Hillcrest Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Jeffersonville, Indiana.
- Location
- 203 Sparks Ave, Jeffersonville, Indiana 47130
- CMS Provider Number
- 155203
- Inspections on file
- 43
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Hillcrest Village during CMS and state inspections, most recent first.
Surveyors found that the facility failed to accurately document narcotic medication administration on MARs for several residents. Controlled substance records showed multiple administrations of PRN and scheduled narcotic pain medications and an anti-anxiety medication, but these doses were not consistently recorded on the corresponding MARs. An LPN reported that narcotics should be documented on both the controlled substance record and the MAR, and facility procedures required recording administration on the EMAR after giving medications, yet this did not occur for multiple documented doses.
QMAs failed to practice within their scope when administering PRN narcotic pain medications and performing advanced wound care. A resident with chronic pain and another with diabetes and depression received PRN narcotic analgesics from a QMA without documented RN/LPN assessment, nurse authorization, or nurse initials on the controlled substance records, despite facility policy requiring nurse assessment and co-signature for PRN administration. In addition, a resident with a stage 4 sacral pressure ulcer had complex wound treatments and wound monitoring signed off by QMAs, even though the facility’s QMA scope of practice prohibits QMAs from providing treatments for stage II–IV pressure ulcers or independently assessing residents’ conditions.
A resident with hypotension had a physician order for Midodrine 5 mg three times daily with instructions to hold the dose if systolic BP was greater than 140. Review of the MAR showed the resident was given Midodrine on two occasions when systolic BP readings were above this parameter. An LPN acknowledged that BP medications should not be given outside ordered parameters, and the DON stated there was no facility policy addressing medication parameters.
The facility failed to ensure ordered wound and pressure ulcer treatments were consistently provided and accurately documented for three residents with Stage 4 pressure ulcers and other chronic wounds. One resident with a sacral Stage 4 ulcer reported that night-shift wound care was not performed, even though an RN had signed the TAR; a subsequent dressing check showed the prior day-shift dressing still in place. Another resident with heel and buttock wounds had missing TAR documentation for several shifts and reported that a buttock wound treatment was not done, while the dressing in place matched the prior day-shift application despite the TAR indicating completion by night shift. A third resident with a coccyx/sacral Stage 4 ulcer had multiple shifts with no TAR documentation of the ordered every-shift wound care.
A resident with traumatic brain injury, anoxic brain damage, schizophrenia, and quadriplegia was physically abused by a CNA during a transfer to bed. While assisting with care, the resident punched and spat on the CNA and verbally insulted her, after which the CNA, by her own account and corroborated by another CNA, became angry and struck the resident on the right side of the face multiple times with an open hand, including hitting the resident in the mouth. Subsequent assessment documented scratches to the resident’s forehead and right brow and a swollen, discolored upper lip. These actions occurred despite a facility policy that prohibits willful physical abuse such as hitting or slapping residents.
The facility did not ensure that the administration of narcotic medications was properly documented in the MARs for three residents, despite records showing the medications were given. Staff confirmed that documentation should occur at the time of administration, and facility policy requires recording in both the MAR and controlled substances inventory, but this was not followed.
Blood pressure medications were administered to two residents with hypotension despite physician orders to hold the medication for out-of-parameter systolic blood pressure readings. An LPN confirmed that medications should not be given when blood pressure is outside the specified range, but records showed multiple instances where midodrine was administered contrary to orders.
A resident with multiple health conditions requiring assistance with ADLs did not consistently receive scheduled showers. The care plan specified two showers per week, but records showed multiple instances of missing documentation, indicating showers were not provided. Interviews with the resident and staff confirmed the deficiency, with staff acknowledging that blank shower sheets meant showers were not given.
Two residents experienced delays in receiving their prescribed medications due to issues with pharmacy services and medication availability. One resident, with chronic respiratory and pain conditions, missed multiple doses of Percocet, while another resident with acute respiratory failure and other conditions faced delays in receiving scheduled antibiotics. Staff interviews highlighted that medications should not take days to arrive, yet the facility encountered significant delays despite having 24-hour pharmacy access.
A resident with hypertension and hemiparesis experienced multiple instances of elevated blood pressure readings over several months, which were not communicated to the physician as required by the facility's policy. Despite the resident's blood pressure consistently exceeding the acceptable range, the clinical record lacked evidence of physician notification. A Nurse Practitioner confirmed that such changes should have been reported immediately.
A facility failed to conduct a self-administration assessment for a resident, resulting in medications being left at the bedside without proper authorization. The resident, with a history of hypertension, hemiparesis, hemiplegia, and diabetes, was observed with morning medications on the bedside table. Interviews confirmed the absence of a self-administration assessment or physician's order, contrary to facility policy.
A resident with a history of hypertension and CVA experienced consistently high blood pressure readings without adequate follow-up or rechecks by the facility. Despite a care plan that included monitoring and medication administration, the resident frequently refused medication and called 911 due to feeling unwell. Interviews with staff revealed the resident's noncompliance with the medication regimen, and the facility failed to implement sufficient monitoring or interventions to address the resident's condition effectively.
A facility failed to accurately document medication administration for a resident with hypertension and diabetes. The MAR lacked records for metformin and hydralazine on several occasions, and a one-time clonidine order was not documented. An LPN confirmed the requirement to sign off medications on the MAR, and the DON provided a procedure document emphasizing this practice.
A resident reported an incident of verbal abuse by an LPN to another LPN, who informed the Executive Director. However, the Executive Director claimed no such report was made, and the facility failed to document or report the incident to the Indiana Department of Health as required by their policy.
A facility failed to document a resident's blood pressure before administering Clonidine, a medication for hypertension, as required by the physician's order. The resident's blood pressure was not recorded on several occasions, and there was no explanation for withholding the medication on one occasion. An LPN confirmed the necessity of documenting blood pressure when parameters are in place, highlighting a procedural lapse.
Failure to Accurately Document Narcotic Medication Administration on MARs
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of accurate medication administration records for multiple residents receiving narcotic medications. For one resident with osteomyelitis and necrotizing fasciitis, the controlled substance record showed multiple administrations of PRN Oxycodone-Acetaminophen on specific dates and times in March and April 2026, but the corresponding MARs for those months lacked documentation of these administrations. An LPN stated that narcotic medications should be documented both on the controlled substance record and the MAR, indicating that this dual documentation did not occur as required. Similar documentation gaps were found for three additional residents. One resident with rheumatoid arthritis and chronic pain syndrome had several administrations of PRN Oxycodone recorded on the March 2026 controlled substance record, but these doses were not documented on the March MAR. Another resident with multiple sclerosis and generalized anxiety had scheduled Oxycodone-Acetaminophen doses and Lorazepam doses missing from the March MAR on specific dates and times. A fourth resident with diabetes, depression, and peripheral vascular disease had multiple administrations of PRN Hydrocodone-Acetaminophen documented on the April 2026 controlled substance record, but none of these were recorded on the April MAR. The facility’s written procedure stated that medication administration would be recorded on the EMAR after being given, but the survey findings showed that this did not occur consistently for these narcotic medications.
QMAs Functioning Outside Scope for PRN Narcotics and Stage 4 Wound Care
Penalty
Summary
The deficiency involves failure to ensure qualified medication aides (QMAs) practiced within their defined scope and that care was provided by qualified persons according to each resident’s written plan of care. For one resident with rheumatoid arthritis, chronic pain, and osteoarthritis, a physician’s order directed PRN oxycodone 5 mg every 4 hours for pain. Documentation showed that a QMA administered the PRN narcotic, but the clinical record lacked evidence of a licensed nurse’s initials on the controlled substance record, a documented nursing assessment prior to administration, and documented permission from a licensed nurse, contrary to facility practice as described by an LPN. For another resident with a stage 4 sacral pressure ulcer, the physician’s order required cleansing with normal saline, packing with Dakin’s-soaked gauze, and covering with an ABD pad twice daily, and a separate order required monitoring the sacral wound for signs of infection or decline. The treatment administration record showed QMAs signed off as having completed the stage 4 wound treatment and the monitoring of the stage 4 sacral wound, despite the QMA scope of practice prohibiting them from performing treatments involving stage II–IV pressure ulcers. A third resident with diabetes and major depression had a physician’s order for PRN hydrocodone-acetaminophen 5-325 mg every 8 hours for pain. Records indicated a QMA administered the PRN narcotic, but the clinical record again lacked documentation of a licensed nurse’s initials on the controlled substance record, a nursing assessment prior to administration, and documented permission from a licensed nurse. The facility’s QMA Parameters and Scope of Practice, provided by the DON, specified that QMAs may not assess a resident’s condition and may administer previously ordered PRN medications only after contacting a licensed nurse, documenting the contact, symptoms, permission, and time, and ensuring the record is co-signed by the nurse by the end of the shift or next tour of duty. The same scope document also stated that QMAs may not administer treatments involving advanced skin conditions, including stage II, III, and IV pressure ulcers. These documented practices and omissions show that QMAs performed tasks outside their authorized scope and without required licensed nurse assessment and documentation.
Failure to Hold Midodrine When Blood Pressure Exceeded Ordered Parameters
Penalty
Summary
A resident with a diagnosis that included hypotension had a physician’s order, dated 3/3/26, for Midodrine 5 mg to be administered three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m., with instructions to hold the medication if the systolic blood pressure was greater than 140. Review of the March 2026 medication administration record showed that the resident received Midodrine on two occasions when the systolic blood pressure exceeded the ordered parameter: once with a systolic blood pressure of 157 and once with a systolic blood pressure of 150. In an interview, an LPN stated that blood pressure medications should not be administered if they are not within the physician-ordered parameters, and the DON reported that the facility did not have a policy related to medication parameters. These findings demonstrate that the facility failed to ensure the resident’s blood pressure medication was held when the blood pressure was out of the ordered parameters for one of five residents reviewed for quality of care.
Failure to Provide and Accurately Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer and wound care every shift and to accurately document wound treatments on the treatment administration record (TAR) for multiple residents with Stage 4 pressure ulcers and other chronic wounds. For one resident with a Stage 4 sacral pressure ulcer, the physician ordered wound cleansing with normal saline, application of bacitracin, packing with Dakin’s-moistened gauze, skin prep to the peri-wound, and coverage with a bordered dressing every shift. An anonymous complaint alleged that this resident repeatedly requested night-shift wound care from a specific RN, who did not perform the treatment. Although the April TAR showed the treatment as completed by that RN on a specific night, a CNA reported the resident’s concern that the treatment had not been done, and another RN later confirmed that the dressing in place was still the one applied by the prior day-shift nurse, indicating the night-shift treatment had not been completed as documented. Another resident with a chronic non-pressure ulcer of the left heel and mid-foot and a Stage 4 pressure ulcer to the left buttock had physician orders for heel wound care with betadine and Optifoam every shift, and for buttock wound care with cleansing, packing with normal saline–moistened gauze, skin prep, and a bordered dressing every shift. The March TAR lacked documentation of completed heel wound treatments on two specified shifts, and the resident later reported that the buttock wound treatment was not completed on a particular night. A CNA relayed this concern to an RN, who found that the dressing in place was still the one applied by the prior day-shift nurse, despite the April TAR indicating the night-shift RN had completed the treatment. A third resident with a Stage 4 coccyx/sacral pressure ulcer had orders for wound cleansing with normal saline, peri-wound skin prep, packing with Dakin’s-soaked gauze, and coverage with an ABD pad and tape every shift; review of the March and April TARs showed multiple shifts with no documentation of completed wound treatments. A nurse interview confirmed that nurses are expected to sign the TAR when they complete wound treatments.
Staff-to-Resident Physical Abuse During Transfer
Penalty
Summary
The facility failed to protect a resident from staff-to-resident physical abuse when a CNA intentionally struck the resident during care. The resident involved had significant medical conditions, including traumatic brain injury, anoxic brain damage, schizophrenia, and quadriplegia, and was observed on a later date resting in a reclining high-back wheelchair, well groomed and without visible facial injuries. According to an incident report and subsequent wound assessments from the date of the event, the resident sustained a right forehead scratch measuring 2 cm by 0.1 cm, a right eyebrow scratch measuring 0.1 cm by 0.5 cm, and a swollen area of the right upper lip measuring 0.3 cm by 1.8 cm, all without depth. During a telephone interview, the CNA admitted that while assisting with transferring the resident to bed, the resident punched her in the face and spat on her multiple times, after which she became angry and smacked the resident on the right side of the face before leaving the room and self-reporting the incident to the Executive Director. Another CNA who assisted with the transfer reported that the resident cursed at and verbally insulted the first CNA, which appeared to trigger her, and that the CNA then approached and smacked the resident multiple times with an open hand on the right side of the face. The second CNA further stated that before she could intervene, the resident spat on the first CNA, who then struck the resident again in the mouth with an open hand. The Unit Manager later assessed the resident and confirmed the presence of a scratch to the forehead, a scratch near the right brow, and a swollen, discolored upper lip. These actions occurred despite the facility’s written abuse policy, which prohibits physical abuse and defines it as a willful act such as hitting or slapping a resident.
Failure to Document Narcotic Medication Administration in MARs
Penalty
Summary
The facility failed to ensure that medication administration records (MARs) accurately reflected the administration of narcotic medications for three residents. For one resident with diagnoses including anxiety, diabetes, and chronic pancreatitis, the MAR did not document the administration of prescribed Xanax and oxycodone, despite the controlled substance record indicating these medications were given on multiple occasions. Similarly, another resident with depression and rheumatoid arthritis received Tramadol as documented in the controlled substance record, but the administration was not recorded in the MAR for both March and April. A third resident with a left femur fracture and osteoarthritis was administered hydrocodone-acetaminophen, as shown in the controlled substance record, but the MAR lacked corresponding documentation. Interviews with staff confirmed that the MAR should be signed when narcotic medications are administered. The Director of Nursing provided a policy stating that administration of controlled substances must be recorded in both the MAR and the controlled substances inventory record at the time of administration. Despite this policy, the required documentation was missing from the MARs for all three residents, as observed during the review.
Failure to Hold Blood Pressure Medication per Physician Orders
Penalty
Summary
The facility failed to ensure that blood pressure medications were held according to physician-ordered parameters for two residents diagnosed with hypotension. For one resident, midodrine was ordered to be held if the systolic blood pressure (SBP) exceeded 135 mmHg or diastolic blood pressure (DBP) exceeded 85 mmHg. Despite this, the medication was administered when the resident's SBP was 142 mmHg. An LPN confirmed during interview that blood pressure medications should not be given when readings are outside the specified range. For another resident, midodrine was ordered to be held if the SBP was greater than 140 mmHg. The medication administration record showed multiple instances where midodrine was administered despite SBP readings ranging from 144 to 151 mmHg. These actions were not in accordance with the physician's orders and the residents' clinical needs as documented in their records.
Inconsistent Shower Provision for Resident
Penalty
Summary
The facility failed to consistently provide showers for Resident 84, who was reviewed for Activities of Daily Living (ADL) care. Resident 84 had multiple diagnoses, including Parkinson's disease, spinal stenosis, type 2 diabetes mellitus, and reduced mobility, which necessitated staff assistance for ADL tasks. The care plan for the resident, dated 9/6/24, specified that the resident should receive two showers per week, with partial baths in between, and assistance with other ADL tasks as needed. However, a review of the resident's shower report records revealed multiple instances in December 2024 where documentation was lacking, indicating that the resident did not receive the scheduled showers. Interviews with the resident and staff members confirmed the deficiency. The resident reported not receiving the showers as scheduled, stating she was supposed to get two showers a week but was lucky to get one. Certified Nursing Aides (CNAs) and a Licensed Practical Nurse (LPN) confirmed that the shower sheets were supposed to be checked off when showers were given, and if the sheets were blank, it meant the showers were not provided. The Director of Nursing (DON) also indicated that staff should document on the shower report sheet when a shower was given and what care was provided.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received their medications as ordered and in a timely manner. Resident 62, who had diagnoses including acute and chronic respiratory failure, COPD, asthma, and chronic pain, did not receive their prescribed Percocet on multiple occasions due to issues with medication availability and prior approval requirements. The resident's care plan emphasized the importance of administering pain medications as ordered, yet there were repeated instances where the medication was unavailable, and the pharmacy was notified but did not provide the medication promptly. The Director of Nursing acknowledged the challenges with obtaining prior approvals and indicated that medications should not take more than a few hours to a day to be delivered. Resident 64, diagnosed with acute respiratory failure, atrial fibrillation, cardiomegaly, type 2 diabetes, hypertension, and chronic pain, also experienced delays in receiving their scheduled antibiotic treatment. The resident's vascular access was replaced, and a scheduled dose of meropenem was administered late. Additionally, three doses of IV antibiotics were missed, and the pharmacy was informed of the need to extend the order due to these missed doses. The facility's Emergency Drug Kit did not have the correct dose available, and the reconstitution was out of stock, further delaying the administration of the medication. Interviews with facility staff, including an LPN, revealed that medications should not take days to arrive and that the facility had access to pharmacy services 24 hours a day. Despite having a backup pharmacy, the facility experienced significant delays in obtaining necessary medications, impacting the timely administration of prescribed treatments for the residents involved.
Failure to Notify Physician of Resident's Out-of-Range Blood Pressure
Penalty
Summary
The facility failed to notify the physician when a resident's blood pressure readings were outside the established parameters. Resident B, who had a history of hypertension and left-sided hemiparesis secondary to a cardiovascular accident, experienced multiple instances of elevated blood pressure readings over several months. These readings were consistently above the acceptable range set for the resident, with systolic pressures reaching as high as 200 mmHg and diastolic pressures exceeding 100 mmHg on numerous occasions. Despite these out-of-range blood pressure readings, the clinical record did not show any evidence that the physician was notified of these changes in the resident's condition. During an interview, a Nurse Practitioner confirmed that such high or low blood pressures should be considered a change in condition, warranting immediate notification to the physician. The facility's policy on resident change of condition, which mandates communication with the physician for any changes, was not adhered to in this case.
Failure to Conduct Self-Administration Assessment for Resident Medications
Penalty
Summary
The facility failed to ensure that medications for a resident, identified as Resident B, were not left at the bedside without a self-administration assessment. Resident B, who has a medical history including hypertension, left-sided hemiparesis, hemiplegia secondary to a cerebral vascular accident (CVA), and diabetes, was observed with a medication cup containing six tablets/capsules on her bedside table. These medications were scheduled to be administered between 7:00 a.m. and 11:00 a.m. and included Amlodipine, Aspirin, Clopidogrel, Metformin, Metoprolol, and Hydralazine. However, there was no documentation in the clinical record of a self-administration medication assessment or a physician's order allowing Resident B to self-administer these medications. During interviews, an LPN confirmed that Resident B did not self-administer medications and that the medications observed were her morning doses. The Director of Nursing also confirmed that Resident B did not have a medication self-administration assessment. The facility's policy on self-administration of medications, dated January 2015, requires an interdisciplinary team assessment and a physician's order for a resident to self-administer medications. This deficiency was identified during a complaint investigation related to Resident B.
Failure to Monitor and Intervene for Resident with High Blood Pressure
Penalty
Summary
The facility failed to ensure increased monitoring and interventions for a resident with consistently high blood pressure and a history of cardiovascular accident. The resident, diagnosed with hypertension and CVA with left-sided hemiparesis, had a care plan that included various interventions such as medication administration, monitoring vital signs, and notifying the physician of any changes. Despite these interventions, the resident's blood pressure readings were frequently out of the acceptable range, and there was a lack of follow-up or documented rechecks for these elevated readings. The resident often refused the prescribed hydralazine medication, believing it was too strong, and this refusal was communicated to the nurse practitioner. The resident's blood pressure remained high, leading to multiple instances where the resident called 911 due to feeling unwell. The facility's records showed numerous instances of elevated blood pressure readings without appropriate follow-up or rechecks, indicating a failure to adequately monitor and address the resident's condition. Interviews with facility staff, including an LPN and a nurse practitioner, revealed that the resident was noncompliant with the medication regimen, often refusing medications and calling emergency services instead. The nurse practitioner noted the resident's noncompliance and did not make changes to the medication regimen, considering the resident's refusals as non-compliance. Despite the resident's high blood pressure readings and frequent calls to emergency services, the facility did not implement sufficient monitoring or interventions to address the resident's condition effectively.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident diagnosed with hypertension and diabetes. The resident's care plan required the administration of metformin and hydralazine as ordered by the physician. However, the Medication Administration Record (MAR) for October 2024 lacked documentation of metformin administration on two occasions and hydralazine on multiple occasions. Additionally, a one-time order for clonidine was not documented in the MAR, indicating a failure to record the administration of this medication. During an interview, an LPN confirmed that medications should be signed out on the MAR once administered, and one-time orders should be entered and signed off in the electronic medical record. The Director of Nursing provided a document outlining the medication administration procedure, which emphasized the need for recording medication administration on the MAR after it is given. This deficiency was identified during a complaint investigation, highlighting lapses in the facility's medication administration documentation process.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility management failed to report an incident of alleged verbal abuse involving a resident, identified as Resident B, to the Indiana Department of Health. Resident B, who was alert and oriented, reported having multiple negative interactions with an LPN, specifically mentioning an incident where the LPN became aggressive after a request for pain medication. The LPN allegedly called Resident B a 'smart a**,' to which Resident B responded in kind. This incident was reported by Resident B to another LPN, who then informed the Executive Director (ED). However, the ED indicated that no such report was made to him, and the facility's records for June 2024 did not document this allegation of verbal abuse. The facility's policy, titled 'Abuse Prohibition, Reporting, and Investigation,' mandates that all abuse allegations must be reported to the ED immediately and to the Long-Term Care Division of the Indiana Department of Health within two hours. Despite this policy, the facility did not provide any additional information related to the incident, and the required report was not made. This deficiency was identified during a review of the facility's handling of the complaint, which was related to Complaint IN00436365.
Failure to Document Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's blood pressure was obtained prior to the administration of Clonidine, a medication prescribed for hypertension. The clinical record for Resident D, who has diagnoses including cardiovascular disease and hypertension, was reviewed. The physician's order specified that Clonidine 0.1 mg should be administered every six hours, with the condition that it should be held if the systolic blood pressure was less than 100. However, on multiple occasions in June 2024, the medication was administered without documenting the resident's blood pressure. Additionally, on June 8, 2024, the Clonidine was not administered as it was on hold, but there was no documentation explaining why the medication was withheld. During an interview, an LPN confirmed that blood pressure should have been documented and obtained prior to medication administration when parameters are in place. The Director of Nursing provided a document titled Medication Administration, which included the requirement for obtaining vital signs if necessary, indicating a procedural lapse in this instance.
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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