Springs Valley Meadows
Inspection history, citations, penalties and survey trends for this long-term care facility in French Lick, Indiana.
- Location
- 457 S Sr 145, French Lick, Indiana 47432
- CMS Provider Number
- 155126
- Inspections on file
- 26
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Springs Valley Meadows during CMS and state inspections, most recent first.
Infection control practices were not followed during medication administration and incontinence care. An RN handled multiple residents’ medications with bare hands and washed hands with only a five second lather, while CNAs performed perineal care after touching room items and without changing gloves after contact with other surfaces. The Infection Preventionist stated staff should not touch medications with bare hands, should lather hands for at least 20 seconds, and should remove gloves and perform hand hygiene after touching random items before incontinence care.
Unlocked Narcotic Box in Medication Cart: The facility failed to ensure narcotics were double locked in 1 of 2 observed med carts. During observation, the South Long Hall med cart narcotic box was found unlocked. An LPN stated med carts should always be locked and the narcotic box should always be under a double lock, and the facility policy stated controlled substances should be kept under double lock.
Inaccurate resident documentation was found for one resident receiving hospice care and one resident receiving nutritional support. A resident’s chart contained hospice records that belonged to another resident, and another resident’s dietary record showed a peanut butter sandwich as eaten even though unopened sandwiches were observed in the room. The DON and Administrator provided information about hospice uploads and staff documentation responsibilities.
The facility failed to securely store narcotics in the South Long Hall Medication Cart, as the narcotic box lid was not fully closed to engage the lock. An LPN confirmed the lock was functional and should have been secured. The DON stated that all narcotics must be double locked, in line with the facility's policy.
The facility failed to serve meals at an acceptable temperature on the South Hall unit. Residents reported that their food was not hot, and an observation confirmed that a cheeseburger was served at 113 degrees Fahrenheit, below the facility's policy of 135 degrees Fahrenheit for hot foods. A staff member indicated that cheeseburgers should be served at a minimum of 145 degrees Fahrenheit.
A facility failed to implement person-centered interventions for a resident with dementia, leading to multiple incidents of disruptive and aggressive behaviors. Despite having a care plan, the interventions were often ineffective, and the resident's participation in activities of interest was not consistently documented.
The facility failed to ensure Social Services followed up on residents exhibiting mood and behavior issues and did not consult with family members for four of six residents reviewed. Despite multiple nurse's notes documenting deteriorating conditions, there was no documentation indicating that Social Services reassessed or followed up with the residents accordingly.
The facility failed to ensure accurate documentation of controlled substances for two residents. One resident's medication card showed discrepancies in the number of tablets, and the QMA admitted to not signing them out. Another QMA administered Ativan without referring to the MAR and had already documented it as administered earlier. The DON confirmed that staff should document medication administration accurately and in a timely manner, which was not followed.
A facility failed to ensure medication errors were less than 5% when a QMA administered multiple medications without referring to the MAR and documented them as administered earlier, leading to incorrect administration times for a resident with multiple medical conditions.
The facility failed to ensure appropriate labeling and storage of medications for three residents. Insulins were found with outdated labels and not removed after orders were discontinued, and inhalers were stored improperly in the medication cart.
A facility failed to promptly obtain dental services for a moderately cognitively impaired resident with multiple medical conditions. Despite the resident's repeated complaints of oral pain and a broken tooth, no dental appointment was made, and there was no documentation indicating that the family was contacted. The facility did not follow its policy to obtain needed dental services and make prompt referrals.
Infection Control Lapses During Medication Pass and Incontinence Care
Penalty
Summary
The facility failed to ensure infection control practices were followed during medication administration and incontinence care for multiple residents. During medication pass observations, RN 32 was seen preparing and administering medications for two residents by pulling medication cards from the cart and placing the tablets directly into her bare hand before putting them into a medication cup and giving them to the residents. The medications handled this way included aspirin, lisinopril, memantine, Zoloft, Vascepa, vitamin D3, Tylenol, citalopram, galantamine, and a multivitamin. During another medication pass observation, RN 32 washed her hands with only a five second lather. During incontinence care observations, CNA 21 and CNA 44 provided care to one resident after both had washed their hands and put on gloves, but they touched multiple items in the room, including the bed controller, wipes from the nightstand drawer, and the privacy curtain, and continued care without changing gloves. CNA 44 wiped the resident’s external female genitalia from back to front and CNA 21 wiped stool from the resident’s buttocks while wearing the same gloves. In another observation, CNA 14 put on gloves, adjusted the bed with the remote, retrieved wipes from a drawer, and then began perineal care for another resident without changing gloves. The Infection Preventionist stated staff should not touch resident medications with bare hands and should lather hands for at least 20 seconds during handwashing, and that staff should remove gloves and perform hand hygiene after touching random items before providing incontinence care.
Unlocked Narcotic Box in Medication Cart
Penalty
Summary
The facility failed to ensure narcotics were double locked in the medication cart for 1 of 2 medication carts observed. During observation on 4/27/26 at 6:15 A.M., the South Long Hall Medication Cart narcotic box was found unlocked. During an interview on 4/30/26 at 9:09 A.M., an LPN stated that medication carts should always be locked and that the narcotic box should always be under a double lock. A current Controlled Substances Policy dated November 2024, provided on 5/2/26 at 10:25 A.M., stated that all controlled substances administered by the facility should be kept under double lock.
Inaccurate Resident Documentation and Mixed Hospice Records
Penalty
Summary
The facility failed to accurately document clinical records for a resident receiving hospice care and for a resident receiving nutritional supplementation. For one resident with Alzheimer’s disease and a significant change MDS dated 3/13/26 indicating hospice care, the clinical record contained scanned and uploaded hospice documentation dated 4/7/26 that belonged to a different resident in the facility who was also under hospice care. The DON stated on 4/29/26 that hospice documentation was generally uploaded to the resident’s clinical record every three months, with updates to the plan of care, and when the resident passed. For another resident with heart failure, an IDT note dated 2/17/26 documented an 11.3% weight loss in 30 days and a new recommendation for a peanut butter and jelly sandwich and chips at 10:00 A.M., and physician orders reflected that snack. The dietary administration history showed the snack as provided and eaten on 4/25/26, 4/26/26, and 4/28/26. However, on 4/28/26 at 1:06 P.M., two unopened peanut butter sandwiches were observed on the bedside table and one on the dresser, with dates of 4/25/26, 4/26/26, and 4/28/26 and all marked for 10:00 A.M. The Administrator later provided a nursing job description stating that direct care staff were responsible for complete and accurate resident documentation.
Medication Storage Deficiency in South Long Hall
Penalty
Summary
The facility failed to maintain safe and secure storage of medications, specifically narcotics, in one of the four medication carts observed. During an observation, it was noted that the lid of the narcotic box inside the South Long Hall Medication Cart was not closed completely, preventing the lock from engaging. This allowed narcotics to be stored in an unsecured manner. An LPN confirmed that the lock was not broken and acknowledged that it should have been closed and locked. The Director of Nursing later confirmed that all narcotics should be double locked, as per the facility's Medication Storage Policy, which mandates that Schedule II-V controlled substances and other at-risk medications be stored in a separately locked, affixed compartment in a cart.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to provide meals at an acceptable temperature for residents on the South Hall unit. During interviews conducted on February 24 and February 26, 2025, anonymous residents reported that their food was not served hot. An observation on February 26, 2025, revealed that meal trays were being distributed from a meal cart with insulated domes, but the cheeseburger sampled was only 113 degrees Fahrenheit, cold to the touch, and the cheese was not melted. According to the facility's Food Temperatures policy, revised in June 2023, hot foods that are potentially hazardous should be held for service at or above 135 degrees Fahrenheit. An interview with a staff member confirmed that cheeseburgers should be served at a minimum of 145 degrees Fahrenheit.
Failure to Implement Person-Centered Interventions for Dementia-Related Behaviors
Penalty
Summary
The facility failed to ensure person-centered interventions were implemented for a resident diagnosed with dementia and related behaviors. The resident, who had a history of dementia with agitation, cognitive communication deficit, and insomnia, exhibited various disruptive behaviors such as wandering into other residents' rooms, hallucinating, and attempting to exit the facility. Despite having a care plan that included interventions like calling a family member, assessing for pain, offering snacks, and redirecting to activities, these measures were often ineffective. The resident's family restricted the use of psychotropic medications, allowing only melatonin, which further complicated the management of her behaviors. The resident's care plan and interventions were not consistently followed or updated to address her aggressive behaviors towards other residents and staff. Multiple incidents were documented where the resident slapped other residents, wandered intrusively, and exhibited manic behavior. Despite these occurrences, the care plan lacked specific interventions for aggressive behaviors, and there was insufficient documentation of the resident's participation in activities that could have potentially mitigated her disruptive behaviors. Observations revealed that the resident was often left unsupervised or asleep in her wheelchair without engaging in any activities of interest, such as listening to gospel music or participating in Christian activities, which were noted as important to her. The facility's failure to provide consistent, person-centered care and activities contributed to the resident's ongoing disruptive and aggressive behaviors, impacting the safety and well-being of other residents and staff.
Failure to Follow Up on Residents with Mood and Behavior Issues
Penalty
Summary
The facility failed to ensure Social Services followed up on residents exhibiting mood and behavior issues and did not consult with family members related to these behaviors for four of six residents reviewed. Resident 8, diagnosed with vascular dementia and mood disturbances, showed signs of increased depression and withdrawal following his wife's passing. Despite multiple nurse's notes documenting his deteriorating condition, there was no documentation indicating that Social Services reassessed the resident for signs and symptoms of increased depression or followed up with him accordingly. Resident 33, diagnosed with unspecified dementia and recurrent major depressive disorder, exhibited inappropriate sexual comments, refusal of care, and increased incontinence. Despite numerous nurse's notes detailing these behaviors and refusals, there was no documentation of the Social Service Director visiting the resident after these incidents. The only documentation available was from the Interdisciplinary Team (IDT) meetings discussing the resident's condition. Resident 54, diagnosed with anxiety disorder, depression, PTSD, and bipolar disorder, experienced manic episodes and mood swings. The resident's behavior included insomnia, pacing, and paranoia. Although the IDT meetings documented discussions about the resident's condition, there was no documentation of the Social Worker visiting the resident after these behaviors. The Social Services Director admitted to not always charting visits and indicated that only new behaviors were usually documented, not ongoing issues.
Failure to Accurately Document Controlled Substances
Penalty
Summary
The facility failed to ensure accurate documentation of controlled substances for two residents. During an observation of the South Short Hall Medication Cart, it was found that Resident 2's acetaminophen-codeine #4 medication card contained only 20 tablets, while the controlled drug storage record sheet indicated there should be 21 doses remaining. Similarly, Resident 2's clonazepam 0.5 mg medication card contained only 22 tablets, whereas the record sheet indicated there should be 23 tablets remaining. QMA 3 admitted to administering the medications that morning but had not signed them out. Additionally, QMA 4 was observed preparing and administering Ativan 0.5 mg to Resident 28 without referring to the MAR, and she had already documented the medication as administered earlier in the day, despite the resident not waking up to take it initially. The DON indicated that staff should document medication administration accurately and in a timely manner, which was not followed in these instances. Resident 2 had diagnoses including generalized anxiety disorder and muscle spasm, with a physician's order for acetaminophen-codeine #4 three times daily for chronic pain. Resident 28 had a diagnosis of anxiety disorder, with a physician's order for Ativan 0.5 mg three times daily for anxiety. The facility's Controlled Substances policy requires strict records of controlled substances stored and administered, which was not adhered to in these cases. The discrepancies in documentation and administration times were confirmed through interviews with the QMAs and the DON.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medication errors were less than 5% during the administration of medications for a resident. During an observation, a Qualified Medication Aide (QMA) prepared and administered multiple medications without referring to the resident's Medication Administration Record (MAR). The QMA had previously documented the medications as administered, even though the resident had not taken them earlier in the day. This led to the administration of medications outside the prescribed times, including Ativan, levothyroxine, and famotidine, which were not given at their scheduled times of 8:00 a.m. and 7:00 a.m., respectively. The resident's medical history included dementia, hypokalemia, depressive episodes, osteoarthritis, muscle weakness, GERD, hypothyroidism, hypertension, insomnia, major depressive disorder, hyperlipidemia, heart disease, and dysphagia. The QMA admitted to documenting the medications as administered earlier and indicated the need to amend the records. The Director of Nursing (DON) and the Regional Director of Clinical Operations (RDCO) confirmed that medications should be administered within a specific time frame and documented accurately. The facility's medication administration procedure was not followed, leading to the deficiency.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure appropriate labeling and storage of medications for three residents. During an observation of the South Short Hall Medication Cart, a bottle of lispro and a Fiasp insulin pen for one resident were found with outdated labels and were not removed after the orders were discontinued. The Qualified Medication Aide confirmed that the insulins should have been removed when the orders were discontinued, and they were beyond their 28-day usability period. Another resident's Breyna and albuterol sulfate inhalers were found stored improperly in the medication cart, lying on their sides instead of with the mouthpiece down as per storage instructions. The Director of Nursing was aware of the policy for some inhalers to be stored upright but was unsure which ones. Additionally, another resident's albuterol inhaler was also found lying on its side in the medication cart, contrary to the storage instructions. The Director of Nursing indicated that the insulins were good for 30 days and acknowledged the policy for some inhalers to be stored upright. The most current Medication Storage Guidelines were not followed, leading to improper storage and labeling of medications for the residents involved.
Failure to Obtain Prompt Dental Services for Resident
Penalty
Summary
The facility failed to promptly obtain dental services for a resident who was moderately cognitively impaired and had multiple medical conditions, including functional dyspepsia, constipation, muscle weakness, chronic vascular disorders of the intestine, nausea, and vomiting. The resident complained of oral pain due to the loss of a filling and a broken tooth, which made it difficult to chew. Despite multiple nurse's notes documenting the resident's complaints of pain and discomfort over a period of time, no dental appointment was made, and there was no documentation indicating that the family was contacted about making a dental appointment for the resident. The resident's care plan included obtaining dental consults as indicated and observing chewing or eating difficulties at meals. However, the facility did not follow through with these interventions. The Social Service Director confirmed that the resident declined the in-house dentist and had an outside dentist to go to, but there was no information documented that an appointment was made or that the family was contacted. The facility's policy stated that it would obtain needed dental services and make prompt referrals, but this was not adhered to in this case.
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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