Alpha Home - A Waters Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 2640 Cold Spring Rd, Indianapolis, Indiana 46222
- CMS Provider Number
- 155717
- Inspections on file
- 39
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Alpha Home - A Waters Community during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, dementia with behavioral disturbance, and PTSD had a history of verbal and physical aggression, exit-seeking, and medication refusal, culminating in an incident where the resident struck a nurse and was sent to an acute psychiatric hospital. Facility documentation showed no 30‑day transfer/discharge notice to the resident’s representative, no documentation of appeal rights or bed-hold policy, and a discharge MDS that characterized the hospitalization as an unplanned discharge with return anticipated. After transfer, the psychiatric hospital Social Worker repeatedly attempted to coordinate the resident’s return, but the DON was often unavailable, the receptionist stated the resident was not allowed back, and facility staff gave inconsistent, undocumented explanations that the resident would not be re-admitted or had been discharged to another SNF, despite the hospital and the representative reporting no such acceptance. The facility’s actions and omissions conflicted with its own transfer/discharge policy requiring 30‑day notice for non-emergency discharges, continuity of care planning, and provision of bed-hold information.
A resident with severe cognitive impairment and significant psychiatric and behavioral diagnoses exhibited escalating verbal and physical aggression, leading to emergency transfer to a behavioral hospital. Although staff had previously discussed behavior concerns with the resident’s representative, the record shows no 30‑day notice of facility‑initiated discharge was issued, and no notice of transfer or discharge with appeal rights or attached bed‑hold policy was provided to the representative at the time of transfer or afterward. Documentation reflects that only the resident, not the representative, received the bed‑hold policy despite the resident’s confusion, and there were no subsequent facility notes of communication with the representative or the psychiatric facility. The Administrator and DON later acknowledged that the required 30‑day notice and transfer/discharge and bed‑hold notices were not provided, and the representative reported she never received any paperwork or appeal information.
A resident who was totally dependent on staff and at high risk for pressure ulcers developed a stage II coccyx wound that progressed to an unstageable ulcer, requiring hospitalization and surgical debridement. The facility failed to document or implement preventive interventions such as regular turning, incontinence care, and use of barrier creams, and did not promptly identify or address the wound, resulting in actual harm.
A resident with a history of stroke, aphasia, and high fall risk fell out of bed while being cared for by a newly hired CNA working alone, despite requiring extensive assistance. The care plan lacked individualized fall prevention interventions and was not updated after the incident. Required 72-hour post-fall assessments and care plan revisions were not completed, contrary to facility policy.
A treatment cart containing biologicals, insulin, blood glucose testing supplies, and unidentified pills was found unlocked and unattended near the nurse's station and dining area. The cart's top drawer was open, exposing medications and supplies, while several residents and a visitor were nearby. An LPN responsible for the cart was out of sight, and later admitted to forgetting to secure it as required by facility policy.
A resident with a history of stroke and chronic pain was injured when he slid out of his wheelchair on a facility bus due to improper securing. The lap belt was not installed, and an incorrect cross-belt was used. The bus driver and maintenance director lacked specific training on the new bus equipment, leading to the incident.
The facility did not ensure Resident Council grievances were addressed and reported back for review, affecting four residents. Despite multiple meetings where residents requested more outings and raised care concerns, no responses were documented. Interviews confirmed that residents often did not receive timely feedback, and the Activity Director acknowledged the lapse in the process.
The facility inaccurately coded the MDS for several residents, leading to discrepancies in medication and PASRR Level II requirements. A resident was incorrectly listed as taking an anticoagulant instead of an antiplatelet, while another's need for PASRR Level II was not reflected. Interviews confirmed these errors, and no specific policy for MDS accuracy was in place.
The facility failed to date opened medications on a treatment and a medication cart, including insulin pens and other medications, as observed with a QMA. The facility's policy on medication storage did not address the requirement to date medications when opened.
A resident expressed dissatisfaction with her long facial hair and requested assistance with shaving, which was not promptly addressed by the facility. Despite her care plan indicating a need for staff assistance with ADLs, her preference for a specific staff member to assist was not initially documented or honored, leading to a delay in addressing her grooming needs.
The facility failed to develop comprehensive care plans for two residents, one with ESRD and another with sleep difficulties, leading to deficiencies in addressing their specific medical needs. The care plans did not initially include necessary details related to dialysis and melatonin use, respectively, despite facility policy requirements.
The facility failed to update care plans for two residents. One resident, with depressive and anxiety disorders, had a care plan that did not reflect her refusal of gradual dose reductions for medications. Another resident, with dementia and major depressive disorder, had a care plan indicating a risk for mood decline but did not have an antidepressant in her medication regimen. These issues were identified during record reviews and interviews with the DON and RCS.
A resident with a history of stroke and other medical conditions fell from a wheelchair on a facility bus and was moved back into the chair by staff without a medical assessment. The resident was not properly secured in the bus, and the facility's policy requiring immediate nurse assessment before moving a resident after a fall was not followed. This led to a deficiency in providing appropriate care.
A facility failed to provide necessary care to a resident to prevent worsening contractures in her hand and wrist. Despite therapy recommendations for passive range of motion (PROM) and palm protector use, these were not documented or implemented in her care plan. Observations showed the resident's hand and wrist were contracted without a splint or palm protector, and the contracture angle increased slightly. The Director of Nursing acknowledged the lack of a policy for range of motion treatments, expecting staff to follow therapy recommendations.
A facility failed to document a resident's blood pressure and pulse before administering metoprolol, an antihypertensive medication, as required by the prescription. The resident's care plan included monitoring blood pressure according to the medical doctor's order or facility policy, but the medication administration records for two months lacked this documentation. The facility's policy required vital sign monitoring before administering medications dependent on such measures.
The facility failed to document adequate justification for declining pharmacy recommendations to reduce psychotropic medications for two residents. One resident, with multiple psychiatric diagnoses, had no documented symptoms to support the physician's decision to decline a medication reduction. Another resident's medical record lacked behavior monitoring and non-pharmacological interventions, despite recommendations for gradual dose reduction. The facility's Director of Nursing acknowledged the need for better documentation and behavior monitoring.
A resident with a history of supraventricular tachycardia and chronic respiratory failure experienced left mid-foot pain after an incident with a Hoyer lift. An NP ordered a three-view x-ray to rule out acute injury, but the x-ray was delayed, and no results were initially available in the resident's record. The resident reported ongoing pain and difficulty moving, and the DON confirmed the x-ray was only conducted later, indicating a lapse in timely care.
A facility failed to properly sanitize a blood glucometer used for a resident. An LPN performed a blood sugar test and cleaned the glucometer with a Sani-wipe, allowing it to dry for 5 minutes. However, the facility's policy required a more thorough cleaning process, including wiping the glucometer with a towelette three times horizontally and vertically, and ensuring it remained wet for 2 minutes with a Super Sani cloth wipe. The LPN did not adhere to this procedure, resulting in a deficiency.
A resident with diabetes, chronic kidney disease, and chronic hepatitis did not receive requested influenza, pneumonia, and COVID-19 vaccinations. Despite signed consents for pneumococcal and COVID-19 vaccines, the facility failed to administer them due to unavailability and preference for a clinic session. The influenza vaccine was not documented for acceptance or declination.
A resident with a tracheostomy was admitted to the facility without the necessary physician's orders for tracheostomy care, oxygen, and suctioning. Despite the setup of respiratory equipment by a supply company, the facility did not have a care plan or orders in place until weeks later. The DON acknowledged the oversight, which was contrary to the facility's policy requiring immediate care orders upon admission.
Failure to Readmit Psychiatric Resident and Follow Required Transfer/Discharge Procedures
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return following a psychiatric hospitalization and failure to follow required transfer/discharge and bed-hold procedures. The resident had been admitted with multiple mental health diagnoses, including schizoaffective disorder bipolar type, dementia with behavioral disturbance, and PTSD. The facility’s own assessment indicated it provided care for residents with these conditions and behaviors requiring interventions. Prior to the final hospitalization, the resident had a documented history of verbal and physical aggression, exit-seeking, and refusal of medications and meals, with multiple progress notes describing attempts to leave the unit, threats toward staff and other residents, and physical aggression such as pushing a walker into staff and raising a fist. On one occasion, the resident’s escalating behaviors led to police escorting the resident out of the facility. The resident was later re-admitted and continued to exhibit verbal aggression, threats, and attempts to push a chair into another resident, which resulted in a transfer to an acute psychiatric hospital. Subsequent documentation described ongoing challenging behaviors, including demanding unavailable food items, verbal aggression and profanity toward staff, accusations against other residents, refusal of medications, calling 911 claiming poisoning, and physical aggression such as throwing items and threatening to overturn the medication cart. Despite this pattern, the record lacked documentation that a 30‑day notice of transfer or discharge was issued due to the resident’s behaviors, and a care plan meeting note with the resident’s representative did not document that a transfer/discharge notice was provided or that alternative placement was required. On the date of the final incident, the resident struck a nurse in the face with a closed fist and grabbed the nurse’s head when the nurse attempted to prevent the resident from exiting the unit. 911 was called, and the resident was transferred to a behavioral facility. The daughter was notified of the transfer, but the note lacked documentation that she was provided with a transfer/discharge notice, appeal rights, or the bed-hold policy. A discharge MDS indicated an unplanned discharge to a short-term hospital with return anticipated. A subsequent SSD note stated that, after a prior psychiatric hospitalization, the resident and POA had been told that any violent behavior would result in immediate discharge to a hospital with no option to return. After the resident’s transfer, the psychiatric hospital Social Worker repeatedly attempted to contact the DON to determine if the resident could return, leaving multiple messages and sending clinical information, while the facility’s receptionist stated the resident was not allowed back and that her representative had picked up her belongings. Over the following weeks and months, the psychiatric hospital Social Worker documented multiple unsuccessful attempts to reach the DON, intermittent brief contacts, and inconsistent information from the facility. The DON at various times requested clinical information, stated the resident would not be accepted back until stabilized on oral medications, and later indicated she believed the resident had been discharged to another SNF, though she could not provide documentation of such an acceptance or notification. The SSD reported that the IDT had determined on the date of the last hospitalization that the resident would not be re-admitted based on prior discussions with the representative about behavior, and the SSD believed the resident had been discharged to another SNF. The psychiatric hospital Social Worker and the resident’s representative both indicated there had been no confirmed acceptance by another SNF and no communication to them of such a plan. The facility’s own transfer/discharge policy required 30‑day notice for non-emergency transfers/discharges, provisions for continuity of care, and provision of bed-hold information before hospital transfers, but the record lacked documentation that these requirements were met for this resident, and the resident remained at the psychiatric hospital because the facility refused to re-admit her and did not assist with discharge planning.
Failure to Provide Required Transfer/Discharge Notice, Appeal Rights, and Bed-Hold Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required notices of transfer or discharge, appeal rights, and bed-hold policy information to a resident’s representative in connection with a hospital transfer and subsequent facility-initiated discharge. The resident, who had diagnoses including schizoaffective disorder bipolar type, dementia with behavioral disturbance, and post-traumatic stress disorder, had a history and physical noting safety risk factors such as childhood maltreatment, impulsive tendencies, and aggression. A comprehensive MDS showed severe cognitive impairment and verbal behavioral symptoms. Interdisciplinary documentation described escalating challenging behaviors, including verbal aggression, threats, accusations toward other residents, refusal of medications, inappropriate phone use, calling 911 claiming poisoning, and physical aggression such as throwing items and threatening to overturn the medication cart. These records did not document that a 30‑day notice of transfer or discharge was issued due to the resident’s behaviors. A care plan meeting with the resident’s representative was held and the resident’s behaviors were discussed, with staff requesting information on effective interventions. However, the care plan note did not document that the representative was informed that the resident needed alternative placement or that a 30‑day notice of transfer or discharge was provided. On the date of transfer, a nursing progress note documented that the resident attempted to exit the unit, struck a nurse in the face with a closed fist, grabbed the nurse’s head, and that 911 was called, resulting in transfer to a behavioral facility. The daughter was notified of the transfer, but the note lacked documentation that she was provided with a notice of transfer or discharge, information on how to appeal the discharge, or the bed-hold policy. A discharge MDS characterized the event as an unplanned discharge to a short‑term hospital with return anticipated. A bed‑hold policy form completed that day indicated the resident was being transferred due to physical aggression and showed the bed‑hold policy was provided to the resident, but there was no documentation that it was provided to the resident’s representative despite the resident’s cognitive status. The record lacked any notice of transfer or discharge accompanying the hospitalization. A detailed SSD note on the day of transfer described the aggressive incident, referenced prior counseling of the resident and POA that violent behavior would result in immediate discharge with no option to return, and documented attempts to contact the POA and communication with a second daughter. This note did not document that a notice of transfer or discharge or bed‑hold policy was provided to the representative at the time of transfer or afterward, nor that a 30‑day notice had been issued before the hospital transfer. There were no further facility progress notes after this SSD entry, and no documentation of additional communication with the representative or the psychiatric facility. Notes from the acute psychiatric facility later recorded that the resident’s representative stated she had not received a 30‑day notice and believed the resident was supposed to return, and that the psychiatric facility Social Worker told the facility DON that a 30‑day notice needed to be given. In interviews, the Administrator and DON acknowledged that a 30‑day notice of transfer or discharge was not issued and that the representative was not provided the notice of transfer or discharge or bed‑hold policy with this transfer. The SSD reported assuming notices went with the ambulance for confused residents and was unaware the resident remained in the psychiatric facility. The resident’s representative confirmed she received no paperwork, including a notice of transfer or discharge or bed‑hold policy, and stated she would have appealed if she had known how, underscoring that the required notice and appeal information were not provided as mandated by facility policy and state forms.
Failure to Prevent and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
A resident with a history of nontraumatic intracerebral hemorrhage, aphasia, dysphagia, and total dependence for activities of daily living was admitted to the facility without any skin impairment. Upon admission, assessments identified the resident as high risk for pressure ulcers due to immobility, incontinence, and comorbidities. The care plan included interventions such as keeping the resident clean and dry, performing peri care after each incontinent episode, and using emollients and barrier creams as recommended by the wound nurse practitioner. However, the clinical record lacked documentation that these preventive measures were implemented, including the use of emollients, barrier creams, regular turning and repositioning, and off-loading. Within two weeks of admission, the resident developed a stage II pressure ulcer on the coccyx, which rapidly progressed to an unstageable wound requiring surgical debridement and hospitalization. Documentation was missing regarding the identification of the wound, notification of the physician or family, and initiation of appropriate nursing interventions when the wound was first observed. Preventive skin care orders were not documented in the Medication Administration Records, and there was no evidence that a personalized skin care plan was developed or implemented prior to the development of the pressure ulcer. Interviews with staff and review of facility policy revealed that the resident was dependent on staff for all care, including incontinence management and repositioning, but there was no documentation to confirm these interventions were consistently provided. The facility's policy required prompt identification of at-risk residents and immediate implementation of specific interventions, but the record did not show that these steps were taken before the pressure ulcer developed. The lack of preventive care and timely intervention resulted in actual harm to the resident, who required hospitalization and advanced wound care.
Failure to Individualize and Implement Fall Prevention Interventions and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that fall prevention interventions were individualized and implemented for a resident with significant medical needs, and did not complete required fall follow-up assessments and care plan updates after a fall incident. The resident, who had a history of stroke, aphasia, dysphagia, pressure ulcer, and right-sided weakness, was identified as high risk for falls and required extensive assistance from two or more staff for bed mobility and transfers. Despite these needs, the resident fell out of bed while being cared for by a newly hired CNA working alone during a check and change. The care plan at the time lacked resident-specific interventions and was not updated following the fall. Additionally, the clinical record did not contain documentation of 72-hour post-fall assessments with vital signs, a Post Fall Review assessment, or updates to the care plan as required by facility policy. Interviews with the DON and LPN confirmed that the fall occurred during care provided by a single aide, and that the care plan had not been appropriately individualized or revised after the incident. The facility's policy required documentation and investigation after falls, as well as the implementation of new care plan interventions, but these steps were not completed for this resident.
Unattended and Unlocked Treatment Cart with Exposed Medications and Supplies
Penalty
Summary
During a random observation, a treatment cart containing tubes and bottles of biologicals, including medications for skin conditions and wounds, was found unlocked and unattended near the nurse's station, outside the main dining room, and close to the entry of a hallway. The top drawer of the cart was open, exposing insulin, blood glucose testing supplies, a box of exposed lancets, bottles of blood glucose strips, packaged dressings, and alcohol pads. Additionally, a plastic medication cup with unidentified pills and capsules was left unsecured on top of the cart. Eight residents were observed in the main dining room within view of the cart, and one resident was standing beside it. A visitor was also present near the unsecured cart, conversing with the resident for over two minutes while the cart remained unattended. The LPN responsible for the cart was inside the nurse's station, approximately twelve feet away and out of sight of the treatment cart. Upon noticing the situation, the LPN quickly secured the cart by closing the drawer, locking it, and moving it inside the nurse's station. The LPN later acknowledged that the cart should not have been left unlocked but stated she became distracted by another resident and forgot about it. Facility policy requires that medication carts and supplies be locked or attended by authorized personnel at all times, and that external medications be kept in a treatment cart or a separate, labeled drawer.
Resident Injury Due to Improper Securing on Facility Bus
Penalty
Summary
The facility failed to prevent potential accidents when transportation staff were not adequately trained on new bus equipment, leading to an incident where a resident was not properly secured with a safety lap belt. This resulted in the resident sliding out of his wheelchair during transit on the facility bus, causing him to sustain a fracture of the L1 vertebra with a 20% height loss. The resident, who had a history of stroke, left-sided weakness, vascular dementia, and chronic pain, was on his way to a dental appointment when the incident occurred. Upon review, it was found that the resident was not properly secured into the bus prior to departure. The lap belt, which was necessary for securing the resident, was still in its original packaging and had not been installed. Instead, an incorrect cross-belt was used, which was buckled into the adjacent seat's clip across the aisle. This improper securing method contributed to the resident's fall from the wheelchair. The investigation revealed that the bus driver and maintenance director had not received job-specific orientation or training for transportation safety on the new facility bus. The new bus had been delivered earlier in the year, and basic functions were reviewed with the administrator and a regional consultant, but no formal training was documented for the staff responsible for resident transport.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the Resident Council were followed up on and reported back to the council for review and approval. This deficiency was identified through interviews and record reviews, revealing that the facility did not document responses to requests and grievances made by the Resident Council. Specifically, during meetings held on various dates, residents expressed desires for more outings and raised concerns about general nursing care, including call light response times and staff behavior. However, there was no documentation of any responses to these concerns. Interviews with residents and the Activity Director (AD) confirmed that residents often did not receive timely responses to their grievances. The AD acknowledged that the process should involve submitting response forms to department heads to ensure residents receive feedback at subsequent meetings. The facility's policy on Resident Council participation emphasizes the importance of timely responses to concerns, yet this process was not adhered to, as evidenced by the lack of documented responses to the council's minutes.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for five residents, leading to discrepancies in their medical records. Resident 9 was incorrectly coded as taking an anticoagulant when she was prescribed aspirin, an antiplatelet. Similarly, Resident 12's MDS inaccurately indicated she was on an anticoagulant, despite her prescriptions for aspirin and Plavix, both antiplatelet medications. Resident 11's MDS also incorrectly listed an anticoagulant instead of the antiplatelet aspirin he was taking. These inaccuracies in medication coding could potentially affect the residents' care plans and risk assessments. Additionally, Resident 47's MDS failed to reflect the requirement for a PASRR Level II, despite documentation indicating the necessity due to his mental health conditions. Resident 33's MDS inaccurately recorded the use of an anticoagulant, which was not supported by her medical orders. Interviews with the Director of Nursing and the Regional Nurse Consultant confirmed these discrepancies, and it was noted that there was no specific policy for ensuring MDS accuracy, with reliance placed on the RAI manual.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to date medications when opened, as observed during a survey. On the 300-hall treatment cart, a Lantus pen and a Humalog pen, both used for diabetes treatment, were found without dates indicating when they were opened. Additionally, on the 300-hall medication cart, a Flonase bottle and a bottle of ear drops were also found without opening dates. These observations were made with a Qualified Medication Assistant (QMA) present. The facility's policy on medication storage, provided by the Regional Nurse Consultant, did not include information regarding the requirement to date medications when opened.
Failure to Ensure Resident Dignity in Grooming Needs
Penalty
Summary
The facility failed to ensure dignity for a female resident, identified as Resident 33, who expressed dissatisfaction with her long facial hair and requested assistance with shaving. Despite her request, the facility did not promptly address her need for assistance. Resident 33, who had a self-care deficit and required staff assistance with activities of daily living (ADLs), was observed with long facial hair on multiple occasions. She communicated her desire to have the facial hair removed to the staff, but no action was taken to fulfill her request in a timely manner. Resident 33's care plan indicated she had late loss ADLs and required staff assistance, yet her preference for a specific staff member to assist with shaving was not initially documented or honored. The Director of Nursing (DON) later discovered Resident 33's preference for a particular staff member, Qualified Medication Assistant (QMA) 16, to perform the task. However, QMA 16's schedule did not align with the times Resident 33 requested assistance, leading to a delay in addressing her grooming needs. This oversight resulted in a failure to honor the resident's right to dignity and respect, as outlined in the facility's policy on resident rights.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 47, diagnosed with end-stage renal disease (ESRD), dementia, hypertension, and age-related physical debility, did not have a care plan that addressed his nutritional needs related to ESRD with dialysis. Although a care plan was eventually provided, it was not initially included in his medical record, indicating a lapse in comprehensive care planning. Similarly, Resident 12, who had diagnoses including dementia, chronic kidney disease, major depressive disorder, and anxiety, was prescribed melatonin for difficulty sleeping. However, her care plan did not address her sleep difficulties or the use of melatonin. This oversight highlights a failure to incorporate all aspects of her care needs into the comprehensive care plan. The facility's policy requires that comprehensive care plans be finalized within seven days of completing the full comprehensive minimum data set (MDS) assessments, but this was not adhered to in these cases.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans with changes in resident care for two residents. Resident 25, diagnosed with depressive disorder, generalized anxiety disorder, and a history of opioid abuse, had a care plan addressing the use of medications for behavior management, including Buspar, trazodone, duloxetine, and mirtazapine. However, the care plan did not reflect her refusal to undergo gradual dose reductions (GDR) as per her preference. Resident 12, diagnosed with dementia, major depressive disorder, and insomnia, had a care plan indicating a risk for mood decline related to her major depression diagnosis. Despite this, her medication regimen did not include an antidepressant, which was inconsistent with her care plan. These deficiencies were identified during record reviews and interviews with the Director of Nursing and Regional Nurse Consultant.
Failure to Ensure Medical Assessment Before Moving Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident who experienced a fall was not moved until after a medical assessment was completed. The incident involved a long-term care resident with a history of stroke, weakness/paralysis on the left side, vascular dementia, muscle wasting and atrophy, chronic pain syndrome, and a wedge compression fracture of the L1 vertebra. The resident fell while being transported on the facility bus to a dental appointment, sliding out of his wheelchair and landing on the floor. He complained of pain in his left shoulder/elbow and mentioned hitting his head on the wheelchair. Upon the resident's return to the facility, neurological checks were performed and were within normal limits. However, the resident later exhibited symptoms of nausea and vomiting, leading to a hospital evaluation where an acute to subacute compression fracture of the L1 vertebra was discovered. The investigation revealed that the resident had not been properly secured in the bus prior to departure. The bus driver and maintenance director moved the resident back into his wheelchair without waiting for a medical assessment, contrary to facility policy. The facility's policy requires that any incident or accident, including falls, be reported immediately to a nurse or designated person in charge, and that an immediate assessment be completed by a nurse to determine if the resident can be moved. The Director of Nursing indicated that the bus driver and maintenance director should have called for a medical professional's assessment before moving the resident, as moving him could have worsened any injuries. The facility's failure to adhere to this policy resulted in a deficiency in providing appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Prevent Worsening of Contractures in Resident
Penalty
Summary
The facility failed to provide appropriate care to a resident, identified as Resident 35, to prevent the worsening of contractures in her hand and wrist. Observations on multiple occasions revealed that Resident 35's right hand was contracted into a fist, and her wrist was contracted upward, without the use of a splint or palm protector. Despite recommendations from an Occupational Therapy (OT) referral summary for continued assistance with hand hygiene, passive range of motion (PROM), and palm protector wear to prevent skin breakdown and increase joint mobility, these measures were not documented or implemented in her care plan. Resident 35's medical record lacked documentation of PROM services and an order to wear a palm protector. The Director of Rehab confirmed that although Resident 35 had completed therapy after meeting a goal of decreasing her contracture, the angle of her contracture had increased slightly. The Director of Nursing indicated there was no policy for range of motion treatments and services, but expected nursing staff to follow therapy recommendations. This oversight resulted in a deficiency as the facility did not ensure the resident received necessary treatments and services to prevent the worsening of her condition.
Failure to Monitor Vital Signs Before Administering Antihypertensive Medication
Penalty
Summary
The facility failed to adhere to the prescribed medication administration protocol for a resident diagnosed with hypertension. The resident was prescribed metoprolol, an antihypertensive medication, with specific instructions to hold the medication if the systolic blood pressure was less than 100 or the pulse was less than 60. However, a review of the medication administration records for August and September 2024 revealed a lack of documentation of the resident's blood pressure and pulse prior to administering the medication. This oversight occurred despite the resident's care plan, which included monitoring blood pressure as per the medical doctor's order or facility policy. The facility's policy on drug administration emphasized the necessity of performing vital sign monitoring before administering medications dependent on such measures.
Inadequate Documentation for Declining Psychotropic Medication Reduction
Penalty
Summary
The facility failed to ensure adequate documentation and justification for declining pharmacy recommendations to reduce psychotropic medications for two residents. Resident 34, diagnosed with dementia, schizoaffective disorder, bipolar type, and anxiety, was scheduled for a trial reduction of an antianxiety medication. The physician declined the recommendation, citing symptoms, but there was no documentation of symptoms in the resident's behavior monitoring records or nursing progress notes. The Director of Nursing acknowledged that there were no symptoms of increased or worsening anxiety, and the recommendation should have been accepted or a different reason provided for declining it. Similarly, Resident 9, with diagnoses including schizoaffective disorder, bipolar type, delusional disorder, and major depressive disorder, was prescribed multiple psychotropic medications. The pharmacist recommended a gradual dose reduction, but the request was declined due to the resident reportedly remaining symptomatic. However, the medical record lacked documentation of daily behavior monitoring or symptoms. The care plans for Resident 9 did not include non-pharmacological interventions to address identified behaviors. The Director of Nursing and Regional Nurse Consultant noted the need for detailed reasons for not performing a gradual dose reduction and added behavior monitoring to the resident's medical record.
Failure to Provide Timely X-Ray Services
Penalty
Summary
The facility failed to ensure timely x-ray services for a resident who was reviewed for x-rays. The resident, who had a history of supraventricular tachycardia, chronic respiratory failure, and age-related debility, complained of left mid-foot pain after an incident involving a Hoyer lift pad. A Nurse Practitioner ordered a three-view x-ray of the resident's left foot to rule out acute injury and prescribed acetaminophen for pain management. Despite the order, there were no x-ray results available in the resident's record. The resident reported ongoing soreness in her left foot and difficulty pushing herself up in bed, indicating that the x-ray had not been performed. The Director of Nursing later confirmed that the x-ray was conducted the night before the interview, indicating a delay in providing the necessary diagnostic service. The facility's policy on resident rights emphasizes the importance of enhancing residents' well-being and quality of life, which was not upheld in this instance.
Improper Sanitization of Glucometer
Penalty
Summary
The facility failed to properly sanitize a blood glucometer used for Resident 103. During an observation, an LPN performed a blood sugar test for Resident 103 using a glucometer that was stored on the treatment cart. The LPN indicated that the glucometer was clean from its previous use and proceeded with the blood sugar test. After completing the test, the LPN used a Sani-wipe to clean the monitor and placed it on a Kleenex to dry, stating it would sit for 5 minutes before being returned to its box. However, the facility's policy required the glucometer to be wiped with a towelette three times horizontally and vertically, using a second towelette to ensure it remained wet for 2 minutes with a Super Sani cloth wipe. The LPN did not follow this procedure, leading to a deficiency in infection prevention and control.
Failure to Administer Requested Vaccinations
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 102, received the influenza, pneumonia, and COVID-19 vaccinations as requested. Upon review of Resident 102's medical records, it was found that the sections for these immunizations were left blank. The resident had signed consents for the pneumococcal and COVID-19 vaccines, dated 9/6/24, but there was no documentation for the acceptance or declination of the influenza vaccine. The Director of Nursing (DON) indicated that the pneumonia vaccine was not administered upon admission due to its unavailability and preferred to administer all vaccines during a clinic session. Resident 102's medical history includes diabetes mellitus, chronic kidney disease, and chronic hepatitis, which are significant conditions that necessitate timely vaccinations. Despite the resident's consent and the facility's provision of CDC vaccination information sheets upon admission, the facility did not follow through with the administration of the requested vaccines. This oversight was identified during a review and interview process, highlighting a lapse in the facility's vaccination protocol for residents who have expressed their desire to receive these immunizations.
Failure to Obtain Physician Orders for Tracheostomy Care
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy had the necessary physician's orders for tracheostomy care, oxygen, oxygen humidity, suctioning, and to maintain oxygen saturation levels above 90%. This deficiency was identified for one of the two residents reviewed with a tracheostomy, referred to as Resident B. Resident B was admitted to the facility with multiple complex medical conditions, including acute respiratory failure with hypoxia, pulmonary embolism, and a history of kidney transplant rejection, among others. Upon admission, the respiratory care supply company set up the necessary respiratory equipment for Resident B, including an Airvo system, oxygen mask, and suctioning equipment. However, the facility did not have a care plan or physician's orders for the tracheostomy care and oxygen management until several weeks after the resident's admission. The Director of Nursing acknowledged that these orders were overlooked and should have been entered into the resident's medical record when the equipment was set up and before the resident's admission. The facility's policy requires that physician orders for a resident's immediate care be in place at the time of admission. This includes orders for dietary needs, medications, and routine care to maintain or improve the resident's functional abilities. Despite this policy, the necessary orders for Resident B's respiratory care were not obtained or implemented in a timely manner, leading to the identified deficiency.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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