Ambassador Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerville, Indiana.
- Location
- 705 E Main St, Centerville, Indiana 47330
- CMS Provider Number
- 155490
- Inspections on file
- 31
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Ambassador Healthcare during CMS and state inspections, most recent first.
Two newly admitted residents, one with dementia and another with multiple chronic conditions, were unable to access TV in their rooms due to missing or nonfunctional remotes. One resident's remote lacked batteries and was frequently missing, leading to an incident where the resident fell while attempting to turn on the TV. Another resident, unable to walk or stand, went three days without a remote and was told by staff to wait for maintenance. Both residents' preferences for watching TV as a leisure activity were not accommodated.
A resident with Parkinson's disease and a rib fracture had multiple care concerns raised by their family, including missing equipment, discarded items, delayed follow-up after a fall, and room cleanliness. The Admission's Director forwarded the concerns to other staff but did not formally document or file a grievance as required by policy, resulting in no investigation or written report being completed.
A resident who recently had back surgery experienced a fall, and staff did not follow the neurosurgeon's discharge instructions to send the resident to the emergency department or call 911. Instead, an x-ray was delayed until the next day despite the family's request. Additionally, during a scheduled virtual follow-up with neurosurgery, the LPN handled the call without including the resident or family, contrary to their wishes and the appointment's intent.
A resident with Parkinson's disease and a recent vertebral fracture, identified as high risk for falls, experienced a fall when the enabler bar on the bed was found to be stuck and not functioning. Staff did not complete required post-fall assessments or implement fall interventions until the following day, despite facility policy requiring immediate and ongoing evaluation after a fall.
The facility did not complete or document inventory sheets for the belongings of three newly admitted residents, as confirmed by interviews with residents, family, and staff, and review of electronic health records. The affected residents had various medical conditions, and in one case, a family member reported a missing back brace. Staff acknowledged that inventory sheets were not completed as required.
A resident reported to facility staff and the Executive Director that a physical therapist had been verbally rude, but the allegation was not reported to the state within the required two-hour window. The Executive Director determined internally that the incident did not constitute abuse and did not make the required report, despite facility policy mandating timely reporting of all abuse allegations.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
Multiple residents did not receive proper fall prevention interventions as care planned, including lack of ongoing monitoring for alarm efficacy and failure to use alarms to assess resident routines. In one case, a resident's chair alarm was not connected, and in another, two CNAs transferred a resident without using a gait belt as required by policy. The DON confirmed that alarm use was not routinely monitored or documented for effectiveness.
Staff did not ensure privacy for two residents during personal care and treatment. In both cases, staff entered rooms without waiting for a response, and privacy curtains were not used, leaving residents exposed to the hallway. The residents involved had significant medical conditions, including cognitive impairment and pressure ulcers, and the facility's policy required staff to maintain privacy during care.
Three residents were not provided with reasonable accommodations for their needs, as two were unable to reach their call lights and one did not have fluids available at the bedside despite being able to drink independently. Staff and policy confirmed that call lights should be within reach and thickened fluids can be provided at the bedside, but these requirements were not met until after staff intervention.
A resident with significant care needs was subjected to frequent, loud bed alarm noises that she found distressing. The facility did not routinely monitor or document the effectiveness of alarm use, nor did it ensure that alarms were used in accordance with its own policies for maintaining a homelike environment and comfortable sound levels.
Three residents who required assistance with ADLs did not receive proper nail or oral care. One resident had persistent buildup under her fingernails, another had extremely long and curled toenails with no documented podiatry consent or follow-up, and a third was observed with significant oral debris and buildup. Staff and care plans confirmed these residents were dependent on staff for these tasks, but care was not provided as required.
Two residents did not receive timely optometry services or appropriate follow-up for missing glasses. One resident with a history of cataracts and dementia had no record of a needed eye exam or a care plan for vision services, and her glasses could not be found. Another resident with dementia was no longer using glasses as care planned, and family members reported his glasses were missing and he had not seen the optometrist. Facility staff were unaware of these issues, and required referrals were not made.
A resident at high risk for pressure ulcers, with severe cognitive impairment and contractures, did not receive ordered preventative interventions. The resident was observed without pressure-reducing boots and a prescribed foam dressing, despite clear orders and facility policy requiring their use. An LPN was unaware of the dressing order, and the necessary interventions were not in place at the time of observation.
A resident with bilateral hand contractures, severe cognitive impairment, and multiple medical diagnoses was observed multiple times without any splints or supportive devices in place, despite the care plan identifying risk and the facility's policy requiring such interventions. The responsible RN confirmed that no splints or carrots had been used since admission.
A resident with an unstageable pressure ulcer on the coccyx did not receive consistent wound care or documentation. The facility's records lacked routine assessment of the wound, and the Treatment Administration Record did not indicate treatments provided between admission and December 11. The Director of Nursing acknowledged the lack of detailed documentation and the absence of formal training for the new documentation process, which did not adhere to the facility's policy on pressure ulcers.
A resident with multiple health issues, including dementia and muscle weakness, experienced two falls in one night. The facility failed to conduct a thorough investigation or implement adequate interventions, as the DON was unaware of the second fall, believing it was a duplicate entry. Staff interviews revealed no management discussion about the falls, and the only intervention noted was ensuring nonskid footwear. The facility's fall policy was not fully adhered to, contributing to the deficiency.
A facility failed to maintain accurate documentation of a resident's fall. A resident with multiple health issues, including COPD and dementia, was found on the floor after sliding off the bed. The progress note documenting this incident was struck out by the DON, who believed it was a duplicate. An LPN confirmed the resident fell twice and was unsure why the documentation was removed. The facility's policy requires complete and accurate documentation to ensure effective communication among the care team.
A resident with chronic kidney disease and Alzheimer's was left with unattended medication, which they consumed without supervision. The facility's policy requiring staff to observe medication consumption was not followed, leading to a deficiency in safe medication administration practices.
The facility failed to protect residents from physical abuse, as evidenced by incidents involving two residents. A resident with severe cognitive impairment exhibited aggressive behaviors, including grabbing and twisting another resident's wrist. The facility lacked documentation of the incidents and follow-up assessments, and staff failed to notify the affected resident's physician and family. Interviews revealed a lack of communication and timely response, contributing to the facility's failure to address the abuse effectively.
The facility failed to report an allegation of sexual abuse and resident-to-resident physical altercations to the Indiana Department of Health. An incident involved a resident entering another's room and touching her genitalia, which was reported to the police but not to IDOH. Additionally, a resident with dementia attempted to grab peers, and another resident with end-stage renal disease was involved in an altercation, but these were not reported to IDOH as required by facility policies.
The facility failed to conduct initial and follow-up assessments after falls involving two residents. One resident, with cognitive impairments, fell after entering another resident's room and sustained a skin tear, but no follow-up assessments were documented. Another resident fell due to an external force when a door was slammed, leading to a hospital visit, yet no follow-up assessments were recorded. The facility did not consider the latter incident a fall, thus no root cause analysis was conducted.
The facility failed to monitor and supervise residents with dementia, leading to inappropriate interactions. A resident entered another's room and allegedly touched her inappropriately, while another resident was found engaging in inappropriate contact with a fellow resident. The facility did not conduct thorough assessments or notify families and physicians promptly, highlighting deficiencies in resident care and protection.
The facility failed to protect three male residents from sexual abuse by a staff member during incontinence care. The staff member, on his first night of orientation, provided unsupervised care, leading to mental anguish for the residents. The facility's investigation revealed lapses in supervision and thoroughness.
The facility failed to implement its abuse prohibition policies, resulting in delayed reporting and incomplete investigation of a staff-to-resident abuse incident involving a CNA and three male residents. The investigation did not include all relevant staff members, and the initial report to the Indiana Department of Health was submitted beyond the required two-hour window.
The facility failed to report an allegation of staff to resident sexual abuse to the Indiana Department of Health within the required two-hour timeframe. The incident involved a CNA accused of inappropriately touching two male residents. The report was submitted later in the day, beyond the mandated reporting window.
Failure to Provide TV Remotes for Newly Admitted Residents
Penalty
Summary
The facility failed to provide a homelike environment for newly admitted residents by not ensuring access to functioning television remotes, which impacted two of three residents reviewed for accommodation of needs. One resident, who had dementia and atrial fibrillation, was admitted with a TV remote that lacked batteries. The resident's family reported that the remote frequently went missing during the stay, and on the morning the resident fell, he had been asking about his TV and was believed to be attempting to turn it on when he got out of bed and fell. Staff interviews indicated that the responsibility for ensuring rooms were set up with working equipment and supplies was shared among the Admissions Coordinator, CNAs, and maintenance staff. Another resident, diagnosed with lung cancer, emphysema, heart failure, osteoporosis, anxiety, and depression, reported being without a TV remote for three days after admission. The resident, who was unable to walk or stand, stated she could not turn on her TV and spent the weekend staring at the walls. She reported her need for a remote to nursing staff, who informed her she would have to wait until maintenance was available. The resident's care plan included watching TV as a preferred self-directed activity, but this was not accommodated due to the lack of a remote.
Failure to Follow Grievance Policy and Ensure Follow-Up on Care Concerns
Penalty
Summary
The facility failed to follow its grievance policy and did not ensure proper follow-up on care concerns raised by a resident and the resident's family. The resident, who had diagnoses including Parkinson's disease and a rib fracture, had multiple care concerns communicated via email by their family to the Admission's Director. These concerns included a missing back brace, discarded personal items, delayed follow-up after a fall, cleanliness of the resident's room, and issues with care assistance. The Admission's Director forwarded the email to other staff members, including the Social Service Director (SSD), Director of Nursing (DON), Executive Director (ED), and physical therapy, but did not formally document or file the grievance as required by facility policy. Interviews with facility staff revealed confusion regarding responsibility for filing grievances. The DON indicated that social services were responsible for filing grievances, while the SSD believed the Admission's Director was handling the concerns. The SSD stated that whoever received the grievance was typically responsible for documenting it and then submitting it to her for filing. Despite this, no formal grievance was filed, and the required investigation and written report were not completed within the specified timeframe outlined in the facility's grievance policy.
Failure to Follow Neurosurgeon's Discharge Instructions and Exclude Resident/Family from Virtual Follow-Up
Penalty
Summary
The facility failed to follow a neurosurgeon's discharge instructions for a resident who had recently undergone major back surgery and had diagnoses including obstructive sleep apnea and a T11-T12 vertebral fracture. After the resident experienced an unwitnessed fall in his room, the discharge instructions specified that the resident should be sent to the emergency department or 911 should be called. Instead, the facility delayed action, with an x-ray not being performed until the following day despite the family's request for immediate imaging due to the recent surgery. Documentation shows that the order for the x-ray was not placed until several hours after the fall, and the discharge instructions were not followed as written. Additionally, the facility did not ensure that the resident and his family were included in a scheduled virtual follow-up appointment with the neurosurgeon. Although the family and resident wished to participate and had questions regarding the fall and the absence of a required back brace, the LPN took the call from the neurosurgeon's office alone, without including the resident or family as requested. The LPN also indicated a lack of familiarity with the technology required for virtual visits, and the facility did not have a policy in place for conducting such appointments.
Failure to Ensure Functioning Safety Equipment and Post-Fall Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's enabler bar was functioning properly, did not complete a thorough assessment after the resident experienced a fall, and did not implement fall interventions for a resident identified as high risk for falls. The resident, who had diagnoses including Parkinson's disease and a recent vertebral fracture, was admitted with a history of falls and was assessed as being at risk for further falls. Upon admission, bilateral side rails were indicated for safety, but the left bedside rail was found to be stuck down and not functioning. Staff interviews revealed that the enabler bar could not be fixed due to lack of tools, and responsibility for ensuring equipment functionality was shared among the Admissions Coordinator, CNAs, and maintenance staff. Following the resident's fall, the facility's policy required post-fall assessments every shift for 72 hours, but no such assessments were documented in the electronic health record for the day of the fall. Additionally, the resident's care plan, which identified the risk for falls, did not include any fall interventions until the day after the incident. The DON was unable to explain the lack of post-fall assessments. The facility's own policy outlined specific assessment and documentation requirements after a fall, including monitoring for injury, changes in cognition, and neurological status, none of which were documented as completed for this resident.
Failure to Document Resident Belongings on Admission
Penalty
Summary
The facility failed to implement and document inventory sheets for resident belongings upon admission for three newly admitted residents. For one resident with diagnoses including type 2 diabetes mellitus and congestive heart failure, the family reported that a back brace was missing upon arrival, and there was no inventory sheet in the electronic health record. Interviews with staff confirmed that the inventory sheet was not completed at admission, despite the facility's usual practice to do so. The Director of Nursing acknowledged that staff were responsible for ensuring inventory sheets were completed. Another resident, admitted with multiple diagnoses such as lung cancer, emphysema, and heart failure, reported that no inventory sheet was completed for her belongings, and she was unsure if anything was missing. Staff confirmed that all records were kept electronically and that no inventory sheet was present in the resident's record. A third resident, with conditions including hypertension, diabetes, and malnutrition, also indicated that no inventory sheet was completed at admission. Review of his clinical record confirmed the absence of an inventory sheet. All three cases demonstrated a lack of documentation and safeguarding of resident belongings at the time of admission.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the Indiana Department of Health within the required two-hour timeframe after it was received. A resident reported to both Social Services staff and the Executive Director that a physical therapist had been rude to her, specifically recounting that the therapist told her, 'Show me what you can do,' after she had been removed from physical therapy. The Executive Director acknowledged receiving this information but did not report it as an allegation of abuse to the state, stating that the facility's investigation quickly determined it was not abuse but rather a direct comment from the therapist. Facility policy requires that all possible incidents of abuse be identified, investigated, and reported within federally mandated timeframes.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Implement and Monitor Fall Prevention Interventions and Safe Transfer Techniques
Penalty
Summary
The facility failed to implement and monitor fall prevention interventions as care planned for multiple residents. For one resident with rheumatoid arthritis, diabetes, and a stage four pressure ulcer, a bed alarm was in use, but there was no documentation that its efficacy was monitored on an ongoing basis or that it was used to assess the resident's patterns and routines. The resident expressed dissatisfaction with the alarm, stating it was loud and frequently activated. The DON confirmed that alarm use was not routinely monitored for effectiveness and that there was no documentation supporting the intended use of alarms for pattern assessment. Another resident with Alzheimer's disease and multiple psychiatric diagnoses had a chair alarm attached to her wheelchair following a recent fall. However, there was no evidence in the clinical record that the alarm's effectiveness was regularly reviewed or that it was used to assess the resident's routines. The DON acknowledged the lack of routine monitoring and documentation for alarm use. Additionally, a third resident with a history of stroke and heart failure was observed with a chair pad alarm that was not connected to the alarm box, rendering it nonfunctional until a nurse reconnected it during the observation. In a separate incident, two CNAs transferred a resident with severe cognitive impairment and high fall risk from a wheelchair to bed without using a gait belt, contrary to facility policy and the resident's care plan. The CNAs lifted the resident by his arms and pants, and when questioned, one CNA admitted forgetting to use the gait belt. The facility's policy requires the use of appropriate techniques and devices, such as gait belts, for safe resident transfers, and staff are expected to be trained in their use.
Failure to Provide Privacy During Resident Care
Penalty
Summary
Staff failed to provide privacy during care for two residents. In one instance, a registered nurse entered a resident's room immediately after knocking, without waiting for a response, while a certified nurse aide was applying an incontinent brief. The resident was unclothed, the privacy curtain was not drawn, and the resident was visible from the hallway. The resident's clinical record indicated diagnoses including schizophrenia, diabetes, depression, and muscle weakness, and the resident was cognitively intact and frequently incontinent. In another case, a resident with multiple diagnoses, including diabetes, Alzheimer's disease, dementia, and a stage three pressure ulcer, was receiving a pressure ulcer treatment. During the procedure, another nurse entered the room without knocking, and the resident's buttocks were visible from the hallway. The room did not have a privacy curtain, and staff were unsure why it was missing. The facility's dignity policy required staff to promote and maintain resident privacy, including knocking and requesting permission before entering rooms.
Failure to Ensure Call Lights and Fluids Were Accessible to Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents by not ensuring call lights were within reach and by not providing fluids at the bedside as required. One resident with an anoxic brain injury and contractures, who was severely cognitively impaired and dependent on staff for activities of daily living, was observed with a call light out of reach and confirmed he could not use it. Another resident, who was cognitively intact but totally dependent for several activities of daily living, was observed on two occasions unable to reach her call light, which was either wedged between the enabler bar and mattress or had its cord tied and out of reach. Both instances were verified by staff, who then repositioned the call lights within reach after being notified. A third resident, diagnosed with anxiety and diabetes mellitus and prescribed a regular diet with nectar-thickened fluids, was observed multiple times without any fluids at the bedside. The resident was able to drink independently if fluids were placed in front of her. Staff interviews confirmed that while residents with thickened liquids were not allowed pitchers of water, they could have thickened fluids at the bedside. Facility policy required providing residents with a fresh supply of drinking water and adequate liquids, but this was not followed for the resident in question.
Failure to Maintain Comfortable Sound Levels Due to Inappropriate Alarm Use
Penalty
Summary
The facility failed to maintain comfortable sound levels for a resident who was reviewed for accidents. The resident, who had diagnoses including rheumatoid arthritis, diabetes mellitus, and a stage four sacral pressure ulcer, was cognitively intact but required total or substantial assistance with most activities of daily living. She had a care plan and physician's orders for bed and chair alarms due to her risk of falls, including a history of climbing out of bed and unplugging her alarm. During observation and interview, the resident reported that the bed alarm beeped frequently and was very loud, which she disliked. Interviews with the DON revealed that the facility was not routinely monitoring the efficacy of alarm use for residents, including this resident, and lacked documentation or verification that alarms were being used to assess residents' patterns and routines. The facility's own policies required regular review of alarm effectiveness, documentation of findings, and minimizing institutional characteristics such as bed and chair alarms to maintain a homelike environment with comfortable sound levels. These requirements were not being met, resulting in the deficiency.
Failure to Provide Required Nail and Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail and oral care for three residents who required assistance with activities of daily living (ADLs). One resident was repeatedly observed with a dark or black substance under her fingernails over several days, and both the resident and a CNA confirmed that nail care was not being performed as required. The resident's care plan indicated she needed staff assistance for showers and nail care, and her MDS assessment showed she required substantial assistance with personal hygiene. Facility policy required cleaning the nail bed to prevent infection, but this was not followed. Another resident was observed with extremely long and curled toenails on multiple toes, and his records indicated he was totally dependent on staff for footwear and required maximum assistance with showers and nail care. There was no documentation of consent or refusal for podiatry services, and staff interviews revealed that the need for podiatry care had not been communicated to social services or the family. A third resident, who was cognitively impaired and required maximal assistance with oral care, was observed with thick white buildup and a film on her teeth and lips, as well as a blue substance and dry skin around her mouth. The DON confirmed that staff were responsible for ensuring residents were clean from food debris after meals, but this care was not provided as required by facility policy.
Failure to Provide Timely Vision Services and Address Missing Glasses
Penalty
Summary
The facility failed to provide timely optometry services and address missing glasses for two residents. One resident with a history of cataracts, cerebral infarction, and dementia reported difficulty seeing and not having seen the optometrist recently. Her clinical record showed no evidence of a follow-up comprehensive eye exam after a previous recommendation, and she was not included in the most recent optometry visit. Additionally, there was no care plan in place for her vision or ancillary services, and her glasses could not be located by staff. Another resident with dementia was noted to have had glasses upon admission, with care plan interventions to ensure their use and maintenance. However, subsequent assessments indicated he was no longer using corrective lenses, and family members reported his glasses were missing and were unsure if he had seen the optometrist. The resident was not scheduled for the upcoming optometry visit, and the staff responsible for ancillary services was unaware of the missing glasses. Facility policy required prompt referral to an optometrist for lost or damaged glasses, but this was not followed.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident with anoxic brain injury, contractures, and severe cognitive impairment was identified as being at high risk for developing pressure areas. The resident's care plan included wound care as ordered, and a physician's order specified the application of a foam dressing to the top of the right foot as a preventative measure. Additionally, a wound practitioner recommended the use of pressure-reducing boots at all times. During observation, the resident was found in bed without the pressure-reducing boots, which were instead on the bedside table. The preventative dressing was also not in place on the resident's right foot. An LPN confirmed that the boots and dressing were not being used and was unaware of the dressing order, though the order was verified in the electronic medical record. Facility policy required the use of appropriate supportive devices and regular review of interventions, but these measures were not implemented for this resident.
Failure to Provide ROM Interventions for Resident with Hand Contractures
Penalty
Summary
A deficiency was identified when a resident with bilateral hand contractures did not receive appropriate interventions to maintain or improve range of motion (ROM) as required. The resident, who had diagnoses including anoxic brain damage, anxiety, and respiratory arrest, was assessed on admission as having both arms contracted to varying degrees and was severely cognitively impaired. The care plan noted the resident was at risk for skin breakdown due to the contractures. Despite this, observations on multiple occasions found the resident lying in bed without any splints or supportive devices, such as carrots, in place to address the contractures. During an interview, the registered nurse responsible for the resident confirmed that the resident had bilateral hand contractures since admission and that no splints or carrots had been used. The facility's contracture prevention policy requires individualized care plans for at-risk residents, including the use of ROM exercises and supportive devices. The lack of implementation of these interventions for the resident with contractures constituted a failure to follow the facility's own policy and to provide necessary care to maintain or improve the resident's ROM.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate care and documentation for a resident with a pressure ulcer. Resident B, who was admitted with an unstageable pressure ulcer on the coccyx, did not receive consistent wound care or documentation of the wound's status. The wound was initially identified as having 100% eschar tissue with no granulation, slough, or epithelial tissue, and was described as causing no pain or drainage. However, the Treatment Administration Record (TAR) did not indicate any treatments provided between the resident's admission and December 11, except for a single notation of an abdominal pad covering the ulcer. The nursing progress notes and Daily Skilled Notes for Resident B lacked routine documentation of the wound's assessment. There were no progress notes or Daily Skilled Notes addressing the pressure ulcer's status on December 8 and 9. From December 10 to 14, the notes indicated no skin concerns and no skilled nursing services related to wound care, despite the presence of the pressure ulcer. On December 21 and 22, the notes mentioned skilled nursing services related to wound care but no new skin concerns, and similar entries were made on December 23 and 24. The Director of Nursing (DON) acknowledged the lack of detailed documentation and indicated that the facility's documentation process was new and lacked formal training. The facility's policy on pressure ulcers required comprehensive documentation of the wound's assessment, including location, stage, and treatment details, which was not adhered to in this case. The deficiency was related to a complaint and highlighted the need for improved documentation and adherence to established protocols.
Failure to Investigate and Address Fall Risk for Resident
Penalty
Summary
The facility failed to conduct a thorough investigation into the root cause of falls experienced by Resident B and did not implement adequate fall interventions. Resident B, who had multiple diagnoses including COPD, dementia, and muscle weakness, experienced two falls on the same night. The first fall occurred when the resident attempted to get out of bed to change her shirt, and the second fall happened when she was trying to reach her closet. Both falls were reported to the physician, and no injuries were noted. However, the facility's Director of Nursing (DON) was unaware of the second fall, mistakenly believing it was a duplicate entry. Interviews with the staff involved, including a CNA and an LPN, revealed that no facility management staff had discussed the falls with them. The facility's fall policy requires staff to identify and implement interventions to prevent falls, but in this case, the only intervention noted was ensuring nonskid footwear was in place. The DON indicated that the protocol for investigating falls included chart reviews and camera footage, but there were no cameras in resident rooms. This lack of thorough investigation and communication among staff contributed to the deficiency in addressing Resident B's fall risk.
Incomplete Documentation of Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate documentation of a resident's fall, specifically for Resident B, who was one of three residents reviewed for accidents. Resident B's clinical record indicated multiple diagnoses, including chronic obstructive pulmonary disease, chronic pain, hypertension, hypertensive heart disease, muscle weakness, dementia, abnormal gait, anxiety, and osteoarthritis. On December 2, 2024, a progress note documented that Resident B was found sitting on the floor next to her bed after sliding off the side. The note indicated no injuries were observed, and the resident was assisted back to bed. However, this progress note was later struck out with the reason cited as a duplicate order. During an interview, an LPN who was responsible for Resident B on the day of the incident confirmed that the resident fell twice and expressed confusion about why her documentation of the second fall was marked out. The Director of Nursing later admitted to striking out the progress note, believing it to be a duplicate. The facility's charting and documentation policy requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented accurately to facilitate communication among the interdisciplinary team. This deficiency was related to a specific complaint, IN00449305.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure safe medication administration practices, as observed during a survey. In one instance, medication was left unattended at a resident's bedside, which was against the facility's policy. Resident G, who was moderately cognitively impaired and had a history of chronic kidney disease and Alzheimer's disease, was found with two cups of similar-looking white oblong tablets left in his room. The resident consumed one set of pills without knowing their purpose, and the nurse had left the medication at the resident's request without assessing his ability to take medication independently. The Director of Nursing (DON) was informed of the situation and confirmed that the nursing staff should not leave medication unattended unless the resident has been assessed for independent consumption. The incident involved two nurses, LPN 3 and RN 4, who administered the medication at incorrect times. The facility's policy, which requires staff to remain with residents until medication is consumed, was not followed. The incident was documented, and the physician was notified several days later.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by incidents involving two residents, Resident K and Resident M. Resident K, who had severe cognitive impairment and a history of behavioral issues, was observed on multiple occasions exhibiting aggressive behaviors towards other residents. On one occasion, Resident K grabbed and twisted the wrist of Resident M, causing her pain. Despite these incidents, there were no documented follow-up assessments or interventions to address Resident K's aggressive behaviors. The clinical records for both residents lacked documentation of the incidents and any subsequent assessments or interventions. Resident K's care plan for behaviors was only initiated after the incidents, indicating a delay in addressing his aggressive tendencies. Additionally, the facility staff failed to notify Resident M's physician and family about the incident, as they believed there was no visible injury. The lack of communication and documentation highlights a failure in the facility's procedures for handling resident-to-resident altercations. Interviews with facility staff revealed a lack of clarity and communication regarding the incidents. LPN 2 did not report the incident to the physician or families, assuming that another staff member was handling the situation. The Director of Nursing was not informed of the incident, and the Social Services staff had not yet addressed the aggressive behaviors in Resident K's care plan. This lack of coordination and timely response contributed to the facility's failure to prevent and address the abuse incidents effectively.
Failure to Report Allegations of Abuse and Altercations
Penalty
Summary
The facility failed to thoroughly report an allegation of sexual abuse and resident-to-resident physical altercations to the Indiana Department of Health (IDOH) for four residents. An incident report filed by the facility indicated an alleged altercation between two residents, where one resident reported entering another's room and touching her genitalia. The incident was reported to the police, and a DNA test was conducted, but the facility did not report the allegation of sexual abuse to IDOH. Additionally, the facility did not report resident-to-resident physical altercations involving two other residents to IDOH, as required by their policies. In one case, a resident with dementia and other health issues was observed attempting to grab peers, making contact with one and twisting another's wrist. The incident was not reported to the physician or families, as the staff believed it was handled by a Qualified Medication Aide. Another resident with end-stage renal disease and dementia was involved in an incident where a peer grabbed their wrist, but the facility did not report this to IDOH, citing no injuries or malicious intent. The facility's policies require reporting allegations of abuse and unusual occurrences to appropriate agencies, but these incidents were not reported as required.
Failure to Conduct Follow-Up Assessments After Resident Falls
Penalty
Summary
The facility failed to complete initial and follow-up assessments after falls involving two residents, Resident D and Resident C. Resident D, who has diagnoses including schizoaffective disorder, dementia, and unsteadiness on feet, fell on 8/22/24 after entering another resident's room. She sustained a skin tear and complained of elbow pain, but no follow-up assessments or neurological checks were documented in her clinical record. The Director of Nursing (DON) indicated that the incident was documented on a risk management form, which is not part of the clinical record, and acknowledged that follow-up assessments were not completed. Resident C, with diagnoses including dementia and osteoporosis, fell in the hallway on 8/15/24 after another resident slammed a door, causing him to fall. Although he was sent to the hospital and returned with no fractures, there was no documentation of follow-up assessments in his clinical record. The DON stated that the fall was not considered a fall by the facility because it was caused by an external force, and therefore, a root cause analysis was not conducted. The lack of follow-up assessments for both residents indicates a deficiency in the facility's procedures for managing falls and ensuring resident safety.
Inadequate Supervision and Monitoring of Residents with Dementia
Penalty
Summary
The facility failed to adequately monitor and supervise residents with dementia, leading to inappropriate resident-to-resident interactions. Resident N, who was cognitively intact, entered Resident P's room and allegedly touched her inappropriately. Resident P, who was moderately impaired and bedridden, was unable to defend herself. The incident was reported to the police, and an investigation was initiated. However, the facility did not notify Resident P's family or physician promptly, raising concerns about the safety and supervision of residents. In another incident, Resident K, who had severe cognitive impairment, was found in Resident L's room, engaging in inappropriate physical contact. Resident K had a history of seeking companionship and had previously exhibited similar behaviors. Despite this, the facility did not conduct thorough assessments or document follow-up actions after the incident. The lack of documentation and communication with Resident L's family further highlights the facility's failure to address and manage resident behaviors effectively. The facility's deficiencies in monitoring and supervising residents, as well as in assessing and documenting incidents, resulted in potential risks to resident safety and well-being. The facility's failure to implement appropriate interventions and communicate with families and physicians demonstrates a lack of adherence to regulatory requirements for resident care and protection.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from sexual abuse for three male residents by a staff member while providing incontinence care. The staff member, CNA 3, was on his first night of orientation without the presence of the regular staff member he was paired with for his orientation shift. This resulted in mental anguish for all three residents involved. The incident was reported to the Indiana Department of Health, Long Term Care Division, and an investigation was initiated, leading to the suspension and eventual termination of CNA 3. Resident B reported that CNA 3 attempted to masturbate him during incontinence care, which left him in shock and upset. Resident C shared that CNA 3 made inappropriate comments and physically contacted his penis, causing discomfort and mental distress. Resident D indicated that CNA 3's behavior during assistance with urination was unusual and made him feel uncomfortable, although no physical contact was reported. All three residents were cognitively intact and able to provide detailed accounts of the incidents. The facility's investigation revealed that CNA 3 had been providing unsupervised care to male residents, despite being on his first orientation shift. The facility had followed its usual abuse prohibition policy, including pre-employment checks and abuse prohibition training. However, the facility acknowledged that the investigation could have been more thorough, particularly in interviewing all relevant staff members promptly. The facility's policies on orientation and abuse prohibition were reviewed, and it was noted that the facility did not have strict guidelines for the length of direct supervision during orientation, which may have contributed to the incident.
Failure to Implement Abuse Prohibition Policies and Procedures
Penalty
Summary
The facility failed to implement its policies and procedures related to abuse prohibition, specifically in preventing staff-to-resident abuse, timely reporting of abuse allegations, and ensuring comprehensive investigations. On the night shift of 3-19-24 into 3-20-24, CNA 3 was reported to have inappropriately touched two male residents while providing personal care. The Director of Nursing (DON) received the report of the abuse on the morning of 3-20-24, and the Executive Director (ED) was informed shortly thereafter. However, the initial report to the Indiana Department of Health's Long Term Care Division was not submitted until 4:28 p.m. on 3-20-24, which was beyond the required two-hour reporting window. Additionally, the investigation did not include all individuals who might have had pertinent information, such as CNA 4, who was paired with CNA 3 during his orientation shift but was not formally interviewed by the management team during the investigation. The report indicated that CNA 3, who was on his first shift of orientation, was providing unsupervised incontinence care to the residents. Resident C reported the abuse to CNA 5, who then informed the DON. During the investigation, it was revealed that Resident B was also touched in a sexual manner by CNA 3, and Resident D felt uncomfortable in CNA 3's presence during incontinence care. Despite these findings, the facility's investigation did not include interviews with all relevant staff members, such as CNA 4, who had concerns about CNA 3's behavior during the shift but did not report any abuse concerns at the time. The facility's policy on abuse prohibition, reporting, and investigation, which was revised in 9/2017, mandates that all alleged violations be thoroughly investigated and reported immediately to the Long Term Care Division of the State Department of Health. The policy also requires that the investigation include statements from all individuals with pertinent information. However, the facility did not adhere to these requirements, resulting in a delayed report and an incomplete investigation. This deficiency was identified during a complaint investigation related to the incident involving CNA 3 and the three male residents.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of staff to resident sexual abuse to the Indiana Department of Health's Long Term Care Division and other state agencies within the required two-hour timeframe. The incident involved CNA 3, who was accused of inappropriately touching two male residents during the night shift. The Director of Nursing (DON) received the allegation on the morning of 3-20-24 and informed the Executive Director (ED) shortly thereafter. However, the initial submission of the reportable incident to the Indiana Department of Health was not made until 4:28 p.m. on the same day, which was beyond the mandated two-hour reporting window. The facility's policy on abuse prohibition, reporting, and investigation, which was revised in 9/2017, mandates immediate reporting of all allegations of abuse to the Long Term Care Division of the State Department of Health. Despite this policy, the facility did not comply with the immediate reporting requirement. The policy also outlines the responsibilities of the Administrator and DON in initiating and directing investigations, notifying relevant agencies, and ensuring that all alleged violations are thoroughly investigated. The failure to report the incident in a timely manner constitutes a deficiency in adhering to the established protocols for handling allegations of abuse.
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.
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.
Trusted by long-term care providers and associations.
