Springs Of Richmond, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Indiana.
- Location
- 400 Industries Road, Richmond, Indiana 47374
- CMS Provider Number
- 155843
- Inspections on file
- 40
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Springs Of Richmond, The during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure bedside fluids for three residents who were care planned as at risk for dehydration. A resident with stroke, CKD, and UTI, and another with CHF and anemia, both cognitively intact, reported that fluids were only provided with meal trays or that they sometimes had to ask for water, with observations showing minimal or delayed water provision. A third, moderately cognitively impaired resident with severe sepsis, septic shock, and acute respiratory failure was repeatedly observed with an empty, undated Styrofoam cup and stated she always had to request water and that water had not been passed with her lunch. The Administrator reported there was no hydration policy and that water cups were only passed once per shift.
A resident, cognitively intact per MDS, developed a large, worsening bruise on the back that was documented in progress notes and led to an internal event and NP notification, but there was no documentation that the responsible party was informed. The family only became aware of the bruise and the resident’s report of a prior fall during a transfer when the resident was later hospitalized. This failure to notify occurred despite a facility policy requiring immediate notification of the responsible party for changes in condition.
A resident with a history of stroke was admitted from the hospital with a large traumatic wound on the right side of the back, described as purple, red, and erythematous. Facility documentation later noted that dark areas on the back were worsening, darkening, and increasing in size, and an internal event was opened and an NP notified, but no further assessments of the back or bruise were documented in the wound management record. The DON explained that events in the EHR became internal incident reports, yet no additional assessment notes were available despite a bruising policy requiring a bruise incident and assessment progress note. The resident reported having fallen during a staff-assisted transfer and hitting the bed, and the family stated they were not informed of either the large bruise or the fall.
A resident with multiple chronic conditions was given another resident's medications in error and later transferred to a hospital. The facility did not inform the hospital of the medication error at the time of transfer, and the hospital only learned of the incident after the resident's family provided the information. Staff interviews confirmed the expectation to report such errors, but no policy existed to guide this process.
A resident with complex medical needs, including end-stage renal disease and a history of medication allergies, was given another resident's morning medications in error. The resident did not receive their own prescribed medications, and the error was confirmed by staff and family interviews. The facility's medication administration policy, which requires verification of the five rights and resident identification, was not followed, leading to the error.
A resident with cancer and cognitive impairment did not receive timely follow-up after a hemolyzed CBC sample was reported, resulting in a missed critical lab value and subsequent hospitalization for acute on chronic anemia requiring transfusions. The facility lacked documentation of redraw or provider notification, and staff interviews revealed no clear policy for handling hemolyzed labs.
Two residents experienced significant delays in call light response, with one waiting up to 45 minutes and another waiting over two hours for assistance, leading to discomfort and feelings of helplessness. A staff member confirmed that inadequate staffing contributed to the inability to provide timely care and respond to residents' needs, resulting in a failure to promote resident dignity.
A resident with a knee infection was allowed to self-administer home medications, including narcotics, after admission when the facility did not have the prescribed drugs available. Nursing staff witnessed the resident and his son handling and taking medications from an unlabeled container, but did not complete the required self-administration assessment or obtain a physician order, contrary to facility policy.
A resident with multiple medical conditions did not receive her scheduled morning medications, including antihypertensives and other critical prescriptions, because she was marked as unavailable. The missed administration was not identified or reported by staff until several days later, and appropriate notifications to supervisors and providers were not made at the time.
A resident with a left knee infection was reported by multiple staff to have exhibited verbally aggressive behaviors and refused care, including wound dressing changes and urinal emptying. Despite these incidents, the medical record did not reflect any documentation of the refusals or behaviors, and staff confirmed there was no specific policy for documenting such events, resulting in incomplete medical records.
A facility failed to assess a resident's ability to self-administer a nebulizer medication. An LPN allowed the resident, who had a right arm sling due to a humerus fracture, to self-administer the nebulizer without documented assessment or care plan. The facility's policy required an assessment and return demonstration, which was not documented.
A facility failed to provide a homelike environment for a resident with acute respiratory disease, heart failure, and obesity. Observations revealed that the corner molding in the resident's room was detached, exposing drywall, and there were areas with missing paint. The Executive Director was unaware of these issues, which were attributed to the resident's use of a motorized wheelchair. The facility's expectation was to ensure a safe, clean, and homelike environment for all residents.
A facility failed to document and follow up on a resident's bowel movements, leading to inadequate constipation management. The resident, who was cognitively intact and continent, went 13 days without a bowel movement after admission. The facility lacked a policy for monitoring bowel movements, resulting in multiple undocumented periods of constipation.
A facility failed to administer g-tube feeding and water flushes as ordered for a resident with severe sepsis and dysphagia. The resident's feeding pump was observed running at outdated settings due to a communication lapse by the ADHS, who did not ensure nursing staff were informed of the updated physician's orders. This failure was contrary to the facility's policy requiring regular assessment and monitoring by a Registered Dietitian.
A facility failed to date oxygen tubing for a resident with acute kidney failure and falls, who required continuous oxygen. Observations over several days showed the tubing was not dated, contrary to the facility's policy. The ADHS noted that dates rubbed off, and labels were ordered to resolve the issue.
A resident with chronic pain conditions did not receive effective pain management despite reporting moderate pain. An LPN failed to administer or offer pain relief after the resident reported a pain level of 5 out of 10. The facility's policy on pain management was not followed, as no follow-up or documentation was completed.
The facility failed to administer medications as ordered for three residents, leading to deficiencies in pharmaceutical services. A resident with a UTI received an antibiotic for longer than prescribed, another resident did not receive several medications during a respite stay, and a third resident was given a higher dose of Ambien than ordered. The facility did not notify physicians or the pharmacy about these discrepancies.
The facility failed to provide a clinical rationale for denying a gradual dose reduction of antidepressant and antianxiety medications for two residents. One resident, with no documented anxious behaviors, was prescribed clonazepam, and despite recommendations for dose reduction, the physician denied changes without initial rationale. Another resident, receiving two antidepressants, had dose reduction evaluations denied without specific justification until later documentation cited severe depression. The facility's policy requires documented medical necessity for psychotropic medications, which was not initially met.
A facility failed to follow Enhanced Barrier Precautions (EBP) during care for a resident with a feeding tube. Despite a sign indicating the need for gloves and gowns during high-contact activities, two CRCAs provided perineal care without gowns. The Director of Health Services acknowledged the oversight, which violated the facility's infection control policy.
A resident with a pressure ulcer did not receive consistent wound assessments and documentation as required. The wound nurse failed to enter handwritten notes into the EHR, and the attending physician was not informed of the ulcer until weeks later. The care plan included weekly assessments, but these were not consistently documented, and discrepancies were found in the records of dressing changes and wound assessments.
The facility failed to document meal intakes for three residents with nutritional concerns, leading to a deficiency. A resident with multiple health issues had difficulty chewing and inconsistent meal documentation. Another resident with a history of rhabdomyolysis and heart conditions had missing meal records despite weight monitoring. A third resident with malnutrition and pressure ulcers also had incomplete meal documentation, despite interventions. The facility's policy required meal intakes to be recorded, which was not consistently followed.
Failure to Ensure Bedside Hydration for Residents at Risk of Dehydration
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate residents’ hydration needs and preferences by not ensuring fluids were available at bedside for three residents assessed as at risk for dehydration. One resident with diagnoses including stroke, chronic kidney disease, and UTI, and care plans identifying risk for dehydration, diuretic use, and constipation with interventions to encourage and offer fluids, reported only receiving fluids with meal trays. The resident’s family member, who visited daily, stated the resident never had fluids in the room and that the family had to provide fluids every day. Another resident, cognitively intact with diagnoses including CHF and iron deficiency anemia and a care plan indicating risk for dehydration with an intervention to offer fluids, was observed in the morning with a Styrofoam cup containing only a small amount of water and reported that no water had been brought that day and that sometimes he had to ask for it. Later that day, he reported receiving fresh water for the first time about twenty minutes prior. A third resident, moderately cognitively impaired with diagnoses including severe sepsis with septic shock and acute respiratory failure with hypoxia, and care planned as at risk for dehydration with an intervention to offer fluids, was twice observed with an empty Styrofoam cup without a date, first stating she always had to ask for water and later indicating the empty cup with ice came on her lunch tray and that water had still not been passed. The Administrator stated there was no facility hydration policy and that water cups were passed once per shift.
Failure to Notify Family of Resident’s Significant Bruising and Possible Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family of a significant change in condition, specifically the development and worsening of a large bruised area on the resident’s back. A family member reported that they first observed the large bruise when the resident was admitted to the hospital on 12/21/25 and stated they had not been informed of the bruise or of any fall. The resident told the family member that about a week prior to the hospital admission, she had a fall during a transfer with staff. Review of the clinical record showed no documentation that the resident had a fall. The resident’s admission MDS, dated 9/24/25, indicated the resident was cognitively intact and able to make consistent and reasonable daily decisions. A progress note dated 12/21/25 at 2:23 p.m. documented that dark areas on the resident’s back had worsened, were getting darker, and had increased in size. An event was opened to ensure the wound nurse was aware, and the Nurse Practitioner was notified. However, the documentation did not show that the resident’s family had been notified of this change in condition. During an interview, the DNS explained that when an event was created in the computer, it was turned into an internal incident report, and no further information or documentation of family notification was provided. The facility’s notification policy stated that the resident’s responsible party would be notified immediately of a change in condition, but this was not reflected in the record for this resident.
Failure to Assess and Document Large Back Bruise and Notify Family
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough and accurate assessment of a large bruised area on a resident’s back and to document ongoing evaluation of the condition. Hospital documentation dated 1/21/26 indicated that the resident had a traumatic wound on admission to the right side of the back measuring 22 cm by 9 cm, described as purple and red with erythema. The resident’s diagnoses included stroke, and the clinical record did not indicate that the resident had a fall. A progress note dated 12/21/25 at 2:23 p.m. documented that dark areas on the resident’s back had worsened, were getting darker, and increasing in size, and that an event was opened to ensure the wound nurse was aware and the Nurse Practitioner was notified. However, there were no further assessments of the back area documented after this note. Review of the wound management record on 1/28/26 showed no bruising assessment for the resident’s back or any other assessment of the back. During interview, the DNS stated that when an event was created in the computer it was turned into an internal incident report, and no additional documentation or assessments were provided to surveyors. The facility’s bruising policy required completion of a bruise incident in the electronic health record along with a template/assessment progress note, but such documentation was not present. In addition, during an interview, the resident’s family member reported they were not notified of a large bruise on the resident’s back. The resident reported having had a fall during a transfer with staff and hitting the side of the bed, and the family member was not aware of either the fall or the bruising.
Failure to Notify Hospital of Medication Error During Resident Transfer
Penalty
Summary
A resident with multiple complex medical conditions, including chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, dependence on renal dialysis, and pulmonary edema, received another resident's morning medications in error. The incident was immediately reported to the nursing supervisor, Director of Health Services (DHS), and Nurse Practitioner (NP), who assessed the resident and implemented orders to monitor for potential side effects. The resident was made aware of the error, and an attempt was made to notify his wife. The resident was subsequently transferred to a local hospital. Upon transfer, the facility failed to notify the receiving hospital that the resident had received the wrong medications prior to admission. There was no documentation provided to the hospital regarding the medication error, and the hospital only became aware of the incident after the resident's family member obtained and delivered the information. Interviews with facility staff confirmed that it was expected for the nurse transferring the resident to report such incidents, but there was no policy in place outlining what should be communicated to the hospital during transfers.
Resident Received Another Resident's Medications Due to Medication Administration Error
Penalty
Summary
A resident with multiple complex medical conditions, including chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, and dependence on renal dialysis, was administered another resident's morning medications in error. The resident's care plan included interventions to administer medications as ordered, and the resident was identified as being at risk for dehydration, fluid imbalance, and pain related to several chronic conditions. On the day of the incident, the resident did not receive their scheduled morning medications and instead received a full set of medications intended for another resident. The medications administered in error included several drugs with significant potential side effects, such as amlodipine, atorvastatin, duloxetine, Eliquis, furosemide, gabapentin, potassium chloride, sotalol, and atenolol. The resident had a documented allergy to atorvastatin, with previous reactions of dizziness and rash. At the time of the incident, the resident was assessed and found to have no immediate signs or symptoms of adverse effects, and no rash was present. The resident was later sent to the hospital due to symptomatic bradycardia and ongoing concerns related to his medical history, including orthostatic hypotension and dialysis needs. Interviews with facility staff, the resident's family member, and the nurse practitioner confirmed that the resident received the wrong medications and did not receive his own scheduled medications. The facility's medication administration policy required verification of the five rights of medication administration, including resident identification, but this process was not followed, resulting in the medication error.
Failure to Follow Up on Hemolyzed Lab Results Leads to Hospitalization
Penalty
Summary
The facility failed to timely follow up on hemolyzed laboratory results for a resident with a history of malignant melanoma and encephalopathy, who was at risk for complications related to cancer. The resident had physician orders for weekly complete blood count (CBC) tests, with results to be faxed to the oncologist. On one occasion, a CBC drawn was found to be hemolyzed and the laboratory requested a new order and recollection, but there was no documentation in the progress notes that the lab was redrawn or that the provider was notified. The resident's care plan included monitoring laboratory results as ordered, but this was not followed. Subsequently, several days later, the resident exhibited confusion and a new CBC was obtained, revealing a critically low hemoglobin level. The resident was then transferred to the emergency room and hospitalized for acute on chronic anemia, requiring multiple blood transfusions. Interviews with family and the oncologist's office confirmed that no CBC results were received during the period in question, and facility staff were unable to explain why the labs were not redrawn or the provider notified. There was no specific policy in place for handling hemolyzed samples.
Failure to Ensure Timely Call Light Response and Resident Dignity
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence and timely assistance, as evidenced by prolonged call light response times for two residents. One resident, who was cognitively intact and had diagnoses including aftercare following joint replacement surgery and hypertensive heart disease, reported that call light response times varied from a few minutes to as long as 45 minutes, with waits usually exceeding 15 minutes. She expressed discomfort and distress due to the delays, particularly when needing immediate assistance to use the bathroom. The facility's policy required call lights to be answered as quickly as possible, but this standard was not met. Another resident, alert and oriented with a diagnosis of infection related to an internal prosthetic, reported waiting over two hours for assistance after initially requesting help, and an additional 45 minutes after a second request. This resident described feeling helpless due to the repeated and prolonged waits. A Certified Resident Care Associate confirmed that staffing levels were inadequate, often leaving her responsible for 37 patients and unable to provide routine care or respond to call lights promptly. She acknowledged that residents sometimes waited 30 minutes or more for assistance, especially when she required help from a nurse for certain residents, leaving no one available to respond to other needs.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident with a medical history of a left knee infection related to an internal prosthetic was admitted to the facility and was alert and oriented upon admission. On the night of admission, the resident's son brought in home medications, including narcotics, because the facility did not have the resident's prescribed medications available. The resident and his son administered the medications, and the resident confirmed taking his own oxycodone. Nursing staff, including two LPNs, were aware that the resident was using medications brought from home, some of which were in an unlabeled container. One LPN attempted to verify the medications verbally with the resident but did not complete a self-administration of medication assessment and was unfamiliar with the facility's policy on self-administration. The other LPN, who admitted the resident, also did not complete the required assessment. Review of the clinical record revealed there was no documentation of a Self-Administration of Medication assessment or a physician order authorizing self-administration. Facility policy required an assessment to be completed for any resident requesting or engaging in self-administration of medication. The failure to assess the resident's ability to safely self-administer medications and to follow policy regarding verification and documentation led to the deficiency.
Failure to Administer Prescribed Medications as Ordered
Penalty
Summary
A resident with diagnoses including aftercare following joint replacement surgery, cerebral ischemia, and hypertensive heart disease did not receive her prescribed morning medications on a specific date. The medications missed included antihypertensives, an antiplatelet, a supplement, an antidepressant, an antianginal, and an antidiabetic agent. The medication administration record indicated these medications were not administered because the resident was marked as unavailable. The resident later reported feeling dizzy that afternoon and realized she had not received her morning medications. She did not inform facility staff of the missed dose at the time. The facility only became aware of the missed medication administration several days later, on the resident's discharge date, when the issue was brought to their attention. The nurse responsible was a relatively new staff member and had not communicated any difficulties in locating the resident, despite being checked on multiple times by supervisory staff. Documentation showed that the nurse practitioner was informed of the missed dose, but no new orders were received. The facility's process for notifying supervisors, providers, and the resident or responsible party was not followed at the time of the incident.
Failure to Document Resident Refusals and Aggressive Behaviors
Penalty
Summary
The facility failed to accurately document the behaviors and refusals of care for a resident with a medical diagnosis of a left knee infection related to an internal prosthetic. The resident was alert and oriented upon admission. Multiple staff interviews revealed that the resident exhibited verbally aggressive behaviors, including cussing at staff, refusing care such as wound dressing changes and urinal emptying, and expressing intentions to leave the facility against medical advice. Staff described the resident as agitated, frustrated, and resistive to assistance, with specific incidents where the resident verbally abused staff and refused interventions. Despite these reported behaviors and refusals, a review of the resident's medical record showed no documentation of these events. The facility did not have a specific policy for documenting behaviors, but the expectation was that refusals of care would be recorded in the chart. The lack of documentation was confirmed during interviews with staff and the corporate nurse, indicating a failure to maintain accurate and complete medical records in accordance with accepted professional standards.
Failure to Assess Resident's Ability to Self-Administer Nebulizer
Penalty
Summary
The facility failed to ensure that a resident was clinically assessed and deemed appropriate to self-administer a nebulizer medication. During an observation of medication administration, an LPN prepared and handed a nebulizer face mask to a resident who then self-administered the medication. The LPN left the room while the resident continued the nebulizer treatment. The resident had a sling on her right arm due to a humerus fracture, and the nebulizer machine was placed on the right side of her bed, which could have posed a challenge for her to manage the equipment safely. The resident's clinical record indicated a recent orthopedic appointment where she was advised to be non-weight bearing on her right upper extremity. Although the resident expressed a desire to self-administer medications, there was no documented assessment or care plan in the electronic health record to confirm her capability to safely self-administer the nebulizer treatment. The facility's policy required an assessment and return demonstration to ensure safety, which was not documented in this case.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident 14, who was reviewed for homelike environment. The resident's clinical record indicated diagnoses including acute respiratory disease, heart failure, and obesity. During observations, it was noted that the corner molding in Resident 14's room was detached from the wall, exposing the drywall where it connected at the corner. The molding was found leaning against the opposite wall, and there were areas where paint was missing on the wall behind the head of the bed. These observations were made on multiple occasions. During a tour, the Executive Director stated he was unaware of the molding issue and missing paint, acknowledging that this had been a recurring problem due to the resident's use of a motorized wheelchair. The facility's expectation was to maintain a safe, clean, and homelike environment for all residents.
Failure to Document and Follow Up on Resident's Bowel Movements
Penalty
Summary
The facility failed to ensure proper documentation and follow-up for a resident's bowel movements, leading to a deficiency in care for constipation management. Resident G, who was cognitively intact and always continent of bowel, was admitted with a diagnosis that included constipation. Despite having a bowel and bladder care plan in place, which required notifying the charge nurse of changes in bowel patterns, the facility did not document or follow up on the resident's bowel movements adequately. The resident went 13 days without a bowel movement after admission, as reported by a family member. The electronic health record showed multiple instances where Resident G went several days without a documented bowel movement, including periods of up to six days without any record. The Executive Director confirmed that there was no facility policy regarding the monitoring of bowel movements. This lack of documentation and follow-up is contrary to the guidelines from the National Library of Medicine, which defines constipation as having three or fewer bowel movements per week.
Failure to Administer G-Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer gastric tube (g-tube) feeding and water flushes as ordered by the physician for Resident 299, who was reviewed for nutrition. Resident 299 had a medical history that included severe sepsis with septic shock, dysphagia, and was receiving orthopedic aftercare following surgical amputation. The care plan for tube feeding, initiated and revised in February 2025, required adherence to specific feeding and flushing orders. However, observations on two separate occasions revealed that the feeding pump was running at the previous order's settings, which had been discontinued, rather than the updated physician's orders. The discrepancy arose because the Assistant Director of Health Services (ADHS) entered the new order for the g-tube feedings and flushes but failed to ensure that the nursing staff was informed of the change. The Director of Health Services (DHS) confirmed this lapse in communication during an interview. The facility's policy on tube feedings, which was revised in May 2024, mandates that residents requiring tube feeding be assessed by a Registered Dietitian or Nutrition & Dietetics Technician, Registered, with monthly monitoring. This policy was not effectively followed, leading to the deficiency in care for Resident 299.
Failure to Date Oxygen Tubing for Resident
Penalty
Summary
The facility failed to properly date oxygen tubing for a resident requiring respiratory care. Resident 253, who has diagnoses including acute kidney failure and falls, was observed on multiple occasions with oxygen tubing that was not dated. A physician's order required the resident to be on continuous oxygen at two to three liters per minute. Observations on three separate days revealed that the oxygen tubing at the resident's bedside was not dated as per the facility's policy. The Assistant Director of Health Services acknowledged the issue, noting that the dates rubbed off the tubing, and indicated that labels had been ordered to address the problem. The facility's Administration of Oxygen Policy mandates that tubing be dated when initiated and changed monthly or as needed.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for Resident 251, who had diagnoses including Alzheimer's disease, chronic back pain, and chronic vertebral fractures due to osteoporosis. A physician's order required monitoring of the resident's pain three times a day for seventy-two hours, and a pain medication order allowed for morphine concentrate solution to be administered every four hours as needed. Despite the resident rating her pain as a 5 out of 10, indicating moderate pain, on 2/12/25, no pain medication was administered, and no follow-up was documented in the electronic health record (EHR). During an interview, an LPN admitted to not providing any pharmacological or non-pharmacological interventions after the resident reported her pain level. The LPN acknowledged forgetting to check if there was an order for pain medication. Additionally, the resident's daughter reported that the resident experienced discomfort during care activities. A progress note later indicated that the resident was resting without outward signs of pain, but the facility's policy required evaluation and documentation of pain management effectiveness, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders for three residents, leading to deficiencies in pharmaceutical services. Resident G, diagnosed with sepsis and a urinary tract infection (UTI), was prescribed cefdinir 300 mg twice a day for seven days. However, the medication administration record (MAR) indicated that the antibiotic was administered for eight days on two separate occasions, contrary to the physician's orders. This discrepancy in medication administration was not addressed or corrected by the facility. Resident C, admitted for a respite stay, did not receive several medications as they were listed as unavailable in the MAR. These included Depakote, ropinirole, Rytary, and trazodone. There was no documentation indicating that the physician was notified of the missed doses or that the pharmacy was contacted to ensure medication delivery. Additionally, Resident 40, who had orders for Ambien 5 mg for insomnia, was incorrectly administered 10 mg on multiple occasions, as documented in the controlled drug use record. The Director of Health Services confirmed that medications should be administered as ordered, highlighting a failure in the facility's medication management processes.
Failure to Provide Rationale for Denial of Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure a clinical rationale was provided for the denial of a gradual dose reduction (GDR) of antidepressant and antianxiety medications for two residents. Resident 30, diagnosed with conditions including major depressive disorder and agoraphobia with panic disorder, was prescribed clonazepam. Despite a lack of documented anxious behaviors and multiple pharmacist recommendations for a GDR, the physician repeatedly denied the reduction without providing a specific rationale. It was only after a recent fall that the physician noted the resident's seizure disorder and risk of breakthrough seizures as reasons for maintaining the current dosage. Resident 26, who was cognitively intact and exhibited no behaviors, was receiving two antidepressants: venlafaxine and Wellbutrin. The facility's care plan required attempts at GDR unless clinically contraindicated. However, despite pharmacy recommendations for dose reduction evaluations, the physician denied changes without initially providing a specific rationale. It was later documented that the resident's severe depression related to recent illness and overall decline justified the continuation of the current dosages. The facility's policy on psychotropic medication usage and GDRs mandates that residents receive such medications only if medically necessary, with documented justification. The policy also requires ongoing efforts to reduce dosages unless contraindicated. In both cases, the facility did not initially provide adequate documentation or rationale for the continued use of the medications at their current dosages, leading to the identified deficiency.
Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices by not adhering to Enhanced Barrier Precautions (EBP) during the provision of activities of daily living (ADL) care for a resident. Resident 299, who had a history of severe sepsis with septic shock, dysphagia, and was receiving tube feeding, was observed in a room with a sign indicating the need for EBP. The sign instructed that gloves and gowns should be worn for high-contact care activities, such as providing hygiene and toileting assistance. However, during an observation, two Certified Resident Care Associates (CRCAs) were seen providing perineal care to the resident without wearing gowns, although gloves were used. A cart with the necessary personal protective equipment (PPE) was available in the room. The Director of Health Services confirmed that the CRCAs should have been wearing the appropriate PPE, as outlined in the facility's Enhanced Barrier Precautions Standard Operating Procedure. This policy mandates the use of gloves and gowns during high-contact care activities for residents with indwelling medical devices, such as feeding tubes, which was applicable to Resident 299. The failure to adhere to these precautions during the care of Resident 299 represents a deficiency in the facility's infection control practices.
Inadequate Wound Care Documentation and Assessment
Penalty
Summary
The facility failed to ensure routine and timely wound assessments for a resident with a pressure ulcer. Resident B, who was admitted with an unstageable pressure ulcer, did not receive consistent weekly wound assessments and documentation as required. The initial wound assessment was incomplete, lacking details such as the stage of the wound, drainage, color, odor, wound margins, surrounding tissue, and presence of tunneling or undermining. The wound nurse admitted to not entering the handwritten notes into the electronic health record (EHR), and the attending physician was not informed of the pressure ulcer until several weeks after admission. The care plan for Resident B included weekly skin assessments and wound measurements, but these were not consistently documented. The wound nurse acknowledged being overwhelmed with responsibilities, which contributed to the lack of documentation. The facility's records showed discrepancies in the documentation of dressing changes and wound assessments, with only one dressing change recorded in the Treatment Administration Record (TAR) for May 2024, despite orders for daily changes. Additionally, the application of a foam dressing was not documented in the EHR. Interviews with facility staff revealed that the wound nurse did not document the application of a foam dressing or enter specific care orders into the EHR. The facility's policy required weekly documentation of wound measurements and conditions, but this was not adhered to until later in May 2024. The lack of consistent documentation and communication regarding Resident B's pressure ulcer care led to a deficiency in the facility's wound care practices.
Failure to Document Meal Intakes for Residents with Nutritional Concerns
Penalty
Summary
The facility failed to routinely document meal intakes for three residents with nutritional concerns, leading to a deficiency in maintaining adequate nutrition records. Resident B, who had multiple health issues including a heart attack, diabetes, and obesity, was noted to have difficulty chewing due to not wearing dentures. Despite a family member's request for a nutritionist, there was no follow-up, and meal intakes were not consistently documented. The Registered Dietitian (RD) recommended dietary supplements and monitoring, but several meals were not recorded, indicating a lapse in documentation. Resident C, with a history of rhabdomyolysis, sepsis, and heart conditions, was on a mechanical soft diet. The RD noted significant weight gain, which was considered beneficial, and planned to monitor weights and intakes. However, meal documentation was missing for several meals in June, indicating a failure to consistently record meal intakes as per the facility's policy. Resident D, who had malnutrition and pressure ulcers, was closely monitored by the RD due to significant weight loss. Despite interventions like a liberalized diet and nutritional supplements, meal intakes were not consistently documented. The RD noted a recent weight gain, but the lack of meal documentation on specific dates highlights a deficiency in maintaining accurate nutritional records. The facility's policy required meal intakes to be recorded in the electronic health record, which was not adhered to, leading to this deficiency.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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