Mitchell Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Mitchell, Indiana.
- Location
- 24 Teke Burton Dr, Mitchell, Indiana 47446
- CMS Provider Number
- 155324
- Inspections on file
- 32
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Mitchell Manor during CMS and state inspections, most recent first.
Strong urine odor in Hallway B. Surveyors repeatedly observed a noticeable urine smell at the beginning of and down Hallway B, including near the entrance where multiple residents were sitting in the hall. CNA 1 and CNA 2 both confirmed the odor, and the DON acknowledged the facility was aware of the strong smell at the entrance of Hallway B and cited the facility policy that residents have the right to a clean and comfortable environment.
Inaccurate MDS coding affected two residents. One resident’s PASARR Level II status was coded inconsistently with the record, and another resident’s MDS failed to code an antidepressant on Item N0415 even though the resident was receiving Trazodone for insomnia and had diagnoses including schizoaffective disorder, major depressive disorder, and anxiety.
A resident who smoked and had COPD, paranoid schizophrenia, and mild neurocognitive disorder was observed smoking during designated smoking times with staff supervision, but the clinical record lacked a smoking care plan. The MDS and progress notes identified the resident as a smoker, and the DON confirmed that a smoking assessment and individualized smoking care plan should have been completed for the resident.
A Business Office Manager misappropriated resident funds by making unauthorized withdrawals and transferring money between resident accounts without proper documentation or authorization. Multiple residents were affected, with funds missing or moved to cover up cash payments that were not deposited. Audits revealed numerous undocumented transactions, and the misappropriation was confirmed through interviews and record reviews.
A resident with a history of behavioral and medical issues became verbally aggressive after a change in pain medication. During the incident, an LPN who was not assigned to the resident engaged in a verbal altercation, exchanging profanities and inappropriate remarks with the resident. The staff did not follow the resident's care plan interventions for de-escalation, resulting in a failure to protect the resident from verbal abuse.
A resident with multiple complex medical conditions experienced significant, unaddressed weight loss due to inconsistent monitoring, gaps in documentation, and delays in implementing dietary interventions. Despite being at risk for nutritional problems, the resident's fluctuating weights were not consistently verified or acted upon, and staff interviews revealed a lack of awareness regarding the weight loss. The facility did not follow its own policy for monitoring new admissions, resulting in prolonged periods without appropriate nutritional support.
A resident with COPD and depression was left unattended in a facility van for about 15 minutes while the transportation staff exited to deliver lunch to his wife at a hospital. The van's air conditioning was off and the window was rolled down. The resident eventually left the vehicle to seek help, and a hospital security guard assisted until the staff returned. The incident was not documented in the clinical record and was reported by the resident over a week later, indicating a failure to provide adequate supervision during transport.
The facility failed to maintain a homelike environment, with worn and stained carpets in multiple hallways affecting all residents. Additionally, signs with private information were found in two residents' rooms, indicating a lack of privacy and comfort. The DON acknowledged the need for carpet replacement and sign removal.
A facility failed to complete the Discharge MDS assessment within the required timeframe for a resident with Alzheimer's, anxiety, and major depressive disorder. The resident was discharged to another facility, but the Discharge MDS was not completed, with the last assessment being a Quarterly MDS. The MDS nurse confirmed the oversight and noted the lack of a resident assessment policy, relying on RAI tool criteria for timeframes.
The facility failed to accurately assess active diagnoses for two residents. One resident's MDS assessment did not reflect a recent UTI diagnosis, despite lab results and treatment indicating otherwise. Another resident's assessment failed to mark bipolar disorder as active, despite an active medication order for the condition. The MDS nurse confirmed these oversights, noting the absence of a formal MDS policy.
The facility failed to document the shower preferences of two residents in their care plans. One resident preferred showers on specific days, while another preferred evening showers. Despite these preferences being noted in their ADL forms, they were not updated in the care plans, as confirmed by the MDS nurse and DON. The facility's policy requires care plans to be developed within seven days after the comprehensive assessment, which was not followed.
Strong urine odor in Hallway B
Penalty
Summary
The facility failed to provide a safe and sanitary environment in Hallway B, where a strong urine odor was repeatedly observed during the survey. On 4/27/26, 4/28/26, 4/29/26, 4/30/26, and 5/1/26, surveyors noted a strong urine smell at the beginning of or down Hallway B, including at the entrance where multiple residents were observed sitting in the hall. During interviews, CNA 1 and CNA 2 both acknowledged a noticeable urine odor in Hallway B, and the DON stated the facility was aware of a strong odor at the entrance of Hallway B and confirmed the facility policy that all residents have the right to a clean and comfortable environment.
Inaccurate MDS Coding for PASARR Status and Antidepressant Use
Penalty
Summary
The facility failed to ensure the accuracy of the MDS assessment for 2 of 24 residents reviewed for MDS accuracy. For Resident 64, the clinical record showed diagnoses including anxiety and bipolar disorder, and a PASARR dated 5/8/23 indicated a Level II screening. However, the annual MDS assessment dated 1/30/26 stated the resident was not currently considered by the State to have a Level II PASARR screening, which was inconsistent with the PASARR information in the record. For Resident 9, the clinical record included diagnoses of schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. A physician order dated 6/26/25 showed Trazodone HCl 25 mg by mouth at bedtime for insomnia, but the quarterly MDS assessment dated 2/18/26 did not indicate the resident received an antidepressant medication on Item N0415. The RAI Manual stated medications are to be coded in Item N0415 according to therapeutic category and/or pharmacological classification, and the MDS Coordinator acknowledged the resident was taking an antidepressant at the time of the assessment and that Item N0415C1 should have been coded yes.
Missing Smoking Care Plan for Resident Who Smoked
Penalty
Summary
The facility failed to ensure a comprehensive plan of care was created for a resident who was a smoker, and failed to ensure appropriate supervision and interventions were in place to prevent the potential for accidents for 1 of 4 residents reviewed for accidents. Resident 55 was observed smoking during the designated smoking time with staff supervision on 4/28/26, 4/29/26, and 4/30/26. The resident’s record showed diagnoses of COPD, paranoid schizophrenia, and mild neurocognitive disorder. The admission MDS dated 10/20/25 indicated the resident was a smoker, and progress notes showed the resident was a smoker on admission and continued to smoke through the present. The resident’s clinical record lacked a care plan for smoking. During interview, the resident confirmed he was a current smoker and had smoked since admission. The DON stated that a smoking assessment should be completed on admission and quarterly for each resident who smokes, and that any resident who smokes should have a care plan implemented on admission. The DON also confirmed there was no smoking-related care plan for Resident 55. Facility policy required that all residents who smoke have a smoking assessment completed with appropriate care plan interventions documented, and that the IDT develop an individualized smoking care plan including smoking safety/assistance and education of the smoking policy and level of understanding.
Misappropriation of Resident Funds by Business Office Manager
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically resident funds, as evidenced by unauthorized withdrawals and transfers between resident accounts. The Business Office Manager (BOM) was responsible for managing the Resident Funds Management System (RFMS), which maintained individual accounts for each resident. An incident was discovered when the Administrator identified discrepancies in the resident trust account, prompting an internal investigation. The investigation revealed that the BOM had made unauthorized withdrawals from the accounts of seven residents and transferred these funds into the accounts of other residents without proper authorization or documentation. Audit records showed multiple instances where funds were withdrawn from specific residents and deposited into other residents' accounts, with amounts and batch numbers detailed in the audit sheet. Additionally, the audit of the RFMS Petty Cash fund indicated 100 transactions from February 2023 through September 2025 that lacked verification tickets or resident/resident representative signatures, all completed by the BOM. The Administrator and Regional Field Controller confirmed that the BOM had accepted cash payments from residents or their representatives but failed to deposit the cash into the trust account, instead covering the missing funds by moving money from other resident accounts. During interviews, the BOM admitted to taking resident money but did not provide full details or documentation regarding the missing funds. The Administrator and Regional Field Controller verified that the misappropriation occurred over an extended period, with the BOM manipulating accounts to conceal the missing funds. The facility's policy on abuse prevention, which prohibits misappropriation of resident property, was not followed in these instances, resulting in the substantiated deficiency.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with a history of multiple rib fractures, right tibia fracture, antisocial personality disorder, and seizures was subjected to verbal abuse by a staff member. The resident, who had been at the facility for four months, became agitated and verbally aggressive after a reduction in his pain medication. Multiple staff interviews confirmed that the resident was yelling and cursing at the nursing station, demanding to speak with management. During this episode, an LPN who was not assigned to the resident approached and engaged in a verbal altercation with him. Both the resident and the LPN exchanged profanities and inappropriate remarks, escalating the situation rather than de-escalating it as outlined in the resident's care plan. The care plan for the resident specifically included interventions for managing verbally aggressive behavior, such as analyzing triggers, allowing the resident to express feelings, and staff walking away if the resident became aggressive. However, these interventions were not followed during the incident. Instead, the LPN confronted the resident and participated in the exchange of abusive language. This failure to adhere to the care plan and facility policy resulted in the resident not being protected from verbal abuse by staff.
Failure to Monitor and Address Significant Weight Loss in a Resident
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and address the nutritional status of a resident with significant weight loss. The resident, who had multiple diagnoses including dementia, Parkinson's disease, chronic kidney disease, muscle weakness, and dysphagia, was identified as being at risk for nutritional problems. Despite this, there were inconsistencies and gaps in the documentation of the resident's weights, with several periods lacking recorded weights or care management notes. Notably, there were significant fluctuations in the resident's recorded weights, including a drop from 178 pounds to 166.9 pounds within a month, and later a drastic decrease to 103.6 pounds, with some weights suspected to be inaccurate but not verified or clarified in the record. The care plan and dietary notes indicated that the resident was to be monitored for weight changes and provided with appropriate dietary interventions. However, the clinical record lacked timely documentation of interventions in response to the resident's weight loss, such as the initiation of supplements or changes in diet. There were also delays in updating care plans and implementing interventions like health shakes and fortified foods, with orders for supplements not being entered into the electronic health record until much later, despite being dated earlier. The interdisciplinary team did not consistently document reassessment or adjustment of interventions in response to ongoing weight loss. Interviews with staff revealed a lack of awareness regarding the resident's weight loss, and the facility's policy for monitoring new admissions was not consistently followed. The resident required assistance with eating, but this need was not always reflected in the care documentation. The failure to consistently monitor, document, and intervene in the resident's nutritional status led to unaddressed and significant weight loss over several months.
Resident Left Unsupervised in Facility Van During Transport
Penalty
Summary
A deficiency occurred when a resident with diagnoses including chronic obstructive pulmonary disease and depression was left unsupervised in the facility transportation van during a scheduled doctor's appointment. The staff member responsible for transportation admitted to leaving the resident alone in the vehicle with the window rolled down while he delivered lunch to his wife at a nearby hospital. The van's air conditioning was turned off, and the resident remained unattended for approximately 15 minutes. During this time, the resident exited the vehicle and entered the hospital to locate the driver, where a security guard provided assistance until the driver returned. The clinical record lacked documentation of the incident, and the event was not reported by the resident until over a week later. The facility's policy on transportation coordination and services required adherence to safety procedures, but these were not followed in this instance. The average high temperature during the week of the incident was 90 degrees, and the resident was not available for interview during the survey period. The deficiency was identified through interviews and record review, revealing a failure to provide adequate supervision and ensure the area was free from accident hazards during resident transport.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents. During an initial tour, the carpets in Hallways A, B, C, and D were observed to be worn and stained, affecting all 63 residents residing in the facility. Additionally, signs containing private information were found in the rooms of two residents. In Resident 33's room, a sign instructed to place dentures in a cup before picking up meal trays or stray Kleenex. In Resident 16's room, a sign displayed his turning schedule from 8 a.m. to 6 p.m. These signs were still present days later, indicating a failure to ensure a homelike environment. The Director of Nursing acknowledged the need for carpet replacement and the removal of the signs, as they contained private information meant for staff convenience only.
Failure to Complete Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to complete the Discharge Minimum Data Set (MDS) assessment within the required timeframe for one resident. Resident 48, who had diagnoses including Alzheimer's disease, anxiety, and major depressive disorder, was discharged to another facility on 10/1/24. However, the Discharge MDS assessment was not completed, with the last recorded assessment being a Quarterly MDS Assessment on 9/10/24. According to the Resident Assessment Instrument (RAI) Version 3.0 User's Manual, the Discharge MDS assessment should have been completed within 14 calendar days of the discharge date. During an interview, the MDS nurse confirmed that the assessment was not completed as required and acknowledged the absence of a resident assessment policy, relying instead on the RAI tool criteria for completion timeframes.
Inaccurate Resident Assessments for Active Diagnoses
Penalty
Summary
The facility failed to ensure accurate assessments of active diagnoses for two residents. For Resident 20, the clinical record review revealed a diagnosis of Parkinson's disease, dementia, and benign prostatic hyperplasia. However, the Quarterly MDS assessment did not reflect a recent diagnosis of a urinary tract infection (UTI), despite laboratory results indicating the presence of Aerococcus urinae and the administration of Ceftriaxone Sodium for a UTI. The MDS nurse confirmed that the assessment should have marked the UTI as an active diagnosis, acknowledging the oversight and the absence of a specific MDS policy at the facility. Similarly, for Resident 57, the Admission MDS assessment failed to mark bipolar disorder as an active diagnosis, even though the resident had an active medication order for Depakote to treat bipolar disorder. The MDS nurse confirmed that the resident had an active diagnosis of bipolar disorder at the time of the assessment, which was incorrectly marked. The facility relied on the RAI tool for MDS assessments but lacked a formal MDS policy, contributing to these inaccuracies.
Failure to Document Resident Preferences in Care Plans
Penalty
Summary
The facility failed to develop and document care plans for the preferences of two residents regarding their shower schedules. Resident 24 expressed a preference for showers on Tuesdays and Fridays, which was noted in her Activities of Daily Living (ADL) Preferences form dated 12/30/24. However, this preference was not updated in her care plan. The Admission Minimum Data Set (MDS) assessment indicated that it was very important for Resident 24 to choose her bathing method, yet the care plan did not reflect this preference. Interviews with the MDS nurse and the Director of Nursing (DON) confirmed the absence of a care plan for Resident 24's preferences. Similarly, Resident 49 indicated a preference for evening showers, although she had no specific preference for the days. This preference was documented in her ADL Preferences form dated 1/2/25, but it was not updated in her care plan. The Admission MDS assessment noted that it was not very important for Resident 49 to choose her bathing method, yet a care plan should have been developed. The MDS nurse and the DON confirmed that Resident 49's care plan lacked documentation of her preferences. The facility's policy requires care plans to be developed within seven days after the comprehensive assessment, which was not adhered to in these cases.
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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