Rensselaer Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rensselaer, Indiana.
- Location
- 1309 E Grace St, Rensselaer, Indiana 47978
- CMS Provider Number
- 155287
- Inspections on file
- 36
- Latest survey
- May 6, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Rensselaer Care Center during CMS and state inspections, most recent first.
Surveyors determined that the main kitchen’s low-temp dishwasher was not maintaining proper sanitizer levels when test strips repeatedly showed 0 PPM, even though the Dietary Manager reported that the chemical solution was checked each shift and should read 100 PPM. On the same day, staff had documented a 100 PPM sanitizer level and appropriate rinse temperature on the dish machine log, which conflicted with the observed test results. Facility policy required recording sanitizer levels between 50–100 PPM on the log multiple times per day. This issue had the potential to affect all residents receiving meals from the kitchen.
The facility did not provide required education on the benefits and risks of the COVID-19 vaccine or offer the vaccine to its staff, despite having a policy stating that such education and vaccination would be provided unless medically contraindicated or already immunized. An MDS nurse and a nurse consultant both reported that neither COVID-19 education nor vaccination had been offered to them or other staff. Administration reported that approximately 99 staff members, including therapy staff, were employed at the time, and this failure had the potential to affect all residents in the facility.
Surveyors found multiple instances of improper medication and biological storage and labeling, including an opened nitroglycerin bottle for a resident with the expiration date torn off, an opened Cetaphil cream labeled for a former resident, and an unlabeled bottle of antifungal powder whose owner was unknown. A multi-dose vial of Tuberculin solution in the refrigerator lacked an opened date, and an opened tube of antibiotic ointment in a treatment cart was stored without a bag or label, with staff unable to identify its owner. These practices did not follow the facility’s policy requiring dating, labeling, and proper storage of medications and biologicals.
A resident with paraplegia and cognitive communication deficit, but assessed as cognitively intact, was observed keeping and self-applying labeled nystatin cream at bedside and self-administering other medications left in a cup per physician order. The care plan stated the resident could self-administer medications and required quarterly assessments, and a prior self-administration review months earlier had approved several oral supplements and a sleep aid for unsupervised self-administration. However, no subsequent self-administration assessments were completed, contrary to the facility’s policy requiring quarterly interdisciplinary reassessment to ensure medications remained appropriate and safe for self-administration.
Surveyors found that the facility did not develop or implement required care plans for two residents with identified needs related to hypotension and pain. One resident with chronic kidney disease and heart failure had ongoing MD orders for midodrine to treat low BP, but no hypotension care plan was in place, which the DON acknowledged should have existed. Another resident with peripheral autonomic neuropathy and peripheral vascular disease was cognitively intact, had pain that interfered with daily activities, received PRN tramadol 1–3 times per day and scheduled gabapentin, yet had no pain care plan; the MDS nurse stated she had forgotten to initiate it.
Two residents did not receive necessary care and services when ordered medications and bowel interventions were not provided as prescribed. One resident with hypertension, hypothyroidism, and weight loss missed doses of appetite stimulant and thyroid medication, and received an anti-hypertensive even when BP readings were outside ordered parameters, with additional doses omitted. Another resident with uterine cancer and constipation had no documented bowel movements for several days, repeatedly complained of constipation, and had a PRN bisacodyl suppository ordered but never administered, despite a facility bowel protocol and subsequent imaging showing significant bowel issues.
A resident with nicotine dependence was care planned as a smoker who could go out to smoke at designated times or with family, with an intervention that a smoking evaluation be completed quarterly. The last documented smoking safety evaluation showed the resident could safely smoke with supervision, but no additional evaluations were completed for several months, contrary to facility policy requiring smoking assessments at admission, readmission, with significant change, and quarterly by a licensed nurse, even though the resident continued to smoke under staff and family supervision in the courtyard.
Surveyors found that two residents with indwelling urinary catheters did not receive care consistent with their care plans, physician orders, or facility policy. Catheter collection bags were repeatedly observed resting directly on the floor when residents were in bed or seated, and the bags were not contained in basins as specified for one resident. Required catheter care every shift was not documented, and an LPN reported that a catheter bag hung on a recliner had slipped down. The facility’s written policy required keeping catheter bags below bladder level and off the floor, as well as providing routine hygiene, but these standards were not followed.
A resident with paraplegia and a documented colostomy required staff assistance to manage a colostomy and urinary catheter, and the MDS and care plan identified an ostomy with interventions for ostomy care as needed. Despite this, the monthly Physician’s Order Summary contained no orders for colostomy care, and there was no documentation of colostomy bag changes or stoma care. During interview, the DON could not provide further information, and these omissions occurred despite a facility policy requiring ostomy services to meet professional standards of quality.
A resident with osteoarthritis, chronic neck and arm pain, and intervertebral disc degeneration did not consistently receive ordered pain management interventions. The care plan and physician orders called for daily application of a warm neck wrap with skin checks and scheduled tramadol doses, as well as PRN hydrocodone-acetaminophen every 8 hours. Documentation showed multiple missed neck wrap applications and several missed tramadol doses, and one instance where hydrocodone-acetaminophen was administered twice within 1.5 hours instead of at the ordered 8-hour interval. The resident reported significant pain and difficulty getting staff to administer pain medications as needed, while facility policy required adherence to the 10 Rights of medication administration, including right dose and right time/frequency.
A resident with heart failure and stage 3 CKD had a standing midodrine order changed to a PRN order for 10 mg every eight hours based on SBP parameters. After this change, the MAR showed no administrations of midodrine, and there were no documented BP readings in the MAR or vital signs section for this resident. During interview, the DON confirmed that no BPs had been recorded since the PRN order was initiated and could not explain why monitoring was not performed, resulting in a deficiency related to failure to monitor BP for a PRN antihypotensive medication.
A resident with Alzheimer’s disease received multiple doses of PRN lorazepam for anxiety and agitation over an extended period without documentation that non-pharmacologic interventions were attempted beforehand, despite a care plan and behavioral health policy requiring such measures. On many occasions, there was no record of the specific behaviors present at the time of administration on the MAR, behavior sheets, or progress notes, and when behaviors such as yelling, agitation, and inappropriate comments were noted, there was still no evidence of attempted interventions prior to giving the medication. Staff later reported increased behaviors after the PRN order expired and indicated the resident had been receiving lorazepam routinely before meals, leading a psychiatric NP to order scheduled lorazepam BID without documented behavioral justification in the record for the period immediately preceding the change.
A resident with a history of stroke, moderately impaired cognition, and a care plan requiring staff assistance with ADLs was scheduled to receive showers twice weekly in the evening. Review of records showed no signed shower forms or completed bathing tasks on multiple scheduled shower days over several months. A nurse interview confirmed that no additional documentation could be found to show the resident received bathing on those missed dates.
The facility did not follow its policy requiring annual staff training on abuse, neglect, exploitation, and resident rights. Record review showed that an LPN and a CNA, each employed for more than four months, had not completed abuse or resident rights training since their hire dates. The Business Office Manager confirmed they had no such training during the following year, while the Corporate Regional Manager stated that this training was required yearly. The current facility policy specified that all staff must receive training on abuse and abuse prevention, which was not implemented for these employees.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
Multiple residents reported not receiving meal choices or having their dietary preferences honored, with staff failing to post menus or assist with meal selections as required. One resident with diabetes and other health conditions was repeatedly served unwanted foods, and her preferences were not reflected on her dietary card, contrary to facility policy.
A resident reported concerns about cold food, and during a subsequent meal observation, a supper tray was served with BBQ chicken, mashed potatoes, and spinach at temperatures below the facility's required minimum of 135°F. The dietary aide noted the steam table had been turned off shortly before the tray was tested, resulting in food that was not served at an appetizing or safe temperature. This deficiency had the potential to affect 71 residents on regular diets.
A resident with paraplegia, diabetes, and two stage four pressure ulcers did not consistently receive physician-ordered wound care treatments. Multiple missed applications of prescribed wound care products were documented in the TAR, and the resident and family reported several days when treatments were not completed as scheduled. The facility's policies required adherence to physician's orders for wound care, but these were not followed in this case.
A resident with severe cognitive impairment and multiple medical conditions did not receive proper monitoring during a nebulizer treatment. The LPN left the resident unattended, resulting in the resident not wearing the nebulizer mask during the treatment, contrary to facility policy requiring staff to remain with the patient until the treatment was complete.
An agency LPN inaccurately documented completion of a prescribed wound treatment for a resident with stage four pressure ulcers, despite the treatment not being performed. The resident, who was cognitively intact, reported the omission, which was confirmed by another LPN and the treatment was subsequently completed by the night shift.
Three agency LPNs did not have their medication administration competency and understanding of medication management completed or signed off on the required checklist, as mandated by facility policy for all staff, including contracted personnel.
A resident with cognitive impairments was found with a medication cup containing multiple pills, which he intended to self-administer without the necessary physician's orders or assessments. The facility's DON was unaware of any self-administration, and the required interdisciplinary team assessment was not conducted.
A facility failed to maintain a resident's ADL functions as care planned, specifically in assisting with walking. The resident, with multiple health conditions, was observed in a wheelchair, and his daughter reported a lack of staff assistance with walking. The care plan required staff to assist the resident in walking twice daily, but records showed this occurred only five times in 30 days. Interviews revealed unclear responsibility for implementing therapy recommendations, contributing to the deficiency.
A facility failed to provide necessary care for three residents: one resident received an incorrect dosage of Eliquis post-procedure, another had a bandage applied without an order, and a third was observed without prescribed compression stockings. The LPN was unsure of the medication order source, and the DON confirmed the lack of proper documentation for the bandage and compression stockings.
A resident with paraplegia and other conditions did not receive recommended range of motion (ROM) exercises as outlined in a Physical Therapy Discharge Summary. Despite being cognitively intact and requiring substantial assistance, the facility did not implement the restorative ROM program. The Occupational Therapist and Director of Nursing indicated a lack of clarity and responsibility in executing therapy recommendations, with no specific restorative nursing program in place.
A facility failed to monitor the nutritional intake of a resident with a history of weight loss, resulting in significant weight reduction. Despite being on a regular diet with supplements, the resident's meal consumption was inconsistently documented, with several meals missing from the log. The DON acknowledged the missing documentation, suggesting frequent meal refusals by the resident, but provided no further information.
The facility failed to provide necessary respiratory care and treatments for residents with respiratory infections and oxygen therapy needs. A resident with COVID-19 did not receive prescribed medications, and two residents received incorrect oxygen flow rates, contrary to physician orders. These discrepancies were confirmed by staff interviews, indicating a failure to adhere to prescribed treatments.
The facility failed to provide ground meat as ordered for six residents on a memory care unit, resulting in a cognitively impaired resident's death due to aspiration of food. The dietary staff did not send the required ground meat or dietary cards, and the nursing staff did not alert them about the missing items.
A cognitively-impaired resident with a history of food stuffing was not adequately supervised during meals, leading to her death from aspiration of unchewed food. The resident wandered in and out of the dining room, taking food from other residents' plates, and was later found unresponsive with sausage obstructing her airway. Despite resuscitation efforts, the resident could not be revived.
Improper Sanitizer Levels and Inaccurate Documentation for Dishwashing
Penalty
Summary
Surveyors found that the facility failed to maintain a sanitary main kitchen by not ensuring proper chemical sanitizer levels in the low-temperature dishwasher. During an initial kitchen tour with the Dietary Manager (DM), the DM stated that the dishwasher was a chemical dishwasher and that the chemical solution was tested every shift. When the DM used a test strip to check the sanitizer level after a wash cycle, the strip registered 0 parts per million (PPM), despite her statement that the reading should be 100 PPM. She then used a different bottle of test strips and again obtained no PPM reading, with the strip color remaining unchanged. The Low Temperature Dish Machine Log for the month indicated that, for the breakfast meal on the same day, staff had documented a rinse temperature of 120°F and a chemical level of 100 PPM. The facility’s policy on ware washing required that the temperature and sanitizer PPM (50–100 PPM) be recorded on the log at least three times per day. This deficiency had the potential to affect 89 residents who received food from the kitchen. No specific residents, medical histories, or clinical conditions were described in the report beyond the notation that 89 residents were served food from the main kitchen.
Failure to Educate and Offer COVID-19 Vaccination to Facility Staff
Penalty
Summary
The facility failed to provide education on the benefits and risks of the COVID-19 vaccine and failed to offer the COVID-19 vaccine to its employees, contrary to its own COVID-19 policy dated 11/25/25, which required education and vaccine offering unless medically contraindicated or already immunized. During an interview on 4/30/26, the MDS nurse reported that COVID-19 education and vaccination had not been offered to her. In a separate interview on 5/1/26, the Nurse Consultant also stated that COVID-19 education and the vaccine had not been offered to the staff. On 5/6/26, Administration indicated there were 99 staff members, including therapy staff, employed by the facility. The surveyors determined that the failure to provide COVID-19 vaccine education and to offer vaccination to staff had the potential to affect all residents residing in the facility.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication and biological storage and labeling practices. On observation of the East Wing medication cart, an opened bottle of nitroglycerin 0.4 mg labeled for Resident 28 was found with the expiration date torn off by tape on the lid; the bottle showed a date opened of 11/16/24, but the current expiration date was not visible. In the skilled medication room, an opened container of Cetaphil cream was stored on a shelf with a label for an individual who was no longer a resident at the facility. Additional observations in the skilled medication room and treatment cart showed further failures to follow labeling and dating requirements. An opened bottle of miconizide nitrate 2% powder was stored on a shelf without any name or label, and the RN present was unsure to whom it belonged. A partially used multi-dose vial of Tuberculin solution was stored in the refrigerator without an opened date on the vial. In the treatment cart, an opened and used tube of antibiotic ointment was stored without a plastic bag and without a label, and the RN was again unsure of its owner. These conditions were inconsistent with the facility’s medication storage policy, which required medications and biologicals to have expiration dates on labels, be dated when opened, and be destroyed and reordered if labels were worn, incomplete, or missing.
Failure to Complete Required Quarterly Self-Administration Medication Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete required quarterly assessments for a resident who was permitted to self-administer medications per the care plan and facility policy. Surveyors observed a tube of nystatin cream with a medication label on the bedside table of a resident with diagnoses including paraplegia and cognitive communication deficit; the resident stated she applied the cream herself and knew how to use it. The nystatin cream was again observed at the bedside on a subsequent day. The resident’s Quarterly MDS indicated she was cognitively intact but had limited range of motion in both upper and lower extremities. A prior Medication Self-Administer Review dated several months earlier documented that the resident was able to self-administer several oral supplements and a sleep aid unsupervised. Record review showed no additional self-administration assessments had been completed after the November assessment, despite a care plan initiated in early January stating the resident was able to administer medications to herself and directing staff to assess her for self-administration of medications quarterly. Physician’s orders included nystatin cream to be applied to the groin twice daily and as needed, and an order allowing the resident to self-administer medications brought to her by nursing staff, with the resident requesting pills be left in a cup at the bedside. During interview, the DON confirmed there were no other self-administration assessments completed. The facility’s Self-Administration of Medication policy required that medications be assessed for appropriateness and safety for self-administration and that the interdisciplinary team conduct reassessments quarterly and with any significant change in condition to ensure safe self-administration remained feasible.
Failure to Develop and Implement Care Plans for Hypotension and Pain
Penalty
Summary
The facility failed to develop and implement complete care plans addressing all identified needs for two residents, specifically related to hypotension and pain management. For one resident with diagnoses including stage 3 chronic kidney disease and heart failure, a physician’s order dated 11/16/25 directed administration of midodrine 10 mg three times daily for hypotension, to be held if systolic blood pressure exceeded 120, and this order was later changed on 3/23/26 to midodrine 10 mg every eight hours as needed for systolic blood pressure less than 120. Despite these ongoing medical orders for treatment of hypotension, there was no corresponding care plan addressing hypotension in the resident’s record. During interview, the DON acknowledged that there should have been a care plan for hypotension. Another resident, admitted with diagnoses including peripheral autonomic neuropathy and peripheral vascular disease, was documented on the admission MDS as cognitively intact and experiencing pain that occasionally interfered with day-to-day activities, with receipt of pain interventions. Physician’s orders included tramadol 50 mg every six hours as needed for pain, which the MAR showed was administered 1–3 times daily, and gabapentin 300 mg three times daily for neuropathy. Despite the documented pain, frequent use of PRN tramadol, and scheduled gabapentin, there was no pain care plan in the resident’s record. In interview, the MDS nurse stated there should have been a pain care plan and that she must have forgotten to initiate it.
Failure to Administer Ordered Medications and Bowel Interventions
Penalty
Summary
The deficiency involves failures to administer medications as ordered and to follow bowel management interventions for two residents. One resident with diagnoses including hypertension, hypothyroidism, and excessive weight loss had multiple medication administration issues. A physician’s order for megestrol acetate to stimulate appetite was not followed when the morning dose was not given on one documented date. For the same resident, metoprolol tartrate was ordered twice daily with parameters to hold the dose if the systolic BP was less than 110 or diastolic BP less than 50, yet the MAR showed the medication was administered on multiple dates when the systolic BP was below 110. Additionally, several scheduled doses of metoprolol were not administered on specified dates. The resident’s levothyroxine, ordered once daily, was also not administered at the scheduled time on one date. The Nurse Consultant confirmed that these medications were not given as ordered, despite a facility policy requiring medications to be administered per physician orders. A second resident, with diagnoses including malignant neoplasm of the uterus and constipation, was admitted cognitively intact and had no documented bowel movements from admission through several days. The resident complained of constipation, reporting no bowel movement for a while, and the NP ordered a PRN bisacodyl rectal suppository every 24 hours for constipation. The MAR for the relevant months showed that the bisacodyl suppository was never administered, despite ongoing complaints of constipation and documentation that the resident had not had a bowel movement since arrival. Subsequent abdominal imaging showed an ileus versus obstructive bowel gas pattern, and the NP was notified of the results, after which the resident was sent to the emergency room and later diagnosed with a bowel obstruction. The facility had a bowel protocol policy stating that standing orders would be implemented to address lack of bowel movement, but the ordered intervention was not provided.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
The facility failed to ensure resident safety related to smoking by not completing required smoking safety assessments at the prescribed frequency for one resident. A resident with a diagnosis that included nicotine dependence was observed smoking in the courtyard with his daughter present, and later in the presence of Activities staff who remained outside with the residents while they smoked. The resident’s care plan, dated 2/4/25, identified him as a smoker who could go out to smoke at designated times or with family and specified that a smoking evaluation would be completed quarterly. Record review showed the most recent Smoking Safety Evaluation had been completed on 11/6/24 and indicated the resident could safely smoke with supervision, but no further evaluations were completed until 4/30/26, despite facility policy requiring smoking assessments upon admission, readmission, with significant change, and quarterly by a licensed nurse.
Failure to Maintain Proper Indwelling Catheter Care and Bag Positioning
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate indwelling urinary catheter care and to keep catheter collection bags off the floor for two residents with catheters. For one resident with paraplegia, cognitive communication deficit, and an indwelling catheter, surveyors repeatedly observed the catheter collection bag resting directly on the floor, both when the resident was in bed and when she was seated in a recliner. The bag was not contained in a basin despite a care plan revision indicating the catheter bag was to be kept in a basin on the floor per the resident’s preference, with the basin next to the bed. There were no physician orders or documentation indicating that catheter care was being provided, even though the resident’s care plan included interventions such as catheter care per orders and positioning the catheter bag and tubing below the level of the bladder. An LPN later stated she had hung the catheter bag on the side of the recliner and that it must have slipped down. For a second resident with diagnoses including obstructive and reflux uropathy and hydronephrosis with ureteral stricture, surveyors observed on multiple occasions that the urinary catheter collection bag was attached to the side of the bed in a low position and resting directly on the floor, without being contained in a basin. The resident’s care plan and physician orders required catheter care every shift and positioning the catheter bag and tubing below the level of the bladder. The facility’s own policy on indwelling urinary catheter management specified that the collecting bag must be kept below the level of the bladder and not rested on the floor, and that routine hygiene was appropriate. Despite these requirements, the observed practices for both residents did not comply with the care plans, physician orders, or facility policy.
Failure to Provide and Document Ordered Colostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate colostomy care and services for a resident with a colostomy. The resident, who was cognitively intact and had diagnoses including paraplegia and colostomy status, reported needing staff assistance to manage her colostomy and urinary catheter. A recent MDS assessment documented that the resident had an indwelling catheter and an ostomy, and the care plan, revised in April, identified the colostomy with an intervention for ostomy care as needed. However, review of the May Physician’s Order Summary showed no physician orders for the colostomy or for the care to be provided, and there was a lack of documentation of completed colostomy bag changes and stoma care. During interview, the DON was unable to provide any additional information, and the facility’s colostomy and ileostomy care policy required that services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality. The survey finding is that, for this resident, the facility did not ensure that colostomy care was supported by specific medical orders and documented care consistent with the resident’s assessed needs and the facility’s own policy.
Failure to Follow Ordered Pharmacologic and Non-Pharmacologic Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pharmacological and non-pharmacological pain management for a resident with chronic pain. The resident, who was cognitively intact and had diagnoses including osteoarthritis, low back pain, bilateral arm pain, and intervertebral disc degeneration, reported significant pain in her right arm and shoulder and difficulty getting staff to administer pain medications as needed after a recent schedule change. Her care plan, revised on 4/30/26, identified neck pain due to osteoarthritis and included interventions such as medications and a warm neck pack as ordered. A physician’s order directed nursing staff to apply a warm neck wrap daily for 20 minutes with skin checks before and after application, but the April 2026 Treatment Administration Record showed the neck wrap was not documented as administered on multiple specified dates. The resident also had multiple physician orders for pain medications that were not followed as written. An order dated 4/9/26 for hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every 8 hours as needed, was documented on the April 2026 Medication Administration Record as being given at 8:00 p.m. and again at 9:30 p.m. on the same day, which did not comply with the ordered 8-hour interval. Another order dated 4/14/26 for tramadol 50 mg by mouth four times a day was not documented as administered at several scheduled times throughout April, including missed doses on multiple mornings, noons, and evenings. During an interview, the DON stated she had no further information to provide. The facility’s own medication administration policy required adherence to the “10 Rights” of medication administration, including right dose and right time/frequency, and checking the MAR and physician’s orders before medicating.
Failure to Monitor BP for PRN Midodrine Order
Penalty
Summary
The facility failed to ensure appropriate monitoring for a PRN blood pressure medication, resulting in a deficiency related to unnecessary drugs for one resident. Resident 5, who had diagnoses including heart failure and stage 3 chronic kidney disease, had an order dated 11/16/25 for midodrine 10 mg three times daily for hypotension, to be held if systolic blood pressure (SBP) was greater than 120; this order was discontinued on 3/23/26. On 3/23/26, a new PRN order was written for midodrine 10 mg every eight hours as needed if SBP was less than 120. The March 2026 MAR showed no administrations of midodrine after the order change on 3/23/26, and the April and May 2026 MARs indicated the medication was never administered. There were no blood pressure readings documented in the MAR or in the vital signs section of the medical record after 3/23/26, and during interview the DON confirmed there were no blood pressures recorded since that date for the PRN midodrine and was unsure why they had not been checked when the new order was initiated. This lack of documented blood pressure monitoring and absence of vital sign entries following the initiation of a PRN midodrine order formed the basis of the cited deficiency under 410 IAC 16.2-3.1-48(a)(6).
Failure to Attempt and Document Non-Pharmacologic Interventions Before PRN and Scheduled Lorazepam Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that non-pharmacological interventions were attempted and documented prior to administering PRN lorazepam for anxiety and agitation, and before converting it to a scheduled medication, for a resident with Alzheimer’s disease. The resident had multiple PRN lorazepam orders beginning in early December, with doses administered on numerous dates in December and January for behaviors such as yelling, agitation, and inappropriate comments. Nursing progress notes occasionally described behaviors like yelling in the dining room or at other residents, but consistently lacked documentation that any non-pharmacological interventions were attempted before giving the medication, despite a behavioral health policy stating that pharmacologic interventions should only be used when non-pharmacologic measures are ineffective or clinically indicated. On several dates when lorazepam was administered, there was no documentation at all on the MAR, behavior sheets, or progress notes describing what behaviors the resident was exhibiting at the time of administration. Even when behaviors were described, such as yelling at staff and residents or becoming aggressive after medication, there was still no indication that staff tried interventions like redirection, removal from the situation, or environmental modification before administering the PRN medication. The resident’s care plan, initiated in early January, identified physical aggressiveness, poor impulse control, and a history of physical altercations with other residents, and included interventions such as assessing and anticipating needs, using physical and verbal cues to alleviate anxiety, and documenting behaviors and attempted interventions. However, the documentation reviewed did not show that these care-planned interventions were implemented prior to medication use. Later, staff reported to a psychiatric NP that the resident’s behaviors had increased after the PRN lorazepam order expired, and that the resident had been receiving lorazepam routinely in the morning and evening prior to meals. Based on this report and discussion with the DON and Social Service Director, the NP ordered lorazepam 0.5 mg twice daily on a routine basis for generalized anxiety disorder. There was no documentation in the progress notes or MAR of behaviors between the end of the last PRN order and the start of the scheduled lorazepam, aside from behavior monitoring entries on a few dates in early February that showed both effective and ineffective non-pharmacological interventions. During interview, the DON acknowledged that there had been no interventions documented prior to lorazepam administration before early February, and the Administrator could not provide a facility policy specific to PRN medication administration, only the behavioral health policy requiring non-pharmacologic measures first.
Failure to Provide Scheduled Twice-Weekly Bathing for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who required assistance with activities of daily living received bathing or showers at least twice weekly as care planned. Record review for Resident J, who had a diagnosis including stroke, a care plan revised on 10/2/25 indicating a need for staff assistance with ADLs, and a Quarterly MDS dated 2/7/26 showing maximum assistance required for bathing and moderately impaired cognition, showed that scheduled showers were to occur on Wednesday and Saturday evenings. However, there were no signed shower forms or tasks indicating that bathing occurred on multiple scheduled days, specifically 12/17/25; 1/7/26, 1/17/26, and 1/21/26; and 2/4/26, 2/18/26, and 2/25/26. During interview, the Wound Nurse confirmed that no additional shower forms could be found to show the resident was bathed on those dates. This deficiency was cited under 410 IAC 16.2-3.1-38(a)(3) and 16.2-3.1-38(b)(2) and relates to Intake 2733197.
Failure to Provide Required Annual Abuse and Resident Rights Training to Staff
Penalty
Summary
The facility failed to implement its abuse policy and procedure requiring annual training on abuse, neglect, exploitation, and resident rights for staff who had been employed more than four months. Record review on 3/6/26 showed that an LPN who started on 4/12/24 and a CNA who started on 7/11/24 had not completed abuse training or resident rights training since their start dates in 2024. During interview, the Business Office Manager confirmed that these two staff members had no abuse or resident rights training in 2025, and the Corporate Regional Manager stated that such training was required to be completed yearly. A facility policy dated 5/6/25, identified by the Administrator as current, indicated the facility would maintain an effective training program for all staff that included, at a minimum, training on abuse and abuse prevention, which was not followed for these two staff members.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints in a timely and non-retaliatory manner.
Failure to Honor Resident Meal Preferences and Dietary Needs
Penalty
Summary
The facility failed to provide residents with meal choices and did not honor their dietary preferences, as evidenced by interviews and record reviews involving nine residents. Resident Council meeting notes and a grievance form indicated that residents were not receiving requested meals, and the issue was not addressed by facility leadership. Residents reported that menus were not posted in a timely manner, making it difficult to make meal selections, and that CNAs were no longer assisting residents in filling out their meal orders for the following day. As a result, residents were often served whatever was on the menu without consideration for their preferences. One resident with diabetes, paraplegia, and stage four pressure ulcers reported consistently receiving meals high in carbohydrates and being served scrambled eggs despite a documented preference for fried eggs. The resident's dietary card did not reflect her dislike for scrambled eggs, and her care plan indicated a need for dietary interventions. The facility's food preference policy required that allergies, dislikes, and special requests be addressed prior to meal service, but this was not followed, resulting in residents not receiving meals according to their preferences and needs.
Failure to Serve Hot Foods at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve a supper meal at an appetizing and safe temperature, as required by its food temperature policy. During an observation, a test tray of BBQ chicken, mashed potatoes, and spinach was served with temperatures below the minimum standard of 135°F: the chicken measured 133.6°F, the mashed potatoes 126.2°F, and the spinach 90.3°F. The chicken and mashed potatoes were warm to taste, while the spinach was cold. This issue was identified after a resident had previously voiced a grievance about cold food, which was documented and marked as resolved. The dietary aide reported that the steam table had been shut off for about two minutes prior to the sample tray being received. The deficiency had the potential to affect 71 residents on a regular diet with regular textured foods. No further information was provided by the administrator at the time of the sample tray testing, and the facility's policy required hot foods to be held at a minimum of 135°F.
Failure to Complete Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered by the physician for a resident with significant medical conditions, including paraplegia, diabetes mellitus, and two stage four pressure ulcers on the sacrum and right ischium. Record review and interviews revealed that there were multiple instances where prescribed wound care treatments were not administered as scheduled. Specifically, the resident and a family member reported missed treatments on several days, including a missed evening shift treatment that was only completed after being reported to the night shift nurse. Review of the Treatment Administration Record (TAR) showed several missed applications of wound care products such as zinc oxide, collagen, hydroferablue, betamethasone valerate, calcium alginate, and BNZ cream, with specific dates and times documented where treatments were not completed as ordered. The care plan for the resident indicated that pressure ulcer treatments were to be completed as ordered, and physician's orders detailed specific wound care regimens for both the sacrum and right ischium. Despite these orders, the TAR documented multiple missed treatments across different shifts and dates. The facility's own pressure ulcer and wound care policies required that physician's orders for wound care be followed, but these were not adhered to in this case. The Director of Nursing was informed of the missed treatments, but no additional information was provided at the time of the survey.
Failure to Monitor and Administer Nebulizer Treatment as Required
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, dementia, and hemiplegia, did not receive safe and appropriate respiratory care during a nebulizer treatment. During observation, the resident was found lying in bed with the nebulizer running, but the mask was not on the resident and was instead lying next to him, disconnected from the medication cup. The LPN was notified and assisted the resident in putting the mask back on, but then left the room to administer medications to another resident. When the LPN returned, the resident was again not wearing the mask, which was lying next to him, and the treatment was completed at that time. The resident's medical record indicated severe cognitive impairment and a need for substantial to maximum assistance with activities of daily living. The care plan required oxygen therapy, and physician orders specified nebulizer treatments four times daily. The facility's policy, based on the Lippincott procedure and an approved addendum, required staff to remain with the patient and continue the treatment until the nebulizer began to sputter. The LPN reported that she typically set a timer and monitored the resident via video, acknowledging the resident's tendency to remove the mask due to confusion and impulsivity. The failure to remain with the resident during the treatment and ensure the mask was worn as required led to the deficiency.
Inaccurate Documentation of Wound Care by Agency LPN
Penalty
Summary
A deficiency occurred when an agency LPN documented that a prescribed wound treatment for a resident with paraplegia, diabetes mellitus, and two stage four pressure ulcers had been completed, when in fact the treatment was not performed. The resident, who was cognitively intact, reported that the evening shift did not complete the treatment on her pressure areas, despite the Treatment Administration Record showing the LPN's initials indicating completion. The resident informed the night shift nurse, who confirmed the treatment had not been done and subsequently completed it. Record review showed physician orders for specific wound care, including the application of BNZ cream and various wound dressings to the sacral area, to be performed twice daily. During interviews, it was confirmed by another agency LPN that the treatment had not been completed as documented, and the lapse was not communicated during shift report. The Director of Nursing stated that the agency LPN responsible would not return to work at the facility.
Deficiency in Contracted Staff Medication Administration Training
Penalty
Summary
The facility failed to ensure that contracted agency staff completed required training and competency checks for medication administration. Record review showed that three agency LPNs did not have their medication pass competency and understanding of medication management completed and signed off on the Agency Competency Checklist. The facility's current policy, which includes contracted staff in its training requirements, specifies that all staff must be trained and demonstrate competency in relevant areas. During an interview, the Administrator confirmed that the checklist should have been signed off and no additional information was provided.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident had the necessary physician's orders and assessments to self-administer medications. During a random observation, a resident was found with a medication cup containing multiple pills, which he intended to take. The resident indicated that the nurse had left the medications in his room that morning. Upon reviewing the resident's records, it was noted that there were no assessments or physician's orders authorizing the resident to self-administer medications. The resident in question had a history of cognitive communication deficit, age-related cognitive decline, and type 2 diabetes mellitus. The resident's care plan indicated a moderately impaired cognitive status, requiring cues and reminders from staff. Despite this, the facility's Director of Nursing was unaware of any self-administration by the resident and confirmed the absence of necessary assessments or orders. The facility's policy requires an interdisciplinary team assessment to determine the safety and appropriateness of self-administration, which was not conducted in this case.
Failure to Maintain Resident's ADL Functions
Penalty
Summary
The facility failed to maintain a resident's ability to perform activities of daily living (ADLs) as care planned, specifically in relation to walking. Resident 70, who has diagnoses including acute and chronic respiratory failure, cerebral ischemia, and acute kidney failure, was observed in a wheelchair with a rollator walker present in his room. His daughter reported that staff were not assisting him with walking as they previously did. The resident's care plan, dated August 14, 2024, indicated a walking program that required staff to assist him in walking with his rollator walker twice daily, 6-7 days a week. However, the Point of Care (POC) tasks showed that the resident was only walked on five occasions over a 30-day period, with the remaining days marked as the activity did not occur. Interviews with facility staff revealed a lack of clarity and responsibility regarding the implementation of therapy recommendations. The Occupational Therapist mentioned that therapy recommendations were made to nursing staff upon discharge, but there was no clear assignment of responsibility for carrying out these recommendations. The Director of Nursing confirmed that therapy recommendations were included in the POC tasks for CNAs to complete, but there was no specific restorative nursing program in place. This lack of documentation and follow-through on the resident's walking program contributed to the deficiency in maintaining the resident's ADL functions.
Deficiencies in Medication Management and Skin Care
Penalty
Summary
The facility failed to provide necessary care and services for Resident B, who was cognitively intact and required assistance for mobility and transfers. The resident was prescribed Eliquis, an anticoagulant, to be taken twice daily for a chronic pulmonary embolism. However, after a medical procedure, the medication was incorrectly resumed at a reduced frequency of once daily, despite hospital discharge instructions to resume the original dosage. The LPN involved was unsure of the source of the incorrect order, and the Nurse Practitioner confirmed that no changes were made to the medication list. Resident D, who was cognitively impaired and dependent on staff for activities of daily living, had a skin tear on the left forearm. Although there was an order to monitor the area for redness and drainage, there was no order for a bandage, yet a white bandage was observed on the resident's forearm. The Director of Nursing confirmed the absence of an order for a dressing, indicating a lack of proper documentation and adherence to treatment protocols. Resident C, who had chronic kidney disease, heart failure, and stasis dermatitis, was observed without compression stockings on multiple occasions, despite a physician's order to wear them during the day. The resident's legs were swollen and red, and there was no documentation for a bandage on the right lower leg. The Director of Nursing noted that the resident was independent and sometimes removed the stockings, but the nursing staff failed to document their status accurately. This lack of documentation and adherence to care plans contributed to the deficiency in care for Resident C.
Failure to Implement Therapy Recommendations for ROM
Penalty
Summary
The facility failed to maintain a resident's range of motion (ROM) as per therapy recommendations. Resident 21, who has diagnoses including paraplegia, diabetes mellitus, and spinal stenosis, was observed seated in a recliner with her legs elevated. She reported that she used to receive ROM exercises from the staff, but these had not been performed recently. The resident's record indicated she was cognitively intact and required substantial to maximum assistance for bed mobility, and was dependent for transfers and toileting. However, she had not received restorative nursing services as recommended. A Physical Therapy Discharge Summary from February 2024 outlined a restorative ROM program with specific interventions, but these were not implemented. The Occupational Therapist confirmed that therapy recommendations were made to the nursing staff upon discharge, but there was uncertainty about who was responsible for executing them. The Director of Nursing indicated that therapy recommendations were included in the point of care tasks for CNAs, but there was no specific restorative nursing program in place. A review of records back to February 2024 showed no evidence of the implementation of the therapy recommendations for ROM.
Failure to Monitor Nutritional Intake for Resident with Weight Loss
Penalty
Summary
The facility failed to adequately monitor the nutritional intake of a resident with a history of weight loss. The resident, who was cognitively intact and required only setup help for eating, had diagnoses including multiple sclerosis, protein-calorie malnutrition, and adult failure to thrive. Despite being on a regular diet with additional supplements, the resident experienced significant weight loss, dropping from 88 pounds to 78 pounds over several months. The care plan noted the resident's risk for weight fluctuations due to variable meal intakes and refusals of nutritional supplements. The deficiency was further highlighted by the lack of documentation in the meal consumption log for several meals across different days. The Director of Nursing acknowledged the missing documentation and suggested that the resident might have refused those meals, as she often did. However, there was no further information provided to account for the missing records, indicating a lapse in monitoring and documentation of the resident's nutritional intake, which is crucial for managing her health condition.
Failure to Provide Appropriate Respiratory Care and Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and treatments for residents with respiratory infections and oxygen therapy needs. Resident 70, diagnosed with COVID-19, acute and chronic respiratory failure, cerebral ischemia, and acute kidney failure, did not receive prescribed medications such as Vitamin C, Zinc, Mucinex, Duonebs, and oxygen. These medications were ordered on 1/31/25 but were not entered into the Physician's Orders or documented in the Medication Administration Record for January and February 2025. Additionally, the facility did not maintain correct oxygen flow rates for two residents. Resident 10, with chronic obstructive pulmonary disease, heart failure, and dementia, was observed receiving oxygen at 2.5 liters per minute, contrary to the prescribed 2 liters. Similarly, Resident 65, with a history of stroke, chronic obstructive pulmonary disease, and asthma, was observed receiving oxygen at 1 liter per minute instead of the prescribed 3 liters during napping and nighttime. These discrepancies were confirmed by staff interviews, indicating a failure to adhere to physician orders for oxygen therapy.
Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
The facility failed to ensure that ground meat was provided in accordance with physician orders and did not provide specialized dietary instructions to nursing staff for six residents on a memory care unit. This resulted in a cognitively impaired resident with a history of food stuffing ingesting regular meat, leading to airway blockage and the resident's death. The resident had an order for a diet with ground meat, but the dietary staff did not send the ground meat or dietary cards for the evening meal. The staff served the resident Polish sausage cut into pieces, which led to the resident becoming unresponsive and ultimately passing away due to aspiration of food. The incident report indicated that the resident was found unresponsive with sausage in her mouth and airway after the evening meal. Despite attempts to revive the resident using the Heimlich Maneuver and CPR, the resident was pronounced deceased by EMS. The coroner confirmed the cause of death as aspiration of food. The facility's dietary manager admitted that the dietary staff forgot to send the ground meat and meal tickets, and the nursing staff did not alert the dietary staff about the missing items. Further review revealed that five other residents on the memory care unit had physician orders for mechanically altered diets with ground meat, but their care plans did not include these dietary instructions. During a meal observation, another resident was served breaded shrimp that was not mechanically altered, contrary to the physician's order. The facility's policies required that meals be verified to match the prescribed diet, but these procedures were not followed, leading to the deficiencies observed.
Removal Plan
- The facility assessed all residents for their current diet orders.
- Audits to residents' care plans and dietary tray cards were completed.
- Any discrepancies were corrected.
- Nursing staff were in-serviced regarding checking resident tray cards when setting up resident trays and removing trays when residents were done eating.
- Dietary staff were in-serviced on preparing diet consistencies and sending tray cards to the units.
Failure to Supervise Cognitively-Impaired Resident During Meals
Penalty
Summary
The facility failed to ensure adequate supervision for a cognitively-impaired resident with a history of food stuffing, leading to the resident's death. The resident, who was on the Memory Care Unit, had a care plan that required supervision during meals due to her tendency to stuff food into her mouth without chewing. However, during the evening meal, the staff did not adequately supervise the resident, allowing her to ingest and aspirate a large amount of unchewed food, specifically sausage, which led to her becoming unresponsive and ultimately passing away despite resuscitation efforts by the staff and EMS. The incident report and subsequent interviews revealed that the resident was wandering in and out of the dining room during the meal and was observed trying to take food from other residents' plates. The staff present in the dining room did not have a clear view of the entire area and failed to monitor the resident effectively. The resident was later found unresponsive in her room with sausage obstructing her airway. Despite attempts to clear the airway and perform CPR, the resident could not be revived and was pronounced dead by EMS. The coroner confirmed the cause of death as aspiration of food. The resident's medical records indicated a history of dementia and psychotic disorder with delusions, and she had a documented behavior of rapidly consuming food without chewing. Despite this, the care plan did not include specific interventions for her behavior of taking food from other residents' plates. The dietary staff also failed to provide the required ground meat for the resident's meal, and the nursing staff did not follow up to ensure the dietary instructions were met. This lack of supervision and failure to adhere to dietary requirements directly contributed to the resident's death.
Removal Plan
- The facility assessed all residents for the need of additional supervision and implemented at-risk interventions.
- Reviewed residents in need of additional supervision for appropriate care and interventions, and updated care plans.
- Inserviced nursing staff regarding supervision and safety during meals.
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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