Seymour Crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Seymour, Indiana.
- Location
- 707 S Jackson Park Dr, Seymour, Indiana 47274
- CMS Provider Number
- 155377
- Inspections on file
- 31
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Seymour Crossing during CMS and state inspections, most recent first.
A resident with stroke-related R-sided hemiparesis and a hand contracture was ordered to wear a resting hand splint on the R hand at all times except for hand washing and skin checks. Surveyors observed the resident multiple times without the splint, and the device was found stored in the room rather than in use. The resident said he did not think he had worn it for some time, CNA staff said they usually applied it but did not document it, and the EMAR/progress notes lacked documentation of application or refusal.
A facility failed to follow a physician order for a resident with diabetes and moderate cognitive impairment when an ordered hemoglobin A1C was not completed as scheduled. The record showed prior A1C results earlier in the year, but no result for the missed test, and the DON/Administrator stated the lab had a requisition but never obtained the specimen and the facility did not catch that the test was not done.
Failure to Deliver Saturday Mail: Residents reported in council that mail was not delivered on Saturdays and weekend mail was held until Monday. The ADON/Activity Director stated she did not have a mailbox key and had not been distributing mail on Saturdays, despite weekend Activity Aides being present. The facility policy stated residents have the right to send and promptly receive mail.
A cognitively intact resident with cardiac and hematologic conditions reported that over four hundred dollars in cash kept in her dresser went missing after she and an LPN friend had previously counted and documented a higher amount in an envelope. Financial records showed a large petty cash check from the resident’s account written directly to an LPN, contrary to the stated practice of issuing such checks for family to cash, and the administrator and DON were unaware the check had been made out to staff. In addition, several cognitively intact residents with COPD, heart failure, cerebral palsy, stroke, depression, anxiety, diabetes, and hypertension had orders for PRN or scheduled hydrocodone-acetaminophen or oxycodone-acetaminophen, and review of MARs and controlled substance records revealed multiple instances where an LPN signed out extra narcotic doses between scheduled times that were not documented as given on the MAR and were not reported as received by the residents. When confronted, an LPN admitted in a signed statement to taking residents’ narcotic medications for personal use beginning shortly after hire, constituting misappropriation of both resident funds and medications.
Multiple residents, including those with cognitive impairment and significant medical needs, were exposed to excessive heat in common areas due to a broken air conditioning unit. The facility did not monitor or document air temperatures as required by policy, and residents avoided activities and dining in affected areas. The deficiency was identified during a complaint investigation.
The facility did not have an RN on duty for eight consecutive hours on two days, as required. The DON was unsure why coverage was lacking, and the Administrator confirmed there was no specific policy for RN coverage, relying instead on State and Federal regulations.
The facility failed to follow physician orders for three residents, including not administering midodrine for low blood pressure for a resident with atrial fibrillation, administering Lisinopril-Hydrochlorothiazide despite low blood pressure for another resident, and not following nephrostomy tube care orders for a third resident. These actions were contrary to the specified medical orders and facility policies.
The facility failed to document meal consumption for two severely cognitively impaired residents, both with significant medical conditions. Despite the facility's policy requiring staff to document nutritional intake after each meal, records for these residents were incomplete on multiple occasions, leading to a deficiency in maintaining accurate documentation.
A facility failed to implement pharmacy recommendations for a resident's medication regimen. Despite a physician's agreement to switch the resident's iron therapy from ferrous sulfate to Ferrex, the change was not reflected in the EMAR, and the resident continued receiving the incorrect medication. The facility's policy required timely review and implementation of pharmacy recommendations, which was not followed in this case.
A medication error occurred when an LPN initially prepared the wrong insulin dosage for a resident without verifying the current order. Upon checking the EMAR, the LPN corrected the dosage from 2 units to 6 units, as required by the resident's blood sugar level. The facility's policy mandates a 3-way check to ensure correct medication administration.
A resident receiving Coumadin therapy experienced a significant medication error due to delayed communication of PT/INR lab results. The resident continued to receive a 7.5 mg dose of Coumadin daily without necessary adjustments, as the high PT/INR results were not communicated to the physician until several days later. The facility's process required timely communication of lab results to adjust medication dosages appropriately.
A facility failed to ensure a resident was clinically appropriate for self-administration of medication before leaving it unattended at the bedside. The resident was found with a medicine cup and bottles on her table, indicating she sometimes administered them herself. Staff interviews revealed a lack of awareness and adherence to the facility's medication policy, with no care plan or order for self-administration in place prior to the incident.
Failure to Apply Ordered Splint for Resident With Hand Contracture
Penalty
Summary
The facility failed to ensure a splinting device was applied as ordered for a resident with a hand contracture and limited ROM. Resident 74 had a history of stroke with right-sided hemiparesis/hemiplegia and was assessed as moderately cognitively impaired. An OT note dated 02/19/2026 documented that the resident could not use his carrot splint because he kept losing it, and the therapist applied a resting hand splint to the resident’s right hand, educated the resident on its use, and recommended the splint to prevent further spasticity, worsening contracture, and sores on the hand. The physician’s order directed staff to apply the resting hand splint to the resident’s right hand at all times, removing it only for hand washing and skin checks. During multiple observations, the resident was repeatedly found without the splint in place while in bed and while seated in his wheelchair in the lounge. On one observation, the splint was found lying on the dresser behind the television next to the resident’s ball cap, and the resident stated he did not think he had worn it for some time. CNA 2 stated staff usually put the splint on the resident but did not document it anywhere, and that CNAs would tell the nurse, who would check it off in the EMAR. Review of the resident’s February, March, and April 2026 EMARs and progress notes showed no documentation that the splint was applied or that the resident refused it.
Failure to Complete Ordered Hemoglobin A1C Testing
Penalty
Summary
The facility failed to follow a physician’s order for laboratory services for one resident with diabetes and moderate cognitive impairment. The resident had an order for a hemoglobin A1C to be completed every third month on the first Thursday, and the clinical record showed results in April and July 2025, but no hemoglobin A1C result for October 2025 was found in the record. During interview, the Administrator stated the facility could not provide the October 2025 hemoglobin A1C result. The Administrator said the laboratory had a requisition for the test, but the lab never came to obtain it and the facility did not catch that the test was not completed. The facility policy on lab and radiology tracking stated that one person should be assigned to track labs, daily order checks should ensure all orders are entered, and the designated person should run lab tracking reports daily to confirm each due test has been obtained.
Failure to Deliver Saturday Mail
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays. During a Resident Council meeting held on 04/02/2026, residents stated that mail was not delivered on Saturdays and that any mail received over the weekend had to wait until the following Monday to be distributed. The Activity Director was present at the meeting and stated she did not have a key to the mailbox and had not been delivering mail to residents on Saturdays. Clinical record review showed that Resident 16, Resident 57, Resident 59, and Resident 64 were cognitively intact based on MDS assessments dated between 01/15/2026 and 03/31/2026. During an interview on 04/07/2026, the Activity Director stated she had been filling in since May 2025 and became the permanent Activity Director in December 2025, worked Monday through Friday, and was in the facility as manager on duty every 5th or 6th weekend. She also stated the Activity Aides were in the facility every weekend, and the mailbox key was provided to the Activity Director during the survey process for Saturday mail access. The facility policy stated residents have the right to send and promptly receive mail.
Misappropriation of Resident Funds and Narcotic Medications by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to prevent misappropriation of a cognitively intact resident’s money and misappropriation of multiple cognitively intact residents’ narcotic pain medications. One resident, diagnosed with heart failure, hypertension, and anemia, kept a large amount of cash in an envelope in her dresser drawer. She reported that over four hundred dollars was missing from this envelope, which she kept in her room where she had no roommate and no family visitors, and she rarely left the room except for showers or using the restroom. A close friend who was an LPN at the facility had helped her count the money the day after Christmas, documenting $510 on the outside of the envelope, but when they recounted the money in early January, only $77 remained, leaving $433 unaccounted for. The administrator later confirmed the envelope amounts and stated he had not known the resident had that much money in her possession. Further review of the resident’s financial records showed that the business office had written a petty cash check for $767 from the resident’s account payable to the same LPN, with the resident’s name in the memo line, leaving only $0.81 in the resident’s facility account. The business office manager stated that the facility’s practice was to allow residents to receive up to $50 in cash per day, and for amounts over $50, checks were written so that a resident’s family could cash them; however, in this case, the check was written directly to the LPN, who reported that she cashed the check and returned the cash to the resident. The LPN stated that after the resident made some Christmas purchases and mailed a gift to an out-of-state loved one, there was still $510 left in the envelope. The administrator and DON reported they were unaware that a check for this resident had been written in the LPN’s name, and the resident had no family involvement. The deficiency also includes misappropriation of narcotic pain medications for several cognitively intact residents with diagnoses such as COPD, cerebral palsy, heart failure, depression, anxiety, stroke, diabetes, and hypertension. For one resident receiving hydrocodone-acetaminophen as needed every eight hours, the MAR showed a single narcotic dose administered by an LPN on a specific date, while the controlled substance record showed another nurse signing out multiple doses that same day at different times. Another resident with heart failure, hypertension, diabetes, depression, and COPD had an order for hydrocodone-acetaminophen every 12 hours; the controlled substance record showed multiple doses signed out by an LPN on several days and times, including doses between scheduled intervals, while the MAR reflected only some of these administrations and lacked documentation for others. Similar discrepancies were found for two additional residents ordered oxycodone-acetaminophen as needed every six hours, where the controlled substance records showed multiple doses signed out by the same LPN at various times, but the MARs documented far fewer administrations. The administrator and DON reported that the LPN who began working in early August had initially done well in orientation, but it was later reported that she appeared to have signed out too many narcotic pills over a weekend. Upon investigation, the DON identified multiple instances where this LPN had signed out narcotic doses between scheduled times for residents. Interviews with the involved residents confirmed they received their scheduled pain medications but did not receive any additional doses beyond what was ordered. When confronted with documentation showing narcotics signed out outside of scheduled doses, the LPN admitted in a written, signed statement that she had been taking narcotic medications from residents for her own use starting about two weeks after hire. A nurse described that narcotics were kept under double lock in medication carts, with each administration documented in a narcotic count book, and a random count of one cart on the day of survey was correct. The facility’s abuse policy defined misappropriation of resident funds or property as wrongful use of a resident’s property or money without consent, which was not adhered to in these instances.
Failure to Maintain Safe and Comfortable Environment Due to Excessive Heat
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for five of seven residents reviewed, as evidenced by excessive heat in common areas due to a broken air conditioning unit. Resident B, who was cognitively intact and had diagnoses including hypertension, diabetes, and asthma, reported that the air conditioning in the hallway and dining room was broken, causing him to avoid these areas due to excessive heat. He stopped attending activities and sometimes avoided eating in the dining room. The Maintenance Director confirmed that the air conditioning unit serving the B hallway, kitchen, and dining room had been nonfunctional for about two months and required replacement. During this period, the facility did not have a thermometer to monitor air temperatures and relied on thermostats, which showed temperatures in the common areas ranging from 81 to 83 degrees Fahrenheit. Observations revealed that the main dining room, where multiple residents were eating, was affected by heat from the kitchen, as the door was propped open. Residents D, E, F, and G, all of whom were severely cognitively impaired, required extensive staff assistance for mobility, and had significant medical conditions, were present in the restorative dining area during these conditions. The facility's Emergency Operations Plan required monitoring and documentation of ambient air temperatures and specified actions if temperatures exceeded 81 degrees Fahrenheit, but these procedures were not followed. The deficiency was identified during a complaint investigation and related to the facility's failure to ensure a safe and comfortable environment as required.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required Registered Nurse (RN) coverage for eight consecutive hours a day on two specific days, as identified during a review of the nursing schedule from July to September 2024. On Saturday, September 28, 2024, and Sunday, September 29, 2024, there was no RN on duty for the required duration. During an interview, the Director of Nursing (DON) acknowledged that the schedule typically included an RN for eight hours each day but was unsure why coverage was lacking on those two days. The facility's Administrator confirmed that there was no specific policy for RN coverage, and they adhered to State and Federal regulations without any nursing waivers in place.
Failure to Follow Physician Orders for Medication and Treatment
Penalty
Summary
The facility failed to adhere to physician's medication hold parameters and treatment orders for three residents. Resident 18, who was cognitively intact and had diagnoses including atrial fibrillation and renal insufficiency, did not receive midodrine as ordered when their blood pressure was below 110 on multiple occasions. Despite having an order to administer midodrine for low blood pressure, the medication was not given when the resident's blood pressure readings were below the specified threshold. Interviews confirmed that the medication should have been administered according to the physician's order. Resident 70, also cognitively intact, had an order to hold Lisinopril-Hydrochlorothiazide if their systolic blood pressure was less than 130. However, the medication was administered on several occasions when the resident's blood pressure was below this parameter. Additionally, Resident 38's nephrostomy tube care was not performed according to the physician's order, which specified cleansing with soap and water. Instead, normal saline was used, contrary to the order. The facility's policies were not followed, and there was no specific policy on adhering to physician orders, which was considered standard practice.
Failure to Document Meal Consumption for Cognitively Impaired Residents
Penalty
Summary
The facility failed to document meal consumption for two residents who were severely cognitively impaired. Resident 16, with diagnoses including hypertension, diabetes, non-Alzheimer's dementia, anxiety, and depression, had missing meal consumption records on multiple occasions throughout January and February 2025. These omissions included several meals such as dinner, lunch, and breakfast on specific dates, indicating a lack of consistent documentation of the resident's nutritional intake. Similarly, Resident 36, who was also severely cognitively impaired and diagnosed with anemia, heart failure, hypertension, non-Alzheimer's dementia, and depression, experienced weight loss without being on a prescribed weight loss regimen. The resident's meal consumption records were incomplete on several dates, mirroring the pattern observed with Resident 16. During an interview, a CNA confirmed that staff were responsible for documenting meal consumption after each meal, as per the facility's policy. However, the records for these residents were not consistently maintained, leading to a deficiency in documenting nutritional intake.
Failure to Implement Pharmacy Recommendations for Resident's Medication
Penalty
Summary
The facility failed to follow pharmacy recommendations for a resident reviewed for medication irregularities. The resident, who was moderately cognitively impaired, had diagnoses including hypertension, diabetes, cirrhosis, malnutrition, and anemia. A Pharmacy Consultation Report recommended optimizing the resident's iron therapy by switching from ferrous sulfate 325 mg every other day to Ferrex 150 mg daily. Although the physician agreed with this recommendation, the change was not implemented in the resident's medication administration record. The February 2025 Electronic Medication Administration Record showed that the resident continued to receive ferrous sulfate every other day, and there was no new order for Ferrex 150 mg daily. During an interview, the IP Nurse indicated that the signed recommendations were given to the nurse responsible for the resident's care to transcribe the physician's order, but the medication changes were not made. The facility's policy required pharmacy recommendations to be reviewed and followed up by the physician within 30 days, but this process was not completed for the resident in question.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to prevent a medication error during the administration of insulin to Resident 69. During an observation, an LPN prepared to administer 2 units of insulin without verifying the resident's current insulin order on the computer. Upon being prompted to verify the order, the LPN checked the Electronic Medication Administration Record (EMAR) and discovered that the resident's blood sugar level of 207 required 6 units of insulin according to the sliding scale order. The LPN then corrected the dosage and administered the correct amount of insulin to the resident. The clinical record for Resident 69 included a physician's order for insulin administration based on a sliding scale, which specified different insulin dosages according to blood sugar levels. The facility's policy on medication administration required a 3-way check to ensure the correct medication, dose, route, rate, time, and resident. The LPN initially failed to follow this policy by not verifying the insulin order before preparing the medication, leading to a potential medication error.
Failure to Prevent Significant Medication Error in Coumadin Therapy
Penalty
Summary
The facility failed to prevent a significant medication error for a resident who was receiving Coumadin therapy. The resident, who was cognitively intact and had diagnoses including hypertension, diabetes, anxiety, depression, and cerebrovascular accident, was supposed to have their PT/INR levels monitored to adjust the Coumadin dosage accordingly. However, the PT/INR lab results, which were drawn on a Friday, were not received by the facility until the following Monday. During this period, the resident continued to receive the prescribed 7.5 mg dose of Coumadin daily without the necessary adjustment based on the lab results. The facility's process required that the PT/INR results be communicated to the physician before administering the next dose of Coumadin. Despite this, the results indicating a high PT/INR were not communicated to the physician until several days later. The Director of Nursing acknowledged that the staff should have contacted the Nurse Practitioner on the day the lab was drawn to verify the medication dosage. This oversight led to the resident receiving potentially inappropriate doses of Coumadin for several days.
Failure to Ensure Clinical Appropriateness for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate for self-administration of medication before leaving medication unattended at the bedside. During an observation, a resident was found in her wheelchair with a medicine cup filled with various colored pills on her bedside table and two separate medicine bottles with liquid drop medications on the bed. The resident indicated that the nurse left the medications on the table for her to take while she was in the restroom, and she sometimes administered them herself. No staff were present in the room or within sight of the resident at the time. Interviews with facility staff revealed a lack of awareness and adherence to the facility's medication administration policy. A Qualified Medication Aide mentioned the presence of a confused resident who wandered the hallway regularly, while an LPN stated she was unaware of any residents self-administering medications and emphasized that staff should remain in the room until medication is taken. The Director of Nursing confirmed that the resident lacked a care plan and an order for self-administration prior to the incident. The resident's clinical record, reviewed after the observation, showed no assessment or order for self-administration until after the deficiency was noted.
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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