Aperion Care Tolleston Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Gary, Indiana.
- Location
- 2350 Taft St, Gary, Indiana 46404
- CMS Provider Number
- 155580
- Inspections on file
- 41
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Aperion Care Tolleston Park during CMS and state inspections, most recent first.
Surveyors found that staff failed to consistently provide and document required ADL assistance, including oral care, shaving, nail care, bathing, personal hygiene, and incontinence care, for several dependent residents. One resident repeatedly had unshaven facial hair and no oral care supplies available despite care plan orders for assisted oral hygiene. Another resident was often observed with food and mucus on his face, greasy hair, and wet clothing from incontinence, while a CNA acknowledged checks and changes were not done at the expected two-hour intervals. Additional residents were seen over multiple days with persistent facial hair, dirty or long jagged fingernails, and inconsistent showers or bed baths, even though their MDS assessments and care plans required partial to total staff assistance with personal hygiene and bathing, and there was no documentation of refusals. A review of a discharged resident’s record also showed missed scheduled showers despite a need for substantial to maximum assistance with bathing.
Two residents were not adequately protected from accidents when one cognitively impaired, fully dependent resident was left alone on the toilet and sustained an unwitnessed fall while attempting to transfer, despite a care plan identifying her fall risk and need for staff assistance, and another cognitively intact resident with supervision needs injured his foot on a broken closet door that remained hanging off its track in his room for several days, causing pain, swelling, and difficulty ambulating.
A resident with end stage renal disease left the facility for dialysis with documentation indicating no acute distress at the time of departure, but no further progress notes were entered afterward. The resident coded and died while at dialysis and did not return, yet the death was not documented in the progress notes, as confirmed by the DON. Although the resident’s discharge was reflected in the census and a Death in Facility MDS entry was completed, the absence of a progress note documenting the death resulted in an incomplete and inaccurate medical record.
A facility failed to thoroughly investigate an abuse allegation after a resident with severe cognitive impairment and multiple disabilities was reported to have been inappropriately touched by staff. The investigation was limited to a physical assessment and did not include interviews with other staff or residents, nor was the incident documented in the resident's record or communicated to the family.
Two residents who required substantial to maximum assistance with ADLs, including bathing, did not have showers or bed baths documented over extended periods. The facility relied on weekly skin assessments for documentation, but these did not indicate whether bathing was performed.
Two residents did not receive necessary care and services as ordered, including missed doses of prescribed medications for one resident and incomplete neurological and post-fall assessments for another following an unwitnessed fall. The DON was unable to provide explanations for the missed medication administrations or the incomplete documentation.
A facility failed to follow updated physician orders for a resident's pressure ulcer treatment. The resident had a pressure ulcer on the coccyx, and the physician's order was changed from a duoderm dressing every three days to a daily calcium alginate and border gauze dressing. However, the updated treatment was not transcribed into the resident's record until several days later, and the DON was unaware of the change, leading to the application of incorrect dressings.
A facility failed to ensure correct PPE use by a staff member cleaning a COVID-19 positive resident's room. The staff member wore only a surgical mask instead of the required N95 mask and face shield, despite the room being marked as a Red Zone. The resident's record confirmed COVID-19 diagnosis and droplet precautions, aligning with the facility's policy for PPE in Red Zones.
A facility failed to perform required neurological assessments every four hours for a resident identified as a fall risk after an unwitnessed fall. The assessments were incomplete, with gaps in documentation, contrary to the facility's policy. The DON acknowledged the failure to adhere to the protocol.
The facility was found to have multiple environmental deficiencies across three units, including dirty and discolored floors, marred walls, and missing or broken fixtures. Observations revealed issues such as rusty toilet bolts, missing caulk, and broken mini blinds. The Maintenance Director and Housekeeping Supervisor acknowledged these issues and were working on addressing them.
Two residents reported that staff did not knock before entering their rooms, compromising their privacy. Observations confirmed that a CNA and a housekeeper entered without knocking. Both residents had cognitive impairments, and the DON acknowledged the oversight.
The facility failed to provide adequate personal hygiene for three residents who were dependent on staff for ADLs. One resident was observed with dirty and long fingernails, while another had long facial hair despite recent shaving. A third resident was observed with facial hair, and the family had to assist with shaving. The care plans indicated a need for assistance, but documentation in the EMR was lacking.
The facility failed to complete ordered treatments for a resident with a skin condition and did not obtain a psychiatric consult for another resident on psychiatric medications. A resident's leg treatment was not documented as completed on multiple occasions, and another resident did not receive a timely psychiatric evaluation despite being on several psychiatric medications.
A facility failed to apply a palm protector as ordered for a resident with hemiplegia, observed without the device during a survey. The resident's care plan required a palm protector due to limited range of motion from a stroke. Despite physician orders, documentation was lacking in the Medication and Treatment Administration Records and electronic medical records, with no record of refusal by the resident.
A resident with a Foley catheter was observed multiple times with the catheter bag and tubing on the floor, contrary to the facility's urinary catheter care policy. Despite staff awareness, the issue persisted during various observations, including when the resident was transported for therapy. The resident had multiple medical conditions and required substantial assistance with personal hygiene.
The facility failed to manage feeding tubes properly for two residents. One resident's tube feeding was not administered according to physician's orders, while another resident's PEG tube site was not cleaned as required, leading to inadequate care. Both residents had cognitive impairments and required specific feeding interventions, which were not properly executed.
The facility failed to maintain correct oxygen flow rates for two residents. One resident was observed with oxygen set at 2.5 liters per minute instead of the prescribed 3 liters, while another had oxygen set at 3 liters per minute instead of the prescribed 2 liters. These discrepancies were confirmed by the ADON during observations.
The facility exceeded the acceptable medication error rate with two errors during medication administration. An LPN failed to prime an insulin pen before administering insulin to a resident, contrary to facility policy. Another LPN administered Aldactone to a resident despite a physician's order discontinuing the medication. These errors contributed to a medication error rate of 6.06%.
A resident with missing teeth had not seen a dentist since 2022, despite expressing a desire for dentures. The resident's medical record showed multiple health issues and moderate impairment in decision-making, but lacked a dental care plan. A misunderstanding about insurance delayed dental services, and the resident was not included on the dental list for a recent dentist visit.
A facility failed to maintain accurate clinical records for a resident with a history of aggression who was placed on 15-minute checks after an altercation. The documentation of these checks was either time-stamped incorrectly or left incomplete, as confirmed by the ADON.
The facility failed to ensure proper infection control practices, including hand hygiene during a glucometer check, PPE use for a resident under enhanced barrier precautions, and proper positioning of a Foley catheter drainage bag. An LPN did not sanitize hands before donning gloves, a CNA did not wear a gown for a resident requiring enhanced precautions, and a resident's catheter bag was observed on the floor multiple times.
Failure to Provide Consistent ADL Assistance and Hygiene Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate assistance with activities of daily living (ADLs), including oral care, shaving, nail care, bathing, personal hygiene, and incontinence care, for multiple dependent residents. One resident reported that staff did not set him up to brush his teeth and that shaving with dull razors was "very brutal"; he stated he would like an electric razor but none had been offered. Over several days of observation, this resident repeatedly had a large amount of facial hair and there was no evidence that oral care had been provided, despite care plan interventions specifying oral hygiene in the morning, after meals, and at bedtime, with partial to moderate assistance. When a CNA searched his drawers, no toothbrush or toothpaste could be found, and the CNA acknowledged she had not completed or set up oral care, even though documentation in the CNA task section indicated oral hygiene and personal hygiene had been provided on nearly all days, with no refusals noted. Another resident was repeatedly observed with food on his clothes, crumbs in his beard, a dry face with peeling skin, greasy hair, and dried mucus hanging from his nose while staff were present but did not clean his face. On one occasion, he was returned to the dining room after being checked for incontinence with his nose cleaned, but later the same day he was observed with the front of his pants and between his legs wet. The CNA caring for him stated she was supposed to check and change residents at least every two hours and reported that she had last checked him before lunch when he was dry, and then after lunch when he would not let her check him, with no further checks until the time he was found wet. Documentation showed he required supervision with eating and personal hygiene and substantial to maximum assistance with toileting and toilet transfers, and that he was mostly incontinent. CNA task documentation showed personal hygiene signed out every shift for the last 14 days, with no documentation of refusals, despite repeated observations of unaddressed hygiene needs. Additional residents were observed with persistent facial hair, long or dirty fingernails, and inconsistent bathing. One resident with Alzheimer’s disease and dementia was seen multiple times over several days with a large amount of white facial hair on her chin and face, despite care plan interventions for partial to moderate assistance with personal hygiene and no documentation of refusals for personal hygiene during the review period. Another resident with depressive and psychotic disorders and dementia was observed with a growth of facial hair and dirty fingernails, reported it had been several days since he had been shaved and that he preferred to be clean shaven, and continued to have dirty fingernails even after being shaved; his care plan required substantial to total dependence on staff for personal hygiene, with no refusals documented. A further resident with type 2 diabetes and vascular dementia was repeatedly observed over several days with facial hair on her chin and face and long, jagged fingernails, despite care plan interventions for partial to moderate assistance with personal hygiene and no documentation that she refused shaving. A closed record review for another resident with non-traumatic subarachnoid hemorrhage and chronic respiratory failure showed that the resident, who required substantial to maximum assistance for bathing, did not consistently receive showers at least twice weekly. Facility shower documentation indicated missed showers on multiple scheduled days, with only intermittent showers and bed baths recorded during the admission period. Nurse’s notes referenced a shower and patient care on certain dates, but overall records showed gaps in providing the frequency of bathing consistent with the resident’s assessed needs and care plan interventions. Across these residents, the survey findings showed discrepancies between observed care and documented CNA task entries, as well as failures to carry out care plan interventions for ADLs, including shaving, nail care, showers, personal hygiene, and timely incontinence care, without documented refusals.
Failure to Provide Adequate Supervision and Remove Environmental Hazards
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent falls for one resident and to maintain a safe, hazard‑free environment for another resident. Resident B, who had diagnoses including subarachnoid hemorrhage and chronic respiratory failure, was not cognitively intact for daily decision making and was dependent on staff for toileting and transfers. Her care plan identified her as at risk for falls and required staff to anticipate and meet her needs, keep the call light within reach, respond promptly to requests for assistance, and ensure appropriate footwear. Despite this, she experienced multiple falls, including an unwitnessed fall in the bathroom. The North Unit Manager reported that on one occasion the resident was left alone on the toilet and fell while attempting to transfer herself, even though she should not have been left unattended. The deficiency also includes the presence of an accident hazard in another resident’s room and the resulting injury. Resident C, who was cognitively intact and required supervision with ADLs, was observed with visible swelling of the right foot, ankle, and lower leg and reported that he injured his foot when a broken closet door in his room hit him while he was trying to fix it. The closet door was observed hanging off its track and away from the closet on multiple days, and the resident stated that staff were aware of the issue. He reported difficulty walking due to pain and swelling, at times ambulating with a cane and at other times propelling himself in a wheelchair with only his left shoe on because the right shoe would not fit. A nurse practitioner note documented that the resident had previously reported right foot pain after hurting his foot on the closet in his room, and the closet door remained hanging off the track during subsequent observations.
Failure to Accurately Document Resident Death in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record related to a resident death when documentation of the death was missing from the progress notes. Resident J, who had diagnoses including end stage renal disease, had a Death in Facility MDS entry completed on 12/11/25. A progress note on that date at 9:39 a.m. documented that the resident left the facility to go to dialysis with no acute distress noted at that time, and there were no further progress notes entered afterward. During interview, the Director of Nursing stated that the resident went to dialysis, coded there, died that day, and did not return to the facility, and acknowledged that the resident’s death had not been documented in the progress notes, although the discharge would have been reflected in the midnight census. This deficiency was identified for 1 of 5 residents reviewed for accidents (Resident J) and relates to Intake 2712287 under 3.1-50(a)(1), which requires safeguarding resident-identifiable information and maintaining medical records in accordance with accepted professional standards.
Failure to Thoroughly Investigate Abuse Allegation Involving Non-Communicative Resident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with severe cognitive impairment and multiple disabilities. An incident was reported in which a resident claimed to have witnessed inappropriate sexual contact between a staff member and another resident who was non-communicative and dependent in all activities of daily living. The facility's investigation was limited to a head-to-toe assessment of the alleged victim, a brief interview in which the resident was unable to respond, and a review of staffing and camera footage. No interviews were conducted with other staff or residents, and there was no documentation of the incident in the resident's record. Additionally, the facility did not perform a psychosocial follow-up assessment or notify the family or responsible party of the abuse allegation or investigation. The resident's medical record lacked any mention of the reported incident, and the facility's own policy required more comprehensive investigative procedures, including interviews with all relevant parties and documentation of all incidents. The administrator confirmed that no further assessments or notifications were made regarding the alleged abuse.
Failure to Complete and Document Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically showers and bathing, were completed and properly documented for dependent residents. For one resident with diagnoses including spinal cord disease, schizophrenia, gout, and depression, records showed the individual required substantial to maximum assistance for most ADLs and was dependent for showering. However, there was no documentation of showers or bed baths for a three-month period, and the weekly skin assessments used by the facility did not indicate whether bathing had occurred, only documenting skin observations. Similarly, another resident with diagnoses such as COPD, depression, adult failure to thrive, dementia, cerebral palsy, and schizophrenia, also required substantial to maximum assistance for showering. Review of this resident's records revealed no documentation of showers over a nearly one-month period. In both cases, the DON confirmed that the facility relied on weekly skin assessments to document showers, but these assessments did not specify if showers or bed baths were completed.
Failure to Complete Medication Administration and Post-Fall Assessments
Penalty
Summary
The facility failed to provide necessary care and services for two residents, resulting in deficiencies related to medication administration and post-fall assessments. For one resident with diagnoses including heart disease, COPD, sepsis, depression, dementia, and anxiety, the Medication Administration Records showed that prescribed medications (aspirin, Zoloft, and Norco) were not documented as administered on multiple occasions. Physician orders required these medications to be given via PEG-tube, but the records for October and November indicated several blank entries where medications were not signed out as completed. The Director of Nursing was unable to provide an explanation for the missed doses. Another resident, with diagnoses such as respiratory failure, COPD, diabetes, kidney disease, dialysis, and dementia, experienced an unwitnessed fall. Although initial neurological checks were started, the Neurological Assessment Form was not completed at several required intervals, and the 72-hour post-fall documentation was discontinued prematurely. The resident's care plan called for ongoing assessment and interventions following the fall, but documentation and follow-up assessments were not completed as required by facility policy. The Director of Nursing confirmed that the required neurological and post-fall assessments were not fully carried out.
Failure to Follow Updated Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as Resident C, who had a pressure ulcer on the coccyx. The deficiency was observed when the Director of Nursing (DON) and Unit Manager 1 were performing pressure ulcer treatments and found that the dressing applied was not as per the physician's updated orders. The physician had ordered a duoderm dressing to be applied every three days, which was later changed to a calcium alginate and border gauze dressing to be applied daily. However, the dressing observed was a border gauze dressing dated 1/22/25, indicating a failure to follow the updated treatment plan. The resident's medical record review revealed a significant change in the treatment order on 1/17/25, which was not transcribed into the resident's record until 1/22/25. The DON was unaware of the change in orders until the day of the observation. The Treatment Administration Record showed that the duoderm dressing was applied on 1/20/25, and the new treatment was supposed to start on 1/23/25. This oversight in updating and following the physician's orders led to the deficiency in providing necessary treatment and services to promote healing of the pressure ulcer.
Failure to Use Correct PPE in COVID-19 Red Zone
Penalty
Summary
The facility failed to ensure the correct use of Personal Protective Equipment (PPE) by a staff member when cleaning a room of a COVID-19 positive resident, identified as Resident F, who was under COVID-19 Transmission-Based Precautions. During an observation, Housekeeper 1 was seen mopping the floor in Resident F's room, which was marked as a Red Zone, indicating the need for specific PPE including a N95 mask, gown, gloves, and face shield. However, Housekeeper 1 was only wearing a surgical mask and no face shield. Upon interview, Housekeeper 1 expressed uncertainty about the requirement to wear a N95 mask and face shield. Resident F's medical record confirmed a diagnosis of COVID-19 and required droplet precautions. The facility's COVID-19 policy, dated 7/24/23, specified the necessary PPE for Red and Yellow Zones, which was not adhered to in this instance.
Inadequate Neurological Assessment Follow-Up After Resident Fall
Penalty
Summary
The facility failed to complete adequate follow-up for a fall incident involving Resident B, who was identified as a fall risk due to cancer and medications. Resident B experienced an unwitnessed fall and the facility's neurological assessment protocol required checks every four hours for 24 hours following such an event. However, the documentation showed that neurological assessments were not consistently completed as required. Specifically, assessments were recorded at three intervals on the day of the fall and only once the following day, leaving gaps in the required four-hourly checks. The Director of Nursing confirmed that the assessments should have been completed and documented every four hours, as per the facility's policy.
Environmental Deficiencies in Facility Units
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents across three units: North, South, and PCU. Observations during an environmental tour revealed multiple deficiencies, including dirty and discolored floor tiles, marred walls, and missing or broken fixtures. In the North Unit, several rooms had issues such as discolored floors with dirt and debris accumulation, marred doors, and broken towel racks. Bathrooms in these rooms were particularly problematic, with dirty floors, scuffed tiles, and missing toilet bolt covers. In the South Unit, broken and missing mini blinds were noted, along with marred walls and dirty floors. The PCU also exhibited significant environmental issues, including scuffed floors, rusty toilet bolts, and missing caulk around toilets. The bathroom ceiling vents were found to be dusty and dirty. During an interview, the Maintenance Director and Housekeeping Supervisor acknowledged awareness of these issues and indicated ongoing efforts to address them. These findings relate to a specific complaint, IN00436414.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy of two residents, as staff members did not knock on their doors before entering their rooms. Resident 2 reported that staff did not always knock before entering her room. This was observed when a CNA opened the door without knocking and then closed it, and another staff member partially opened the door without knocking. Resident 2's medical record indicated diagnoses including bipolar disorder, type 2 diabetes, major depressive disorder, and schizophrenia, with a moderate impairment in daily decision-making as per the Quarterly MDS assessment. Similarly, Resident 9 also reported that staff did not always knock before entering her room. This was confirmed when a housekeeper entered the room to replace a trash bag without knocking. Resident 9's medical record showed diagnoses of major depressive disorder and anxiety, with cognitive impairment in daily decision-making according to the Quarterly MDS assessment. The Director of Nursing acknowledged that staff should have knocked before entering the residents' rooms.
Failure to Provide Adequate Personal Hygiene for Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately completed for three residents who were dependent on staff for personal hygiene. Resident 35 was observed multiple times with dirty and long fingernails on both hands. The resident had a history of stroke, aphasia, diabetes, hemiplegia, heart disease, and high blood pressure, and was not cognitively intact for daily decision-making. The care plan indicated a need for staff assistance with personal hygiene, but there was no documentation in the electronic medical record (EMR) that the resident's fingernails had been cleaned or trimmed. The Assistant Director of Nursing (ADON) confirmed the need for nail care. Resident 58 was observed with long facial hair under her chin and neck, despite being shaved two days prior. The resident had diagnoses including type 2 diabetes, stroke, hemiplegia, high blood pressure, UTI, obstructive uropathy, dementia, anxiety, and depressive disorder, and was cognitively impaired for daily decision-making. The care plan noted an ADL self-care performance deficit, but no shaving was documented in the EMR. Similarly, Resident 236 was observed with facial hair, and the resident's daughter indicated that her brother was shaving him. The resident had a care plan indicating an ADL self-care deficit related to mobility and weakness, but no shaving was documented in the EMR. The ADON was unaware of the resident's preference to be clean-shaven.
Failure to Complete Ordered Treatments and Obtain Psychiatric Consults
Penalty
Summary
The facility failed to ensure that non-pressure ulcer treatments were completed as ordered for three out of four residents reviewed for skin conditions. Specifically, Resident 94 was observed with a scaly, scabbed, and inflamed left lower leg without any bandages, despite having a physician's order for Hydrocortisone cream application and wrapping with Kerlix on specific days. The Treatment Administration Records (TAR) for Resident 94 showed multiple instances from April to August 2024 where the treatment was not documented as completed. The resident's care plan indicated resistance to care and refusal of wound care, but the treatments were still not signed out as completed, as confirmed by the Assistant Director of Nursing (ADON) during an interview. Additionally, the facility failed to obtain a psychiatric consult as ordered for Resident 107, who was reviewed for unnecessary medications. Resident 107, diagnosed with multiple conditions including Parkinson's disease and psychotic disorder, was prescribed several psychiatric medications. However, there was no documentation or consents obtained for the resident to seek outside behavior management, and the psychiatric consult was not obtained in a timely manner. The ADON and Nurse Consultant confirmed the oversight during interviews, indicating a lapse in ensuring the resident received the necessary psychiatric evaluation and management.
Failure to Apply Palm Protector as Ordered
Penalty
Summary
The facility failed to ensure that a palm protector was applied as ordered by the physician for a resident with limited range of motion. During an observation, the resident was seen without the required anti-contracture device in her right hand, which was clenched like a fist. The resident's medical history includes stroke, aphasia, diabetes, hemiplegia, heart disease, and high blood pressure. The care plan specified the use of a palm protector for the resident's right hand due to hemiplegia from a stroke. The physician's orders allowed for a palm protector or a rolled washcloth to be used, but there was no documentation in the Medication and Treatment Administration Records for several months to indicate whether the palm protector was applied or removed. The electronic medical record task section also showed that the palm protector was marked as not applicable, with no documentation of refusal by the resident. The Assistant Director of Nursing confirmed the lack of documentation regarding the use of the palm protector.
Improper Foley Catheter Care Observed in Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with a Foley catheter, as the catheter bag and tubing were repeatedly observed on the floor. During multiple observations, the catheter bag and tubing were seen on the floor while the resident was in bed and in a wheelchair. Staff members, including CNAs and the Director of Rehabilitation, were aware that the catheter bag should not be on the floor, yet it remained there during various times, including when the resident was transported to and from therapy. The resident involved had a history of type 2 diabetes, stroke, hemiplegia, high blood pressure, urinary tract infection, obstructive uropathy, dementia, anxiety, and depressive disorder. The resident was cognitively impaired and required substantial assistance with personal hygiene. Despite the facility's urinary catheter care policy, which mandates that catheter bags and tubing should not touch the floor, the deficiency persisted. The Director of Nursing confirmed that the catheter bag and tubing should not be on the floor, indicating a lapse in adherence to the facility's policy.
Deficiencies in Feeding Tube Management and Care
Penalty
Summary
The facility failed to ensure proper management and care for residents with feeding tubes, as observed in two cases. Resident 10, who had a PEG tube due to an intestinal obstruction and was cognitively impaired, was found with his tube feeding pump turned off and not connected to his feeding tube during scheduled feeding times. The physician's order specified that the tube feeding should be administered from 7:00 p.m. to 9:00 a.m., but observations indicated non-compliance with these orders. The resident's care plan required dependency on tube feeding and water flushes, yet these interventions were not properly executed. In the case of Resident 107, who had a PEG tube and was not cognitively intact, there was a lack of appropriate stoma site care. The resident's PEG tube site was observed with dried crusty drainage and no bandage, and there were no physician's orders for cleaning the stoma site. Despite the facility's policy requiring stoma site cleaning, the staff did not perform this care, as confirmed by interviews with the RN and the DON. The resident's care plan indicated the need for tube feeding due to swallowing difficulties, but the absence of orders for stoma care led to inadequate management of the resident's condition.
Oxygen Flow Rate Discrepancies for Two Residents
Penalty
Summary
The facility failed to ensure that oxygen was set at the correct flow rate for two residents requiring respiratory care. Resident 236 was observed multiple times with oxygen set at 2.5 liters per minute, despite the physician's order and care plan indicating it should be set at 3 liters per minute. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an observation. Resident 236 had been admitted with diagnoses including pneumonia and high blood pressure, and the care plan specifically required oxygen therapy at the prescribed rate. Similarly, Resident 55 was observed with oxygen set at 3 liters per minute, contrary to the physician's order of 2 liters per minute. The resident's medical history included anoxic brain damage, dysphagia, hypertension, and COPD, necessitating precise oxygen therapy. The Medication Administration Record indicated that oxygen was documented as being administered at the correct rate of 2 liters, yet observations showed otherwise. The ADON acknowledged the discrepancy and noted that staff had been auditing the oxygen settings.
Medication Error Rate Exceeds 5% Due to Insulin and Discontinued Medication Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by two errors observed during medication administration for two residents. The first error involved an LPN who did not prime an insulin pen before administering 10 units of insulin to a resident. The facility's policy requires that insulin pens be primed to remove air bubbles and ensure proper dosage delivery. This step was omitted during the medication pass, as confirmed by the 200 Unit Manager. The second error occurred when another LPN administered a 25 mg tablet of Aldactone to a resident, despite a physician's order discontinuing the medication. The error was identified upon review of the resident's records, which showed the discontinuation order dated prior to the administration. The Nurse Consultant confirmed that the medication should not have been given, as it was no longer prescribed for the resident.
Failure to Provide Annual Dental Services
Penalty
Summary
The facility failed to ensure that a resident received dental services at least annually, as required. Resident 88, who was observed with missing upper and lower teeth, reported not having seen a dentist since arriving at the facility in 2022 and expressed a desire for dentures. The resident's medical record, reviewed on 9/18/24, included diagnoses such as hypotension, anemia, adult failure to thrive, respiratory failure, heart failure, kidney disease, and dependence on renal dialysis. The Quarterly MDS assessment indicated the resident was moderately impaired in daily decision-making, yet there was no dental care plan in place. A physician's order from 2/5/24 allowed for dental care as needed, but the resident had not been seen by a dentist due to an initial misunderstanding about insurance issues, which was later corrected. Despite signing a new dental agreement on 8/29/24, the resident was not included on the dental list for the dentist's visit on 9/11/24.
Inaccurate Documentation of 15-Minute Checks for Resident
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident who was involved in an abusive incident. Resident 94, who has a history of schizophrenia, morbid obesity, cellulitis, high blood pressure, major depressive disorder, anxiety, osteoarthritis, and bipolar disorder, was not cognitively intact for daily decision-making according to a recent assessment. The resident had a potential for physical aggression as noted in their care plan. An incident occurred where Resident 94 pushed another resident to the ground after a verbal altercation in the bathroom. Following this incident, Resident 94 was moved to a different room and placed on 15-minute checks. However, the documentation of these 15-minute checks was found to be inaccurate and incomplete. The records showed that the checks were either time-stamped before or significantly after the actual observation times. For instance, on one day, the checks were documented at times that did not align with the required 15-minute intervals, with some periods left blank. During an interview, the Assistant Director of Nursing (ADON) confirmed that the time stamps were not accurate, indicating a failure in maintaining proper clinical records as per professional standards.
Infection Control Deficiencies in Hand Hygiene, PPE Use, and Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices during a glucometer blood sugar check for a resident. An LPN was observed entering the resident's room and donning gloves without washing or sanitizing her hands upon entry or before putting on the gloves. The facility's hand hygiene policy, which was identified as current, indicated that hand hygiene should be completed upon room entry. This oversight was confirmed during an interview with the Nurse Consultant, who stated that it would be expected for staff to sanitize their hands prior to donning gloves. Additionally, a CNA failed to don the required personal protective equipment (PPE) for a resident under enhanced barrier precautions (EBP) due to wounds and infection. The CNA provided incontinence care to the resident without wearing a gown, as required by the EBP sign above the resident's bed. The CNA mistakenly believed the EBP was for another resident. Furthermore, a resident with a Foley catheter was observed multiple times with the catheter drainage bag on the floor, contrary to the facility's urinary catheter care policy, which mandates that drainage bags and tubing should not touch the floor. The resident's medical history included stroke, chronic kidney disease, and other conditions, and the resident was not cognitively intact for daily decision-making.
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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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