Paoli Health And Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Paoli, Indiana.
- Location
- 559 W Longest St, Paoli, Indiana 47454
- CMS Provider Number
- 155333
- Inspections on file
- 27
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Paoli Health And Living Community during CMS and state inspections, most recent first.
The facility failed to maintain a safe, sanitary, and homelike environment on multiple halls, as shown by a resident grievance about dirty laundry left in a room, persistent urine odors, and repeated observations of soiled towels and washcloths on room floors. Surveyors also found uncovered and unlabeled toothbrushes stored on sinks and a commode in shared restrooms, as well as uncovered bedpans stored between a handrail and the bathroom wall. An LPN acknowledged that bedpans and toothbrushes should be covered and properly stored in shared restrooms, and a QMA stated that staff should not leave linens on the floor after care, contrary to the facility’s infection control policy for handling linens and patient care equipment.
A resident with heart disease, heart failure, obesity, and atrial fibrillation was admitted from a hospital with an order for metoprolol tartrate 25 mg, 0.5 tablet BID, but the order was incorrectly transcribed into the facility MAR as 25 mg, 1 tablet BID. The resident consequently received four double-dose administrations of metoprolol before becoming short of breath during therapy, with documented hypotension and bradycardia that led to EMS transport and hospital observation. An RN later confirmed the transcription error, and staff described an admission checklist for verifying transfer orders and medications that was available but not required or incorporated into the resident record, despite a facility policy requiring accurate and careful transcription of physician orders.
Surveyors found that staff failed to follow infection control practices during multiple episodes of resident care, including incontinence care and assistance with toileting. CNAs performed dirty tasks such as removing soiled briefs and draw sheets, then moved on to clean tasks like applying new briefs, handling bedside drawers, and repositioning residents without changing gloves appropriately or performing hand hygiene between glove changes. In another case, a resident with an order for enhanced barrier precautions due to MRSA colonization was assisted to and from the restroom by a CNA and an LPN without the use of required gowns or other EBP measures, and the room lacked signage to alert staff that EBP was required, despite PPE supplies being present.
Surveyors found that MDS assessments were not accurately completed for several residents, including failures to document the use of anticoagulant, antiplatelet, and anticonvulsant medications, as well as omissions of cancer diagnoses and recent falls. These inaccuracies were confirmed by staff interviews and review of clinical records and medication administration records.
The facility did not maintain complete and accurate medical records for two residents who self-administered medications, as there were no documented assessments of their ability to do so safely, and for two other residents, documentation of dental and podiatry services was missing from their records. Staff interviews confirmed that required documentation, including service consents and family notifications, was not present in the clinical records.
Staff failed to maintain resident dignity and personal hygiene, including leaving a resident with an uncovered head dressing, not cleaning blood from a dependent resident's neck, failing to provide promised oral care, and not assisting another resident with grooming and cleanliness. These actions did not meet the facility's standards for respect and dignity.
Three residents requiring assistance with ADLs did not consistently receive support for bathing, nail care, and oral hygiene. One resident missed scheduled baths and wore the same clothing for an extended period, another was repeatedly observed with poor personal hygiene and missed showers, and a third had unaddressed nail and oral care needs. Staff interviews and documentation revealed missed care and lack of proper documentation, with no specific ADL policy in place.
A resident with diabetes and depression developed an open boil on the buttock, but after the initial assessment, staff failed to complete and document ongoing measurements and descriptions of the area as required by the care plan and facility policy. The ADON indicated that only certain wounds were routinely measured, and the boil was only visually observed without documentation, resulting in a lack of ongoing assessment for the open skin area.
A resident with a history of TBI, PTSD, and schizophrenia exhibited behaviors such as yelling at staff and refusing care, but staff failed to document these behaviors or update the care plan accordingly. Despite care plans requiring monitoring of behavior and mood due to psychotropic medication use, the facility did not follow its own behavioral health management policy to identify, monitor, and document behavioral events.
Staff did not follow infection control protocols during incontinence and feeding tube care for two residents, including failing to sanitize hands between glove changes, touching clean linens and residents with soiled gloves, and not properly cleaning soiled surfaces or addressing active bleeding. Hand hygiene lapses were observed before, during, and after care, and contaminated items were placed on clean surfaces.
The facility did not ensure all staff received adequate behavioral and mental health training as determined by its own assessment, resulting in insufficient education on individualized care, behavior monitoring, and interventions for residents with conditions such as schizophrenia, PTSD, and TBI. Staff were unaware of some residents' behavioral health diagnoses and appropriate interventions, and resident records lacked proper documentation of behavior monitoring.
A resident in an LTC facility alleged sexual abuse by a CNA, who admitted to inappropriate contact during care. The resident, with a history of cerebrovascular disease and other conditions, required significant assistance. The incident led to the CNA's arrest for sexual battery, highlighting a failure in the facility's abuse prevention policy.
A resident with hemiplegia and hemiparesis fell from a mechanical lift during a transfer, resulting in multiple fractures and a head laceration, leading to her death. The CNAs involved used an incorrect method for placing the lift pad, contrary to the operator's instructions, due to the resident's rigidity. The facility had not conducted specific assessments or provided adequate training for the use of the mechanical lift.
A facility failed to accurately report an allegation of sexual abuse involving a resident and a CNA to the state agency. The resident reported inappropriate contact by the CNA, which was not fully detailed in the facility's report. The CNA was suspended, terminated, and later arrested after admitting to the conduct during a police investigation.
A facility failed to follow a care plan requiring two staff members for a resident's transfer using a Hoyer lift. The resident, with multiple health issues, experienced pain when a CNA attempted the transfer alone, contrary to facility policy. Observations and interviews confirmed the need for two staff members during such transfers.
A resident's privacy was violated when facility staff shared two photographs of her on the facility's social media website without her consent. The resident had explicitly refused permission for her images to be used, as documented in a signed consent form. The images were later removed after the issue was brought to the staff's attention.
Failure to Maintain Sanitary and Homelike Environment in Resident Halls
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, sanitary, and homelike environment on three of four resident halls, as evidenced by persistent odors, improper storage of personal care items, and soiled linens left on floors. A grievance had been filed by a resident in December alleging that dirty laundry was left in the resident’s room. During the survey, a urine odor was noted on the 300 hall on two separate days. Multiple observations showed shared restrooms containing uncovered and unlabeled resident toothbrushes placed on the back of sinks and on the back of a commode, and uncovered bedpans stored between a handrail and the bathroom wall in shared restrooms. Additional observations on several occasions revealed towels and washcloths left on the floors of resident rooms, including near restroom doors, next to beds, and under the foot of beds. In interviews, an LPN stated that resident bedpans should be covered if stored in shared restrooms and that resident toothbrushes should be stored away and covered when in shared restrooms. A QMA stated that staff should not leave linens or washcloths on the floor after providing care and should clean up after themselves following care. Review of the facility’s infection control policy indicated that used linens and patient care equipment should be handled and transported in a manner that prevents exposure and avoids transfer of pathogens to other patients or the environment, which was not followed in these instances.
Medication Transcription Error Leading to Significant Metoprolol Overdose
Penalty
Summary
The deficiency involves a failure to ensure a resident was free from significant medication errors when a hospital discharge order for metoprolol tartrate was incorrectly transcribed into the facility’s medication administration record (MAR). The hospital discharge orders directed metoprolol tartrate 25 mg, 0.5 tablet twice a day, but the facility’s physician orders and MAR listed metoprolol tartrate 25 mg, 1 tablet twice a day. As a result of this transcription error, the resident received double the ordered dose of metoprolol for four administrations: the evening of 12/31/25, the morning and evening of 1/1/26, and the morning of 1/2/26. The resident’s diagnoses included heart disease, obesity, heart failure, and atrial fibrillation. During therapy on 1/2/26, the resident became short of breath, and vital signs showed hypotension with a blood pressure of 86/48 mm Hg and bradycardia with a pulse of 42 BPM. EMS was called, and the resident was transported to the hospital emergency department, where the hospital kept the resident for observation. In interviews, an RN confirmed that the metoprolol order from the hospital discharge paperwork had been entered incorrectly into the facility’s MAR, resulting in the resident receiving twice the ordered dose. Staff also reported that an admission checklist existed which included verification of physician orders and medications by two nurses, but this checklist was not required to be completed and was not part of the resident’s record. The facility’s transcribing orders policy stated that physician orders must be transcribed timely, completely, and accurately, and that great care must be taken to ensure accuracy and completeness when transcribing orders.
Failure to Follow Hand Hygiene, Glove Use, and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during resident care, including improper glove use, lack of hand hygiene, and failure to implement ordered enhanced barrier precautions (EBP). During incontinence care for Resident C, two CNAs removed a wet brief and provided perineal care while wearing gloves, then one CNA applied a new brief, opened a bedside table drawer, retrieved and applied a tube of cream to the perineal area, and returned the tube to the drawer without changing gloves. The CNA then removed gloves, donned new gloves from a pants pocket without performing hand hygiene, and, along with the other CNA, repositioned the resident and adjusted the pillow before finally removing gloves and washing hands. In a separate observation involving Resident D, a CNA removed a soiled brief, provided perineal care, and removed a soiled draw sheet, then removed gloves and put on new gloves without performing hand hygiene. The CNA then held a clean sheet against his scrub top while rolling and placing it under the resident, applied a new brief, and, together with another CNA, adjusted the resident and pillow before removing gloves and performing hand hygiene. Another deficiency occurred with Resident F, who had a physician order for EBP after a positive methicillin-resistant Staphylococcus aureus (MRSA) nare swab at the hospital and documentation that the resident was colonized and to be placed in EBP. During observed assistance of Resident F from bed to the restroom and back, a CNA and an LPN did not wear gowns or implement EBP while providing this personal care. Although PPE supplies were present in the resident’s restroom, there was no signage indicating that EBP was required for the resident. An LPN later indicated that the resident had recently received an order for EBP and that a sign was still needed in the room to indicate to staff that PPE should be used for all personal care, as the physician’s order did not specify particular care tasks.
Inaccurate MDS Assessments for Medications, Diagnoses, and Incidents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for several residents, resulting in incomplete or incorrect documentation of medications, diagnoses, and incidents. For one resident with a history of stroke, hypertension, and congestive heart failure, the most recent MDS assessment did not reflect the use of antiplatelet and anticoagulant medications, despite current physician orders and medication administration records confirming daily administration of these drugs. Another resident with dementia and anxiety experienced multiple falls within the assessment period, but these incidents were not recorded on the corresponding MDS assessment. Additionally, a resident with diabetes, depression, and hypertension had an MDS assessment that failed to accurately document the administration of insulin injections and the use of an anticonvulsant, even though medication records showed consistent administration during the look-back period. In another case, a resident with a diagnosis of malignant melanoma did not have cancer documented on the most recent MDS assessment, despite the diagnosis being present in the clinical record and confirmed by the resident. Interviews with MDS staff confirmed that these omissions were errors and that the information should have been included in the assessments.
Failure to Maintain Complete and Accurate Medical Records for Medication Self-Administration and Ancillary Services
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, specifically in the areas of self-administration of medications and documentation of ancillary services. For two residents who self-administered medications, there was no documented assessment to confirm their ability to safely self-administer, nor was there evidence that staff observed or evaluated their competency in this area. In one case, a resident was permitted to self-inject insulin without any formal assessment or documentation, and staff indicated that no self-administration assessment was completed because they believed the standard questions did not apply. Another resident self-administered a nasal spray without a physician's order or care plan reflecting this preference, and there was no documentation of the resident's ability to use the medication correctly. Additionally, the facility did not accurately document ancillary services for two residents. Family members reported not being informed about dental visits, and clinical records lacked notes from dental and podiatry providers, even though these services were reportedly provided. In one instance, a resident's oral and nail hygiene was observed to be poor, but there was no documentation of recent dental or podiatry visits, nor was there a signed consent or refusal for ancillary services in the clinical record. Staff interviews confirmed that documentation of these services, including refusals and notifications to family, was missing from the residents' records. The facility was unable to provide policies or documentation supporting accurate and complete record-keeping for these areas. While a dental services policy was available, there was no specific policy for accurate documentation, and the nurse job description only generally referenced the need to complete required documentation. The lack of proper documentation and assessments led to incomplete medical records for the affected residents.
Failure to Maintain Resident Dignity and Personal Hygiene
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by multiple observations and interviews involving three residents. One resident with anemia, hypertension, and anxiety disorder was observed with an uncovered, undated yellow gauze dressing on her forehead. The LPN applied the dressing without securing or covering it, despite the resident's preference for it to be covered to avoid feeling stared at. The Assistant Director of Nursing confirmed that the resident sometimes had the gauze covered for dignity reasons, but this was not consistently done. Another resident with traumatic brain injury, schizophrenia, and dysphagia, who was totally dependent on staff, was observed during incontinence care where a CNA leaned over him and roughly removed a soiled sheet while the resident's back was still on it. The resident was left with blood running down his neck from a bleeding sore, which was not cleaned, and staff failed to notify a nurse. Later, the resident, who was NPO, repeatedly requested water, but the nurse did not provide oral care as promised, and a cup of water with a straw was left at the bedside despite the NPO status. The resident's mouth was observed to be in poor condition, with a strong odor and peeling skin inside the mouth. A third resident with Parkinson's disease, dementia, and schizophrenia was observed multiple times with dried food on his mouth and shirt, long fingernails with a brown substance underneath, and a thick white film on his teeth. His hair was also observed to be disheveled. The resident was dependent on staff for personal hygiene, oral care, and grooming, but these needs were not met, as confirmed by both staff and family members. The facility's policy requires residents to be treated with kindness, respect, and dignity, but these standards were not upheld in the care provided to these residents.
Failure to Provide Adequate ADL Assistance Including Bathing, Nail, and Oral Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), including bathing, nail care, and oral care, for three residents who required such support. One resident, who was cognitively intact and required substantial to maximal assistance, reported not receiving scheduled baths and was observed wearing the same dress for over a week. Documentation showed gaps in recorded complete baths, with no refusals documented, despite the resident's care plan specifying her bathing preferences. Another resident, dependent on staff for showering and requiring assistance with personal hygiene, was repeatedly observed with dried food on his mouth and shirt, long fingernails with a brown substance underneath, and a thick white film on his teeth. Family members expressed ongoing concerns about his cleanliness, and records indicated missed showers without documentation of refusals. The care plan conference had previously noted similar issues raised by the resident's wife. A third resident, totally dependent on staff, was observed with long toenails, dirty fingernails, and poor oral hygiene, including strong mouth odor and peeling skin inside the mouth. Although oral care was supposed to be provided, it was not completed as observed. The resident's clinical record showed multiple missed showers without documentation of refusals. Staff interviews confirmed the existence of a shower schedule and expectations for nail and oral care, but also revealed inconsistencies in documentation and follow-through. The facility did not have a specific ADL policy, relying instead on a general resident rights policy.
Failure to Assess and Document Open Skin Area
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services for a resident with an open skin area. The resident, who had diagnoses including diabetes mellitus and depression, was identified as having a boil on the buttock that was open and draining. Although initial documentation included a description and measurement of the area, subsequent assessments and measurements were not completed or documented after the initial event. The clinical record lacked ongoing assessments of the open area, and there was no documentation explaining the discontinuation of prescribed mupirocin ointment. Additionally, the care plan required recording the location, size, and characteristics of the boil, but this was not consistently done. Staff interviews revealed that the resident sometimes refused observation, but at times allowed the area to be checked. The ADON stated that only certain types of wounds were routinely measured and documented, and considered the boil to be similar to a skin tear, which was only visually observed without documentation. The facility's wound management policy required the wound team to assess all new or open wounds, but this was not followed for the resident's boil. As a result, there was a lack of ongoing assessment and documentation for the resident's open skin area.
Failure to Document and Monitor Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with multiple behavioral health diagnoses, including traumatic brain injury, post-traumatic stress disorder, and schizophrenia. Observations showed the resident exhibiting behaviors such as yelling at staff and refusing care, but the clinical record lacked documentation of these behaviors. The resident's care plans for antipsychotic and antidepressant medications included interventions to monitor behavior and mood, yet there was no evidence in the record that these behaviors were being tracked or monitored as required. Interviews with staff, including CNAs and the DON, confirmed that the resident sometimes called staff names, refused care, or isolated himself, but these behaviors were not reflected in the care plan or documented in the clinical record. The facility's own behavioral health management policy required identification, monitoring, and documentation of behavioral events, especially for residents on psychotropic medications, but these procedures were not followed for this resident.
Failure to Maintain Infection Control During Incontinence and G-Tube Care
Penalty
Summary
Staff failed to maintain proper infection control practices during incontinence and feeding tube care for two residents. During incontinence care for one resident, certified nurse aides did not sanitize their hands between glove changes, touched clean linens and the resident's bare skin with soiled gloves, and placed soiled linens on clean bedding. Wash cloths were laid on the side of the bathroom sink, potentially contaminating them, and were then used to wipe the resident. The resident was rolled onto a urine-soaked sheet, and the mattress was not properly cleaned or allowed to dry before clean linens were applied. Additionally, the resident's bleeding chin was not addressed, and blood was left on the resident's neck and bed sheet, which was not changed after care or following medication administration through a gastrostomy tube by a registered nurse. In a separate incident, a licensed practical nurse performed feeding tube care for another resident without proper hand hygiene. The nurse did not clean hands before or after entering the room, handled a soiled washcloth identified as having stool, removed gloves without washing hands, and then donned new gloves. The nurse continued with the feeding tube procedure, including checking tube placement, administering feeding and water flushes, and handling equipment, all without appropriate hand hygiene between tasks. The nurse only washed hands after removing gloves, gown, and mask at the end of the procedure. The infection preventionist confirmed that staff should sanitize hands and change gloves between dirty and clean tasks, avoid touching residents or clean linens with soiled gloves, and ensure soiled linens are not placed on clean bedding. The infection preventionist also stated that contaminated wash cloths should not be placed on the side of the sink, and that mattresses should be cleaned and dried if soiled. The facility's incontinence care skills validation form indicated that hand washing and glove use are required, but these practices were not consistently followed by staff during the observed incidents.
Failure to Provide Adequate Behavioral Health Training and Monitoring
Penalty
Summary
The facility failed to implement a sufficient and competent behavioral and mental health training program for all staff, as required by the facility assessment and resident needs. The facility assessment identified a population with a range of behavioral health needs, including psychosis, impaired cognition, mental disorders, depression, bipolar disorder, schizophrenia, PTSD, anxiety, TBI, Down Syndrome, autism, Alzheimer's disease, non-Alzheimer's dementia, and behaviors requiring intervention. Despite this, in-service training records from the past year lacked documentation of education on individualized care, behavior monitoring, non-pharmacological interventions, and specific approaches for residents diagnosed with schizophrenia, PTSD, and TBI. Staff interviews confirmed a lack of training on these specific diagnoses, with CNAs unaware of certain residents' behavioral health conditions, their triggers, or appropriate interventions. Additionally, the facility's behavioral health management policy required identification, monitoring, and management of behavioral events, as well as individualized services based on resident needs. However, the absence of adequate behavioral health in-services and training led to failures in behavior monitoring and documentation in resident clinical records. Staff were not consistently informed about residents' behavioral health diagnoses or how to address them, resulting in non-compliance with the facility's own policies and regulatory requirements.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by staff, resulting in an incident involving a Certified Nurse Aide (CNA) and a female resident. The resident, who was alert and oriented, alleged that the CNA lifted her gown and engaged in inappropriate sexual contact by licking or sucking on her breast. This incident was reported to have occurred a week prior to the resident's allegation on December 28, 2024. The CNA admitted to the police that he engaged in the act, claiming it was done at the resident's request to silence her. The resident expressed distress during interviews, indicating she did not consent to the act. The resident involved had a medical history that included cerebrovascular disease, major depressive disorder, anxiety, dysphagia, altered mental status, and chronic pain. She required substantial assistance for mobility and toileting, as noted in her care plan. The facility's investigation revealed that the CNA was often alone with the resident and had been accused of inappropriate behavior. The incident was reported to local law enforcement, leading to the CNA's arrest for sexual battery. The facility's policy on abuse prevention was not adhered to, resulting in this deficiency.
Resident Falls from Mechanical Lift Due to Improper Use
Penalty
Summary
The facility failed to ensure a resident was free from accidents during a transfer using a mechanical lift. The incident involved a resident who was being transferred by two CNAs using a mechanical lift. The lift pad was incorrectly placed under the resident's legs instead of through them, contrary to the operator's instructions. This improper method was used due to the resident's rigidity in her lower extremities, and no assessment had been completed to determine if the resident was suitable for this method. As a result, the resident slid feet first out of the lift pad, leading to multiple fractures and a head laceration. The resident, who had a history of hemiplegia and hemiparesis, was dependent on mechanical lift transfers with two assistants. During the transfer, the resident fell approximately 3.5 to 4 feet from the lift, sustaining severe injuries including fractures to both femurs, the left tibia, and the right ankle, as well as a head laceration. The resident was transferred to a local emergency department, where she later expired. The CNAs involved in the transfer did not follow the mechanical lift's operator instructions, which required the lift pad to be placed through the resident's legs unless the resident had good torso stability, which this resident did not possess. The facility's investigation revealed that the CNAs had not been adequately trained or assessed for competency in using the mechanical lift with the under-leg method. The facility lacked specific assessments to determine the appropriate transfer method for residents requiring mechanical lifts. The CNAs involved in the incident were not aware of the correct procedure, and the facility had not provided adequate training or competency checks for the use of the mechanical lift prior to the incident.
Failure to Accurately Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to completely and accurately report an allegation of sexual abuse involving a resident to the state agency. The incident involved a resident who reported that a Certified Nurses Aide (CNA) made inappropriate contact with her chest area during care. The resident initially did not report the incident to staff but mentioned it to a supposed roommate, who did not exist. The facility's investigation did not find any witnesses to the alleged inappropriate actions, but the CNA was suspended and later terminated. A police report was filed, and the police department began an investigation, which led to the CNA's arrest after admitting to the inappropriate conduct. The facility's policy on abuse, neglect, and misappropriation requires immediate reporting of such allegations to the state licensing/certification agency and local law enforcement. However, the facility's report to the state agency was incomplete and inaccurate, as it did not fully detail the nature of the allegation. The police investigation revealed that the CNA admitted to the actions, which were initially reported to the police by the facility staff. The facility's failure to report the complete details of the allegation to the state agency constitutes a deficiency in their reporting obligations.
Failure to Implement Care Plan for Resident Transfer
Penalty
Summary
The facility failed to implement the care plan for a resident who required assistance from two staff members during transfers. The incident involved a resident with multiple diagnoses, including age-related physical debility, contracture of the left knee, and a displaced fracture of the fourth cervical vertebra. The resident's care plan specified the need for assistance with activities of daily living, including transfers, and required the use of a mechanical lift with two staff members present. However, during a transfer, a CNA attempted to use a Hoyer lift alone, causing the resident to experience pain when her leg was pulled. The facility's investigation revealed that the CNA was using the Hoyer lift without a second staff member, contrary to the facility's policy, which mandates at least two trained staff members for safe mechanical lift use. Observations and interviews confirmed that the resident was dependent on transfers and required a mechanical lift with two staff members for safety. The incident was documented in a facility-reported incident and was related to a complaint investigation.
Resident Privacy Violation Due to Unauthorized Social Media Posting
Penalty
Summary
The facility failed to ensure a resident's right to privacy was protected when two photographs of a resident were shared on the facility's social media website without the resident's consent. The resident, who had previously withdrawn permission for her images to be used, was photographed during a solar eclipse and around Easter. These images were later shared on social media, leading to the resident being contacted by a friend who saw the photographs online. The resident had explicitly indicated her refusal to allow her images to be used, as documented in a Photography and Videography Consent Form/Release signed by her. During an interview, the Activity Director acknowledged that the resident had withdrawn her consent and that the images were shared by facility staff without proper authorization. The facility's policy on social media usage clearly states that photographs of residents may only be posted with the resident's knowledge and consent. Despite this policy, the photographs were posted, resulting in a violation of the resident's privacy rights. The images were subsequently removed after the issue was brought to the staff's attention.
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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