Riverside Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkhart, Indiana.
- Location
- 1400 W Franklin St, Elkhart, Indiana 46516
- CMS Provider Number
- 155695
- Inspections on file
- 29
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Riverside Village during CMS and state inspections, most recent first.
The facility failed to ensure residents could file grievances anonymously as required by its own grievance policy. During a Resident Council meeting, multiple residents reported that grievance forms were kept behind the nursing station and could only be obtained by asking staff, preventing anonymous submission. In an interview and observation, the Executive Director confirmed that grievance forms were stored behind the nurse’s station, were not directly accessible to residents, and were not present in the wall-mounted holder at the station. This practice affected all residents in the facility and conflicted with the written policy stating that residents, representatives, and families may submit grievances anonymously.
Surveyors found unsanitary food storage and equipment conditions in the kitchen, including mildew on a freezer seal, expired concentrated beef broth base that had not been discarded, unlabeled house-made shakes in the freezer, and grease buildup on the side of the stovetop and oven, all contrary to facility policies on food storage and kitchen cleanliness. During a lunch meal observation in the main dining hall, a CNA repeatedly handled cups by touching the rims and even placing fingers inside a coffee cup before pouring and serving beverages to a resident, in violation of the facility’s policy requiring avoidance of contact with food-contact surfaces on drinkware and dishes.
A resident with chronic CHF, receiving a daily diuretic, had a physician’s order for daily weights and provider notification for a weight gain of 3 lbs in one day or 5 lbs in one week. Documentation showed the resident’s weight increased by 3.1 lbs in one day, but the physician was not notified as required by the order. During interview, the DON acknowledged the physician should have been notified and reported that the facility did not have a specific policy on following physician orders, relying instead on standards of practice.
A resident with Alzheimer’s disease, dementia, anxiety, and schizophrenia was repeatedly observed with a strong urine odor in her room and in common areas, wearing the same ill-fitting, increasingly soiled clothing over several days, and hoarding paper towels without staff intervention. Records showed she had moderate cognitive impairment, occasional incontinence, and needed assistance with toileting and hygiene, yet her care plans, while listing multiple behavioral concerns and refusals of care, lacked individualized behavioral interventions. The resident’s guardian reported longstanding poor hygiene behaviors and stated the facility was not addressing them or communicating about behavioral health. Facility staff, including an LPN, a social services staff member, and the psychiatric NP, indicated that behaviors and refusals were not consistently documented or reported, and the NP was not advised of issues that might require intervention. No behavioral health program policy was provided when requested.
A resident with multiple chronic conditions, including dementia and psychosis, was started on Divalproex and received it continuously for several months while also receiving antianxiety, antidepressant, anticonvulsant, and hypnotic medications. The care plan identified risk for adverse effects from anticonvulsant use and called for labs as ordered, and a physician ordered a one-time ammonia and valproic acid level. However, this lab order was discontinued without the tests ever being completed, and no valproic acid or ammonia levels were obtained or followed up, despite facility policy requiring tracking and investigation of outstanding labs. This failure to perform and track ordered lab monitoring for the anticonvulsant regimen resulted in a deficiency related to unnecessary medications.
A resident with dementia and multiple comorbidities, who required partial assistance with bathing and had a care plan specifying twice-weekly showers, was repeatedly observed with greasy, unkempt hair. Review of EMR and shower sheets over about a month showed inconsistent provision of showers, limited documented attempts after refusals, and weeks in which the resident was only offered or received one shower despite the schedule. Nursing notes lacked documentation of shower refusals, and staff interviews confirmed that expected re-approach and nurse notification procedures were not reflected in the record. Leadership reported there was no facility policy governing ADL provision, including showers and baths.
A resident with a history of chronic pain and recent injury was not properly assessed or treated for pain upon admission, despite physician orders for as-needed pain medication. During evening care, the resident experienced severe pain, which was not addressed by staff through assessment or medication, resulting in the resident calling 911 and leaving the facility for hospital care.
The facility did not obtain or complete required discharge documentation for several residents, including missing physician orders for discharge, incomplete discharge summaries lacking key clinical and personal information, and failure to provide or document discharge medications as required by policy. These deficiencies affected residents with complex medical needs and were confirmed through record review and staff interviews.
The facility failed to store food safely in the kitchen, potentially affecting 70 residents. An observation revealed open and unsealed bags of frozen peas and mixed vegetables in the reach-in freezer. The Culinary Nutrition Manager confirmed that these bags should have been sealed after use.
The facility failed to document and notify the transfer of two residents to the hospital. A resident with mild cognitive impairment was hospitalized without a completed transfer/discharge assessment. Another resident with dementia and anxiety disorder was transferred to a psychiatric hospital without the necessary transfer forms. Staff interviews confirmed the lack of required documentation, which was against the facility's policy.
The facility failed to provide bed hold policies to two residents during hospital transfers. One resident with mild cognitive impairment did not receive the policy before hospitalization, and another with dementia and anxiety disorder lacked documentation of the policy during a psychiatric hospital transfer. Staff interviews confirmed the omission, despite facility policies requiring the provision of bed hold policies at the time of transfer.
The facility failed to provide timely ADL care for three dependent residents, including nail care, shaving, and repositioning. A resident with multiple health issues had long, dirty nails despite requests for trimming. Another resident, with hemiparesis, was not shaved by staff and had to rely on a roommate. A third resident, with impaired mobility, was not repositioned as required. The facility lacked specific ADL policies, relying on checklists without frequency guidelines.
A facility failed to timely address pharmacy recommendations for a resident's medication regimen, which included multiple medications for conditions such as anxiety and repeated falls. Despite pharmacy reviews in August and September recommending a decrease in gabapentin due to fall risk, the physician did not address these until October, determining gabapentin was unrelated to falls. The DON confirmed that recommendations should be addressed within 30 days, as per facility policy.
A CNA failed to follow infection control practices by not wearing gloves or a gown while changing bed linens for a resident in an Enhanced Barrier Precautions (EBP) room. The CNA was unaware of the resident's EBP status, despite signage indicating the need for precautions due to the resident's chronic wounds and risk of MDRO colonization.
A resident with multiple diagnoses did not receive prescribed medications on several occasions due to unavailability. The facility failed to notify the physician about the missed administrations, as required by their policy. The Director of Nursing and Regional Nurse Consultant acknowledged the oversight, which led to the deficiency.
A resident with multiple diagnoses did not receive prescribed medications on several occasions due to unavailability and lack of timely administration. The facility's policy required obtaining medications from the emergency supply or arranging immediate delivery, but this was not followed. The MAR noted the unavailability of drugs, and the Director of Nursing acknowledged the issue, highlighting a failure in adhering to the 'five rights' of medication administration.
A resident with multiple diagnoses did not receive prescribed medications, Caplyta and Pregabalin, on several occasions due to unavailability. The facility failed to follow its policy on medication shortages, which required notifying the physician and seeking alternative instructions. The Director of Nursing confirmed the order was sent timely, but the medication did not arrive immediately.
Failure to Provide Anonymous Access to Grievance Forms
Penalty
Summary
The facility failed to honor residents’ right to file grievances anonymously by not making grievance forms readily and independently accessible to residents. During a Resident Council meeting, all 12 residents present reported that grievance forms were kept behind the nursing station and that they had to ask staff to obtain a form, which prevented them from submitting grievances anonymously. In a subsequent observation and interview, the Executive Director confirmed that grievance forms were located behind the nurse’s station and were not available for residents to access without staff assistance, and also noted that there were no forms present in the plastic wall hanger behind the nurse’s station at that time. This practice conflicted with the facility’s written “Resident Concerns and Grievances” policy, which states that residents, representatives, and family members have the right to file grievances orally or in writing, to file grievances anonymously, and that grievances can be submitted anonymously with anonymity maintained by the Grievance Official throughout the resolution process. As a result, for all 65 residents in the facility, grievance forms were not readily available in a manner that allowed anonymous submission, and residents were required to request forms from staff, contrary to the facility’s stated policy and residents’ rights to file grievances without fear of reprisal or discrimination.
Unsanitary Kitchen Conditions and Improper Handling of Drinkware During Meal Service
Penalty
Summary
Surveyors identified that the facility failed to maintain sanitary conditions in the kitchen and main dining hall. During a kitchen tour with the Dietary Manager, a two-door upright freezer was observed with a thick black substance on the rubber seal and adjacent stainless steel, which the Dietary Manager identified as mildew. In the walk-in cooler, a container of concentrated beef broth base was found with a best-by date of 12/2025, and the Dietary Manager acknowledged it should have been discarded in January. The freezer also contained four house-made shakes that were unlabeled and undated, contrary to facility policy requiring opened and prepared foods to be labeled and dated. Additionally, a large area of dark brown substance, identified by the Dietary Manager as grease, was observed on the side of the stovetop and oven, indicating that kitchen equipment was not kept clean as required by the facility’s kitchen cleanliness policy. During a lunch meal observation in the main dining hall, a CNA was seen handling drinkware in a manner that did not prevent contamination of food contact surfaces. The CNA cupped her hand over a plastic cup of water, touching the rim where a resident would drink, and similarly placed her fingers on the drinking area of a coffee cup before serving it to the same resident. She also put her fingers inside a resident’s coffee cup before pouring coffee and again placed her hands on the rim of another cup of water while serving it. These actions conflicted with the facility’s meal service and distribution policy, which requires utensils, cups, glasses, and dishes to be handled in a way that avoids touching any food contact surface. The Dietary Manager later confirmed that the correct method of serving drinks is to hold the bottom of the cup and keep fingers away from the drinking surface.
Failure to Notify Physician of Significant Weight Gain for Resident With CHF
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to notify the provider of a specified weight gain for a resident with chronic congestive heart failure (CHF). Record review showed that the resident, who was receiving a daily diuretic for CHF per a Quarterly MDS dated 1/12/2026, had a physician’s order dated 1/14/2026 to be weighed daily and for the physician to be called for a gain of 3 pounds in one day or 5 pounds in one week. The MAR documented that the resident’s weight was 197 pounds on 2/8/2026 and 200.1 pounds on 2/9/2026, reflecting a 3.1-pound gain in one day. Despite this documented weight increase meeting the threshold in the physician’s order, the MAR indicated that the physician was not notified of the 3.1-pound gain. In an interview, the DON confirmed that the physician should have been notified of the weight gain and stated that the facility did not have a policy regarding following physician orders, indicating they followed standards of practice instead.
Failure to Provide Individualized Behavioral Health Interventions and Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including individualized behavioral interventions, for a resident with significant behavioral-emotional issues. Surveyors repeatedly observed the resident and her room with a very strong odor of urine on multiple days and at various times, including in her room and in the dining room. The resident was also observed hoarding paper towels from a dispenser in the dining room, folding them, and placing them under her arm while staff present did not intervene. Over several days, the resident was seen wearing the same ill-fitting, oversized clothing that dragged on the ground, hung off her buttocks, and became visibly stained, with a strong urine odor detectable from several feet away. Record review showed the resident had diagnoses including Alzheimer’s disease, dementia, generalized anxiety, and schizophrenia, with a recent MDS indicating moderate cognitive impairment, occasional bladder incontinence, and a need for assistance or supervision with toileting, personal hygiene, dressing, and showering. A nurse practitioner note documented that the resident was co-managed with psychiatry, was not taking medications for schizophrenia, and was receiving supportive care only due to non-compliance related to psychosis. The resident’s care plans listed multiple behavioral concerns such as difficulty adjusting to changes, self-hitting while talking to imaginary persons, refusing showers and facial hair trimming, rummaging through others’ belongings, refusing assessments, refusing to wear incontinence briefs and using textured bath towels instead, carrying plastic bags with belongings, and episodes of verbal and combative agitation. However, the care plans lacked personalized interventions specifically aimed at preventing or managing these behavioral issues. Interviews further demonstrated a lack of coordinated behavioral health intervention and documentation. The resident’s guardian reported that the resident would not use the toilet, instead stacking towels under herself to urinate on, and stated that the facility allowed these behaviors to continue without doing anything for her situation or discussing her behavioral health. The guardian also reported not being contacted by the psychiatric NP about the resident’s behavioral issues and being told that nothing could be done because the resident would not take medication. The floating SSD acknowledged that refusals to change clothing and shower should have been charted as behaviors and became tearful after noting the strong urine odor in the resident’s room. Nursing staff stated they tried different staff and times to approach the resident but acknowledged that care plan interventions were not specific to her needs. The psychiatric NP reported not being informed of behavioral complaints, refusals of care, or documented behaviors, and the Executive Director stated that the resident had rights, had refused clothing changes, and was content and at baseline. When requested, the facility did not provide a behavioral health program policy prior to survey exit.
Failure to Complete Required Lab Monitoring for Anticonvulsant Therapy
Penalty
Summary
Surveyors identified a deficiency related to failure to ensure a resident’s drug regimen was free from unnecessary drugs by not completing required blood monitoring for an anticonvulsant medication. The resident had multiple diagnoses including dementia, psychosis, anxiety, anemia, atherosclerotic heart disease, severe protein-calorie malnutrition, spondylosis, hypertension, dysphagia, hydronephrosis, hypotension, obstructive and reflux uropathy, and atrophy of the kidney. A quarterly MDS assessment documented that the resident was receiving antianxiety, antidepressant, anticonvulsant, and hypnotic medications. The care plan, initiated in mid-November, identified the resident as being at risk for adverse side effects related to anticonvulsant/antiseizure medication use, with interventions that included obtaining labs as ordered. Physician’s orders showed that Divalproex (Depakote) 125 mg, two capsules twice daily, was started in mid-November, and MARs for November, December, January, and February showed the resident received this medication continuously from mid-November through late February. A physician’s order dated in mid-November directed a one-time blood draw for ammonia and valproic acid levels, but this lab order was discontinued later in November without the tests ever being completed. During interviews, the DON acknowledged that the valproic acid level was intended to be drawn and that no lab results could be found in the chart. The DON further stated that the lab order had been discontinued later in November after being ordered earlier that month. The Regional Director of Clinical Services confirmed that the resident had not had any valproic acid or ammonia levels monitored at all while receiving Divalproex. The facility’s policy on lab and radiology tracking, provided by the DON, required confirmation that each ordered lab was obtained and that any labs not resulted as expected be investigated, but the ordered monitoring labs for this resident were not completed or followed up, leading to the cited deficiency.
Failure to Provide and Document Scheduled Showers and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received showers and ADL care as planned and documented. Surveyors repeatedly observed the resident in the Memory Care unit with greasy, unkempt, and disheveled hair over several days. Review of the clinical record showed the resident had multiple significant diagnoses, including Alzheimer’s disease, paranoid schizophrenia, diabetes mellitus, severe protein-calorie malnutrition, vascular dementia, and other conditions. A recent MDS indicated the resident had both short- and long-term memory problems, moderately impaired cognitive skills for daily decision-making, and required partial assistance with bathing and showering. The care plan documented that the resident refused showers and required staff to explain tasks in detail, allow time to process, and continue to encourage care as tolerated. The care plan also specified assistance with ADLs, including offering showers twice weekly in the morning or early afternoon per the resident’s preference. Review of the EMR and shower sheets for a one-month period showed inconsistent provision and documentation of showers and shower attempts. The records showed a shower on one date in late January, a single documented refusal with no further attempts that week, and another shower at the end of January. In early February, there was one documented refusal with no further attempts that week, followed by three documented attempts on another date, a shower on a mid-February date, and three documented refusals on a later date. Nursing notes did not contain documentation of the resident’s refusals to shower during the review period. Interviews with staff indicated that the expectation was to attempt showers up to three times, then notify the nurse so the refusal could be documented in the EMR, but there was no explanation for why the resident was only offered or received one shower in certain weeks and why nursing notes lacked refusal documentation. The Regional Director of Clinical Services stated the facility did not have a policy for providing ADLs, including showers and baths.
Failure to Assess and Manage Resident Pain Leading to Hospital Transfer
Penalty
Summary
A resident with a complex medical history, including left shoulder and arm pain, multiple sclerosis, spastic hemiplegia, polyneuropathy, and chronic pain, was admitted to the facility following a recent hospital stay for similar complaints. Upon admission, the resident reported new onset pain, and physician orders included as-needed oxycodone-acetaminophen for pain management. However, there was no documentation of further pain assessments or administration of pain medication on the day of admission, despite the resident's ongoing pain. Later that evening, during routine care, the resident expressed significant pain when repositioned by CNAs, who then returned her to a more comfortable position. The resident subsequently called 911 due to unresolved pain and left the facility against medical advice. Interviews with staff revealed that pain assessments were not conducted as required, and pain medication was not offered or administered, even though the resident was visibly in distress. The facility's pain management policy required pain assessment upon admission and during medication administration, but these procedures were not followed in this case.
Failure to Ensure Complete and Proper Discharge Documentation and Orders
Penalty
Summary
The facility failed to ensure proper discharge documentation and procedures for five out of six residents reviewed for transfer or discharge. In multiple cases, residents were discharged without a physician's order authorizing the discharge, as required by facility policy. For example, several residents with complex medical histories, including conditions such as cerebral palsy, diabetes, hypertension, and heart failure, were discharged home without the necessary physician documentation. Interviews with the Regional Director of Clinical Services confirmed that physician orders should have been present for each discharge but were missing in these cases. Additionally, the discharge summaries and clinical narratives for these residents were incomplete or missing critical information. Key sections such as transportation arrangements, customary routines, continence status, cognitive patterns, dental and nutritional status, vision, pressure ulcer/injury status, mood and behavior patterns, activity pursuits, psychosocial well-being, and physical functioning were left blank in the electronic records. In some instances, the discharge medication lists were not included, and the summaries lacked signatures from the residents or their representatives. The facility's own policies required that these sections be completed using information from the most recent Minimum Data Set (MDS) assessment, but this was not consistently done. Furthermore, there were failures in the handling of medications at discharge. In at least one case, medications that should have been sent home with the resident were instead returned to the pharmacy, contrary to physician orders. The facility's policies stipulated that a reconciliation of discharge orders and medications should be completed, and that a physician's order must specify if medications are to be sent with the resident. These steps were not followed, resulting in incomplete or missing discharge instructions and medication lists for the affected residents.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food in a safe and sanitary manner in the kitchen, which had the potential to affect 70 of 71 residents who consumed food prepared there. During an observation of the kitchen, an open and unsealed bag of frozen peas and an open and unsealed bag of frozen mixed vegetables were found in the reach-in freezer. The Culinary Nutrition Manager, during an interview, acknowledged that the bags of opened, frozen food should have been sealed after use.
Failure to Document and Notify Resident Transfers
Penalty
Summary
The facility failed to provide proper documentation and notification for the transfer of two residents to the hospital. Resident 21, who had mild cognitive impairment, was hospitalized but the facility did not complete the required transfer/discharge assessment. Interviews with staff revealed that the necessary paperwork was not filled out prior to the resident's transfer, and the transfer/discharge assessment was not found in the resident's chart. The Infection Prevention Nurse confirmed that the assessment was not completed, which was against the facility's protocol. Similarly, for Resident 48, who had diagnoses including unspecified dementia and generalized anxiety disorder, the facility did not document the transfer to a psychiatric hospital for evaluation and treatment. The required hospital transfer forms were missing from the electronic medical record. An LPN confirmed that the necessary transfer paperwork was not completed, which should have included an emergency transfer observation, CCD, and bed hold policy. The facility's policy, revised in 2019, mandates that these documents be attached to the resident's medical record during a transfer, but this was not adhered to in these cases.
Failure to Provide Bed Hold Policies During Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold policies to residents or their representatives at the time of hospital transfer, as required. This deficiency was identified for two residents. Resident 21, who had mild cognitive impairment, was hospitalized and did not recall receiving any paperwork, including the bed hold policy, prior to her transfer. Interviews with facility staff revealed that the bed hold policy should have been included in the paperwork sent with the resident, but it was not found in the resident's records. Similarly, for Resident 48, who had diagnoses including unspecified dementia and generalized anxiety disorder, there was no documentation of the bed hold policy being provided at the time of transfer to a psychiatric hospital. Staff interviews confirmed that the necessary transfer paperwork, which should have included the bed hold policy, was not completed. The facility's policies, as provided by the Regional Nurse, indicated that the bed hold policy should be given to residents at the time of hospital transfer, but this was not adhered to in these cases.
Deficiencies in ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely Activities of Daily Living (ADLs) care for three dependent residents, specifically in the areas of nail care, shaving, and turning and repositioning. Resident 15, who is blind and has multiple diagnoses including Parkinson's disease and congestive heart failure, was observed with long, dirty fingernails despite requesting assistance multiple times. His care plan indicated he required assistance with ADLs, but his requests for nail trimming were not fulfilled, leading to a scab under his eye from scratching himself. Resident 38, who has conditions such as radiculopathy and hemiparesis, expressed dissatisfaction with his facial hair and long fingernails, having requested assistance multiple times without receiving it. Despite his care plan indicating a need for assistance with grooming and hygiene, he was not shaved by staff and had to rely on his roommate for help. The Executive Director acknowledged the oversight but was unaware that staff had not provided the requested care. Resident 14, with a history of cerebrovascular diseases and impaired mobility, was observed lying supine in bed with a wedge cushion next to him, indicating a lack of adherence to his care plan, which required turning and repositioning every two hours to prevent skin breakdown. Interviews with CNAs revealed inconsistencies in care practices, and the facility lacked specific policies for providing ADLs to dependent residents, relying instead on checklists that did not specify the frequency of care tasks.
Delayed Response to Pharmacy Recommendations for Medication Review
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for a resident reviewed for unnecessary medications. The resident, who had diagnoses including generalized anxiety, radiculopathy, hemiparesis/hemiplegia, and repeated falls, was taking multiple medications such as buspirone, diazepam, trazodone, fluoxetine, and gabapentin. A pharmacy review conducted in August and September 2024 recommended decreasing the gabapentin dose due to the potential increased risk for falls. However, these recommendations were not addressed by the physician until October 2024, when the physician decided that the gabapentin was unrelated to the falls. During an interview, the Director of Nursing (DON) indicated that pharmacy recommendations should be addressed when received or at least within 30 days. The facility's current policy, dated October 2018, also stated that pharmacy recommendations should be reviewed with follow-up to the physician within 30 days of receipt. The delay in addressing the pharmacy's recommendations for the resident's medication regimen led to the deficiency noted in the report.
Infection Control Breach in EBP Room
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for a staff member providing high contact care in an Enhanced Barrier Precautions (EBP) room. During an observation, a CNA was seen changing bed linens for a resident in isolation without wearing gloves or a gown, which are required under EBP. The CNA was unaware of the resident's EBP status, as she had not noticed the sign indicating the precautions on the resident's door. The resident in question had a history of type 2 diabetes with a foot ulcer and was at risk for colonization with a Multi-drug Resistant Organism (MDRO) due to chronic wounds. The care plan for the resident, initiated months prior, specified the need for EBP, including the use of gowns and gloves during high contact care activities. The facility's policy on EBP, provided by the Regional Nurse, also outlined these requirements, indicating a failure in adherence to established protocols.
Failure to Notify Physician of Missed Medication Administrations
Penalty
Summary
The facility failed to notify the physician of multiple missed medication administrations for a resident diagnosed with Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder, and chronic low back pain. The resident had prescribed medications including Baclophen, Caplyta, and Pregabalin, which were not administered on several occasions due to unavailability. The Medication Administration Record (MAR) indicated that Baclophen was missed on specific dates and times, with no nursing comments explaining the omissions. Caplyta and Pregabalin were also not administered on multiple occasions, with nursing comments noting the unavailability of the drugs. The Director of Nursing acknowledged that the physician should have been notified when medications were not available for administration, and the MAR should have reflected the reasons for non-administration. The facility's policy on medication shortages required the nurse to obtain medications from the Emergency Medication Supply or contact the attending physician for new orders if an emergency delivery was unavailable. However, these steps were not followed, leading to the deficiency. The Regional Nurse Consultant confirmed that the physician should have been informed about the missed medication administrations.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician. Resident C, who had diagnoses including Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder, and chronic low back pain, did not receive prescribed medications on multiple occasions. The medications in question were Baclophen, Caplyta, and Pregabalin, which were not administered at various times between June 10 and July 2, 2024. The Medication Administration Record (MAR) indicated that Baclophen was missed on several dates and times without any nursing comments explaining the omissions. Caplyta and Pregabalin were also not administered on specific dates, with the MAR noting that the drugs were unavailable. The facility's policy on medication shortages required staff to obtain medications from the emergency supply or arrange for immediate delivery if necessary. However, the Director of Nursing and the Regional Nurse Consultant acknowledged that the facility did not have Caplyta in the emergency supply and that the physician should have been notified when medications were unavailable. The pharmacy's Proof of Delivery statement confirmed that the medications were shipped and received by the facility, but there was a delay in administration. The failure to administer medications as prescribed violated the standard nursing practice of the 'five rights' of medication administration, which includes administering medications at the right time as intended by the prescriber.
Failure to Provide Timely Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medications in a timely manner, resulting in multiple missed doses. Resident C, who had diagnoses including Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder, and chronic low back pain, did not receive their prescribed Caplyta and Pregabalin medications on several occasions. The Medication Administration Record (MAR) indicated that the medications were unavailable, and the facility did not have Caplyta in their emergency medication supply. The Director of Nursing confirmed that the order for Caplyta was sent to the pharmacy in a timely manner, but the medication did not arrive immediately. The facility's policy required staff to notify the physician if medications were unavailable and to seek alternative instructions, which was not done in this case. The Regional Nurse Consultant also noted that the physician should have been notified when the resident did not receive medications as ordered. The facility's policy on medication shortages was not followed, leading to the deficiency.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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