Signature Healthcare Of Muncie
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 4301 N Walnut St, Muncie, Indiana 47303
- CMS Provider Number
- 155242
- Inspections on file
- 48
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Signature Healthcare Of Muncie during CMS and state inspections, most recent first.
Dishwasher sanitization was not properly verified when repeated testing showed no sanitizing solution in the final rinse water, despite a dish room log indicating 100 ppm and an illegible signature. The Dietary Manager stated there had been a problem with testing and documentation for about a month, and maintenance records noted clogging and parts replacement on the machine. All but one resident ate meals prepared in the facility kitchen.
A facility locked a dementia unit without documented IDOH approval and without records showing that several residents met criteria for secured placement. Staff said the unit was locked for secured dementia care, but the charts for multiple residents lacked physician evaluations, care conferences, IDT notes, or documented wandering/exit-seeking before the unit was secured. The residents had diagnoses including dementia, Alzheimer’s disease, and neurocognitive disorder, and their MDSs generally showed severe cognitive impairment but no maladaptive behaviors.
Medication Left Unattended Without Self-Administration Assessment: An RN prepared multiple meds for a cognitively intact resident with CHF, HTN, anemia, GERD, and pulmonary issues, then left the medication cup in the resident’s room while she went to the cart and was out of sight. The resident questioned the pills, poured them onto the bedside table, and the RN returned multiple times to identify and remove one medication. The record had no self-administration assessment or order, and staff confirmed meds should not be left unattended without one.
A cognitively intact resident with depression, AFib, and COPD was told by the Interim Administrator to wear a hood while going outside to smoke, even though his care plan and smoking assessment did not require it. When the resident refused, the administrator reportedly pulled the hood up on him multiple times, and the resident said he felt embarrassed and humiliated in front of other residents. Witness statements and facility records reflected the same smoke-break incident and showed the resident had the right to choose his attire without coercion or interference.
Missing Transfer Notices, Bed Hold Information, and Receiving-Facility Communication: Three residents were transferred to the hospital after acute changes in condition, including hypoxia, lethargy with facial drooping and weakness, and a fall with pain and altered speech. Records showed staff notified the physician and family and completed transfer paperwork, but documentation was missing for communication to the receiving facility and for providing/reviewing the written transfer/discharge notice and bed hold policy with the resident or resident representative.
A resident admitted with a feeding tube, acute pancreatitis, gastrostomy status, and protein-calorie malnutrition did not have a baseline care plan in the record. The resident had orders for enteral feeding tube site care and Jevity 1.5 via feeding tube. An LPN was unsure who completed baseline care plans, while an RN stated the admitting nurse or next shift nurse was responsible for finishing the admission checklist and baseline care plan within 24 hours, and the Corporate Nurse Consultant confirmed the facility could not provide the required baseline care plan.
A resident with a feeding tube had a clogged tube and later showed tan drainage, redness, and tenderness at the insertion site, with the bumper shifted outward. RN documentation and report did not show physician notification or charting of the change in condition, and the record lacked documentation related to the clogged g-tube and site changes.
Failure to Post Current Nursing Staffing Information: The facility did not have current and accurate daily nurse staffing postings available for residents and visitors. A posted staffing sheet was found to be dated earlier than the observation date, and another posting showed a different census and staffing hours. The Scheduler said he was new and used an online system to populate the form, while the Corporate Nurse Consultant stated the postings should have been updated daily and that the weekend postings were not accurate.
QAPI Program Failed to Sustain Monitoring of Medication Self-Administration Assessments. The facility had a repeated deficiency involving self-administration of medications, with prior survey findings showing that a medication self-administration assessment was not completed before medications were left unattended in a resident's room. During the current survey, staff reported the QAA committee reviewed concerns quarterly and used mock surveys, but there was no current QAPI or PIP in place for this issue, and the same concern was again identified for a resident during observation, interview, and record review.
Failure to follow EBP during feeding tube site care. An RN provided tube site care to a resident with a gastrostomy and malnutrition, but did not wear a gown, did not perform hand hygiene after removing the soiled dressing, and leaned against the resident’s bedding during care. The resident had an EBP order, and the IP stated gown and gloves were required for any manipulation of the feeding tube.
Surveyors found that food was not consistently served at proper temperatures for safety and palatability. During a test meal tray temperature check, milk measured 46°F and coleslaw measured 64.2°F, and the Dietary Manager acknowledged the milk temperature was too high for service. The Dietary Manager reported that food temperatures were checked before plating, after which food was placed in meal carts and delivered to the halls. These practices did not comply with the facility’s written policy requiring food to be served at safe, appetizing temperatures appropriate to the type of food.
A resident with severe cognitive impairment and multiple medical conditions was hospitalized with altered mental status and found to have unprescribed barbiturates and opiates in her system, requiring Narcan administration. Despite concerns of a medication mix-up and facility policy requiring immediate reporting of potential neglect, the incident was not reported to the state health department because no medication error was confirmed by staff.
A resident with severe cognitive impairment was found to have received unprescribed substances, including opiates and barbiturates, resulting in hospitalization and Narcan administration. The facility's investigation into the incident was incomplete, lacking statements from key staff, emergency medical services, and the resident's roommate, and did not document who completed resident questionnaires or when. The investigation did not meet the facility's policy requirements for investigating alleged violations involving neglect.
A resident with multiple comorbidities was admitted with several pressure injuries, but the facility failed to consistently assess, document, and implement appropriate interventions for these wounds. Wound measurements and characteristics were incompletely recorded, some treatments lacked physician orders, and care plans for pressure injuries were not fully implemented in a timely manner, resulting in a deficiency in pressure injury management.
The facility did not report suspected drug diversion involving narcotic medications for four residents to the appropriate regulatory agencies. Discrepancies in medication administration and documentation were identified, including mismatched narcotic counts and missing signatures. Staff observed an LPN impaired at work and found narcotic counts to be off, but a thorough reconciliation was not performed and the required reporting was not completed.
The facility did not thoroughly investigate suspected drug diversion after discrepancies were found between narcotic sign-out sheets, eMARs, and medication counts for several residents receiving narcotic pain medications. Staff interviews revealed confusion about medication administration, and the Corporate Nurse Consultant did not reconcile records or report the issue to regulatory agencies.
The facility did not ensure accurate documentation and reconciliation of controlled medications for multiple residents with chronic pain and complex medical needs. Discrepancies were found between eMARs, narcotic sign-out sheets, and physical medication counts, with doses administered at unscheduled times, missing signatures, and unaccounted-for tablets. Staff interviews revealed confusion about medication administration responsibilities and failure to follow facility policy for controlled substance handling and documentation.
A resident with multiple chronic conditions and a history of verbal aggression was discharged after a verbal altercation and police involvement, but the facility failed to provide supporting documentation or rationale for the discharge, did not address the resident's needs or preferences, and did not offer the resident the opportunity to return after hospital observation, resulting in a deficiency related to safe and appropriate discharge procedures.
The facility failed to provide adequate dietary staff, resulting in significant delays in dinner meal delivery to residents on three units. Observations and interviews revealed that meal trays were often delivered 30 to 57 minutes late, leading to resident dissatisfaction and cold meals. Despite awareness and some managerial interventions, the issue persisted due to understaffing and ineffective solutions.
The facility failed to inform residents of their right to verbally rescind arbitration agreements within 30 days and did not allow rescission for subsequent stays. This affected 57 residents, with staff uncertain about the rescission process and lacking a policy for arbitration agreements.
A resident was found self-administering multiple eye drops without a completed self-administration assessment or proper physician orders. Staff were aware of the situation, but no formal assessment was conducted to ensure the resident's ability to safely manage her medications, contrary to facility policy.
A resident's funds were misappropriated after a CNA assisted with an online order using the resident's debit card, against facility policy. The resident, who was cognitively intact, reported missing his debit card and unauthorized charges. The facility lacked a clear policy for handling such requests outside normal business hours, contributing to the deficiency.
A resident with a history of UTIs and sepsis experienced a worsening condition due to a UTI, leading to hospitalization. Despite severe symptoms and requests for hospital evaluation, the facility delayed intervention and antibiotics. The care plan lacked specific interventions for sepsis, and the DON prioritized in-house treatment over hospital transfer. The facility's policy on change of condition notification was not effectively followed, contributing to the resident's hospitalization for sepsis.
A facility failed to securely store smoking materials for a resident who was cognitively intact and used oxygen therapy. The resident retained her smoking paraphernalia in her room, contrary to the facility's policy, which required staff to manage and store all smoking materials in a locked tackle box. Interviews revealed that the facility did not track the receipt and return of smoking materials, leading to a deficiency in maintaining a safe environment.
The facility failed to properly label and store medications in two medication rooms and two medication carts. Open vials of vaccines lacked open dates, and loose, unlabeled medications were found in a medication cart. Additionally, treatment cart medications lacked resident identifiers. The facility did not follow its policies or manufacturer guidelines for medication storage and labeling.
The facility failed to implement an effective QAPI program, leading to repeat deficiencies in infection control and medication labeling. Despite having a QAA committee, there were no current PIPs for isolation procedures or medication storage. The survey found issues with labeling and storage in medication rooms and carts, and inadequate infection control measures for two residents.
The facility failed to implement effective infection control measures for two residents, leading to confusion and improper use of PPE. One resident had conflicting isolation orders and unclear PPE requirements, while another lacked necessary signage and PPE for wound care. The Infection Preventionist acknowledged the issues and delayed implementation of Enhanced Barrier Precautions.
A facility failed to maintain its AED in working condition, leading to its inability to function during a cardiac arrest emergency involving a resident. The AED's battery was dead, and staff were unclear about who was responsible for its maintenance. The facility lacked a system for routine monitoring of the AED, and there was no policy in place for its upkeep.
A facility failed to prevent verbal abuse by a CNA towards a resident who required assistance with all ADLs. The CNA used inappropriate language when the resident had feces on her bed sheets and hands. Despite another CNA's intervention, the resident was left alone with the abusive CNA, contrary to the facility's abuse policy. The investigation concluded with no substantiation of abuse, and the Administrator believed the staff acted appropriately.
A facility failed to accurately assess and promptly treat a pressure ulcer for a resident, leading to a deficiency in care. The resident, initially assessed with no wounds, developed a skin tear on the sacrum that was later reclassified as a pressure ulcer. The facility did not implement a care plan with individualized interventions, and treatment orders were delayed by 11 days. Inconsistencies in wound documentation and categorization were noted, and the resident was discharged with the wound still present.
A facility failed to create a care plan for a resident with a history of alcohol use and aggression. The resident, with a complex medical history, was involved in a physical altercation and exhibited aggressive behavior towards staff, requiring police intervention. Despite known behaviors, no care plan or interventions were documented, violating facility policy on comprehensive care plans.
A resident was verbally abused by a CNA, who made derogatory remarks and neglected to provide care, leading to a confrontation. The resident, with multiple medical conditions, reported feeling singled out. The facility's policy on verbal abuse was violated, and the CNA was suspended pending investigation.
A facility failed to report a verbal abuse allegation to the State Agency within the required timeframe. A resident alleged that a CNA intentionally skipped providing ice water, resulting in a loud verbal exchange. The incident was reported three days later, contrary to the facility's policy requiring reporting within two hours.
The facility failed to provide scheduled showers and bed baths for two residents, despite their care plans and preferences. One resident, who required assistance, received only four out of 12 scheduled showers over 29 days, while another resident, dependent on staff for bathing, received only two out of 13 scheduled bed baths over 30 days. Staff often cited time constraints, and the facility did not assess bathing preferences, violating resident rights.
A resident with anemia due to gastrointestinal blood loss did not receive the physician-ordered copper sulfate medication upon admission to the facility. The pharmacy received the order late and did not have the medication in stock, leading to a delay in administration. The facility's DON and nurse practitioner were informed of the issue, but the medication was not obtained promptly, violating the facility's policy to contact the prescriber when medication is unavailable.
The facility failed to ensure effective monitoring and services for a resident who experienced acute abdominal pain and requested hospital transfer. Despite complaints and requests, staff did not perform adequate assessments or notify the physician timely, resulting in delayed treatment and emergent hospitalization for a perforated bowel with sepsis, requiring surgical intervention and a permanent colostomy.
Dishwasher Sanitization Not Properly Verified
Penalty
Summary
The facility failed to ensure dishware and utensils were washed in a method that ensured proper sanitization. During an observation of dishwasher testing, the Dietary Manager tested the dishwasher three separate times and each attempt registered no sanitizing solution in the final rinse water. The Dietary Manager then obtained a second container of sanitation test strips and ran the dishwasher cycle again, which again showed no sanitizing solution in the final rinse. A facility testing log posted in the dish room indicated the sanitizer that morning had tested at 100 ppm, but the signature on the log was illegible, and no employee present in the dietary department indicated they had made the entry. The two employees working in the dish room stated they had not made the entry, and the Dietary Manager did not know who had completed it. A facility poster in the dishwasher room stated the chemical sanitizing PPM range was between 50 and 100. The Dietary Manager stated during interview that there had been a problem with proper testing and documentation of dishwasher sanitation for about one month. A maintenance company report documented parts replaced on the machine, including the squeeze tube and sanitizer-related components, and noted clogging on the bottom nozzle with the arm replaced. Facility education materials stated that all dishware, serviceware, and utensils were to be cleaned and sanitized after each use and that sanitizer concentration logs were to be completed as appropriate. The Corporate Nurse Consultant stated that only one resident did not consume food orally, and all other 111 residents ate meals prepared in the facility's kitchen.
Locked dementia unit placed residents without required approval or documented need
Penalty
Summary
The facility failed to protect residents’ rights to be free from involuntary seclusion when it locked a dementia unit without documented approval from the Indiana Department of Health and without showing that residents on the unit met criteria for placement in a secured unit. The report states the facility had a secure dementia unit, but it could not provide a dementia disclosure form completed before the unit was locked, and leadership could not locate a Certificate for Occupancy issued by IDOH. During interviews, facility leaders and nursing staff stated the unit was locked in response to an identified need for secured dementia care in the community, while staff who worked on the unit reported they were unaware of residents displaying exit-seeking behavior before or after the doors were locked. For Resident 6, the record showed diagnoses including vascular dementia, depression, anxiety, and diabetes mellitus. The resident lived in the same room before and after the unit was locked, and the chart lacked documentation of wandering, exit-seeking, a physician evaluation supporting secured placement, a care conference with the representative, or an IDT note addressing the need for a secured dementia unit before the order to admit to a gated community. The resident’s MDS assessments before and after the change indicated severe cognitive impairment but no maladaptive behaviors, including wandering. Similar gaps were identified for Resident 87, whose diagnoses included Alzheimer’s disease, anxiety, mood disturbance, and unspecified dementia; the record lacked documentation of wandering, physician evaluation, care conference, and IDT review before the secured-unit order, and the resident remained in the same room after the unit was locked. Resident 94’s record showed vascular dementia, peripheral vascular disease, and hypertension, with a physician order to admit to a gated community due to vascular dementia with mild agitation. The chart lacked documentation of wandering or elopement attempts before the unit was locked, and the resident’s MDS assessment indicated severe cognitive impairment with no maladaptive behaviors during the assessment period. Resident 12 had diagnoses including Alzheimer’s disease, major depressive disorder, and autistic disorder, and the record similarly lacked documentation supporting the need for a secured unit before the order; the resident’s MDS assessments showed severe cognitive impairment and no wandering. Resident 3 had diagnoses including neurocognitive disorder with Lewy bodies, cognitive communication deficit, and visual hallucinations, but the record lacked documented wandering, physician evaluation, care conference, and IDT documentation before the gated-community order. Observations showed these residents in the secured unit dining area, in their rooms, or participating in activities after the unit had been locked, while the clinical records indicated their rooms were not relocated and the change in services was the locking of the unit.
Medication Left Unattended Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure a self-administration of medication assessment was completed before medications were left unattended in a resident’s room. During a medication administration observation, an RN prepared acetaminophen, acetazolamide, bumetanide, carvedilol, a multivitamin, ferrous sulfate, omeprazole, and spironolactone for a resident who was cognitively intact and had diagnoses including hypertension, pulmonary hypertension, pleural effusion, acute on chronic systolic CHF, anemia, and GERD. When the resident questioned an extra pill and declined to take another water pill, the RN was unsure which pill was acetazolamide and left the medication cup in the resident’s room while she went to the medication cart, out of line of sight of the room. The resident poured the medications onto the bedside table and looked through them while the RN was away. The RN later returned with the acetazolamide card, removed that medication, and then left again to retrieve all of the medication cards so she could identify each pill for the resident. The resident’s record did not contain a medication self-administration assessment or order. Staff interviews indicated medications should not be left unattended in a resident’s room unless there was a self-administration order, and the DON confirmed medications should not be left with a resident out of the nurse’s line of sight unless such an order existed.
Resident’s Choice About Smoking Attire Not Respected
Penalty
Summary
The facility failed to promote and protect a resident’s right to make choices concerning personal attire when going outdoors to smoke. Resident 43 was cognitively intact, had diagnoses including depression, atrial fibrillation, and COPD, and was documented as safe to participate in supervised smoking. His care plan addressed his wish to smoke, but it did not include any requirement to wear a hood or hat when smoking, and the smoking assessment also did not indicate that a hat or hood should be worn. During a smoke break, the Interim Administrator told residents they would need to wear their heaviest coats and have hats or hoods because of the cold wind chill. Resident 43 refused to wear his hood and stated he did not want to and did not have to. According to the resident, the Interim Administrator said, “I make the rules here,” put hands on his shoulders, and yanked the hood up on his head. The resident pushed the hood down, and the Interim Administrator yanked it up again and then a third time. The resident stated he felt embarrassed and humiliated, and that other residents witnessed the interaction. Confidential interviews and witness statements described the same smoke break and indicated the Interim Administrator pulled Resident 43’s hood up after the resident refused to comply. One witness stated the administrator treated the resident like a child and put hands on him, while another stated the administrator asked everyone to put their hoods up and did not believe he was abusive. The facility’s resident rights policy stated residents have the right to be treated with respect and dignity and to exercise their rights without interference, coercion, or discrimination, and the abuse policy defined mental abuse to include humiliation and demeaning behavior. The resident council minutes and smoking policy did not address a requirement for hats or hoods when smoking.
Missing Transfer Notices, Bed Hold Information, and Receiving-Facility Communication
Penalty
Summary
The facility failed to ensure that written transfer/discharge notices and bed hold policy information were provided to residents and/or their resident representatives, and failed to ensure information was communicated to the receiving facility for three residents transferred to the hospital. Resident 105 had vascular dementia, chronic kidney disease, and heart failure, and was severely cognitively impaired. On 1/22/26, the resident was found pale, hypoxic, and breathing strenuously, 911 was called, and the resident was transferred to the ER. The record indicated a notice of transfer/discharge was reviewed and given to the resident, but it lacked documentation that the receiving facility was notified and lacked documentation that the notice and bed hold policy were reviewed with the resident’s representative. Resident 113 had multiple sclerosis, pneumonia, lung disorders, severe protein-calorie malnutrition, dysphagia, and adult failure to thrive. The resident was cognitively intact on the quarterly MDS. On 3/3/26, staff found the resident lethargic with facial drooping, increased confusion, and weakness, and the NP ordered transfer to the hospital for evaluation and treatment; the resident’s representative was informed. The clinical record lacked documentation of notification to the receiving facility and lacked documentation that the notice of transfer/discharge and bed hold policy were reviewed with the resident or resident’s representative. Resident 30 had right-sided hemiplegia and hemiparesis following cerebrovascular disease, type 2 diabetes mellitus, and chronic congestive heart failure. The resident was cognitively intact on the quarterly MDS and later discharged with return anticipated. On 3/15/26, the resident was found on the floor, was yelling in pain, unable to explain the fall, had mumbled and nonsensical speech, and could not follow basic instructions; the resident was sent to the hospital for evaluation and treatment, and the facility director, physician, and family were notified. The record lacked evidence that the resident and/or resident representative received a copy of the notice of transfer/discharge form or the bed hold policy, and the transfer form lacked a resident or resident representative signature.
Baseline care plan not completed for newly admitted resident with feeding tube
Penalty
Summary
The facility failed to ensure a baseline care plan was completed for a newly admitted resident with a feeding tube. Resident 47’s record showed diagnoses of acute pancreatitis without necrosis or infection, gastrostomy status, and unspecified protein-calorie malnutrition. Current physician orders included enteral feeding tube site care with normal saline and a dry dressing once daily, and Jevity 1.5 at 52 ml per hour via feeding tube to run every shift when not eating during meal service. The clinical record lacked a baseline care plan, and a progress note documented that the resident had been admitted with a feeding tube in place. During interviews, an LPN stated she was uncertain who was responsible for completing baseline care plans for new admissions. An RN stated the admitting nurse was required to complete the new admission assessment checklist, which included the baseline care plan, and if it was not finished, the next shift nurse was required to ensure it was completed within 24 hours; completed documents were then to be given to the Unit Manager or placed in the Unit Manager’s mailbox. The Corporate Nurse Consultant stated the facility was unable to provide a baseline care plan for Resident 47 and that it should have been completed within 48 hours of admission. The facility policy titled Baseline Care Plan Policy stated the baseline care plan would be developed and implemented within 48 hours of admission.
Feeding Tube Site Changes and Clogged Tube Not Reported or Documented
Penalty
Summary
The facility failed to provide services to prevent complications related to a feeding tube for a resident with a gastrostomy status, acute pancreatitis without necrosis or infection, and unspecified protein-calorie malnutrition. The resident was cognitively intact, received tube feeding overnight, took medications by mouth, ate some food by mouth, and required set-up assistance for meals. The care plan identified the resident as at risk for complications related to enteral feeding and included skin care to the insertion site as needed and reporting complications to the MD. The resident’s record showed a clogged feeding tube on 3/11/26. Staff attempted to flush the tube with warm water, a 60 ml syringe using a gentle push-pull technique, and de-clogger, but the attempts were unsuccessful. Later that same day, the tube was flushed again using the gentle push-pull technique and flushed with ease. The clinical record lacked physician notification of the clogged g-tube, orders to unclog the feeding tube, documentation of changes to the feeding tube site, and physician notification of drainage, tenderness, and redness at the site. During observation, the feeding tube split gauze dressing contained tan drainage and the insertion site had redness extending about one fourth of an inch around the tube. The resident stated the site was tender during care and reported that the rubber bumper had moved outward and was no longer directly against the abdomen, leaving about a half-inch gap. RN 13 indicated the drainage, redness, and tenderness were a change from baseline and needed to be reported to the physician, but LPN 14 later stated she had not received any report of concerns and found no documentation of a change in condition or physician notification in the record.
Failure to Post Current Nursing Staffing Information
Penalty
Summary
The facility failed to post current and accurate nursing staff information daily for residents and visitors. During observation on 3/16/26 at 9:23 a.m., the nurse staffing sheet posted at the front receptionist desk was dated 3/11/26 and listed census and staffing hours for RN, LPN, and CNA positions. During observation on 3/17/26 at 9:55 a.m., the staffing sheet posted at the front receptionist desk was dated 3/17/26 and listed a different census and staffing hours for RN, LPN, and CNA positions. During interview on 3/20/26 at 1:30 p.m., the Scheduler stated he was new to the position, was in his first week, and used an online system that populated the staff posting form. He said he intended to prepare the daily staff posting the night before and print weekend postings on Friday evenings for the weekend manager to ensure the correct day was available to residents and visitors. The Corporate Nurse Consultant stated the staff posting should have been updated daily from 3/11/26 through 3/16/26, that the facility would not have had accurate staff posting available over the weekend, and that the 3/18/26 posting should have contained an accurate census number. The facility policy revised 1/30/26 stated that the facility must post the current date, resident census, and actual hours worked by RN, LPN/LVN, and CNA staff daily at the beginning of each shift.
QAPI Program Failed to Sustain Monitoring of Medication Self-Administration Assessments
Penalty
Summary
The facility failed to develop and implement approaches to maintain an ongoing QAPI program to prevent repeat deficiencies related to self-administration of medications. Review of the prior annual recertification and licensure survey completed on January 23, 2025 showed a deficiency for failure to ensure the self-administration of medications assessment was completed before medications were left unattended in a resident's room. During interview, the VP of Operations stated the QAA committee met quarterly, used an online program to review trends and document meetings, and generally followed prior survey concerns through the plan of correction for about six months, extending review only if audits continued to show deficiency. The Corporate Nurse Consultant stated the company completed mock surveys and focused on previously cited areas to maintain compliance, but the facility did not have any current QAPI or Performance Improvement Plans in place for ensuring self-administration assessments were completed before medications were left unattended in a resident's room. The March 20, 2026 survey again identified the same concern, including an observation, interview, and record review involving Resident 29, where the facility failed to ensure a self-administration of medication assessment was completed before medications were left unattended in the resident's room.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
The facility failed to follow enhanced barrier precautions during feeding tube site care for one resident who had diagnoses of acute pancreatitis without necrosis or infection, gastrostomy status, and unspecified protein-calorie malnutrition. The resident was cognitively intact and had current orders for enteral feeding tube site care with normal saline and a dry dressing once daily, along with enhanced barrier precautions every shift. The care plan also identified the need for enhanced barrier precautions related to enteral feeding and included personal protective equipment as indicated. During observation, an RN entered the resident’s room to provide feeding tube site care while an enhanced barrier precaution sign and PPE were available at the doorway. The RN performed hand hygiene and donned gloves, removed the soiled split gauze dressing, and discarded it with the gloves, but did not complete hand hygiene afterward. The RN then donned clean gloves and cleansed the feeding tube insertion site, which had redness approximately one fourth of an inch around it, but did not wear a gown during the care. The RN also leaned against the resident’s bed sheet and blanket with her right pant leg while placing the new split gauze dressing. The RN stated she did not wear a gown and did not notice the enhanced barrier precaution sign until after exiting the room. The Infection Preventionist stated that EBP was required for any manipulation of the feeding tube and that a gown and gloves were required during feeding tube care.
Improper Food Temperatures During Meal Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service related to failure to distribute food at correct temperatures for safety and palatability, potentially affecting all 114 residents receiving food from the kitchen. During a test meal tray temperature check conducted at 12:47 p.m. on 2/20/26, with the Dietary Manager present, the milk on a test tray measured 46°F and coleslaw measured 64.2°F. The Dietary Manager acknowledged that the milk temperature was too high for service. In an interview earlier that day at 11:40 a.m., the Dietary Manager explained that food temperatures were checked prior to plating and then the food was placed in meal carts and delivered to the appropriate halls for distribution. The facility’s current policy, dated 5/2014 and titled “Food: Quality and Palatability,” stated that food will be prepared to conserve nutritive value, flavor, and appearance, and will be palatable, attractive, and served at a safe and appetizing temperature, with proper temperature defined as appropriate to the type of food to ensure resident satisfaction and minimize the risk for scalding and burns. The observed temperatures of the milk and coleslaw did not align with this policy requirement. This citation relates to Intakes 2733549 and 2744835 and regulatory reference 3.1-21(a)(2).
Failure to Report Potential Neglect After Unprescribed Controlled Substances Found in Resident
Penalty
Summary
The facility failed to report an unusual occurrence involving potential neglect to the Indiana Department of Health (IDOH) when a dependent resident was found to have unprescribed controlled substances in her system during a hospital stay. The resident, who had diagnoses including unspecified dementia, hypertension, asthma, convulsions, and heart failure, was severely cognitively impaired and required staff assistance for daily activities. Her prescribed medications did not include opioids or barbiturates, and she was allergic to gabapentin. During a hospital admission for altered mental status, the resident was found to have a low respiratory rate, hypoxia, and low blood pressure. A urine drug screen was positive for barbiturates and opiates, and she required Narcan administration for suspected opioid overdose. Despite concerns from emergency medical services and the resident's family about a possible medication mix-up with her roommate's medications, the facility did not report the incident to IDOH. The Director of Nursing indicated that the event was not reported because no medication error was identified by the night shift nurse, and the facility believed it had followed IDOH guidelines for reporting potential neglect. However, facility policy required immediate reporting of all alleged violations involving abuse, neglect, or mistreatment, regardless of whether a medication error was confirmed.
Failure to Thoroughly Investigate Medication Error and Potential Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an unusual occurrence involving a potential medication error and possible neglect when a resident with severe cognitive impairment was found to have received unprescribed substances, including opiates and barbiturates, as evidenced by a positive urine drug screen during a hospital stay. The resident, who had a documented allergy to gabapentin and no orders for opiates, was administered her roommate's medications in error on a previous occasion, and subsequently experienced a significant change in condition, including lethargy, low respiratory rate, and hypoxia, leading to hospital admission and administration of Narcan. Despite these events, the facility's investigation into the incident on the day of the resident's hospital transfer was incomplete and lacked critical documentation. The investigation did not include statements from key staff members who were on duty or may have cared for the resident at the time of the incident, nor did it include statements from emergency medical services staff who transported the resident to the hospital. Additionally, the resident's roommate, who was a potential witness and had relevant information regarding the medication administration, was not interviewed or included in the investigation. The facility also failed to collect statements from the resident or her representative, despite the resident's ability to answer yes/no questions, and did not document who completed the resident questionnaires or when they were completed. Interviews with facility staff revealed a lack of clarity regarding who was spoken to during the investigation, and the Director of Nursing and Administrator could not confirm which staff had been interviewed, as no statements were collected. The facility's policy required a reasonable investigation of all alleged violations involving abuse, neglect, or injuries of unknown origin, but the investigation into this incident did not meet those standards, as it lacked essential documentation and failed to include pertinent information from staff, residents, and witnesses directly involved in or knowledgeable about the event.
Failure to Thoroughly Assess and Intervene for Pressure Injuries
Penalty
Summary
The facility failed to thoroughly assess and intervene to promote the healing of pressure injuries for a resident with multiple comorbidities, including a right femoral neck fracture, chronic kidney disease, severe malnutrition, and dementia. Upon admission, the resident was found to have a stage 2 pressure injury on the right elbow, redness to the coccyx, and discoloration to both heels. Orders were in place for wound management, heel protectors, pressure-relieving devices, and other supportive measures. Initial care plans and interventions were documented, but there were gaps in the ongoing assessment and documentation of the resident's pressure injuries. Throughout the resident's stay, documentation of wound assessments and measurements was inconsistent and incomplete. The wound management detail report only included the initial measurement of the right elbow pressure injury and lacked further assessments or documentation for the coccyx and heels. A spreadsheet maintained by the DON contained some wound measurements but was not part of the official clinical record and lacked comprehensive wound characteristics. There was also no documentation of a specific treatment order for the right elbow or coccyx pressure injuries, and the care plan for pressure injuries was not fully implemented until much later, despite the presence of multiple wounds. Interviews with nursing staff and the DON revealed that wound assessments were sometimes missed or not entered into the electronic medical record, and that some treatments were provided as routine nursing measures without physician orders or proper documentation. Weekly skin assessments were recorded as existing skin impairment, but no detailed follow-up or wound progression was documented. The facility's policy required ongoing documentation of all impaired skin integrity areas in the electronic medical record, but this was not consistently followed, leading to a deficiency in the assessment and management of the resident's pressure injuries.
Failure to Report Suspected Drug Diversion to Regulatory Agencies
Penalty
Summary
The facility failed to report a suspected drug diversion involving narcotic medications for four residents to the appropriate regulatory agencies. Multiple discrepancies were identified in the administration and documentation of oxycodone and oxycodone-acetaminophen for residents with chronic pain and other serious conditions. For example, medication administration records and narcotic count sheets did not align, with doses being signed out at incorrect times, missing signatures, and mismatched tablet counts. In one case, a resident's narcotic card showed fewer tablets than should have remained, and in another, a medication card for comparison was not provided. Staff interviews revealed confusion and lack of clarity regarding medication administration and documentation. One LPN was observed to be impaired at work and was sent home, after which narcotic counts were found to be off. Staff reported these discrepancies to their supervisors, but a thorough reconciliation of medication records was not performed. The Corporate Nurse Consultant acknowledged that the narcotic counts were off but did not compare narcotic sheets with the Medication Administration Record during the investigation. Despite the facility's policy requiring immediate reporting of any suspected misappropriation of resident property, including drug diversion, to the State Regulatory Agency within 24 hours, the concerns were not reported as required. The investigation into the missing medications was incomplete, and the appropriate authorities were not notified of the suspected diversion, as mandated by facility policy and federal and state law.
Failure to Investigate Suspected Drug Diversion and Medication Discrepancies
Penalty
Summary
The facility failed to conduct a thorough investigation into suspected drug diversion involving four residents who were prescribed and administered narcotic pain medications. For these residents, discrepancies were found between the electronic medication administration records (eMAR), narcotic sign-out sheets, and the physical count of medication tablets. In several cases, doses were documented as given at times inconsistent with physician orders, and some doses were signed out but not properly accounted for in the medication count. For example, one resident's narcotic card showed fewer tablets remaining than should have been present, and another resident's medication card was not provided for verification. Staff interviews revealed confusion and lack of clarity regarding who administered certain doses, and in one instance, a nurse admitted to removing medication from the card for another staff member to administer, which she acknowledged was inappropriate. The Corporate Nurse Consultant, upon being informed of missing medications, reviewed medication carts and narcotic count books but did not reconcile narcotic sheets with the eMAR or report the discrepancies to regulatory agencies. No medication reconciliation was performed for certain doses, and the investigation did not include a comparison of narcotic sheets with the medication administration records. The facility's failure to properly investigate and reconcile these discrepancies led to the deficiency cited in the report.
Failure to Accurately Document and Reconcile Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and reconciliation of controlled medication administration for four out of six residents reviewed. For one resident with chronic pain and multiple diagnoses, discrepancies were found between the electronic medication administration record (eMAR), the narcotic sign-out sheet, and the physical count of oxycodone tablets. Documentation showed doses being administered at times inconsistent with the schedule, missing signatures, and mismatched tablet counts. Interviews revealed confusion among staff regarding medication administration times and the number of tablets given, with one resident reporting having received two tablets early, though unable to recall specifics during a follow-up interview. Another resident with chronic pain and significant physical disabilities had inconsistencies between the eMAR and the narcotic sheet, including doses marked as not given and missing documentation for certain time slots. For a third resident with COPD and chronic pain, the eMAR and narcotic count sheet showed doses administered at incorrect times and uncertainty among staff about who administered the medication. One LPN admitted to removing medication from the card and having another staff member administer it, which was acknowledged as inappropriate. A fourth resident with a history of opioid use and chronic pain had doses signed out on the narcotic count sheet that were not reconciled with the eMAR, and no medication reconciliation was performed for several doses. Facility policies required physical inventory and reconciliation of controlled medications at each shift change, immediate documentation of administration, and reporting of discrepancies to the DON. However, these procedures were not consistently followed, leading to unaccounted-for medication doses and incomplete records.
Failure to Ensure Safe and Justified Resident Discharge
Penalty
Summary
A resident with multiple chronic conditions, including congestive heart failure, COPD, pressure ulcer, chronic osteomyelitis, polyneuropathy, chronic pain syndrome, and depressive disorder, was admitted to the facility and assessed as cognitively intact with moderate depression. The resident had a history of verbal aggression, but there was no care plan addressing physical aggression. On the day of the incident, the resident became verbally aggressive and threatened staff after being informed of a new roommate assignment, following a previous altercation with a former roommate. Staff attempted to de-escalate the situation, but the resident continued to display verbal aggression and made threatening remarks. The police were called, and the resident was taken to the hospital for evaluation, with staff citing outstanding warrants as a reason for police involvement. The facility initiated an emergency discharge, citing the resident's behavior and the police intervention. However, documentation and interviews revealed inconsistencies regarding the resident's physical aggression, with several staff members and the resident's sister stating that the resident was not physically aggressive, only verbally so. The facility did not provide clear supporting rationale or documentation for the discharge, and the clinical record lacked evidence that the resident's needs and preferences were considered or that the resident was prepared for a safe transfer or discharge. The resident was not offered the opportunity to return to the facility after hospital observation, despite not being arrested, and was instead released to a family member. The facility's actions did not align with its own transfer/discharge policy, which requires that a resident may only be discharged if their needs cannot be met, their health has improved, or the safety or health of others is endangered. The lack of documentation supporting the discharge decision, failure to provide adequate notice, and not allowing the resident to return after hospital observation constituted a deficiency in ensuring that the transfer/discharge met the resident's needs and preferences and that the resident was prepared for a safe transition.
Inadequate Dietary Staffing Leads to Delayed Meal Delivery
Penalty
Summary
The facility failed to provide adequate dietary staff to ensure timely delivery of dinner meal trays to residents on three units, resulting in significant delays. Observations on specific dates revealed that meal trays were delivered much later than scheduled, with delays ranging from 30 to 57 minutes. Residents expressed dissatisfaction, with some waiting in their doorways or calling out for their meals. Interviews with staff and residents confirmed that late meal deliveries were a recurring issue, often resulting in cold meals. The dietary department was consistently understaffed, with only three dietary staff members on duty for dinner service, which was insufficient to serve all residents promptly. Despite the presence of the Dietary Manager and District Dietary Manager on some occasions to assist with meal service, delays persisted. Staff turnover and reliance on a limited number of dietary aides contributed to the problem, and previous reports to management about the issue had not resulted in effective solutions. The facility's internal audits and interviews with staff indicated that the problem had been ongoing for a significant period, with meal delivery times frequently running into residents' evening routines. The Administrator and dietary management were aware of the issue, but efforts to address it, such as meal delivery tracking audits and additional managerial support during meal times, had not resolved the delays. The lack of a timely response to dietary concerns and insufficient staffing levels were key factors leading to the deficiency.
Failure to Inform Residents of Arbitration Agreement Rescission Rights
Penalty
Summary
The facility failed to ensure that residents who entered into a binding arbitration agreement were informed of their right to verbally rescind the agreement within 30 days of signing it. Additionally, the facility did not grant residents the right to rescind the original agreement for a subsequent stay if they were discharged and readmitted to the facility or admitted to another facility owned by the same corporation. This deficiency potentially affected 57 of the 127 residents residing in the facility. During interviews, it was revealed that the facility's arbitration agreement required written notice to rescind, contrary to the verbal rescission right, and staff members, including the Facility Liaison and Admissions Coordinator, were uncertain about the rescission process. The Corporate Legal Counsel confirmed that the arbitration agreement would remain in effect for any subsequent admissions if not rescinded within 30 days, even if the resident was discharged and readmitted. The facility did not have a policy for the arbitration agreement, and staff members were unclear about the process for residents to change their minds and rescind the agreement. The lack of clarity and proper communication regarding the arbitration agreement's terms and the rescission process contributed to the deficiency.
Failure to Conduct Self-Administration Assessment for Resident's Eye Drops
Penalty
Summary
The facility failed to ensure a self-administration assessment was completed for a resident who was self-administering eye drops. During observations, the resident was found with multiple bottles of eye drops on her bedside table, some of which were prescription medications without labels or resident identifiers. The resident indicated she used the eye drops twice daily and that staff were aware of her self-administration. However, the clinical record lacked physician orders for some of the eye drops and did not include an assessment for self-administration of medication. Interviews with staff revealed that they were aware of the resident's self-administration of eye drops, but no formal assessment had been conducted to determine the resident's ability to safely manage her medications. The Director of Nursing confirmed the absence of a self-administration assessment and noted that physician orders did not include instructions for self-administration. The facility's policy requires an interdisciplinary team assessment and a prescriber's order for residents who wish to self-administer medications, but these steps were not documented in the resident's case.
Misappropriation of Resident Funds Due to Lack of After-Hours Policy
Penalty
Summary
The facility failed to prevent the misappropriation of resident funds, specifically for Resident B, who was cognitively intact and required partial assistance with personal care. Resident B reported missing his debit card, grocery card, and driver's license upon returning from dialysis. He suspected CNA 31, who had assisted him with an online order the night before, of taking his belongings. Resident B had to shut off multiple debit cards due to unauthorized charges, which included purchases totaling approximately $500. The facility was notified, and the local police were involved in the investigation. The investigation revealed that CNA 31 had assisted Resident B in ordering a pizza using his debit card, which was against facility policy. CNA 31 was in orientation at the time and was advised by her preceptor, CNA 33, to seek permission from the RN on staff before proceeding. Despite this, CNA 31 took the resident's debit card and returned it after some time. The facility's policy clearly stated that staff should not take money or debit cards from residents, even to assist them with purchases. However, there was no official policy for handling such requests outside of normal business hours. Interviews with various staff members, including the DON, Unit Manager, and Social Services Assistant, confirmed that the facility lacked a clear policy for assisting residents with purchases after hours. The facility's Conduct & Behavior policy prohibited borrowing or accepting money from residents, and the Abuse, Neglect, and Misappropriation of Property policy aimed to prevent such incidents. Despite these policies, the lack of a specific protocol for after-hours assistance contributed to the deficiency, leading to the misappropriation of Resident B's funds.
Failure to Monitor and Intervene in Resident's UTI Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate monitoring and timely intervention for a resident experiencing a worsening change in condition due to a urinary tract infection (UTI). The resident, who was cognitively intact, reported experiencing severe symptoms such as vomiting and diarrhea in November 2024, and expressed concern over the facility's delay in sending her to the hospital. Despite her requests, the facility was slow to administer antibiotics, and she was eventually hospitalized with a peripherally inserted central catheter (PICC) line due to sepsis secondary to a UTI. The resident's clinical records indicated a history of UTIs and sepsis, with diagnoses including sepsis, overactive bladder, and post COVID-19 condition. The records showed that the resident had frequent urinary and bowel incontinence and required substantial staff assistance for certain activities of daily living. Despite these conditions, the facility's care plan lacked specific interventions for sepsis or being at risk for sepsis. The records also revealed that the resident had bacterial growth on a urine culture for ESBL, but no antibiotics were administered due to the bacteria count being under 100,000 CFU/mL. Interviews with staff and the Director of Nursing (DON) highlighted a lack of urgency in addressing the resident's deteriorating condition. The DON was aware of the resident's history and symptoms but did not prioritize sending her to the hospital, opting instead to treat her in-house. The facility's policy on notifying changes in condition was not effectively followed, as the Medical Director was not contacted for urgent orders, and the resident's condition was not adequately monitored or assessed. This lack of timely intervention and monitoring contributed to the resident's hospitalization for sepsis.
Failure to Securely Store Resident Smoking Materials
Penalty
Summary
The facility failed to ensure that smoking materials were securely stored for a resident, leading to a deficiency in maintaining a safe environment free from accident hazards. Resident 86, who was cognitively intact and used oxygen therapy, was observed to keep her smoking paraphernalia in her room, contrary to the facility's policy. The resident, who had a diagnosis of chronic respiratory failure with hypoxia and current tobacco use, was allowed to retain her cigarettes and lighter in her purse after signing out for a leave of absence, instead of returning them to the staff as required. Interviews with staff, including CNAs and RNs, revealed that the facility's policy mandated that all smoking materials be managed by staff and stored in a locked tackle box in the medication room. However, the resident's smoking materials were not found in the designated storage area, and the facility did not track the receipt and return of smoking materials. The Administrator confirmed that residents were not permitted to keep smoking paraphernalia after smoke breaks or upon returning from a leave of absence, yet the resident's smoking materials were found in her room by the Social Services Assistant, indicating a lapse in adherence to the facility's smoking policy.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, treatments, and biological products in two medication rooms and two medication carts. During an observation in the Medication Room East, an open vial of influenza vaccine and an open vial of tuberculin purified protein derivative (PPD) were found without open dates. The Director of Nursing (DON) confirmed that the temperature was recorded daily, but the vials should have been labeled with open dates. Similarly, in the Medication Room [NAME], an open vial of influenza vaccine was found without an open date, and RN 3 acknowledged that open dates should be placed on vials. In the medication cart for the 200 Hall, 11 loose, unlabeled medications were discovered in the drawers, including various capsules and tablets. LPN 4 indicated that these medications should be disposed of immediately. Additionally, the treatment cart for the 800 and 500 hallways contained several tubes of medications without resident identifiers and directions, such as miconazole anti-fungal cream, Medi-honey wound gel, Hydrogel wound dressing, lidocaine anesthetic cream, and mupirocin ointment. RN 22 noted that the cart was used for treatments on these halls and that medications should be labeled with the resident's name. The facility lacked a specific policy on vaccine storage, as indicated by the DON. The manufacturer's instructions for the influenza vaccine and guidelines from the CDC were not followed, as the multi-dose vials were not discarded within the recommended time frame. The facility's policies on medication storage and labeling were not adhered to, resulting in medications being improperly labeled and stored, which could potentially affect their integrity and safety.
Failure to Implement Effective QAPI Program for Infection Control and Medication Labeling
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program to address and prevent repeat deficiencies related to infection control and medication labeling. During the last annual recertification and licensure survey, deficiencies were noted in the facility's adherence to infection control guidelines, specifically regarding isolation procedures, and in ensuring medications were labeled with resident identifiers and directions. Despite having a Quality Assessment and Assurance (QAA) committee that met quarterly to review facility concerns, the facility did not have any current Performance Improvement Plans (PIP) in place for these specific issues. The survey conducted on January 23, 2025, revealed repeat concerns in infection control and medication labeling. The facility failed to ensure proper labeling and storage of medications, treatments, and biological products in two medication rooms and two medication carts. Additionally, the facility did not implement an infection control program that provided Enhanced Barrier Precautions (EBP) or isolation services to reduce the risk of contagion spread for two residents reviewed for infection prevention. The facility's policy, revised in September 2023, indicated an ongoing QAPI program, but it did not effectively address the identified problem areas.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) and isolation services, for two residents. Resident 66's room had multiple signs indicating different types of precautions, leading to confusion among staff about the necessary protective measures. Staff members were observed not wearing the required personal protective equipment (PPE) during care, and there was a lack of clarity about when PPE was needed. The resident's clinical records showed conflicting orders for isolation and EBP, and the care plan did not specify when PPE was indicated. The Infection Preventionist acknowledged the confusion and indicated that the resident should not have been on isolation but required EBP. For Resident 86, there was a lack of signage and readily available PPE in or near the resident's room, despite the resident having a pressure ulcer. Staff were observed not wearing gowns during wound care, and the resident's care plan did not include interventions for EBP. The facility's infection control policy required EBP for residents with chronic wounds, but this was not implemented until later. The Infection Preventionist admitted uncertainty about which residents required EBP and had not sought clarification from external sources. The facility's infection control policies and practices were intended to prevent the transmission of infections, but there were significant lapses in their implementation. The Enhanced Barrier Precautions Policy required appropriate signage and PPE for residents with chronic wounds or indwelling devices, but these measures were not consistently applied. The Infection Preventionist's lack of clarity and delayed implementation of EBP contributed to the deficiencies observed in the care of Residents 66 and 86.
Failure to Maintain AED in Working Condition
Penalty
Summary
The facility failed to maintain the automated external defibrillator (AED) in safe operating condition, which was crucial during a medical emergency involving Resident F. The resident was found unresponsive and without a pulse, prompting staff to initiate CPR and call emergency services. However, when the AED was retrieved and attempted to be used, it failed to operate due to a dead battery. This malfunction was discovered during the emergency, and the staff was unable to utilize the AED as intended. Interviews with various staff members, including registered nurses and the unit manager, revealed that there was a lack of clarity regarding who was responsible for ensuring the AED was in working order. The Director of Nursing (DON) and the Administrator were both unaware of the AED's maintenance status until after the incident. The Maintenance Director mentioned that he ordered a battery every six months, but the most recent order was on backorder. The facility lacked a system or practice for routine monitoring and management of the AED, and there was no facility policy related to the AED's maintenance.
Failure to Prevent Verbal Abuse and Implement Abuse Policy
Penalty
Summary
The facility failed to prevent verbal abuse from a staff member towards a resident, identified as Resident F, and did not fully implement its abuse policy to protect the resident from potential further abuse. The incident involved a staff member, CNA 5, who was reported to have used derogatory language towards Resident F, who was dependent on assistance for all activities of daily living due to conditions such as unspecified convulsions and adult failure to thrive. The incident was self-reported by the facility, and immediate actions included a skin assessment of the resident, which showed no signs of injury, and the suspension of the staff member pending an investigation. The investigation revealed that CNA 5 had been impatient and used inappropriate language towards Resident F, who had feces on her bed sheets and hands. Despite being asked by another CNA, CNA 6, not to speak to the resident in such a manner, CNA 5 continued to exhibit inappropriate behavior. The facility's policy required immediate intervention and separation of the resident from the abusive environment, which was not fully adhered to, as CNA 6 left Resident F alone with CNA 5 after the incident. The facility's investigation concluded with no substantiation of abuse, and the Administrator believed that the staff acted appropriately, despite the failure to fully implement the abuse policy.
Failure to Accurately Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to accurately and consistently assess a new pressure injury and did not promptly initiate wound treatment for a resident, leading to a deficiency in pressure ulcer care. Resident B, who was cognitively intact and required partial assistance for bed mobility and transferring, was initially assessed with no wounds or pressure ulcers. However, a skin tear was identified on the sacrum, which was later reclassified as a pressure ulcer. The clinical record showed inconsistencies in the documentation of the wound, with different wound types being referred to for the same area. Despite the presence of a skin integrity care plan indicating the resident was at risk for pressure ulcers, the facility did not develop and implement a care plan with individualized interventions to support the healing of the pressure injury. The clinical record lacked treatment orders for the skin impairment until 11 days after the initial identification of the wound. Interviews with staff revealed that there was a delay in obtaining treatment orders and that the wound was not categorized correctly initially. The resident was discharged with the wound still present.
Failure to Develop Care Plan for Resident's Aggressive Behavior
Penalty
Summary
The facility failed to develop a resident-centered care plan and interventions for a resident, identified as Resident K, who exhibited alcohol use and physical aggressive behaviors. Resident K, who was cognitively intact, had a complex medical history including conditions such as chronic kidney disease, congestive heart failure, and opioid use. Despite these conditions, the clinical record lacked a care plan addressing the resident's alcohol consumption and aggressive behavior. An incident occurred where Resident K was involved in a physical altercation with another resident off facility property, after which he returned to the facility exhibiting aggressive behavior towards staff. This behavior included physical aggression such as punching, choking, and grabbing staff members, necessitating police intervention and sedation before being removed to a hospital. Interviews with facility staff revealed that Resident K had a known history of smoking and drinking off facility property, as well as verbal aggression, but no documented care plan or interventions were in place to manage these behaviors. The facility's policy on comprehensive care plans mandates the development of person-centered plans with measurable objectives and time frames to address residents' needs, which was not adhered to in this case. The lack of documentation for new or worsening behaviors was also noted, indicating a failure to update the care plan in response to Resident K's aggressive actions.
Resident Subjected to Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved a resident, identified as Resident F, who was subjected to derogatory and disparaging remarks by CNA 6. Witnesses, including other residents, reported that CNA 6 told Resident F that she should leave the facility and live with her ex-husband, and that her grandchildren did not love her. Additionally, CNA 6 was reported to have intentionally neglected to provide ice water to Resident F, which was perceived as singling her out. The situation escalated when Resident F confronted CNA 6, leading to a verbal altercation where CNA 6 accused Resident F of bullying and threatened to have her arrested. Resident F's clinical record indicated she had several medical conditions, including peripheral vascular disease, muscle weakness, and anxiety disorder, and was on medication for anxiety and depression. Despite being cognitively intact, she required supervision for certain activities. The facility's policy on abuse defines verbal abuse as the use of threatening or derogatory language, which was violated in this case. The Administrator was aware of the incident and had suspended CNA 6 pending an investigation, but the clinical record lacked documentation of a care plan or nurses' notes related to the incident.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Agency in a timely manner. The incident involved a resident who alleged that a CNA intentionally skipped providing ice water, leading to a loud verbal exchange with angry language. The incident occurred on June 27, 2024, at 4:45 p.m., but was not reported to the Indiana State Department of Health until June 30, 2024, at 8:27 a.m. The facility's policy requires that any abuse allegations be reported to the State within two hours from the time the allegation was received. This deficiency was identified during a review of three reportable abuse allegations, and it relates to complaint IN00438076.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
The facility failed to ensure that dependent residents received showers or bed baths according to their care plans and personal preferences. Resident E, who was cognitively intact and required supervision and touch assistance for showers, was scheduled for showers three times a week but only received four showers over a 29-day period, despite being scheduled for 12. Resident E expressed a preference for showers and reported that staff often told her they did not have time to assist her, leading her to manage on her own. The facility's records did not reflect an assessment of Resident E's bathing preferences, and there was a noted history of refusal for other treatments. Resident M, also cognitively intact and dependent on staff for bathing, was scheduled for complete bed baths three times a week but only received two complete bed baths over a 30-day period, despite being scheduled for 13. Resident M preferred a complete bed bath at night due to her transfer needs and had not refused care. Staff interviews revealed that evening shifts were not completing the assigned showers, and partial bed baths were given instead. The facility's policy on resident rights emphasized the importance of respecting residents' preferences, which was not adhered to in these cases.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that a physician-ordered medication, copper sulfate, was obtained and administered to a resident, identified as Resident B, who was admitted with a history of anemia due to gastrointestinal blood loss, among other conditions. Upon admission from an acute care hospital, the resident had discharge orders for copper sulfate 2 mg daily for 30 days. However, the medication was not available upon the resident's arrival at the facility. The pharmacy received the order 52 hours after the resident's admission and processed it the following day, but the medication was not in stock. The pharmacy notified the facility's Director of Nursing (DON) about the unavailability of the medication, but the issue was not resolved promptly. The DON was informed of the delay, and the nurse practitioner was unaware of the unavailability until several days later. Despite attempts to obtain the medication from another vendor and eventually ordering it online, the medication was not administered as required. The facility's policy required nursing staff to contact the prescriber for direction when a medication delivery was delayed or unavailable, but this procedure was not followed. This deficiency was identified during a complaint investigation, highlighting a failure in the facility's pharmaceutical services to meet the resident's needs.
Failure to Monitor and Address Resident's Acute Abdominal Pain
Penalty
Summary
The facility failed to ensure effective monitoring and services for Resident B, who experienced acute abdominal pain with nausea and requested to be transferred to the hospital. Despite the resident's complaints and requests, the facility staff did not perform adequate assessments or notify the physician in a timely manner. This resulted in a delay in treatment, leading to the resident's emergent hospitalization for a perforated bowel with sepsis, requiring surgical intervention and a permanent colostomy. Resident B's clinical record indicated she was cognitively intact and had a history of conditions including paroxysmal atrial fibrillation, rheumatoid arthritis, and type 2 diabetes mellitus. She was dependent on others for toileting and frequently incontinent of bowel. The resident had been receiving opioid pain medication, which is known to cause constipation, and had a physician's order to monitor for side effects. Despite this, the facility staff failed to adequately address her complaints of constipation and abdominal pain. On multiple occasions, Resident B complained of pain and constipation, but the staff did not perform thorough assessments or notify the physician. The resident's condition worsened, leading to severe abdominal pain, vomiting, and eventually black coffee ground emesis. It was only after the resident's condition became critical that she was sent to the hospital, where she was diagnosed with a perforated bowel and sepsis. The facility's failure to follow their own policies on change of condition and bowel management contributed to the delay in treatment and the resident's subsequent severe health complications.
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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