Waterford Place Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Kokomo, Indiana.
- Location
- 800 St Joseph Dr, Kokomo, Indiana 46901
- CMS Provider Number
- 155678
- Inspections on file
- 24
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Waterford Place Health Campus during CMS and state inspections, most recent first.
The facility failed to follow physician orders and internal policies for weight monitoring and physician notification. A resident with multiple cardiopulmonary conditions had numerous missed daily weights despite an order and care plan requiring daily weighing. Two residents admitted with complex medical histories, including severe malnutrition and prior CVA, did not have admission weights obtained within the expected 24-hour timeframe, with one weight delayed several days. Another resident with DM and a right fibula fracture had an order for Humalog insulin per sliding scale with instructions to call the physician for blood glucose values outside a specified range, but a critically elevated blood sugar was not reported to the NP until days later. Staff interviews and facility policies confirmed that daily and admission weights, as well as timely provider notification, were required but not consistently carried out.
A resident with multiple medical and behavioral health diagnoses, including depression, vascular dementia, PTSD, and an adjustment disorder with anxiety, was started on diazepam twice daily for anxiety without a timely PASARR Level I screen. The PASARR assessment related to the new anxiety diagnosis and new antianxiety medication was not completed until after the survey had begun, despite the Administrator’s acknowledgement that a new Level I is required when a new psychotropic medication or mental health diagnosis is added and facility policy directing contact with the PASARR office for such behavioral health conditions.
A resident with a Foley catheter and history of UTI was observed with the catheter drainage bag attached to a trash can containing trash, and the urine in the tubing appeared cloudy with sediment. The resident’s care plan identified neurogenic bladder and the need to observe catheter tubing, and the resident was on ciprofloxacin for a UTI. Facility staff, including the ADON, Medical Record Nurse, and a QMA, acknowledged that the catheter bag should be hung on the bed rail and not on a trash can, and that this practice placed the resident at risk of infection, contrary to the facility’s urinary catheter care policy.
A resident with a history of UTI and multiple comorbidities, including acute kidney failure and urinary retention, was observed with an indwelling catheter drainage bag attached to a trash can containing trash, with cloudy urine and sediment noted in the tubing. The ADON, Medical Record Nurse, and a QMA all acknowledged that the catheter bag should not be placed on a trash can and should instead be hung on the bed rail, stating that this practice placed the resident at risk of infection. This practice was inconsistent with the facility’s Infection Prevention and Control Program, which is intended to prevent the development and transmission of infections and monitor compliance with infection control procedures.
The facility failed to administer oxygen at the physician's ordered level for four residents. A resident had varying oxygen levels set on her concentrator, contrary to the physician's order for 2 liters as needed. Another resident was observed with an oxygen concentrator set at 3 liters, despite an order for 2 liters continuously. A third resident had no physician's order for oxygen until after the survey start date, yet was observed with oxygen levels between 3.5 and 7 liters. Similarly, another resident was observed with 3.5 liters of oxygen without a physician's order until after the survey start date.
The facility failed to maintain a clean and sanitary environment, with strong odors, unsecured outlets, and blood smears observed in resident rooms. Hallways were cluttered with equipment due to insufficient storage. Staff were aware of these issues, but actions to address them were delayed or insufficient.
The facility failed to follow physician orders for three residents, leading to deficiencies in care. A resident received metoprolol despite low blood pressure, and hospice was not notified of high blood glucose levels. Another resident also received metoprolol against hold parameters. A third resident's blood glucose was not monitored as ordered. Staff interviews confirmed these oversights.
Failure to Obtain Ordered and Admission Weights and Notify Physician of Critical Blood Glucose
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document ordered weights and to notify the physician as ordered, as well as delays in obtaining admission weights. For one resident with acute respiratory failure with hypoxia, COPD with exacerbation, heart failure, fluid overload, chronic kidney disease, and acute pulmonary edema, a physician’s order dated 12/2/25 required a daily weight once a day, and the care plan reflected this order. However, the MAR for December and January showed multiple days on which the daily weight was not obtained or documented. Facility staff, including a QMA and the DON, stated that daily weights should be completed every day, typically in the morning before breakfast. Another resident with severe protein-calorie malnutrition, encephalopathy, pneumonia, rhabdomyolysis, atherosclerotic heart disease, ischemic cardiomyopathy, repeated falls, hypovolemic shock, and gastrostomy status had physician’s orders on consecutive days to obtain an admission weight, but the admission weight of 106.5 pounds was not obtained and documented until six days after admission, contrary to staff statements that admission weights should be completed on the day of admission or within 24 hours. A third resident with diabetes mellitus and a right fibula fracture had a care plan indicating use of hypoglycemia medication and risk for adverse effects, with interventions including administering medication as ordered. A physician’s order directed staff to administer Humalog insulin per sliding scale and to call the physician for blood sugars less than 60 or greater than 400. The clinical record showed a blood sugar of 435, but the NP was not notified until several days later, as documented in an IDT note and confirmed by the Clinical Support Nurse. A fourth resident with a history of UTI and cerebrovascular accident had an admission weight of 165 pounds obtained and documented several days after admission, despite facility policy and staff statements that admission observation and data collection, including weight, should be initiated within 12 hours and completed within 24 hours. Facility policies on admission nursing observation and weight monitoring required timely completion of admission assessments and daily review of missing admission and ordered weights, but the records for these residents showed that these processes were not followed as required.
Failure to Complete Timely PASARR Level I for New Mental Health Diagnosis and Psychotropic Medication
Penalty
Summary
The facility failed to ensure a timely PASARR (Preadmission Screening and Resident Review) Level I screen was completed when a resident had a new mental health diagnosis and was prescribed a new psychotropic medication. The clinical record for Resident 4 showed multiple diagnoses including depression, atrial fibrillation, heart disease, vascular dementia, pseudobulbar affect, post-traumatic stress disorder (PTSD), and adjustment disorder with anxiety. A physician’s order dated 9/19/25 directed administration of diazepam 2 mg twice daily for anxiety, but a PASARR Level I screen related to the new anxiety disorder diagnosis and the new antianxiety medication was not completed until 2/2/26, after the survey had begun. During interview, the Administrator stated that when a resident has a new psychotropic medication or a new mental health diagnosis added, a new Level I PASARR is required, confirming that this was not done until 2/2/26 for this resident. The facility’s PASARR Quick Sheet policy indicated that when an individual has a severe mental illness/behavioral health diagnosis such as major depressive disorder or anxiety disorder, and the diagnosis is given by a psychiatric provider, the PASARR office should be contacted, but this process was not followed in a timely manner for Resident 4’s new anxiety diagnosis and diazepam order.
Improper Positioning and Sanitary Maintenance of Foley Catheter Drainage Bag
Penalty
Summary
Surveyors observed that a resident with a Foley catheter had the urinary drainage bag attached to a trash can next to the bed. The trash can contained trash in the bottom, and the urine in the catheter tubing was described as cloudy with sediment. The resident’s clinical record showed diagnoses including a history of UTI, acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, COPD, urinary retention, and atrial fibrillation. The care plan indicated the resident had a Foley catheter related to neurogenic bladder, with interventions that included observing the catheter tubing. A recent physician’s order documented that the resident was receiving ciprofloxacin 500 mg twice daily for 14 days for a UTI. Facility staff, including the ADON, Medical Record Nurse, and a QMA, each stated in interviews that the catheter bag should not be placed on a trash can and should instead be hung on the bed rail, and that placing the bag on the trash can put the resident at risk of infection. The facility’s urinary catheter care policy required checking urine for unusual appearance, keeping the drainage bag positioned lower than the bladder to prevent backflow, and ensuring the catheter and tubing were free of kinks, but did not direct staff to place the bag on a trash can.
Improper Catheter Bag Placement on Trash Can
Penalty
Summary
Surveyors observed that a resident’s indwelling urinary catheter drainage bag was improperly attached to a trash can next to the bed. The urine in the catheter tubing was described as cloudy with sediment, and the trash can being used to support the bag contained trash in the bottom. The resident’s clinical record showed diagnoses including a history of urinary tract infection (UTI), acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, chronic obstructive pulmonary disease, urinary retention, and atrial fibrillation. A recent physician’s order documented that the resident had been prescribed ciprofloxacin 500 mg twice daily for 14 days for a UTI. During interviews, the ADON stated the catheter bag should not be placed on the trash can and acknowledged that the resident had a history of UTI and that placing the catheter bag on the trash can could contribute to infection. The Medical Record Nurse also indicated the catheter bag was not supposed to be on the trash can and that the resident was at risk of infection. A QMA confirmed that the catheter bag should be hung on the bed rail and never on the trash can, explaining that hanging the bag on a dirty trash can would put the resident at risk of developing a major infection. The facility’s Infection Prevention and Control Program policy indicated it was designed to help prevent the development and transmission of communicable diseases and infections and to monitor compliance with infection control practices and procedures, which was not followed in this instance.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician's ordered level for four residents. Resident 118 was observed with varying oxygen levels set on her concentrator, ranging from 0.5 to 3 liters, despite a physician's order for 2 liters as needed. The LPN was unsure of the resident's oxygen order, and the care plan indicated the need to administer oxygen per the physician's order. Resident 51 was observed with an oxygen concentrator set at 3 liters, although the physician's order specified 2 liters continuously. Documentation showed multiple instances where the resident was on 3 liters, and once on 1.5 liters, contrary to the physician's order. The care plan required oxygen administration according to the physician's order. Resident 9 was observed with oxygen levels set between 3.5 and 7 liters, but there was no physician's order for oxygen until after the survey start date. Similarly, Resident 58 was observed with 3.5 liters of oxygen without a physician's order until after the survey start date. The facility's policy required verification of the physician's order for oxygen administration, which was not adhered to in these cases.
Environmental Deficiencies in Resident Rooms and Hallways
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in several resident rooms and hallways. Observations revealed strong odors of urine and bowel movements in the 100-hallway and rooms, as well as peeling paint and cracks on the wall in one room. Another room had an unsecured electrical outlet with cords plugged in, and a large dried blood smear was found on the wall and sheets in a different room, accompanied by flying bugs. The Maintenance Director acknowledged previous repairs to the outlet, which had been damaged by staff moving the bed. The Regional Support Executive Director confirmed a sewer backup in one room's bathroom, contributing to the presence of bugs. Additionally, the 200-hallway was cluttered with mechanical lifts and wheelchairs due to a lack of storage space, as confirmed by the Regional Support Executive Director. The facility did not have an environmental policy and relied on state guidelines. Interviews with staff indicated awareness of the issues, but actions to address them were delayed or insufficient. The facility's policy on resident rights emphasized dignity and respect, yet the observed conditions contradicted these principles.
Failure to Follow Physician Orders for Medication and Monitoring
Penalty
Summary
The facility failed to adhere to physician's orders for three residents, leading to deficiencies in care. For Resident 30, the facility did not follow the hold parameters for metoprolol tartrate, a medication used to treat high blood pressure, as it was administered despite systolic blood pressure readings below the specified threshold. Additionally, the facility did not notify hospice of blood glucose readings exceeding 250, as required by the physician's order. Interviews with staff confirmed the oversight in following these orders. Resident 54 also experienced a similar issue with the administration of metoprolol tartrate. The medication was given despite systolic blood pressure readings being below the hold parameter of 110, as specified in the physician's order. This was documented multiple times in the Medication Administration Record, and staff interviews confirmed that vital signs should have been checked and hold parameters followed. For Resident 24, the facility failed to obtain and document a 4:00 a.m. blood glucose reading as ordered by the physician to prevent hypoglycemia. The order was entered incorrectly into the electronic health record, and there was no documentation of the reading being obtained or the physician being notified of the oversight. Interviews with nursing staff and the Director of Nursing revealed a lack of policy for blood glucose monitoring and a failure to verify and enter orders correctly.
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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