Waters Of Scottsburg, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsburg, Indiana.
- Location
- 1350 N Todd Dr, Scottsburg, Indiana 47170
- CMS Provider Number
- 155494
- Inspections on file
- 42
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 33 (1 serious)
Citation history
Health deficiencies cited at Waters Of Scottsburg, The during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction, right-sided hemiplegia, cognitive communication deficit, aphasia, and documented elopement risk was left unsupervised on an outdoor porch after off-duty and oncoming staff each assumed others were responsible for supervision. Despite prior exit-seeking behaviors and use of a wander guard, the resident self-propelled in a wheelchair off the property, reached a heavily traveled road, and fell from the wheelchair onto the pavement. The resident was found on the roadside by a staff speech therapist driving home, confirmed as a facility resident, and was transported by EMS to the ED, where abrasions to the right hand and foot were documented.
Facility management failed to report an elopement incident involving a cognitively impaired, high elopement-risk resident with a history of stroke, aphasia, and cognitive communication deficit. The resident, care planned for elopement risk due to confusion and expressed desire to go home, exited through the front doors, left the property in a wheelchair, and fell from the wheelchair. The incident was not included in state reportable incident documentation. The Administrator reported that, after consulting corporate and reassessing the resident’s BIMS score as 12, she was told not to report the event, despite state guidance defining elopement and requiring reporting under applicable regulations.
A resident with a Stage 4 sacral pressure ulcer and an indwelling urinary catheter had a physician order for catheter care every shift, but the clinical record showed no documentation of such care over an extended period. A staff member confirmed that catheter care should be performed and documented each shift, and facility guidelines state that trained clinical staff are responsible for indwelling Foley catheter care to prevent CAUTIs. This lack of documented catheter care resulted in a deficiency citation.
A resident with osteomyelitis and a PICC line had physician orders for IV Vancomycin twice daily and IV Cefazolin every 8 hours, but the MAR lacked documentation for several scheduled doses. Specifically, morning Vancomycin doses and an afternoon Cefazolin dose were not recorded, despite facility guidelines requiring nurses to sign the MAR immediately after medication administration.
A resident with a history of cerebral infarction and cognitive communication deficit was care planned as being at risk for elopement due to confusion, inability to express needs, and repeated statements about wanting to leave and go home. Interdisciplinary documentation described a consistent pattern of exit-seeking behaviors, including leaving on LOA with a family friend and not returning until the next day, requiring EMS assistance and hospital evaluation upon return, and later being found off facility grounds along a roadside. Despite these ongoing behaviors and the facility’s written Behavior Management Program requiring monitoring forms for residents with problematic behaviors, the clinical record contained no behavior tracking or monitoring specific to the resident’s exit-seeking behaviors, and staff acknowledged that such monitoring should have been in place.
Unsanitary kitchen conditions were observed across multiple kitchen checks, including brown water with egg particles on a dish room table, sticky film on coffee decanters, dried spills on the floor, heavy crust on stovetop burners, debris under dry storage shelving, and breadcrumbs on a prep table and floor. A walk-in freezer had a leaking condenser pipe wrapped in foam tube and tape, and a bucket had been used to catch water; a Robot Coupe used for pureeing food had a cracked lid and remained in use until replacement. The Dietary Mgr and Maintenance Dir described ongoing issues with the freezer pipe, and the facility policy required the food service area and equipment to be kept clean and in good repair.
MDS Did Not Reflect Anti-Depressant Use: A resident with depressive disorder had an MDS that listed no anti-depressant use even though the chart included an order for mirtazapine 15 mg at bedtime for depression. The resident’s MDS also noted slight cognitive impairment and symptoms of depression and fatigue, while the MDS Coordinator and ED stated coding followed RAI instructions.
Inaccurate controlled substance documentation was found for two residents when narcotic counts on the Controlled Drug Receipt/Record/Disposition Form did not match the medication cards. An LPN documented Pregabalin as administered before actually giving it, and another LPN forgot to sign out Norco after administration because she was distracted. The residents had diagnoses including neuralgia, neuritis, and chronic pain syndrome, and both had orders for scheduled pain-related medications.
Failure to disinfect glucometers between uses: An LPN completed blood sugar checks for two residents and returned each glucometer to the resident’s case without cleaning it before giving insulin. One resident had type 2 DM with diabetic neuropathy and scheduled accu checks; the other had type 2 DM with orders to monitor for hypo/hyperglycemia symptoms. The DON stated glucometers should be cleaned after every use, and the facility policy required disinfection between each resident use.
A facility failed to ensure residents received Saturday mail when it arrived at the post box. During a Resident Council meeting, alert and oriented residents said they were not getting weekend mail because no Activity staff were available to distribute it, and they had seen the mail left in the outside mailbox. The AD stated no one was assigned to pass out mail on Saturdays, and HR retrieved it Monday morning, sorted bills and other important mail, and then gave the rest to the AD for distribution.
Surveyors found that kitchen staff with visible facial hair were working in food preparation and dishwashing areas without required beard guards, despite posted signage and a written policy mandating hairnets and beard guards in all food prep, processing, and storage areas. The Dietary Manager acknowledged that beard guards had run out but confirmed they were required by facility policy, which states that all facial hair must be fully covered when in these areas. This resulted in a cited deficiency related to food safety and hygiene standards.
The facility failed to prevent and adequately respond to multiple episodes of resident-to-resident abuse. A resident with schizophrenia and dementia verbally threatened another resident, and the threat was reported to the DON and Social Services, but no effective protective action is described. The next day, the same resident physically grabbed and shoved the threatened resident in the hallway, with staff witnesses describing grabbing by the neck and repeated shoving, while documentation minimized the contact as a slight push. In a related incident, another resident with a history of TBI admitted to pushing her rollator into the same resident’s legs due to perceived intrusion into personal space, after which staff had to separate them. These events occurred amid ongoing reports that the victim resident was pacing halls, entering others’ rooms, and disturbing residents, leading to repeated physical altercations that met the facility’s own definition of abuse.
A resident with hypotension had a physician’s order for Midodrine 10 mg via G-tube three times daily, with instructions to hold the dose if systolic blood pressure (SBP) was greater than 110. Review of the MAR showed that staff administered the medication on several occasions when the resident’s SBP was above this parameter, including readings of 122, 126, and 119. In an interview, an LPN acknowledged that physician orders should be followed, confirming that the medication should have been held when SBP exceeded the ordered limit.
Surveyors found that meal service failed to provide adequate food temperature, quality, and portion sizes. Observations showed overcooked meatloaf with very small portions and soup bowls filled only a quarter of the way. Multiple residents reported being consistently hungry after meals and described portions as suitable for a young child. Residents also stated that food, especially breakfast items and meals served in rooms, was often cold. A tray temperature check confirmed substandard temperatures for scrambled eggs and sausage links, despite a facility policy requiring TCS foods to be held at or above 135°F.
Surveyors found that between-meal snacks were not consistently available or nutritionally adequate, with observations showing only a jar of peanut butter, a few peanut butter or peanut butter and jelly sandwiches on hard bread with minimal filling, and limited snack options such as small bags of Cheez-Its. Several residents reported that snacks were not always offered, especially at night, and that when provided, the sandwiches lacked substance. A staff member confirmed that dietary repeatedly sent sandwiches with only a small clump of peanut butter that was not spread. These practices did not follow facility policies requiring three meals daily plus an evening or bedtime snack and a variety of high-nutritional-value snacks stocked in each service area.
The facility failed to keep residents and their representatives informed about key aspects of care and treatment. A resident with a recent above-knee amputation and chronic pain had a prescribed narcotic pain medication dose reduced without being informed, only discovering the change when the medication appeared different, and there was no documentation of notification in the record. The same resident had a hospital-ordered vascular follow-up appointment for suture management that was missed, with no documented effort by the facility to notify the resident of the appointment or to reschedule after a no call/no show. In a separate case, another resident with dementia was discharged from therapy after about a month when max potential was deemed reached, but the PT did not notify the family and relied on nursing staff, and the record contained no documentation that the resident’s representative was informed of the discontinuation of therapy.
The facility failed to ensure complete, accurate, and timely reporting of multiple resident-to-resident abuse allegations to the abuse coordinator and Administrator. A staff member overheard a male resident threaten to kill a female resident if she entered his room and, after reporting this to the DON and Social Services, no clear abuse report followed and the Administrator later stated she was unaware of the threat. The next day, the same male resident physically grabbed and shoved the same female resident in the hallway; staff witnesses described grabbing at the neck and shoulder, twisting an arm, and repeated shoving, but the written incident report minimized the contact as a slight push after she entered his room. In a separate event, another resident admitted to striking the same female resident’s legs with a rollator walker due to perceived intrusion into personal space, yet this was not promptly or fully reported as abuse. These actions and omissions conflicted with the facility’s abuse policy requiring immediate reporting of all incidents and allegations of potential mistreatment and prompt initiation of an investigation.
Surveyors found that multiple residents on anticoagulants and insulin were not consistently monitored or had no documented monitoring for bleeding or hypo/hyperglycemia, despite physician orders for aspirin, Xarelto, apixaban, and various insulin regimens. Records for several residents with diabetes, cardiovascular disease, and thromboembolic conditions lacked required assessments for bleeding and blood sugar-related symptoms over extended periods. An LPN acknowledged that residents on blood thinners and insulin should be monitored and that this monitoring should be recorded on the MAR, consistent with the facility’s medication administration policy.
A resident with COPD was found to have a room closet that was not properly maintained, with the sliding closet door off its track and leaning against the closet side, and extensive gray/black spotted areas identified by staff as mold on the closet walls and above the closet entrance. Facility records showed the room had been marked as deep cleaned, and the housekeeping supervisor later acknowledged that housekeeping was responsible for cleaning closets and that this closet had likely been missed during deep cleaning.
Surveyors found that a resident with significant neurologic impairments had multiple discrepancies between the MAR and controlled substance records for Modafinil, including undocumented doses on the narcotic log and additional or duplicate doses without corresponding physician orders, along with no documented physician or NP visits in the chart. Other residents with complex conditions, including cancer, liver transplant, diabetes, respiratory failure, paraplegia, traumatic brain injury, and CHF, lacked timely or ongoing physician and NP progress notes in their records. Staff interviews confirmed that medications are expected to be given only with orders and that controlled substances must be documented at the time of administration, and facility policies required current, complete health records and properly maintained MARs and physician visit documentation.
A resident with depression and anxiety, who was cognitively intact, reported that a Social Services Designee (SSD) entered her room with a new roommate, abruptly pulled open the privacy curtain without knocking or identifying herself, and told the roommate that the resident was a woman, then told the resident in front of the roommate that she needed to shave her face. The resident stated she felt humiliated and cried after the incident. The SSD later documented that she entered with the roommate to address the roommate’s concern about not wanting to sleep in a room with a man and that she pulled the curtain, introduced the residents, and explained that the resident was a woman who had facial hair, offering help with shaving, but did not document identifying herself or obtaining permission before opening the curtain. The facility’s resident rights document included the right to be treated with dignity and respect.
A resident with a history of atrial fibrillation had a physician’s order for Propranolol 20 mg TID with instructions to hold the dose if systolic BP was below 110, but nursing staff repeatedly administered the medication when the resident’s BP readings were below the ordered parameter. Record review showed multiple administrations at times when SBP values were documented under 110, contrary to the order. An RN acknowledged that physician-set parameters must be followed, and the facility’s medication administration policy required medications to be given as prescribed, including adherence to ordered parameters.
A resident with anoxic brain injury, acute respiratory failure with hypoxia, hypercapnia, and anxiety, who was care planned as a fall risk with instructions to keep the call light within reach, was observed resting in bed without an accessible call light, while the only call cord in the room was positioned for the roommate. A CNA confirmed there was no call light available for this resident and noted a split call cord should have been present, and an LPN stated all residents should have a call light within reach. The facility’s call light policy, provided by the regional nurse consultant, requires a functioning, accessible call system in each resident room, but this was not in place for the resident involved.
A resident with end stage renal disease and psychiatric diagnoses, but documented intact cognition, was moved to a secured memory care unit and had his cell phone removed from his possession without his consent or documented discussion with him. He reported that after independently going outside to the front porch, staff later placed a monitor on him, moved him to the secured unit, and took his phone, leaving him feeling like a prisoner and unsure why he was on the unit. Facility records showed that the IDT and Social Services discussed exit seeking and impulsive or manic behaviors with the resident’s family, who agreed to the room change and phone restriction, but behavior logs did not document exit seeking or related behaviors during the reviewed period, and there was no documentation that the resident himself was informed of or involved in these decisions, despite a policy affirming residents’ rights to dignity and respect.
A resident with bipolar disorder, major depressive disorder, dementia, and exit-seeking behaviors was transferred to a secured memory care unit, but the facility did not initiate a secured unit baseline care plan at the time of the move. Documentation shows the room change occurred, yet the first secured unit care plan entry was not made until weeks later. The DON acknowledged that the care plan for the secured unit should have been started when the resident was moved. Facility policy indicated that comprehensive care plans must address resident risks, goals, and interventions using a person-centered approach and be updated based on assessed needs, but this was not followed for this resident’s timely care planning.
A resident with diagnoses including diabetes, end-stage renal disease, major depressive disorder, anxiety, and bipolar disorder was placed on a secured memory care unit based on a physician order and a care plan that cited dementia and exit seeking, despite the clinical record lacking any diagnosis of dementia, Alzheimer’s disease, or other irreversible dementia or documentation of clinical need for a secured unit. The former primary care physician reported that the resident did not have a dementia diagnosis and that he would not have initiated an order for dementia unit placement. This conflicted with the facility’s Memory Springs admission criteria, which require a diagnosis of Alzheimer’s or irreversible dementia and a physician determination of clinical need for a secured unit.
Surveyors observed unsanitary conditions in the kitchen and nourishment rooms, including food and equipment stored directly on the floor, accumulation of crumbs and unknown substances, and undated or expired food items in refrigerators. Cleaning schedules were missing, and staff interviews confirmed that cleaning responsibilities and documentation were not maintained according to facility policy.
A resident with a history of falls and impaired mobility was physically restrained in a wheelchair using a gait belt for approximately 15 minutes by a CNA, who did so to prevent the resident from falling while staff were busy with another resident. The restraint was not part of the care plan and was reported by staff during shift change, with the gait belt found still attached in a restraining position. The CNA stated she was unaware this action constituted abuse, despite prior education on abuse and restraints.
Staff and resident interviews, along with direct observation, revealed that snacks were frequently unavailable, with nursing staff often purchasing snacks themselves due to inadequate supply from dietary services. Essential food items were out of stock, and the nourishment pantry was poorly stocked, resulting in residents—including those with specific dietary needs—not consistently receiving snacks as required by facility policy.
Two residents with hypertension received blood pressure medications despite physician orders to hold the medications for SBP less than 120. The EMAR showed multiple instances where atenolol and metoprolol were administered when SBP readings were below the ordered threshold, contrary to facility policy and physician instructions.
A resident with generalized anxiety received additional doses of Lorazepam without a physician's order, as documented in controlled drug records. The medication, ordered for bedtime use, was also administered in the morning on several dates without proper documentation or authorization. Staff confirmed that medications should only be given as prescribed, in accordance with facility policy.
A resident with orders for double portions at all meals, due to conditions including Parkinson's disease and prostate cancer, did not receive the required double portions during a meal service. The meal ticket clearly indicated the need for double portions, and facility policy requires accuracy in meal service, but the dietary staff did not follow the order.
A resident with vascular dementia and a severe intellectual disorder, who required a pureed consistent carbohydrate diet with an inner lip plate, was served a meal without the necessary assistive device, despite clear orders and care plan instructions. The meal was served in individual bowls, and dietary staff did not follow the meal ticket or facility policy for therapeutic diet accuracy.
The facility failed to provide 8-hour consecutive RN coverage from July to December 2024, affecting all 60 residents. The nursing schedule showed multiple days with only 6 hours of RN coverage. The Executive Director and Corporate Nurse Consultant were unaware of the requirement, while the DON knew but acknowledged the lack of coverage every other weekend. The Facility Assessment required 6 licensed nurses and 4 CNAs per 12-hour shifts, but the facility did not meet the RN coverage requirement.
The facility failed to properly document narcotic medication counts and remove expired insulins from medication carts. Discrepancies were found in narcotic counts, with staff admitting to not signing out medications immediately. Expired insulin vials were also found in use, contrary to facility policy. These issues were observed across multiple medication carts, affecting the safe care of residents.
A resident with multiple health issues was not properly secured in a wheelchair van, resulting in a fall during transport. The van driver did not follow the facility's emergency procedures, and the incident was not immediately reported. The resident later experienced pain and required medical assessments.
A facility failed to monitor a resident's dialysis site after returning from the hospital, as the physician's order was not reinstated. The resident, with end-stage renal disease, continued dialysis without proper monitoring of their AV fistula for two months. Interviews revealed the oversight was due to the order not being re-entered into the system.
A facility failed to properly store and dispose of insulin pens in the Eagle Court Hall Medication Cart. A resident's Humalog kwikpen was found without a pharmacy label and had an incorrect open date, despite the order being discontinued. Other insulin pens were also improperly stored, lacking proper labeling and documentation. These actions violated the facility's policies on medication storage and disposal.
The facility failed to provide snacks to residents, with several residents and staff reporting that snacks were not available, leading to residents purchasing their own. The dietary department did not supply snacks, and the Director of Nursing confirmed the issue since a new company took over. Observations showed limited pantry supplies, and the dietary service manager acknowledged the lack of specific items. The facility's policy indicated snacks should be available 24/7, but this was not adhered to.
A resident with end-stage heart failure and anxiety was not informed in a timely manner about the cancellation of her pain management appointment after hospice took over her care. The resident only learned of the cancellation on the day of the appointment, leading to distress. Staff interviews confirmed the lack of communication, violating the resident's rights to be informed of her health status.
An LPN in a facility verbally abused two residents, one with schizoaffective disorder and another with anxiety and chronic respiratory failure. The LPN used derogatory language, dismissed residents' concerns, and escalated situations, causing distress. These actions violated the facility's Abuse Prevention Program policy.
The facility failed to report and document incidents of abuse and inappropriate conduct involving two residents. An LPN was heard using inappropriate language and upsetting a resident with schizoaffective disorder. Another resident with anxiety and chronic respiratory failure experienced a delay in care and was subjected to derogatory remarks by the same LPN. Despite reports to the DON, the incidents were not documented as required by the facility's Abuse Prevention Program policy.
A facility failed to implement a care plan for a resident after all her teeth were extracted. Despite the resident's significant health change, the clinical record lacked documentation of a care plan addressing the extraction. The DON assumed a care plan would be in place, but the RDO provided a policy indicating care plans should be updated with health changes.
A resident with hypertension and end-stage heart disease had all her teeth extracted, but the facility delayed implementing a necessary diet change. The resident's clinical record lacked documentation of dietary adjustments until four days after the procedure, despite the significant impact on her ability to eat. Interviews indicated that no paperwork was provided by the dentist, and there was a failure to promptly clarify the new diet.
A facility failed to provide a prescribed therapeutic diet for a resident with diabetes, anxiety, and major depressive disorder. The resident was supposed to receive prune juice with lunch daily, as per a physician's order. However, the resident reported never receiving it, and the facility lacked prune juice, as confirmed by the Regional Director of dietary services.
The facility failed to change PICC line dressings as ordered for two residents. One resident with acute osteomyelitis and another with bacteremia had dressings that were not changed weekly as required. Observations showed dressings dated from October, despite records indicating changes. An LPN confirmed the need for weekly changes, and the DON provided documentation supporting this protocol.
A resident with anxiety and COPD did not receive her routine Lorazepam as ordered, with significant gaps in administration noted in October and November. Interviews revealed frequent delays or missed doses, and controlled drug records lacked documentation. An RN confirmed the need for proper documentation, as outlined in the facility's medication administration policy.
The facility failed to serve meals at appropriate temperatures and times on [NAME] Hall. Observations showed that food temperatures were not consistently appetizing or safe, with residents expressing dissatisfaction over cold and late meals. Resident council minutes from September and October 2024 also highlighted concerns about breakfast and dinner service.
A facility failed to accurately document the administration of PRN Morphine Sulfate for a resident with end-stage heart failure and other conditions. The controlled drug records showed multiple administrations, but the medication administration record lacked documentation for these instances. An RN confirmed the procedure for documenting PRN narcotics, and the DON provided a document outlining safe medication administration practices.
Elopement of High-Risk Resident Left Unsupervised Outdoors
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent accidents for a cognitively impaired resident with known elopement risk, who was left outside without staff supervision and subsequently eloped from the premises. The resident had diagnoses including cerebral infarction, right-sided hemiplegia and hemiparesis, cognitive communication deficit, and aphasia. Progress notes documented that the resident was alert only to self, unable to understand most things, communicated via a white board, and was able to self-propel in a wheelchair. The record also showed that the resident had been identified as an elopement risk, with a care plan citing periods of confusion, inability to verbally express needs, not wanting to be at the facility, and making statements about leaving to go home. A wander guard had been placed on the resident’s ankle and later moved to the wrist, and there was documentation that the resident had removed the wander guard at least once. The interdisciplinary team note indicated the resident had a consistent pattern of exit-seeking behaviors and a strong desire to leave the facility, including a prior leave of absence with a family friend where the resident did not return as expected and required EMS assistance upon return. Despite this history and the documented elopement risk, on the day of the incident the resident was among a group of residents sitting on the front porch. Two CNAs from the oncoming night shift were outside at a table before their shift when residents, including this resident, came out to the porch. An activity aide, who had clocked out and was waiting for a ride home, was also sitting outside. The CNAs then went inside to clock in, and they were unaware that the activity aide had already clocked out and was no longer on duty. The activity aide later reported that when she left at 6:00 p.m., the resident was still outside, and she was unaware the resident was an elopement risk. Subsequently, the resident was able to exit the front doors and propel himself off the property without staff noticing. A police report documented that a call was received for a medical issue on a busy road 0.2 miles from the facility. The resident was found on the roadside after having flipped out of his wheelchair, and emergency department records noted abrasions to his right foot and right hand. A speech therapist, who had left the facility for the evening, encountered a person lying on the side of the road, turned around, and confirmed via photograph and communication with her manager that the individual was the resident from the facility. EMS and police responded to the scene, and the resident was transported to the emergency department for evaluation and treatment of his injuries. Subsequent observation confirmed abrasions and scabbed areas on the resident’s right hand and toes consistent with the reported fall.
Failure to Report Elopement of Cognitively Impaired Resident
Penalty
Summary
Facility management failed to timely report an elopement incident involving a cognitively impaired resident to the Indiana Department of Health. The resident, identified as having diagnoses including cerebral infarction (stroke), aphasia, cognitive communication deficit, and altered mental status, had an admission BIMS assessment indicating cognitive impairment. An elopement risk assessment documented the resident as high risk for elopement, and the care plan noted risk for elopement related to periods of confusion, inability to verbally express needs, and statements about wanting to leave and go home. Despite these documented risks, the incident report indicated that on a specific date the resident attempted to leave against medical advice, exited the front doors, propelled himself in a wheelchair off the property, and fell out of the wheelchair. Review of the facility’s state reportable incidents showed no documentation that this elopement incident had been reported to the Indiana Department of Health. During an interview, the Administrator stated she consulted with the corporate team and was advised to reassess the resident’s BIMS score, which was 12, and based on that score was told not to report the incident. The Regional Director of Operations indicated the facility follows state guidance on reporting incidents and provided the state’s Long-Term Care Abuse and Incident Reporting policy, which defines elopement as occurring when a resident without decision-making capacity leaves the premises or safe area without authorization and/or necessary supervision, or when a resident with decision-making capacity leaves without facility knowledge. The failure to report this elopement incident was cited under 410 IAC 16.2-3.1-28(c).
Failure to Provide and Document Ordered Indwelling Catheter Care
Penalty
Summary
The facility failed to ensure ordered catheter care was provided and documented for a resident with an indwelling urinary catheter. The resident, who had diagnoses including a Stage 4 pressure ulcer to the sacrum, was observed on 4/29/26 with an indwelling urinary catheter in place. A physician’s order dated 4/8/26 directed that catheter care be provided every shift. However, review of the clinical record showed no documentation of catheter care being provided between 4/9/26 and 4/29/26. During an interview, a staff member stated that indwelling urinary catheter care should be provided every shift and documented. The facility’s written guidelines for indwelling Foley catheter care, provided by the Regional Director of Operations, stated that the main purpose of proper catheter care is to prevent catheter-associated urinary tract infections and that trained clinical staff will conduct this care. This deficiency was cited under 410 IAC 16.2-3.1-41(2) and related to Intake 2996274.
Failure to Document Ordered IV Antibiotic Administration on MAR
Penalty
Summary
The facility failed to ensure that a resident’s IV antibiotic therapy was accurately documented on the medication administration record (MAR) as ordered by the physician. The resident, who had osteomyelitis and a PICC line in the right upper extremity, had a physician’s order dated 4/8/26 for Vancomycin HCl 1.25 grams IV twice daily at 8:00 a.m. and 8:00 p.m. The April 2026 MAR lacked documentation of the 8:00 a.m. Vancomycin doses on 4/23/26 and 4/27/26. A subsequent physician’s order dated 4/20/26 directed Cefazolin Sodium 2 grams IV every 8 hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. for the same diagnosis, and the April 2026 MAR lacked documentation of the 2:00 p.m. Cefazolin dose on 4/23/26. During the survey, the resident was observed with an active PICC line, and staff confirmed that the MAR should be signed by the nurse administering the medication. The Regional Director of Operations provided the facility’s Medication Administration Guidelines, which state that the MAR is to be signed immediately after administering medications, under “The Right Documentation.” Despite this policy, the MAR entries for the specified IV antibiotic doses were not completed, resulting in missing documentation for multiple ordered IV antibiotic administrations.
Failure to Implement Behavior Monitoring for Exit-Seeking Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement behavior monitoring for a resident with known exit-seeking behaviors. Resident B’s clinical record showed diagnoses including cerebral infarction and cognitive communication deficit, and a care plan dated 4/24/26 identified the resident as being at risk for elopement due to periods of confusion, inability to verbally express needs, and verbal statements about wanting to leave and go home and not wanting to be at the facility. An IDT note dated 4/27/26 documented that the resident had a consistent pattern of expressing a desire to leave, with gesturing and behaviors indicative of exit-seeking. The note further described that on 4/19/26 the resident left the facility on a leave of absence with a family friend and did not return until the next day, and upon return initially refused to exit the vehicle, requiring assistance and EMS, and was sent to the hospital for evaluation before returning to the facility the following day. The IDT note also documented that the resident continued to express a desire to leave and exhibited ongoing exit-seeking behaviors, and that on 4/25/26 the resident was identified off facility grounds and located on the roadside at approximately 8:06 p.m. Despite these documented behaviors and events, the clinical record lacked documentation of the implementation of behavior tracking or monitoring for the resident’s exit-seeking behaviors. During the survey, a staff member indicated the resident had exit-seeking behaviors prior to the day of the elopement, and Social Services confirmed that the resident should have had behavior monitoring in place for exit-seeking behaviors. The facility’s Behavior Management Program policy, provided by the Regional Director of Operations, stated that residents exhibiting problematic behavior are to be observed to identify causal factors and appropriate interventions, and that each such resident should have a monitoring form listing behaviors and interventions specific to the resident, which was not in place for this resident.
Unsanitary kitchen conditions and damaged food equipment
Penalty
Summary
Food was not stored and prepared in a sanitary manner during three kitchen observations. On 4/7/26, the kitchen had a large accumulation of brown water with egg particles on a metal table in the dish room, sticky film on three glass coffee decanters, dried sticky spills on the kitchen floor, heavy black crust on stovetop burners, debris and dust under dry storage shelving, and a walk-in freezer with a condenser pipe wrapped in foam tube and black tape, plus a bucket collecting water from an occasional leak. In the same observation, the Robot Coupe used to puree beef stroganoff, broccoli, and rolls had a lid cracked from the edge to the center. The Dietary Manager stated the freezer pipe would freeze at times and that maintenance was aware of the occasional leaking. On 4/9/26, the same kitchen sanitation concerns remained, except the standing brown water on the dish room table was no longer present. Breadcrumbs were observed on the prepping table near the toaster and on the floor, and the daily cleaning schedule showed multiple kitchen tasks were completed and initialed on 4/6/26, 4/7/26, and 4/8/26. During interviews, the Maintenance Director said he had been letting kitchen staff verbally tell him if the pipe was leaking and would enter a work order in the electronic system, while the Dietary Manager said the cracked Robot Coupe lid had been present since before he started working at the facility and that maintenance had fixed the freezer condenser pipe. On 4/13/26, the Robot Coupe was still in use until replacement, and the freezer condenser pipe remained wrapped in foam tube and heat tape, with no bucket present to catch potential leaking water. The facility policy stated the food service area shall be maintained in a clean and sanitary manner and that utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and free from breaks, corrosions, open seams, cracks, and chipped areas.
MDS Did Not Reflect Anti-Depressant Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s medication status for Resident 10. The resident’s record showed diagnoses including moderate depressive disorder, recurrent, and the Quarterly MDS indicated slight cognitive impairment, frequent feelings of being down or depressed, and feeling tired. However, the MDS medication section marked the resident as not having used any anti-depressants, even though a physician’s order dated 11/24/25 directed the resident to receive mirtazapine (Remeron) 15 mg at bedtime for depression. During interview, the MDS Coordinator stated that if the assessment had not already been transmitted, she would correct the needed areas, and if it had been transmitted, she would complete a correction MDS. The Executive Director stated there was no specific policy on MDS coding and that coding followed RAI instructions.
Inaccurate Controlled Substance Documentation
Penalty
Summary
The facility failed to ensure accurate documentation on the Controlled Drug Receipt/Record/Disposition Form for administered narcotics for two residents. For one resident, the form showed Pregabalin documented as administered by an LPN, but the medication count on the form did not match the medication card count. During interview, the LPN stated she thought she had given the medication, could not explain the discrepancy, and later said she had not administered it and should not have signed it out before giving it because the count would be off. The resident’s record showed diagnoses including neuralgia and neuritis, and the physician’s order and MAR directed Pregabalin 300 mg twice daily between 7:00 a.m. and 11:00 a.m. For another resident, the Controlled Drug Receipt/Record/Disposition Form showed Hydrocodone-Acetaminophen (Norco) with a count of 11 tablets, while the medication card showed 10 tablets left. The last administration was documented by an LPN, and another LPN stated she forgot to sign out the Norco because she was distracted by another resident and acknowledged that narcotics should be signed out when administered. The resident’s record showed chronic pain syndrome, and the care plan identified the resident as at risk for alteration in pain or discomfort and adverse effects from opioid use. The physician’s order and April 2026 MAR directed Norco 5-325 mg twice daily for pain.
Failure to Disinfect Glucometers Between Uses
Penalty
Summary
The facility failed to ensure glucometers were cleaned according to infection control guidelines after blood sugar checks for 2 of 3 residents observed. On 4/9/26 at 8:05 a.m., an LPN completed an accu check for Resident 29, whose blood sugar was 254 mg/dL, then returned the glucometer to the medication cart and placed it into the resident’s case without cleaning it before obtaining insulin and administering it. Resident 29’s record showed a diagnosis of type 2 diabetes mellitus with diabetic neuropathy and an order for accu checks twice daily. On 4/10/26 at 9:01 a.m., the same LPN obtained Resident 7’s blood sugar from the right index finger, with a reading of 215 mg/dL, and again placed the glucometer into the resident’s case without cleaning it before administering Humalog. Resident 7’s record showed a diagnosis of type 2 diabetes mellitus and an order to monitor blood sugar for signs or symptoms of hypoglycemia or hyperglycemia and follow the prn blood sugar flowchart if symptoms were present. During interview, the LPN stated shared glucometers were cleaned after each use but believed individually stored glucometers in resident cases did not need cleaning, and she was unsure how long to let the glucometer dry after using Sani-Cloth. The DON stated glucometers should be cleaned after every use, even when used for only one resident, and the facility policy required disinfection between each resident use.
Failure to Deliver Residents’ Saturday Mail
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when Saturday mail was not delivered to residents upon arrival to the post box. During the Resident Council meeting, 6 alert and oriented residents stated they were not receiving their Saturday mail because no Activity staff were present on weekends to pass it out, and they reported seeing the mail delivered to the outside mailbox without anyone retrieving it. The Activities Director stated there was no one assigned to pass out mail on Saturdays, and that Human Resources retrieved the mail first thing Monday morning, sorted through bills and other important mail that needed attention, and then brought the remaining residents' mail to her for distribution.
Failure to Enforce Beard Guard Use for Kitchen Staff
Penalty
Summary
The facility failed to ensure kitchen staff used required facial hair coverings while working in food preparation and dishwashing areas. On 3/15/26 at 12:14 p.m., signage on the kitchen door stated that staff must have hairnets and beard guards in place to enter the kitchen. During an observation at 12:16 p.m., a dietary aide and a dishwasher, each with 1/2 inch or longer facial hair on their lip and chin areas, were seen working in the kitchen dish and food preparation areas without beard guards. In an interview at 12:19 p.m., the Dietary Manager stated they had just run out of beard guards, but confirmed that facility policy required beard guards to be worn while in the kitchen. The Executive Director later provided the facility’s written policy, last reviewed on 6/2/25, which specified that all personnel must wear approved beard guards in food preparation, processing, or storage areas, and that beard guards must fully cover all facial hair. This deficiency was cited under 410 IAC 16.2-3.1-21(i)(3) and related to multiple complaint intakes, indicating noncompliance with state requirements for food procurement, storage, preparation, distribution, and service in accordance with professional standards.
Failure to Prevent and Respond to Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident abuse despite clear warning signs and prior incidents. Resident B, who had diagnoses including schizophrenia, depression, suicidal ideations, and vascular dementia, verbally threatened Resident C on one day, telling her he would kill her if she came into his room. Staff Member 8 overheard this threat and reported it to the Director of Nursing, who instructed her to inform Social Services. When the incident was reported to Social Services, the staff member was asked what she wanted Social Services to do about it. The Administrator later stated she was unaware of this threat when she initially reported the subsequent physical incident and had not yet obtained staff statements. The following day, Resident C, who had a history of traumatic subarachnoid hemorrhage, traumatic brain injury, affective mood disorder, and anxiety, continued to pace the halls, enter other residents’ rooms, rummage through belongings, and disturb other residents, and was described as difficult to redirect and agitated. Around that time, Resident C approached the area near Resident B’s room. Multiple staff interviews indicated that Resident B came out of his room, grabbed Resident C by the neck and shoulder area, twisted her arm behind her back, and pushed her into a geriatric chair in the hallway, shoving her multiple times as she tried to get away. Staff Member 9 intervened and separated the residents, and both Staff Member 9 and Staff Member 17 reported what they witnessed to the Director of Nursing. The incident report and progress note, however, documented the event as Resident B placing his hands on Resident C’s shoulders, turning her around, and slightly pushing her from the back. In a separate but related incident, Resident D, who had a history of traumatic brain injury and anxiety, admitted to pushing her rollator walker into Resident C’s legs because Resident C had entered her personal space. Staff Member 9 reported that she had to separate Resident C and Resident D after Resident D rammed her walker into Resident C’s legs and reported this to the Director of Nursing. An incident report later documented that Resident D made contact with Resident C’s legs with her rollator walker. These events occurred in the context of Resident C’s ongoing behavior of pacing the halls, entering other residents’ rooms, and disturbing them, and demonstrate multiple instances of resident-to-resident physical contact that met the facility’s own definition of physical abuse under its Abuse Prevention Program, which states the facility will not tolerate abuse by anyone, including other residents.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
Surveyors found that the facility failed to follow a physician’s ordered blood pressure parameter for administration of Midodrine for one resident. Resident K had a diagnosis that included hypotension and a physician’s order, dated 2/14/26, for Midodrine 10 mg via gastrostomy tube three times daily at 6:00 a.m., 2:00 p.m., and 10:00 p.m., with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 110. Review of the February 2026 medication administration record showed that staff administered Midodrine despite SBP readings above the ordered parameter on multiple occasions: on 2/16/26 at 10:00 p.m. when SBP was 122, on 2/17/26 at 6:00 a.m. when SBP was 126, on 2/17/26 at 10:00 p.m. when SBP was 119, and on 2/19/26 at 6:00 a.m. when SBP was 119. In an interview, an LPN stated that physician’s orders should be followed, confirming that the medication should not have been given when the SBP exceeded the ordered threshold.
Inadequate Food Temperature, Quality, and Portion Sizes During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide palatable, adequately portioned food at safe and appetizing temperatures during meal service. During a kitchen observation, meatloaf on the steam table was noted to have blackened areas across the top and along the edges, and the portion size being served measured approximately 3 inches by 1 inch by 1 inch. Multiple residents reported that soup bowls at supper and dinner were only filled a quarter of the way, and that meatloaf portions were equivalent to two or three bites. Several residents stated that after every meal they were still hungry because the portion sizes were so small and described the quantity of food as what would be served to a young child. Residents also reported and observations confirmed that food was frequently served cold, particularly breakfast items and meals delivered to rooms. One resident stated that the previous night’s soup and the morning’s hash brown and sausage links were cold when served. Another resident reported that food served in rooms, especially eggs, was always cold. A random tray temperature check showed scrambled eggs at 98.8°F and sausage links at 86.4°F, while oatmeal measured 149.2°F. Residents described the food as generally cold, overcooked or undercooked at times, and of poor quality, with one resident stating the meatloaf was way overcooked and another reporting that twice they had been served undercooked food. The facility had a written policy requiring TCS foods to be held at 135°F or above and temperatures to be recorded before service, but the observed temperatures and resident reports showed this was not consistently achieved.
Inadequate Availability and Quality of Nutritional Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a variety of snacks with nutritional value were consistently available and properly prepared for residents, as required by facility policy. Surveyors observed the snack pantry containing only one jar of peanut butter, no bread, and a tray with a small number of peanut butter and peanut butter and jelly sandwiches in baggies, with hard bread crusts and no other snacks available except those purchased by residents themselves. The snack cart was observed to have only small bags of Cheez-Its as snacks. On another observation of snack sandwiches sent from dietary, surveyors found several peanut butter and peanut butter and jelly sandwiches with hard crusts and such minimal fillings that the peanut butter and jelly had saturated into the bread, leaving no substance to the sandwiches. Multiple residents reported that snacks were not always available or offered, particularly at night, because staff did not have anything to provide. One resident stated that the peanut butter and jelly sandwiches had barely any filling, with only thinly spread peanut butter and jelly that soaked into the bread, which was hard. Another resident reported that the only snacks available were peanut butter sandwiches on hard bread with very little peanut butter. A staff member confirmed that dietary had repeatedly sent peanut butter sandwiches with only a small clump of peanut butter, about the size of a quarter, placed in the middle of the bread and not spread. Another resident indicated that nursing staff had to go out and buy peanut butter and bread so residents could have snacks because the dietary department rarely sent snacks. These findings were inconsistent with the facility’s written policies stating that each resident shall receive three meals daily plus an evening or bedtime snack, and that a variety of snacks of high nutritional value will be stocked in each service area by dining services.
Failure to Inform Residents of Treatment Changes and Missed Follow-Up Care
Penalty
Summary
The facility failed to ensure residents were fully informed about their health status, care, and treatments, and failed to arrange a necessary follow-up appointment. One resident with intact cognition and diagnoses including diabetes, chronic pain, depression, and a recent left above-knee amputation was discharged from the hospital with orders for a follow-up appointment with a vascular nurse practitioner and was prescribed Oxycodone-Acetaminophen 7.5-325 mg every 6 hours for pain. A subsequent physician order decreased this pain medication to 5-325 mg every 6 hours, but the clinical record contained no documentation that the resident was notified of this change. The resident reported he only realized his pain medication had been decreased when he noticed the pills were a different color and was then told by a nurse that the nurse practitioner had decreased the dose. The clinical record also lacked documentation that the resident was informed of the original follow-up appointment, the need to reschedule it, or any related communication. The same resident’s hospital discharge orders included a follow-up appointment on 2/16/26 with the vascular provider, but the vascular center reported the facility made no contact to reschedule after the resident was listed as a no call/no show for that appointment. The appointment was later rescheduled after involvement from an external social worker, and the resident ultimately arrived late but was still seen for suture removal. In a separate case, another resident with dementia and lack of coordination had been receiving therapy services. The resident’s representative stated she had requested therapy to help increase the resident’s strength and had not observed any therapy being provided, nor had she been notified about the status of therapy. The physical therapist reported working with the resident for about a month, stated that maximum potential had been reached, and that the resident was discharged from therapy, but he did not notify the family and instead relied on nursing staff to do so. The clinical record lacked documentation that the resident or representative was notified of the discontinuation of therapy services.
Failure to Accurately and Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate information was provided to the abuse coordinator, failure to report an allegation of resident-to-resident abuse to the abuse coordinator, and failure to timely report an allegation of verbal abuse for multiple residents. On one day, a staff member overheard a male resident (Resident B) threaten to kill a female resident (Resident C) if she entered his room. This staff member reported the threat to the DON, who instructed the staff member to inform Social Services; when informed, Social Services questioned what they were supposed to do about it. The Administrator later stated she was unaware of this threat. The following day, Resident C was ambulating down a hall when Resident B exited his room, grabbed her by the neck and shoulder, twisted her arm behind her back, and pushed her into a geriatric chair in the hallway, continuing to push her as she tried to get away. A staff member intervened and reported the incident to the DON, who said it would be reported to the Administrator. Another staff member witnessed Resident B grab Resident C at the top of her left shoulder and neck area, swivel her around, and shove her three times down the hallway. However, the incident report documented only that Resident C entered Resident B’s room and that Resident B, upset, placed his hands on her shoulders to turn her around and slightly pushed her from the back. The Administrator indicated she reported only what she had been told, had not yet obtained staff statements, and did not have the full story when she reported the incident. The deficiency also includes a separate resident-to-resident physical contact incident that was not fully reported to the abuse coordinator. A staff member reported that she had to separate Resident C from another resident (Resident D) after Resident D rammed her walker into Resident C’s legs. The Administrator later indicated that Resident D admitted to hitting Resident C in the leg with her walker because Resident C was in her personal space, and Resident D herself confirmed she pushed her walker into Resident C and hit her legs for the same reason. An incident report dated two days after the event indicated it was reported to the Administrator that Resident D made contact with Resident C’s legs with her rollator walker. The facility’s Abuse Prevention Program policy requires supervisors to immediately inform the Administrator or person in charge of all reports of incidents or allegations of potential mistreatment and requires the Administrator or designee to initiate an incident investigation upon learning of a report. The survey findings show that these requirements were not followed for the verbal threat, the physical altercation between Residents B and C, and the walker incident between Residents C and D.
Failure to Document Monitoring for Anticoagulant and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and documentation for residents receiving anticoagulant and insulin therapy, as required by its medication administration policy. For one resident with diabetes and a history of left above-knee amputation, admission orders included aspirin 81 mg daily, Xarelto 20 mg daily with breakfast, and insulin lispro 5 units subcutaneously with meals. Review of this resident’s medication administration records for January, February, and March 2026 showed no documentation that nursing staff monitored for signs or symptoms of bleeding related to the blood thinners or for signs or symptoms of hypoglycemia or hyperglycemia related to the insulin. Another resident with diabetes had an order for Lantus 25 units subcutaneously twice daily at 9:00 a.m. and 9:00 p.m., but the clinical record lacked documentation that nursing staff monitored for signs or symptoms of hyperglycemia or hypoglycemia. Two additional residents receiving anticoagulant therapy also lacked documented monitoring for bleeding. One resident with chronic embolism and thrombosis of the right upper extremity had an order for apixaban 5 mg twice daily at 8:00 a.m. and 8:00 p.m., yet the clinical record showed no documentation of bleeding assessments from March 12 through March 16, 2026. Another resident with hypotension and cardiovascular disease had an order for apixaban 5 mg twice daily at 8:00 a.m. and 8:00 p.m. for cardiovascular health, but the record similarly lacked documentation of monitoring for signs of bleeding. During an interview, an LPN confirmed that residents on blood thinners should be monitored for signs of bleeding and residents on insulin should be monitored for hyperglycemia and hypoglycemia, and that such monitoring should be documented on the medication administration record. The facility’s Medication Administration Policy Guideline stated that medications are to be administered as prescribed and in accordance with good nursing principles and practices.
Environmental Deficiency in Resident Closet Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, and intact environment in a resident’s room closet, specifically for Resident B. Resident B’s clinical record showed diagnoses including chronic obstructive pulmonary disease. During observation of the resident’s room, the sliding closet door was found off its track and leaning against the right side of the closet rather than being properly installed. Inside the closet, the right upper wall contained multiple gray/black spotted areas extending across the width of the wall and approximately 10 inches downward, and the interior wall above the closet entrance had a large vertical area of gray/black spotting with two streaked areas and a larger dark gray/black area measuring about 3 inches by 1.5 inches. A staff member identified these gray/black spotted areas as mold. Review of the deep cleaning schedule showed the room was documented as deep cleaned on 2/25/26, and the housekeeping supervisor later indicated that housekeeping was responsible for ensuring closets were mopped, cleaned, and free of debris and that this closet had likely been missed during deep cleaning. This deficiency was cited under 410 IAC 16.2-3.1-19(f) and relates to Intake 2730662.
Medication Documentation Errors and Missing Physician Visit Notes
Penalty
Summary
The deficiency involves failures in medication documentation and medical record maintenance for multiple residents. For one resident with diagnoses including subarachnoid hemorrhage with loss of consciousness, paraplegia, and traumatic brain injury, the physician ordered Modafinil 100 mg daily at 8:00 a.m. Review of the November, December, and January medication administration records (MARs) and controlled substance records showed multiple discrepancies. On several dates, the MAR reflected administration of Modafinil, but the corresponding controlled substance record was not signed to show it was given. On other dates, the controlled substance record showed additional doses at 8:00 p.m. or duplicate 8:00 a.m. doses without any physician order for those extra administrations. The resident’s clinical record also lacked documentation of any physician or nurse practitioner visits. Additional deficiencies were identified in the timeliness and completeness of physician and nurse practitioner documentation for other residents. One resident with malignant neoplasm of the larynx, liver transplant, diabetes, and acute respiratory failure had an admission date earlier in the year, but the first physician or nurse practitioner progress note in the record was dated several months later. For another resident with paraplegia and traumatic brain injury, the clinical record lacked physician and nurse practitioner visit documentation after a specific date in the spring. A further resident with acute and chronic respiratory failure and congestive heart failure had no documented physician or nurse practitioner visit after a date in the fall. Interviews with staff confirmed expectations and highlighted gaps in practice. An RN stated that medications could not be administered without a physician’s order and that narcotic medications should be signed out on the narcotic sheet when pulled and then signed as administered on the MAR at the time of administration. The DON reported that both the physician and nurse practitioner had been in to see residents but was unsure why the notes were not present in the records. An LPN reported that the nurse practitioner indicated notes had been uploaded on their end and needed to be retrieved by the facility. Facility policies provided by the Regional Nurse Consultant required that each dose of controlled substances be recorded at the time of administration, that medications be administered as prescribed, that physicians or non-physician practitioners write, sign, and date progress notes at each required visit, and that each resident have a current, complete, and available health record including a MAR with date, time, and person administering each medication.
Failure to Maintain Resident Dignity and Privacy During Room Interaction
Penalty
Summary
The facility failed to maintain a resident’s dignity and respect for privacy when a Social Services Designee (SSD) entered the room of Resident F without proper identification or permission and exposed her to another resident. Resident F had diagnoses including depression and anxiety, and her quarterly MDS dated 12/23/25 indicated intact cognition. According to an incident report dated 1/28/26, Resident F reported that the SSD entered her room with her new roommate, Resident G, and hastily pulled open Resident F’s privacy curtain. The SSD then stated to Resident G, “see, she is a woman,” and told Resident F that she needed to shave her face. Resident F stated she did not know the SSD had entered until the curtain was flung open and that other staff typically knock and identify themselves before entering. In an interview, Resident F reported that after Resident G moved into the room, she had introduced herself to Resident G earlier. Later, the SSD came in with Resident G, abruptly opened the privacy curtain, and told Resident G that Resident F was not a man, then told Resident F in front of Resident G that she needed to shave. Resident F reported feeling humiliated, horrible, and that she cried after the incident. A written interview from the SSD indicated that it had been reported to her that Resident G refused to sleep in a room with a man, and that the SSD went into the room with Resident G, pulled the privacy curtain, introduced the residents to each other, and told Resident G that Resident F was a woman, adding that Resident G may have thought Resident F was a man due to facial hair. The SSD stated she told Resident F she could get someone to help her shave, but her written account did not document that she identified herself to Resident F upon entering or that she asked permission before pulling back the privacy curtain. The facility’s resident rights document provided by the Regional Nurse Consultant included the right to be treated with dignity and respect.
Failure to Follow Blood Pressure Parameters for Ordered Cardiac Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s parameter order for a resident with atrial fibrillation who was prescribed Propranolol HCL 20 mg three times daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. The physician’s order, dated 10/9/25, directed that the medication be held if the resident’s systolic blood pressure (SBP) was less than 110. Review of the resident’s clinical record and medication administration records for November 2025, December 2025, and January 2026 showed that the Propranolol was administered despite SBP readings below the ordered threshold on multiple occasions. Specifically, the medication was given when the SBP was 106 at 8:00 a.m., 12:00 p.m., and 5:00 p.m. on 11/17/25; 105 at 12:00 p.m. on 12/24/25; 107 at 12:00 p.m. on 12/30/25; 109 at 5:00 p.m. on 01/06/26; and 107 at 5:00 p.m. on 01/16/26. During an interview, an RN stated that all parameters set by the physician must be followed. The facility’s Medication Administration Policy Guideline, dated 5/17/21 and provided by the Regional Nurse Consultant, stated that medications are to be administered as prescribed and in accordance with written physician orders, including parameters. The documented administration of Propranolol outside the ordered SBP parameters constituted the basis for the cited deficiency.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s room was adequately equipped with an individual call system device, as required by facility policy. Resident C’s clinical record, reviewed on 1/23/26, showed diagnoses including anoxic brain injury, acute respiratory failure with hypoxia, hypercapnia, and anxiety. The resident’s care plan dated 1/13/26 identified a risk for falls and directed that the resident’s call light be placed within reach. During an observation on 1/28/26 at 1:26 p.m., Resident C was found resting in bed with eyes closed and without a call light in place. In the same observation, only a single call cord was present in the room, and it was positioned for the use of the resident’s roommate, leaving Resident C without access to a call system. When CNA 5 entered the room at 1:27 p.m., she confirmed that she did not see a call light for Resident C and stated there should have been a split call cord in the room. At 1:29 p.m., an LPN stated that all residents should have a call light within reach. The Regional Nurse Consultant later provided the facility’s undated “Call Lights” policy, which states that the facility will have a system in place to allow staff to respond promptly to residents’ calls for assistance and that a functioning call light must always be available and accessible to the resident in their room. This deficiency was cited under 3.1-19(u) and related to intakes 2712868, 2713745, and 2718083.
Failure to Involve Cognitively Intact Resident in Room Change and Phone Restriction
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident was informed of and involved in decisions about his care, specifically a room change to a secured memory care unit and the temporary removal of his cell phone from his possession. Resident B had diagnoses including end stage renal disease, major depressive disorder, bipolar disorder, and anxiety, but his quarterly MDS assessment documented intact cognition. His care plan noted that he enjoyed independent activities, walking, and being outdoors. Despite this, he was moved from his prior location to the secured memory care unit and had his cell phone removed from his possession without his consent. According to the resident’s account, he had gone outside to the front porch for fresh air, as he had done multiple times before, without being aware of any rule requiring him to ask permission. Staff brought him back inside, later placed a monitor on his ankle, and about a week later moved him to the memory care unit and took his phone, all without asking him or obtaining his permission. He reported feeling like he had no freedom, felt like a prisoner, and stated he would prefer to be around higher functioning people. At the time of surveyor observation, he was well groomed and alert and oriented to person, place, time, and situation, and he continued to express that he did not know why he had been placed on the secured unit. Facility documentation showed that staff and the IDT discussed the resident’s exit seeking, impulsive, anxious, pacing, and manic behaviors with his spouse and other family members, and that the family agreed to the room change and to having his cell phone kept at the nurse’s station. However, behavior tracking logs for the months reviewed lacked documentation of exit seeking, impulsive behaviors, anxiousness, pacing, restlessness, or manic behaviors, and progress notes did not document any conversations with the resident about the room move or his permission for removal of his phone. The Social Services Designee confirmed she had not spoken with the resident about the move or his phone and was unsure if any other IDT members had done so, and acknowledged that nursing staff did not document behaviors as they should. The facility’s Resident Rights policy stated that each resident has the right to be treated with dignity and respect, but the record lacked evidence that this resident was informed of or involved in these significant care decisions.
Failure to Timely Initiate Care Plan After Transfer to Secured Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to timely implement a care plan for a resident who was moved to a secured memory care unit. Resident B, whose diagnoses included bipolar disorder and major depressive disorder, was transferred to the memory care unit as documented on a room change notice dated 7/18/25. Although the resident was residing on a secure unit due to dementia and exit-seeking behaviors, the clinical record did not contain a secured unit baseline care plan until 8/30/25, approximately two weeks after the room change. The care plan dated 8/30/25 indicated the resident resided on a secure unit due to dementia and exit seeking, but there was no earlier documentation of a secured unit baseline care plan in the record. During an interview, the Director of Nursing stated that the resident’s care plan for the secured unit should have been initiated at the time of the move. The Administrator provided a current policy document titled “Baseline Care Plan Assessment/Comprehensive Care Plans,” dated 3/23/21, which stated that the comprehensive care plan would expand on the resident’s risks, goals, and interventions using a person-centered plan of care with measurable goals and timetables, and that additional changes would be made to the comprehensive care plan based on the assessed needs of the resident. Despite this policy, the resident’s secured unit baseline care plan was not initiated until weeks after the transfer, resulting in noncompliance with care plan timeliness requirements.
Resident Placed on Secured Memory Care Unit Without Dementia Diagnosis or Documented Need
Penalty
Summary
The facility failed to ensure that a resident placed on the secured memory care unit had an appropriate dementia-related diagnosis or documented clinical need for that placement. The resident, who had diagnoses including diabetes, end-stage renal disease, major depressive disorder, anxiety, and bipolar disorder, was ordered by a physician on 7/18/25 to reside on the secured unit. The resident’s care plan dated 8/30/25 documented that the resident lived on the secured unit related to dementia and exit seeking, with interventions such as activities per schedule, secured unit per physician order, and review and assessment of appropriate placement. However, the clinical record lacked any diagnosis of dementia, Alzheimer’s disease, or other irreversible dementia, and there was no documentation supporting a clinical need for a secured unit. The resident’s former primary care physician stated that the resident did not have a dementia diagnosis and that he would not have initiated an order for placement on the dementia unit. The facility’s Memory Springs admission/discharge criteria required that individuals have a diagnosis of Alzheimer’s or irreversible dementia and be deemed by a physician to be in clinical need of a secured unit, criteria that were not supported by the documentation in this resident’s record.
Failure to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not store food items appropriately, as observed during two separate kitchen inspections and reviews of two snack refrigerators. Surveyors found the main kitchen door propped open, food service areas unattended, and significant accumulations of crumbs and unknown substances on floors, carts, and equipment. Food items, including cabbages and milk crates, were stored directly on the floor in the walk-in refrigerator, and dry storage areas had bags of food placed on the floor with visible debris around the shelves. The reach-in refrigerator contained undated and opened food items, sticky residue on handles, and spilled substances inside. Cleaning schedules were missing at the time of inspection, and the Dietary Manager could not provide them when requested. In the Main Hallway Nourishment Room and Dementia Unit Nourishment Room, snack refrigerators contained undated and expired food items, including sandwiches, salads, chicken strips, and yogurts. Some items belonged to specific residents and were past their labeled dates, while others were unmarked and undated. The refrigerators also had visible spills and residue, and staff interviews confirmed that kitchen staff were responsible for cleaning but had not maintained proper cleaning records or schedules. The Dietary Manager and Administrator acknowledged the lack of cleaning documentation and the presence of unclean surfaces and improperly stored food. Facility policies required all food contact and non-food contact surfaces, equipment, and utensils to be kept clean and free of residue, and for all leftovers and opened foods to be labeled and dated. However, these policies were not followed, as evidenced by the observations of unclean conditions, undated and expired food items, and missing cleaning schedules. The deficiencies had the potential to affect nearly all residents receiving food from the kitchen.
Resident Restrained with Gait Belt for Staff Convenience
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including chronic obstructive pulmonary disease, muscle weakness, impaired mobility, and a history of falls, was physically restrained in a wheelchair using a gait belt. The care plan for the resident included interventions such as a high back wheelchair for comfort and positioning, keeping the call light within reach, and ensuring the resident was within sight of staff when up in the wheelchair. However, during an incident, a CNA used a gait belt to restrain the resident in the wheelchair for approximately 15 minutes to prevent the resident from falling while staff were occupied with another resident. The CNA stated the restraint was applied for the resident's safety and was not aware it constituted abuse. The use of the gait belt as a restraint was reported by staff during shift change, and the nurse on duty, as well as the DON, were notified. The gait belt was found still attached to the wheelchair in a restraining position. The facility's abuse prevention policy defines unreasonable confinement as abuse, and the CNA involved had previously received education on abuse and restraints. The incident was documented and discussed among staff, and the resident did not exhibit any immediate effects from the restraint.
Failure to Provide Consistent and Adequate Snack Availability for Residents
Penalty
Summary
The facility failed to ensure that snacks were consistently available and provided to residents in accordance with their needs, preferences, and requests. Staff interviews revealed that it was common for nursing staff to purchase snacks out-of-pocket because the dietary department frequently did not supply adequate food or drink items. The Dietary Manager confirmed ongoing shortages of essential items such as pasteurized eggs, bread, oatmeal, and coffee, with some items completely unavailable at the time of survey. Observations showed that there were no hydration or snack carts present in the hallways, and the nourishment pantry was inadequately stocked, containing only minimal items such as a small jar of peanut butter, a squeeze container of jelly, a half box of crackers, applesauce, and a single sandwich and small bag of deli meat, both unlabeled or undated. Multiple residents reported that they were often unable to receive snacks, with some stating they had to purchase their own or were only offered snacks a few times a week. One resident, who is diabetic and supposed to receive a bedtime snack, indicated that staff told him there was nothing available when he requested a snack in the evening. The facility's policy stated that between-meal snacks should be available for all residents and that snacks for specific residents should be labeled and prepared by dining services, but these procedures were not being followed, as evidenced by the lack of available snacks and inconsistent provision to residents.
Failure to Follow Physician Orders for Blood Pressure Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician orders regarding medication hold parameters for two residents diagnosed with hypertension. For one resident, the physician ordered atenolol 25 mg daily to be held if the systolic blood pressure (SBP) was less than 120. Despite this, the medication was administered on multiple occasions when the resident's SBP was below the specified threshold, with recorded SBP values ranging from 89 to 118 on several dates. The medication administration records (EMAR) confirmed these instances, and staff interviews indicated an understanding that blood pressure medications should be held if readings fall outside physician-ordered parameters. Similarly, another resident with hypertension was prescribed metoprolol 12.5 mg twice daily, also to be held for SBP less than 120. The EMAR showed that this medication was administered on several occasions when the resident's SBP was below 120, with values between 111 and 119. Facility policy requires medications to be administered as prescribed and in accordance with physician orders, but these orders were not followed in the cases reviewed.
Administration of Unordered Anxiety Medication Dose
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of generalized anxiety received additional doses of Lorazepam without a corresponding physician's order. The resident's care plan indicated a risk for anxiousness and directed that medications be administered as ordered by the physician. However, the clinical record showed that Lorazepam, prescribed for administration at bedtime, was also given at 8:00 a.m. on multiple dates. There was no documentation of a physician's order authorizing these additional morning doses. Further review of the controlled drug records for May and June revealed that the medication was administered twice daily on several occasions, despite the absence of an order for the morning dose. The medication administration records did not document these extra doses. During interviews, staff confirmed that medications should not be administered without a physician's order, and facility policy required medications to be given only as prescribed.
Failure to Provide Prescribed Double Portions for Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a resident with physician orders for double portions at all meals received the prescribed diet. The resident, who had diagnoses including Parkinson's disease and malignant neoplasm of the prostate, had a physician's order dated 10/10/24 specifying double portions at all meals. During a lunch meal service observation, the resident did not receive double portions as indicated on their meal ticket, which clearly stated the requirement in capital letters. The Dietary Manager confirmed that dietary staff are expected to follow the meal tickets when serving meals. Facility policy requires all meals to be checked for accuracy, including proper portion sizes and adherence to therapeutic diet extensions, prior to serving.
Failure to Provide Required Assistive Eating Device During Meal Service
Penalty
Summary
A deficiency occurred when a resident with vascular dementia and a severe intellectual disorder, who was prescribed a pureed consistent carbohydrate diet with an inner lip plate (divided plate) at meals, was not provided with the required assistive device during a lunch observation. Despite physician orders, care plan directives, and the resident's meal ticket all specifying the need for an inner lip plate, the resident was served lunch in individual bowls without the assistive device. The Dietary Manager confirmed that dietary staff should have followed the meal ticket instructions. Facility policy also required accuracy in following therapeutic diet extensions, but this was not adhered to in this instance.
Failure to Provide Consecutive RN Coverage
Penalty
Summary
The facility failed to provide 8-hour consecutive Registered Nurse (RN) coverage for six months, from July to December 2024. The review of the nursing schedule revealed multiple instances where only 6 hours of consecutive RN coverage were provided on specific days across these months. This deficiency had the potential to affect all 60 residents residing in the facility. The Executive Director was unaware of the requirement for 8 consecutive hours of RN coverage, and the Corporate Nurse Consultant also indicated a lack of awareness regarding this requirement. However, the Director of Nursing was aware of the requirement but acknowledged that the facility lacked the necessary RN hours every other weekend. The Facility Assessment dated June 28, 2024, indicated the need for 6 licensed nurses providing direct care and 4 Certified Nursing Aides per 12-hour shifts. Despite this, the facility did not meet the required RN coverage, leading to a deficiency. Interviews with the facility's leadership revealed a lack of understanding and compliance with the regulatory requirement for consecutive RN coverage, contributing to the deficiency observed by the surveyors.
Medication Documentation and Expired Insulin Management Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and management of narcotic medication counts and expired insulins across multiple medication carts. During observations, discrepancies were noted in the narcotic drawers of the medication carts, where the Controlled Drug Receipt Record/Disposition sheets did not match the actual count of medications. For instance, Resident 53's Tramadol count was off by one tablet, and similar discrepancies were found with other residents' medications, such as clonazepam and Pregabalin. Licensed Practical Nurse (LPN) 6 admitted to administering medications without signing them out immediately, which contributed to the discrepancies. Additionally, expired insulin vials were found in the medication carts, which were not removed in a timely manner. Resident 5's Admelog vial and Resident 63's Lispro kwikpen were both past their expiration dates, yet they remained in use. The facility's policy required insulin pens to be dated upon opening and considered expired after 28 days, but this was not adhered to, leading to the administration of potentially ineffective insulin. The Memory Care Unit also exhibited similar issues with narcotic documentation. The Controlled Drug Receipt Record/Disposition sheets did not match the actual medication counts for several residents, including alprazolam and lorazepam. Qualified Medication Aide (QMA) 9 acknowledged a habit of not signing out narcotics immediately after administration, which resulted in inaccurate records. These lapses in documentation and medication management highlight significant deficiencies in the facility's pharmaceutical services, impacting the safe and effective care of residents.
Failure to Secure Resident in Wheelchair Van Leads to Accident
Penalty
Summary
The facility failed to adequately secure a resident in the facility van during transport, leading to an accident. The resident, who had multiple diagnoses including chronic osteomyelitis, muscle weakness, and impaired mobility, was being transported in a wheelchair van. During the transport, the van driver rounded a corner, causing the resident and the wheelchair to fall to the right side. The resident was assessed for injuries and initially reported no pain, but later complained of pain in the right hip and knee, and a bump on the head. The incident was not immediately reported or documented by the facility's Executive Director, who was on vacation at the time. The corporate Executive Director did not fill out an incident report, and the facility's Executive Director was unaware of the need to do so, as she was informed that the resident was not injured. The incident report was completed several days later. The facility's Director of Nursing confirmed that the bus driver had not secured the resident correctly, which led to the wheelchair turning over. The facility's Transportation Policy and Procedure manual, which outlines emergency procedures and safety measures during transport, was not followed. The policy requires that in the event of a fall during transport, 911 should be called, and the resident should not be moved or transported by the facility staff. However, the bus driver did not call 911 and instead assisted the resident back into an upright position and returned her to the facility. The resident later required medical assessments and imaging due to complaints of pain and a headache following the incident.
Failure to Monitor Dialysis Site for Resident
Penalty
Summary
The facility failed to ensure proper monitoring and assessment of a dialysis site for a resident who required such services. Resident 24, who had diagnoses including dependence on renal dialysis, end-stage renal disease, and diabetes mellitus, was supposed to have their AV fistula monitored for signs of infection, bleeding, and bruit/thrill every shift as per a physician's order dated 5/13/24. This order was discontinued when the resident was sent to the hospital on 12/29/24. Upon the resident's return, the order was not reinstated, resulting in a lack of documentation and monitoring of the fistula for two months, despite the resident continuing to receive dialysis three times a week. Interviews with facility staff, including an LPN and the DON, revealed that the oversight occurred because the physician's order was not re-entered into the computer system after the resident's return from the hospital. The facility's policy on the care of residents receiving dialysis treatments, which includes monitoring for infection or clotting of the access area, was not followed. The staff failed to confirm the resident's dialysis orders, leading to the deficiency in care for Resident 24.
Improper Storage and Disposal of Insulin Pens
Penalty
Summary
The facility failed to properly store and dispose of discontinued insulin pens in the Eagle Court Hall Medication Cart. During an observation, Resident 18's Humalog kwikpen was found without a pharmacy label, only bearing a sticker with the resident's name, and had an open date of 2/17/25 despite the order being discontinued on 1/16/25. The resident's medical record showed a diagnosis of type 2 diabetes mellitus with diabetic neuropathy, and the last documented administration of Humalog was on 1/16/25. There was no documentation of a current physician's order for Humalog in February, and RN 7 confirmed that the resident was only receiving Lantus at bedtime, with no insulin administered during the day. Additionally, other insulin pens were improperly stored in the medication cart. An Aspart kwikpen with an illegible name had an open date of 1/3/25 and an expiration date of 2/3/25, while another Insulin Aspart kwikpen lacked a name, physician's order, or pharmacy label, with an open date of 11/18/24 and an expiration date of 12/18/24. These findings indicate a failure to adhere to the facility's policies on insulin pen storage and disposal, which require that outdated or improperly labeled medications be immediately withdrawn from stock and disposed of according to drug disposal procedures.
Failure to Provide Snacks to Residents
Penalty
Summary
The facility failed to ensure that snacks were provided and available for residents, affecting 8 out of 10 residents reviewed for dietary services. Residents reported that they had to purchase their own snacks as the kitchen did not provide any. Certified Nurse Aides confirmed that they had to buy snacks themselves because the dietary department did not supply them. The Director of Nursing acknowledged the issue, stating that the dietary department had not been providing snacks since a new company took over. Observations of the nourishment pantry revealed limited supplies, with no meats or peanut butter available. Residents expressed dissatisfaction with the lack of snacks, with some indicating they were not receiving snacks as ordered by their physicians. The Manager of the dietary service company mentioned that they provide bulk snacks but do not follow specific snack times, and acknowledged the lack of prune juice and peanut butter, which they planned to purchase. The facility's meal schedule was reviewed, and a policy document indicated that snacks should be available 24 hours a day, but this was not being followed. This deficiency was related to complaints IN00452715 and IN00453276.
Failure to Inform Resident of Appointment Cancellation
Penalty
Summary
The facility failed to ensure that Resident B was informed in a timely manner about the cancellation of her pain management appointment. Resident B, who had diagnoses including end-stage heart failure and anxiety, was upset and angry upon discovering that her appointment was canceled. The cancellation occurred because hospice services had taken over her care, including pain management. However, there was no documentation in the clinical record indicating that Resident B was notified of the cancellation before the day of the appointment. Interviews with the resident and staff revealed that Resident B was not informed of the cancellation until she was dressed and waiting for her ride on the day of the appointment. LPN 7 confirmed that the appointment was canceled without notifying the resident, and CNA 13 was unaware of the cancellation until the day of the appointment, as the original appointment was still listed on the transportation log. This oversight violated the resident's rights to be fully informed of her health status and care, as outlined in the facility's Resident Rights document.
Verbal Abuse by LPN Towards Residents
Penalty
Summary
The facility failed to protect residents from verbal abuse by a staff member, specifically involving two residents, Resident D and Resident L. Resident D, diagnosed with schizoaffective disorder, psychotic disorder with delusions, and major depressive disorder, reported concerns about the behavior of an LPN. The LPN was described as argumentative and using a mean tone, which agitated Resident D. An incident was observed where the LPN was cursing and speaking rudely to Resident D, escalating the situation. Despite an investigation, the facility was unable to substantiate the allegations of abuse. Resident L, who has diagnoses including anxiety, chronic respiratory failure with hypoxia, and diabetes, also experienced verbal abuse from the same LPN. The LPN referred to Resident L as a 'cry baby' and dismissed her concerns as lies during a phone conversation with the resident's family member. This conversation was overheard by Resident L, causing her distress. The LPN's behavior included using inappropriate language and dismissing the resident's needs, which was witnessed by other staff members. The facility's Abuse Prevention Program policy was not adhered to, as it mandates that residents receive care in a person-centered environment free from verbal abuse. The incidents involving the LPN's interactions with both Resident D and Resident L demonstrate a failure to uphold this policy, as the LPN's actions were derogatory and disrespectful, contributing to the residents' distress.
Failure to Report Abuse and Inappropriate Conduct
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with 1150B of the Act for two residents, Resident D and Resident L. Resident D, who was diagnosed with schizoaffective disorder, psychotic disorder with delusions, and major depressive disorder, reported concerns about care provided by an LPN. An incident occurred where the LPN was heard using inappropriate language and purposefully upsetting Resident D. Although RN 15 witnessed the incident and submitted a written statement to the Director of Nursing (DON), the facility's reportables lacked documentation of this incident. Resident L, diagnosed with anxiety, chronic respiratory failure with hypoxia, and diabetes, experienced a delay in care and was subjected to derogatory remarks by the same LPN. The LPN was overheard making inappropriate comments about Resident L to her family member and in the presence of Resident L. Despite the incidents being reported to the DON by CNA 13 and RN 5, the facility failed to document these incidents in their reportables. The facility's Abuse Prevention Program policy requires immediate reporting of abuse incidents, which was not adhered to in these cases.
Failure to Implement Care Plan After Dental Extractions
Penalty
Summary
The facility failed to implement a care plan for a resident after all of the resident's teeth were extracted. The resident, who had diagnoses including end-stage heart failure and anxiety, had all her teeth removed on January 10, 2025. Despite this significant change in her condition, the clinical record lacked documentation of a care plan addressing the extraction and its implications for her care. The resident was observed without teeth and mentioned she was awaiting dentures. A physician's order dated January 31, 2025, indicated dietary preferences related to the extraction, but no comprehensive care plan was documented. During an interview, the Director of Nursing expressed an assumption that a care plan would have been implemented following the extractions. The Regional Director of Operations provided a policy document indicating that comprehensive care plans should be reviewed and updated quarterly or more frequently based on changes in the resident's condition. This deficiency was related to complaints IN00451851 and IN00452480, highlighting the facility's failure to adhere to its policy of updating care plans in response to significant health changes.
Delayed Diet Change for Resident Post-Dental Procedure
Penalty
Summary
The facility failed to timely implement a diet change for a resident who had all her teeth extracted. Resident B, diagnosed with hypertension and end-stage heart disease, underwent a dental procedure on 1/10/25, resulting in the extraction of all her teeth. Despite this significant change in her ability to eat, the clinical record did not document any dietary adjustments until 1/14/25, when a physician's order was made for a modified diet of chicken noodle soup, ice cream, pudding, and milk. Interviews revealed that the resident did not return with any paperwork from the dentist, and there was a lack of immediate action to clarify the new diet with the dentist upon her return.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to adhere to a therapeutic diet order for a resident, identified as Resident H, who was diagnosed with diabetes, anxiety, and major depressive disorder. The physician's order, dated March 12, 2024, specified that Resident H was to receive prune juice with her lunch every day. However, during an interview on February 6, 2025, Resident H reported that she had never received the prune juice with her lunch tray. Further investigation revealed that the facility did not have prune juice available, as confirmed by the Regional Director of the dietary service, who stated that they would need to purchase some. This deficiency was noted during a review of the resident's clinical record and interviews conducted with the resident and facility staff.
Failure to Change PICC Line Dressings as Ordered
Penalty
Summary
The facility failed to ensure that dressing changes for peripherally inserted central catheter (PICC) lines were completed as ordered for two residents, Resident B and Resident D. Resident B, diagnosed with acute osteomyelitis of the right foot and ankle, had a physician's order to change the PICC line dressing weekly and as needed. However, observations on November 1st and 2nd revealed that the dressing, dated October 24th, had not been changed as per the order. The medication administration record inaccurately indicated that the treatment was completed on November 1st, and an LPN confirmed that PICC line dressings should be changed every seven days. Similarly, Resident D, diagnosed with bacteremia, had a physician's order to change the transparent dressing to the PICC line on admission and then weekly. Observations on November 1st and 2nd showed that the dressing was still dated October 24th, despite the medication administration record indicating a change on October 31st. The Director of Nursing provided a document outlining the process for dressing changes, which confirmed that transparent dressings should be changed every seven days. These findings indicate a failure to adhere to physician orders and facility protocols for PICC line dressing changes.
Failure to Administer Lorazepam as Ordered
Penalty
Summary
The facility failed to ensure that a resident's routine Lorazepam, a narcotic antianxiety medication, was administered as ordered by the physician. The resident, identified as Resident E, had diagnoses including anxiety and chronic obstructive pulmonary disease. The care plan indicated an increased risk for anxiousness and required the administration of anxiety medication as ordered. However, the medication administration records for October and November 2024 showed that the resident did not receive the medication at the prescribed times, with significant gaps in administration noted. Interviews and record reviews revealed that Resident E frequently experienced delays or missed doses of her anxiety medication. The controlled drug records lacked documentation of the administration of Lorazepam on several occasions. An RN confirmed that routine narcotics should be signed off on the controlled drug record when removed and documented on the medication administration record after administration. The facility's medication administration policy, provided by the Director of Nursing, emphasized the importance of documenting medication administration appropriately.
Inadequate Meal Temperature and Timeliness
Penalty
Summary
The facility failed to ensure that food was served at appropriate temperatures, as observed during a survey on [NAME] Hall. On November 1, 2024, lunch trays were delivered at 12:58 p.m., and food temperatures were recorded shortly after. The cheesy grits with shrimp were at 145 degrees, collard greens at 126 degrees, and garlic toast at 108.6 degrees. These temperatures suggest that some items were not served at an appetizing or safe temperature. Additionally, the resident council minutes from September and October 2024 indicated ongoing concerns about breakfast being served cold and dinner being served late. Multiple residents expressed dissatisfaction with the temperature and timeliness of their meals. Resident B noted that food was hot in the dining room but cold and late when served on the hall. Resident D shared a similar experience, preferring the dining room to avoid cold meals. Resident K described the food as consistently late and cold, while Resident L echoed these sentiments, stating that meals were usually late and cold by the time they reached the hall. These observations and resident testimonies highlight a pattern of inadequate meal service on [NAME] Hall.
Inaccurate Documentation of PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure that a resident's medication administration record accurately reflected the administration of as-needed narcotic pain medication. Specifically, the clinical record for a resident with diagnoses including end-stage heart failure, anxiety, and chronic obstructive pulmonary disease was reviewed, revealing discrepancies in the documentation of Morphine Sulfate administration. The physician's order prescribed 0.75 mg of Morphine Sulfate every two hours as needed for pain. However, the October and November 2024 controlled drug records indicated multiple instances where the medication was administered, but the medication administration record lacked corresponding documentation for these dates and times. During an interview, an RN confirmed that when a PRN narcotic is administered, it should be signed out on the controlled drug record and initialed on the medication administration record by the nurse. Additionally, the resident should be followed up on after 30 minutes to assess the effectiveness of the pain medication. The Director of Nursing provided a document titled Medication Administration, which outlined the procedure for administering medications safely and appropriately, including documenting medication administration with initials in the appropriate spaces.
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.
Trusted by long-term care providers and associations.
