Waters Of Tipton Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Tipton, Indiana.
- Location
- 300 Fairgrounds Rd, Tipton, Indiana 46072
- CMS Provider Number
- 155556
- Inspections on file
- 34
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Waters Of Tipton Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A resident with dementia, depression, muscle weakness, and documented weight loss/malnutrition experienced progressive, unaddressed weight loss over several months. Although care plans and hospital records identified malnutrition risk and the need to monitor weights, facility records showed ongoing declines in weight and frequent meal refusals or low intake, with observations of the resident not eating or consuming less than half of meals and requiring cueing and feeding assistance. Dietician recommendations for house shakes to promote weight stability were not promptly implemented, and the resident was not consistently included on nutrition-at-risk monitoring lists. Despite significant percentage weight losses over time, there was no clear documentation that the physician was notified or that the interdisciplinary team assessed and addressed the weight loss, leading to continued decline in the resident’s weight.
A resident with muscle weakness, dementia, and dependence on staff for bed mobility was placed on an inflated low air loss mattress with the bed raised for incontinent care. During a brief change, a CNA rolled the resident toward the wall, and due to the combination of the inflated mattress and rolling the resident too far, the resident’s head struck a wooden chair rail/trim on the wall, causing a scalp laceration that required repair with staples. Facility staff, including the CNA, DON, and ED, confirmed that the incident occurred while the resident was being rolled in bed for care and that the resident could not roll independently.
Staff failed to follow standardized recipes and facility policy for pureed food preparation and hot holding temperatures. A cook pureed beef pot roast and carrots for several residents on pureed diets using unmeasured amounts of water as a thinning agent instead of the prescribed juice, milk, or broth, and without measuring portions as required. Residents reported that meals in a dining room were not always hot, and resident council members stated that food was served cold. During a lunch service, staff in the dining room lacked an available food thermometer at the start of service, and subsequent checks showed pureed carrots, pureed beef pot roast, and hamburgers being held below the required 135°F hot holding temperature, in violation of facility policy and state code.
The facility failed to resubmit required PASARR screenings when residents experienced new or worsening mental health symptoms, started psychotropic medications, had psychotropic dose changes, or when short‑term PASARR approvals expired. One resident with dementia developed aggressive behaviors and was started on Valium and buspirone without a new PASARR reflecting the new anxiety diagnosis and medications. Another resident with depression, anxiety, and bipolar disorder had a Level II PASARR with a 90‑day approval that expired and later received buspirone for anxiety, but no updated PASARR was found. A third resident with a PASARR limited to a 60‑day approval for suspected intellectual disability remained without a resubmitted screen after the approval period. A fourth resident with depression and anxiety had increased Cymbalta dosing and multiple buspirone orders without a timely new PASARR. The Social Service Director acknowledged that PASARRs should have been resubmitted for these changes and that internal responsibility for monitoring PASARR timeliness was unclear.
The facility failed to maintain complete and accurate clinical records for several residents, including missing and incomplete documentation of oxygen therapy and TB testing. A resident with acute respiratory failure and pneumonia had a hospital discharge indicating use of 2 L O2 via nasal cannula and a written telephone order for oxygen that lacked nurse signature, date, and time and was never entered into the EHR, despite multiple assessments and therapy notes referencing ongoing oxygen use. Transfer documentation during a respiratory arrest left oxygen device and liter flow sections blank. For three other residents, TB testing records were absent, incomplete, or inconsistent, with missing dates and times for when tests were administered and read, and conflicting dates between the clinical record and an immunization report, contrary to the facility’s own documentation guidelines.
A resident with Alzheimer’s disease, dementia, and anxiety was started on Valium and later buspirone for anxiety, agitation, and irritability, with multiple changes in dosing and frequency, without any signed informed consent documented in the clinical record. The resident’s spouse reported she was not asked to sign an informed consent and only received information about the medication from the pharmacy when picking it up. The Social Service Director stated that informed consents were required for all psychotropic medications but did not recognize buspirone as requiring consent due to the absence of a black box icon in their system and relied on nursing staff to notify her of dose changes. Despite a facility policy requiring documentation of discussions about risks and benefits of psychoactive medications, no such documentation or signed consents were present for these medications.
A resident with dementia, depression, muscle weakness, and documented hospital problems of weight loss and malnutrition experienced substantial, ongoing weight loss over several months, dropping from about 181 lbs to 140.7 lbs. Facility weight records showed multiple significant losses, but the admission weight was cancelled as a data entry error without explanation, and there was no documentation that the physician was notified of the initial or subsequent weight changes. Physician notes continued to reference the higher weight or did not address prior losses, and there was no evidence of assessment for significant weight loss. Staff reported the resident required cueing and encouragement to eat, observations showed poor intake and a refused meal without documented alternatives, and the DON acknowledged the resident was not being followed for weight loss despite continued decline, contrary to the facility’s weight management policy requiring MD and family notification.
A resident with depression, muscle weakness, and dementia was kept on continuous bed and chair alarms ordered after a fall, but the orders lacked a related diagnosis, indication for use, and end date. The facility did not complete an initial physical restraint assessment, did not document that less restrictive interventions were tried and failed before using the alarms, and did not perform required quarterly restraint/device reassessments. IDT documentation referenced continuing the alarm but did not address alternatives, and fall assessments omitted any mention of the alarms, while the DON later acknowledged limited documentation and that the alarms did not appear necessary.
A resident with a history of repeated falls and dementia was transferred to the hospital by EMS after being found on the floor with back pain, but there was no documentation that required bed-hold policy information was provided to the resident or the resident’s representative at the time of transfer. Social Services staff reported that such information should be documented when given, yet the transfer note lacked any reference to bed-hold information, and the facility did not have a policy addressing provision of bed-hold information at transfer, resulting in a regulatory deficiency.
A resident with multiple serious mental health diagnoses, including bipolar disorder, PTSD, anxiety, panic disorder, delusional disorder, and dementia, was admitted after an extended psychiatric hospitalization with orders and consent in place for psychiatric services, counseling, and medication management. Despite a PASSAR requirement for individual therapy and care plans calling for psychiatric referrals, counseling, and supportive group or one-on-one therapy, the clinical record showed no documented mental health services over extended periods, and the resident reported not receiving therapy and wishing to attend it. Staff, including a unit manager and the DON, confirmed the resident was not currently being seen by a psychiatric provider or receiving mental health services, and the facility lacked a policy on mental health services.
Surveyors found that medication storage and labeling practices were not followed on two medication carts. An expired bottle of levothyroxine remained in a cart despite being marked as expired. On another cart, a Humalog insulin pen lacked its own pharmacy label and was stored in a bag labeled for a different insulin, and a single dose of amoxicillin/clavulanate was found loose in its manufacturer packaging without a pharmacy label. Staff interviews confirmed that medications removed from the EDK are expected to be labeled by nursing staff and that expired medications should be removed from carts, but these practices were not followed.
Staff failed to follow the facility’s enhanced barrier precautions policy during catheter care for a resident with an indwelling urinary catheter and multiple bladder-related diagnoses. A CNA provided catheter care without wearing a gown, despite a physician’s order for enhanced barrier precautions every shift and a facility policy requiring gowns and gloves for high-contact device care such as urinary catheters. Both the Unit Manager and DON acknowledged that a gown should be used during catheter care, but this was not done during the observed care.
Two residents with severe cognitive impairment were not treated with dignity when one was sprayed in the face with wound cleanser and marked on the forehead by a QMA, and another had his facial hair and eyebrows shaved off without consent. Staff statements and interviews confirmed that these actions were not in line with the residents' preferences or rights, and the residents did not provide permission for these interventions.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, and the facility did not ensure the regimen was free from unnecessary drugs.
A resident with dementia and cognitive deficits exhibited multiple incidents of sexually inappropriate behavior toward staff, which were recorded on handwritten notes but not entered into the electronic medical record as required by facility policy. This resulted in an incomplete and inaccurate clinical record.
A resident with Alzheimer's disease and mobility issues sustained a leg laceration requiring staples during a transfer. The family was not informed until the resident was sent to the hospital, and the on-call physician was not properly notified at the time of the incident, despite documentation suggesting otherwise. The facility's policy requiring physician notification after injury was not followed.
A resident with severe cognitive impairment and mobility issues sustained a laceration requiring staples when two CNAs transferred her to bed without using a gait belt, contrary to facility policy. Instead, the CNAs lifted the resident by her armpits and pants, resulting in her leg rubbing against the bed frame and causing injury. Staff interviews confirmed the required use of gait belts for such transfers, but the policy was not followed.
The facility was found to have insufficient staffing, leading to delayed care and cold meals for residents. A QMA took 57 minutes to assist a resident to the bathroom due to a lack of available staff, resulting in the resident soiling herself. Residents and staff reported long wait times for call lights, late meal service, and cold food. Temperature checks confirmed meals were served below policy standards, attributed to staffing shortages during meal times.
The facility failed to ensure the high temperature dishwasher's thermometer was operational, leading to uncertainty about whether dishware was washed at the correct temperature. Staff continued to use the dishwasher without verifying temperatures, potentially affecting all residents receiving food from the kitchen.
The facility failed to maintain proper infection control practices, with catheter bags touching the floor for two residents and improper PPE use by dental staff. Additionally, an LPN did not perform hand hygiene before and after glove use during a blood sugar test.
A resident with dementia and cognitive impairment was found with a bed and chair alarm without proper re-evaluation or documentation of family consent. Physician's orders for the alarms were in place, but there was no evidence of ongoing monitoring or quarterly reviews by the IDT. Interviews with the ED and DON confirmed the lack of documentation and adherence to facility policy.
The facility failed to conduct timely care plan meetings for two residents, as required by policy. One resident's care plan meetings were not documented between September 2024 and March 2025, while another resident did not have a meeting until March 2025 despite being admitted earlier. The Social Service Designee and DON confirmed the absence of required documentation.
The facility failed to assist two residents with ADLs and follow physician orders. One resident waited 57 minutes for toileting assistance, resulting in soiling due to insufficient staffing. Another resident, with a history of falls, fell while wearing non-skid socks instead of shoes as per physician's orders, leading to a fall during a restroom transfer.
The facility failed to ensure residents with catheters had appropriate physician's orders, affecting three residents. One resident had a catheter without an order, confirmed by an LPN. Another resident required a suprapubic catheter but lacked a current order specifying details. The DON acknowledged the oversight post-readmission. A third resident's catheter order was discontinued, and the DON was unsure why it wasn't active. Facility policy mandates adherence to professional standards and having physician orders for routine care.
The facility failed to adhere to respiratory care protocols for three residents. An oxygen line for a resident was not labeled or stored correctly, and another resident received oxygen without a documented order. Additionally, a third resident's nebulizer equipment was improperly stored, and there was no current order for nebulizer treatments. The facility's policy requires proper labeling and disposal of respiratory equipment.
The facility failed to provide RN coverage for at least 8 consecutive hours in a 24-hour period due to an oversight in scheduling. The weekend RN was on vacation, and the shift was not covered, violating the facility's policy and resulting in a deficiency.
A resident did not receive her prescribed medication, Creon, due to a delay in authorization, despite multiple attempts by the pharmacy to obtain it. The facility also failed to maintain proper narcotic count sheets, with numerous instances of missing signatures from on-coming and off-going staff. These deficiencies indicate lapses in the facility's pharmaceutical services and controlled substance management.
The facility failed to serve food at safe and appetizing temperatures, as observed on the Terrace unit where a chili dog and corn were served below the required temperature. Residents and staff reported ongoing issues with cold food and insufficient staff to assist with meal service, leading to delays and cold meals. The facility's policy required food to be served at 135 to 170 degrees, which was not met.
A resident with cognitive and cardiac conditions was found to have bruising on both shoulders, but unlicensed staff failed to notify a licensed nurse for assessment. The facility's policy required immediate notification and assessment by a licensed nurse, which was not followed, resulting in a deficiency.
A resident with severe cognitive impairment fell from her wheelchair due to the absence of foot pedals during transport, resulting in a subarachnoid hemorrhage and bruising. The facility lacked a wheelchair transfer policy and did not assess the resident's wheelchair needs, contributing to the incident.
Failure to Assess and Address Significant Weight Loss and Poor Intake
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and respond to a resident’s significant weight loss and poor nutritional intake. The resident was admitted with documented problems of weight loss and malnutrition and diagnoses including dementia, major depressive disorder, muscle weakness, muscle wasting and atrophy of both arms, and cognitive communication deficit. Initial records showed a weight of about 181 lbs and a care plan identifying risk of malnutrition with interventions to monitor weights and refer to the dietician for significant weight loss or poor intake. Despite this, subsequent weights showed a decline from 181 lbs in November to 160 lbs in early December, then further decreases over the following months, without consistent documentation that the physician or interdisciplinary team was notified of these changes. Throughout December, January, February, and March, meal intake records showed the resident frequently refused meals or ate less than half, with numerous entries of 0–50% intake and only some meals at 51–75%. Observations by surveyors showed the resident not eating lunch on one day, with CNA charting indicating refusal and no documented replacement meal or alternatives, and on another day eating less than half of lunch. Nursing notes documented that the resident often did not attempt to feed herself and required cueing, encouragement, and feeding assistance. A December dietician recommendation to add house shakes three times daily for weight stability was not followed by a corresponding order in the medical record for December or January, and a later January dietician note recommending house shakes twice daily was not implemented until mid‑February. Weight logs and assessments showed progressive weight loss: 160 lbs on 12/8, 149.3 lbs on 1/4, 146.4 lbs on 1/11, 143.9 lbs on 2/15, and 140.7 lbs on 3/23, amounting to approximately a 22% loss over about four months. There was no documentation that the physician was notified of the significant weight loss, and physician progress notes did not reflect assessment or concern regarding the ongoing decline. A quarterly nutritional risk review in February documented no significant weight loss and no referral to the dietician, despite the documented losses, and the dietician’s weekly nutrition-at-risk report for January did not list the resident. During interviews, an LPN stated the resident needed cueing and encouragement to eat but was not being monitored for weight loss, and the DON acknowledged the facility expected some weight loss after hospitalization but was not following the resident for continued weight loss months after discharge and cessation of diuretics. These actions and omissions resulted in unaddressed, significant weight loss for the resident.
Head Laceration During Incontinence Care Due to Improper Positioning Near Wall Trim
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained safe from accident hazards during incontinence care, resulting in the resident striking her head and sustaining a laceration requiring six staples. The resident had diagnoses including muscle weakness, Alzheimer’s disease, dementia, and muscle wasting and atrophy, and a care plan dated 11/18/25 indicated she required assistance with activities of daily living, including proper positioning while in bed. An MDS assessment dated 1/28/26 documented that the resident required substantial to maximal assistance to roll from back to side and return to back while in bed. On 2/13/26, while a CNA was completing care, the resident was rolled toward the wall and her head was bumped on the wall trim, causing a laceration to the top of her head. Facility documentation of the incident stated that the resident was placed on her back on an inflated low air loss mattress with bolsters, with the bed raised to the CNA’s waist height for incontinent care. As the CNA started to roll the resident to the right side, the resident’s head struck the chair rail/wooden strip on the wall, resulting in a 4.5 cm scalp laceration that required repair with six staples in the emergency room. Witness statements from an LPN and the CNA indicated that the CNA rolled the resident toward the wall and the resident’s head clipped the wooden strip on the wall, with the CNA acknowledging that it was a combination of rolling the resident too far and the inflated bed that caused the resident to roll further and hit the wall trim. The DON and Executive Director both stated that the combination of the inflated low air loss mattress and the CNA rolling the resident too far led to the resident’s head striking the wall trim, and it was noted that the resident could not roll on her own and needed staff assistance to do so.
Improper Puree Preparation and Inadequate Hot Holding Temperatures
Penalty
Summary
The deficiency involves failure to properly prepare pureed foods according to facility policy and standardized recipes, and failure to maintain appropriate hot holding temperatures for multiple menu items. During observation, a cook pureed beef pot roast and carrots for seven residents on pureed diets by adding unmeasured amounts of hot water to the food processor until the desired consistency was reached, then adding a small scoop of juice from the main roasting pan. The Dietary Manager stated that staff used water as a thinning agent during pureeing and then added a small amount of juice afterward, despite the written recipe for beef pot roast directing staff to count and measure portions and to use juice, milk, or broth as needed to achieve the desired consistency. The facility’s pureed food preparation policy required use of standardized recipes, specified that milk, broth, soup, gravy, and margarine be used to thin pureed food instead of water (unless water was mixed with a thickening agent), and required that pureed hot items be prepared while maintaining a temperature above 135°F. The deficiency also includes failure to maintain and verify safe and appetizing food temperatures during meal service. One resident reported that meals in the second-floor dining room were not always hot, and three resident council members reported that food served during meal services was cold. When surveyors requested food temperatures in the second-floor dining room during a lunch service, the staff member present did not have a food thermometer available in the serving area and had to obtain one from the main kitchen, by which time meal service had already started. Temperature checks then showed pureed carrots at 128°F, pureed beef pot roast at 103°F, and hamburgers at 119°F, all below the facility’s policy requirement that hot foods be held at 135°F or above throughout service. The Dietary Manager confirmed that these items were not at appropriate holding temperatures and could not be served, contrary to the facility’s food temperature policy and applicable Indiana Administrative Code requirements.
Failure to Resubmit PASARR for Residents With Mental Health Changes and Psychotropic Medication Adjustments
Penalty
Summary
The deficiency involves the facility’s failure to ensure required Preadmission Screening and Resident Review (PASARR) updates and resubmissions were completed when residents experienced changes in mental health status, psychotropic medication use, or when short-term approvals expired. For one resident with Alzheimer’s disease and dementia, the hospital discharge documentation did not list anxiety or psychotropic medications, and the initial Level I PASARR identified only dementia with a requirement for a Level II evaluation and resubmission if changes occurred. After admission, this resident developed significant new behaviors, including attempts to force open a fire exit door, yelling, cursing, threatening to hit staff, and physically hitting and pushing staff. In response, the physician ordered multiple psychotropic medications, including Valium and buspirone, for anxiety and agitation, but no new PASARR Level I screen reflecting the new anxiety diagnosis and psychotropic medications was found in the medical record. Another resident with major depressive disorder, anxiety disorder, and bipolar disorder had a Level I PASARR that identified Seroquel use and required a Level II evaluation. The Level II PASARR granted a 90‑day short‑term approval, with a specified end date, but there was no evidence in the clinical record that a new Level II PASARR was completed before the approval period ended. During this time, a new physician’s order was written for buspirone for anxiety, yet no PASARR documentation including this new psychotropic medication was located. A third resident, with diagnoses including mild cognitive impairment, hypertension, and type 2 diabetes, had a Level I PASARR with a 60‑day approval related to a suspected or confirmed intellectual disability, which required a new Level I screen if the resident remained beyond the approved days. The record did not contain a resubmitted PASARR after the 60‑day approval period expired. For a fourth resident with severe recurrent major depressive disorder, anxiety disorder, and chronic pain, the PASARR documented depression, anxiety, and treatment with Cymbalta. Subsequent physician orders showed an increased Cymbalta dosage and multiple changes in buspirone dosing over time, with buspirone ultimately remaining on the scheduled medication list along with Cymbalta. Despite these changes in psychotropic medication regimen, there was no evidence of a timely new PASARR screen when the new medication was started or when the regimen changed. Interviews with the Social Service Director confirmed that new PASARR submissions were expected when psychotropic medications were added, when short‑term approvals were ending, or when new mental health diagnoses were made, and acknowledged that the affected residents’ PASARRs were not resubmitted as required and that responsibility for timely PASARR submission had not been clearly established within the facility.
Incomplete Clinical Records for Oxygen Therapy and TB Testing
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for multiple residents, including missing and incomplete documentation of oxygen therapy and tuberculosis (TB) testing. For one resident with acute respiratory failure, heart failure, RSV pneumonia, pneumonia of the left lower lobe, and acute hypoxic respiratory failure, the hospital discharge paperwork indicated the resident was using 2 L of oxygen via nasal cannula at discharge. A written physician telephone order dated the same day directed oxygen at 2 L/min as needed for shortness of breath, but this order lacked the nurse’s signature, date, and time of receipt and was never entered into the electronic health record. Although the admission assessment, post‑admission assessment, care plan, and occupational therapy evaluation all referenced oxygen use at 2 L via nasal cannula, the electronic record contained only intermittent oxygen saturation entries, some on room air, and transfer documentation related to a later respiratory arrest left the respiratory device and oxygen use sections blank. Staff interviews confirmed that an oxygen order should have been present and that the DON could not explain why it was missing, while the unit manager gave conflicting information about whether the resident was discharged with an oxygen order. The facility also failed to maintain complete TB testing documentation for several residents. One resident’s electronic medical record initially contained no TB testing information until it was added later, and even then the record did not show the times the tests were administered or read, nor the dates the tests were read. The ADON/Infection Preventionist stated that TB tests must be read within 48–72 hours and that the medical record should include the date and time the tests were given and read, but this information was not present in the record. For two additional residents, TB testing records were incomplete or inconsistent. One resident’s testing record showed TB tests given on two dates at “midnight,” with no indication of the date or time either test was read. Another resident’s admission TB tests were documented as given on two separate dates, but the clinical record did not include the date or time either test was read. An immunization report later provided showed different TB test dates for this resident, and still did not include the date or time the tests were read. The facility did not provide an admission TB policy, and the existing nursing documentation guideline emphasized being definite, using quantifiable data, and timely documentation, stating that if something was not written down, it was not done.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to initiating and adjusting psychotropic medications for one resident. After admission, the resident experienced increased anger, and the neurologist ordered Valium, an antianxiety medication. The resident’s wife reported that she picked up the Valium prescription from the pharmacy and brought it to the facility, and that the only person who asked if she had any questions about the medication was the pharmacist. She stated she did not sign any informed consent for the use of Valium. Review of the clinical record showed diagnoses including Alzheimer’s disease, dementia, and anxiety. Record review revealed multiple physician orders for Valium and buspirone for anxiety, agitation, irritability, and dementia-related behaviors over several weeks, including changes in frequency and dosing, without any signed informed consent forms in the clinical record for either medication. The Social Service Director stated that signed informed consents were required for all psychotropic medications but acknowledged that buspirone did not have a black box icon in their system, so she did not realize it required informed consent. She also indicated that nursing staff were expected to notify her when psychotropic dosages increased so that new consents could be obtained. The DON stated the facility followed all state and federal regulations. The facility’s policy on behavioral management required documentation of discussions with the resident or responsible party regarding risks versus benefits of psychoactive medications, including any black box warnings, but such documentation and signed consents were not found for this resident’s Valium and buspirone orders.
Failure to Notify Physician of Significant Ongoing Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a resident’s significant and ongoing weight loss and to document this change as required. The resident had diagnoses including dementia, major depressive disorder, muscle weakness, muscle wasting and atrophy of both arms, and a cognitive communication deficit. A hospital discharge document listed weight loss and malnutrition as ongoing problems, with a most recent hospital weight of 181 lbs, and the facility’s weight log on admission showed 180.6 lbs. On 12/8, the resident’s weight was documented as 160 lbs, representing an 11.41% loss from 180.6 lbs, but the admission weight was later cancelled as a data entry error by the dietician without a progress note explaining why. There was no documentation that the physician was notified of this weight change, and a physician progress note dated several days later still listed the resident’s weight as 180.6 lbs with no indication of awareness of the 160-lb weight. Subsequent weights showed continued decline: 149.3 lbs in early January, 146.4 lbs a week later, 143.9 lbs in mid-February, and 140.7 lbs in late March, amounting to approximately a 22% loss from the documented 181 lbs over about four months. Physician progress notes in January and March did not indicate that the facility had informed the physician of the resident’s significant weight loss or that the resident had been assessed for it. Nursing staff reported the resident needed cueing and encouragement to eat and that she was not being monitored for weight loss. Observations showed the resident refused one lunch without documented alternatives offered and ate less than half of another lunch. The DON stated the facility expected some weight loss after hospitalization for sepsis and fluid/diuretic use and acknowledged the facility was not following the resident for weight loss even as it continued for months, and there was no documentation that the physician had been notified and evaluated the resident for this ongoing significant weight loss, contrary to the facility’s weight management policy requiring MD and family notification.
Failure to Assess and Justify Ongoing Use of Bed and Chair Alarms as Physical Restraints
Penalty
Summary
Surveyors found that a resident with diagnoses including major depressive disorder, muscle weakness, and dementia was subjected to ongoing use of a bed alarm and a pull (chair) alarm without proper assessment, documentation, or physician orders that met regulatory and facility policy requirements. The resident was observed with a pull alarm attached to her and her wheelchair, and a device connected to her bed. Physician orders dated 9/24/25 directed use of a pull alarm when in the wheelchair and a bed alarm when in bed every shift, but these orders lacked a related diagnosis or indication for use and had indefinite end dates. The alarms were initiated after a fall on 9/24/25, and the resident had no documented falls for more than seven months afterward, yet the alarms continued to be used. The facility’s documentation did not include an initial physical restraint assessment, did not show that least restrictive interventions were attempted and failed before initiating the alarms, and did not contain quarterly physical restraint/device reassessments as required by facility policy. An IDT note from 9/25/25 documented that the team met after the fall, noted placement of a pull alarm as an immediate intervention, and recommended continuing the alarm with routine evaluations, but did not discuss which less restrictive alternatives had been tried first. Fall assessments later provided by the facility did not mention the alarm devices. During interviews, the DON acknowledged there was little documentation about the devices, could not produce reassessments that addressed the alarms, and later stated it did not appear the resident needed the bed and chair alarms, while also asserting that the facility followed all federal and state regulations.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required bed-hold policy information to a resident or the resident’s representative at the time of transfer to the hospital. Resident 78, who had diagnoses including repeated falls, history of falling, and dementia, was found on the floor complaining of back pain and was transferred to the hospital by EMS, as documented in a progress note dated 6/25/25. Review of the clinical record showed no indication that bed-hold policy information was given to the resident or the resident’s representative at the time of this transfer. In interviews, Social Services staff stated that staff are expected to document when bed-hold policy information is provided during a hospital transfer and confirmed that the transfer note contained no such documentation. It was also determined that the facility did not have a policy addressing the provision of bed-hold information to residents and their representatives at the time of transfer, in violation of 410 IAC 16.2-3.1-12(a)(25)(A), 410 IAC 16.2-3.1-12(a)(25)(B), and 410 IAC 16.2-3.1-12(a)(26).
Failure to Provide Required Mental Health Services to a Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary mental health services to a resident with multiple serious mental health diagnoses. The resident, who had bipolar disorder, conversion disorder, anxiety disorder, PTSD, panic disorder, delusional disorder, and dementia, was admitted after an extended inpatient psychiatric hospital stay. Initial physician orders dated 9/5/25 authorized psychiatric services, counseling, and medication management, and consent for behavioral health services was obtained from the resident’s next of kin. A care plan initiated on 9/8/25 identified anxiety with an intervention of psychiatric services per order. However, a physician’s order allowing evaluation and treatment for psychology and psychiatry services was discontinued on 10/12/25, and a level of care document dated 11/17/25 showed zero days of psychological therapy. A PASSAR dated 11/19/25 required the facility to provide mental health services such as individual therapy. The clinical record contained no documentation of mental health services from 9/5/25 to 1/11/26. On 1/12/26, a psychiatric telehealth visit determined the resident was eligible for behavioral health integration and psychiatric collaborative care management, and the resident consented to enroll. Care plans dated 2/6/26 documented PTSD, use of antipsychotic medications, and a history of severe, persistent mental illness, with interventions to refer the resident to psychiatric services, appropriate individual counseling or other mental health programs, and to involve the resident in supportive group or one-on-one counseling. A psychotropic drug evaluation dated 3/5/26 indicated the resident was receiving psychiatric services, yet the clinical record again lacked documentation of mental health services from 1/13/26 to 3/26/26. A quarterly social service interview on 3/10/26 recorded moderate depression symptoms with a PHQ-9 score of 13. During observations and interviews, the resident reported not receiving mental health services, stated she would like to attend therapy, and said staff had not asked if she wanted therapy. Staff interviews confirmed the resident was not currently being seen by a psychiatric provider or receiving mental health services, and the DON stated the facility did not have a policy regarding mental health services.
Expired and Unlabeled Medications Found on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices during review of two of three medication carts. On the orchard hall medication cart, a prescription bottle of levothyroxine 200 mg was found in a large drawer with several small round pills remaining. The pharmacy label on the bottle showed a discard-after date of 1/4/25 and had “expired” written in pink ink, yet the medication remained in the cart instead of being removed from stock. When interviewed, an LPN stated she believed expired medications should be taken out of the medication cart. On the garden hall medication cart, surveyors found additional labeling and storage issues. In the first large drawer, a Humalog insulin pen was stored in a zip-lock bag with another lispro insulin pen; the bag contained a pharmacy label for the lispro pen, but the Humalog pen itself had no pharmacy label. In the fourth large drawer, a single dose of amoxicillin/clavulanate potassium in sealed manufacturer packaging was found loose in the drawer without a pharmacy label. Unit managers explained that the Humalog pen and the amoxicillin/clavulanate dose had been removed from the emergency drug kit (EDK), which does not provide pharmacy labels, and that nurses are expected to label such medications with the resident’s name, room number, and physician’s name at the time of removal. Another LPN indicated that if a pharmacy label comes off, the nurse should write the resident’s last name, provider’s name, and “see MAR” on the packaging. The facility’s medication storage policy requires that outdated drugs be immediately withdrawn from stock and that medications and biologicals be stored safely, securely, and properly.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The deficiency involves staff failure to follow the facility’s infection prevention and control program, specifically its enhanced barrier precautions policy, during catheter care for one resident. During an observation of catheter care, a CNA performed the care without wearing a gown, while a Unit Manager was present in the room. The resident involved had diagnoses including benign neoplasm of the bladder, neuromuscular dysfunction of the bladder, and a stroke affecting the left non-dominant side. The resident’s clinical record contained a physician’s order, dated 12/17/25, for enhanced barrier precautions every shift for the indwelling catheter. Interviews confirmed that facility leadership expected staff to wear a gown during catheter care. The Unit Manager stated that a gown should be worn when performing catheter care, and the DON also indicated that staff should use a gown when performing catheter care. The facility’s written policy on Enhanced Barrier Precautions, reviewed December 2022, required the use of gowns and gloves during high-contact resident care activities, including device care such as urinary catheters, to prevent the spread of multidrug-resistant organisms. Despite this policy and the physician’s order, the CNA did not wear a gown while providing catheter care to the resident.
Failure to Honor Resident Dignity and Personal Preferences
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity, as required by resident rights regulations. In the first instance, a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, was subjected to inappropriate actions by a Qualified Medication Aide (QMA). The QMA sprayed the resident's hair and face with wound cleanser and then marked the resident's forehead with a marker while at the nurse's station. Multiple staff members witnessed the incident, and statements confirmed that the resident's face was wiped off after being sprayed and the marker was removed with a wet wipe. The resident was known to require maximal assistance with personal hygiene and was at risk for psychosocial distress. In the second instance, another resident with severe cognitive impairment and a history of Parkinson's disease, diabetes, and dementia, had his facial hair and eyebrows shaved off without consent. Staff statements indicated that a QMA shaved the resident's eyebrows and facial hair, later claiming it was accidental and that she was attempting to match the eyebrows after shaving one off. The resident's legal guardian and daughter confirmed that the resident always preferred to have facial hair and had not requested the removal of his beard, mustache, or eyebrows. The resident himself stated he did not give permission for the shaving. Both incidents were corroborated by staff witness statements and interviews, as well as documentation in the residents' clinical records. The actions taken by staff in both cases were not aligned with the residents' preferences or rights to dignity and self-determination, as outlined in the facility's own resident rights documentation.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Document Resident Behaviors in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's inappropriate sexual behaviors were documented in the electronic medical record in accordance with accepted professional standards. For one resident with diagnoses including dementia, cognitive communication deficit, and muscle weakness, multiple incidents of sexually inappropriate behavior toward staff were recorded on handwritten 'Behavior Sheets.' These incidents included grabbing, inappropriate touching, and attempts to kiss staff members during care. The handwritten notes described the behaviors, staff interventions, and outcomes, but were not included in the resident's official electronic medical record. The Executive Director confirmed during interview that such behaviors should be documented in the electronic medical record's progress notes. The facility's policy also required documentation of behavioral incidents in the clinical record, including details such as time, causative factors, actual behavior, interventions, and outcomes. However, the handwritten notes were only provided after the survey began and were not part of the resident's official medical record, resulting in an incomplete and inaccurate clinical record for the resident.
Failure to Notify Physician After Resident Injury
Penalty
Summary
The facility failed to notify the physician when a resident sustained an injury during a transfer. Specifically, a resident with diagnoses including Alzheimer's disease, unsteadiness on feet, and muscle weakness, suffered a laceration on the lower left leg that required staples. The family was not notified until the resident was sent to the hospital, and there was confusion regarding whether the on-call physician had been contacted at the time of the incident. Documentation by the LPN indicated the on-call physician was notified, but the nurse practitioner later confirmed that the on-call provider was not actually informed, and no notes were received regarding the incident. Interviews revealed that the LPN used her personal cell phone to attempt notification, citing difficulty accessing the facility's designated device for contacting providers. The nurse practitioner was unaware of the incident until informed by the day shift nurse, and questioned why the resident was not sent to the hospital immediately. The facility's policy requires notification of the attending physician for any accident or incident resulting in injury, but this was not followed in this case, as confirmed by the Director of Nursing during the exit conference.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, unsteadiness on feet, and muscle weakness, who was severely cognitively impaired and required substantial to maximum assistance for transfers, sustained a laceration during a transfer to bed. The incident happened when two CNAs transferred the resident by holding her under the armpits and using the waist of her pants, rather than utilizing a gait belt as required by facility policy. The resident's leg rubbed against the bed frame, resulting in a wound that required hospital treatment and staples. Observations confirmed the wound and that the bed frame did not have any sharp or protruding edges. Interviews with staff revealed that the use of a gait belt was the facility's policy for such transfers, but the CNAs involved had not followed this procedure and one was unaware of the policy. The DON confirmed that a two-person transfer with a gait belt was the appropriate method for this resident. The facility did not have a step-by-step transfer procedure, and the policy on gait belts emphasized their use for safety during transfers. The failure to use the gait belt and follow proper transfer procedures directly led to the resident's injury.
Inadequate Staffing Leads to Delayed Care and Cold Meals
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of its residents, as evidenced by multiple observations and interviews. A Qualified Medication Aide (QMA) was observed taking 57 minutes to assist a resident to the bathroom due to a lack of available staff. The resident was found to have soiled herself during the wait. Interviews with the QMA and other staff members revealed that staffing was insufficient, particularly in certain halls, leading to delays in care and completion of tasks. Resident council meeting minutes and interviews with residents further highlighted the staffing issues. Residents reported long wait times for call lights to be answered, late meal service, and cold food. The resident council had previously noted these issues, indicating that they were ongoing concerns. Additionally, a facility concern form from a family member pointed out issues with cleanliness and personal care, suggesting that staffing shortages were affecting multiple aspects of resident care. Temperature checks of meal trays revealed that food was being served at temperatures below the facility's policy standards, which was attributed to a lack of staff to distribute trays promptly. Interviews with staff and family members consistently pointed to a shortage of aides, particularly during meal times and on heavier care halls. The facility's own assessment tool indicated a need to determine necessary resources for resident care, yet the staffing levels remained inadequate, affecting the quality of care provided to all 88 residents.
Dishwasher Temperature Gauge Malfunction
Penalty
Summary
The facility failed to ensure the proper functioning of the high temperature dishwasher's thermometer, which is essential for verifying that dishware is washed at the correct temperature. During observations and interviews, it was noted that the wash cycle thermometer on the dishwasher was not operational. Staff members, including those responsible for running the dishwasher and the kitchen manager, were unaware of how to gauge the temperature without the working thermometer. Despite the broken gauge, staff continued to wash dishes without verifying the temperature, which is a critical step in ensuring the cleanliness and safety of dishware. The maintenance staff confirmed that the temperature gauge was broken, and there was no alternative method in place to measure the temperature. The facility's dishwasher manual specifies that the wash temperature should be 155 degrees Fahrenheit and the rinse temperature should be 180 degrees Fahrenheit. However, due to the broken thermometer, these temperatures could not be confirmed. This deficiency had the potential to affect all 88 residents who received food from the kitchen, as the cleanliness of the dishware could not be assured.
Infection Control Deficiencies in Catheter Management and PPE Use
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple observations of catheter bags touching the floor. Resident 43 was observed in the hallway with his catheter bag lying on the ground, unnoticed by several staff members who walked by. The resident's clinical record indicated a diagnosis of stage 4 chronic kidney disease and a physician's order for a urinary catheter. Similarly, Resident 56 was observed with his catheter drainage bag touching the floor on multiple occasions. The resident's care plan required the catheter drainage bag to be below the waist and covered, yet this was not adhered to. Additionally, infection control lapses were noted with Dental Staff 8, who was observed wearing PPE in the common area hallway and entering rooms without changing gowns. This practice was contrary to the facility's guidelines, which did not cover walking in halls/common areas in PPE. The staff member indicated she was under the impression that PPE should always be worn, and Corporate Support Nurse 1 confirmed that dental staff should not enter residents' rooms. Furthermore, LPN 5 was observed failing to perform hand hygiene before and after glove use while conducting a blood sugar test for a resident. The LPN retrieved gloves from a restroom, assisted the resident, and then returned to the medication cart without washing hands or using an alcohol-based hand rub. The Director of Nursing later confirmed that hand hygiene should be performed before and after glove use, as per the facility's hand hygiene policy.
Failure to Re-evaluate and Document Use of Alarms for Resident
Penalty
Summary
The facility failed to ensure the need for a bed and chair alarm was re-evaluated and ongoing monitoring was documented for a resident reviewed for physical restraints. The resident, who had diagnoses including dementia and cognitive impairment, was observed with a bed alarm and a chair alarm. Physician's orders indicated the use of these alarms for fall prevention, but there was no documentation in the Electronic Health Record (EHR) about monitoring or reevaluating the alarms. Additionally, there was no documentation indicating that the family agreed to the use of the alarms prior to their placement, nor was there evidence that the Interdisciplinary Team (IDT) reviewed the sensors quarterly. Interviews with the Executive Director (ED) and the Director of Nursing (DON) revealed that there should have been documentation of family education and permission for the use of alarms. The care plan was revised to reflect the family's preference for the use of sensor alarms, but this was not documented until after the surveyor's inquiry. The facility's policy required family agreement for alarm placement and quarterly reviews by the IDT, which were not adhered to in this case.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were held quarterly and timely upon admission for two residents. For Resident 12, the clinical record review revealed that care plan notes were documented in September 2024 and March 2025, but there was no documentation of a care plan meeting between these dates. The Social Service Designee confirmed the absence of documentation for a care plan meeting during this period, despite the requirement for quarterly meetings. For Resident 30, the resident reported not having a care plan meeting until March 2025, although she was admitted earlier. The clinical record review showed no documentation of a care plan meeting in February, as initially thought by the Social Service Designee. The Director of Nursing confirmed the lack of documentation for the care plan meetings, indicating they were not completed. The facility's policy requires that comprehensive care plans be reviewed and updated quarterly, which was not adhered to in these cases.
Failure to Assist with ADLs and Follow Physician Orders
Penalty
Summary
The facility failed to provide timely assistance to residents who were unable to perform activities of daily living (ADL) independently. Resident 187, who required a two-person assist for toileting due to conditions such as dementia and a history of falls, waited 57 minutes to be taken to the bathroom after a call light was activated by the family. During this time, the resident soiled her incontinence brief. The delay was attributed to insufficient staffing, as indicated by the Qualified Medication Aide (QMA) who responded to the call light. The resident's care plan required staff to assist with toileting as needed to maintain cleanliness and dryness, but this was not adhered to due to staffing constraints. In another incident, Resident 237, who had a physician's order to always wear shoes when out of bed due to gait abnormalities and a history of falls, was found wearing non-skid socks during a transfer to the restroom. This non-compliance with the physician's order resulted in a fall when the resident slipped in urine. The Director of Nursing confirmed that the resident should have been wearing shoes at the time of the fall, as per the physician's directive. The facility's failure to follow the physician's order for footwear during transfers contributed to the resident's fall.
Lack of Physician Orders for Catheter Use in Residents
Penalty
Summary
The facility failed to ensure that residents with catheters had appropriate physician's orders in place, affecting three out of four residents reviewed for catheter use. Resident 59 was observed with a catheter bag draining to gravity, but upon review, it was found that there was no physician's order for the indwelling catheter. LPN 6 confirmed that a physician's order was necessary, but Resident 59 did not have one. Similarly, Resident 56, who required a suprapubic catheter due to untreatable urinary retention and chronic obstruction, did not have a current physician's order specifying the type and size of the catheter and the indication for its use. The Director of Nursing (DON) acknowledged that the order was not completed after the resident's last readmission. Resident 10 was also found to have a urinary catheter without a current physician's order. The resident's care plan indicated the need for a suprapubic catheter due to obstructive and reflux uropathy, but the last catheter order had been discontinued months prior. The DON was unsure why the catheter order was not active, noting that the unit manager was responsible for ensuring orders were placed upon a resident's return from discharge. The facility's policy required adherence to professional standards and infection prevention techniques, as well as having physician orders for routine care to maintain or improve residents' functional abilities.
Deficiencies in Respiratory Care Protocols
Penalty
Summary
The facility failed to provide proper respiratory care for three residents by not adhering to protocols for oxygen line labeling, storage, and order documentation. Resident 59's oxygen line was not labeled with the date it was put into use, and it was not stored in a bag when not in use. An LPN later dated the tubing, but it was still improperly stored. Resident 140 was observed receiving oxygen without a documented order for its use, which was acknowledged by the Executive Director as a requirement. Resident 71 had a nebulizer mask and mouthpiece that were not stored correctly, as they were left unbagged on the bedside table and nebulizer machine. Although the resident had been given a nebulizer treatment for shortness of breath, there was no current order for nebulizer treatments in the clinical record. The Director of Nursing indicated that the facility's policy on oxygen therapy, which includes nebulizer equipment, requires disposable masks, cannulas, and tubing to be discarded after use, and tubing to be labeled with the date, time, and initials of the individual who changed it.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours in a 24-hour period on one of the 14 days reviewed. Specifically, on March 2, 2025, the facility's daily nursing staff schedule indicated that there was no RN present for any shift throughout the day. This lapse in RN coverage was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the absence of an RN was due to an oversight when filling an open shift. The weekend option RN, who typically worked on that day, was on vacation, and the shift was not adequately covered. The facility's policy, titled 'Registered Nurse Coverage,' mandates that RN services be provided for at least 8 consecutive hours each day. The policy also requires that if there is a potential gap in RN coverage, the DON and the Administrator must be informed immediately to implement incentives to ensure compliance. However, on the day in question, this policy was not adhered to, resulting in a deficiency in RN coverage as required by regulations.
Deficiencies in Pharmaceutical Services and Narcotic Management
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident, identified as Resident 71, who was not receiving her prescribed medication, Creon, necessary for digestion due to pancreatic cancer. Despite a physician's order dated 2/20/25, the medication was not administered as required with meals and snacks. The Medication and Treatment Record (MAR/TAR) showed multiple instances where the medication was either not given or marked as refused without proper documentation in the nursing notes. Interviews revealed that the resident did not refuse the medication, and the delay was due to a lack of authorization from the facility, which was only approved on 3/11/25 after multiple attempts by the pharmacy to obtain it. Additionally, the facility failed to maintain proper narcotic count sheets, as observed in four different narcotic log books. There were numerous instances where the on-coming and off-going staff did not sign the narcotic logs, which is a critical procedure to ensure the accountability and security of controlled substances. This was confirmed through observations and interviews with staff members, who acknowledged the requirement to sign off the narcotic sheets at the beginning and end of their shifts. The facility's policies on pharmacy services and controlled substances, dated 3/2023, were not adhered to, as evidenced by the lack of proper documentation and authorization for medication dispensing and the failure to maintain accurate narcotic count sheets. These deficiencies highlight significant lapses in the facility's pharmaceutical services and controlled substance management, impacting the care and safety of the residents.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and appetizing temperatures, as evidenced by observations and interviews. During an interview, Resident 66 and Resident 10 both indicated that the food was sometimes served cold. An observation on the Terrace unit revealed that a room tray containing a chili dog and corn was about to be delivered with temperatures of 110 degrees and 85 degrees, respectively, which were below the required 145 degrees as indicated by Kitchen Manager 16. The resident council meeting minutes from March 2024 and January 2025 also highlighted ongoing issues with cold food and inadequate serving times. Interviews with staff and residents further revealed systemic issues contributing to the deficiency. Residents and staff reported that there was insufficient staff to assist with passing out room trays, leading to delays and cold food. An anonymous staff member expressed that passing out meal trays was the most stressful part of the day, and leadership rarely assisted. Additionally, residents receiving room trays were rarely checked on during their meals. The facility's policy on serving food and beverages, dated 2017, specified that foods should be served at temperatures between 135 to 170 degrees, which was not adhered to in this instance.
Failure to Notify Licensed Staff of Resident's Skin Changes
Penalty
Summary
The facility failed to ensure that unlicensed staff notified a licensed staff member when a resident was found to have discolored areas on both shoulders. The clinical record for the resident, who had diagnoses including cognitive communication deficiency, atrial fibrillation, and dementia, showed that red bruising was noted on both shoulders by a QMA on a shower sheet. However, there was no documentation of a nurse's assessment or any follow-up on the bruising. The Medication Administration Record and Treatment Administration Record did not include an order to monitor the bruising, and no nurse's note was found in the progress notes regarding the bruising. Interviews with facility staff revealed that the QMA and CNAs were expected to inform a nurse if a new skin area was observed, and the nurse was responsible for assessing, measuring, and documenting the area. The Director of Nursing confirmed that there was no initial assessment by a licensed nurse for the bruising found on the resident's shoulders. The facility's policy stated that only licensed nurses could assess the skin, and caregivers were required to notify a nurse immediately if they observed a change in a resident's skin. However, this protocol was not followed, leading to a deficiency in care.
Failure to Ensure Wheelchair Safety Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, who was severely cognitively impaired and had memory problems, had the necessary assistive devices in place to prevent a fall from her wheelchair. This deficiency resulted in the resident falling forward from her wheelchair and sustaining a subarachnoid hemorrhage, along with facial, neck, and shoulder bruising, which required hospitalization. The root cause of the fall was identified as the absence of foot pedals on the wheelchair during transport by a CNA. The resident, who had a history of vascular dementia with psychotic disturbances and difficulty in walking, was being transported in her wheelchair without foot pedals, which led to her fall. The facility's investigation revealed that the CNA was in a hurry to get the resident weighed and to the dining room for lunch, which contributed to the oversight of not using foot pedals. The resident had previously broken her hip and was unable to propel herself with her feet, contrary to the CNA's assumption. The facility lacked a wheelchair transfer policy and did not have documentation showing that the resident's wheelchair and safety needs were effectively assessed prior to the incident. The facility's policy indicated that Physical Therapy was responsible for ensuring the appropriate fit and application of additional appliances for wheelchairs, but there was no evidence of such an assessment for the resident. This oversight in ensuring proper wheelchair safety measures directly contributed to the resident's fall and subsequent injuries.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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