Poplar Care Strategies
Inspection history, citations, penalties and survey trends for this long-term care facility in Loogootee, Indiana.
- Location
- 313 Poplar St, Loogootee, Indiana 47553
- CMS Provider Number
- 155374
- Inspections on file
- 29
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Poplar Care Strategies during CMS and state inspections, most recent first.
A resident with diagnoses including heart failure and anxiety was admitted without a baseline care plan developed within 48 hours to address immediate and individualized care needs. An Interim Care Plan assessment for this resident was started but not completed, so no individualized interim care plan was in place. The DON reported that the admitting nurse typically completes this assessment to initiate the interim care plan, but this did not occur, despite facility policy requiring a baseline plan of care to be developed within 48 hours of admission.
The facility failed to prevent accident hazards when a resident on continuous O₂ was placed in a shared room with another resident who had a documented history of non‑compliance with the no‑smoking policy, including repeated marijuana and vape use. Despite prior notes of marijuana or vape odors in the room and hallway, a report of smoking in the lobby, and staff suspicion and later confirmation that the resident possessed a vape device, the two residents remained roommates. The O₂‑dependent resident and his spouse reported that the roommate smoked in the shared bathroom, with smoke observed while the O₂ concentrator was running, and staff acknowledged that smoking by this resident had been an ongoing problem.
A resident with heart failure and anxiety was observed receiving continuous supplemental O2 via nasal cannula from a concentrator, with the flow set just above 2 L, and reported using O2 at all times. Record review showed the resident had been receiving O2 every shift since admission, but there was no physician order for routine O2 therapy, no clarification of the required O2 flow rate, and no care plan addressing ongoing O2 use. An LPN confirmed the resident routinely received supplemental O2 and should have had a physician order, contrary to facility policy requiring verification of an order before O2 administration.
Surveyors identified that medications brought in by a resident's family were stored in a medication cart without proper labeling or a physician's order, and there was no documentation in the medical record or notification to the physician. Additionally, a medication storage refrigerator containing both resident beverages and medications had incomplete temperature log documentation, contrary to facility policy. Staff interviews confirmed that required procedures for medication labeling, physician orders, and temperature monitoring were not followed.
Staff failed to perform hand hygiene after removing gloves and before donning new gloves while assisting a resident with toileting and personal care. After glove removal, a CNA also handled the resident's personal items without hand hygiene, contrary to facility policy and infection prevention standards.
The facility failed to prevent and treat pressure wounds for two residents, leading to deficiencies in care. One resident, with multiple wounds and at risk for pressure injuries, did not have a care plan in place, and treatments were missed due to the resident being asleep. Another resident's coccyx wound worsened from a pink area to a Stage II pressure wound, with inadequate documentation and communication regarding the wound's progression. Staff interviews revealed a lack of awareness and communication about the residents' conditions, contributing to the deficiencies.
The facility did not ensure a qualified Infection Preventionist was working at least part-time. The DON, who was also the appointed IP, indicated that the time spent on IP duties varied and was insufficient. There was no documentation of hours worked for IP duties, and the job description for the IP role was undated.
A facility failed to document a clinical contraindication for not performing a gradual dose reduction (GDR) on a resident's psychotropic medication. The resident, with anxiety and depression, was on Alprazolam 0.5mg twice daily. A GDR was recommended but denied without documented contraindication, contrary to the facility's policy requiring GDR attempts unless clinically contraindicated.
The facility failed to maintain professional standards in food safety and hygiene. Observations revealed dietary staff with hair not fully covered by hairnets, incomplete food temperature logs, and improper storage of measuring devices in food containers. Staff were seen handling food with bare hands, and resident trays were transported with uncovered food items. These actions were contrary to the facility's policy requiring covered food, proper hair containment, and glove use.
The facility failed to ensure proper hand hygiene during incontinence care for three residents. CNAs did not perform hand hygiene between glove changes and did not change gloves after touching multiple items before starting care. The Infection Preventionist noted that staff should sanitize hands before putting on gloves and between dirty and clean tasks, as per the facility's Handwashing/Hand Hygiene Policy.
The facility failed to ensure a sanitary and homelike environment, with issues such as unlabeled personal items, dust-caked vent fans, soiled toilets, and peeling non-skid strips observed across multiple areas. Interviews with staff revealed a lack of adherence to cleaning protocols and labeling of personal items, despite expectations outlined in the facility's policy.
The facility failed to update care plans for three residents, leading to deficiencies. A resident continued using bed and chair alarms without a current physician's order, while another had alarms in use without documentation in the care plan. Additionally, a third resident's care plan included outdated interventions for diuretic and antibiotic therapy. Staff interviews and observations confirmed these oversights, indicating non-compliance with facility policies on care plans and alarms.
The facility failed to provide adequate respiratory care for three residents, including not following physician orders for oxygen levels, improper storage of respiratory equipment, and lack of a physician's order for oxygen use. Residents with COPD and other conditions were affected, and staff interviews confirmed discrepancies in care and adherence to infection control protocols.
The facility failed to meet pharmaceutical service needs, as a nurse administered medications from other residents' supplies due to missing prescriptions. The DON cited issues with the pharmacy, including delayed deliveries and lack of after-hours support, leading to medication borrowing against policy.
A resident with dementia exited a facility unsupervised due to a failure in the alarm system on a back door, which had been silenced and not reset. The resident, who had a history of elopement and was wearing a WanderGuard bracelet, was found 200 yards off the property. The back door lacked a WanderGuard system, and the resident's care plan interventions were insufficient to prevent the incident.
A resident's privacy was violated when a video was recorded in their restroom, showing them on the commode. The video, posted on social media by an unlicensed staff member, led to the suspension and termination of two staff members. The resident, with moderate cognitive impairment, was exposed in the video, violating facility policies on privacy and HIPAA regulations.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one of three newly admitted residents reviewed. Record review on 4/28/26 showed that Resident B, whose diagnoses included heart failure and anxiety, was admitted on an unspecified date and did not have a baseline care plan in place addressing individualized care needs. An Interim Care Plan assessment for this resident, dated 4/21/26, had been initiated but was not completed, and therefore no individualized interim care plan was in place. During an interview on 4/29/26, the DON stated that the admitting nurse usually completed the Interim Care Plan assessment, which would then initiate an individualized interim care plan. The facility’s policy, dated 2026, required that a baseline plan of care to meet each resident’s immediate health and safety needs be developed within 48 hours of admission. This deficiency was cited in relation to Intakes 29994502, 2738801, and 2989481. This deficiency was cited under 410 IAC 16.2-3.1-30(a).
Failure to Prevent Smoking-Related Accident Hazards in Shared Room with Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to prevent accident hazards by placing a resident on continuous supplemental O₂ in a shared room with another resident who had a documented history of non‑compliance with the facility’s no‑smoking policy. One resident, diagnosed with heart failure and anxiety and routinely receiving 2 L of O₂ via nasal cannula from an in‑room concentrator, reported that his roommate smoked in their shared bathroom, causing him difficulty breathing. Staff notes documented that the resident’s spouse called to report the roommate was smoking in the bathroom, and the resident later described seeing his roommate wheel out of the bathroom with a cloud of smoke behind him while he was on O₂. A no‑smoking sign was posted outside the room due to oxygen in use. The roommate had multiple prior documented incidents related to marijuana and vape use despite having signed the facility’s smoke‑free/tobacco‑free policy on admission. His diagnoses included cannabis use, hallucinations, and delusional disorder, and his care plan noted that he had brought marijuana and marijuana vape pens into the facility. Nursing notes described repeated reports of marijuana or vape odors in his room and hallway, and an incident where a visitor reported he was smoking marijuana in the lobby, with staff suspecting he possessed a marijuana vape pen. Staff interviews confirmed that smoking in the facility by this resident had been an ongoing problem, that a vape device had been found in his room and confiscated by police, and that on the night of the reported bathroom smoking incident, it was obvious he had been smoking even though he initially denied it. The facility’s accident/incident policy referenced review of reports for trends and resident vulnerabilities, but the residents continued to be roomed together despite the known smoking behavior and the roommate’s O₂ use.
Lack of Physician Order and Care Plan for Routine Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving routine supplemental oxygen had corresponding physician orders and a plan of care for that oxygen therapy. During observation, one resident was seen wearing supplemental oxygen via nasal cannula connected to an oxygen concentrator in a shared room. Record review showed this resident had diagnoses including heart failure and anxiety and had been receiving oxygen via nasal cannula daily, every shift, from admission through the review period. However, the physician orders did not include any order for routine supplemental oxygen or clarification of the oxygen flow rate, despite an existing order to monitor temperature and oxygen levels every shift. Further observation showed the resident wearing a nasal cannula and receiving oxygen from a concentrator set just above 2 L, and the resident reported receiving oxygen at all times. Interview with an LPN confirmed that the resident did receive routine supplemental oxygen and should have had a physician’s order for this ongoing use. Record review also confirmed there was no plan of care addressing the resident’s routine supplemental oxygen. The facility’s own policy on oxygen administration required verification of a physician’s order prior to the procedure, but this was not followed for this resident’s continuous oxygen therapy.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
The facility failed to ensure the safe, secure, and orderly storage of medications in both a medication cart and a medication storage room. In one instance, a medication cart contained Alka-Seltzer, melatonin, and Dulcolax in an original box with a resident's name handwritten on it, but without any labeling indicating the ordered dosage, route, frequency of administration, or prescriber name. The medications had been brought in by the resident's family without a physician's order, and there was no documentation in the resident's medical record regarding the receipt of these medications or physician notification. The resident's physician orders did not include these medications, and nursing progress notes lacked any mention of the family's action or subsequent staff response. Additionally, the medication storage refrigerator in a medication storage room was found to contain both resident beverages and medications, with a temperature log that was not consistently completed as required by facility policy. Several shifts had missing temperature documentation, despite the policy stating that temperature checks must be completed each shift. Staff interviews confirmed that the required procedures for labeling, physician orders, and temperature monitoring were not followed, and facility policies were provided that outlined these requirements.
Failure to Perform Hand Hygiene Between Glove Changes and After Glove Removal
Penalty
Summary
During an observation of care, two CNAs assisted a resident with toileting and perineal care. After providing perineal care, one CNA removed (doffed) used gloves and immediately donned new gloves without performing hand hygiene in between glove changes. Both CNAs then assisted the resident with dressing and transferring to a wheelchair. Subsequently, the CNA removed gloves and, without performing hand hygiene, opened the resident's bedside table drawer and handed the resident a hair comb. The CNA verbally indicated to the resident that she needed to wash her hands, but did not perform hand hygiene herself at the required times. The facility's infection preventionist confirmed during an interview that staff are expected to change gloves when moving from dirty to clean tasks and to perform hand hygiene between glove uses and immediately after removing gloves. Review of the facility's hand hygiene policy also indicated that hand hygiene should be performed after removing gloves and as the final step after removing personal protective equipment. These lapses in infection control practices were directly observed and confirmed through staff interviews and policy review.
Failure to Prevent and Treat Pressure Wounds
Penalty
Summary
The facility failed to provide adequate care to prevent and treat pressure wounds for two residents, Resident D and Resident F. For Resident D, initial observations of deteriorating skin areas were not documented or communicated, and initial wound care was not documented following the development of pressure wounds. Despite being at risk for pressure wounds as indicated by a Braden Scale assessment, no care plan was in place to prevent the development of pressure wounds. Additionally, ordered treatments for existing wounds were not consistently completed, with several instances where treatments were missed because the resident was asleep, which was deemed an inappropriate reason by the staff. Resident D had multiple wounds, including on the feet and coccyx, with diagnoses such as hemiplegia, type II diabetes, and obesity. The resident's care plan included interventions for deep tissue injuries and skin integrity impairments, but there was a delay in initiating a care plan for a wound first observed on the gluteal fold. The treatment administration record showed missed treatments, and weekly wound assessments indicated worsening conditions of the wounds over time. Interviews with staff revealed a lack of awareness and communication regarding the resident's wounds, contributing to the deficiency. Resident F, with diagnoses including neurocognitive disorder and protein-calorie malnutrition, was also at risk for pressure wounds. A skin check revealed a pink area on the coccyx, which later worsened to a Stage II pressure wound. There was no documentation of a wound treatment order or administration prior to a specific date, and the wound assessments showed a progression in the severity of the wound. Staff interviews highlighted a lack of communication and documentation regarding changes in the resident's skin condition, which contributed to the deficiency in care.
Inadequate Infection Preventionist Staffing
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, as required for the infection prevention and control program. The Director of Nursing (DON) was appointed as the facility's IP while also serving as the full-time DON. During interviews, the DON admitted that the time spent on IP duties varied weekly and was less than desired. Additionally, there was no documentation available to verify the hours worked specifically for IP duties. The job description provided for the IP role was current but undated, indicating the responsibilities for controlling the spread of infections and outbreaks.
Failure to Document Contraindication for GDR in Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, who was prescribed psychotropic medication, had a documented clinical contraindication for not undergoing a gradual dose reduction (GDR). The resident, diagnosed with anxiety and depression, was taking Alprazolam 0.5mg twice daily since April 2023. A nurse's note from January 2024 indicated a recommendation for a GDR to decrease the dosage to 0.25mg, which was denied on the grounds that it would not be in the resident's best interest. However, no further documentation of contraindication was found in the resident's clinical record. The facility's Medication Monitoring policy requires a GDR to be attempted within the first year after admission or initiation of the medication, and annually thereafter, unless clinically contraindicated with documented rationale from a physician.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, distribution, and service, as observed in the kitchen. Dietary staff members were seen with hair not fully covered by hairnets, and food temperature logs were incomplete for several meals over a week-long period. Additionally, measuring devices were improperly stored inside containers of food items such as oats, sugar, and ice. Staff were observed handling food with bare hands, including touching bread and using a measuring spoon from a thickener container without gloves. Furthermore, the facility did not ensure that food items on resident trays were covered during transport. Certified Nurse Aides and Dietary Aides were observed carrying trays with uncovered drinks and desserts through hallways to resident rooms. The facility's policy, as indicated by the Administrator, requires that food be covered in the halls, hair be fully contained in hairnets, and gloves be used when handling food. However, these practices were not consistently followed, leading to deficiencies in food safety and hygiene.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections during incontinence care for three residents. Observations revealed that Certified Nurse Aides (CNAs) did not perform hand hygiene between glove changes and did not change gloves after touching multiple items before starting incontinence care. For Resident 13, CNAs did not change gloves after adjusting the bed and handling the resident's brief, and one CNA did not sanitize her hands before putting on new gloves. Similarly, during the care of Resident 27, CNAs failed to perform hand hygiene between glove changes and did not offer the resident an opportunity to wash her hands after using the bathroom. In the case of Resident 15, CNAs did not perform hand hygiene before putting on gloves and failed to sanitize hands between glove changes after assisting with a bowel movement. The facility's Infection Preventionist indicated that staff should sanitize hands before putting on gloves and between dirty and clean tasks, as per the facility's Handwashing/Hand Hygiene Policy. This policy emphasizes hand hygiene as the primary means to prevent infection spread, requiring handwashing with soap and water when hands are visibly soiled and the use of alcohol-based hand rubs before and after direct resident contact and after removing gloves.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and home-like environment across multiple areas, including five halls and a dining room. Observations revealed numerous issues such as unlabeled personal items in shared bathrooms, dust-caked vent fans, soiled toilets, peeling non-skid strips, missing paint, and uncovered incontinence pads in shower rooms. Specific rooms, such as Room B6 and its shared bathroom, had peeling non-skid strips, soiled caulking, and dusty vent fans. Similar conditions were noted in other rooms, with additional issues like overflowing trash cans and unlabeled personal hygiene items. The dining room floor was found to be uneven, cracked, and peeling, with discoloration observed. In the shower rooms, there were soiled grout, worn non-skid strips, and uncovered hygiene supplies. The facility also had structural issues, such as cracked ceiling tiles and light casings, and sand-like debris was noted on the floor in certain areas. Vent fans in various locations, including above the nurse's station and in hallways, were consistently observed to be caked with dust. Interviews with staff, including an LPN and the Housekeeping Supervisor, highlighted a lack of adherence to cleaning protocols and labeling of personal items. The Housekeeping Supervisor indicated that rooms should be cleaned daily according to a checklist, but there was no formal policy in place. The Infection Preventionist noted that incontinence pads should be stored covered, and personal items should be labeled, especially in shared spaces. Despite these expectations, the facility's environment did not meet the standards outlined in their Quality of Life-Homelike Environment policy.
Failure to Revise Care Plans and Obtain Orders for Alarms
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. Resident 29, who was admitted after a fall resulting in a fracture and had diagnoses including dementia and depression, had discontinued orders for bed and chair alarms. However, the care plan did not reflect this change, and alarms were still in use without a current physician's order. The oversight occurred after the resident's hospitalization, where all orders were supposed to be re-entered upon readmission, but the alarms were omitted in error. Observations confirmed the continued use of alarms, and staff interviews revealed that orders should have been placed shortly after initiating alarms. Resident 1 was observed with bed and chair alarms in use, but the clinical record lacked orders for these alarms, and the care plan did not include them as interventions. Despite the resident's cognitive impairment and need for assistance, the alarms were not documented as part of the care plan. Similarly, Resident 2's care plan included outdated interventions for diuretic and antibiotic therapy, which were no longer applicable as the resident lacked a current UTI diagnosis. The MDS Coordinator acknowledged the need for care plan updates when orders are discontinued, but this had not been done. The facility's policies on care plans and alarms were not adhered to, contributing to these deficiencies.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for three residents. For Resident 133, the facility did not adhere to the physician's order for oxygen administration. Observations revealed that the resident was receiving oxygen at different levels than prescribed, and staff were unsure of the correct settings. The resident's clinical records indicated a diagnosis of COPD and hypertension, with a physician's order for oxygen at 1 LPM, which was not consistently followed. Resident 6 was observed with improper storage of respiratory equipment, including oxygen tubing and a nebulizer mouthpiece. The tubing was found uncovered on the floor, and the nebulizer mouthpiece was left uncovered on the nightstand, contrary to infection control protocols. The resident's clinical records showed a diagnosis of dementia with behavioral disturbance and COPD, with orders for continuous oxygen therapy. Staff interviews confirmed that the equipment should have been stored in a provided bag when not in use. For Resident 28, the facility failed to obtain a physician's order for oxygen, despite the resident using it continuously. Observations showed the resident using oxygen at 2 LPM, but the clinical records lacked a specific order for oxygen administration. The resident's diagnoses included COPD with acute exacerbation, and care plans indicated the use of oxygen therapy. Staff interviews revealed that there was an expectation for an order, but it was not present in the records. The facility's policies on oxygen administration and infection control were not followed, contributing to the deficiencies observed.
Medication Administration Deficiency Due to Pharmacy Delays
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of each resident, as evidenced by the improper administration of medications. During an observation, a registered nurse (RN) was unable to locate the prescribed Miralax for one resident and subsequently administered the medication from another resident's supply. Similarly, the RN could not find the Colace for another resident and used the medication from a different resident's card. These actions were contrary to the facility's medication administration policy, which explicitly states that medications supplied for one resident should never be administered to another. The Director of Nursing (DON) acknowledged ongoing issues with the pharmacy, including delays in medication delivery and the absence of a pharmacist after 5 P.M. The pharmacy's failure to deliver medications on time, particularly those on auto-refill, forced nursing staff into a position where they had to choose between not administering necessary medications or borrowing from other residents. The DON confirmed that the pharmacy was expected to deliver medications within four hours of a request, but this was not consistently happening, contributing to the deficiency.
Resident Elopement Due to Unsecured Exit and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a secured environment, resulting in a resident with dementia exiting the facility unsupervised. On the specified date, the resident was last seen by staff at approximately 2:20 P.M. and was not noticed missing until 3:15 P.M. A search was initiated, and the resident was found by the Activity Director approximately 200 yards off the facility property along a gravel road. The resident was returned to the facility without injury. The deficiency was linked to a failure in the facility's alarm system. The back door near the kitchen, through which the resident exited, was not alarming when opened. It was discovered that the door alarm had been silenced for an unknown reason and had not been reset. The facility's electronic security control panel, which should have indicated the door's status, was not effectively monitored, allowing the resident to leave unnoticed. The resident involved had a history of elopement and was at risk for such behavior, as indicated by previous incidents and assessments. Despite wearing a WanderGuard bracelet, the back door was not equipped with a WanderGuard system, allowing the resident to exit. The resident's care plan included interventions for impaired cognitive function and elopement risk, but these measures were insufficient to prevent the incident.
Violation of Resident Privacy Due to Unauthorized Video Recording
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident, identified as Resident B, by allowing a video recording to be made in the resident's restroom where the resident was identifiable. The incident came to light when an anonymous community member reported a video on a social media site to the Business Office Manager. The video showed a staff member, CNA 4, in the restroom with Resident B visible in the background sitting on the commode with her stomach exposed. The video was posted by Unlicensed Staff (US) 3, who, along with CNA 4, was later suspended and terminated from employment. CNA 4 claimed to be unaware of the video being taken, although she was seen posing in the video. Resident B, who has diagnoses including dementia, overactive bladder, and anxiety, was assessed to have moderate cognitive impairment. The facility's investigation revealed that the incident occurred a few months prior when CNA 4 and US 3 were assisting Resident B to the restroom. The facility's policy prohibits the use of camera or recording devices on the premises to comply with HIPAA regulations, and staff are strictly prohibited from recording or photographing residents. The facility's policy on resident rights also emphasizes the right to personal privacy, including during personal care.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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