Allisonville Meadows
Inspection history, citations, penalties and survey trends for this long-term care facility in Fishers, Indiana.
- Location
- 10312 Allisonville Rd, Fishers, Indiana 46038
- CMS Provider Number
- 155786
- Inspections on file
- 39
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Allisonville Meadows during CMS and state inspections, most recent first.
Resident council concerns were not reviewed back with members at the next meeting as required. Minutes showed repeated complaints about early bedtimes, missed bingo, meds left in rooms, late food service, and CNA staff using cell phones during care, but there was no documentation that prior concerns and resolutions were discussed with the council. During the council meeting, members said they had filed grievances but never heard back with resolutions, and the Resident Council President confirmed there had been no communication from staff about how concerns were addressed.
Anonymous Grievance Filing Not Available to Residents: Residents reported they could not file grievances anonymously and were unaware of any anonymous submission location. Grievance forms were kept at the nurse's station and had to be requested from staff, with an LPN stating residents would receive the forms from the desk and return completed forms to staff. An Activities Assistant said residents with concerns were directed to social services, while the facility grievance policy stated residents have the right to file grievances anonymously.
A resident with dementia and deafness was reportedly mocked by a CNA during toileting care, with an interpreter stating the CNA used the sign for poop and repeated, “it’s always poop, poop, poop.” Another cognitively intact resident reported CNA attitudes and anger during care, and a family member found a resident with lung cancer in an unkempt room with urine containers and an unemptied BSC. Resident council members also reported staff were disrespectful, put them to bed too early, and used cell phones or spoke in another language while providing care.
Meal service was not provided at scheduled times for multiple residents, with several residents on the 500 Hall reporting breakfast, lunch, and dinner were routinely late. A resident council also stated meals were often delayed, especially dinner, and the Dietary Mgr acknowledged staffing concerns on 3rd shift had caused some late dinner service.
A resident with dementia and a history of intrusive wandering and agitation was found lying in another resident’s bed despite care plans directing staff to redirect her to her own room or a quiet area. A laundry aide identified the room but did not redirect the resident or notify nursing staff, and an MCSS initially looked into the room and left before being informed the resident was still there. The other resident became visibly upset and stated the resident did not belong in the room.
A resident scheduled for a colonoscopy received bisacodyl as part of the prep, but colyte was not available because it was out of stock/backordered at the pharmacy. The prep was not completed, the colonoscopy had to be rescheduled, and the resident stated the facility did not ensure all needed meds were available.
A resident with CKD, nausea, vomiting, and diarrhea had STAT CBC and BMP orders, but the labs were not completed the same day and were not resulted until later. Nursing notes stated the lab failed to draw the ordered tests, while interviews indicated a new lab system integration caused the STAT orders not to go through. The resident later had critical BUN and creatinine results and was assessed with no acute distress.
Failure to document meal consumption for a resident with dementia, seizure disorder, poor appetite, diabetes, and weight loss. The resident required supervision with eating and monitoring of nutrition and hydration, but breakfast, lunch, and dinner intake were missing on multiple occasions over several weeks. Her weight declined from 172 lbs to 161 lbs and later to 154 lbs, and the RD stated staff should document consumption of all meals.
A facility failed to notify a physician promptly after a resident's fall, resulting in delayed treatment for a humerus fracture. Additionally, another resident's abnormal lab results indicating acute kidney injury were not communicated in a timely manner, delaying necessary treatment. These deficiencies highlight lapses in communication and adherence to protocols.
A resident with a history of falls and severe cognitive impairment fell and was not assessed by a licensed nurse, leading to a delay in treatment for a fractured humerus. Facility staff failed to document the fall or notify the physician, resulting in the resident self-reporting the incident the following day. The lack of communication and adherence to the fall management policy contributed to the deficiency.
The facility failed to provide adequate ADL care for several residents, including improper hair washing, positioning, and incontinence management. A resident with a traumatic brain injury reported unwashed hair and improper bed positioning. Another resident with Alzheimer's was left in urine for extended periods, and a resident with COPD experienced delays in care and double briefing. Additionally, a resident with dementia was not checked for incontinence as required.
The facility failed to ensure proper hand hygiene and infection control practices, as observed in the care of several residents. A CNA did not perform hand hygiene during incontinent care for a resident with a history of traumatic brain injury and diabetes. Another CNA failed to perform hand hygiene during catheter care for a cognitively impaired resident at risk of MDRO transmission. Additionally, staff did not perform hand hygiene during coffee service, and medication carts were not cleaned after being touched by residents, indicating non-compliance with the facility's hand hygiene policy.
A facility failed to honor a resident's choice regarding her bedtime. The resident, who is cognitively intact, preferred to be put to bed between 7:15 p.m. and 7:30 p.m., but reported being put to bed much later on some days. The Unit Manager confirmed that the resident's care plan did not include her bedtime preferences, despite documentation indicating its importance. A CNA acknowledged the resident's preference but noted it was not always followed due to other situations.
A facility failed to document urinary output for a resident with an indwelling catheter as ordered. The resident, who was severely cognitively impaired, had a care plan requiring documentation of urinary output every shift, but records were incomplete or missing on several occasions. The facility's policy required documentation in milliliters, but output was recorded qualitatively instead.
The facility failed to provide timely medications for two residents. One resident, admitted with pneumonia, did not receive several prescribed medications due to pharmacy order issues and lack of follow-up by staff. Another resident with chronic pain did not receive a buprenorphine patch as ordered, as it was not re-ordered in time and was unavailable in the emergency drug kit.
A resident in an LTC facility experienced a significant medication error when nursing staff failed to administer fentanyl patches according to the physician's order and professional standards. The resident, who was cognitively impaired, had two patches applied simultaneously, leading to an overdose and hospitalization. The facility's failure to remove old patches and adhere to the prescribed schedule resulted in the resident's adverse reaction.
A resident with Alzheimer's and hypertension fell and sustained a hip fracture, but the family was not notified until the next day. The fall was not documented immediately, and the resident was found in pain the following day, leading to a hospital transfer.
A resident with Alzheimer's and other conditions was not provided with hipsters as part of their fall prevention plan, despite a physician's order and facility policy. Observations showed the resident without hipsters, and an LPN was unaware of their requirement or location.
A facility failed to document and manage a resident's behavioral health needs, who exhibited problematic behaviors such as yelling and inappropriate comments. Despite care plans including interventions like providing care in pairs and mental health services, these were not consistently implemented or evaluated. The facility's lack of documentation and evaluation led to ongoing issues with the resident's adjustment to LTC.
A resident with a urinary catheter experienced frequent leakage, resulting in a strong urine odor in the hallway. Despite the resident's care plan to manage catheter care, the staff reportedly did not lock the tubing correctly, causing leakage. Housekeeping staff mopped urine from the floor multiple times a week, but the DON and ED were unaware of the issue.
A facility failed to maintain accurate records for controlled medications for a hospice resident with multiple diagnoses, including hypertension and respiratory failure. The resident was prescribed lorazepam with specific administration instructions, but records showed incorrect dosages were administered. An interview with the DON revealed discrepancies in medication documentation, indicating a failure in the facility's medication administration and record-keeping processes.
The facility failed to ensure proper nail trimming and hand hygiene for three residents requiring upper extremity devices. Observations revealed long nails and unclean hands, with the FDNS confirming the need for better adherence to care plans and procedures.
Resident Council Concerns Not Reported Back
Penalty
Summary
The facility failed to ensure that follow-up resolutions to concerns raised in resident council meetings were reported back to resident council members. The January 2026, February 2026, and March 2026 resident council minutes showed concerns about residents being put to bed too early and missing evening bingo, medications being left in resident rooms without waiting for residents to take them, late food service, and CNA staff talking on cell phones while providing care. In each set of minutes, the Resident Council President signed that she had received follow-up with resolutions to the concerns reported that day, but the minutes did not document any discussion with the resident council members about resolutions to concerns from the prior month. During the 4/13/26 resident council meeting, attended by Residents G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z, the council stated they had filed grievances during resident council meetings but never heard back with resolutions to their concerns. The Resident Council President stated there were no discussions or communication from staff about how the facility had addressed concerns reported in resident council meetings. The Executive Director stated the Resident Council President was informed of the resolutions on the day the concerns were reported and signed off that she had been informed. The facility’s resident council policy stated that facility responses to concerns and suggestions would be reviewed by the Resident Council President and the resident council at their next meeting.
Anonymous Grievance Filing Not Available to Residents
Penalty
Summary
The facility failed to ensure residents were able to file grievances anonymously for 16 of 134 residents reviewed during resident council, including Residents G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z. During a resident council meeting, the residents stated they were unable to file a grievance anonymously and were unaware of any location where a grievance could be submitted anonymously. They reported that grievance forms had to be requested from staff at the nurse's station, and that the forms were not available within reach for residents to take without anyone knowing. The residents also stated there was no privacy to report a grievance without staff knowing what was written on the form. An observation of the 500 Hall nurses' station showed orange grievance forms sitting in a tray in the corner of the station, not accessible to anyone standing outside the nurses' station. An LPN stated the forms were grievance forms that residents had to ask for if they wanted to report a grievance, and staff could assist with completing them if requested. The LPN said residents would return the completed forms to staff at the desk, who would then turn them in for the residents. The Activities Assistant stated activity staff did not have grievance forms available for residents to take, and directed residents with concerns to social services. The Executive Director/Grievance Official stated residents could address concerns to their care companion or go to the nurse's station for grievance forms. The facility's grievance policy stated residents have the right to file grievances orally or in writing, file a grievance anonymously, and that grievances may be submitted anonymously as preferred by the resident, representative, and/or family member.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents’ dignity was maintained and respected. For Resident B, who had dementia, no useful hearing, no speech, and communicated with American Sign Language, the record showed she required assistance with ADLs, toileting, and incontinent care. A family member reported that a CNA had an attitude toward Resident B, and an incident report documented a concern that the CNA made an inappropriate comment in Resident B’s presence. The family member stated the CNA mocked Resident B during care, while the interpreter present during the interaction reported that the CNA used the sign for poop and said, “it’s always poop, poop, poop,” and appeared to be mocking the resident. Resident E, who was cognitively intact and had diabetes, reported that some CNAs had attitudes when they came into work. The resident stated they appeared angry, complained about their shifts and coworkers, and that he would prefer not to have to deal with those attitudes. Resident F, who had lung cancer, was described by a family member as having a urinal full of urine on the bedside table, a styrofoam cup with urine in it, and an unemptied bedside commode from the prior day. The family member also reported that the room had a foul smell and that staff did not promptly come to empty the commode. Resident council minutes and a resident council meeting showed repeated concerns from multiple residents that staff were not respectful. Residents reported being put to bed too early, which caused them to miss evening bingo and other activities, despite their requests to be placed in bed after activities. Residents also reported that staff were talking on cell phones while providing care and speaking in a language other than English in their presence. When residents asked what was being said, staff responded that they were not talking about them. The residents stated these concerns had been reported before and continued without improvement.
Late Meal Service for Multiple Residents
Penalty
Summary
Meal services were not provided at times in accordance with residents’ needs, preferences, and requests for 19 of 134 residents who ate food served from the kitchen. The facility’s meal service schedule showed breakfast, lunch, and dinner were to be served at set times by hall and dining area, but multiple residents reported that meals on the 500 Hall were routinely late. Resident CC stated breakfast was served after 10:00 a.m., lunch around 2:00 p.m., and dinner at 7:00 p.m., while Resident N said dinner trays were delivered to her room at 7:00 p.m. and sometimes later. Resident BB was observed receiving breakfast at 10:30 a.m. and said it was always late, and Resident G reported receiving breakfast at 10:30 a.m. that morning. Resident DD stated all meals were served late all the time. During a resident council meeting, attendees including Residents G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z stated meals were often provided late, with evenings described as the worst and dinner sometimes served between 7:00 p.m. and 8:00 p.m. A kitchen tour with the Dietary Manager confirmed lunch normally would be served at 11:30 a.m., but dinner had recently been provided late at times, with the latest meals served at 6:30 p.m. The Dietary Manager stated staffing concerns on 3rd shift, including vacations and call-ins, had caused dinner meals to be served late at times.
Failure to Redirect Resident with Dementia from Another Resident’s Bed
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with dementia who displayed intrusive wandering and agitation. Resident 4’s clinical record showed diagnoses including dementia and multiple behavior care plans directing staff to redirect her to her own room or a quiet area, offer calm reassurance, and have her lay down when she became verbally or physically aggressive or wandered into other residents’ rooms. Despite these care plan interventions, Resident 4 was observed lying in another resident’s bed in a shared room on the memory care unit, with her eyes closed, while the door remained open and the other resident entered and then shut the door with Resident 4 still in the bed. During the observation, a laundry aide who was in the adjacent room came to the doorway, identified whose room it was, and left without redirecting Resident 4 or notifying nursing staff that she was in another resident’s bed. The Memory Care Support Specialist later came to the room, looked inside, and left before being informed that Resident 4 was still there; after being told, the MCSS entered to address the situation while the other resident repeatedly stated, in a raised and irritated voice, that Resident 4 did not belong in the room. The Memory Care Unit Manager stated that when Resident 4 was found in another resident’s bed, staff would normally redirect her to her own room and indicated the laundry aide should have redirected her or informed nursing staff.
Medication Unavailable for Colonoscopy Prep
Penalty
Summary
The facility failed to ensure medication was available for administration for one resident who was scheduled for a colonoscopy. The resident had a diagnosis that included diabetes and was cognitively intact. A nursing progress note documented that the resident was scheduled for a colonoscopy, and the March MAR showed he received bisacodyl 20 mg as part of the bowel prep, but colyte was not given because it was unavailable. A nursing progress note stated the resident did not complete the colonoscopy preparation and the appointment needed to be rescheduled because the colyte was out of stock at the pharmacy. During interview, the resident stated the facility did not ensure all medication was available for his colonoscopy prep and that he had to deal with the results of receiving only one of the medications. The DON stated the colyte had been on backorder, the pharmacy did not normally inform the facility of medications on backorder, and the physician did not want an alternative treatment, so the procedure was rescheduled.
Delayed STAT Lab Draw for Resident With Nausea, Vomiting, and Diarrhea
Penalty
Summary
The facility failed to timely complete a physician-ordered STAT CBC and BMP for a resident with chronic kidney disease who had nausea, vomiting, and diarrhea. On 4/6/26, the resident had an extra large amount of liquid greenish stool, his ostomy bag was changed three times, and he had one episode of emesis with thick, clear vomit and undigested food. The NP documented the chief complaint as nausea, vomiting, and diarrhea and ordered STAT CBC and BMP labs, but the resident’s record did not contain results for 4/6/26 or 4/7/26; the first CBC and BMP results were dated 4/8/26. A nursing note entered later stated the laboratory failed to draw the resident’s labs ordered on 4/6/26 and that the provider was notified for new orders. Another note documented two more episodes of emesis and a verbal order for a KUB. Later that evening, critical lab results showed a BUN of 61 and creatinine of 10.7, and the resident was assessed with no acute distress. Interviews indicated the facility was integrating a new lab system on 4/6/26 and that the STAT orders were not going through, and the lab procedure stated STAT draws were to be dispatched and received by a phlebotomist within 15 to 30 minutes, with a STAT turnaround time of 5 hours.
Failure to Document Meal Consumption
Penalty
Summary
The facility failed to timely document meal consumption for one resident who was reviewed for nutrition. The resident had diagnoses including seizure disorder and dementia, and her care plan indicated she required assistance and/or monitoring with nutrition and hydration. Her admission MDS showed she had no useful hearing, no speech, and required supervision with eating. A care plan also identified her as being at risk for altered nutritional status related to impaired skin integrity, dementia, diabetes, poor appetite, family-provided food, change in environment, decreased social interaction, weight loss, and poor oral intake. Meal consumption amounts were not documented for multiple meals across numerous dates, including missed documentation for breakfast, lunch, and dinner entries on several occasions from late January through mid-April. The resident’s weight decreased from 172 pounds on admission to 161 pounds, then to 154 pounds, with a later weight of 157 pounds. During interview, the RD stated the resident had a poor appetite when she first admitted, several interventions were attempted, her appetite was improving, and staff should document consumption of all meals.
Failure to Notify Physician of Fall and Lab Results
Penalty
Summary
The facility failed to ensure timely notification of a fall and subsequent injury for Resident D, who was moderately cognitively impaired and diagnosed with Alzheimer's disease. On the morning following the fall, Resident D reported shoulder pain to a nurse, who observed bruising and swelling but was not aware of the fall until later. The resident had self-reported the fall to staff the previous evening, but the nurse on duty was not informed, resulting in a delay in treatment for a left humerus fracture. The resident was eventually transferred to the emergency room for evaluation and treatment after experiencing significant pain and a fainting spell. Additionally, the facility did not promptly inform a physician of a significant change in laboratory values for Resident B, who had a history of urinary tract infection, diarrhea, and dementia. Despite a physician's order for a basic metabolic panel (BMP) to be conducted, the results indicating elevated creatinine and BUN levels were not communicated to the physician until two days later. This delay in communication resulted in a delay in the initiation of intravenous fluids, which were necessary to address Resident B's acute kidney injury. The facility's failure to adhere to its policies regarding the notification of physicians and timely intervention following significant changes in resident conditions contributed to the deficiencies identified in the report. The lack of immediate communication and assessment following Resident D's fall and the delay in addressing Resident B's abnormal lab results highlight the need for improved staff training and adherence to established protocols.
Failure to Assess and Monitor Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident who had fallen was properly assessed and monitored by a licensed nurse. On the night of the incident, the resident fell and was assisted back to bed by facility staff, including a Qualified Medication Aide and a Certified Nurse Aide, without notifying a licensed nurse. The resident, who was severely cognitively impaired and required substantial assistance with mobility, later reported pain and was found to have a fractured humerus, which required hospitalization. The resident's clinical record indicated a history of falls and a care plan that included various interventions to prevent falls. Despite these measures, the resident fell and was not immediately assessed by a nurse. The following day, the resident self-reported the fall and exhibited signs of pain and injury, including bruising and swelling on the left shoulder and a skin tear on the left elbow. The facility staff failed to document the fall or notify the physician immediately, as required by the facility's fall management policy. Interviews with staff revealed a lack of communication and documentation regarding the fall. Several staff members, including a Licensed Practical Nurse and a Registered Nurse, were unaware of the fall until the resident self-reported it the next day. The resident's representative was also not informed of the fall until they arrived at the facility. The facility's failure to follow its fall management policy and ensure timely assessment and documentation of the fall led to a delay in the resident receiving appropriate medical care.
Deficiencies in ADL Care and Incontinence Management
Penalty
Summary
The facility failed to provide adequate care for several residents, leading to deficiencies in activities of daily living (ADL) care. Resident L, who had a history of traumatic brain injury and diabetes, required assistance with ADLs due to weakness from a recent hospital stay. Despite being cognitively intact, Resident L reported that her hair had not been washed in two weeks, and she felt that incontinence care was lacking. Observations confirmed that her hair was unwashed, and she was improperly positioned in bed, increasing the risk of skin shearing. Resident D, diagnosed with Alzheimer's disease, was moderately cognitively impaired and required assistance with toileting due to various health issues. Despite a care plan indicating the need for incontinence checks every two hours, Resident D's family reported instances where he was left in urine for extended periods. Observations and interviews revealed that staff were not consistently performing the required checks, and documentation of urinary output was infrequent. Resident 20, with chronic obstructive pulmonary disease and moderate cognitive impairment, reported infrequent changes and was under the impression that double briefing was standard care. Observations confirmed delays in response to her requests for assistance, and staff were found to be using double briefs, which was not a standard practice. Similarly, Resident G, who required assistance due to dementia and incontinence, was not checked for incontinence every two hours as required. Family members reported and observations confirmed that staff did not perform regular checks, leading to prolonged periods without necessary care.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during the provision of care for several residents, leading to potential infection control issues. For Resident L, who has a history of traumatic brain injury and diabetes, a Certified Nurse Aide (CNA) did not perform hand hygiene when changing gloves during incontinent care. The CNA used double gloves, which was not in accordance with the facility's policy, and failed to perform hand hygiene between glove changes, despite Resident L's concerns about the quality of care and risk of urinary tract infection. In another instance, during catheter care for Resident E, who is severely cognitively impaired and at risk of MDRO transmission, a CNA failed to perform hand hygiene after touching high-contact surfaces before handling clean washcloths and providing care. The CNA touched various surfaces, including a doorknob and a bedside table, without changing gloves or performing hand hygiene, which compromised the infection control measures required for Resident E's care. Additionally, during a coffee service, staff members did not perform hand hygiene before and after interacting with residents, and medication carts were not cleaned after being touched by residents. A CNA and a Qualified Medication Aide (QMA) failed to sanitize the medication cart surfaces after residents placed items on them or touched them, which could lead to cross-contamination. These observations indicate a lack of adherence to the facility's hand hygiene policy, which outlines specific moments when hand hygiene should be performed to minimize infection transmission.
Failure to Honor Resident's Bedtime Preference
Penalty
Summary
The facility failed to honor and facilitate a resident's choice regarding her bedtime, as evidenced by the case of Resident 30. Resident 30, who is cognitively intact and has diagnoses including muscle weakness and obesity, expressed a preference to be put to bed between 7:15 p.m. and 7:30 p.m. However, she reported that there were days when she was not put to bed until 9:30 p.m. to 10:00 p.m. An interview with the Unit Manager revealed that Resident 30's care plan did not include her bedtime preferences, although a document titled 'Preferences for Customary Routine and Activities' indicated that choosing her own bedtime was very important to her. A Certified Nurse Aide confirmed that Resident 30 preferred to be put to bed after the evening meal but acknowledged that this did not always occur due to other situations.
Failure to Document Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to accurately document urinary output for a resident with an indwelling catheter, identified as Resident E. The resident, who was severely cognitively impaired, had a care plan requiring documentation of bowel and urinary output every shift. A physician order also specified that the nurse should record the output every shift. However, the urine output was not documented for two out of three shifts on specific dates and was entirely missing for other dates. When documented, the output was recorded in qualitative terms such as 'Large' or 'Medium' rather than in milliliters as required. During an interview, the facility's Nurse Consultant indicated that urinary output should be documented in milliliters for residents with indwelling catheters. The Director of Nursing provided a Bowel and Bladder Program Policy, which stated that urinary output from indwelling catheters should be documented. The failure to document urinary output as ordered represents a deficiency in the care provided to Resident E.
Medication Availability Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure the timely availability of medications for Resident 182, who was admitted with diagnoses including pneumonia. Upon admission, several physician orders were placed for medications such as finasteride, hydroxyurea, levofloxacin, metoprolol, tamsulosin, and a Trelegy inhaler. However, these medications were not available for administration on multiple occasions as documented in the Medication Administration Record (MAR). The Nurse Consultant indicated that the pharmacy had not received all medication orders upon the resident's admission, and the staff did not follow up promptly to obtain the medications. For Resident 47, who was moderately cognitively impaired and had a diagnosis of chronic pain, the facility failed to administer a buprenorphine patch as ordered on two occasions. The Unit Manager explained that the nurse was supposed to re-order the patch when the last one was placed, but it was not available in the facility's emergency drug kit. The facility's re-ordering policy required medications to be re-ordered when there was a 3-day supply remaining, but this procedure was not followed, resulting in the unavailability of the medication.
Failure to Properly Administer Fentanyl Patches Leads to Resident Overdose
Penalty
Summary
The facility failed to administer a synthetic opioid pain patch in accordance with the physician's order, manufacturer's specifications, or accepted professional standards, resulting in a significant medication error for a resident. The resident, who was cognitively impaired and receiving pain management, was found to have two fentanyl patches applied simultaneously. This error led to a significant change in the resident's consciousness, requiring the emergent administration of an opioid overdose medication and subsequent hospitalization. The clinical record review revealed that the resident was to receive a 75 mcg fentanyl patch every three days for pain, but the patches were applied more frequently than ordered, and previous patches were not removed before new ones were applied. Specifically, the resident received fentanyl patches five times within an eight-day period, and there was no documentation of patch removal or monitoring for changes in the resident's condition. On one occasion, the resident was found unresponsive with two patches in place, necessitating the administration of Narcan and hospitalization. Interviews and documentation indicated that the medication errors were due to nursing staff not adhering to the prescribed schedule and failing to remove old patches. The errors were compounded by a lack of proper documentation and monitoring, which contributed to the resident's adverse reaction. The facility's medication administration procedure policy was not followed, leading to the resident's overdose and subsequent medical intervention.
Failure to Notify Family of Resident's Fall
Penalty
Summary
The facility failed to timely notify a resident's representative of a fall incident involving Resident B, who had a history of Alzheimer's disease and hypertension. On 12/11/24, Resident B was found on the floor in another resident's room, but no injuries were noted at that time. Despite being assessed and showing no immediate signs of pain, Resident B later exhibited pain in her left lower extremity, leading to a physician's order for a STAT X-Ray, which revealed a left femoral neck fracture. The resident was subsequently sent to an acute care hospital for treatment. The deficiency arose because the family member, FM 10, was not informed of the fall until the following day when she visited and noticed Resident B in distress. The facility's investigation revealed that the fall was not documented in the clinical record on the day it occurred, and the family was not notified promptly. Interviews with staff indicated a lack of communication and documentation regarding the fall, which contributed to the delay in notifying the family and addressing Resident B's injury.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement care-planned fall interventions for a resident identified as being at risk for falls. The resident, who has diagnoses including Alzheimer's disease, dementia, anxiety, fibromyalgia, and osteoarthritis, was observed multiple times without wearing hipsters, which were part of the prescribed fall prevention measures. A physician's order from July 2024 required the use of hipsters at all times, with nursing staff checking for their use every shift. However, observations on January 2nd and 3rd, 2025, revealed that the resident was not wearing hipsters while sitting in a wheelchair at the nurse's station. When questioned, an LPN was unsure if the resident was supposed to be wearing hipsters and confirmed that the resident was not wearing them upon inspection. The resident's room did not contain hipsters, and the LPN was unaware of their whereabouts, despite knowing the resident had worn them previously. The facility's Fall Management Policy, revised in March 2024, mandates the implementation of resident-centered fall prevention plans for those at risk, but this was not adhered to in the case of this resident.
Failure to Document and Manage Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to adequately document and manage the behavioral health care needs of Resident H, who was admitted with diagnoses including stroke and dementia. Despite being cognitively intact upon admission, Resident H exhibited problematic behaviors such as yelling, cursing, and making inappropriate sexual comments. These behaviors were noted in various nursing and care plan notes, but the facility did not consistently document these incidents or evaluate the effectiveness of the interventions put in place to address them. Resident H's care plans included interventions such as providing care in pairs, encouraging expression of feelings, administering medications, and providing mental health services. However, these interventions were not consistently implemented or evaluated. For instance, there were instances where care was provided by a single staff member, contrary to the care plan's directive to provide care in pairs. Additionally, the facility did not document all behavioral incidents, such as inappropriate sexual comments, in the resident's clinical record. The facility's failure to document and evaluate Resident H's behaviors and the effectiveness of interventions led to ongoing issues with the resident's adjustment to long-term care. Despite discussions during care plan meetings and awareness of the resident's behaviors, the facility did not ensure that staff consistently followed the behavior management policy. This lack of documentation and evaluation contributed to the deficiency identified in the report.
Failure to Maintain Odor-Free Environment Due to Catheter Leakage
Penalty
Summary
The facility failed to maintain an environment free from strong urine odors, affecting one of the three residents reviewed for environmental conditions. Resident J, who has a medical history of neuromuscular dysfunction of the bladder and urinary retention, required an indwelling urinary catheter. The care plan for Resident J, initiated in December 2018, included interventions such as recording urinary output every shift and maintaining a closed catheter system. However, observations on multiple occasions revealed a strong urine odor in the 500 hallway, traced back to Resident J's room. Resident J reported that her urinary catheter frequently leaked onto the floor, suspecting that the staff did not lock the tubing on the bag correctly, leading to the leakage. Housekeeping staff confirmed that they mopped urine from the floor in Resident J's room 2-3 times a week due to leakage from the catheter bag. Despite these occurrences, the Director of Nursing Services and the Executive Director were unaware of the strong urine odor and had not received any concerns regarding the nursing staff's handling of the urinary bag. This deficiency was identified during a complaint investigation related to Complaint IN00446808.
Inaccurate Controlled Medication Records for Hospice Resident
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled medications for a resident receiving hospice services. The resident, who had diagnoses including hypertension, congestive heart failure, and respiratory failure, was prescribed lorazepam, an antianxiety medication, with specific administration instructions. A physician order indicated lorazepam was to be administered at a dosage of one milliliter every three hours, which was later adjusted to every two hours. However, the controlled substances record showed that the medication was administered at a significantly lower dosage of 0.1 milliliters at various times, contrary to the physician's orders. An interview with the Director of Nursing revealed that the lorazepam bottle should have been empty by a certain date, but a new bottle was received and not utilized according to the records. This discrepancy indicated that the documentation on the controlled substances record was inaccurate, as the nursing staff recorded administering a much lower dosage than prescribed. This issue was identified during a review related to a specific complaint, highlighting a failure in the facility's medication administration and record-keeping processes.
Failure to Ensure Proper Nail Trimming and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper nail trimming and hand hygiene for three residents who required upper extremity devices. Resident D, diagnosed with chronic kidney disease and hemiplegia following a stroke, was observed with long nails and a brown flaky substance on his hand, which was only cleaned on shower days. The Float Director of Nursing Services (FDNS) confirmed that the resident's nails needed trimming and that staff should wash the resident's hand before placing the palm protector on it. Resident C, diagnosed with diabetes mellitus, dementia, and chronic kidney disease, was found with long nails despite a care plan indicating the need for nail trimming twice a week. A hospice RN noted a foul smell from the resident's hands and observed maceration between the fingers due to long nails. The FDNS confirmed that the resident's nails needed trimming and that the nursing staff should be responsible for this task. Resident F, diagnosed with dementia and muscle weakness, was observed with long nails with uneven edges and a black substance underneath them. The FDNS confirmed that the resident's nails needed cleaning and trimming. The facility's procedures for splinting device application and fingernail care were not followed, leading to the deficiencies observed in the care of these residents.
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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