Byron Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 1661 Beacon Street, Fort Wayne, Indiana 46805
- CMS Provider Number
- 155364
- Inspections on file
- 31
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Byron Health Center during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to follow facility policies for food labeling, storage, and sanitation, affecting all residents receiving meals. Multiple food items in freezers, refrigerators, dry storage, and on countertops were left open to air, lacked lids, and were not labeled with open or expiration dates, including frozen items, bread products, cereals, and seasonings that had been removed from original packaging. In addition, a set of keys was left on the steam table serving area, the handwashing sink contained visible debris, and the grill and grill foil had significant black buildup despite documentation that these surfaces had recently been cleaned. The Dietary Manager confirmed that these conditions did not comply with the facility’s standards for labeling, covering, and cleaning food and food-contact surfaces.
The facility failed to maintain proper kitchen sanitation and food labeling for all residents receiving meals, with surveyors observing multiple open and undated food items, including frozen products, dry goods, and bread, as well as seasoning stored without a lid. Similar issues had been cited previously under F812 for sanitation, open food items, and lack of labeling and dating. The ED reported that she and an assistant conducted undocumented kitchen observations and that a committee had been working on food temperatures, labeling, dating, and cleanliness, but no related policy was provided at survey exit.
Two residents with neurological impairments and contractures did not consistently receive prescribed cervical collars and a mechanical back/cervical splint during bedrest and meals. One resident, ordered to wear a soft cervical collar in bed and for all meals for neck contracture management, was repeatedly observed without the collar, which was found on the bedside stand, and her care plan and CNA Kardex lacked instructions for its use or refusal despite documentation that she preferred wearing it. Staff gave conflicting accounts about whether the collar was still in use, and there was no documentation of refusals as required by facility policy. Another resident, ordered to wear a cervical brace during all meals, was repeatedly observed with her head leaning to one side, without the brace, and not eating, while CNAs reported the brace’s Velcro failed and her head slipped out despite repeated attempts to reposition and reapply it. Therapy and restorative staff acknowledged ongoing issues with the brace, missed reassessment, and lack of reported concerns, contrary to facility policy requiring regular assessment and reporting of problems with assistive devices.
The facility failed to complete post-fall neurological assessments as described by staff practice for three residents with conditions including dementia, epilepsy, abnormal posture, and diabetes. After unwitnessed and other falls, required neuros at specified intervals and every shift for 72 hours were repeatedly missing across multiple days and shifts, despite care plan directives to follow the fall protocol. The DON and an LPN described a detailed neuro check schedule after falls, but record reviews showed numerous omitted assessments and entire periods with no documented neuros, even though the written falls protocol required assessment and documentation of neurological status.
A resident with Alzheimer’s disease, anxiety, depression, and significant cognitive impairment expressed suicidal ideation to a volunteer, stating she had nothing to live for and wanted to kill herself. The resident’s care plan required immediate supervisor notification and redirection for suicidal comments, and facility policy required immediate reporting to the nurse supervisor, continuous supervision, completion of a suicide risk assessment, provider notification, and documentation. The volunteer documented the statement on a 1:1 visit log and verbally reported it to staff on an adjacent unit, but nursing staff on the resident’s unit were unaware of the incident, the Life Enrichment Specialist read the log days later and did not report it, and no further assessment, provider notification, or documentation of follow-up occurred.
A resident with altered mental status and diabetes had a portable urinal repeatedly observed over several days hanging, still containing urine, from a trash bin that also held other discarded items, and later placed on a table with personal items. The CNA acknowledged this as an infection control concern and reported uncertainty about where to store the urinal, while also noting the resident’s preference to keep it close due to frequent bathroom use. The DON stated that urinals were expected to be cleaned after use and stored on the back of the toilet, and that any preference to keep a urinal at bedside should be reflected in the care plan, but this was not documented for this resident despite a facility policy outlining proper bedside urinal management and care plan notation.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised, traveling several miles and crossing busy streets before being returned by police. The resident's care plan did not address her risk for elopement or include interventions for wandering, and staff were unaware of her absence until notified by an external party. No elopement risk assessments were completed despite documented wandering behaviors.
Surveyors observed multiple failures in kitchen sanitation and food handling, including unlabeled and undated opened food items, expired and uncovered food, improper storage of scoops in dry goods, and inadequate cleaning of kitchen surfaces and equipment. Baking pans were stacked while still wet, and food items were left open to air exposure. These deficiencies affected nearly all residents served by the kitchen.
A resident with diabetes and dementia received a subcutaneous injection of Trulicity from an LPN in a common dining area while eating breakfast, requiring the resident to expose his abdomen in front of others. Staff interviews and facility policy confirmed that medication administration in public areas during meals is not permitted due to dignity and privacy concerns.
A resident's personal and medical information, including medication list and vital signs, was left visible on an unattended computer screen and paper worksheet on a medicine cart in a hallway. The information was accessible to staff and residents passing by, and the RN later acknowledged not securing the records as required by facility policy.
Two residents with significant medical conditions were transferred to the hospital without documentation that the facility's bed hold policy was explained to them or their families. The DON confirmed that this notification should have been documented in the progress notes, in accordance with facility policy.
The facility did not ensure accurate assessment and documentation for two residents with complex medical needs. One resident with chronic neurological issues had repeated documentation of normal pupil response despite observed unequal pupils, and the care plan did not address this known condition. Another resident with acute respiratory conditions did not receive required shift-by-shift respiratory assessments as ordered, with several shifts missing documentation of breath sounds. Staff interviews confirmed gaps in awareness and adherence to assessment protocols.
A resident with chronic respiratory failure and cognitive impairment was found on two occasions with unbagged oxygen tubing left out and the oxygen concentrator running while not in use. The resident was also observed in bed with labored breathing, poorly positioned, and unable to access her oxygen, with staff confirming she could not have moved the tubing herself. Facility policy requiring proper oxygen application and storage was not followed.
A resident at high risk for falls was left unattended in a shower chair by a CNA, leading to an unwitnessed fall. The resident, with a history of traumatic brain injury and quadriplegia, began foaming at the mouth, prompting the CNA to leave the room to seek help. Upon return, the resident was found on the floor. The facility's policy lacked specific interventions for high fall risk residents.
Improper Food Labeling, Storage, and Kitchen Sanitation in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food labeling, storage, and protection from contamination affecting all 103 residents who received food from the facility’s kitchen. During an initial kitchen observation, multiple food items in the walk-in freezer, refrigerator, dry storage, countertop, and reach-in freezer were found open to air, without lids, and lacking open or expiration dates. These included a bag of frozen chips, a box of cinnamon rolls, an open container of beef base without a lid, elbow macaroni removed from original packaging and placed in an unlabeled plastic container, multiple bags of sliced bread and buns in various locations, and an open box of frozen hamburgers. On the spice rack, an open container of dill weed seasoning without a lid was observed, and on the back cabinets, Raisin Bran and Trix cereals had been removed from their original packaging and placed into plastic containers without open dates. The Dietary Manager stated that facility practice was to label and date all items when opened and to follow manufacturer expiration dates when items remained in original packaging, and confirmed that the observed items were not labeled or dated and that food should not be left open to air. Surveyors also observed sanitation and cleanliness issues in the kitchen environment. A set of keys was found sitting on the steam table serving area, the handwashing sink contained brown chunks and white debris, and the grill had black buildup between and underneath the grates, with a large accumulation of black residue on the grill foil. A review of the facility’s weekly cleaning list showed that the grill foil, grill grates, shelving, grill, and stovetop had been documented as cleaned on the two days prior to the observation. The Dietary Manager attributed the black buildup on the grill to cooking breakfast and suggested that staff may have had food on their hands when using the handwashing sink, and also acknowledged that keys should not have been left on the kitchen serving area. These conditions were inconsistent with the facility’s written policies requiring all foods stored in refrigerators, freezers, and dry storage bins to be covered, labeled, and dated, and requiring food service equipment and food-contact surfaces to be cleaned and sanitized at a frequency that prevents contamination.
Repeat Failure to Maintain Kitchen Sanitation and Food Labeling
Penalty
Summary
The facility failed to effectively implement interventions to maintain kitchen sanitation for all 103 residents who consumed food prepared in the kitchen. During a kitchen observation, surveyors found multiple food items improperly stored and not dated, including a bag of frozen chips and cinnamon rolls in the freezer open to air with no open dates, beef base without an open date, and elbow macaroni in a clear bin without a date. Additional undated bread products included white bread, whole wheat bread, hamburger buns, and sub buns, and dill weed seasoning was observed without a lid and open to air. These sanitation and food labeling issues were similar to those cited under F812 in a prior recertification survey, which had identified problems with maintaining sanitation, open food items, labeling of food, and dating of opened food. In an interview, the Executive Director reported that she and the Assistant Executive Director conducted various observations of the main kitchen and neighborhood kitchenettes but had no documentation of these observations. The Executive Director stated that the committee had been working on food temperatures, labeling, dating, and cleanliness since the previous April and noted there had been turnover among dietary aides, which she believed had corrected the problem until the most recent annual survey results. No policy related to these issues was provided at the time of survey exit.
Failure to Provide and Maintain Prescribed Cervical Collars and Splints for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and maintain prescribed cervical collars and a mechanical back/cervical splint for two residents with significant neurological and musculoskeletal impairments. For one resident with a history of cerebral infarction, right middle cerebral artery occlusion, and left-sided hemiplegia/hemiparesis, surveyors repeatedly observed her in bed without the ordered soft cervical collar in place, despite a physician’s order that she wear the collar while in bed and for all meals for neck contracture management. The collar was seen on the bedside stand during one observation, and the resident’s care plan and CNA Kardex contained no instructions regarding use or refusal of the collar. The NP’s earlier progress note documented that the resident liked wearing the collar and wanted to wear it more frequently than ordered, and there were no subsequent notes documenting refusal or discontinuation. Staff interviews further showed inconsistent understanding and implementation of the collar order for this resident. A CNA reported believing the collar had been discontinued after a trial for meals only, stating it was unsuccessful and that she understood it was no longer in use. The DON stated the collar had been used when the resident was eating meals consistently, but that it was not being used because the resident was now being offered food for pleasure only and was expected to receive a feeding tube. The DON also stated the collar was in the laundry because it was dirty and acknowledged that refusals should have been documented and that frequent refusals should have triggered re-evaluation of the device. The Director of Therapy confirmed the collar had been implemented for a right-sided neck contracture and that the resident initially wanted to wear it more often, and indicated that documentation of refusals was the responsibility of nursing. The facility’s policy on braces and assistive devices required documentation of refusals, follow-up actions, and care plan updates addressing device type, application instructions, monitoring guidelines, and specific risks, which were not reflected in the record. For a second resident with diagnoses including unspecified intracranial injury, left-sided hemiplegia, and traumatic subarachnoid hemorrhage, surveyors repeatedly observed her during meals with her head leaning to the left, without the prescribed mechanical back/cervical splint in place, and with full or covered meal trays that she was not eating. Her care plan identified an ADL self-performance deficit and included an intervention for application of a cervical/back splint during meals and removal afterward. Physician orders directed that she wear a cervical brace during all meals, angled approximately 30 degrees in extension with a towel under the brace. However, the most recent MDS did not indicate use of splints or braces, and staff interviews revealed ongoing problems with the brace’s fit and function that were not effectively addressed. CNAs reported that the resident should have had the brace on but that her head repeatedly slipped out of it, even after attempts to reposition her and reapply the brace, and one CNA stated she was unsure whether the NP or therapy had been notified. Another CNA described the Velcro on the brace releasing and the resident sliding in her seat so that the brace could not support her head, and indicated she had not been instructed on alternative interventions if the brace was ineffective and was unaware of any notification to NP or therapy. The Director of Therapy stated that therapy was initially responsible for the brace and that, after discharge, restorative nursing managed issues, with therapy performing screenings every three months; she acknowledged awareness that the Velcro continued to come undone but did not describe additional actions to ensure the brace was safe and properly fitting. The restorative nurse reported that Velcro had been replaced earlier in the month and that staff had not reported ongoing issues. The DOT later stated that the resident had been missed for a scheduled reassessment that should have occurred approximately three months after the last assessment and that she was on a list for reevaluation while therapy awaited an order. The facility’s policy required assessment of braces and assistive devices on admission, with changes in condition, and periodically as part of the care plan process, with nursing staff reporting changes in mobility or tolerance and reassessment quarterly with MDS review, which was not consistently carried out for this resident.
Failure to Complete Post-Fall Neurological Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete neurological assessments after falls in accordance with its described practice for multiple residents. For unwitnessed falls, an LPN and the DON both stated that staff were to assess the resident for injuries, determine the cause of the fall, initiate neurological checks every 15 minutes for the first hour, then hourly for four hours, and then every shift for 72 hours, along with provider and family notification, skin and post-fall assessments, dehydration assessment, and documentation. Record review for a resident with epilepsy, dementia, and diabetes showed missing neurological assessments following an unwitnessed fall on specific dates and times, including incomplete checks on the night and subsequent shifts. Another resident, also with epilepsy, dementia, and diabetes and care planned as being at risk for falls with an intervention to follow the facility fall protocol, had multiple missing neurological assessments after falls. These included missing second-shift neuros on several consecutive days, missing neuros at multiple specified times on another date, and absent first- and second-shift neuros on a subsequent date, as well as missing neuros at designated early-morning times and no documented every-shift neuros for 72 hours on three days. A third resident with dementia, abnormal posture, and diabetes had no neurological assessments located by the DON for multiple falls over several days, and neuros were also missing for three days following a fall later in the year. The facility’s written Falls Clinical Protocol required assessment and documentation of neurological status and related factors after falls but did not specify the frequency of neurological assessments.
Failure to Investigate and Respond to Resident’s Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond to a resident’s verbalization of suicidal ideation as required by the resident’s care plan and facility policy. The resident had diagnoses of Alzheimer’s disease, anxiety, and depression, and a current MDS showed significant cognitive impairment with a BIMS score of 4. The resident’s care plan for depression with a history of suicidal ideation directed staff to immediately notify a supervisor and redirect the resident when suicidal comments were made. On 3/9/2026, a progress note documented that the resident told a volunteer she had nothing to live for and wanted to kill herself, and a 1:1 visit log from that same encounter recorded the same statement. However, there were no additional progress notes or documentation showing that the suicidal ideation was further assessed, that the care plan interventions were implemented, or that the provider was notified. Interviews revealed multiple communication and follow-through failures. The DON stated that any resident verbalizing suicidal ideation should be asked if they had a plan to harm themselves, the care plan should be reviewed and followed, and the resident might be sent for inpatient psychiatric care if appropriate. A QMA who regularly worked on the resident’s unit reported she was not aware of the suicidal statement made on 3/9/2026, although she recalled the resident had made suicidal remarks upon admission months earlier. The Life Enrichment Specialist stated that volunteers complete visit logs and that she entered the 3/9/2026 log into the computer on 3/18/2026, at which time she read the suicidal statement but did not report it as she should have. The volunteer reported that after hearing the suicidal statement, he offered supportive words and then reported it to staff on an adjacent unit when he could not immediately find the unit nurse. The facility’s “Suicide Threats” policy required immediate reporting of any suicide threats to the Nurse Supervisor, continuous supervision of the resident, completion of a Columbia Suicide Severity Rating Scale, reporting findings to the provider, following any provider orders, and documenting the situation, but these steps were not carried out for this resident’s suicidal verbalization.
Improper Storage and Handling of Bedside Urinal
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to improper storage and handling of a portable urinal for one resident. On multiple observations over three consecutive days, the resident was seen sitting in a recliner with a portable urinal containing yellow liquid hanging by its handle on a trash bin in the room. On one of those days, the trash bin also contained a glove, a plastic drinking cup, a piece of folded paper, and three paper towels, while the urinal remained hanging from the bin. In a later observation the same day, the urinal was seen sitting on top of the resident’s table alongside three remote controls and a piece of folded paper. The urinal had been dated several days earlier, and there was no indication it had been emptied and cleaned between observations. Record review showed the resident had diagnoses including altered mental status and diabetes mellitus. The resident’s current care plan did not indicate that a urinal was to be kept at the bedside or within immediate reach while seated in a recliner. During interview, the CNA caring for the resident acknowledged that hanging the urinal on the trash can was an infection control concern and stated she was unsure where to place the urinal because the resident’s table had items on it, while also noting the resident liked to have the urinal close by due to frequent bathroom use. The DON stated that staff were expected to clean the urinal after use and store it on the back of the toilet when not in use, and that clean urinals should be stored there. The DON also stated that the care plan should reflect if a resident preferred to keep a urinal close by, but this preference was not documented for this resident. The facility’s policy indicated that if a resident keeps a urinal at bedside, it should be checked frequently, emptied and cleaned as necessary, documented on the care plan, and stored on a paper towel on the bedside stand with a cover when not in use.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with a history of severe cognitive impairment and high risk for wandering was able to leave the facility unsupervised and travel approximately three miles, crossing heavily trafficked streets, before being returned by local police. The resident, who had a BIMS score of 3/15 indicating severely impaired cognition and diagnoses including an unspecified mental disorder and chronic obstructive pulmonary disease, resided on an unsecured unit and had a documented history of wandering within the facility. Despite these risk factors, the resident's care plan did not address her ability to exit the facility alone, did not include interventions for wandering, and did not specify how often her whereabouts should be checked. On the day of the incident, the resident was observed by the facility's CFO exiting and re-entering the building multiple times in the morning, with the final exit occurring at 10:03 AM. No staff member was aware that the resident had left the facility, and her absence went unnoticed until the CFO received a call from the resident's friend at 12:49 PM, informing her that the resident was at her former apartment and that the police were returning her to the facility. Interviews with staff revealed that the last known sighting of the resident was around 9 AM, and staff did not realize she was missing until notified by an external party. The resident did not sign out or have a family member or friend accompany her, as required for a leave of absence. Review of the resident's records showed that while she was assessed as high risk for wandering, no elopement risk assessments were completed, and her care plan lacked specific interventions for her wandering behavior. Nursing notes prior to the incident documented episodes of the resident being lost within the facility and expressing intentions to leave, but these behaviors were not addressed with targeted interventions. The facility's policy required assessment and interventions to prevent elopement, but these were not implemented for this resident prior to the incident.
Deficient Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and food handling practices, as evidenced by multiple observations during a survey. Opened food items, such as a container of ice cream and chef salads, were found in the kitchen without being labeled or dated. Several food items in the freezer, including hamburger patties, chicken strips, and French fries, were left open to air exposure and not dated when opened. An open box of popsicles was observed past its expiration date, and a cart containing expired fruit and cake was not disposed of as required. Additionally, scoops for flour and sugar were stored inside the bins, contrary to policy, and the fruit and cake on the cart were not individually covered and appeared dry. Sanitation issues were also noted, including a shelf next to the fryer with a large amount of oily liquid and debris, and multicolored streaks and splatters on the freezer doors. Baking pans were found stacked while still wet, with clear liquid dripping from them, indicating they were not thoroughly air dried before storage. The Dietary Manager confirmed that these practices did not align with facility policies, which require all food to be covered, labeled, and dated, and all equipment to be sanitized and properly air dried. These deficiencies affected 95 of 96 residents who were served food prepared in the kitchen.
Medication Administration in Common Area Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a nurse administered medications, including a subcutaneous injection of Trulicity, to a resident in a common dining area while the resident was eating breakfast. The resident, who had diagnoses of type 2 diabetes, chronic gingivitis, and unspecified dementia, was observed pulling up his shirt to expose his abdomen for the injection in the presence of others. The resident's care plan did not indicate any preference for receiving medications in common areas. Interviews with staff confirmed that it was not permitted to administer medications in the common area during meals due to concerns about resident dignity and the expectation that residents should enjoy their meals without interruption. Facility policy also required staff to maintain resident privacy and dignity during treatment procedures, including protecting bodily privacy. The administration of the injection in a public setting was not consistent with these policies.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
A deficiency occurred when a computer screen displaying a resident's name, picture, medication list, and other personal health information was left open and visible on top of a medicine cart in a hallway. Additionally, a paper worksheet containing vital signs and other health information for multiple residents was left on top of the cart. Both the computer screen and worksheet were accessible in an area where staff and residents were passing by, making the information visible to unauthorized individuals. The incident was observed during routine activities, including medication administration and meal assistance. The resident involved had diagnoses including cerebral palsy, abnormal weight loss, dysphagia, and altered mental status, with a BIMS score indicating cognitive impairment. During interviews, the RN acknowledged forgetting to lock the computer screen and failing to turn over the worksheet to protect resident information. The DON confirmed that facility policy requires computer screens to be locked and paper records to be secured when unattended, in order to maintain confidentiality of resident information.
Failure to Provide Bed Hold Policy Notification Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide required documentation or notification regarding the bed hold policy to two residents prior to their discharge to the hospital. Resident 35, who had diagnoses including kidney failure, respiratory failure, and pneumonitis due to inhalation of food and vomit, was sent to the hospital without any documentation in the medical record indicating that the bed hold policy had been explained to her or her family. Similarly, Resident 47, with diagnoses of respiratory failure, dysphagia, and altered mental status, was also transferred to the hospital without evidence that the bed hold policy was communicated to him or his family. The Director of Nursing confirmed that the bed hold policy should have been documented in the progress notes and that residents or their representatives should always be informed of the policy prior to leaving the facility. The facility's current policy requires informing residents upon admission and prior to transfer for hospitalization or therapeutic leave about the bed hold policy, but there was no documentation to show this occurred for the two residents.
Failure to Accurately Assess and Document Neurological and Respiratory Status
Penalty
Summary
The facility failed to ensure accurate assessments and documentation for two residents with significant medical conditions. For one resident with a history of 6th abducent nerve palsy, 3rd oculomotor nerve palsy, and blepharoconjunctivitis, observations revealed unequal pupils—one dilated and nonreactive, the other normal—yet skilled charting repeatedly documented the pupils as equal, round, and reactive to light over several months. The resident's care plan addressed issues such as impaired vision and droopy eyelids but did not include interventions or monitoring for the known unequal pupils, despite this being a longstanding condition. Staff interviews confirmed a lack of awareness and proper documentation regarding the resident's pupil irregularities. For another resident with acute respiratory failure, pneumonitis, and dysphagia, physician orders required shift-by-shift documentation of breath sounds and related respiratory assessments following episodes of pneumonia and chest tube removal. However, multiple shifts lacked documentation of breath sounds as ordered, with specific dates noted where assessments were not completed. The DON acknowledged that the required assessments were missed. Facility policies required comprehensive neurological and respiratory assessments, but these were not consistently followed for the residents reviewed.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and hypoxia. On two separate occasions, oxygen tubing was observed lying unbagged and not in use, with the oxygen concentrator left on and releasing oxygen while the resident was not present or not wearing the nasal cannula. Staff interviews confirmed that oxygen should be turned off when not in use and tubing should be bagged, but a bag was not available in the resident's room. The facility's policy required oxygen to be turned on only at the time of application and placed on the resident, but this was not followed. Additionally, the resident was found in bed with labored breathing, poorly positioned with her chin tucked to her chest, and without access to her oxygen tubing, which was out of her reach. The resident was cognitively impaired, required assistance with personal care, and had no documented refusal of care. Staff confirmed the resident could not have moved the tubing herself or accessed her wheelchair, indicating a lack of appropriate monitoring and intervention to ensure her respiratory needs were met.
Failure to Follow Fall Prevention Protocols for High-Risk Resident
Penalty
Summary
The facility failed to ensure fall prevention interventions were followed for a resident identified as being at high risk for falls. On the evening of the incident, a Certified Nurse Aide (CNA) assisted the resident in the shower. During the shower, the resident began to foam at the mouth and turned blue. The CNA left the resident alone in the shower chair to seek help, and upon returning with a Qualified Medication Aide (QMA), they found the resident on the floor of the shower. The incident was unwitnessed, and the resident was left unattended, which is against the facility's protocol for high fall risk residents. Interviews with staff members, including the Director of Nursing (DON), confirmed that the resident should not have been left alone in the shower chair. The facility's policy on falls did not specify interventions for high fall risk residents, which contributed to the deficiency. The resident's medical history included a traumatic brain injury, muscle weakness, and quadriplegia, and a recent fall assessment had indicated a high risk for falls. The care plan required assistance with transfers and showers, which was not adequately provided during the incident.
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.
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