Woodmont Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Boonville, Indiana.
- Location
- 1325 Rockport Rd, Boonville, Indiana 47601
- CMS Provider Number
- 155682
- Inspections on file
- 30
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Woodmont Health Campus during CMS and state inspections, most recent first.
Surveyors found that pharmaceutical services were not sufficient to ensure physician-ordered routine medications were available and administered as prescribed for two residents. One resident with multiple conditions, including HF, CKD, type II DM, anemia, SIRS, and an acute URI, had several missed doses of artificial tears, ferrous sulfate, sliding-scale insulin, ipratropium-albuterol nebs, and methylprednisolone documented on the MAR as unavailable. Another resident with type II DM, HF, and CKD missed a dose of cyanocobalamin and an evening dose of Novolog insulin because the medications were not available. These missed doses occurred despite a facility policy stating that medications would be administered in accordance with prescriber orders and supported by a sufficient medication distribution system.
A resident with multiple chronic conditions, including type II DM, heart failure, and kidney failure, experienced significant medication errors when two nurses administered Novolog 10 units twice due to failure to document on the MAR, and on another occasion an LPN gave the resident a full set of medications intended for the roommate, resulting in wrong-resident and wrong-medication administration. Staff interviews confirmed the errors, and facility policy and a QMA’s statements indicated that proper resident identification and adherence to the five rights of medication administration were required but not followed.
The facility failed to adhere to proper hand hygiene practices during care activities for two residents. A CNA performed insufficient handwashing during urostomy and incontinence care, while an RN improperly handled gloves and a glucometer during glucose monitoring. These actions did not comply with the facility's hand hygiene policy.
The facility failed to store food safely and maintain proper sanitation in the kitchen. Observations revealed unlabeled and open food items in the freezer, and the dishwasher did not reach the required rinse temperature. Temperature logs were incomplete, and staff failed to report or address the dishwasher's malfunction. Facility policies on temperature checks and documentation were not followed.
The facility failed to conduct quarterly care plan conferences for four residents, as required by their policy. A resident with dementia and hypertension, another with anxiety and depression, a third with hypertension and anxiety, and a fourth with fibromyalgia and depression all missed scheduled care conferences. The Social Service Director acknowledged the oversight, and the facility's policy mandates quarterly meetings to ensure communication and participation in the residents' care plans.
The facility failed to ensure a sanitary and homelike environment, with observations of soiled toilets, uncovered bedpans, and dirty equipment across resident halls and a shower room. Staff interviews revealed unclear cleaning protocols and responsibilities, contributing to the deficiencies.
The facility failed to ensure proper hand hygiene during incontinence care for two residents. CNAs did not change gloves or perform adequate handwashing between tasks, and a clean incontinence pad was placed on the bathroom floor before use. The DON confirmed that staff should lather hands for 20-30 seconds and change gloves when touching different items.
The facility did not ensure daily posting of accurate nurse staffing information, as observed on one occasion when the staffing sheet was outdated. The ADON indicated that the Scheduler and weekend nurse were responsible for posting the information, according to the facility's policy.
Failure to Provide Prescribed Medications Due to Unavailable Pharmacy Stock
Penalty
Summary
The deficiency involves the facility’s failure to ensure pharmaceutical services were available so that physician-prescribed routine medications were administered as ordered for two residents. For one resident with diagnoses including heart failure, kidney failure, type II diabetes, anemia, SIRS, and acute upper respiratory infection, the MAR for February 2026 showed multiple missed doses of ordered medications because they were unavailable at the facility. These included artificial tears not given for an evening and night time period, ferrous sulfate not given on one day, sliding-scale insulin lispro not given before breakfast on one day, ipratropium-albuterol nebulizer solution not given for a scheduled morning dose, and methylprednisolone not given for a morning time block. The resident reported that staff had informed her on more than one occasion that they were out of her routine medications. A second resident, with diagnoses including type II diabetes, heart failure, and kidney failure, also did not receive prescribed medications due to unavailability. Record review showed that this resident’s daily cyanocobalamin (vitamin B-12) was not administered on one day in January 2026 because it was unavailable, and a scheduled evening dose of Novolog insulin was not given on another day for the same reason. The facility’s written policy stated that the facility would have sufficient personnel and a medication distribution system to ensure safe administration of medications and that medications are administered in accordance with written prescriber orders, but the documented missed doses due to unavailability demonstrate that this did not occur for these two residents.
Failure to Prevent Significant Medication Errors and Wrong-Resident Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, including a double insulin dose and administration of another resident’s medications. Record review showed that the resident had diagnoses including type II diabetes, heart failure, kidney failure, anxiety, and depression, and was receiving insulin, antidepressant, diuretic, anticoagulant, hypoglycemic, and anticonvulsant medications. Nursing progress notes documented that on one occasion the resident was given Novolog 10 units twice by two different nurses because the first administration was not documented as given on the MAR, leading the second nurse to be unaware that the insulin had already been administered. On another occasion, an event report documented that the resident received a full set of medications intended for the roommate, including Xanax 0.5 mg, atorvastatin 40 mg, Aricept 10 mg, metoprolol 25 mg, Remeron 7.5 mg, Singulair 10 mg, ranolazine 500 mg, and ropinirole 1 mg. The error was described as involving the wrong resident and wrong medications, with the reason identified as wrong resident. During interview, an LPN stated she mistakenly administered the roommate’s medications to the resident. Another staff member (a QMA) indicated that nursing staff are expected to use the five rights of medication administration, and the facility’s policy required resident identification before medication administration by checking a photograph, calling the resident by name, having the resident verify their last name, or verifying identification with other personnel.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to maintain proper infection control practices, specifically in hand hygiene, during care activities for two residents. In the first observation, a CNA provided urostomy and incontinence care for a resident requiring Enhanced Barrier Precautions. The CNA performed handwashing for only 10 to 12 seconds, which is below the facility's policy requirement of at least 20 seconds. After removing gloves, the CNA touched the resident's privacy curtain with bare hands before completing hand hygiene in the bathroom. In the second observation, an RN conducted glucose monitoring for another resident. After pricking the resident's finger and checking the blood sugar level, the RN removed one glove and carried the glucometer out of the room. The RN placed a used glove on a medication cart in the hallway, removed the other glove, and disposed of both gloves in the trash on the cart before completing hand hygiene. These actions were contrary to the facility's hand hygiene policy, which requires handwashing after removing gloves and before having direct physical contact with residents.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food and proper sanitation procedures in the kitchen. During observations, food items such as beef patties and chicken breasts were found open to air and unlabeled in the walk-in freezer. Additionally, the high-temperature dishwasher did not reach the required rinse temperature of 180 degrees Fahrenheit, with recorded temperatures of 168, 170, and 172 degrees during various observations. Temperature logs for food, dish machine, refrigerator, and freezer were incomplete or missing for several days, indicating a lack of proper documentation and monitoring. Interviews with staff revealed that there was a lack of communication and action when the dishwasher failed to reach the required temperature. A staff member admitted to not notifying the Dietary Manager or Maintenance Director when the rinse temperature was below the required level, as they were not present. The Administrator was only informed of the issue after the surveyor's observation, and it was noted that the facility had not used disposable dishes despite the dishwasher's malfunction. The facility's policies required specific temperature checks and documentation, which were not adhered to, contributing to the deficiency.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were completed quarterly for four out of five residents reviewed for unnecessary medications. Resident 28, diagnosed with dementia with behaviors and hypertension, did not have a care conference between January 2, 2024, and June 3, 2024. Resident 8, with anxiety disorder and depression, lacked a care conference between December 12, 2023, and May 8, 2024. Resident 19, diagnosed with hypertension and anxiety disorder, missed care conferences between August 27, 2023, and January 3, 2024, as well as on May 30, 2024. Resident 29, with fibromyalgia and depression, did not have care conferences between August 27, 2023, and December 12, 2023, and on June 11, 2024. During an interview, the Social Service Director confirmed that these residents should have had care plan conferences every three months. The facility's policy, as provided by Regional Support 2, indicated that subsequent meetings for residents should be conducted at a minimum of quarterly, emphasizing communication and participation regarding the resident's plan of care, medical condition, and care needs.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment across multiple areas, including resident halls and a shower room. Observations revealed that resident toilets were visibly soiled, and fracture pans and urine hats were left uncovered and improperly stored. Equipment such as vitals machines and lift equipment were also found to be visibly soiled. Additionally, the carpet in the 200 Hall was stained, and the shower room had soiled grout, chipped tiles, and a broken tile by the bathroom wall. Specific observations included a brown substance on the back of a toilet, uncovered bedpans on handrails, and dusty vent fans and handrails in resident bathrooms. Rooms were found with dusty surfaces, unpainted plaster, and scuff marks on walls. In one instance, a sit-to-stand lift was observed with food and debris on the footplate. The shower room had multiple cleanliness issues, including a strong urine smell, stained upholstery, and a black substance smeared on the floor. Interviews with staff revealed a lack of clarity and adherence to cleaning protocols. The Environmental Services Director indicated that daily cleaning tasks should be completed and signed off by staff, but there was no checklist for cleaning the shower room. The Maintenance Director relied on staff notifications for maintenance needs, but staff were not adequately trained to enter work orders. Additionally, there was no clear policy for cleaning resident equipment, and confusion existed among staff regarding responsibilities for maintaining cleanliness.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections during incontinence care for two residents. In the first instance, two CNAs were observed providing care to a resident without adhering to proper hand hygiene protocols. CNA 48 washed her hands with a 5-second lather and CNA 56 with a 10-second lather before donning gloves. During the care process, CNA 48 laid a clean incontinence pad on the bathroom floor, which was then placed on the resident. Additionally, CNA 48 did not perform hand hygiene after removing gloves and before handling the resident's wheelchair and other items. When questioned, CNA 48 acknowledged the lapse in hand hygiene and washed her hands with a 6-second lather. In the second instance, CNA 23 and a CNA in training provided incontinence care to another resident. CNA 23 used the same pair of gloves to handle various items, including the bedside table, trash bag, and bed remote, without changing gloves or performing hand hygiene. CNA in training 21 also failed to change gloves and perform hand hygiene before placing a clean brief on the resident. After completing the care, CNA 23 did not perform hand hygiene before handling the resident's blankets and other items. The Director of Nursing indicated that staff should lather their hands for 20-30 seconds and change gloves when touching different items during care.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing sheets were posted and contained the correct information daily, as required. On July 21, the Posted Nurse Staffing form was observed at the nurse's station with a date of July 19, indicating that the staffing information was not updated for that day. During an interview, the Assistant Director of Nursing (ADON) stated that the Scheduler was responsible for posting the staffing form daily in the morning at the beginning of the shift, and on weekends, the 300 Hall nurse was responsible for posting it at the change of shift. The facility's policy, revised on May 11, 2016, requires that the number and hours of licensed nurses and unlicensed nursing personnel providing direct care to residents be posted at the beginning of each day.
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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