Waters Of Sullivan Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Sullivan, Indiana.
- Location
- 505 W Wolfe St, Sullivan, Indiana 47882
- CMS Provider Number
- 155262
- Inspections on file
- 27
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Waters Of Sullivan Nursing Facility, The during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to follow food safety and sanitation standards, including improper use of beard restraints while working over food, inadequate hot-holding temperatures for items such as baked chicken, mashed potatoes, and vegetables, and visibly soiled hall tray carts with heavy brown debris on rails and wheels. Several cognitively intact residents reported poor food quality, including cold or lukewarm meals, dry and overcooked items, and rubbery eggs, particularly for trays delivered to rooms. Grievance records documented repeated complaints about cold and poor-quality food, while facility policies required proper hair restraints, correct cooking and holding temperatures, and regular cleaning and sanitizing of carts and equipment.
A resident with diabetes, heart failure, and HTN, who was cognitively intact and on a consistent carb, regular texture diet, repeatedly received oatmeal on meal trays despite stating multiple times that he did not like it. Review of the care plan and nutrition assessment showed no documented food preferences, and the daily menu for the resident lacked any notation of likes or dislikes, even though the facility’s policy and the DM’s process required recording such information on nutritional assessments and menus.
A resident with Type II DM had a standing order for mealtime Lispro insulin without any parameters for holding doses, yet nursing staff repeatedly held scheduled insulin at various times for blood glucose values ranging from the 50s to just over 100, and on some occasions failed to document any blood glucose value or whether insulin was given. The clinical record did not show MD notification or new orders for these held doses, and interviews with a QMA and the DON confirmed that no physician parameters for holding insulin had been provided and that staff did not contact the prescriber as required by facility policy.
The facility required CNAs and nursing staff to cover laundry duties in addition to resident care, resulting in longer call light response times, increased staff workload, and delays in meal tray delivery. The Administrator did not seek additional staffing or external support, and the actual staffing levels did not match the facility's assessment plan. Staff reported running out of linens and increased stress, with no additional staff scheduled to address the shortage.
The Administrator failed to address ongoing gnat infestations, unsafe environmental conditions, and staffing shortages, resulting in residents experiencing contaminated food, injuries from unrepaired fixtures, and inadequate laundry and housekeeping services. Staff and residents reported that the Administrator was not present on the floor and did not communicate about these issues, leading to unresolved problems affecting all residents.
A gnat infestation persisted throughout the facility, affecting all residents and multiple areas such as resident rooms and the dining room. Residents reported gnats contaminating food and beverages, and one developed maggots between her toes. Staff repeatedly reported the issue to administration, but responses were delayed and insufficient, with pest control measures failing to resolve the problem in a timely manner.
A resident admitted with orders for enoxaparin, Humalog, and Lantus did not receive scheduled doses because the required medications were unavailable in the Emergency Drug Kit and not obtained in time from the pharmacy. The Director of Nursing confirmed that staff should have used the EDK or arranged for emergency delivery, but the EDK was out of stock for the needed insulins and did not have the correct enoxaparin dose, resulting in missed medication administration.
Three residents, including those with cognitive impairments and special dietary needs, reported that their meals were frequently served cold and unappetizing. Observations confirmed that food was delivered on unheated carts without adequate warming devices, resulting in meal temperatures below the facility's policy requirements. The Dietary Manager acknowledged insufficient warming equipment, and complaints were noted about both food temperature and appearance.
The facility failed to manage food safety and storage, with incomplete temperature logs, expired food items, and improper storage practices. Bread lacked expiration dates, and sanitizer concentration levels were not properly tested or logged. Staffing shortages contributed to these deficiencies.
The facility did not conduct quarterly care plan meetings for two residents, as required by policy. One resident reported not attending a recent meeting, and records showed only one meeting in the past year. Another resident's records indicated only two meetings over a year, despite the quarterly requirement. The facility lacked a Social Service Director, which may have contributed to these oversights.
A resident with a history of prostate cancer and atrial fibrillation experienced edema in his feet and ankles, but the facility failed to notify the physician of this change in condition. Despite the resident's significant weight gain and the care plan's directive to monitor for edema, the facility did not document notifying the physician, resulting in a deficiency.
A resident was observed self-administering medications without supervision, contrary to facility policy requiring licensed nursing staff to administer medications or have physician authorization for self-administration. The resident's records lacked necessary assessments and orders, and staff interviews confirmed non-compliance with supervision protocols.
A facility failed to properly store and obtain physician orders for a resident's CPAP equipment. Observations showed the CPAP mask and tubing were unbagged and undated, and the resident's medical record lacked specific CPAP settings or humidification orders. An LPN confirmed the equipment should have been bagged and dated, and the facility's policy required a written physician's order for CPAP therapy, which was missing.
A facility failed to ensure proper physician documentation for a resident's continued use of Vesicare, despite a pharmacy recommendation to discontinue it. The resident, diagnosed with neuromuscular dysfunction of the bladder, had no documented rationale from the physician for continuing the medication, contrary to facility policy. This deficiency was confirmed by the Regional Nurse Consultant during an interview.
A facility failed to complete physician-ordered lab tests for a resident with multiple medical conditions, including heart failure and diabetes. Despite orders for various tests such as Digoxin levels, Hemoglobin A1C, and CBC, the records lacked documentation of their completion. The Regional Nurse Consultant confirmed the absence of lab results, highlighting a deficiency in following the facility's policy for nursing actions related to physician orders.
The facility failed to maintain infection prevention measures during meal service and medication administration. A CNA did not sanitize hands after touching her ear and hair while serving ice, and an LPN did not wash hands between checking blood sugar for two residents. Staff also did not follow hand hygiene guidelines, washing hands for less than 20 seconds and turning off faucets with bare hands.
Food Safety, Temperature Control, and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The deficiency involves multiple failures in food safety and sanitation practices in the facility’s dietary services. Surveyors observed contracted dietary staff working in the kitchen food preparation area without properly using beard restraints, despite a facility policy requiring hair and beard coverings at all times. One dietary aide with facial hair repeatedly entered and worked in the food preparation and tray assembly areas with his beard restraint either not in place or pulled down below his mouth, leaving his beard and mustache uncovered, including while standing directly over the steam table and loading trays into hall tray carts. Another dietary aide was observed serving trays over open plates of food with long sideburns exposed because his beard restraint did not fully cover his facial hair. The Dietary Manager acknowledged understanding the policy requirement for hair and beard restraints. Surveyors also identified problems with food temperatures and resident complaints about food quality and temperature. A test tray taken during the noon meal service showed a piece of baked chicken at 112°F, mashed potatoes with gravy at 119°F, and mixed vegetables at 105°F, which the Dietary Manager acknowledged were below the correct holding temperatures and inconsistent with the facility’s policies on cooking and holding food, including poultry at 165°F. Several cognitively intact residents reported that food was often cold or lukewarm, dry, overcooked, rubbery, tough, or otherwise of poor quality. Residents who typically ate in their rooms and received hall trays specifically reported that their food was sometimes or usually cold by the time it reached them. Grievance forms documented prior complaints that food quality was poor, food was cold, often late, and that items were sometimes unavailable. In addition, the surveyors observed that the hall tray food delivery carts used for the East and another hall at the noon meal were visibly soiled. The carts, which contained individual meal trays, cups with liquids, and eating utensils, had a heavy coating of brown debris along the bottom rails and on the wheels. This condition existed despite a facility policy requiring that trays and carts used to carry clean tableware and utensils be cleaned and sanitized daily or as often as necessary. The Dietary Manager stated that the carts were cleaned after every meal service and that the outside was wiped down as needed. The Administrator reported that dietary staff were contracted employees and stated she was aware of kitchen issues but believed she did not have authority over them.
Failure to Document and Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that a resident’s food preferences were documented and honored, resulting in the resident repeatedly receiving an undesired food item. During an interview, Resident B, who was cognitively intact per a 5-day MDS assessment, reported that he did not like oatmeal and had continued to receive it on his meal tray despite telling staff several times not to send it. Review of his medical record showed he was admitted with diagnoses including diabetes, heart failure, and hypertension, and had a physician’s order for a consistent carbohydrate, regular texture diet. However, his care plan contained no specific food preferences, and his nutrition assessment only stated that food preferences were on the tray card, with no additional information recorded. The DON stated that food preferences were recorded on nutritional assessments, while the DM explained that residents were given daily menus and asked to indicate what they wanted, and that she would include likes and dislikes if residents informed her. Neither the DON nor the DM reported being told of any food preferences by this resident. The DM provided a copy of the daily menu for the resident, which lacked any notation of likes or dislikes at the bottom where such information was supposed to be recorded. The facility’s policy, “Clinical Nutrition documentation,” stated that residents have the right to make their own food choices related to individual differences and cultural and ethnic preferences, but the documentation and meal service for this resident did not reflect his stated dislike of oatmeal.
Failure to Follow Insulin Orders and Obtain Parameters for Holding Doses
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin as ordered by the physician and to obtain physician parameters or orders for holding insulin doses for a resident with Type II diabetes mellitus. Resident B had a current signed order for Lispro insulin, 25 units subcutaneously with meals, dated 12/4/25, with no parameters for when to hold doses. The eMAR showed multiple instances where scheduled insulin doses were held without corresponding physician orders or documented parameters: the 7:30 a.m. dose was held on several dates for blood sugar (BS) values of 46, 90, and 116; the 11:30 a.m. dose was held on multiple dates for BS values ranging from 54 to 80; and the 5:30 p.m. dose was held on one date for a BS of 105. The clinical record also lacked documentation of any BS value, progress note, indication of the resident being out of the facility, or indication that insulin was administered for certain scheduled doses. The record further lacked documentation that the physician was notified regarding the held insulin doses. A QMA reported obtaining BS values prior to insulin administration and stated that, on one occasion when the BS was 77 at 11:30 a.m., the nurse instructed her to document in the eMAR that the insulin was held due to that BS value. During interview, the DON confirmed that the physician had not provided parameters for holding mealtime insulin, that the hospital discharge records did not include such parameters, and that the facility physician had not added any. The facility’s medication administration policy stated that if a dosage is believed to be inappropriate or excessive, or associated with potential adverse consequences, the person administering the medication will contact the prescriber or attending physician, but the documentation did not show that this occurred for the held insulin doses.
Nursing Staff Shortage Due to Laundry Coverage
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet resident needs while also requiring nursing assistants to cover laundry services since the end of October. Certified Nursing Assistants (CNAs) reported that they were assigned to laundry duties during their shifts, which resulted in them leaving the floor and being less available for direct resident care. Multiple CNAs and an LPN indicated that this dual responsibility led to longer call light response times, increased workload, and delays in meal tray delivery and pick-up. Staff also noted that there were occasions when only two aides, a nurse, and a QMA were present on night shift to care for all residents while also handling laundry, and that no additional staff had been scheduled to compensate for the increased workload. The Administrator acknowledged that only one full-time housekeeper/laundry person was employed after the termination of the Housekeeping Supervisor, and that CNAs had picked up extra hours to cover laundry. The Administrator had not reached out to regional leadership or considered external sources for laundry coverage, nor had she discussed the impact of the staffing shortage with residents or staff in detail. The Facility Assessment Tool indicated a staffing plan that included more housekeeping/laundry staff than were actually present. Staff reported running out of linens on night shift, necessitating laundry to be done during evenings and nights. One resident noted that staff appeared more stressed, though did not observe increased call light response times.
Failure to Address Bug Infestation, Staffing Shortages, and Unsafe Conditions
Penalty
Summary
The Administrator failed to manage the facility in a manner that ensured effective use of resources and quality of life for residents, as evidenced by ongoing issues with bug infestation, inadequate direct care staffing, and unsafe living conditions. Multiple confidential interviews with staff and residents revealed that the Administrator was not present on the floor, did not engage with staff or residents, and was perceived as indifferent to the facility's challenges. Staff morale was reported to be low, and concerns about vacancies and pest infestations were largely ignored by the Administrator. One resident reported sustaining a cut on his arm from a damaged bathroom door frame, which had not been repaired for over a month due to the absence of a Maintenance Director. The Administrator acknowledged the delay in repairs and indicated that the new Maintenance Director would address the issue when possible. The same resident described severe gnat infestations in his room and the dining area, with gnats contaminating food and beverages. Staff and residents reported that the gnat problem persisted for several weeks, and staff requests to use pest control devices were denied by the Administrator. Another resident reported developing maggots between her toes, which she attributed to the insect infestation in her room. The facility also experienced significant staffing shortages, particularly in housekeeping and laundry. The Administrator had terminated the Housekeeping Manager, leaving only one full-time housekeeper/laundry staff member, and CNAs were required to cover laundry duties, leading to frequent shortages of linens, especially during night shifts. The Administrator admitted to not seeking additional support or outside services to address the laundry staffing gap and had not communicated with staff or residents about the impact of these shortages. The Administrator was aware of the gnat issue but did not fully grasp its extent and did not escalate the problem to higher management or seek alternative pest control solutions.
Failure to Control Gnat Infestation Compromises Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment by not controlling a gnat infestation that affected multiple areas, including resident rooms and the dining room. Residents reported significant issues with gnats over a period of several weeks to months, with gnats found in beverages and food, and residents taking measures such as covering drinks and personal items to avoid contamination. One resident described counting multiple gnats in his coffee, while another mistook gnats for pepper on her food. Staff interviews confirmed that the infestation was widespread and persistent, with reports that the issue was communicated to administration multiple times. Resident interviews revealed that the infestation caused considerable discomfort and annoyance, with one resident covering her face at night to avoid gnats and another developing maggots between her toes, which was documented in a Skin Integrity Issue report. The report noted that this resident had predisposing factors such as a preference for independence, incontinence, fragile skin, improper footwear, and resistance to care. Staff described the infestation as severe, with gnats present in food, beverages, and throughout the facility, and expressed concerns that the facility's response was insufficient and not timely. The Administrator acknowledged being aware of some gnats in her office but was not aware of the extent of the infestation throughout the facility. She had not spoken directly to residents or staff about the issue and relied on department heads for information. The pest control company was called for additional visits, but staff felt these measures were inadequate. The facility's pest control policy outlined responsibilities for prevention, monitoring, and control, but the actions taken did not prevent or resolve the infestation in a timely manner.
Failure to Timely Obtain and Administer Ordered Medications After Admission
Penalty
Summary
The facility failed to ensure that medications were obtained and administered in a timely manner for a newly admitted resident. Upon admission, the resident had physician orders for enoxaparin (an anticoagulant), Humalog (short-acting insulin), and Lantus (long-acting insulin). The Medication Administration Records (MAR) showed that scheduled doses of these medications were not administered as ordered, with documentation indicating to see nurse's notes for the reason. However, progress notes lacked documentation regarding the missed enoxaparin doses, and notes for the missed insulin doses indicated that Humalog and Lantus were not available in the Emergency Drug Kit (EDK) at the time they were needed. The Director of Nursing (DON) confirmed that if residents did not arrive with their medications, staff were expected to use the EDK, which is restocked with regular pharmacy runs. On the dates in question, the EDK was out of stock for Humalog and Lantus, and the available enoxaparin doses did not match the physician's order. The DON was unsure if staff should have contacted the physician regarding alternative dosing with the available enoxaparin. Facility policy required prompt initiation of therapy from the EDK or emergency delivery if needed, but this did not occur, resulting in the resident not receiving ordered medications as scheduled.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature for three residents reviewed for dietary services. Resident C, who was cognitively intact and ate all meals in his room, reported that the food was always cold and not good. Observations revealed that meal trays were delivered on an unheated metal cart, with plates covered only by plastic covers and lacking warming pieces. The Dietary Manager checked the temperature of a test tray after all meals were served and found the barbeque sandwich meat at 107.3°F and baked beans at 117.4°F, both below the facility's policy requirement of 135°F. The Dietary Manager acknowledged there were not enough warming pieces for all trays, especially since most residents preferred to eat in their rooms, and none of the trays on the east wing had warming pieces during the observed lunch service. Additionally, the barbeque meat was noted to be an unnatural bright red color, and there had been complaints about the food's appearance. Resident B, who had moderate cognitive impairment and was on a mechanical soft diet, was reported by a family member to have poor food intake due to the food not being good, with meals also taken in her room. Resident G, cognitively intact, stated that the food was often cold when it arrived. The facility's policy required hot food to be held at 135°F or greater throughout service, which was not met during the observed meal service. These findings were based on interviews, observations, and record reviews, and were related to a specific complaint investigation.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to properly manage food storage and safety protocols, as observed during a kitchen tour. Temperature logs for the walk-in refrigerator and freezer were incomplete, lacking documentation for specific dates. The responsibility for maintaining these logs typically fell to the cook, but due to staffing shortages, this task was neglected. Additionally, thawed raw chicken was found with an outdated label, indicating it should have been discarded. The facility's policy required food to be labeled and dated, with expired items discarded, but this was not consistently followed. Further observations revealed that bread items in dry storage lacked manufacturer expiration dates or received dates. The Dietary Director was unaware of the specific policy regarding this issue, although bread shipments were received weekly and stored in the freezer for up to two weeks. Additionally, boxes of broccoli cuts and sheet cakes were found on the floor of the walk-in freezer, contrary to the facility's policy that required food to be stored at least six inches off the floor. The facility also failed to maintain a testing log for sanitizer concentration levels. A Dietary Assistant demonstrated incorrect testing procedures, initially holding the test strip in the solution for too long and repeating the process multiple times. The Dietary Director acknowledged the absence of a sanitation chemical testing log, although testing was believed to occur throughout the day. The facility's policy required adherence to the manufacturer's recommendations for sanitizer concentration, but this was not consistently monitored or documented.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for two residents, as required by their policy. Resident 19, who was cognitively intact, reported not being invited to or attending a care plan meeting recently. A review of Resident 19's records showed that only one care plan meeting was documented over the past year, despite the requirement for quarterly meetings. The Regional Nurse Consultant confirmed the absence of additional quarterly care plan meetings for Resident 19 and noted the facility's lack of a Social Service Director, which may have contributed to this oversight. Similarly, Resident 30, also cognitively intact, indicated he had not participated in a care plan meeting. His medical records showed only two care plan meetings were conducted from May 2023 to June 2024, failing to meet the quarterly requirement. The facility's policy mandates that comprehensive care plans be reviewed and updated every quarter, but this was not adhered to for Resident 30. The Regional Nurse Consultant provided the facility's policy, which outlines the procedures for scheduling and documenting care plan meetings, highlighting the facility's failure to follow its own guidelines.
Failure to Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to notify a physician of a resident's change in condition related to edema. Resident 46, who has a history of malignant neoplasm of the prostate and atrial fibrillation, was observed multiple times with edema in his bilateral feet and ankles. Despite the resident's observations of swelling and attempts to manage it by elevating his legs, there was no documentation of the physician being notified of this change in condition. The resident's care plan included monitoring for signs of atrial fibrillation, such as edema, but the facility did not follow through with notifying the physician as required. The resident's weight had increased significantly over the last 30 days, yet there was no record of the physician being informed of this weight gain, which was a critical indicator of the resident's condition. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not adhered to in the case of Resident 46. Interviews with staff revealed that some were aware of the swelling but did not take appropriate action to notify the physician, leading to a deficiency in the care provided to the resident.
Failure to Supervise Resident Medication Administration
Penalty
Summary
The facility failed to ensure adequate supervision for a resident self-administering medications, leading to a deficiency in accident prevention. During observations, the resident was seen taking medications without a nurse present, and the resident confirmed that nurses often left her medications in her room for her to take alone. The resident's records lacked documentation of an assessment for self-administration of medications, and there was no physician order authorizing self-administration. The resident's medical conditions included nonrheumatic aortic valve stenosis, congestive heart failure, chronic kidney disease, and a need for assistance with personal care. The facility's policy required medications to be administered only by licensed nursing staff and allowed self-administration only when authorized by a physician. Interviews with staff revealed that the nurses were aware of the policy but did not adhere to it, as one nurse left the resident to meet a pharmacy representative. The Regional Nurse Consultant confirmed that medications should not be left with residents without supervision. The facility's failure to follow its own policy and ensure proper supervision resulted in the deficiency.
Deficiency in CPAP Equipment Management and Physician Orders
Penalty
Summary
The facility failed to ensure proper storage and physician orders for a resident's CPAP equipment. During multiple observations, the CPAP machine of a resident with Parkinson's disease and obstructive sleep apnea was found with unbagged and undated tubing and mask. The resident indicated that staff assistance was required for using the CPAP, and the equipment had not been bagged since her admission. The resident's medical record lacked documentation of a physician order specifying the CPAP settings or humidification, despite a care plan indicating the need for CPAP use at bedtime and during naps. Interviews with facility staff revealed a lack of adherence to the facility's policy on CPAP equipment management. An LPN confirmed that the CPAP tubing and mask should have been bagged and dated, and acknowledged the absence of a storage bag in the resident's room. The LPN also noted that the CPAP machine was set at a different level than the resident believed it should be, and the electronic medical record did not include specific settings or humidification orders. The facility's policy required a written physician's order for CPAP therapy, including the level of CPAP and humidification if needed, which was not present in the resident's records.
Lack of Physician Documentation for Medication Continuation
Penalty
Summary
The facility failed to ensure proper physician documentation to justify the continuation of a medication against a pharmacy recommendation for a resident diagnosed with neuromuscular dysfunction of the bladder. The pharmacy had recommended discontinuing Vesicare, a medication used to treat overactive bladder symptoms, but the physician disagreed and simply noted 'Continue med' without providing further justification. This lack of documentation was confirmed during an interview with the Regional Nurse Consultant, who was unable to find any additional physician notes explaining the decision. The facility's policy requires that if a physician disagrees with a pharmacy recommendation, they must document the rationale in the resident's medical record, which was not adhered to in this case.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed for a resident with multiple medical conditions, including congestive heart failure, atrial fibrillation, type 2 diabetes, hypertension, hyperlipidemia, and gastro-esophageal reflux disease. The resident's medical record indicated several physician-approved lab tests, such as Digoxin levels, Hemoglobin A1C, BMP, Magnesium levels, Lipid profiles, and CBC, were recommended and ordered at various intervals. However, the record lacked documentation that these tests were completed as ordered. During an interview, the Regional Nurse Consultant confirmed the absence of documentation for the lab results within the specified time frame. The facility's policy, as provided by the Regional Nurse Consultant, indicated that the Director of Nursing was responsible for following up on any nursing actions needed in response to the physician's orders. Despite this policy, the necessary lab tests were not documented as completed, leading to a deficiency in the facility's compliance with physician orders for lab testing.
Infection Control Deficiencies During Meal and Medication Administration
Penalty
Summary
The facility failed to maintain proper infection prevention measures during meal service and medication administration. During meal service observations, a Certified Nurse Aide (CNA) was seen touching her ear and hair and then continuing to pass ice to residents without sanitizing her hands. Additionally, the CNA placed the ice scoop back into the ice bucket instead of the designated container. The CNA also failed to sanitize her hands after adjusting oxygen tubing for one resident before assisting another. The facility's policy required staff to wash their hands before serving food and after assisting residents, which was not followed. During medication administration, a Licensed Practical Nurse (LPN) did not wash her hands between checking the blood sugar of two residents. The facility's policy required hand cleansing before contact with each resident, which was not adhered to. Furthermore, random observations revealed that staff did not wash their hands for the required 20 seconds and turned off the water faucet with bare hands, contrary to the facility's hand hygiene guidelines. These actions were inconsistent with the facility's policies on hand hygiene and infection control.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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