Evergreen Crossing And The Lofts
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 5404 Georgetown Road, Indianapolis, Indiana 46254
- CMS Provider Number
- 155826
- Inspections on file
- 45
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Evergreen Crossing And The Lofts during CMS and state inspections, most recent first.
Improper egg pasteurization and unsafe cold food storage. During kitchen observations, the walk-in cooler door was propped open, the floor was wet, and the cooler temperature read 55 degrees F with no second thermometer available. A box of eggs in the cooler had no visible P stamp or label showing they were pasteurized, and an old pizza was also found stored in the cooler. The Dietary Mgr stated eggs were sometimes cooked to order, including eggs with yolks not completely cooked, and later said eggs could be purchased from the store if needed.
A resident who was cognitively intact stated he wanted 3 showers weekly but was receiving showers only 2 times per week. Records showed his bathing preference was documented on admission, yet bathing logs from several weeks reflected only twice-weekly showers. The VP of Risk Mgmt confirmed the resident was receiving showers twice weekly, despite the resident's stated preference and the facility policy supporting resident choice.
A resident with COPD, dementia, a legal guardian, and an active DNR order was transferred to the hospital for shortness of breath, but the transfer form listed CPR status and identified the wrong resident representative as notified. The guardian said the facility called the nephew instead of her, and hospital staff later told her they had been informed the resident was full code. No copy of the transfer packet sent with the resident was provided.
MDS coding was inaccurate for two residents. One resident was coded as receiving an antidepressant even though his medication orders did not include one, and another resident was not coded as edentulous despite an admission assessment and staff confirmation showing he had no natural teeth or tooth fragments. The MDS staff member reported being unable to physically assess the resident because he was often out of the building.
Medications were left at the bedside of two residents without documented authorization for self-administration. One cognitively intact resident had several oral pills on the bedside table after telling an LPN he would take them later, and the record showed he was only documented as able to self-administer his inhaler, not oral meds. Another resident was observed with 9 oral meds and a cup of orangish liquid at her bedside during breakfast; her record lacked a self-administration assessment and care plan, while the facility policy allowed bedside medication storage only with a prescriber order and an interdisciplinary evaluation.
Failure to provide person-centered dementia care and services: A resident with severe dementia, anxiety, and diabetes was repeatedly observed calling out for help while lying or sitting in a hospital gown with poor grooming and minimal stimulation in her room. Staff described her as easily overstimulated, needing one-on-one attention, and having worsening confusion and refusals of care, yet her activity plans were conflicting and did not include her known preferences such as classical music, the Beatles, quiet settings, or individualized sensory interventions. Records also showed no recent activity participation, and staff stated no dementia-specific interventions were in place beyond routine activities.
Medication Labeling and Storage Deficiencies: Facility staff failed to ensure meds were properly labeled and stored in 3 of 6 med carts reviewed. One resident had Sevelamer Carbonate 800 mg without a written or Rx label, another had an open Budesonide/Formoterol inhaler with an open date listed, and an unknown resident had liquid guaifenesin with the pharmacy label ripped off. The facility policy required pharmacy-labeled containers and removal of outdated or deteriorated meds.
The facility failed to maintain accurate reconciliation and accountability of controlled drugs across multiple units, leading to diversion of at least 60 hydrocodone-acetaminophen tablets for a resident. Pharmacy records showed four cards of narcotics were received, but later two cards were missing from the cart while the narcotic count still appeared correct. A resident was found unresponsive and later pronounced dead, and subsequent review revealed missing pages from the narcotic count book, a newly started count sheet, and incomplete two-nurse signatures on shift change inventory trackers. An LPN admitted starting a new narcotic count sheet based only on the remaining medications in the cart, contrary to facility policies requiring double-locked storage, two-nurse shift counts, complete documentation, and timely removal and destruction of controlled substances after discharge or death.
A resident with severe chronic pain and multiple musculoskeletal diagnoses had an order for Norco, with four full cards of medication received from the pharmacy. After the resident was found unresponsive and later pronounced dead, two full cards (60 tablets) of Norco were discovered missing from the med cart. Staff identified that a narcotic count page was missing from the narcotic book and a new count sheet had been started, allowing counts to appear correct despite the missing cards. The resident’s narcotic count sheet continued to be signed for days after death, and the narcotics were not promptly removed from the cart for DON destruction. Review of narcotic tracking sheets across multiple med carts showed that required two-nurse signatures for adding or removing controlled drug cards and count sheets were often missing, reflecting a broader failure to maintain accurate controlled drug counts and chain of custody.
Surveyors found that medications were left unattended at a resident's bedside without a physician's order for self-administration, and a utility cart with hazardous painting supplies was left unsupervised in a hallway near a resident with severe cognitive impairment. Facility policies prohibited these practices, but staff failed to follow them, creating potential accident hazards.
Three residents with diabetes did not receive insulin in accordance with physician orders or manufacturer instructions. Insulin was often administered after meals instead of before, and staff did not consistently notify providers of high blood sugar readings or update care plans. Nursing staff cited workload and resident availability as reasons for delayed or improperly timed insulin administration, leading to significant medication errors.
A resident with multiple risk factors developed a severe unstageable pressure ulcer and a Deep Tissue Injury (DTI) on the heel due to the facility's failure to consistently identify, assess, document, and communicate about wounds. Staff did not perform or document required skin assessments, failed to update care plans, and did not notify the primary care provider or the resident's representative in a timely manner, resulting in the progression of wounds and the need for surgical debridement.
A resident with multiple complex conditions developed new and worsening wounds, including pressure ulcers and a DTI, but the care plan was not promptly or adequately updated to reflect changes in wound management. Physician orders and wound assessments documented the progression of wounds and new interventions, but these were not consistently incorporated into the care plan, and some wounds were not identified or documented in a timely manner. Staff interviews and audits revealed inconsistent execution of care plan updates and documentation.
The facility failed to create comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. A resident with a history of cerebral amyloid angiopathy and dementia exhibited wandering behaviors and a strong desire to ride his bicycle, which was not addressed in his care plan. Another resident admitted with a trans metatarsal amputation lacked a care plan addressing this condition. The facility's care planning process did not adequately accommodate the residents' individual needs and preferences.
The facility failed to update care plans for two residents, one with chewing difficulties due to poorly fitting dentures and another refusing pressure-relieving boots. The care plans lacked necessary interventions, and there was no specific policy for care plan revision.
The facility failed to prevent potential accidents by not ensuring call lights were within reach for three residents, leading to increased fall risk and inadequate supervision. A resident with paralysis had her call light out of reach, resulting in falls and unidentified pills at her bedside. Another resident, admitted for rehab after a back fracture, fell due to an inaccessible call light, with incomplete neurological assessments. A third resident, with limited arm mobility, couldn't reach her call light, expressing fear of falling. Facility policies on fall prevention and resident rights were not followed.
A resident without teeth or dentures experienced significant weight loss due to the facility's failure to provide appropriate nutritional support. Despite having conditions like hemiplegia and dysphagia, the resident was served hard-to-chew foods and did not consistently receive preferred nutrition supplements. Inconsistent weight monitoring and lack of meal assistance further contributed to the resident's nutritional deficiency.
The facility failed to follow medication administration protocols for three residents, leading to unnecessary drug administration. A resident received metoprolol despite low blood pressure readings, another did not receive midodrine when needed, and a third was given hydralazine without blood pressure checks. The President of Risk Management noted staff misunderstanding of orders.
The facility failed to date multi-dose vials of tuberculin serum and remove expired insulin pens from storage. A vial of Aplisol in the medication room refrigerator and a vial of Tubersol in another refrigerator were found without opening dates. Two insulin pens belonging to a resident were not removed after 30 days, as confirmed by an LPN. The facility's policy requires expiration dates to be determined by the pharmacist and specifies shorter expiration dates for certain medications once opened.
The facility failed to notify the physician of changes in condition for two residents who developed new pressure ulcers. One resident with dementia and COPD had an unstageable ulcer, and another with hypertension and peripheral vascular disease had a stage 3 ulcer. In both cases, the physician was not informed, despite the facility's policy requiring notification for changes in condition.
A facility failed to prevent a new pressure ulcer and ensure timely treatment for a resident with a history of pressure ulcers. The resident, dependent on staff for care, developed an unstageable pressure ulcer that worsened due to lack of timely assessment and intervention. The facility did not notify the physician of the change in condition, and the wound deteriorated into a stage IV ulcer with severe complications.
The facility failed to ensure accurate medication quantities were provided at discharge for two residents, resulting in incomplete discharge instructions. One resident's form lacked quantities for three medications, while another's form lacked quantities for multiple medications. The facility's policy requires documentation of medication name, dose, and quantity, which was not followed.
Improper egg pasteurization and unsafe cold food storage
Penalty
Summary
The facility failed to ensure eggs were pasteurized and foods were stored safely during kitchen observations. During an initial observation, the walk-in cooler door was propped open, the floor was wet, and the electronic temperature reading showed 55 degrees F. A second thermometer could not be found inside the cooler. A box of eggs with 18 remaining was observed in the cooler, and the eggs were not noted to be pasteurized; there was no stamped P on the eggs and no note on the box indicating pasteurization. The Dietary Manager confirmed there was no documentation showing the eggs were pasteurized and stated that eggs were sometimes cooked to order, including eggs with yolks not completely cooked. A pizza dated 3/4/26 was also observed in the walk-in cooler, and the Dietary Manager indicated it should have been removed. During later observations, the walk-in cooler temperature was 33 degrees F and a thermometer hanging near the door also read 33 degrees F. On 4/15/26, no eggs were in the cooler, and the Dietary Manager stated that if eggs ran out and no delivery was coming, someone would go purchase eggs from the store. The Administrator later provided a receipt dated 4/3/26 showing a case of pasteurized eggs had been delivered, but was unable to provide documentation of where the box of eggs observed upon entrance came from. The Administrator also provided facility policies stating that only pasteurized egg products would be used for soft cooked egg items and that perishable foods would be maintained at 41 degrees F or below, except during necessary periods of preparation and service.
Resident Bathing Preference Not Followed
Penalty
Summary
The facility failed to ensure a resident received showers and bathing according to his preference. During an interview, the resident stated he was receiving showers twice weekly but wanted three showers a week, and he did not remember staff asking him about his shower and bathing preferences. The resident was cognitively intact per a quarterly MDS assessment, and his record showed a bathing preference documented on admission as a bed bath three times weekly. The care plan identified an ADL self-care performance deficit and included staff assistance with showering and bathing. However, bathing documentation from 3/1/26 through 4/16/26 showed the resident was scheduled for and received showers only twice weekly. During interview, the VP of Risk Management confirmed the resident received showers twice weekly and stated that if the resident told the admitting nurse he wanted a shower three times a week, it should have been scheduled accordingly. The facility policy stated residents have a right to make their own schedule.
Incorrect transfer documentation and guardian notification
Penalty
Summary
The facility failed to ensure a resident’s code status and resident representative information were appropriately communicated during transfer to the hospital for one resident reviewed for hospitalization. The resident had diagnoses including COPD and dementia, had a legal guardian, and had an active DNR order. A POST form signed by the legal guardian and scanned into the chart indicated DNR status, but the transfer form in the record listed the resident’s code status as CPR and identified a male family member as the notified resident representative. During interview, the legal guardian stated the facility called the resident’s nephew instead of her to notify a resident representative of the transfer, and she was not notified until the following Monday when the facility social worker called for an update. The guardian also stated that hospital staff told her they had been informed the resident was full code. The resident was transferred to the hospital for shortness of breath, and a physician’s note later documented respiratory failure and RSI during the hospitalization. The facility stated it normally sent paperwork with the resident, including a POST form if applicable, but no copy of the packet sent with the resident was provided.
MDS Coding Errors for Antidepressant Use and Edentulous Status
Penalty
Summary
The facility failed to accurately code the MDS for a resident who was not taking an antidepressant. Resident 2 had diagnoses including dementia, anxiety, diabetes, major depressive disorder, traumatic brain injury, insomnia, and kidney disease, but his medication orders did not include an antidepressant. Despite this, his MDS dated [DATE] indicated that he was prescribed an antidepressant. During record review on 4/15/26, the Corporate MDS Coordinator indicated the MDS was corrected. The facility also failed to code a resident as edentulous on the MDS. Resident 7 stated during interview that he had dentures, but they had broken. His nursing admission assessment dated 10/31/25 indicated he had no natural teeth or tooth fragments and was edentulous, but his comprehensive MDS assessment dated 11/7/25 indicated he was not edentulous. The VP of Risk Management confirmed the resident was edentulous, and the Regional MDS Coordinator stated the staff member completing the assessment was unable to physically assess the resident because he was out of the building often; the assessment should have indicated he was edentulous or coded as unable to assess.
Medications Left at Bedside Without Self-Administration Authorization
Penalty
Summary
The facility failed to ensure medications were not left at residents’ bedside for 2 of 32 residents observed for potential accidents. One cognitively intact resident was observed lying in bed with a cup containing several oral medication pills on the bedside table after stating the nurse had brought the medications about 15 minutes earlier and that he had told the nurse he would take them later. The resident’s record showed he was scheduled to receive multiple oral medications that morning, had a care plan noting behaviors including refusing medications, and had an admission nursing assessment indicating he could self-administer his inhaler but not his oral medication pills. The record did not document that he had been assessed as safe to self-administer oral medications. Another resident was observed sitting in a chair with her bedside table over her legs while eating breakfast, with a medicine cup containing 9 different oral medication pills next to her tray and a cup of orangish liquid. Her record showed diagnoses including diabetes type 2, hyperlipidemia, hypertension, acute kidney failure, and major depressive disorder, and her MAR listed multiple morning medications. The record lacked a self-administration assessment and lacked a care plan indicating she could self-administer medications. The facility’s Risk Management President identified the orangish liquid as Pro-Stat and stated it did not require an order, while the facility policy stated bedside medication storage is permitted only for residents who wish to self-administer medications, upon written prescriber order and after self-administration skills have been evaluated and deemed appropriate by the interdisciplinary resident assessment team.
Failure to Provide Person-Centered Dementia Care and Services
Penalty
Summary
The facility failed to provide person-centered dementia-specific care and services for a resident with diagnoses including type II diabetes mellitus with diabetic neuropathy, unspecified dementia with agitation, and anxiety disorder. The resident was repeatedly observed lying in bed or sitting in a wheelchair in a hospital gown, with unkempt grooming at times, including tangled or greasy hair, a soiled bandage on the upper right forehead with dried dark substance around it, and long fingernails with dark debris under them. Her room often contained only a television on a news station, with no other sensory stimulation observed, while she was heard repeatedly calling out, "help, help, help me please." Facility staff described the resident as having severe dementia that had worsened after returning from the hospital. The wound NP stated she was confused, often refused turning/repositioning and insulin, and no longer could have mildly coherent conversation, instead repeatedly saying "help help, please help me" even when her needs had been met. An LPN stated the resident used to answer some yes/no questions but now mostly said "help help help," and staff did not know what activities would help beyond visiting with her. Another LPN stated the resident was easily overstimulated, preferred one-on-one time, and most enjoyed someone sitting with her or holding her hand at all times. The resident’s record showed prior documentation that her guardian and the facility agreed she would be better suited for an all-female dementia care unit, and later notes stated she would benefit from a dementia unit and might transition there once Medicaid was approved. Her activity care plans were conflicting, with one indicating she was self-directed and another indicating she was dependent on staff for activities, cognitive stimulation, or social interaction. Neither plan included her documented preferences such as the Beatles, classical music, one-on-one discussion approaches, or other sensory interventions. Activity records showed no coded activities for the prior 30 days, and she was not observed in activities on multiple days. The social service director stated no dementia-specific interventions were in place besides routine activities, and the guardian stated staff needed to be more proactive and dementia-aware, noting the resident did better in small quiet environments and liked music and books.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored in 3 of 6 medication carts reviewed for appropriate storage and labeling of medications, involving Residents 100 and 112 and an unknown resident. On 4/16/26, Medication Cart 1 contained a bottle of Sevelamer Carbonate 800 mg for Resident 100 that did not have a written or prescription label on it. On the same day, Medication Cart 2 contained an open Budesonide and Formoterol inhaler for Resident 112 with an open date of 11/15/26. Also on 4/16/26, Heritage Medication Cart 2 contained a bottle of liquid guaifenesin for an unknown resident with a pharmacy label that had been ripped off the bottle, leaving only a small portion of the top left corner of the label. On 4/17/26, the facility provided its policy titled, Storage of Medications, which stated that all medications dispensed by the pharmacy are stored in the container with the pharmacy label and that outdated or deteriorated medications are immediately removed from inventory. A facility reference guide also stated that Budesonide/Formoterol should be discarded 90 days after removal from the protective pouch.
Failure to Maintain Accurate Controlled Drug Accountability Resulting in Narcotic Diversion
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective system for reconciliation and accountability of controlled medications on all four nursing units, which resulted in diversion of at least 60 hydrocodone-acetaminophen (Norco) tablets from one unit. A facility reported incident documented that two cards of a resident’s hydrocodone-acetaminophen, totaling 60 tablets, were discovered missing from the medication cart. A pharmacy packing slip showed that four cards (120 tablets) of hydrocodone-acetaminophen had been received for this resident and signed for by an RN. A progress note recorded that the resident was found unresponsive at 6:00 a.m., CPR was initiated but unsuccessful, and the resident was pronounced dead at 6:15 a.m. Staff statements and records revealed discrepancies and irregularities in the narcotic count process. One LPN reported last seeing the resident’s hydrocodone-acetaminophen at the end of her shift and, upon returning to work, noted that two cards were missing even though the narcotic count was documented as correct. A narcotic count sheet for the same medication was later signed as having 45 tablets nearly three weeks after the resident’s death. Review of Shift Change/Controlled Substance Inventory Tracker sheets from all six medication carts across the four units showed that two nurses had not consistently signed as required when controlled medication cards and count sheets were added or removed, contrary to the instructions on the forms and facility policy. Further investigation identified that a page was missing from the narcotic count book, which was numbered sequentially, and that a new count page had been started. An LPN who had worked the evening shift before the discrepancy reported that narcotic counts between evening and night shift had been correct, but the night shift nurse only had the new narcotic sheet to reference and was unaware that cards were missing. Another nurse questioned the reduced number of medication cards the following morning. The LPN involved denied that extra cards had been present in the cart but later admitted to starting a new narcotic count sheet, claiming the original sheet was already missing and that the new count was based solely on the medications present in the cart. The facility’s own policies required double-locked storage, accurate shift-to-shift counts by two nurses, proper documentation of controlled drug cards and count sheets, immediate reporting and investigation of discrepancies, and timely removal and destruction of controlled substances after discharge or death, but these procedures were not followed, contributing to the diversion and inaccurate accounting of controlled medications.
Failure to Safeguard and Accurately Account for Controlled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s controlled medications from diversion and to maintain accurate narcotic accountability. A resident with diagnoses including cervical radiculopathy, fibromyalgia, carpal tunnel syndrome, and lumbar disc degeneration had a physician’s order for hydrocodone-acetaminophen (Norco) 5-325 mg, one tablet by mouth every six hours for pain. A pain assessment documented that the resident verbalized severe pain. A pharmacy packing slip showed that a nurse signed for receipt of four cards of 30 Norco tablets (total 120 tablets) for this resident. The resident was later found unresponsive at 6:00 a.m., CPR was initiated but unsuccessful, and the resident was pronounced dead at 6:15 a.m. Subsequently, two full cards of the resident’s Norco, totaling 60 tablets, were discovered missing from the medication cart. A nurse reported that she had last seen the resident’s Norco cards at the end of her shift prior to the discovery, and when she returned to work she noted that two cards were missing even though the narcotic count matched the narcotic count sheets. Staff interviews revealed that the narcotic count sheet for this resident was altered: a page was missing from the narcotic count book, the pages of which were numbered sequentially, and a new narcotic count sheet had been started. The night-shift nurse had only the new narcotic sheet to reference and was unaware that additional cards should have been present. The nurse suspected of involvement admitted starting a new narcotic count sheet but denied removing the original page or taking the missing narcotics. The facility’s records further showed that a narcotic count sheet for the resident’s Norco was still being signed as having 45 tablets nineteen days after the resident’s death, indicating that the medication remained on the cart well beyond the time of death. Staff interviews indicated that, per facility practice and policy, the DON was responsible for destruction of narcotic medications after a resident’s discharge or death, and that narcotics were not to be destroyed by hallway nurses. There was also a delay in removing and destroying the resident’s narcotics from the cart. Review of shift change/controlled substance inventory tracker sheets from all six medication carts showed that two nurses had not consistently signed as required when narcotic cards and count sheets were added or removed, contrary to facility policy that required two-nurse verification of controlled drug counts, cards, and count sheets at each shift change. These actions and inactions resulted in 60 missing Norco tablets and demonstrated a failure to safeguard the resident’s narcotic medications from diversion and to maintain proper chain of custody and documentation.
Failure to Secure Medications and Hazardous Materials
Penalty
Summary
Surveyors observed that the facility failed to secure medications, painting supplies, and hazardous chemicals, resulting in potential accident hazards for residents. In one instance, a resident with moderately impaired cognition and multiple medical conditions, including osteomyelitis, respiratory failure, and dependence on renal dialysis, was found with unidentified pills left unattended at his bedside on multiple occasions. The resident stated that staff routinely left medications for him to take at his discretion, and there was no physician's order or care plan authorizing self-administration of medications. Facility policy explicitly prohibited leaving medications unattended or at the bedside. Additionally, a utility cart containing painting supplies and hazardous chemicals, such as wall putty, caulking, paint remover, cleaner/degreaser sprays, and open buckets of paint, was left unsupervised in a hallway near a resident's room. This resident, who had severe cognitive impairment, autistic disorder, unspecified dementia, and intellectual disabilities, was observed wandering unsupervised and stopping near the cart for extended periods. Staff confirmed the resident's confusion and tendency to wander. Facility policy required hazardous materials to be handled and stored safely, but the cart was not secured as required.
Failure to Administer Insulin per Physician Orders and Manufacturer Instructions
Penalty
Summary
Surveyors identified that the facility failed to ensure insulin was administered in accordance with physician's orders and manufacturer instructions for three residents observed for insulin administration. For one resident with type 2 diabetes and a history of hyperglycemia and ketoacidosis, insulin was routinely administered after meals instead of before meals as ordered. The resident repeatedly complained to staff about high blood sugar readings, delayed insulin administration, and lack of timely physician notification for additional insulin coverage. Documentation showed that blood sugar readings were frequently elevated, with only sporadic documentation of physician notification for extremely high readings. The resident's care plan was not updated after admission, and there were lapses in providing a replacement for his continuous glucose monitoring device. Another resident with type 2 diabetes and diabetic neuropathy was observed receiving Lantus insulin after finishing breakfast, rather than at the prescribed time. The resident's orders required blood glucose testing before meals and timely administration of insulin, but observations and record reviews indicated that insulin was not consistently administered as ordered. Similarly, a third resident with type 2 diabetes was observed receiving Lantus insulin after her blood sugar was checked, with staff indicating that insulin was given according to resident preference or when breakfast trays were served, rather than strictly following the prescribed timing. Interviews with nursing staff revealed inconsistent practices regarding the timing of insulin administration, with some staff prioritizing convenience or resident requests over adherence to physician orders and manufacturer guidelines. Staff also reported challenges in locating residents at medication times and managing multiple diabetic residents, which contributed to delays and deviations from prescribed protocols. Facility policies required medications to be administered as prescribed and at the right time, but these were not consistently followed, resulting in significant medication errors for the residents involved.
Failure to Identify, Assess, and Communicate Pressure Ulcers Resulting in Harm
Penalty
Summary
The facility failed to properly identify, assess, and document wounds for a resident with significant risk factors, resulting in the development and progression of pressure ulcers. The resident, who had a history of hemiplegia, diabetes with neuropathy, Parkinson's disease, and was bedfast with limited mobility, was admitted without skin issues but later developed skin breakdown on the buttocks that progressed to an unstageable pressure ulcer requiring surgical debridement. There was also a failure to assess and treat a Deep Tissue Injury (DTI) on the right heel, which was not identified or documented until brought to staff attention by the resident's representative. Staff did not consistently perform or document weekly skin assessments as ordered, and there were discrepancies in wound identification, staging, and communication among nursing staff, wound care providers, and the primary care physician. Documentation was lacking regarding the identification, measurement, and treatment of wounds, as well as notification of the primary care physician and the resident's representative. The care plan was not updated in a timely manner to reflect the resident's changing skin condition, and interventions such as the use of a low air loss mattress and offloading devices were not consistently implemented or documented. The resident's representative was not kept informed about the extent or severity of the wounds, leading to distress when she discovered the wounds herself. Interviews with staff revealed confusion about roles and responsibilities for wound documentation, notification, and care planning. There were also inconsistencies in the documentation of wound locations and descriptions, and a lack of follow-up on wounds identified during hospitalizations. The facility's failure to identify, assess, and communicate about wounds resulted in harm to the resident, including the need for surgical intervention.
Failure to Update and Personalize Wound Care Plans
Penalty
Summary
The facility failed to ensure that care plan interventions for a resident with multiple complex medical conditions were personalized, implemented, and updated to reflect changes in wound management. The resident had a history of hemiplegia and hemiparesis following a stroke, type 2 diabetes mellitus with neuropathy, Parkinson's disease, encephalopathy, and dysphagia. The initial care plan identified risks for altered skin integrity and included general interventions such as skin assessments, weekly skin checks, and the use of off-loading devices. However, as the resident developed new and worsening wounds, including a full-thickness dermatosis and unstageable pressure ulcers, the care plan was not promptly or adequately updated to address these changes. Physician orders and wound assessments documented the progression of the resident's wounds, including the development of a new full-thickness dermatosis, an unstageable pressure ulcer on the coccyx, and a deep tissue injury (DTI) on the right heel. Orders for specific wound care treatments, such as the application of Triad cream, medical grade honey, and the use of a low air loss mattress, were issued as the resident's condition changed. Despite these changes, the care plan did not consistently reflect the updated interventions or the evolving clinical picture. Documentation also revealed that some wounds were not identified or documented in a timely manner, and there was a lack of detailed information regarding the acquisition, description, and management of certain wounds. Interviews with facility staff indicated that the responsibility for updating care plans in response to new or worsening wounds was not clearly defined or consistently executed. Audits conducted by facility management revealed that a significant proportion of residents with wounds required care plan updates, and that some skin issues were undocumented. The facility's policies required individualized care plans, communication of risk factors and interventions, and ongoing evaluation and modification of care plans, but these practices were not consistently followed for the resident in question.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive and individualized care plans for two residents, leading to deficiencies in addressing their specific needs. Resident 88, who had a history of cerebral amyloid angiopathy, alcohol abuse, and unspecified dementia, exhibited behaviors related to wandering and expressed a strong desire to ride his bicycle, which was not addressed in his care plan. Despite being assessed as at risk for elopement, his care plan lacked person-centered interventions to accommodate his cycling hobby and fitness enthusiasm, resulting in ongoing agitation and wandering behaviors. The staff, including the Social Service Director and LPN, were unsure of how to manage his behaviors effectively, and his care plan was not updated to reflect his preferences or address his irritation about not being able to ride his bike. Additionally, the facility failed to implement a comprehensive care plan for Resident 196, who was admitted with a trans metatarsal amputation (TMA) and other significant medical conditions such as end-stage renal disease and major depressive disorder. The care plan for Resident 196 did not include a problem statement or interventions related to his TMA, indicating a lack of individualized care planning for his specific medical needs. The President of Risk Management confirmed the absence of a care plan for TMA, highlighting a gap in the facility's care planning process.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to reassess the effectiveness of interventions and revise the care plans for two residents, leading to deficiencies in their care. Resident 28, who has hemiplegia and dysphagia, reported difficulty chewing due to poorly fitting dentures and a mechanically altered diet. Despite a care plan revision, there was no documentation of interventions addressing her complaints about chewing and swallowing difficulties. Her care plan was not updated to reflect her dietary needs, and she continued to receive a regular texture diet, which she found difficult to chew, causing discomfort. Resident 241, diagnosed with sepsis and open wounds, was recommended to wear pressure-relieving boots while in bed. However, he consistently refused to wear them, as documented in multiple notes. Despite this ongoing refusal, his care plan did not include interventions to address his refusal or provide guidance for staff on how to manage the situation. The facility also lacked a specific policy related to care plan revision, as confirmed by a registered nurse, which contributed to the oversight in updating the care plans appropriately.
Failure to Ensure Call Light Accessibility and Supervision
Penalty
Summary
The facility failed to prevent potential accidents by not ensuring that call lights were within reach for three residents, leading to increased risk of falls and inadequate supervision. Resident 10, who had left-sided paralysis after a stroke, was observed with her call light on the floor, out of reach, on multiple occasions. This resident had a history of falls, including an unwitnessed fall resulting in a fracture, and was found with unidentified pills at her bedside, which should not have been there according to her care plan. Resident 142, who was admitted for rehabilitation after a back fracture, also had her call light out of reach, leading to a fall when she attempted to transfer herself to the bathroom. Despite interventions to remind her to ask for help, the call light was not consistently placed within her reach, contributing to her falls. Neurological assessments for her falls were incomplete, indicating a lack of thorough follow-up. Resident 15, who had limited arm mobility, was unable to reach her call light, which was often misplaced or hidden. She expressed fear of falling due to her awkward positioning in bed and the absence of her call light within reach. The facility's policies on fall prevention and resident rights were not adhered to, as evidenced by the repeated failure to ensure call lights were accessible, increasing the risk of accidents and compromising resident safety.
Failure to Provide Adequate Nutritional Support for Resident Without Dentures
Penalty
Summary
The facility failed to provide adequate nutritional support for a resident without teeth or dentures, leading to significant weight loss. The resident, who had no natural teeth and lacked dentures, was observed struggling to eat the meals provided, which included hard-to-chew items like fried catfish, chicken wings, and tater tots. Despite expressing a preference for softer foods like Glucerna shakes, these were not consistently provided. The resident's inability to chew the food led to a noticeable weight loss of 11 percent over six months. The resident's medical history included hemiplegia and dysphagia, conditions that necessitate careful dietary management. Despite a speech therapy evaluation and an upgrade to a regular diet, the resident continued to experience difficulty chewing and swallowing. The facility's records showed inconsistent weight monitoring, with the resident not being weighed weekly as recommended after significant weight loss was noted. The resident's weight fluctuated, indicating instability, and no new interventions were implemented despite ongoing weight loss. Interviews with staff revealed a lack of consistent support for the resident during meals. The resident was supposed to receive assistance with meal setup, including cutting food into manageable pieces, but this was not consistently done. Additionally, the facility lacked policies for nutrition management and weight loss management, which contributed to the oversight in addressing the resident's nutritional needs effectively.
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to medication administration protocols for three residents, leading to the administration of unnecessary drugs. Resident 196, who had diagnoses including end-stage renal disease and hypertension, was prescribed metoprolol succinate with specific parameters to hold the medication if systolic blood pressure was less than 110 or pulse was less than 60. Despite these instructions, the medication was administered on multiple occasions when the resident's blood pressure was below the specified threshold, and on several other occasions, the blood pressure was not checked prior to administration. Similarly, Resident 59, with conditions such as end-stage renal disease and dementia, had an order for midodrine to be given if systolic blood pressure was less than 110. However, the medication was not administered when her blood pressure was below this level. Resident 195, diagnosed with end-stage renal disease and heart failure, was prescribed hydralazine with instructions to hold the medication if systolic blood pressure was less than 110. The medication was administered without checking blood pressure on several occasions. The President of Risk Management indicated that staff did not understand the orders, highlighting a failure in executing physician orders as per the facility's policy.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label and manage medications, specifically multi-dose vials of tuberculin serum and insulin pens. During an observation, a vial of Aplisol (tuberculin serum) in the Health unit medication room refrigerator was found without a date indicating when it was opened. Additionally, Health unit medication cart number 2 contained two insulin pens belonging to a resident, with one Semglee (insulin) pen and one Lispro (insulin) pen, both opened on specific dates but not removed after 30 days as required. Another vial of Tubersol (tuberculin serum) in the Heritage unit medication room refrigerator also lacked an opening date. An LPN confirmed that insulin pens are only effective for 30 days after opening. The facility's policy on medication storage, provided by the President of Risk Management, specifies that expiration dates should be determined by the pharmacist and that certain medications require a shorter expiration date once opened to maintain purity and potency.
Failure to Notify Physician of Pressure Ulcer Development
Penalty
Summary
The facility failed to notify the physician of changes in the condition of two residents, Resident B and Resident D, regarding the development of new pressure ulcers. Resident B, who had diagnoses including unspecified dementia, COPD, and hypertensive heart disease, was found to have a new unstageable pressure ulcer on 10/18/24. Although the wound team and family were notified, there was no documentation that the physician was informed of this change. A subsequent consult on 10/22/24 confirmed the presence of the new pressure injury, but the lack of physician notification was noted during an interview with the Regional Clinical Support. Resident D, with diagnoses including hypertension, hyperlipidemia, and peripheral vascular disease, developed a stage 3 pressure ulcer. A nurse's progress note from 9/7/24 indicated the presence of a stage 2 wound, and the wound care team was notified, but there was no documentation of physician or family notification. An observation on 11/15/24 revealed the ulcer had worsened, with a large red open area and blood drainage. The facility's policy on notification of change of condition was not followed, as the physician was not informed of the new pressure ulcer development.
Failure to Prevent and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of a new pressure ulcer for a resident with a history of pressure ulcers and did not ensure timely assessment and treatment of the new pressure ulcer. Resident B, who was totally dependent on staff for all care needs, was observed with a pressure ulcer on her lower sacrum/coccyx area. Despite being compliant with care protocols, the resident developed a new unstageable pressure ulcer, which was not promptly addressed by the facility staff. The resident's medical record indicated a lack of documentation regarding the refusal of care, incontinent check/change care, turning or repositioning, offloading procedures, and other interventions to prevent skin breakdown. The facility's failure to notify the physician of the resident's change in skin condition and the absence of a temporary treatment plan contributed to the worsening of the wound. The wound, initially found by nursing staff, was not assessed by the Wound Nurse Practitioner until several days later, leading to a significant deterioration in the resident's condition. The facility's policies on skin care and wound management, as well as notification of change of condition, were not consistently followed. The resident's wound worsened significantly, resulting in a stage IV pressure ulcer with severe complications, including sepsis and a multifocal infection. The lack of timely intervention and communication among the facility staff and healthcare providers contributed to the resident's deteriorating condition and the development of a severe pressure ulcer.
Failure to Provide Accurate Medication Quantities at Discharge
Penalty
Summary
The facility failed to ensure that residents' discharge instructions accurately reflected their reconciled medications, resulting in residents being sent home without an accurate quantity of medications. For Resident B, who had diagnoses including peripheral vascular disease, type 2 diabetes, hyperlipidemia, morbid obesity, right above knee amputation, and polyneuropathy, the medication discharge form lacked the quantity of three medications: Ozempic, NovoLog pen, and insulin glargine solution. Resident B was discharged to the community on 2/1/24. Similarly, Resident D, who had diagnoses including type 2 diabetes, hemiplegia, cerebral infarction, hyperlipidemia, constipation, polyneuropathy, and hypertension, was discharged to the community on 1/31/24. The medication discharge form for Resident D listed the medication names and directions but lacked the quantity for multiple medications, including clopidogrel, Lantus, multivitamin, Ozempic, pantoprazole, miralax, sodium chloride spray, zinc, acetaminophen, amlodipine, ascorbic acid, carvedilol, ibuprofen, and vitamin D. During an interview, the Executive Director indicated that residents are sent home with all their medications unless they leave against medical advice, in which case they receive three days of medications. The facility's policy on medications upon discharge requires documentation of the name, dose, and quantity of medications sent with the resident, which was not followed in these cases.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
