Rosewalk Village At Lafayette
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Indiana.
- Location
- 1903 Union St, Lafayette, Indiana 47904
- CMS Provider Number
- 155121
- Inspections on file
- 26
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Rosewalk Village At Lafayette during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including type 2 DM with neuropathy and chronic bilateral knee pain, was found with a medicine cup containing a pill left on the bedside table. Staff, including the DON and ADON, confirmed there was no MD order, assessment, or care plan authorizing self-administration, and facility policy required staff to observe medication consumption and obtain an order for any self-administered meds. Multiple RNs stated that meds should not be left at bedside without such an order, indicating that the unattended pill at the bedside occurred in violation of facility policy and physician orders.
A resident with dementia, hypotension, and risk for fluid imbalance had a physician’s order for daily midodrine 5 mg with instructions to hold the dose if systolic blood pressure (SBP) exceeded 130. Review of the MAR showed the medication was administered multiple times when SBP readings were above the ordered hold parameter, and there was no indication the doses were held. An LPN and the DON stated that medications with hold parameters should not be given when vital signs are outside those parameters, and that held doses should be documented on the MAR, while the ADON noted there was no specific policy on medication parameters beyond a general medication administration policy requiring appropriate measures such as obtaining vital signs.
Surveyors found that employee food and drinks were improperly stored in the kitchen, expired food was present, and cardboard boxes were stored on the floor in both the walk-in freezer and food preparation areas. Interviews with the ED and DM confirmed these practices were not allowed and did not comply with facility policy, which requires food to be stored above the floor and in a manner that prevents contamination.
The facility did not hold timely care plan meetings with residents and their representatives as required, resulting in missed quarterly reviews for several residents with complex medical and psychiatric conditions. In each case, care plan meetings were not conducted in alignment with MDS assessment schedules, and staff confirmed the omissions.
A resident was prescribed new psychotropic medications and received new mental health diagnoses, but the facility did not complete an updated PASARR Level I assessment as required by policy. Interviews with the Executive Director and Social Service Director confirmed the oversight, despite facility policies mandating PASARR updates with significant changes in mental or physical status.
A dependent resident with severe cognitive impairment and incontinence was not provided timely incontinence care, resulting in the resident being observed in the dining room with a strong odor of urine and feces, soiled clothing, and bowel movement on his hand. Staff interviews confirmed that care was not provided according to the required two-hour schedule, and a family member reported repeated instances of the resident having dried feces on his hands during meals.
A resident with diabetes and chronic kidney disease received insulin doses despite blood glucose readings below the physician-ordered hold parameter. Nursing staff confirmed that insulin should have been withheld in these cases, but the facility lacked a specific policy on following such hold parameters at the time.
A resident with type 2 diabetes mellitus did not receive proper insulin management as per physician's orders. Insulin was administered despite blood sugar levels being below the specified threshold, and the hypoglycemic protocol was not followed when blood sugar levels dropped below 60 mg/dL. The facility failed to notify the physician promptly, contrary to their policies.
A resident with multiple health conditions experienced significant weight loss, but the facility failed to notify the physician in a timely manner. Despite a care plan directive, the physician was informed 10 days after a 13% weight loss was noted. The facility's policy requires prompt notification of significant weight changes, which was not followed.
A facility failed to properly label OTC medications on a medication cart, affecting two residents. The medications, including aspirin and turmeric, lacked labels, instructions, and physician names, despite existing physician orders. The DON and facility pharmacist were initially unable to confirm labeling regulations, but later clarified requirements for proper identification.
Medication Left at Bedside Without Self-Administration Order
Penalty
Summary
Surveyors observed that a clear plastic medicine cup containing a white oblong pill was left on a resident's bedside table, and the DON later removed it, stating it should not have been left there. The resident's clinical record showed diagnoses including type 2 diabetes mellitus with diabetic neuropathy, chronic pain, bilateral knee pain, abnormal posture, and muscle weakness. The record contained a physician's order for hydrocodone-acetaminophen 7.5/325 mg every four hours and a pain management care plan directing staff to administer medications as ordered. However, there was no physician's order, self-medication administration assessment, or care plan authorizing the resident to self-administer medications. Multiple staff interviews confirmed that medications were not to be left at the bedside unless there was an order for self-administration and that staff were required to observe residents consuming all medications before leaving the room. The ADON, DON, and several RNs each stated that the resident did not have an order to self-administer medications and that the pill cup should not have been left in the room. Facility policies on General Dose Preparation and Medication Administration required staff to observe residents' consumption of medications, and the Self-Administration of Medications policy required a physician order specifying a resident's ability to self-administer medications. The presence of the unattended pill at the bedside without the required order or assessment constituted the deficiency.
Failure to Follow Blood Pressure Hold Parameters for Midodrine
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for holding a blood pressure medication according to specified parameters for one resident. The resident had multiple diagnoses, including Alzheimer’s disease, vascular dementia with psychotic disturbance, psychotic disorder with delusions, adjustment disorder with anxiety, muscle weakness, and hypotension, and was care planned as being at risk for fluid imbalance due to blood pressure issues, with an intervention to administer medications as ordered. A physician’s order directed that 5 mg of midodrine be given every morning and held if the systolic blood pressure (SBP) was greater than 130. Review of the Medication Administration Records over several months showed that midodrine was administered despite SBP readings above the ordered hold parameter on multiple occasions: SBP 155 and 135 in December, SBP 138 and 137 in January, and SBP 153 in February. Interviews with an LPN and the DON confirmed that medications with hold parameters should be withheld when vital signs fall outside those parameters, and that held medications should be documented with initials in parentheses on the MAR. The ADON reported there was no specific facility policy addressing medication parameters, while the general medication administration policy required staff to take necessary measures, including obtaining vital signs, prior to administration.
Deficient Food Storage and Handling Practices in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to food storage and handling. Employee lunches were found stored in brown plastic grocery sacks inside the reach-in refrigerator, and two half-empty clear plastic water bottles were stored on a shelf in the food preparation area. Additionally, a large clear container of diced ham with a use-by date that had passed was found in the food preparation refrigerator. Cardboard boxes, including one containing a bag of frozen blueberries and others stacked on top, were stored directly on the floor of the walk-in freezer, and four empty cardboard boxes were found on the floor under the food preparation sink. Interviews with the Executive Director and Dietary Manager confirmed that employees were not permitted to store personal food or drinks in the kitchen, and that food and cardboard boxes should not be stored on the floor. The facility's policy on food storage requires that food be stored at least six inches above the floor and in a manner that prevents contamination, with all items clearly labeled and dated. These observed practices were not in compliance with the facility's stated policies and professional standards for food safety.
Failure to Conduct Timely Care Plan Meetings with Residents and Representatives
Penalty
Summary
The facility failed to ensure that care plan meetings were held with residents and their representatives in a timely manner for four residents. For one resident with multiple diagnoses including Parkinson's disease, dementia, and diabetes, there was no care plan meeting held during the second quarter between two documented meetings. Another resident with chronic conditions such as COPD, diabetes, and end stage renal disease did not have a care plan meeting for the fourth quarter between two documented meetings. In both cases, facility staff confirmed that the required meetings were not conducted during the specified periods. Additionally, a resident with Alzheimer's disease and other psychiatric and medical conditions did not have a care plan meeting during the second quarter, despite an MDS assessment being completed. The family was invited to a meeting but did not attend, and the facility did not reschedule or conduct the meeting. Another resident with respiratory failure, dementia, and other chronic illnesses did not have a care plan review meeting during the third quarter, even though an MDS assessment was completed. Facility policy required care plan reviews and revisions by the interdisciplinary team following each MDS assessment, but this was not followed for these residents.
Failure to Update PASARR After New Psychotropic Medications and Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a preadmission screening and resident review (PASARR) was updated when a resident was prescribed new psychotropic medications and received new mental health diagnoses. The resident's clinical record showed diagnoses of anxiety disorder and depressive disorder. The initial PASARR, completed prior to these changes, indicated no mental health diagnoses or medications. Subsequently, the resident was prescribed sertraline, an antidepressant, and clonazepam, an antianxiety medication, but no new PASARR Level I was completed after these changes. Interviews with the Executive Director and Social Service Director confirmed that a new PASARR Level I assessment was not conducted when the resident's mental health status and medication regimen changed. Facility policy requires PASARR assessments to be updated with significant changes in mental or physical status, and the policy on psychotropic management emphasizes the importance of assessment and person-centered intervention when such medications are prescribed. The failure to update the PASARR assessment was contrary to these policies.
Failure to Provide Timely Incontinence and Hygiene Care
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple psychiatric diagnoses was not provided timely incontinence care. During an observation, the resident was found in the dining room sitting in a wheelchair, leaning to one side, with a strong odor of urine and bowel movement. The resident's sweatpants were partially pulled down, and there was visible bowel movement on his right hand. Staff confirmed that the resident had last been checked and changed at 10:00 a.m., despite facility policy and care plans requiring checks and changes every two hours. At the time of observation, it had been over three hours since the last care was provided. Interviews with staff and a family member revealed that the resident was frequently found with dried bowel movement on his hands during mealtimes, and staff did not consistently clean his hands before meals. The resident's care plans indicated a need for assistance with all activities of daily living, including toileting and hygiene, and required staff to check and change the resident every two hours. Facility policy and CNA job descriptions also outlined the expectation for prompt and regular incontinence care, which was not followed in this instance.
Failure to Hold Insulin Doses per Physician Order
Penalty
Summary
The facility failed to ensure that insulin doses were withheld when blood glucose readings were below the physician-ordered hold parameter for a resident with type 2 diabetes mellitus, diabetic nephropathy, and chronic kidney disease. The physician's order specified that 35 units of Fiasp FlexTouch U-100 Insulin should be administered three times daily, but included instructions to hold the dose if the blood sugar was below 130. Despite this, the Medication Administration Records showed that insulin was administered multiple times when the resident's blood sugar was below the specified threshold. Interviews with nursing staff confirmed that insulin should have been held according to the order, and the facility did not have a specific policy regarding insulin administration or adherence to physician-ordered hold parameters at the time of the incidents. The facility's general medication administration policy referenced the 'right dose' but did not address the specific issue of holding medications based on blood sugar readings.
Failure to Follow Insulin and Hypoglycemic Protocols
Penalty
Summary
The facility failed to adhere to physician's orders regarding insulin administration and hypoglycemic protocol for a resident with type 2 diabetes mellitus. The resident had specific orders to hold insulin if blood sugar levels were below 110 mg/dL. However, insulin was administered on multiple occasions when the resident's blood sugar was below this threshold, including readings of 109 mg/dL, 83 mg/dL, and 95 mg/dL. The Assistant Director of Nursing indicated that nurses should be aware of when to hold medication by checking the Medication Administration Record, but this was not followed. Additionally, the facility did not follow the hypoglycemic protocol or notify the physician in a timely manner when the resident's blood sugar fell below 60 mg/dL. On two occasions, the resident's blood sugar was recorded at 56 mg/dL and 58 mg/dL, but there was no immediate recheck or notification to the physician as required. The Director of Nursing stated that the protocol was to administer juice and recheck the blood sugar in 15 minutes, which was not done. The facility's policies required prompt documentation and communication of such conditions to the attending physician, which was not adhered to in this case.
Failure to Timely Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician about a significant weight loss in a timely manner for a resident with multiple health conditions, including end-stage renal disease, chronic heart failure, and a below-the-knee amputation. The resident's care plan required notifying the medical doctor or family of significant weight changes. The resident experienced a 9% weight loss over 36 days, which was attributed to the amputation, and the physician was notified. However, a subsequent weight loss of 13% from August to October was not communicated to the physician until 10 days after the significant change was noted. The resident's weight log showed fluctuations and refusals to be weighed, with a notable drop from 198 pounds in August to 171 pounds in October. Despite the care plan's directive, the physician was not informed of the significant weight loss until late October, as confirmed by the Director of Nursing. The facility's policy on resident weight monitoring, last reviewed in July, mandates notifying the physician of unplanned significant weight changes, which was not adhered to in this case.
Improper Labeling of OTC Medications
Penalty
Summary
The facility failed to ensure that over-the-counter (OTC) medications were properly labeled with directions for use and the physician's name on one of the medication carts reviewed. During an observation of medication storage, several bottles of OTC medications, including aspirin and turmeric capsules for two residents, were found without proper labeling. The bottles were either unopened or opened, with the residents' names handwritten on them, but lacked labels, instructions for use, and the physician's name. The clinical records for the residents involved indicated that there were physician's orders for the medications found on the cart. However, the facility's Director of Nursing (DON) and the facility pharmacist were unable to confirm the specific regulations for labeling OTC medications in a long-term care setting. An email from the facility pharmacist later confirmed that OTC medications should be identified with the resident's name, physician's name, expiration date, drug name, and strength. The facility's policy on medication storage and expiration, revised earlier in the year, also emphasized the need for proper labeling and storage of medications.
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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