Community Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 5600 E 16th St, Indianapolis, Indiana 46218
- CMS Provider Number
- 155029
- Inspections on file
- 33
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Community Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic venous insufficiency developed a large blister on the right foot with redness, warmth, tenderness, edema, and concern for cellulitis. The chart showed an order for linezolid and wound care with Xeroform, ABD, and kerlix, but the antibiotic was not given for several scheduled doses and the Xeroform order was missing from the record. The resident was observed with an unraveling dressing and drainage, and an LPN was unsure why only 2 of 10 antibiotic doses had been administered.
Failure to provide ordered vision services and locate missing eyeglasses. Two cognitively intact residents had unmet vision needs: one had lost eyeglasses that could not be found, and another had an eye specialist’s recommendations for an ophth consult, cataract surgery follow-up, and brimonidine eye drops that were missed. The facility’s records and interviews showed the ordered eye care and replacement glasses were not timely addressed.
Failure to Provide Fluids at Bedside: A resident with dementia, hypothyroidism, and a care plan for fluid imbalance risk was observed multiple times without fluids at the bedside, and at times had no fluids in the room. The resident could independently hold a cup and drink through a straw, while an LPN stated staff should be passing ice water each shift and did not know why the resident did not receive any that morning.
A resident with diabetes and obesity was affected when Ozempic was ordered and administered at 4 mg weekly, despite pharmacy clarification indicating the intended dose was 1 mg weekly and the medication guide listing a 2 mg maximum weekly dose. The MAR showed multiple 4 mg administrations, some scheduled doses were not documented, the resident reported missing Tuesday injections, and the med room refrigerator did not contain the resident’s Ozempic when checked. The DON, administrator, NP, and pharmacist gave conflicting accounts of the order and dosing.
A resident with chronic respiratory failure, COPD, and anxiety did not receive humidified oxygen care as ordered when staff failed to follow the physician’s instruction to change the oxygen tubing and humidity once daily on Sunday. Observations found an empty humidity bottle connected to the concentrator, and staff interviews showed confusion about who changed the bottle and why the date on it did not match when it was hung.
A resident with diabetes and morbid obesity had an unclear Ozempic order in the chart, with the facility following a 4 mg weekly order while the pharmacy reported clarifying the order to 1 mg weekly with an NP. The MAR also lacked documentation for several scheduled doses, and staff gave conflicting accounts about the intended dose and the order on record.
A resident with multiple chronic conditions experienced repeated water leakage from a faulty sink drainpipe in his room, leading to water damage, unsafe wet floors, and an unclean environment. Despite multiple notifications to maintenance and a submitted work order, the issue persisted for months, with staff regularly addressing flooding and water damage but no repairs completed.
A resident with complex medical needs accused a CNA of causing a flooded room and of physical abuse following a verbal exchange. Although the incident was reported internally to the DNS and ED, the required notification to the state health department (IDOH) was delayed until the day after the event, contrary to facility policy mandating immediate reporting of abuse allegations.
A resident with multiple chronic conditions who was dependent on staff for ADL assistance did not receive timely incontinent care. Despite activating her call light and reporting concerns, the resident was left in urine for extended periods, and staff found her brief and pads soaked during an observation. The issue persisted even after being reported through a grievance process.
Two residents experienced deficiencies in accident prevention and supervision: one was injured when a CNA transporting her in a wheelchair struck her foot against a wall, and another left the facility alone despite orders requiring a responsible party, due to a lack of monitoring and clear policies. The facility did not have policies for safe wheelchair transport or accident prevention, contributing to these incidents.
A resident with multiple chronic conditions did not receive oxygen therapy as ordered, and the oxygen tubing and humidifier bottle were found on the floor without proper dating. The resident reported waiting for new supplies and noted ongoing issues with the oxygen concentrator. Staff confirmed that the required care and equipment maintenance had not been provided, resulting in a deficiency related to respiratory care.
A resident with a history of seizures and anxiety did not receive multiple physician-ordered anti-convulsant and anti-anxiety medications for three consecutive days due to unavailability, with no documentation of efforts to resolve the issue or notify appropriate parties. The resident experienced increased seizure activity and required hospital transfer, and facility leadership was unaware of the problem until after the incident.
A resident with cognitive impairment and multiple medical conditions was denied their request for chocolate milk by a CNA, who cited concerns about incontinence and time constraints. The refusal was witnessed by an LPN and confirmed by the resident, demonstrating a failure to honor the resident's right to choose their food preferences as outlined in facility policy.
A resident with polyneuropathy was observed with thick, yellowing toenails despite a recent podiatry visit that included a recommendation for daily urea 40% cream. The order for the cream was not entered into the clinical record, as the DON was not made aware of the recommendation, resulting in the treatment not being implemented.
Surveyors identified deficiencies in kitchen operations, including uncovered and undated food items, improper staff hygiene such as failure to wear beard nets, and uncovered trash cans with food waste. These issues were observed during kitchen inspections and meal service, with staff interviews confirming a lack of instruction and adherence to facility policies on food storage, cleanliness, and personal hygiene.
Multiple residents reported being treated roughly or disrespectfully by staff, including being rushed during care, handled roughly, and spoken to in a disrespectful manner. One resident with mental illness described being singled out and denied assistance with daily tasks. Additionally, three residents were observed with tablecloths tied around their necks instead of proper clothing protectors during meals, despite appropriate supplies being available. These incidents reflect a failure to maintain resident dignity and respect as required by facility policy.
Multiple cognitively intact residents, including those with complex medical conditions, reported that meals were frequently served cold or at inappropriate temperatures. Resident council meetings and interviews confirmed ongoing dissatisfaction with food temperature, and a test tray revealed food items outside of safe temperature ranges. Despite grievances, the issue persisted among several residents.
Two residents who were cognitively intact filed grievances—one regarding missing personal items and another about a wandering, incontinent resident entering his room. In both cases, staff failed to follow up or maintain the required grievance documentation, and the forms could not be located as required by facility policy.
Two residents were involved in an incident where one, with a history of sexually inappropriate behaviors, was able to enter another's room and inappropriately touch and kiss her despite prior documented incidents and the need for one-on-one supervision. Staff found the female resident in distress and intervened, but supervision lapses were observed even after the event, resulting in a failure to protect residents from abuse.
The facility did not maintain complete evidence of a thorough abuse investigation after two residents were involved in an incident of alleged inappropriate sexual contact. Although the incident was witnessed by CNAs and reported by a supervisor, the investigation file lacked a required written statement from the supervisor, contrary to facility policy.
Two residents with new psychiatric diagnoses were not promptly referred for required PASRR Level 1 or Level 2 assessments after their conditions changed and new psychotropic medications were started. The facility did not update PASRR screenings as required by policy following significant changes in mental health status.
Two residents did not receive timely assistance with ADLs: one resident with hemiplegia was not promptly repositioned in bed despite repeated requests to staff, and another resident did not consistently receive scheduled showers or partial baths as outlined in her care plan. Staff interviews and documentation confirmed these lapses in care.
Multiple residents did not receive prescribed medications and treatments as ordered, including missed doses of immunosuppressive medication due to unavailability, unadministered insulin without provider notification or documentation, and improper application of rectal cream by a CNA instead of a licensed nurse.
A resident with chronic respiratory failure and hemiplegia was observed not receiving oxygen as ordered, with the nasal cannula out of place and the oxygen concentrator set to five liters instead of the prescribed two liters. The QMA was unable to adjust the oxygen level and did not report the issue to a nurse before leaving the room, resulting in the resident receiving incorrect oxygen therapy.
Two residents with chronic conditions experienced significant delays in receiving prescribed pain medications, with one waiting over five hours for Tylenol and another reporting repeated waits of 30 minutes to an hour for hydrocodone. LPNs were observed prioritizing other tasks or residents before addressing pain requests, despite being notified by staff or the residents themselves.
A resident with severe dementia and behavioral disturbances, including wandering and incontinence, repeatedly entered another resident's room and used their bed, causing distress. Although staff were aware of these behaviors and discussed possible interventions like stop signs, the incidents were not documented in the clinical record, and the care plan was not updated with new strategies. The facility did not implement or record new interventions as required by its behavior management policy.
A resident with a history of stroke did not receive timely follow-up on pharmacy recommendations regarding discontinuation of fenofibrate and necessary lab work, as the facility could not provide evidence that the ordered lipid panel was completed. Additionally, the resident was prescribed two prophylactic antibiotics simultaneously without clear documentation or rationale, and the DON could not explain the continued use or confirm urology consultation.
Surveyors found that insulin vials for three residents with diabetes were not labeled with open or expiration dates on a medication cart, despite facility policy requiring such labeling. A nurse confirmed that insulin should have open dates, and the issue was identified through observation, record review, and staff interview.
Staff failed to perform hand hygiene before administering eye drop medications to two residents, handling multiple surfaces and items before medication administration. In another instance, a resident with a colostomy and under Enhanced Barrier Precautions kept open containers of urine and feces on the bedside table, and a nurse consultant removed these without wearing a gown as required by policy.
Three residents experienced environmental deficiencies, including broken blinds, persistent urine odor, and scraped paint in their rooms. Staff were aware of these issues, with maintenance and housekeeping supervisors confirming the problems and indicating ongoing challenges with repairs and odor control. The facility lacked a specific policy for maintaining a homelike environment.
The facility failed to serve breakfast at safe and palatable temperatures, affecting 54 of 55 residents. Observations revealed that food items, including eggs and sausage patties, were served at temperatures below the required 135 degrees Fahrenheit. Residents reported that breakfast was often served cold, and the facility's Food Temperatures Policy was not consistently followed.
The facility failed to maintain the first-floor shower room in good condition and did not timely repair a leaking pipe in the kitchen, potentially affecting all 55 residents. Observations revealed a leaking pipe with rusted clamps and a dirty, stained shower room floor. The Executive Director and Maintenance Supervisor confirmed these conditions.
A resident with dementia and heart failure was observed wearing the same ill-fitting clothing over several days, despite a care plan indicating the need for assistance with ADLs. Staff interviews confirmed the resident would change clothes if approached correctly, but timely assistance was not provided.
The facility failed to properly assess and manage the care of a resident with multiple medical conditions, including not administering prescribed insulin and antipsychotic medications as ordered, and not documenting or addressing a skin condition. Another resident with constipation did not receive prescribed medications, and bowel movements were not monitored as required by the care plan.
The facility failed to provide oral care as ordered by the physician and did not timely obtain a physician's order for gastrostomy tube site care for a resident. Observations revealed dried brown drainage at the base of the resident's g-tube and a white film on their teeth and lips, indicating a lack of proper care. Interviews confirmed that oral and g-tube site care were not consistently provided, and the DNS acknowledged the absence of a physician's order for g-tube site care.
The facility failed to adequately monitor and document behaviors for a resident with schizoaffective disorder and another with schizophrenia, leading to repeated incidents of inappropriate behavior and verbal aggression. Interventions were insufficient and not effectively documented, and the facility's behavior management policy was not consistently followed.
The facility failed to maintain a medication error rate below 5 percent, resulting in a 5.88% error rate. An LPN did not follow proper procedures for blood sugar monitoring and insulin administration for a resident with type 2 diabetes, leading to medication errors.
Failure to Timely Start Ordered Antibiotic and Wound Care
Penalty
Summary
The facility failed to timely initiate physician’s orders for a resident with chronic peripheral venous insufficiency and a new skin issue on the right foot. The resident’s record showed a quarterly MDS assessment indicating moderately impaired cognition and no foot problems, but a care plan initiated after the skin issue identified an open blister on the right foot, intermittent foot edema, and a history of refusing treatments and labs at times. A skin and wound note documented a large blister on the top of the right foot extending to the right great toe, with the area around the wound edematous, red, warm, and tender to touch, and suggested cellulitis. The note recommended contacting the primary care physician for an oral antibiotic and described treatment with Xeroform, an ABD pad, and kerlix gauze, with dressing changes every other day and as needed. The physician’s order for linezolid 600 mg every 12 hours for 10 doses was dated the same day as the wound note, but the medication administration record showed the resident did not receive linezolid on four scheduled doses. The clinical record also did not contain an order for the Xeroform wound dressing. When the resident was observed, the right foot dressing was unraveling with tan drainage visible on the top of the dressing, and later the resident was seen with a clean kerlix dressing. An LPN stated the resident had received a dose of linezolid that morning and was unsure why only 2 of the 10 dispensed doses had been administered. The Regional Director of Clinical Services stated the antibiotic and wound treatment should have been started when ordered by the physician.
Failure to Provide Ordered Vision Services and Locate Missing Eyeglasses
Penalty
Summary
The facility failed to timely address missing eyeglasses and to ensure ordered vision services were carried out for 2 residents reviewed. One resident had a diagnosis of dry eye syndrome and was cognitively intact. Her eye visit report indicated she had lost her eyeglasses and that a new set of bifocals was recommended upon approval. During interview, she stated she needed eyeglasses and had some that had been missing for a while. A CNA later confirmed the resident wore eyeglasses but they could not be found, and the Administrator stated she was unaware the eyeglasses were missing until that day. A second resident, who had schizoaffective disorder and was cognitively intact, had an eye visit report indicating cataract surgery was recommended, an ophthalmology consultation was ordered, and brimonidine eye drops were to be given in both eyes twice daily. The resident stated he was supposed to have cataract surgery but did not know when it was scheduled. The Regional Director of Clinical Services stated the resident had asked about his cataract surgery and that the eye visit report was reviewed, but the ophthalmology consultation and the brimonidine eye drops ordered earlier had been missed. The resident’s eyeglasses were also noted as lost, with new bifocals to be delivered upon approval.
Failure to Provide Fluids at Bedside
Penalty
Summary
The facility failed to provide fluids at the bedside for 1 of 2 residents reviewed for hydration, identified as Resident C. Resident C’s clinical record showed diagnoses including dementia, anxiety, and hypothyroidism, and a physician’s order indicated a regular diet with thin liquids. A Significant Change MDS assessment dated 4/1/26 indicated Resident C was moderately cognitively impaired and required substantial/maximal assistance with eating. Her care plan identified potential tiredness and weakness due to anemia and risk for fluid imbalance due to dementia and hypothyroidism, with interventions that included encouraging fluids. During observations, Resident C was seen with a small clear cup of pink liquid sitting on a table across the room from her bed, and at other times had no fluids in her room or at her bedside. Her bedside table was adjacent to her bed with a pillow lying on top. Resident C was observed on 4/21/26 at 12:40 p.m. to be able to independently hold a cup and drink through a straw without difficulty. During an interview, an LPN stated staff should be passing ice waters and did not know why Resident C did not receive any ice water that morning. The LPN also stated waters were passed every shift and as needed, and CNAs were assigned to pass waters, though any staff member could pass water if needed.
Excessive Ozempic Dose Ordered and Administered
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when an excessive dose of Ozempic was administered and ordered for a resident with diabetes and morbid obesity. Resident B was cognitively intact, had a care plan addressing risk for hyperglycemia and hypoglycemia related to glucose-lowering medications, and had an order changed from Ozempic 0.5 mg weekly to an order documented as Ozempic 4 mg weekly. The resident’s record showed Ozempic 4 mg was administered on multiple dates in February, March, and April 2026, while some scheduled Tuesday doses were not documented as given. The resident stated she had not been getting her scheduled Tuesday shots, and the medication refrigerator did not contain her Ozempic when observed. The pharmacy technician stated Ozempic had been refilled and sent to the facility, and the facility should have had the medication available. The registered pharmacist stated the pharmacy had clarified the order with the NP and that the clarified order was for Ozempic 1 mg every Tuesday, noting the maximum dose was 2 mg weekly and the pharmacy would not have filled a 4 mg weekly prescription. The DON stated the resident had been receiving 4 mg as ordered by the NP, while the administrator stated the facility had no order on record for Ozempic 1 mg weekly and had been following the 4 mg weekly physician order. The NP who entered the increase could not recall the amount ordered but stated she would not have intended to order an inappropriate dose.
Failure to Follow Oxygen Humidity Order
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with chronic respiratory failure, COPD, and anxiety when staff failed to follow a physician’s order to change the humidified oxygen tubing and humidity once daily on Sunday. The resident’s care plan directed staff to administer oxygen as ordered, and a Significant Change MDS indicated the resident was moderately cognitively impaired and received oxygen therapy. During observation, the resident was found with an empty humidified oxygen bottle dated 4/13/26 connected to the oxygen concentrator. The April 2026 MAR showed a new humidity bottle was hung on 4/19/26 between 11:00 p.m. and 7:00 a.m. A later observation showed a new humidity bottle dated 4/19/26 connected to the concentrator. Interviews with staff indicated confusion about who changed the bottle and why the date on the bottle did not match when it was hung, and the MDS nurse stated the bottle was changed on 4/20/26 because it was empty.
Unclear Ozempic Order and MAR Documentation
Penalty
Summary
The facility failed to ensure a physician’s order was clearly written for one resident whose clinical record was reviewed. The resident had diagnoses including diabetes and morbid obesity and was cognitively intact per the Quarterly MDS completed on 2/16/26. A physician’s order dated 1/20/26 with a start date of 1/27/26 indicated Ozempic 1 mg/dose (4 mg/3 ml); 4 mg subcutaneously every Tuesday, and a physician progress note from the same date stated the resident’s Ozempic was to be increased to 4 mg weekly, with the first dose to be given on 1/27/26. The March 2026 MAR did not document doses on 3/3/26 or 3/10/26, and it showed Ozempic 1 mg/dose (4 mg/3 ml); 4 mg subcutaneously was given on 3/24/26 and 3/31/26. The April 2026 MAR did not document a dose on 4/7/26, showed a dose on 4/14/26, and listed the 4/21/26 dose as not given with a note indicating awaiting pharmacy. The DON stated the resident had been receiving 4 mg of Ozempic as ordered by the NP. The RP stated the pharmacy had clarified the order with an NP on 1/30/26 and that the clarified order was for 1 mg every Tuesday; the pharmacy had sent a multidose pen containing four 1 mg doses and would not have filled a 4 mg weekly prescription because it would exceed the maximum dosage of 2 mg weekly. The Administrator stated the facility was unaware of who the NP was and did not have an order on record for 1 mg weekly, and the facility had been following the order for 4 mg weekly. Another NP stated she had increased the resident’s Ozempic on 1/20/26 but could not recall the amount ordered.
Failure to Maintain Resident Room in Good Repair Resulting in Unsafe and Unclean Environment
Penalty
Summary
The facility failed to maintain a resident's room in good repair, resulting in repeated water leakage from a faulty drainpipe connected to the sink in the resident's room. The issue was observed to cause water damage to the wall, including ripples, bubbles, peeling paint, missing baseboard, and discoloration. The resident reported that the leak had been ongoing since he moved into the room and that he had notified the maintenance director multiple times, including submitting a work order eight months prior, but the problem persisted. Staff routinely had to address water flooding into the hallway by placing wet floor signs and using towels to prevent slips. The housekeeping supervisor confirmed awareness of the wall's condition and noted that renovations had not yet begun as planned. The resident involved had significant medical conditions, including major depressive disorder, cirrhosis of the liver, a liver transplant, severe alcohol dependence, and chronic kidney disease. On one occasion, the water leak triggered a confrontation between the resident and a CNA, with the resident accusing the CNA of causing the flooding and alleging physical abuse, which was denied by the CNA and not substantiated by staff interviews. The ongoing water leakage and lack of timely repair contributed to an environment that was not safe, clean, or homelike, as required by resident rights policies.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse involving a resident with multiple complex medical diagnoses, including major depressive disorder, cirrhosis of the liver, liver transplant, severe alcohol dependence, and chronic kidney disease. On the morning in question, a CNA was accused by the resident of causing water to flood the room and subsequently of pushing him after a verbal exchange. The CNA denied leaving the water running or pushing the resident, stating she was several feet away when the resident moved himself into his wheelchair. The incident was documented in the nurse's note, and the CNA reported the situation to the DNS, who then reported it to the Executive Director (ED). Statements were written and left in the ED's office, and the resident was monitored and found to be in good spirits later that day. Despite the facility's policy requiring immediate reporting of abuse allegations to the ED and the Indiana Department of Health (IDOH), the allegation was not reported to the IDOH until the following day, after the ED became aware of the situation. Interviews confirmed that the DNS reported the incident to the ED on the day it occurred, but the ED did not report to the IDOH until the next day. The facility's policy clearly states that all abuse allegations must be reported to the ED immediately and to the state agency within two hours if abuse or serious bodily injury is involved. This delay in reporting constituted a failure to follow established protocols for timely notification of suspected abuse.
Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder, and major depressive disorder, did not receive timely incontinent care despite being dependent on staff for activities of daily living (ADLs). The resident's care plan required staff assistance with grooming, hygiene, toileting, and incontinent care as needed. Documentation and interviews revealed that the resident frequently activated her call light for assistance but was often left in urine and bowel movement for extended periods. The resident reported these incidents through a grievance form and directly to the admission coordinator, stating that the issue persisted even after the grievance was marked as resolved. During an observation and interview, the resident indicated she had been lying in urine for an hour before staff responded to her call light. Upon entering, staff found her brief and two cloth pads soaked in urine. The admission coordinator confirmed ongoing reports from the resident about delayed responses to her care needs, which were communicated in morning meetings. The Director of Nursing Services stated that the facility's expectation was for incontinent care to be provided immediately when needed, but this standard was not met in the resident's case.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to ensure safe transportation of a resident in a wheelchair and did not provide adequate monitoring to prevent a resident from exiting the facility without a responsible party. One resident, who had diagnoses including heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder, and major depressive disorder, was dependent on staff for wheelchair transport. In September, a CNA accidentally hit the resident's right foot against a wall while turning into the resident's room, resulting in pain and swelling. Although an x-ray showed no fracture at that time, the resident later returned from the hospital with a fractured right toe. The CNA and the Director of Nursing Services (DNS) confirmed the incident, but no safety training or interventions were implemented to prevent recurrence. Additionally, the facility lacked a policy on transporting residents in wheelchairs. Another resident, with diagnoses including schizoaffective disorder, bipolar type, post-traumatic stress disorder, and anxiety, left the facility alone and went to a nearby gas station for snacks. The resident was cognitively intact according to the most recent assessment, but his physician's orders specified that he should only leave with a responsible party. Staff found the resident between the facility's front doors upon his return and assessed him for injuries, finding none. The resident's care plan was updated after the incident, and a wanderguard was applied for safety. The physician noted that the resident had a history of impulsive behavior and poor decision-making, and did not recommend independent leave of absence due to the risk of injury. Interviews with facility leadership revealed that there was no accident policy in place and no specific policy for transporting residents in wheelchairs. The facility's leave of absence policy required a physician's order and specified that residents should only leave with a responsible party unless an independent leave of absence was ordered. The lack of adequate supervision and absence of clear policies contributed to the deficiencies identified for both residents.
Failure to Provide Ordered Oxygen Therapy and Maintain Sanitary Equipment
Penalty
Summary
The facility failed to provide oxygen therapy as ordered by the physician and did not maintain the oxygen tubing and humidifier bottle in a sanitary manner for a resident with multiple medical conditions, including heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder, and major depressive disorder. The resident's care plan required oxygen administration as ordered, and the physician's order specified oxygen at 3 liters per nasal cannula every shift, with tubing and humidity to be changed weekly and dated. During observation and interview, the resident's oxygen tubing and humidifier bottle were found lying on the floor without dates, and the resident reported waiting for an hour for new supplies. The resident also stated that the oxygen concentrator had been broken for a long time and that the humidifier bottle was always placed on the floor. Staff interviews confirmed that the nurse was responsible for maintaining the resident's oxygen equipment, but the required care had not been provided. The Assistant Director of Nursing Services (ADNS) responded by bringing new, dated supplies and attempted to address the broken concentrator. The resident's oxygen saturation was measured at 92-94% without oxygen and increased to 99% when oxygen was provided. The Director of Nursing Services (DNS) stated that staff were expected to ensure residents received oxygen as ordered and that equipment should be dated, confirming that facility expectations were not met in this instance.
Failure to Provide Physician-Ordered Medications Resulting in Increased Seizure Activity
Penalty
Summary
The facility failed to ensure that a resident with a history of traumatic brain injury, seizures, general anxiety, and aphasia received physician-ordered anti-convulsant and anti-anxiety medications for three consecutive days following admission. The resident was dependent on staff for most activities of daily living and was nonverbal with severe cognitive impairment. Despite clear physician orders for multiple medications, including Phenobarbital, Ativan, Vimpat, Dilantin, and olanzapine, the medication administration record (MAR) and progress notes indicated that these medications were not available and were not administered as ordered. During the period in question, the MAR showed that several doses of the prescribed medications were missed, and there was no documentation of any steps taken by staff to resolve the unavailability of the medications. There was also no evidence that the pharmacy, physician, responsible party, or facility administration were notified about the missing medications. The facility's Director of Nursing (DON) confirmed that she was unaware of the issue until after the resident experienced increased seizure activity and was sent to the emergency room. The DON also stated that there was no formal investigation or additional staff training following the incident, and she was unable to locate documentation reflecting any attempts to address the medication access problem. Progress notes documented that the resident experienced multiple seizures during the period when medications were not administered, leading to a transfer to the hospital for evaluation and treatment. Interviews with facility leadership revealed a lack of specific policies regarding actions to take when medications are unavailable, and there was no documentation to substantiate the administration of certain doses. The facility did have a general policy on medication administration, but it did not address the specific situation of missing medications.
Resident Food Choice Not Honored by Staff
Penalty
Summary
A deficiency occurred when a resident's right to self-determination and choice regarding food selection was not honored. The resident, who had diagnoses including encephalopathy, hemiplegia, and dysphagia, and required substantial assistance with activities of daily living, requested chocolate milk during dining service. Certified Nurse Aide (CNA) 2 refused the request, stating that the chocolate milk would upset the resident's stomach and that they did not have time to address the resulting incontinence. This interaction was witnessed by an LPN and corroborated by the resident, who recalled being denied the chocolate milk by CNA 2. The facility's policy on Preferences for Daily Routine requires that resident preferences be identified and incorporated into the plan of care, with information shared among the interdisciplinary team. Despite this policy, CNA 2 did not honor the resident's preference for chocolate milk, instead making a decision based on perceived inconvenience and the resident's incontinence. The incident was reported to the Indiana Department of Health and documented in the facility's investigation file.
Failure to Implement Podiatry Recommendation for Foot Care
Penalty
Summary
The facility failed to timely implement a podiatry recommendation for a resident diagnosed with polyneuropathy. The resident had a physician's order to be seen by a podiatrist and was observed to have thick, yellowing, crusty toenails on both big toes. A podiatry note documented that the resident's toenails had been debrided and recommended a new order for urea 40% cream to be applied daily to all toenails for sixty days. However, the clinical record did not contain an order for the urea cream, and the DON confirmed she had not been made aware of the recommendation and that the order for the cream had not been processed.
Deficiencies in Kitchen Food Storage, Cleanliness, and Staff Hygiene
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to food storage, cleanliness, and staff hygiene. During inspections, various food items in the walk-in refrigerator and dry storage were found uncovered, undated, and open to air, including butterscotch pudding, macaroni and cheese, beef base, juices, salad dressings, deli meats, and thawed meats. Some containers were not labeled with the date opened or a discard date, and several items were not properly covered. The dry storage area also had a bin of oats without a lid and a sticky substance on the floor, which staff acknowledged had been present for some time. Staff interviews revealed a lack of instruction on proper dating and covering of food items, despite the existence of facility policies requiring these practices. Additionally, staff were observed not adhering to personal hygiene standards while handling food. One dietary aide was seen serving food with a beard net around his neck rather than covering his facial hair, contrary to facility policy. The dietary manager confirmed that staff with facial hair are required to wear beard restraints while preparing and serving food. These lapses in hygiene practices were directly observed during meal service. The facility also failed to maintain proper waste management in the kitchen and dry storage areas. Trash cans containing food waste were found uncovered and unattended in both the dry storage and soiled dish areas. In some cases, the lids were present but not in use, and staff were unsure about the requirements for covering trash cans. Facility policy mandates that all trash containers be lined and kept covered with lids when not in use, but this was not consistently followed during the survey.
Failure to Maintain Resident Dignity and Respect During Care and Dining
Penalty
Summary
The facility failed to maintain resident dignity and respect for multiple residents, as evidenced by observations, interviews, and record reviews. Several cognitively intact residents reported that staff were rough or disrespectful during care. One resident described staff as rushing and handling her roughly, while another reported that a CNA dug her nails into his skin during incontinent care. Additional residents indicated that staff had poor attitudes, were not polite, and sometimes yelled at them for using the call light. These interactions were described as disrespectful and lacking in consideration for the residents' comfort and dignity, though not necessarily abusive. Further, a resident with a history of mental illness reported being treated differently by staff due to her higher level of independence. She stated that a CNA refused to assist with tasks such as making her bed or doing laundry, and would provide minimal assistance with meals and water, allegedly to upset her. The resident filed grievances regarding this treatment and requested not to be cared for by the CNA in question. Staff interviews confirmed knowledge of resident rights and abuse training, but also revealed strained relationships and inconsistent care practices. During a dining observation, three residents with dementia or dysphagia were found with tablecloths tied around their necks as makeshift clothing protectors while waiting for their meals, despite the facility having proper clothing protectors available. Staff interviewed were unsure why this practice was occurring. Facility policy requires residents to be treated with consideration, respect, and dignity, but these incidents demonstrate a failure to uphold these standards for several residents.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures for multiple residents. Observations, interviews, and record reviews revealed that several cognitively intact residents reported receiving food that was cold or not at an appropriate temperature. Specific examples included residents stating that their meals, such as eggs and sandwiches, were served cold, and that the quality of meals was inconsistent. Resident council meeting minutes and interviews further confirmed that concerns about food temperature were widespread among residents. During a test tray observation, the Regional Culinary Manager measured food temperatures and found that a tenderloin sandwich was below the proper holding temperature, while pears were above the proper holding temperature. Residents had filed grievances regarding the food temperature, but reported that the issue persisted. The deficiency was identified for several residents with various medical conditions, including cellulitis, liver transplant, major depressive disorder, acute respiratory failure, diabetes mellitus, and stroke, all of whom were cognitively intact and able to communicate their concerns.
Failure to Follow Up and Maintain Resident Grievances
Penalty
Summary
The facility failed to follow up on grievances for two residents who were cognitively intact. One resident reported filing grievances regarding missing personal items, including an arm sling, backpack, purse, and a box of crackers, but did not receive any follow-up from the facility. The Social Services Consultant and Social Services Director were unable to locate the grievances, and the Director did not know where the original forms were kept. Another resident reported an incident where another resident, who was known to wander, entered his room and sat on his bed. The resident was upset due to the other resident's incontinence and requested his sheets be changed. He informed a CNA and the Weekend Supervisor, who completed a grievance form and placed it in a designated location for the DON to review. However, the DON did not recall seeing the grievance, and the Executive Director and Social Services Consultant could not locate the form. The facility's policy required all grievance forms to be signed off by the Executive Director/Grievance Official and maintained on-site for at least three years, but this procedure was not followed.
Failure to Prevent Sexual Abuse Between Residents Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse, specifically sexual abuse, as evidenced by multiple documented incidents involving one resident inappropriately touching and attempting to kiss and fondle another resident. One resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and PTSD, exhibited escalating sexually inappropriate behaviors towards staff and a female peer over several days. Nursing and behavior notes detailed repeated incidents of the resident exposing himself, masturbating in common areas, and making unwanted advances toward staff, which were reported to the medical provider and Director of Nursing. Despite these ongoing behaviors, the resident was able to enter another resident's room and inappropriately touch and kiss her, including attempts to remove her clothing and touch her private areas. The female resident, who had a history of stroke, physical debility, and moderate cognitive impairment, was found by staff in distress, attempting to push the male resident away while he was touching her. Staff intervened and removed the male resident from the room, but observations after the incident revealed that one-on-one supervision was not consistently maintained as required. Interviews with staff confirmed that the male resident was not being properly supervised at all times, even after the incident, and that the female resident was visibly upset and crying following the assault. The facility's abuse policy prohibits any form of abuse, including sexual abuse, and requires an environment free from such incidents. The failure to provide adequate supervision and prevent the male resident's access to the female resident resulted in a violation of residents' rights to be free from abuse.
Failure to Document Thorough Abuse Investigation
Penalty
Summary
The facility failed to maintain evidence that an allegation of abuse was thoroughly investigated for two residents. One resident, who had a history of stroke, physical debility, and moderate cognitive impairment, reported that another resident, who was cognitively intact and independent in mobility, entered her room without permission and attempted to touch and kiss her inappropriately. The incident was witnessed by three CNAs, who intervened and removed the alleged perpetrator from the room. The reporting nurse, Weekend Supervisor (WS) 8, documented the incident in the residents' medical records and notified the Executive Director, Director of Nursing, and the police department. Both residents were placed on one-on-one supervision following the incident. Despite these actions, the facility's investigation file for the incident did not include a written statement from WS 8, who was the staff member in charge and had direct knowledge of the event. The Corporate Executive Director confirmed that while WS 8 had made progress notes in the medical records, there was no separate written statement included in the investigation file. The facility's abuse policy requires that statements be taken from individuals witnessing the incident and from the staff member to whom the initial report was made, but this documentation was missing from the investigation file.
Failure to Timely Refer Residents for PASRR Assessment After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to timely refer residents with new psychiatric diagnoses for appropriate Level 1 or Level 2 Preadmission Screening and Resident Review (PASRR) assessments. In one case, a resident with a history of dementia was newly diagnosed with schizoaffective disorder, and the clinical record showed that after the diagnosis and initiation of antipsychotic medication, there was no documentation of a Level 1 or Level 2 PASRR review being completed. The diagnosis was later included in a subsequent MDS assessment, but the referral for a Level 2 review was not made until several months after the diagnosis. In another instance, a resident with a new diagnosis of borderline personality disorder and subsequent initiation of Depakote did not have a new Level 1 PASRR screening completed following the diagnosis. The Social Services Director acknowledged that the screening had not been done and was unsure of the required timeframe for completion. The facility's policy required PASRR assessments to be updated with significant changes in mental or physical status, but this was not followed in these cases.
Failure to Provide Timely ADL Assistance and Scheduled Showers
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents. One resident with chronic respiratory failure and hemiplegia, who required substantial assistance to reposition in bed, repeatedly requested to be pulled up in bed during medication administration. Despite making multiple requests to staff, including a Qualified Medication Aide (QMA) and the presence of two Certified Nurse Aides (CNAs), the resident was not assisted in a timely manner. The QMA indicated that the CNA was busy and would assist when available, but the resident remained unassisted for an extended period, as confirmed by subsequent observation and resident interview. Another resident with a history of stroke and who was cognitively intact did not consistently receive scheduled showers as outlined in her care plan, which specified showers twice weekly with partial bed baths in between. Documentation and resident interviews confirmed missed showers on scheduled days, and the Director of Nursing acknowledged the expectation for regular showers and partial baths, but there was no formal policy on ADL care. These failures were identified through observation, record review, and interviews with residents and staff.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to administer medications and treatments as ordered for multiple residents. One resident with a history of liver transplant and major depressive disorder did not receive several doses of their prescribed immunosuppressive medication, mycophenolate mofetil, on multiple occasions because the medication was unavailable. The resident, who was cognitively intact, expressed concern about missing these doses. The physician confirmed that missing scheduled doses of this medication was not good practice. Another resident with a history of stroke, major depressive disorder, and physical debility did not receive prescribed doses of aspart insulin on several occasions, with no documented reason or evidence that the medical provider was informed of the missed doses. The insulin order did not include parameters to hold the medication, yet it was not administered at times when blood sugar readings were recorded, and on other occasions, there was no documentation at all. Additionally, a resident with chronic respiratory failure and hemiplegia was observed during incontinent care requesting rectal cream for burning. The CNA applied Preparation H rectal cream, which was not within their scope of practice according to facility leadership. The resident's orders required staff to apply the cream and monitor vital signs, but the application was performed by a CNA rather than a licensed nurse. The DON confirmed that the CNA should not have been applying the rectal cream.
Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
A resident with chronic respiratory failure and hemiplegia had a physician's order to receive two liters of oxygen via nasal cannula every shift. During a medication administration, the resident was observed with the nasal cannula out of her nose and lying on her chest, not receiving oxygen as ordered. The Qualified Medication Aide (QMA) educated the resident and assisted with replacing the nasal cannula in her nose. However, the oxygen concentrator was set to five liters instead of the ordered two liters. The QMA recognized the discrepancy but was unable to adjust the oxygen level and indicated she would notify the nurse, yet there was no observation of her reporting the issue before leaving to continue other tasks. Later, the resident was again observed with the nasal cannula in place, but the oxygen concentrator remained set at five liters. After reviewing the order, the nurse consultant confirmed the resident should be on two liters and adjusted the setting accordingly. The facility's oxygen therapy procedure required verification of the resident and physician order, which was not followed at the time of the initial observation.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents who required pain medication. One resident with diabetes mellitus, who was cognitively intact, requested Tylenol for pain at 3:00 p.m. but did not receive it until over five hours later, after intervention by a nurse consultant. The responsible LPN admitted to not having reached the resident's medication pass and was observed preparing medication for another resident instead. The nurse consultant confirmed that pain medication should be administered shortly after it is requested. Another resident, also cognitively intact and diagnosed with cellulitis and other chronic conditions, reported experiencing significant delays in receiving prescribed hydrocodone for pain. The resident described waiting between 30 minutes to an hour for pain medication after making requests, and on one occasion, had to ask multiple staff members for assistance before the LPN addressed her pain. The LPN acknowledged being informed of the request by CNAs but was observed administering medications to other residents before attending to the resident's pain needs.
Failure to Document and Update Care Plan for Resident with Dementia-Related Behaviors
Penalty
Summary
The facility failed to timely document and update the care plan with new interventions for a resident diagnosed with dementia who exhibited wandering and inappropriate urination behaviors. The resident, who had severe cognitive impairment due to Alzheimer's disease and was occasionally incontinent, was noted to have entered another resident's room and used their bed, which caused distress to the other resident. Although staff were aware of the resident's wandering and incontinence, and interventions such as redirection and routine toileting were in place, there was no documentation of the specific incident in the clinical record, nor were new interventions, such as the use of stop signs on doors, implemented or added to the care plan. Interviews with staff revealed that the resident's behaviors, including wandering into other residents' rooms and using their beds or bathrooms, were known issues. The Weekend Supervisor had suggested using stop signs as a deterrent, but this intervention was not communicated to or recalled by the DON, and no stop signs were observed in the facility. The Social Service Director confirmed that no new interventions had been attempted to help the resident better identify his own room, and that behavior documentation and review processes were inconsistently followed. The facility's behavior management policy required that new or worsening behaviors be documented and reviewed by the interdisciplinary team, with care plans updated as needed. However, the incident involving the resident entering another's room and the associated behaviors were not documented in the clinical record, and the care plan was not updated with new interventions. This lack of timely documentation and failure to initiate or implement new interventions contributed to the deficiency cited during the survey.
Failure to Follow Up on Pharmacy Recommendations and Medication Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely follow-up on pharmacy recommendations for a resident reviewed for unnecessary medications. The resident, who had a history of stroke and was cognitively intact, had a pharmacy recommendation to discontinue fenofibrate and obtain a fasting lipid panel four weeks after discontinuation. Although the physician agreed with the recommendation and ordered the lab, the facility was unable to provide evidence that the lipid panel was completed as ordered. Additionally, the same resident was prescribed prophylactic antibiotics for urinary tract infection prevention. The pharmacy recommended discontinuing both nitrofurantoin and trimethoprim or documenting the intended duration of therapy. The physician referred the case to urology, but the resident did not attend the follow-up appointment, and there was no documentation of urology consultation regarding the continued use of antibiotics. The Director of Nursing was unable to explain the rationale for the resident being on two prophylactic antibiotics simultaneously.
Insulin Vials Missing Open/Expiration Dates on Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to ensure insulin medications were properly labeled with open and/or expiration dates on one of three medication carts observed. Specifically, insulin vials for three residents with diabetes mellitus—prescribed Novolin, Humalog, and lispro insulin—were found without written open or expiration dates during a medication cart observation. The absence of these dates was confirmed during an interview with a registered nurse, who acknowledged that insulin medications should have open dates. The facility's own medication storage policy, provided by the Executive Director, requires that medications have expiration dates on their labels. Despite this policy, the insulin vials for the affected residents did not comply with labeling requirements at the time of the survey. The deficiency was based on direct observation, record review, and staff interview, and involved residents with active physician orders for insulin administration due to their diabetes diagnoses.
Failure to Maintain Infection Control During Medication Administration and Resident Care
Penalty
Summary
Staff failed to maintain proper infection control practices during medication administration and resident care. In two separate instances, a Qualified Medication Aide (QMA) was observed administering eye drop medications to residents without performing hand hygiene beforehand. The QMA handled various items such as medication cards, water cups, and the medication cart before entering the residents' rooms and administering both oral and eye drop medications, but did not wash or sanitize her hands prior to these tasks. The QMA herself indicated uncertainty about glove use for eye medications but acknowledged the need for hand hygiene. The Director of Nursing confirmed that hand hygiene should be performed before administering eye drops. In another case, a resident with multiple diagnoses, including HIV, hepatitis B, Crohn's disease, and a colostomy, was observed keeping open containers of urine and feces on his bedside table, along with a urinal and food items nearby. The resident preferred to keep these containers to monitor his output, and staff had documented his refusal to allow removal or cleaning of the bedside table. Despite education and encouragement from staff to use appropriate disposal methods, the containers remained on the bedside table. The resident was under Enhanced Barrier Precautions due to risk factors such as an indwelling device and chronic wound. When a nurse consultant was notified about the presence of bodily fluids on the bedside table, she entered the resident's room, performed hand hygiene, donned gloves, and removed one of the containers, but did not wear a gown as required by the facility's Enhanced Barrier Precautions policy. Facility policies provided to surveyors specified the need for hand hygiene before and after resident contact and the use of gowns and gloves during high-contact care activities for residents under Enhanced Barrier Precautions.
Failure to Maintain a Homelike Environment Due to Unrepaired Room Conditions
Penalty
Summary
The facility failed to promote a homelike environment for three of five residents reviewed for environmental concerns. Observations revealed that two residents had broken blinds in their rooms, and one resident's room had a strong urine odor and an area of scraped paint on the wall behind the bed. One resident reported that the broken blinds had been an issue for three years and that it bothered him, especially when he had visitors. During a walk-through with the Maintenance Supervisor and Housekeeping Supervisor, these issues were confirmed, including the persistent urine odor and damaged paint. The Maintenance Supervisor acknowledged awareness of the broken blinds and scraped paint, stating that repairs were pending due to budget constraints and the need to obtain the correct paint color. He was unable to provide documentation or work orders for these repairs. The Housekeeping Supervisor indicated that staff cleaned and mopped the room with the urine odor daily and used an odor eliminator, but believed the mattress was the source of the smell and needed replacement. The facility did not have a specific policy addressing a homelike environment, though a general resident rights policy was in place.
Failure to Serve Breakfast at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve breakfast at safe and palatable temperatures, affecting 54 of 55 residents. During a Resident Council meeting, 8 of 10 residents indicated that breakfast was often served cold. Resident 43 and Resident B also reported that breakfast was frequently served cold. Observations in the facility kitchen revealed that plates of fried and scrambled eggs were left sitting on the counter and shelf, with temperatures measured at 100 degrees Fahrenheit and 86 degrees Fahrenheit, respectively. Sausage patties on the steam table were measured at 109 degrees Fahrenheit. The Dietary Manager indicated that the food should be microwaved or reheated before serving, but this was not consistently done. Further observations showed that a breakfast tray delivered by the Infection Preventionist Float contained food items with temperatures below the required 135 degrees Fahrenheit. The sausage patty was measured at 129.3 degrees Fahrenheit, and the oatmeal at 130.5 degrees Fahrenheit. The facility's Food Temperatures Policy, last revised in June 2023, mandates that hot foods be held for service at or above 135 degrees Fahrenheit and served at a palatable temperature. The facility's failure to adhere to this policy resulted in the deficiency.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the first-floor shower room in good condition and did not timely repair a leaking pipe for the pot filler in the kitchen, potentially affecting all 55 residents. On 4/16/24, a leaking pipe in the kitchen was observed with a clear pasty substance at the joints and rusted joint clamps, with a puddle of water underneath. The Dietary Manager indicated that a work order had been submitted, and the Registered Dietician noted that the pipe had been leaking for a while. A service request dated 4/16/24 confirmed the need for repair. On 4/17/24, a resident reported that the first-floor shower room was often dirty and smelled of urine. An observation on 4/22/24 revealed a dingy tile floor with dirt, soiled linen bags on the floor, and stained tiles around the shower drain. The Executive Director and Maintenance Supervisor confirmed the stained and dirty condition of the shower room floor. The Executive Director acknowledged the stained appearance of the shower room floor.
Failure to Provide Timely Assistance with Dressing
Penalty
Summary
The facility failed to timely provide assistance with dressing for a resident diagnosed with dementia and heart failure. The resident's care plan, initiated in June 2020, indicated that he required assistance with activities of daily living (ADL) due to his conditions. Despite this, observations over several days revealed that the resident was wearing the same clothing, which was ill-fitting and improperly worn. The resident was seen in the same brown t-shirt and purplish sweatpants with a binder clip attached to the waistband, which was around his thighs instead of his waist. The resident indicated that the sweatpants were too big for him. Interviews with staff confirmed that the resident would change his clothing if approached correctly, yet he continued to wear the same clothes over multiple days. A CNA acknowledged that the resident was wearing the same clothing as the previous day and stated that she would assist him in changing his clothing. The facility's failure to provide timely assistance with dressing for the resident was evident through these observations and interviews.
Failure to Administer Medications and Monitor Conditions
Penalty
Summary
The facility failed to properly assess and manage the care of Resident B, who had multiple medical conditions including type 2 diabetes mellitus, borderline personality disorder, and bipolar disorder. The resident did not receive her prescribed lispro insulin on several occasions, specifically on 4/4/24, 4/5/24, 4/11/24, and 4/12/24. Additionally, there was confusion regarding the dosage and administration times of her antipsychotic medication, Seroquel, which was not clarified in a timely manner. Furthermore, the resident had an open area on her umbilicus that required cleansing twice a day, but there were no assessments documented for this skin condition until 4/17/24, despite the order being placed on 4/3/24. Resident 27, who had diagnoses including constipation, heart failure, and chronic kidney disease, also experienced deficiencies in care. The resident's care plan indicated the need for monitoring bowel movements and administering medications as ordered to prevent constipation. However, the bowel movement records showed multiple days without a bowel movement, and there was no documentation of the administration of prescribed Dulcolax or Milk of Magnesia. The facility's policy required bowel movements to be recorded daily and for interventions to be taken if no bowel movement occurred for three consecutive days, which was not followed. These deficiencies highlight significant lapses in the facility's adherence to care plans, medication administration, and monitoring protocols. The Director of Nursing Services and other staff members were unable to provide explanations for these lapses, indicating a lack of oversight and communication within the facility. The failure to follow established policies and physician orders resulted in inadequate care for the residents involved.
Failure to Provide Oral and G-Tube Site Care
Penalty
Summary
The facility failed to provide oral care as ordered by the physician and did not timely obtain a physician's order for gastrostomy tube site care for Resident 23. Resident 23, diagnosed with dysphagia, aphasia, and gastrostomy, had a care plan initiated in 2018 to prevent complications related to enteral feedings. Despite a physician's order from 2021 to provide oral care every shift, observations on 4/16/24 and 4/18/24 revealed that Resident 23 had dried brown drainage at the base of his g-tube and a white film on his teeth and lips, indicating a lack of proper oral and g-tube site care. Interviews with Resident 23 and LPN 3 confirmed that oral care and g-tube site care were not consistently provided as required. The Director of Nursing Services (DNS) acknowledged the absence of a physician's order for g-tube site care in the medical record and confirmed that oral care should be performed as ordered. The facility's Enteral Tube Skills Competency guidelines, last reviewed in 2019, stated that dressing or site care of the enteral tube should be done at least daily, which was not adhered to in this case.
Inadequate Monitoring and Documentation of Resident Behaviors
Penalty
Summary
The facility failed to adequately monitor and document behaviors for Resident 45, who had a history of schizoaffective disorder, bipolar disorder, and other cognitive impairments. Despite multiple incidents of inappropriate sexual behavior towards staff and other residents, the facility's interventions were insufficient and not effectively documented. For instance, after Resident 45 inappropriately touched a female staff member on 1/14/24, the only intervention was to explain the inappropriateness of the behavior and redirect him. This intervention proved somewhat effective but did not prevent further incidents. The care plan did not address the potential for inappropriate behavior towards other residents, and subsequent incidents, including one on 2/24/24 where Resident 45 touched another resident's breast, were not adequately addressed with effective interventions or proper documentation. Resident 45's behavior continued to be problematic, with multiple reports of him entering other residents' rooms uninvited and making inappropriate comments and gestures. Despite these ongoing issues, there were no care plans to address his wandering into other residents' rooms or his inappropriate sexual behavior towards residents. The facility's documentation was also lacking, as there were no progress notes or events in the electronic health record referencing the frequent occurrences of Resident 45 going into other residents' rooms uninvited. The Social Services Director acknowledged that the care in pairs intervention, which was eventually put in place, should have been implemented after the first incident in January. Similarly, the facility failed to document and monitor the behaviors of Resident 38, who had a diagnosis of schizophrenia and exhibited episodes of verbal aggression and irritability. Despite a care plan that included interventions such as encouraging activities and redirecting the resident to a calmer space, there were significant gaps in the documentation of his behaviors. For example, an incident on 4/16/24 where Resident 38 became upset and left a resident council meeting while cussing loudly was not documented in his clinical record. The facility's behavior management policy was not followed, as staff did not consistently report and document the resident's behaviors, leading to inadequate monitoring and management of his condition.
Medication Error Rate Exceeds 5 Percent
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent, resulting in a 5.88% error rate during a medication pass observation. Specifically, for Resident 43, who has a diagnosis of type 2 diabetes mellitus, the staff did not follow proper procedures for blood sugar monitoring and insulin administration. The resident's blood sugar was checked after she had already started eating her breakfast, contrary to the physician's order to obtain blood sugars four times a day at specific times. Additionally, the LPN did not prime the lantus flex pen before administering the insulin, which is against the manufacturer's instructions. Interviews with the LPN and the Director of Nursing Services confirmed that the blood sugars should be obtained before meals and that the insulin flex pens should be primed before use. Resident 43 also indicated that staff frequently check her blood sugar after she eats her meals. These actions and inactions led to the observed medication errors, contributing to the facility's failure to maintain a medication error rate below the required threshold.
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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