Waters Edge Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 2200 West White River Blvd, Muncie, Indiana 47303
- CMS Provider Number
- 155038
- Inspections on file
- 25
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Waters Edge Village during CMS and state inspections, most recent first.
A resident with dementia and a documented history of aggression repeatedly shoved, pushed, and physically assaulted other cognitively impaired residents, causing multiple falls, a head laceration, and bruising. Staff and progress notes described the aggressor pacing into other residents’ rooms, pulling on wheelchairs, throwing objects, and becoming hostile toward peers and staff. Despite this pattern and internal recognition that the resident had prior incidents of pushing others, the care plan did not include specific, individualized interventions to mitigate the risk of further resident-to-resident altercations, resulting in repeated physical abuse of several residents on the dementia unit.
The facility failed to thoroughly investigate multiple resident-to-resident abuse incidents involving one cognitively impaired resident who repeatedly pushed other residents, causing falls and, in one case, injury requiring ER transfer. Several residents with dementia and mobility or cognitive impairments reported or were documented as being pushed, resulting in loss of balance and falls. Facility documentation focused on falls and environmental or behavioral interventions, but the investigation files provided by the Administrator lacked abuse investigations for these altercations, even though the Administrator acknowledged being informed of at least one pushing incident.
The facility failed to immediately report multiple resident-to-resident abuse allegations to the Administrator and to the state agency as required by its abuse policy. A resident with dementia and a history of aggressive behavior shoved and pushed other residents, causing falls and, in one case, a head laceration and shoulder bruising that required ER evaluation. Another resident with dementia and behavioral disturbances fell after being pushed by another resident, and a third resident with severe dementia and schizophrenia reported being punched and pushed to the floor by a resident who was seen leaving his room with fists balled. Nursing staff documented these events and some informed leadership, but the DON and Administrator could not clearly identify when or by whom certain incidents were reported, and the Administrator chose not to report specific altercations to the state because the residents were not injured or upset and one was believed to embellish. These decisions conflicted with the written policy requiring immediate reporting of all abuse allegations, including resident-to-resident abuse, to the Executive Director and to the state within two hours.
A cognitively impaired resident was observed wearing the same clothing for several days due to a lack of available clothing in his room. Despite an initial inventory indicating sufficient clothing, staff interviews revealed that the resident's clothing had gone missing after a room change. The facility's policy on personal laundry was not effectively implemented, and staff failed to ensure the resident had adequate clothing, leading to a deficiency in maintaining the resident's dignity.
A resident received an extra dose of hydrocodone-acetaminophen due to an LPN administering medication based on memory rather than verifying the current physician's order. The error occurred after a change in the medication schedule, and the resident was monitored for sedation. The facility's policy requiring verification of the five rights of medication administration was not followed.
The facility failed to post daily nurse staffing information, including the facility census and shift-specific staffing details. Observations showed that the posted data lacked a shift-to-shift breakdown and census numbers for several days. Interviews with the Administrator and DON confirmed the deficiency, as staffing was completed weekly and forms were filled for a 24-hour period instead of per shift, contrary to the facility's policy.
The facility failed to maintain sanitary conditions during meal service on the Cottage Unit, affecting 21 residents. CNA 13 handled sandwiches and cups improperly, using bare hands and touching cup rims, contrary to facility policy. Staff interviews confirmed the breach of protocol, which requires using utensils and avoiding contact with food surfaces.
A resident with severe cognitive impairment was left alone in a bathroom after an incontinence episode, covered in feces. A CNA found the resident in this state but left the facility without providing care. Another CNA, responsible for the resident, was informed but was occupied with another task. It took several minutes before assistance arrived to help the resident to the shower room. The facility's policy on treating residents with dignity was not upheld.
A facility failed to report an alleged abuse incident involving a resident who was left alone in a bathroom covered in feces by two CNAs. The incident was reported internally, but the Administrator and a corporate nurse consultant determined it was not abuse, leading to a failure to report the incident to the Indiana Department of Health as required by policy.
A facility failed to properly investigate an alleged neglect incident involving a resident found in a soiled state. CNA 8 observed the resident but left without providing care, and the Administrator did not document the investigation thoroughly. The incident was not reported to the Indiana Department of Health, contrary to facility policy.
A facility failed to properly document and reconcile narcotic medication administration for three residents, leading to concerns about potential medication diversion by an LPN. Discrepancies in documentation, including unauthorized removal of medication and lack of co-signatures, were found in the records of multiple residents. Additionally, the facility's medication cart shift change verification sheets lacked proper documentation, hindering accurate reconciliation of narcotic medications.
Failure to Prevent Ongoing Resident-to-Resident Physical Abuse by Known Aggressor
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from recurrent resident‑to‑resident physical abuse by one resident with known aggressive behaviors. Resident B, who had dementia with severe cognitive impairment and a documented history of shoving, hitting, scratching, and threatening to hit or physically attack other residents, repeatedly engaged in physical aggression toward other residents on the dementia unit. Progress notes documented numerous episodes of Resident B pushing other residents, throwing objects, yelling expletives, pacing into other residents’ rooms, pulling on wheelchairs, and becoming aggressive with staff attempting redirection. Despite these ongoing behaviors and an existing care plan problem identifying his risk for physical aggression, the clinical record lacked care plan interventions specific to mitigating the risk of Resident B engaging in resident‑to‑resident altercations. Resident E, who had dementia and severe cognitive impairment, experienced two separate incidents in which she was pushed by Resident B. In the first incident, she was walking down the hall when another resident pushed her out of his personal space, causing her to lose balance and fall; the IDT identified the root cause as her being in another resident’s personal space and implemented an intervention to encourage her not to be in others’ personal space. In the second incident, she was walking past Resident B in the dementia unit dining room when he shoved her to the floor and kicked her in the abdomen. Witnesses, including a CNA and a housekeeper, described Resident B pushing her, causing a fall, and then kicking her while staff attempted to intervene. Although these events were documented and reported, the facility’s care planning for Resident B did not include specific interventions to prevent further resident‑to‑resident altercations. Resident F, who had vascular dementia with behavioral disturbance and severe cognitive impairment, was pushed by Resident B while walking past his room, resulting in a fall to the floor. Staff accounts indicated that Resident F was known to wander and enter other residents’ rooms to offer snacks, and that Resident B had prior physical and verbal altercations with other residents, including Resident E. On the date of this incident, Resident B stepped forward from his doorway and pushed Resident F hard enough to propel her across the hallway into a wall and door, causing her to land on the floor. Similarly, Resident D, who had severe dementia, schizophrenia, and required a wheelchair for mobility, reported that another resident came into his room, punched him in the head, and pushed him from his wheelchair to the floor. Staff observed Resident B coming from Resident D’s room and then, shortly afterward, Resident B pushed Resident C, who had Alzheimer’s disease, into a door frame, causing a head laceration and shoulder bruising. These repeated episodes of physical aggression toward Residents C, D, E, and F occurred despite prior knowledge of Resident B’s behaviors and without individualized, documented care plan interventions aimed at preventing resident‑to‑resident abuse. Resident C’s involvement further illustrates the pattern of unmitigated risk. She reported to CNAs that two men were fighting in a room, referring to an altercation involving Resident B. As staff attempted to escort her away, Resident B emerged from another resident’s room with fists balled, appeared angry, and advanced toward them. Staff placed Resident C in front of them and tried to walk away, but Resident B caught up, grabbed her, and pushed her into a door jamb. The ADON later described Resident B grabbing the back of Resident C’s head and slamming it against a metal door frame, resulting in a laceration to the right side of her head and immediate bruising to her right shoulder. These events, combined with prior documented incidents of Resident B pushing other residents and causing falls, demonstrate that the facility did not implement or document specific, individualized care plan interventions to address and reduce the risk of further resident‑to‑resident altercations involving Resident B, leading to repeated episodes of physical abuse of multiple cognitively impaired residents. The facility’s own behavior/high‑risk peer review documentation acknowledged that Resident B had previous incidents of pushing other residents, including the 12/25/25 incident with Resident E and the 1/15/26 incident where he shoved another resident causing a fall. Staff interviews consistently described Resident B as becoming overstimulated around other residents, wandering into rooms, and exhibiting aggressive posturing and actions toward peers. Despite this pattern and the facility’s abuse prohibition policy requiring assessment, root cause analysis, IDT recommendations, and care plan updates to prevent further occurrences, Resident B’s clinical record did not contain care plan interventions specifically directed at mitigating his risk for resident‑to‑resident altercations. This lack of targeted, documented interventions in the face of known, escalating aggressive behavior toward Residents C, D, E, and F constitutes the core deficiency in protecting residents from abuse.
Failure to Investigate Resident-to-Resident Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough and accurate investigations into multiple resident-to-resident abuse incidents involving one resident who repeatedly pushed other residents, resulting in falls and injury. Resident B, who had dementia, hypertension, major depressive disorder, and anxiety, had a care plan problem dated 12/25/25 indicating he might threaten to hit or physically attack other residents and might shove, hit, or scratch. Progress notes documented that on 12/14/25 he pushed another resident out of his personal space, causing the other resident to lose balance, and on 1/15/26 he reportedly shoved another resident causing a fall. On 1/23/26, Resident B pushed another resident against a hallway wall, causing a laceration to the right side of the resident’s head and bruising to her right shoulder, and that resident was transferred to the ER. Resident E, with dementia, generalized anxiety disorder, and mild neurocognitive disorder, was care planned as at risk for falls and had an intervention to encourage her not to be in others’ personal space. A fall event note documented that she lost her balance and fell onto her buttocks after being pushed by another resident when she approached that resident in the hallway; the IDT fall review identified the root cause as her being in another resident’s personal space and implemented staff encouragement for her to avoid others’ personal space. Resident F, with vascular dementia, psychotic disorder with delusions, and anxiety disorder, was documented in a progress note as having fallen after being pushed by another resident, losing her balance and falling without injury; the root cause was identified as loss of balance after being pushed, and an intervention of placing a stop sign on the doorway of a room she preferred to wander into was noted. Resident D, who had severe dementia, schizophrenia, anxiety disorder, and required a wheelchair and partial assistance for transfers, reported multiple incidents involving another resident. On one occasion, a CNA found him sitting on the floor between the bed and wheelchair, and he stated another resident pushed him from the bed; no injuries were noted. On another occasion, he reported that a “crazy man” punched him in the head and then pushed him out of the wheelchair, with no injuries found. An IDT note later described that he stated another resident came into his room and pushed him to the floor, and a stop sign was placed on his doorway to deter other residents from entering. Despite these documented resident-to-resident altercations and falls involving pushing by another resident, the facility’s investigation files provided by the Administrator did not contain abuse investigations for the incidents involving Residents E, F, and D, and the Administrator confirmed that all investigations for the past 60 days had been provided and acknowledged that the pushing incident between Resident B and Resident F had been reported to him.
Failure to Timely Report Resident-to-Resident Abuse Allegations to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report allegations of resident-to-resident abuse to the Administrator and to the Indiana Department of Health (IDOH) as required by policy and regulation. Resident B, who had dementia, major depressive disorder, anxiety, and severe cognitive impairment, had a care plan noting a history of threatening and physically aggressive behaviors such as shoving, hitting, and scratching. Progress notes documented that Resident B shoved another resident causing a fall and, on a later date, pushed another resident against a hallway wall, causing a head laceration and shoulder bruising that required ER transfer. Despite these documented aggressive incidents, the Administrator indicated that such altercations were not always reported to IDOH if they did not meet the facility’s internal guidance, and resident pushing could be considered abuse only depending on the circumstances. Resident F, with vascular dementia, psychotic disorder with delusions, and anxiety disorder, was documented in a progress note as having fallen after being pushed by another resident, with the root cause identified as loss of balance after being pushed. An intervention of placing a stop sign on the doorway of a room she preferred to wander into was implemented. The DON and Administrator both acknowledged awareness of a resident-to-resident altercation involving Resident B and Resident F, but neither could recall who reported it or when, and the Administrator confirmed the incident was not reported to IDOH because it was determined not to meet the facility’s reporting guidance. The Administrator stated that staff typically reported abuse and resident-to-resident altercations to the charge nurse, who then reported to the Administrator, and that staff could also report directly to the Administrator if they chose. Resident D, with severe dementia, schizophrenia, and anxiety disorder, was found sitting on the floor between the bed and wheelchair and reported that another resident had pushed him from the bed; later documentation indicated he reported being punched in the head and pushed from his wheelchair by another resident. CNA 19 reported seeing Resident B leaving Resident D’s room with fists balled and an angry expression, and then observed Resident B push another resident against a door jamb. CNA 22 and RN 4 found Resident D on the floor and documented that Resident D stated Resident B had shoved him to the floor. RN 4 did not report the allegation to the Administrator, assuming another nurse had done so. The Administrator later acknowledged being informed of an altercation involving Resident B and another resident and that Resident D alleged being pulled out of bed, but Resident D’s allegation was not included in the report to IDOH because he had no injuries, was not upset, and was known to embellish, and the facility believed the events were unrelated. These actions and inactions occurred despite a written facility policy requiring all abuse allegations, including resident-to-resident abuse, to be reported immediately to the Executive Director and to IDOH within two hours.
Failure to Provide Adequate Clothing for Resident
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident, identified as Resident 47, was provided with adequate clothing to maintain a dignified existence. Observations over several days revealed that the resident wore the same gray long sleeve shirt and white/black plaid lounge pants without change. During an interview, the resident indicated a lack of clothing, and a search of his room confirmed the absence of adequate clothing items, despite an inventory log showing he initially had sufficient clothing upon arrival. The resident's clinical records indicated moderate cognitive impairment, requiring assistance with activities of daily living, including dressing. Staff interviews revealed that the resident was believed to have adequate clothing, but it was noted that his clothing had been missing since a room change. A CNA confirmed that the resident's clothing was obtained from a boutique due to the lack of available clothing in his room, and the Memory Care Support Specialist was unaware of the shortage. The facility's policy on resident personal laundry required regular washing and timely return of clothing, but it appears this was not effectively implemented for Resident 47. The Memory Care Support Specialist and other staff members failed to ensure the resident had sufficient clothing, and the facility's procedures for managing resident clothing inventory and laundry services were not adequately followed, leading to the resident's prolonged use of the same clothing.
Medication Administration Error Due to Non-Adherence to Protocols
Penalty
Summary
The facility failed to ensure that nursing staff adhered to the five rights of medication administration, resulting in a medication error for a resident. The resident, who was cognitively intact and had a history of peripheral vascular disease and a non-pressure chronic ulcer, was prescribed hydrocodone-acetaminophen for pain management. The physician's order for the medication was changed on January 9, 2025, to be administered every four hours, but a Licensed Practical Nurse (LPN) administered an additional dose based on a previous schedule, leading to an error. On January 11, 2025, the LPN administered an extra dose of hydrocodone-acetaminophen at 5:00 a.m., despite the new order not requiring a dose at that time. The LPN relied on memory rather than verifying the current physician's order, which led to the error. The resident was monitored for sedation, and the next scheduled dose was held as per the provider's instructions. The Director of Nursing (DON) confirmed that the LPN had administered the medication in error and that staff were not permitted to pass medications without verifying the physician's order. The error was reported to the physician and the resident's family, and the resident was observed for any adverse effects. The LPN acknowledged the mistake, attributing it to being in a hurry and assisting another staff member. The facility's policy required staff to check the five rights of medication administration, which was not followed in this instance. The DON and other staff members were interviewed, confirming the sequence of events and the oversight in medication administration.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, including the facility census number and the actual hours worked by licensed and unlicensed nursing staff per shift. Observations and record reviews revealed that the posted Nursing Staffing Data from 1/28/25 to 2/3/25 lacked a shift-to-shift breakdown and did not include the census number for several days. Specifically, the staffing data for 1/28/25 to 1/31/25 showed the total number of staff but omitted the necessary details per shift and the resident census. Interviews with the facility's Administrator and Director of Nursing (DON) confirmed the deficiencies. The Administrator admitted to completing staffing weekly for convenience, while the DON acknowledged filling out the forms for a 24-hour period rather than per shift. The facility's policy, revised in 7/23, mandates posting the resident census and staffing details per shift at the beginning of each shift, which was not adhered to. This oversight in documentation and posting practices led to the identified deficiency.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to ensure food was prepared and served under safe and sanitary conditions on the Cottage Unit, potentially affecting all 21 residents served meals there. During a dining observation, CNA 13 was seen handling a resident's sloppy joe sandwich and another resident's breaded tenderloin sandwich with her bare hands. Additionally, CNA 13 grasped three cups by their rims, which is against the facility's policy. Interviews with staff confirmed that the proper technique was not followed, as cups should be handled from the bottom and sandwiches should be assembled using utensils or gloves. The Memory Care Support Specialist and CNA 6 both indicated that the correct procedure involves using utensils to handle food and avoiding contact with the rims of cups. CNA 13 admitted to using her hands out of habit and possibly due to being rushed. The facility's policy on hand hygiene in the dining room clearly states that food should not be touched with hands, whether gloved or ungloved, and that food contact surfaces of dishware should be avoided. This incident highlights a lapse in adherence to established sanitary protocols during meal service.
Failure to Assist Resident During Incontinence Episode
Penalty
Summary
The facility failed to protect a resident's dignity and provide necessary assistance during an episode of incontinence. Resident C, who had severe cognitive impairment and required substantial assistance with activities of daily living, was left alone in a bathroom after an incontinence episode. The resident was found by a CNA covered in feces, seated on the bathroom floor with the door closed. Despite the resident's need for assistance, the CNA left the facility without providing care, leaving the resident in a soiled state. The incident was captured on the facility's surveillance system, which showed CNA 8 entering Resident C's room, closing the bathroom door, and then leaving the facility. CNA 4, who was responsible for Resident C's care, was informed of the situation by CNA 8 but was occupied with another resident at the time. Upon completing her task, CNA 4 found Resident C in a severely soiled condition and sought assistance from CNA 5. It took approximately 6-7 minutes for CNA 5 to arrive and help escort Resident C to the shower room. Interviews with the CNAs involved revealed that CNA 8 acknowledged she should have cleaned Resident C before leaving. CNA 4 expressed surprise and concern over the decision to leave Resident C in such a condition, considering it potential abuse. The facility's policy emphasizes the importance of treating residents with respect and dignity, which was not upheld in this instance. The administrator's interviews indicated a misunderstanding of Resident C's ability to open doors, further complicating the situation.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident C, to the Indiana Department of Health. The incident occurred when CNA 4 discovered Resident C in a bathroom, covered in feces, after being left alone by CNA 2 and CNA 8. CNA 4 reported the situation to the Administrator, expressing concern that leaving the resident in such a condition could be considered abuse. However, the Administrator and a corporate nurse consultant reviewed the incident and determined it was not abuse or neglect, but rather poor care. Despite this determination, the facility did not report the incident to the appropriate authorities as required by their policy. The facility's policy on abuse prohibition, reporting, and investigation mandates that any deprivation of goods and services by staff, which could result in care deficits, should be reported. The Indiana Department of Health's policy also classifies neglect as the failure to provide necessary goods and services to avoid physical harm or emotional distress. The failure to report this incident, which involved potential neglect and deprivation of necessary care, constitutes a deficiency in the facility's adherence to reporting requirements.
Failure to Investigate Alleged Neglect of a Resident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an alleged neglect incident involving a resident, identified as Resident C. The incident occurred when CNA 8, after observing Resident C in a soiled state in his bathroom, chose to leave the facility with CNA 2 without providing immediate care or ensuring that Resident C was attended to by another staff member. Surveillance footage showed CNA 8 entering Resident C's room and then leaving without addressing the resident's condition. CNA 4 later found Resident C in a severely soiled state, with feces on his clothing, hair, and the bathroom surfaces, and reported the incident to the Administrator. The Administrator and a corporate nurse consultant reviewed the incident and determined it was not abuse or neglect, despite the evidence of inadequate care. The Administrator did not document the investigation thoroughly, as no employee statements or investigation documentation were available, and the surveillance video was overwritten. The facility's policy on abuse prohibition, reporting, and investigation was not followed, as the incident was not reported to the Indiana Department of Health. The report highlights that the facility's actions were inconsistent with the Indiana Department of Health's guidelines on reporting and investigating neglect. The failure to provide necessary care and services to Resident C, as well as the lack of a thorough investigation and reporting, constituted a deficiency in the facility's quality of care. The incident was not considered abuse or neglect by the facility, but the lack of immediate care and proper investigation procedures indicates a significant oversight in handling the situation.
Narcotic Medication Documentation and Reconciliation Failures
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of narcotic medication administration for three residents, leading to concerns about potential medication diversion by a staff member. Resident A reported not receiving scheduled pain medication, prompting an investigation and the suspension of LPN 3. The clinical record review revealed discrepancies in the documentation of narcotic administration, including unauthorized removal of medication and lack of proper co-signatures or explanations for marked-out entries. For Resident E, similar issues were identified, with entries on the narcotic medication count sheet being marked out without explanation or co-signature, indicating possible unauthorized removal of medication. Resident F's records also showed marked-out entries without proper documentation or co-signature, further suggesting potential discrepancies in medication administration. These issues were consistent across multiple residents and involved the same LPN, raising concerns about the integrity of narcotic medication handling. Additionally, the facility's medication cart narcotic shift change verification sheets for August and September lacked documentation for item counts, including the number of narcotic medication containers. The Director of Nursing acknowledged that staff failed to complete the narcotic count shift-to-shift records appropriately, hindering the ability to determine an accurate count of potentially diverted medications. The facility's policies required strict record-keeping and dual verification for controlled substances, which were not adhered to, contributing to the deficiency.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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