Envive Of Sullivan
Inspection history, citations, penalties and survey trends for this long-term care facility in Sullivan, Indiana.
- Location
- 325 W Northwood Dr, Sullivan, Indiana 47882
- CMS Provider Number
- 155468
- Inspections on file
- 27
- Latest survey
- September 29, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Envive Of Sullivan during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses had changes to her medication regimen, including an increased dose of Risperdal and a new order for vitamin D3, but there was no documentation that her representative was notified as required. The DON confirmed the lack of notification after reviewing the medical record, and a family member reported ongoing communication issues regarding changes in care.
The facility did not ensure proper documentation or timely implementation of interventions following falls for two residents with severe cognitive impairments and fall risks. Multiple falls were not promptly or thoroughly documented in the medical record, and required assessments and care plan updates were missing. Interviews revealed that key fall-related documentation was kept in internal systems not accessible to all staff, contrary to facility policy.
The facility did not assign a qualified IP nurse separate from the DON to oversee infection prevention and antibiotic stewardship programs. Infection surveillance and antibiotic tracking were not completed for several months, with the DON solely responsible for these duties and unaware of the requirement for a separate, trained IP nurse. This affected all residents in the facility.
The facility did not consistently track infections or antibiotic use and failed to ensure required TB testing was completed for multiple residents. Medical records showed missing documentation for second TB tests, unread test results, and lapses in annual TB testing. Infection surveillance and antibiotic tracking were not conducted for several months, despite facility policy requiring these measures.
A resident with severe cognitive impairment and multiple mental health diagnoses was prescribed Risperidone and other psychotropic medications. Despite care plans requiring monitoring for side effects, documentation showed that the last AIMS assessment was completed several months prior, with no evidence of the required quarterly assessments. Staff interviews confirmed the expectation for quarterly AIMS assessments, but the DON could not locate recent documentation.
The facility did not update or implement care plans for two residents, including one who continued to have outdated care plan entries for IV antibiotics and another who lacked a pain management care plan despite frequent opioid use. Additionally, care plan meetings were not conducted or documented quarterly for a resident with severe cognitive impairment, and the family was not invited to participate as required.
Two residents who required staff assistance for ADLs, including personal hygiene, were not consistently provided help with shaving. Both residents were observed with untrimmed facial hair and expressed a preference to be clean-shaven, while staff and documentation failed to show that shaving was regularly offered or performed as required by facility policy.
A resident with a history of Parkinson's disease, diabetes, shortness of breath, and COPD had physician orders for nightly oxygen and weekly tubing changes, but observations showed the oxygen tubing was not changed or dated as required. The resident reported not receiving oxygen, and the medical record lacked a care plan for oxygen use, despite documentation indicating oxygen administration. Facility policy requiring weekly changes of oxygen equipment was not followed.
A resident with severe cognitive impairment received doxycycline for pneumonia beyond the prescribed seven-day course because the stop date was not correctly entered into the system, leading to continued administration and additional doses being taken from the Emergency Drug Kit. The DON confirmed the error, which was inconsistent with facility policy requiring clear antibiotic order durations.
Surveyors found that medications, including multi-use vials and insulin pens, were not properly labeled with open dates and expired medications such as hepatitis B vaccines were not disposed of as required. An LPN and the DON confirmed that facility policy and professional standards were not followed, affecting two residents with diabetes who had undated insulin pens on their medication carts.
The facility failed to maintain 24-hour licensed nurse coverage, resulting in two residents falling during a shift without a nurse present. The DON attempted to cover the shift but was absent at times, leaving QMAs to manage alone. Resident W, with a history of falls, suffered a significant drop in oxygen levels after a fall, requiring hospital transfer. Resident T, with an anoxic brain injury, also fell and sustained minor injuries.
A resident with polyneuropathy did not receive pregabalin as prescribed due to delays in obtaining a new prescription. The facility's staff made multiple attempts to contact the physician and pharmacy, but the medication was unavailable for several days, leading to increased pain and hospitalization. Communication issues and a change in Medical Directors contributed to the deficiency.
The facility failed to serve food at a safe and appetizing temperature, as residents reported receiving cold meals in their rooms. A test tray revealed that food items were below the required temperature of 135 degrees Fahrenheit, contrary to the facility's policy. The Dietary Manager confirmed the deficiency in food temperature.
The facility failed to maintain temperature logs for the walk-in refrigerator and freezer for several days in April. The housekeeping supervisor and dietary aide were unaware of the lapses, despite a policy requiring twice-daily checks.
The facility failed to properly administer inhaled medication to a resident, resulting in a medication error rate of 6.67%. An LPN did not follow the required procedure of allowing a waiting period and mouth rinsing between administering Advair and Spiriva inhalers, contrary to physician orders and facility policy.
The facility failed to properly dispose of expired medications in the medication storage room. An RN was unaware of the policy, and both the Administrator and President of Clinical Operations confirmed the medications were expired and should have been discarded according to facility policy.
The facility failed to document wound treatments for a resident with severe cognitive deficit and multiple medical conditions, leading to a deep tissue injury that progressed to a stage 3 pressure ulcer. The treatment administration records lacked documentation of several physician-ordered treatments, and the DON confirmed that without signatures, there was no way to ensure treatments were completed.
The facility failed to ensure accurate staffing sheets were posted daily for three out of five days during the recertification survey. The staffing sheets were dated correctly but lacked documentation of the total number and actual hours worked by licensed and unlicensed nursing staff. The DON was unaware of the inaccuracies and indicated that the night shift nurse was responsible for posting the sheets.
Failure to Notify Resident Representative of New Medication Orders
Penalty
Summary
The facility failed to notify a resident's representative of new medication orders, as required by policy. A resident with severe cognitive impairment, Alzheimer's disease, and major depressive disorder with psychotic symptoms had changes to her medication regimen, including an increase in Risperdal dosage and the addition of vitamin D3. Documentation in the resident's record did not show that the representative was informed of these new orders. Progress notes specifically lacked evidence of notification following both the Risperdal dosage change and the initiation of vitamin D3. Interviews with the resident's family member revealed ongoing issues with communication from the facility regarding changes in the resident's care. The DON confirmed, after reviewing the 24-hour report and medical record, that there was no documentation of notification to the resident's representative for the medication changes. Facility policy requires that residents and their representatives be informed of changes in health status and treatment, but this was not followed in these instances.
Failure to Document and Implement Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure proper documentation and implementation of interventions following falls for two residents with significant cognitive impairments and fall risks. For one resident with moderate dementia, diabetes, and atrial fibrillation, multiple falls occurred over a period of several months. The medical record lacked timely documentation of these falls, including missing fall assessments, skin and pain assessments, and progress notes detailing the circumstances of the incidents. In several instances, there was a delay of several days before any interdisciplinary team (IDT) notes were entered, and there was no evidence that new interventions were added to the care plan after repeated falls. Additionally, family notification was not documented for at least one fall. For another resident with Alzheimer's disease and a cognitive communication deficit, an unwitnessed fall was not properly documented in the progress notes, and the change in condition evaluation did not include details about the fall or any interventions to prevent recurrence. The only documentation of the fall was found in a risk management incident report, which was not part of the resident's official medical record and was not visible to all staff. The IDT note, completed several days after the fall, mentioned the resident's shoes were too big and that a new pair would be obtained, but there was no documentation of immediate interventions or assessments in the medical record. Interviews with the LPN and DON revealed that staff were expected to complete fall assessments, skin and pain assessments, and notify the DON, physician, and family immediately after a fall. However, the DON was unaware that the fall risk management assessment and risk management incident reports were not part of the official medical record and not accessible to all staff. The facility's own falls protocol required detailed assessment and documentation after a fall, but this was not consistently followed for the residents reviewed.
Failure to Designate Qualified Infection Preventionist and Complete Infection Surveillance
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) nurse, other than the Director of Nursing (DON), to oversee the infection prevention and antibiotic stewardship programs. Record review showed that antibiotic tracking and infection surveillance were not completed for a seven-month period. During an interview, the DON stated she began working at the facility in December 2024 and was solely responsible for infection tracking, TB testing, surveillance, and the antibiotic stewardship program. She acknowledged she was unaware that the DON could not serve as the IP nurse and that an additional nurse with infection preventionist training was required for the role. Facility documentation indicated that both a full-time DON and a full-time IP nurse were designated, but in practice, only the DON was fulfilling these responsibilities. Policies provided by the administrator outlined that the IP nurse or designated infection control personnel should conduct ongoing surveillance, gather and interpret infection data, and coordinate the infection prevention program. However, these duties were not being carried out as required, as evidenced by the lack of infection surveillance and antibiotic tracking during the specified period. This deficiency had the potential to affect all 38 residents in the facility.
Failure to Track Infections, Antibiotic Use, and Complete Required TB Testing
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program, specifically in tracking infections, antibiotic use, and conducting required tuberculin (TB) testing for residents. Review of medical records revealed that several residents did not have evidence of a second TB test administered within the required timeframe after admission, and in some cases, there was no documentation of TB test results being read or of annual TB testing being completed. The Director of Nursing, who also served as the Infection Preventionist, acknowledged responsibility for overseeing immunizations and TB testing, and confirmed that two initial TB tests are required upon admission unless contraindicated. Additionally, the facility's infection control program lacked documentation of antibiotic tracking or infection surveillance for a period of several months, specifically from May to November of the previous year. Although the facility had policies in place requiring ongoing surveillance for healthcare-associated infections and routine tracking of antibiotic use, these procedures were not followed during the specified period. The DON indicated that infection tracking began only after her employment started in December, leaving a gap in compliance with infection control protocols.
Failure to Complete Required AIMS Assessments for Resident on Psychotropic Medication
Penalty
Summary
A deficiency was identified when the facility failed to ensure that AIMS (Abnormal Involuntary Movement Scale) assessments were completed as required for a resident receiving psychotropic medications. Record review showed that a resident with diagnoses including Alzheimer's disease, anxiety disorder, and major depressive disorder was prescribed Risperidone and other psychotropic medications. The resident's care plans included interventions to monitor for side effects and effectiveness of these medications, as well as to consult with pharmacy and medical staff regarding ongoing need. Despite these interventions, documentation revealed that the last AIMS assessment for this resident was completed in July 2024, with no evidence of subsequent quarterly assessments as required by facility policy. Interviews with staff confirmed that AIMS assessments should be completed on admission and every three months, but the DON was unable to locate any documentation of assessments after July 2024. The facility's policy also recommended quarterly AIMS assessments for residents on psychotropic medications.
Failure to Update and Implement Care Plans and Conduct Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plans were updated and implemented in accordance with regulatory requirements for multiple residents. For one resident with a history of unspecified mild dementia with psychotic disturbance, a care plan indicated the presence of a venous access device and administration of IV antibiotics for a urinary tract infection due to ESBL. However, after the completion of the antibiotic course and removal of the IV access, the care plan was not updated to reflect these changes. Additionally, both quarterly and annual MDS assessments lacked documentation of antibiotic administration or IV access during the relevant periods, despite clear evidence from progress notes and resident interviews that these interventions had occurred and subsequently ended. Another resident, who experienced frequent pain and was prescribed as-needed opioid pain medication, did not have a care plan implemented for pain management or opioid use, despite regular administration of the medication and frequent complaints of pain interfering with activities of daily living. The DON and MDS coordinator were unaware of the absence of a pain management care plan, even though the resident had been receiving pain medication consistently since admission. The facility also failed to conduct and document quarterly care plan meetings for a resident with severe cognitive impairment. The resident's daughter reported never being invited to a care plan meeting, and the record lacked documentation of such meetings prior to a specific date. The Social Service Director acknowledged not inviting the family due to missing contact information and was unaware of previous documentation practices. The Administrator confirmed the absence of documentation verifying that care plan meetings were held as required.
Failure to Provide Assistance with Shaving for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with shaving for two residents who were unable to perform this activity of daily living (ADL) independently. One resident, who had severe cognitive impairment and required substantial to maximal staff assistance with personal hygiene, was repeatedly observed with untrimmed beard and mustache growth over several days. The resident expressed a preference to be shaved at least once a week and indicated that staff did not ask if he wanted to be shaved during showers. Documentation in the resident's record did not indicate any refusal of shaving care, and shower sheets lacked consistent documentation of shaving or offers to shave, except for one instance. Another resident, who had mild cognitive impairment and required extensive assistance with ADL care due to Parkinson's disease and other medical conditions, was observed with oily, disheveled hair and extensive facial hair. The resident stated a preference for being clean-shaven and confirmed he had not been shaved. Staff interviews confirmed that shaving was expected to occur on shower days, but records did not consistently reflect that shaving was provided or offered. The facility's policy required appropriate support and assistance with hygiene, including grooming, for residents unable to perform ADLs independently.
Failure to Change and Date Oxygen Equipment per Policy
Penalty
Summary
The facility failed to ensure that oxygen equipment was changed and dated according to its own policy for a resident with orders for supplemental oxygen. Observations revealed that the oxygen tubing in the resident's room was stored in a bag dated over a month prior, and interviews with the resident confirmed that she was not receiving oxygen at any time, including at night. Despite this, the medication administration record indicated that oxygen was being administered nightly. An LPN stated that oxygen tubing was supposed to be changed weekly, but acknowledged the resident did not use oxygen often. The Director of Nursing later confirmed that the oxygen order was discontinued because the resident was not using oxygen, and the tubing and storage bag had not been changed as required, due to being overlooked. The resident in question had a medical history including Parkinson's disease, diabetes mellitus, shortness of breath, and COPD, and had a physician's order for oxygen at night for shortness of breath, with instructions to change the tubing weekly and as needed. The medical record lacked a care plan related to oxygen use, despite documentation that the resident was cognitively intact and had received oxygen during a recent assessment period. Facility policy required oxygen cannula and tubing to be changed every seven days or as needed, which was not followed in this case.
Antibiotic Administered Beyond Prescribed Duration Due to Order Entry Error
Penalty
Summary
A resident with severe cognitive impairment was prescribed doxycycline 100 mg twice daily for seven days to treat a pneumonia identified by chest x-ray. The physician's order, dated 5/12/25, specified the duration of therapy as seven days. However, the medication was administered from the evening of 5/12/25 through the evening of 5/27/25, exceeding the prescribed duration. Review of the pharmacy delivery log confirmed that 14 tablets were initially delivered, but additional doses were obtained from the Emergency Drug Kit on multiple occasions after the original supply was exhausted. The Director of Nursing confirmed that the antibiotic was not discontinued as ordered because the stop date was included only in the text of the order and not entered correctly into the system, resulting in continued administration beyond the intended stop date. Facility policy required prescribers to provide complete antibiotic orders, including start and stop dates or number of days of therapy.
Failure to Properly Label and Dispose of Medications
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of medications in accordance with professional standards and facility policy. During observation of the medication storage room, an undated multi-use vial of Aplisol was found, and staff interviews confirmed that the vial should have been dated upon opening and discarded after 30 days. Additionally, three prefilled syringes of hepatitis B vaccine with an expiration date that had already passed were found in the storage room, and staff acknowledged these should have been discarded. Facility policy requires regular review and removal of expired medications, but this was not followed. Further deficiencies were identified on two medication carts. An insulin pen injector for a resident with Type 2 diabetes was found without an open date, and the LPN confirmed that insulin pens should be dated when opened and are only good for 28 days after opening. Another cart contained two insulin pen injectors for a different resident, also without open dates, and the LPN was unable to determine how long they had been open. Both residents had physician orders for Glargine insulin, and the facility's policy requires medications with shortened expiration dates to be labeled with the date opened and the initials of the nurse, which was not done.
Failure to Ensure 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to ensure a licensed nurse was on duty 24 hours a day, specifically on a day shift when two residents fell. On the day in question, an agency nurse did not show up for the scheduled shift, leaving the facility without a licensed nurse from 6:00 a.m. to 6:00 p.m. The Director of Nursing (DON) attempted to cover the shift by administering insulin and checking on residents, but had to leave the facility at times, leaving the Qualified Medication Aides (QMAs) to manage without a licensed nurse present. This lack of coverage was contrary to the facility's policy, which required a licensed nurse to be on duty at all times. During this period, two residents, identified as Residents W and T, experienced falls. Resident W, who had a history of falling and required substantial assistance with transfers, fell in his room and suffered a skin tear. His condition deteriorated, with oxygen levels dropping significantly, necessitating a hospital transfer. Resident T, who had an anoxic brain injury and dementia, also fell and sustained minor injuries. The DON was present for part of the shift but could not provide continuous coverage, and there was no documentation of the exact hours worked due to the DON's salaried status.
Failure to Timely Reorder Medications for Resident
Penalty
Summary
The facility failed to ensure timely reordering of medications, resulting in a deficiency in pharmaceutical services for one resident. Resident D, who was cognitively intact and diagnosed with unspecified polyneuropathy, had a care plan that included administering medications as ordered. However, the Medication Administration Record (MAR) indicated that pregabalin, a nerve pain medication, was unavailable for administration on several occasions in December 2024 and January 2025. The deficiency arose from a series of communication failures and delays in obtaining a new prescription for pregabalin. The facility's staff left messages with the physician and attempted to contact the pharmacy, but the physician did not return calls, and a new prescription was required. The Director of Nursing (DON) and other staff members made multiple attempts to resolve the issue, including contacting the hospital for an on-call physician, but were unsuccessful. As a result, Resident D missed doses of pregabalin from 12/25/24 to 12/30/24 and again from 1/8/25 to 1/11/25. The lack of pregabalin led to Resident D experiencing increased pain and ultimately being hospitalized. The resident reported not feeling well for several days, with generalized pain and high blood pressure, and the hospital records indicated that the resident had been without pregabalin for over a week. Interviews with facility staff revealed issues with obtaining narcotic medications due to a change in Medical Directors and the requirement for prescription authorization to access the Emergency Drug Kit (EDK).
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was at a safe and appetizing temperature, as evidenced by interviews, observations, and record reviews. During confidential interviews, residents reported that meals served in their rooms were often cold. Specifically, Resident C, Resident F, and Resident E indicated that their meals were sometimes or often served cold, affecting the palatability of the food. On a specific date, the Dietary Manager measured the temperatures of a test tray and found that the fried potatoes, cooked broccoli, and BBQ sandwich were below the required temperature of 135 degrees Fahrenheit, with readings of 128 F, 118 F, and 128 F, respectively. The facility's policy on food temperatures, dated January 2023, mandates that hot foods be held at or above 135 degrees Fahrenheit to prevent foodborne illness and ensure palatability at the time of service.
Failure to Maintain Temperature Logs for Refrigeration and Freezing Units
Penalty
Summary
The facility failed to maintain refrigerator and freezer temperature logs for several days in April. During an initial kitchen tour, it was observed that the temperature logs for the walk-in refrigerator and freezer were incomplete. Specifically, the refrigerator log lacked documentation for five days, and the freezer log lacked documentation for two days. The housekeeping supervisor, who was filling in as the cook, was unaware of why the logs were incomplete and why the refrigerator log was not in its usual place. The dietary aide also did not know why the logs were not completed, although he understood that temperatures should be checked and documented daily. The dietary manager later provided a policy document indicating that refrigerator and freezer temperatures should be checked at least twice daily. Despite this policy, the logs were not maintained as required. The failure to document these temperatures was confirmed through interviews with the housekeeping supervisor and dietary aide, who both expressed uncertainty about the lapses in documentation.
Improper Administration of Inhaled Medication
Penalty
Summary
The facility failed to ensure proper administration of inhaled medication during a medication administration pass for one resident, resulting in a medication error rate of 6.67%. During an observation, an LPN administered an Advair inhaler to a resident and immediately followed it with a Spiriva inhaler without allowing the resident to rinse and spit after the first inhaler or wait several minutes between the two medications. This was contrary to the physician's orders and the facility's policy, which required a waiting period and mouth rinsing to prevent complications such as thrush. The resident's medical record indicated diagnoses of emphysema and unspecified asthma, with specific physician orders for the administration of Advair and Spiriva. Interviews with nursing staff and the President of Clinical Operations confirmed that the proper procedure was not followed. The facility's policy documents also supported the need for a waiting period and mouth rinsing after inhaler use. The failure to adhere to these guidelines led to the identified deficiency.
Expired Medications Not Properly Disposed
Penalty
Summary
The facility failed to ensure expired medications were disposed of properly in the medication storage room. During an observation, an opened multi-use vial of Aplisol solution with an open date of 2/27/24 and an opened multi-use vial of flu vaccine solution with an open date of 11/2/23 were found. Registered Nurse (RN) 9 was unaware of the facility policy regarding the duration for which the medication was good once opened but acknowledged that they needed to be discarded. The Administrator and the President of Clinical Operations confirmed that the medications were expired and should have been discarded. The facility policy indicated that Aplisol vials should be discarded 30 days after initial use and flu vaccine vials should be discarded 28 days after initial use.
Failure to Document Wound Treatments for Resident
Penalty
Summary
The facility failed to ensure the documentation of wound treatments for a resident with severe cognitive deficit and multiple medical conditions, including type 2 diabetes mellitus, heart failure, and end-stage renal disease. The resident was at risk for pressure ulcers and had a care plan in place to address this risk. However, the treatment administration records (TAR) lacked documentation of several physician-ordered treatments, including weekly skin assessments, floating heels while in bed, turning/repositioning every 2 hours, and applying triad paste to the buttocks. Specific dates where documentation was missing include 3/27/24 and 4/4/24. Additionally, the resident developed a deep tissue injury on the left buttocks, which was later restaged to a stage 3 pressure ulcer. Despite new treatment orders being provided, the TAR still lacked documentation of the treatments being completed as ordered. During an interview, the Director of Nursing (DON) confirmed that the TAR should always be signed off when treatments are completed, and without a signature, there was no way to ensure the treatments were carried out. The facility's policy on medication administration and general guidelines also emphasized the importance of documenting treatments in the TAR.
Failure to Post Accurate Daily Staffing Sheets
Penalty
Summary
The facility failed to ensure accurate staffing sheets were posted daily for three out of five days during the recertification survey. On multiple occasions, the staffing sheets posted on the wall across from the nurses' station were dated correctly but lacked documentation of the total number and the actual hours worked by licensed and unlicensed nursing staff. Specifically, on 4/15/24, 4/16/24, and 4/19/24, the staffing sheets were incomplete. During an interview, the Director of Nursing (DON) indicated she was unaware that the staffing sheets were not completed accurately and mentioned that the night shift nurse was responsible for ensuring the sheets were posted and completed accurately. The DON provided a document titled 'Posting Direct Care Daily Staffing Numbers,' revised in August 2022, which indicated that the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care should be posted in a prominent location at the beginning of each shift. The policy also required the actual time worked during that shift for each category and type of nursing staff to be documented. Despite this policy, the facility did not adhere to these requirements, leading to the identified deficiency.
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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