River Bend Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 3400 Stocker Dr, Evansville, Indiana 47720
- CMS Provider Number
- 155621
- Inspections on file
- 38
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at River Bend Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident was subjected to verbal abuse when a CNA used inappropriate language during care, in violation of the facility’s abuse policy that requires residents be free from verbal, mental, sexual, and physical abuse and be treated with respect and dignity. The incident was investigated and determined to meet the facility’s definition of verbal abuse, which includes intimidation or punishment causing mental anguish.
The facility failed to maintain complete and timely documentation for several residents, including missing or retroactively entered care conference notes for a resident with multiple sclerosis and another with severe cognitive impairment, where quarterly care plan conferences were not documented until much later. A resident with chronic kidney disease and diabetes had large gaps in recorded weights despite orders for monthly and then weekly weights, and the DON reported the resident refused weights but staff did not document refusals. For a resident with COPD and an indwelling catheter, the eMAR/eTAR showed multiple undocumented administrations of Lyrica, blood glucose checks, BIPAP care, and ordered small frequent meals, with the DON stating staff said they provided the care but failed to chart it. Another resident with congestive heart failure and an insulin lispro sliding scale had numerous early-morning insulin doses not documented as given, with the DON indicating that insulin administration at breakfast was sometimes missed in documentation.
Surveyors identified a failure to maintain a safe, sanitary environment when strong, persistent odors were observed in multiple common areas and units, including hallways, the main lobby, and an area outside a conference room. Odors noted included urine, sewer gas, and bowel movement smells. During an interview, the Administrator stated that odors should be controlled through routine cleaning and increased cleaning in odor-prone areas. The facility’s Environmental policy requires staff and management to promote pleasant, neutral scents and minimize institutional odors, but the observed conditions did not meet these standards.
Surveyors found that the facility failed to consistently implement care plan interventions for two residents, one at high risk for falls and one with a pressure ulcer and continuous tube feeding. A resident with cognitive impairment and a history of multiple falls was observed without required nonskid socks and with the call light out of reach, while the wheelchair was placed in the resident’s line of sight despite prior falls during self-transfer attempts. Another resident with a coccyx wound and PEG tube feeding did not receive wound care as ordered, as an RN applied triad and collagen without cleansing the area first and laid the resident flat without pausing continuous tube feeding, contrary to care plan aspiration precautions requiring head-of-bed elevation during feedings.
A resident receiving O2 therapy was observed with undated O2 tubing, water bottle, and nebulizer equipment, and without an “Oxygen in Use” sign posted on the room door. On another observation, the resident was in bed without O2, and the nebulizer mask was on the floor with undated tubing. Record review showed no physician order for O2 and no care plan addressing O2 use. In interviews, a hospice provider and an RN stated that residents on O2 should have an order with the facility, and the facility’s O2 administration policy requires a physician’s order, review of the care plan, and an O2-in-use sign, which were not in place for this resident.
Surveyors observed failures in infection prevention practices, including a glucometer on the insulin cart with visible blood spots that had not been cleaned between uses, and improper PPE and hand hygiene during tracheostomy suctioning for a resident on Enhanced Barrier Protocol. An RN did not perform hand hygiene before donning gloves, did not wear a gown, used the same gloves to open a trach care kit and sterile water, contaminated a sterile glove by touching the trach collar, and then handled the suction catheter without changing gloves or re-washing hands, while two CNAs assisted in the room without gowns. Staff interviews confirmed that gowns should have been worn for EBP, gloves changed when moving from dirty to clean tasks, and glucometers cleaned after each use, consistent with facility policies on hand hygiene, PPE, and glucometer disinfection.
The facility failed to notify residents or their representatives of the bed hold policy during hospital transfers. A resident with a fractured neck, another with multiple hospitalizations, and others requiring substantial assistance were not provided with the necessary documentation. The DON confirmed the absence of transfer paperwork and bed hold policies.
The facility failed to properly store medications, as loose pills were found in medication carts across three halls. Despite a policy requiring drugs to be stored in their original packaging, numerous loose pills with various markings were observed. An RN noted that carts are cleaned bi-weekly, but the presence of loose pills indicates non-compliance with the storage policy.
The facility failed to serve food at appropriate temperatures, with a test tray showing a grilled cheese at 117°F and fruit cocktail at 60.2°F, both cooler than required. Residents reported the food as unappetizing and repetitive, and the Ombudsman noted several complaints. The facility's policy requires hot food to be at least 135°F and cold food at or below 41°F.
The facility failed to properly store, label, and date food items, as observed during multiple kitchen inspections. Items such as onions, lettuce, tea, and various sauces were found without proper dates, and temperature logs were incomplete. The Interim Dietary Manager confirmed that open lettuce should be dated and temperatures recorded twice daily. Further inspections revealed additional items without dates, and inconsistencies in temperature logs were noted, with housekeeping responsible for checks.
The facility was found to have a persistent urine odor in several areas, including hallways and a conference room, over six days. Staff interviews confirmed awareness of the issue, attributing it to a resident urinating on the floor. Additionally, air conditioning units in resident rooms were observed with flaking paint and rust, indicating poor maintenance. The facility's maintenance policy requires documentation of compliance, but the observed conditions suggest non-adherence.
The facility failed to provide SNF-ABN and NOMNC forms to two residents who remained in the facility after their Medicare services ended. One resident did not receive a SNF-ABN form despite being notified of the end of coverage, while another did not receive either form due to a discharge from therapy. The Social Services Director acknowledged the oversight and a lack of understanding of the Medicare coverage process.
A facility failed to provide necessary transfer documentation for a resident who was emergently sent to the hospital after a fall resulting in a fractured neck. The resident's clinical record lacked any transfer paperwork, which was confirmed by the DON during interviews. The DON acknowledged that essential documents like the face sheet and bed hold policy should have been sent with the resident.
A facility failed to notify the Ombudsman office about an emergency hospital transfer of a resident with a fractured neck. The resident, who is moderately cognitively impaired, was transferred without the necessary paperwork or notification to the Ombudsman. Interviews revealed that the required transfer forms were missing, and the Social Service Director acknowledged the oversight.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing behaviors, accidents, and nutrition. A resident with dementia was observed eating non-food items without a behavior-focused care plan. Another resident involved in an altercation lacked documentation and a care plan for the incident. A third resident experienced significant weight loss without an updated intervention plan, despite being on nutritional supplements.
The facility failed to conduct quarterly care plan conferences for two residents, one with dementia and anxiety, and another with multiple sclerosis and other conditions. Both residents were dependent on staff for daily activities, and the required care plan conferences were not held within the specified periods. The Social Services Director and DON confirmed the necessity of these quarterly reviews.
A facility failed to provide person-centered activities for a resident with dementia and anxiety. The resident was often positioned in a way that obstructed her view of the television and was not invited to group activities. Despite a care plan emphasizing engagement, there was no documentation of activity participation, and a CNA noted restrictions in assisting residents to activities.
A resident with multiple sclerosis and vision impairments was not assessed by vision services for over a year, despite wearing cloudy glasses and having difficulty with her prescription. The facility's policy requires assistance in arranging such services, but the resident's clinical record lacked documentation of evaluations or transportation offers since April 2023. Interviews revealed a gap in the process for arranging vision services.
A resident with a suprapubic catheter experienced infections due to inadequate care and maintenance by the facility. The catheter was not changed or documented as required, and staff failed to follow enhanced barrier precautions. Observations showed improper placement of the catheter bag and lack of training for CNAs on catheter care. Interviews revealed confusion among staff about care responsibilities, contributing to the resident's infections.
A facility failed to provide sufficient fluid intake to a resident, who was found with an empty cup and an unreachable call light. The resident, dependent on staff for daily activities and on diuretic medication, expressed concerns about inadequate fluid intake. Despite being at risk for dehydration due to medical conditions and diuretic use, the facility did not closely monitor fluid intake, contrary to their hydration policy.
The facility failed to provide and dispense medications as ordered for two residents. A resident did not receive their prescribed ProStat supplement due to unavailability, and another resident's ProStat AWC SF was inconsistently administered, with doses missed or incorrectly given. The facility's medication management practices were inadequate, impacting residents with significant medical needs.
The facility exceeded the acceptable medication error rate with an 8% error rate during a medication pass. An LPN failed to prime insulin pens before administering insulin to two residents, contrary to manufacturer instructions. This resulted in incorrect dosing for both residents, as the facility's policy requiring adherence to manufacturer guidelines was not followed.
A facility failed to consistently document wound care treatments for a resident with pressure injuries on the right buttock and heel. Despite specific orders for wound care, records showed incomplete documentation on several dates. The DON could not explain the inconsistency, and the staff nurse's job description included responsibilities for ensuring proper care and treatment administration.
The facility failed to follow infection control practices for three residents, including improper use of mechanical lift slings, inadequate hand hygiene during incontinence care, and inconsistent use of gowns and masks during catheter care. These actions were contrary to the facility's infection control policies.
The facility failed to maintain a pest-free environment, with flies and gnats observed in a resident's room and the Second Floor Nurse's Station. A resident reported previous pest issues, and the Administrator was unaware of the problem. The facility's pest control policy requires a clean environment and an active pest control contract.
A resident sustained fractures to both ankles due to inadequate safety measures during transport. In one incident, the resident's foot was caught under the wheelchair due to missing footrests, and in another, the resident slid out of the wheelchair because the seatbelt was not properly secured. The resident, who had a history of mobility issues, required medical intervention for her injuries.
The facility failed to properly dispose of and store medications for discharged and deceased residents, with controlled medications not double locked and improper temperature controls. Medications for residents who had expired or been discharged were not disposed of timely, and there was inadequate documentation for non-narcotic medication disposition.
The facility failed to develop and implement a timely care plan for a resident with an enteral feeding tube. Despite physician orders, the care plan did not include a focus on the feeding tube until much later, and observations revealed that the enteral feeding pump was not running as ordered. Staff interviews and record reviews indicated a lack of documentation and adherence to facility policies.
A resident with a history of inappropriate sexual behavior inappropriately touched another resident, who has a history of mental health issues, in a common area of the facility. The incident was observed by staff, and the residents were separated immediately. Despite the facility's awareness of the perpetrator's behavior, the incident occurred, indicating a failure in monitoring or intervention strategies.
Failure to Protect a Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse by facility staff. On 4/9/26 at 8:32 a.m., a CNA (CNA 2) used inappropriate language toward Resident B during the provision of care. This conduct was documented in a state reportable incident reviewed on 4/28/26 at 9:00 a.m., which identified the event as verbal abuse. The facility’s own abuse policy, revised in 9/22 and provided by the Administrator, states that residents have the right to be free from abuse, including verbal, mental, sexual, or physical abuse, and that residents must be treated with respect and dignity. The policy further defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish, and includes verbal abuse and mental abuse. Despite this policy, the interaction between CNA 2 and Resident B during care involved inappropriate language that met the facility’s definition of verbal abuse. The Administrator later confirmed that verbal abuse was substantiated following an investigation. This constituted a failure to ensure that Resident B was free from verbal abuse as required by facility policy and regulatory standards.
Incomplete and Late Clinical Documentation for Care Conferences, Weights, and Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical documentation and care conference records for multiple residents. For one resident with multiple sclerosis and quadriplegia who was cognitively intact and dependent on staff for all ADLs, the record showed the most recent completed care conference on one date, with a later care conference note marked as “in progress” and not completed. The Social Services Director later produced several care conference notes for this resident that were all created and signed in the EHR on the same later date, despite being dated for earlier months, and stated she took notes in a notebook and entered them into the EHR whenever she had the chance, acknowledging she had fallen behind on documentation. Another resident with congestive heart failure and severe cognitive impairment had no quarterly care plan conferences documented since admission, and the record later showed multiple quarterly care plan conferences that were all created on the same later date, although they were dated for earlier months. The facility also failed to accurately document weights and refusals for a resident with chronic kidney disease and diabetes mellitus who was cognitively intact and dependent on staff for toileting. The care plan included monitoring weight and intake and educating and documenting refusals, and physician orders required monthly weights and then weekly weights. The weight summary showed only a single weight in October and then weights in January, with a significant decrease, and an IDT note referenced a three percent weight decrease and missing weights from October to January. The TAR for November and December had blank monthly weight entries with no staff signatures, and the DON reported the resident was noncompliant and refused to be weighed in those months, but staff did not document the refusals. Additional documentation deficiencies were identified in medication and treatment administration records for residents with chronic obstructive pulmonary disease and congestive heart failure who required insulin and other treatments. For one resident with COPD, oxygen therapy, and an indwelling catheter, the eMAR/eTAR showed multiple dates when Lyrica, blood sugar checks, BIPAP-related tasks, and ordered small frequent meals were not documented as administered or refused; the DON reported that staff working those shifts stated they had provided the medications and treatments but missed the documentation. For another resident with congestive heart failure and an insulin lispro sliding scale order, the eMAR showed numerous early-morning doses not administered, and the DON explained that night shift nurses obtained blood sugars and relayed results to day shift nurses, who then gave insulin at breakfast, but documentation sometimes was missed.
Failure to Maintain Odor-Free, Sanitary Environment in Common Areas and Units
Penalty
Summary
The facility failed to provide a safe and sanitary environment by not maintaining pleasant, neutral scents and minimizing institutional odors as required by its Environmental policy. During multiple observations, surveyors noted strong, persistent odors in several areas of the building. On 1/22/26 at 9:40 A.M., the hallways on Stocker Unit 1 and Stocker Unit 2 had a strong smell of urine. On 1/23/26 at 8:56 A.M., the main lobby, Stocker Unit 1, and Stocker Unit 2 had a strong, pungent odor consistent with sewer gas. On 1/28/26 at 9:05 A.M., the hallway outside of the conference room had an odor consistent with bowel movement. In an interview, the Administrator stated that odors in the facility should be controlled by general routine cleaning and that staff should increase cleaning in areas prone to odors. The facility’s written Environmental policy, dated 5/17 and provided by the Administrator, states that staff and management shall maximize pleasant, neutral scents and minimize institutional odors, but the observed conditions did not align with these policy expectations. No specific residents or their medical conditions were identified in the report; the deficiency was based on environmental observations in common areas and units accessible to residents, staff, and the public.
Failure to Implement Care Plan Interventions for Falls and Pressure Ulcer Management
Penalty
Summary
Surveyors identified that the facility did not fully implement and maintain care plan interventions for a resident at high risk for falls. One resident with senile degeneration of the brain, muscle weakness, impaired cognition, and a documented high fall risk had a care plan that required a safe environment, call light within reach, and nonskid socks at all times as the resident allowed. Despite multiple prior falls related to self-transfers and added interventions such as nonskid socks, alarms, and safe storage of assistive devices, the resident was observed sitting in a wheelchair wearing plain white socks without nonskid tread. On another occasion, the resident was observed in bed with the call light under the bed and the wheelchair positioned in the resident’s line of sight, contrary to staff’s stated practice of storing the wheelchair out of sight to reduce self-transfer attempts. Surveyors also found that the facility failed to follow physician orders for wound care for a resident with a coccyx wound. The resident, who had chronic respiratory failure, was rarely or never understood, and was dependent on staff for all ADLs, had a physician order directing staff to cleanse the coccyx wound with wound cleanser, pat dry, then apply a mixture of triad and collagen particles to the wound bed and leave it open to air once per day on the day shift. During an observed treatment, an RN entered the room, turned the resident, laid the bed down, removed existing paste from the coccyx area using the pad under the resident, changed gloves, and applied a mixture of collagen and triad with a cotton swab. The RN did not cleanse the wound area before applying the new paste, contrary to the physician’s order. In addition, the facility did not adhere to care plan interventions related to aspiration precautions for the same resident receiving continuous tube feeding. The resident’s care plan required keeping the head of the bed elevated 45 degrees during tube feeding and for one hour after completion. During the observed wound treatment, the RN used the bed remote to lay the bed down without pausing the resident’s continuous PEG tube feeding. The Infection Prevention Nurse later stated that a resident receiving continuous tube feeding should not be laid flat and that staff should follow treatment orders as written by the physician. These observations demonstrated that care plan and physician-ordered interventions for both fall prevention and pressure ulcer management were not consistently implemented as planned.
Failure to Ensure Ordered and Properly Managed Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care for a resident receiving oxygen therapy by not ensuring required orders, care planning, equipment dating, and signage were in place. During an observation, the resident was found in bed with oxygen tubing connected to a concentrator, but the tubing and water bottle, as well as the nebulizer, were not dated, and there was no oxygen administration sign posted on the door. On a later observation, the same resident was in bed without oxygen in use, and the nebulizer face mask was on the floor with tubing that also lacked a date. Review of the physician orders showed there was no documented order for oxygen, and the clinical record did not contain a care plan addressing oxygen use. In interviews, a hospice provider stated that residents on oxygen should have an order with the facility, and an RN confirmed there should be an oxygen order for anyone utilizing it. The facility’s own oxygen administration policy, provided by the Administrator, requires verification of a physician’s order, review of the resident’s care plan for special needs, and placement of an “Oxygen in Use” sign on the room entrance door, all of which were not followed for this resident.
Failure to Follow Infection Control Practices for Tracheostomy Care and Glucometer Cleaning
Penalty
Summary
Surveyors identified a failure to follow infection prevention and control practices related to glucometer cleaning and use of personal protective equipment (PPE) and hand hygiene. During a random observation of the insulin cart, a glucometer was found with two visible spots of blood on the machine, despite facility policy stating that glucometers must be cleaned and disinfected after each use on each patient. In an interview, a registered nurse confirmed there should be no blood on glucometers and that they are to be cleaned between each use. In a separate observation of tracheal suctioning for a resident on Enhanced Barrier Protocol (EBP) due to a tracheostomy, multiple infection control breaches were observed. The RN performing the procedure did not wash hands before donning gloves and did not wear a gown, and two CNAs who entered the room to assist with repositioning the resident also did not don gowns, although they wore gloves. The RN used the same gloves to open the tracheostomy care kit and sterile water, then removed gloves and washed hands before donning a single sterile glove on the right hand. The RN then touched the trach collar with the sterile gloved hand, did not remove the glove or perform hand hygiene, and subsequently touched the suction catheter with a now-contaminated glove without changing to a new sterile glove or washing hands. The RN proceeded to perform multiple suction passes, cleared the catheter with sterile water, placed the catheter into a container uncurled, reattached the trach collar, and then removed gloves and discarded the suction catheter. In interviews, the RN, CNAs, and Infection Preventionist acknowledged that gowns should have been worn for EBP and that gloves should be changed when moving from dirty to clean tasks, and that glucometers should be cleaned after each use. Facility policies on hand hygiene, PPE, and glucometer cleaning supported these requirements.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide notification of transfer and bed hold policy to residents or their representatives in cases of hospitalization. This deficiency was identified in the records of four residents who were reviewed for hospitalizations. Resident 7, who was moderately cognitively impaired, was emergently transferred to the hospital after a fall resulting in a fractured neck, but the clinical record lacked any transfer paperwork and bed hold policy. The Director of Nursing (DON) confirmed the absence of these documents during an interview. Similarly, Resident 51, who was cognitively intact and had multiple hospitalizations, did not receive a bed hold policy for any of the transfers. Resident 53, who required substantial assistance and had been hospitalized twice, also lacked documentation of a bed hold policy. Lastly, Resident 57, who was not cognitively intact and under hospice care, was hospitalized without receiving a bed hold policy. The facility's policy on changes in resident condition or status was provided by the DON, but it was non-dated and did not ensure compliance with the notification requirements.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications, as evidenced by the presence of loose pills in the medication carts across three different halls. On November 7, 2024, during a review of the medication cart for rooms 310 to 317, several loose pills were found in the bottom of the drawers, including a blue oval capsule, red circle pills, light blue circle pills, and others with various markings. Similar observations were made in the 400 hall medication cart and the upstairs medication cart, where numerous loose pills with different markings were found scattered in the drawers. Registered Nurse 5 indicated that medication carts were cleaned out every two weeks during the night shift, and loose pills were disposed of in the drug buster or sharps container. The facility's current Storage of Medications policy, revised in April 2007, states that drugs and biologicals should be stored in the packaging, containers, or other dispensing systems in which they are received. However, the presence of loose pills in the medication carts indicates a failure to adhere to this policy, leading to the deficiency noted in the report.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures and taste, as evidenced by a test tray from the 200 Hall. The grilled cheese sandwich was served at 117 degrees Fahrenheit, and the fruit cocktail was at 60.2 degrees Fahrenheit, both of which were cool to taste. According to the Interim Dietary Manager, hot food should be served at a minimum of 155 degrees Fahrenheit, and cold food should be served at a minimum of 41 degrees Fahrenheit. Additionally, Resident 6 expressed that the food was not appetizing and often repetitive, while Resident 15 mentioned receiving a lot of sandwiches. The Ombudsman reported several anonymous complaints about food and meals after a resident council meeting. The facility's current policy, dated July 2023, states that foods should be transported and delivered to maintain temperatures at or below 41 degrees Fahrenheit for cold items and at or above 135 degrees Fahrenheit for hot items.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of food items in accordance with professional standards during multiple kitchen observations. During an initial tour of the kitchen, several items were found improperly stored or labeled, including a box of onions with a sprouted onion, bags of lettuce, pitchers of tea, and various other food items without dates. The temperature log for the drink refrigerator was incomplete, missing entries for specific shifts. The Interim Dietary Manager acknowledged that open lettuce should be dated and is typically good for only three days, and that temperatures should be recorded twice daily. Further observations revealed additional issues, such as an open bag of biscuits without an open date, and spices and sauces without proper labeling. A second walkthrough found more items without dates, including Worcestershire sauce and cottage cheese. The kitchenette nutrition refrigerator on the first floor lacked a temperature log and contained several items without names or open dates. The administrator indicated that housekeeping was responsible for temperature checks, but inconsistencies were noted in the logs. The facility's policies on storage and food from outside sources were provided, but no specific policy for the kitchenette refrigerator was produced.
Facility Fails to Maintain Sanitary Environment and Equipment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, staff, and the public, as evidenced by multiple observations of strong urine odors and deteriorating conditions of air conditioning units. Over a period of six days, surveyors noted a persistent smell of urine in various areas, including the conference room, the 400 Unit Nurse's Station Hallway, and the 400 Unit Hallway. Interviews with staff, including an LPN and the Administrator, confirmed awareness of the odor issue, attributing it to a resident urinating on the floor. Despite this acknowledgment, the problem persisted across multiple days and locations. Additionally, the facility's maintenance of heating and air conditioning units was found lacking, with observations of paint flaking and rust on units in resident rooms. The facility's current maintenance policy, dated March 2015, was provided by the DON, indicating a requirement for documentation of functional compliance for heating and cooling systems. However, the observed conditions suggest a failure to adhere to these standards, contributing to an unsanitary and potentially unsafe environment for residents.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the necessary SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) forms to two residents who were discharged from Medicare services but remained in the facility. Resident 9, who began receiving Medicare Part A Skilled Services on August 26, 2024, had her last covered day on October 18, 2024. Although she received a NOMNC form indicating the end of her Medicare coverage, she did not receive the required SNF-ABN form. The Social Services Director confirmed that Resident 9 remained in the facility and acknowledged the oversight in not providing the SNF-ABN form. Similarly, Resident 215, who started receiving Medicare Part A Skilled Services on June 24, 2024, had her last covered day on July 31, 2024. She did not receive either the SNF-ABN or NOMNC forms because she was discharged from therapy before the end of her covered days. The Social Services Director admitted that Resident 215 remained in the facility and had not received the necessary forms since 2022. The Director also indicated a lack of understanding of the Medicare Part A coverage process, which contributed to the failure in providing the required notifications.
Failure to Provide Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to provide the necessary documentation for a resident who was emergently transferred to the hospital. The incident involved a resident with diagnoses including a fracture of the neck and disorders of bone density. Upon review of the clinical record, it was found that there was no transfer paperwork accompanying the resident when they were sent to the hospital following a fall that resulted in a fractured neck. During interviews, the Director of Nursing (DON) confirmed the absence of transfer forms and acknowledged that documents such as the face sheet and bed hold policy should have been sent with the resident to the hospital.
Failure to Notify Ombudsman of Emergency Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman office regarding the emergency transfer of a resident to the hospital. Resident 7, who is moderately cognitively impaired and has diagnoses including a fracture of the neck and disorders of bone density, was emergently transferred to the hospital after a fall resulting in a fractured neck. The clinical record lacked any transfer paperwork or information sent to the Ombudsman for this hospitalization. Interviews with the Director of Nursing and the Social Service Director revealed that there were no transfer forms located, and the Social Service Director acknowledged the absence of the required notification to the Ombudsman. An email from the Ombudsman Office indicated that information regarding emergency transfers expected to return can be provided in a monthly list to the State LTC Ombudsman portal.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing behaviors, accidents, and nutrition. Resident 39, who has unspecified dementia and cognitive communication deficits, was observed eating puzzle pieces, indicating a need for a behavior-focused care plan. Despite discussions between the Social Service Director and the family about the resident's behaviors, the care plan lacked specific interventions for these behaviors. Resident 58, diagnosed with dysphagia and PTSD, was involved in an altercation with a roommate, resulting in a room transfer. However, there was no documentation of the incident or a care plan addressing the retaliatory behavior that led to the room change. The Social Services Director acknowledged the oversight in documentation and care planning. Resident 15 experienced significant weight loss, dropping from 200.1 lbs to 164.6 lbs over several months. Despite being on nutritional supplements and having a care plan indicating a risk for weight loss, there was no updated intervention plan to address the ongoing weight loss. The facility's policy required monthly weight monitoring, but the care plan was not revised to reflect the resident's nutritional needs adequately.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to conduct quarterly care plan conferences for two residents, Resident 13 and Resident 29, as required. Resident 13, who has diagnoses including dementia and anxiety, did not have a quarterly care plan conference between March 20, 2024, and September 25, 2024. A significant change MDS assessment dated October 8, 2024, indicated that Resident 13's cognition level was not assessed due to diminished cognition, and the resident was dependent on staff for toileting, bathing, and transfers. Similarly, Resident 29, diagnosed with multiple sclerosis, involuntary eye movements, and kidney calculus, did not have a quarterly care plan conference between April 4, 2024, and August 21, 2024, through November 14, 2024. An annual MDS assessment dated August 13, 2024, showed that Resident 29 was cognitively intact but dependent on staff for eating, toileting, bathing, and transfers. The Social Services Director confirmed that care plan conferences should occur at least quarterly, and the Director of Nursing provided documentation indicating that the interdisciplinary team must review and update the care plan quarterly in conjunction with the required MDS assessment.
Failure to Provide Person-Centered Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide person-centered engagement activities for a resident with dementia and anxiety. Observations over several days revealed that the resident was consistently positioned in her wheelchair in a way that obstructed her view of the television, either by a large plant or by facing away from the screen. On multiple occasions, the television was on a menu screen, indicating a lack of engagement. Additionally, the resident was not offered the opportunity to attend group activities, such as bingo, despite being in the common area during these events. The resident's care plan emphasized the importance of involving her in daily activities, encouraging socialization, and providing one-on-one conversations. However, there was a lack of documentation in the clinical record regarding invitations to or participation in activities since the last care plan revision. A CNA indicated that the resident would participate in group activities if assisted by staff, but personal restrictions prevented the CNA from bringing residents to activities. The facility's policy required effective communication and documentation of resident participation in activities, which was not adhered to in this case.
Failure to Arrange Vision Services for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 29, received proper treatment to maintain vision abilities. Resident 29, who has diagnoses including multiple sclerosis, diplopia, and involuntary eye movements, was observed wearing cloudy glasses and reported not having been assessed by vision services in over a year. The resident's clinical record indicated a lack of documentation showing that she had been evaluated by vision services or offered transportation for such services since April 2023, despite care plan interventions requiring consultation with an eye care practitioner and ensuring glasses are in good repair. Interviews with facility staff revealed a gap in the process for arranging vision services. The Social Services Director indicated that residents must request health services like vision screenings, or it should be agreed upon admission and discussed during care plan conferences. However, the facility's policy on the care of visually impaired residents states that it is the facility's responsibility to assist residents in locating resources, scheduling appointments, and arranging transportation for needed services. This discrepancy contributed to the failure in providing necessary vision care for Resident 29.
Inadequate Suprapubic Catheter Care Leads to Infections
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, leading to an infection at the catheter insertion site and multiple urinary tract infections. The resident, who had a history of prostate cancer and other medical conditions, was found to have a suprapubic catheter that was not being maintained according to physician orders. The clinical record lacked specific orders for routine catheter care beyond monthly changes, and there were inconsistencies in the documentation of catheter changes in the Medication/Treatment Administration Record. Observations revealed that the resident's catheter bag was improperly placed on the floor, and staff did not adhere to enhanced barrier precautions during care. Certified Nursing Aides (CNAs) were observed using a mechanical lift sling on the resident without washing it between uses, and they did not wear gowns as required for enhanced barrier precautions. Additionally, the facility's policies did not specify the frequency of suprapubic catheter care, and there was a lack of in-service training for CNAs on catheter care. Interviews with staff indicated confusion and lack of clarity regarding the responsibilities for catheter care. The Registered Nurse (RN) and Director of Nursing (DON) acknowledged that the catheter site should be cleansed daily, but this was not consistently documented or performed. The facility's failure to ensure proper catheter care and adherence to infection control protocols contributed to the resident's infections.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered sufficient fluid intake to maintain proper hydration and health. During an observation, the resident was found in bed with the call light out of reach and an empty cup labeled from the previous night on the bedside table. The resident expressed that she did not feel she received enough fluids and was unable to call for staff assistance due to her physical condition and the call light being out of reach. The resident's clinical record indicated she was dependent on staff for eating, toileting, bathing, and transfers, and was on diuretic medication, which increases the risk of dehydration. The resident had a history of multiple sclerosis, hydronephrosis, and kidney stones, and had been admitted to the hospital for kidney stones and a urinary tract infection related to sepsis. A nutritional risk assessment indicated the resident was at risk for dehydration due to recurrent infection and diuretic use, requiring an estimated 1600-1900 mL of fluid daily. However, the facility's Director of Nursing indicated that residents were not closely monitored for exact fluid intake unless on a fluid restriction, and nurses were expected to assess for signs of dehydration each shift. The facility's policy on hydration required staff to identify and report individuals with signs of fluid imbalance, but this was not effectively implemented for the resident in question.
Medication Availability and Dispensing Deficiency
Penalty
Summary
The facility failed to ensure that routine medications were available and dispensed according to physician's orders for two residents. For Resident 15, it was observed that the medication cart did not contain ProStat, a protein supplement prescribed to be administered twice daily. The Qualified Medicine Aide (QMA) indicated that the medication was not available and mistakenly believed it could be obtained from medications of discharged residents. Resident 15's medical history included dysphagia and gastro-esophageal reflux disease, necessitating the prescribed supplements. For Resident 47, the facility did not maintain an adequate supply of ProStat AWC SF, a wound healing supplement. The Medication Administration Record indicated multiple instances where the supplement was not administered as ordered, with some doses being missed or incorrectly administered. The Registered Nurse (RN) and Director of Nursing (DON) confirmed the absence of the supplement in the supply room, and it was noted that the resident had been receiving the supplement from a general supply that had run out. Resident 47's medical conditions included pressure ulcers, hemiplegia, cancer, diabetes, and coronary artery disease, highlighting the importance of the prescribed wound healing supplement.
Medication Error Rate Exceeds 5% Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in an observed error rate of 8 percent during a medication pass. This deficiency was identified through the observation of two medication errors out of 25 opportunities for error. Specifically, the errors involved the administration of insulin to two residents. In both cases, the Licensed Practical Nurse (LPN) did not prime the insulin pens before administering the medication, which is a necessary step to ensure accurate dosing as per the manufacturer's instructions. The first incident involved a resident with a blood glucose level of 198 mg/dL, who was administered 3 units of insulin lispro without priming the pen. The second incident involved another resident with a blood glucose level of 145 mg/dL, who was administered 2 units of insulin aspart, again without priming the pen. The facility's insulin administration policy, which requires nursing staff to follow manufacturer instructions for insulin delivery systems, was not adhered to. This oversight was further compounded by a registered nurse's incorrect assertion that priming was unnecessary, despite clear instructions in the insulin pen manuals.
Inconsistent Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure consistent documentation for wound care treatments for a resident with multiple pressure injuries. The resident, who was diagnosed with pressure ulcers on the right buttock and right heel, along with other medical conditions such as hemiplegia, hemiparesis, prostate cancer, diabetes mellitus type 2, coronary artery disease, and peripheral vascular disease, required specific wound care treatments. The clinical records indicated that the resident was mild to moderately cognitively impaired and required extensive assistance from two staff members for bed mobility, transferring, and toileting. Despite having orders for specific wound care treatments, the Medication Administration Record/Treatment Administration Record showed incomplete documentation of these treatments on several dates in October and November 2024. The Director of Nursing was unable to provide an explanation for the inconsistent documentation of the treatments. The job description for the staff nurse indicated responsibilities for receiving and transcribing orders and ensuring the competent administration of care and treatments according to physician orders and facility policy. However, the records revealed that the treatments for the resident's pressure injuries were not consistently documented, leading to a deficiency in the facility's care practices.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices for three residents, leading to deficiencies in care. For Resident 47, who had multiple open wounds and an indwelling suprapubic catheter, CNAs used a mechanical lift sling that had been previously used on another resident without washing it between uses. Additionally, the CNAs did not wear gowns for enhanced barrier precautions during the care of Resident 47. In another instance, CNAs providing incontinence care for Resident 8 did not change gloves or sanitize their hands before placing a new brief on the resident. Furthermore, an LPN changing a dressing on Resident 8's right shoulder did not change gloves or sanitize hands before applying a clean bandage. During catheter care for Resident 29, the resident expressed discomfort with staff wearing gowns and face masks, which was not a usual practice. The facility's policies on infection control and enhanced barrier precautions were not followed, contributing to these deficiencies.
Pest Control Deficiency in Resident Areas
Penalty
Summary
The facility failed to maintain a safe environment free of pests, as evidenced by multiple observations of flies and gnats in resident areas. On three separate occasions, surveyors observed flies and gnats in Resident 15's room and the Second Floor Nurse's Station. Resident 15 reported previous incidents of flies and gnats in their room. During an interview, the Administrator was unaware of the pest issue in the resident's room. The facility's pest control policy, dated August 2011, mandates a clean and sanitary environment free from pests and requires an appropriate pest control contract to be in operation.
Transport Safety Failures Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate safety measures during the transport of a resident, resulting in two separate incidents that led to injuries. In the first incident, the resident was being transported to an appointment when her foot got caught beneath the wheelchair due to the absence of footrests. This resulted in a fracture to her left ankle. The driver, who was aware that footrests should be used, did not attach them because the resident typically self-propelled her wheelchair. However, during this transport, the resident was being pushed, and the lack of footrests led to the injury. In the second incident, the same resident was being transported in the facility van when she slid out of her wheelchair. The driver had not properly secured the seatbelt, which allowed the resident to slide out of the chair, resulting in a fracture to her right ankle. The driver had previously been educated on the proper use of seatbelts but failed to apply this knowledge during the transport. The resident reported that the driver did not buckle her in properly and only secured the legs of the wheelchair, which contributed to her sliding out of the chair. The resident involved in these incidents had a medical history that included fractures to both lower legs, osteoarthritis, diabetes mellitus, and pain. She was dependent on a wheelchair for mobility and required assistance for transfers and other activities of daily living. The facility's failure to adhere to safety protocols during transport directly led to the resident sustaining injuries that required medical intervention.
Medication Disposal and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper disposal and storage of medications for discharged and deceased residents, as well as maintaining appropriate security and temperature controls for medications. Observations revealed that controlled medications were not double locked, and the refrigerator containing these medications was not secured with a locked padlock. Additionally, the refrigerator freezer had a thick layer of ice with unidentifiable medication packages stuck in it, and there was no temperature log sheet for the refrigerator. Medications for residents who had been discharged or had expired were not disposed of in a timely manner, and there was a lack of documentation for the disposition of non-narcotic medications. Specific instances included a bottle of lorazepam intensol for Resident H, whose medication had been discontinued, and a bottle for Resident G, both found in the refrigerator. A bottle of lorazepam intensol with no resident identifier was found in a cup labeled with Resident E's name, who had expired at the facility. Medications for Resident D and Resident J, who had also expired or been discharged, were found improperly stored. The facility's procedure for drug disposition was inadequate, as non-narcotic medications were placed in a tote for pharmacy pickup without proper documentation, contrary to the facility's policy requiring documentation of medication disposal.
Failure to Implement Timely Care Plan for Enteral Feeding
Penalty
Summary
The facility failed to develop and implement a timely care plan for a resident with an enteral feeding tube. The resident, admitted on 3/29/24, had diagnoses including dysphagia, speech and language deficits, and muscle weakness. Despite physician orders for enteral feeding and treatments initiated on 4/30/24, the care plan did not include a focus on the resident's feeding tube until 5/13/24. Observations on 5/13/24 and 5/14/24 revealed that the resident's enteral feeding pump was not running as ordered, and there was a lack of documentation in the medication administration record (MAR) and treatment administration record (TAR) indicating that the physician's orders were followed on multiple occasions. Interviews with staff indicated that the resident's enteral feeding should have been turned on daily at 1:00 P.M., but it was not running during observations. Additionally, the staff failed to document any refusals of the enteral feeding by the resident. The facility's policies on care plans and gastrostomy site care were not adhered to, as evidenced by the lack of a comprehensive, person-centered care plan within 21 days of admission and the failure to follow physician orders for enteral feeding and tube flushing. This deficiency was related to complaint IN00434111.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident where Resident D inappropriately touched Resident E. This incident was observed by a staff member, who reported that Resident D had placed his hand down Resident E's pants. The incident occurred in a common area of the facility, and Resident E was visibly upset by the encounter. Despite the immediate separation of the residents and notification of relevant authorities, the incident highlights a lapse in the facility's ability to prevent resident-to-resident abuse. Resident E, who was the victim of the inappropriate touching, has a medical history that includes bipolar disorder, major depressive disorder, Parkinson's disease, generalized anxiety disorder, and unspecified dementia with mood disturbance. At the time of the incident, Resident E's cognition was moderately impaired, which may have affected his ability to fully comprehend or recall the event. Despite this, Resident E reported feelings of trauma related to past abuse, indicating that the incident had a psychological impact. Resident D, the perpetrator, also has a history of mental health issues, including altered mental status, dementia, and anxiety. His care plan noted a tendency for inappropriate sexual behavior, which suggests that the facility was aware of potential risks. However, the incident still occurred, indicating a failure in monitoring or intervention strategies to prevent such behavior. The facility's policy on abuse prevention was not effectively implemented in this case, leading to the deficiency noted in the report.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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