy outlined the need for a grievance official to oversee the process, but the implementation of this policy was inadequate, leading to unresolved grievances and dissatisfaction among residents.
Failure to Update PASARR Assessment for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Level One PASARR assessment was completed accurately for a resident and did not update the Level 1 review when there was a significant change in the resident's condition. The resident, who had diagnoses including depression, anxiety, PTSD, and dementia, was given a new diagnosis of psychotic disorder with delusions. Despite this change and the addition of antipsychotic medications such as Haloperidol, the facility did not conduct a new Level 1 PASARR assessment as required. The initial PASARR form from 2020 did not reflect the resident's current mental health status or medications accurately, as it only listed Ativan and Trazadone, omitting the newly prescribed antipsychotic medications. The facility's policy mandates that any resident exhibiting a newly evident or possible serious mental disorder should be referred for a Level II resident review. However, this was not done, as confirmed by the Social Service Staff during an interview, who acknowledged that another Level 1 should have been completed following the new mental health diagnosis and medication orders.
Failure to Implement Timely Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement timely preventative measures to prevent the development of pressure ulcers for a resident, identified as Resident 96. The resident had multiple diagnoses, including diabetes mellitus type 2, chronic kidney disease, and legal blindness, which increased her risk for skin breakdown. Despite a Braden Scale assessment indicating a risk for pressure sores, no further assessments were documented after June 2024. The care plan for Resident 96 included interventions such as turning and repositioning, use of a prevalon boot, and skin inspections, but there was no documentation of these interventions being consistently implemented. Resident 96 developed an unstageable pressure ulcer on her right heel, which was later classified as a stage 3 pressure ulcer. The wound nurse practitioner recommended pressure reduction and turning protocols, including floating the resident's heels, but there was no documentation that these recommendations were followed. Additionally, the facility did not document any new interventions when the sore was first identified, and there was a delay in obtaining the recommended prevalon boot for the resident. Interviews with facility staff revealed that the resident had not been provided with the necessary prevalon boots until weeks after the wound clinic's recommendation. The facility's wound management policy stated that residents should not develop new skin conditions and that interventions should be implemented timely, but this was not adhered to in the case of Resident 96. The lack of timely and appropriate interventions contributed to the development and progression of the pressure ulcer.
Failure to Provide Nephrostomy Dressing Changes
Penalty
Summary
The facility failed to provide appropriate nephrostomy dressing changes for a resident, identified as Resident G, who was reviewed for catheter care. Resident G, who was cognitively intact and had an indwelling catheter, reported that her nephrostomy dressings had not been changed for some time, and a new dressing was only recently applied. She also mentioned that the staff seemed unfamiliar with the correct application of the dressings. A review of her medical records revealed diagnoses including nephrostomy, obstructive and reflexive uropathy, overactive bladder, and carcinoma of the bladder. Despite a physician's order to monitor the nephrostomy tube sites every shift, there were no specific orders for routine dressing changes to the nephrostomy sites or the stopcock dressings. Observations confirmed that Resident G's nephrostomy tube sites had undated padded dressings, which were dirty and had excessive zinc oxide ointment with darkened edges. A CNA had changed the dressings after they had fallen off, but there was no physician's order specifying the frequency of dressing changes. An RN confirmed that nephrostomy tube dressings should be changed daily and that there should have been a physician's order for the dressing changes. The facility's policy indicated that care and maintenance of nephrostomy tubes should be in accordance with physician orders, which were lacking in this case.
Failure to Schedule Timely Specialty Appointments for Residents
Penalty
Summary
The facility failed to ensure timely follow-up specialty appointments and referrals for two residents, leading to a deficiency in providing medically-related social services. Resident G, who had a history of cervical cancer, was in need of a gynecological oncology appointment after a hospital ultrasound revealed a 3-centimeter mass in her uterus. Despite a physician's order to schedule the appointment as soon as possible, the facility delayed securing the appointment for over eleven weeks. The resident expressed distress over the delay, and the facility's attempts to schedule the appointment were hindered by miscommunication and the resident's preference for a specific office. Similarly, Resident 64, who had multiple diagnoses including chronic kidney disease and anemia, did not have specialty referrals scheduled in a timely manner. Physician's orders were issued for referrals to hematology, vascular surgery, and nephrology, but there was no documentation in the medical record indicating that these appointments were scheduled. The facility staff indicated that some referrals were still being processed, and there was confusion regarding the resident's refusal to attend appointments. The facility's policy on change in condition and physician notification was not effectively followed, contributing to the deficiency.
Lack of Documentation for Gradual Dose Reduction Contraindications
Penalty
Summary
The facility failed to ensure that the physician documented a clinical contraindication when a gradual dose reduction (GDR) was declined for two residents reviewed for unnecessary medications. Resident 18, who had diagnoses including renal insufficiency, diabetes, depression, anxiety, dementia, and PTSD, was receiving Haloperidol and Trazadone. Despite pharmacy recommendations to reduce the dosages, the facility did not provide a clinical rationale for why the GDR was contraindicated. The documentation merely noted that the GDR was addressed with a nurse practitioner and marked as contraindicated due to hospice care, without further explanation. Similarly, for Resident 101, who had diagnoses of anxiety and depression, the facility did not document a clinical rationale for continuing the use of Alprazolam PRN beyond the recommended short-term use. Pharmacy recommendations suggested evaluating the continued need for the medication and adding a stop date for short-term use. However, the facility's response was to continue the medication without providing a documented clinical rationale for this decision. During an interview, the Director of Nursing acknowledged the lack of documentation to support a medical contraindication for the GDR recommendations. The facility's policy on unnecessary drugs emphasized the need for ongoing review of each resident's drug regimen, considering factors such as dose, duration, and clinical need. However, the facility did not adhere to this policy, as evidenced by the lack of documentation supporting the decisions to decline GDRs for the residents involved.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices, as observed during a survey. On the 100 hall medication cart, several issues were identified, including a bottle of Latanoprost eye drops without a resident identifier, an opened and unlabeled bottle of Timolol eye drops, an opened bottle of Lactulose with no opened date, and four loose pills in two drawers. During an interview, a Qualified Medication Aide (QMA) acknowledged that medications should have an opened date, eye drops should be labeled, and loose pills should not be present in the cart. On the 200 hall middle medication cart, further deficiencies were noted, such as the improper storage of topical creams with oral medications. Items found included four tubes of diclofenac sodium 1% stored with oral medications, a tube of triad wound paste, three tubes of Mupirocin ointment, a tube of nystatin ointment, and a tube of polygrip denture adhesive without a resident identifier. Additionally, an opened bottle of eye drops had a label over the drug name with no resident identifiers. An LPN confirmed that treatments and topical cream medications should not be stored in the medication cart. The facility's policy on medication storage was provided, but a policy regarding labeling medications was not available before the survey concluded.
Failure to Complete Timely Laboratory Testing for a Resident
Penalty
Summary
The facility failed to complete laboratory testing as ordered by the physician for a resident with multiple health conditions, including diabetes mellitus type 2, chronic kidney disease, and a stage 3 pressure ulcer. The resident's care plan required regular monitoring and laboratory tests, such as a Hemoglobin A1c every three months and specific tests ordered by a wound center. However, the facility did not document the completion of the A1c test due on November 18, 2024, and there were delays in conducting the C-reactive protein and erythrocyte sedimentation rate tests ordered by the wound center. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that the laboratory orders were not executed in a timely manner, despite being entered into the electronic system. The lab was scheduled to visit the facility three times a week, yet the tests were not completed as required. The facility's policy on change in condition and physician notification was provided, indicating the need for prompt action and communication regarding changes in resident conditions, but this was not adhered to in the case of the resident's laboratory testing needs.
Failure to Provide Adequate Bathing and Oral Care
Penalty
Summary
The facility failed to provide adequate bathing opportunities and oral care for two residents who were dependent on staff for assistance with Activities of Daily Living (ADL). Resident B, who has a diagnosis of neurogenic bladder, end-stage renal disease, spinal injury, and quadriplegia, was observed with greasy hair and a white film on his teeth. He reported not receiving showers on his scheduled days and having difficulty shaving due to his condition. The care plan indicated he required substantial assistance with bathing and oral hygiene, but records showed inconsistencies in the provision of these services. Resident G, diagnosed with cervical spina bifida and neuromuscular dysfunction of the bladder, also reported not receiving showers on her preferred days, which were important for her social activities. Despite her care plan specifying assistance with ADLs and a shower schedule, records indicated she did not receive showers on the specified days. The Resident Council had previously raised concerns about the shower schedule, but the issue persisted. The facility's policy on ADLs stated that necessary services would be provided to maintain personal hygiene, which was not adhered to in these cases.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident identified as being at high risk for falls. The resident, who had diagnoses including Alzheimer's Disease, dementia, anxiety, and depression, was observed seated in a wheelchair without the prescribed non-slip pad (dycem) that was intended to prevent sliding. Despite a care plan initiated due to the resident's history of falls and impaired cognition, the intervention to place a dycem on the wheelchair cushion was not followed. This oversight was noted during an observation when the resident was found without the dycem on her wheelchair, which was a critical intervention to prevent falls. The resident had previously experienced falls, including an incident where she slid off her wheelchair in the activity room, prompting the interdisciplinary team to update her care plan with the dycem intervention. However, the failure to implement this intervention was evident when the resident was found on the floor after sliding off her wheelchair again. The resident's family expressed concern over the repeated falls, questioning why the incidents continued to occur. The facility's policy on incidents, accidents, and supervision emphasized the need for adequate supervision and assistive devices to prevent accidents, which was not adhered to in this case.
Deficiencies in Urinary Catheter Management and Documentation
Penalty
Summary
The facility failed to ensure proper management of urinary catheters for three residents, leading to deficiencies in catheter care and documentation of urine output. Resident B was observed multiple times with a full Foley catheter collection meter and a partially filled collection bag, indicating that staff had not emptied the catheter as required. Despite the care plan's directive to document catheter output every shift, the Treatment Administration Records (TARs) for October and November showed no documentation of urine output. Resident B, who has a neurogenic bladder, End Stage Renal Disease, spinal injury, and quadriplegia, reported that staff rarely emptied the catheter. Resident G expressed concerns about the infrequent emptying of her Foley catheter, which was observed with significant urine accumulation. The TAR for Resident G showed multiple instances of undocumented catheter output, despite the care plan's requirement for documentation every shift. Similarly, Resident E's TARs for October and November lacked any documentation of urinary catheter output. The facility's policy on indwelling catheters, which mandates appropriate care in line with professional standards, was not adhered to, resulting in these deficiencies.
Failure to Follow Bowel Protocol for Resident
Penalty
Summary
The facility failed to follow the bowel protocol for a resident, identified as Resident B, who was under review for bowel movements. Resident B had a history of right femur fracture, cardiomyopathy, and chronic kidney disease. After being hospitalized for fractures and receiving narcotic pain medication, which can cause constipation, Resident B was discharged with orders for Docusate Sodium 100 mg daily for constipation. However, upon admission to the facility, the medication was not administered as per the physician's orders. The resident had not had a bowel movement for seven days while hospitalized and continued to experience constipation upon admission to the facility. Interviews revealed that the facility did not input some of Resident B's physician's orders into the Electronic Medical Record (EMR) on the day of admission, leading to a delay in medication administration. The Assistant Director of Nursing acknowledged that the facility's bowel movement protocol should have been initiated when Resident B did not have a bowel movement for three days, but it was not. Additionally, a 3-day Voiding and Elimination Pattern assessment, which was part of the facility's policy, was not completed. This oversight resulted in Resident B experiencing significant discomfort due to constipation.
Failure to Prevent Pressure Wound Development
Penalty
Summary
The facility failed to provide timely care and treatment to prevent the development of a pressure wound for Resident B, who was admitted with a right femur fracture, cardiomyopathy, and chronic kidney disease. Upon admission, Resident B was assessed as severely cognitively impaired, requiring extensive assistance for bed mobility, transfers, and toilet use, and was at risk for skin breakdown. Despite these risks, the facility did not complete a skin assessment upon admission, and there was no documentation of any pressure wounds at that time. However, a subsequent assessment by a Nurse Practitioner on 7/22/24 revealed a Stage 1 pressure wound on Resident B's right buttock, which was not identified by the hospital at discharge. The facility's failure to implement timely interventions, such as the use of a pressure-reducing mattress, contributed to the development of the pressure wound. The Administrator acknowledged that some of Resident B's physician's orders were not entered into the Electronic Medical Record on the day of admission, causing a delay in care. Additionally, the Assistant Director of Nursing confirmed that a skin assessment should have been completed upon admission but was not, and there were no admission orders regarding a pressure wound. This oversight led to a delay in the initiation of appropriate preventive measures, such as the pressure-reducing mattress, which was ordered but not implemented in a timely manner.
Failure in Pain Management and Assessment for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management and conduct a pain assessment upon admission for Resident B, who had a history of severe cognitive impairment and required extensive assistance for daily activities. Resident B was admitted to the facility following a fall that resulted in multiple fractures, including a right femur fracture that required surgical repair. Despite hospital discharge orders for pain management with Hydrocodone-Acetaminophen and Morphine Sulfate, Resident B did not receive any pain medication until over 16 hours after his last dose at the hospital. During this time, Resident B experienced severe pain, rated at a 10 on a scale of 1 to 10, and his responsible party reported that the facility staff did not administer pain medication because it had not yet been delivered from the pharmacy. The delay in pain management was attributed to the facility's failure to enter Resident B's physician's orders into the Electronic Medical Record (EMR) on the day of admission, which also affected other treatments such as wound care. The facility had a system (Pyxis) that could have provided the necessary medications, but it was not utilized. Additionally, a pain assessment was not completed upon Resident B's admission, contrary to the facility's policy that required evaluation for pain and its causes upon admission. Interviews with the Administrator and Assistant Director of Nursing confirmed these oversights, and the facility's policies on pain management and pharmacy services were not adhered to, leading to Resident B's prolonged period of unmanaged pain.
Failure to Accommodate Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident C, who was cognitively intact and had specific preferences for showering on Mondays, Thursdays, and Saturdays during the day shift. Despite these preferences being documented in her care plan, the facility altered her shower schedule to Tuesdays and Thursdays, and informed her that she was not eligible for a Saturday shower if she had one on Thursday. This change in schedule resulted in Resident C missing 11 out of 26 scheduled showers over a period from July 1 to August 13, 2024, with no documentation of refusals. The lack of adherence to her preferred shower schedule affected her ability to participate in social activities, such as attending Sunday worship services, due to feeling unkempt. Resident C's clinical record indicated she required substantial to maximal assistance for showering due to her medical conditions, which included spina bifida, chronic respiratory failure, paraplegia, and obstructive and reflux uropathy. The facility's failure to provide showers as per her preference was also highlighted in Resident Council Minutes from July and August 2024, where residents expressed concerns about not receiving scheduled showers. The facility's policy on resident showers and rights emphasized the importance of maintaining proper hygiene and respecting residents' preferences, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Urostomy Care
Penalty
Summary
The facility failed to develop a comprehensive and person-centered care plan for a resident requiring urostomy care. During an observation and interview, it was noted that the resident's urostomy bag was not being emptied regularly, as indicated by the resident. The resident's medical record review revealed diagnoses including spina bifida, chronic respiratory failure, paraplegia, and obstructive and reflux uropathy. The resident was cognitively intact and required substantial to maximal assistance for most activities of daily living, including the management of a urostomy. However, the care plan lacked specific interventions related to urostomy care, management, or monitoring, despite a physician's order to empty the urostomy bag every shift. The facility's policy on comprehensive care plans and ostomy care required the inclusion of measurable objectives and timeframes to meet the resident's needs, including the frequency of pouch changes and monitoring of the surrounding skin for any issues. Despite these policies, the care plan for the resident did not reflect these requirements, leading to a deficiency in providing adequate and person-centered care for the resident's urostomy needs. The facility's failure to adhere to its policies and ensure a comprehensive care plan was in place was identified during a complaint investigation.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers and bathing opportunities for six residents, leading to a deficiency in resident rights. Resident B, who has a history of stroke and requires substantial assistance, missed 14 out of 21 scheduled showers. Despite documented refusals on some dates, the majority of missed showers were not accounted for, indicating a failure in adhering to the resident's care plan. Resident C, who is cognitively intact and has conditions such as spina bifida and paraplegia, expressed dissatisfaction with the change in her shower schedule, which affected her social activities. She missed 11 out of 26 scheduled showers, with no refusals documented, highlighting a lack of compliance with her care plan and personal preferences. Similarly, Resident D, who also has spina bifida and paraplegia, missed 7 out of 12 scheduled showers, with no refusals documented, further demonstrating the facility's failure to meet scheduled care requirements. Other residents, including Residents J, K, and M, also experienced missed showers, with no refusals documented, indicating a systemic issue within the facility. The Resident Council minutes from July and August noted complaints about the lack of showers, and the facility's policy on resident showers was not being followed. The Assistant Director of Nursing and the Administrator acknowledged the issue, but the deficiency remained unaddressed at the time of the report.
Failure in Urostomy Care and Monitoring
Penalty
Summary
The facility failed to ensure proper urostomy care and monitoring for a resident, identified as Resident C, who required such services. During an observation, it was noted that Resident C's urostomy bag was not being emptied regularly, as indicated by the resident herself. The urostomy bag was connected to a catheter bag that was observed to be holding 600 CCs of urine, and the resident reported that her catheter bag was often not emptied during the day shift. The facility's administrator acknowledged that the urostomy orders were not entered into the Electronic Medical Records (EMR) system following the hiring of a new medical director, which contributed to the oversight in care. Resident C's medical records revealed a lack of documentation regarding the emptying of the urostomy bag from the time the new orders were supposed to be in place. The resident's diagnoses included spina bifida, chronic respiratory failure, paraplegia, and obstructive and reflux uropathy, and she required substantial assistance for daily activities. Despite a physician's order to empty the urostomy bag every shift, there was no evidence of compliance with this order. The facility's policy on ostomy care, which was supposed to ensure care consistent with professional standards, was not adhered to, leading to the deficiency noted in the report.
Failure to Follow Up on UTI Symptoms in Residents
Penalty
Summary
The facility failed to complete follow-up assessments for changes in condition related to urinary tract infections (UTIs) for three residents. Resident B, who had diagnoses including acute cystitis with hematuria and chronic kidney disease, was discharged to the hospital due to hematuria and a UTI. Despite being readmitted, the record lacked follow-up of symptoms between 6/21/2024 and 6/26/2024, when the resident was symptomatic with hematuria and sent to the emergency room. The care plan for Resident B included interventions such as administering medication, observing for adverse side effects, and documenting abnormal findings, but these were not adequately followed. Resident D, with diagnoses including type 2 diabetes mellitus and overactive bladder, showed increased confusion and refused medication. Despite receiving antibiotics, the record lacked follow-up assessments between 6/18/2024 and 6/22/2024. The care plan for Resident D also included similar interventions to Resident B, such as administering medication and observing for symptoms of infection, but these were not properly documented or executed. Resident E, who had multiple rib fractures and a UTI, experienced confusion and unwitnessed falls. Although a urine specimen was obtained on 7/18/2024, the antibiotic was not ordered until 7/23/2024, and there was a lack of clear documentation of the resident's symptoms between these dates. The care plan for Resident E included interventions like administering medication and observing for symptoms of infection, but these were not adequately documented. The facility's policy on change in condition did not address follow-up assessments, contributing to the deficiency.
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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