Westpark A Waters Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 1316 N Tibbs Ave, Indianapolis, Indiana 46222
- CMS Provider Number
- 155389
- Inspections on file
- 29
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Westpark A Waters Community during CMS and state inspections, most recent first.
A resident with GERD was found to have a chewable calcium carbonate tablet left unattended at bedside without an assessment or documentation supporting their ability to safely self-administer medication, contrary to facility policy requiring interdisciplinary evaluation and physician order.
Three residents did not receive scheduled doses of controlled medications, including pain and anti-anxiety drugs, due to the facility's failure to timely reorder and obtain prescriptions from the pharmacy. Missed doses were documented for residents with significant pain and psychiatric needs, and staff interviews confirmed delays in medication reordering and supply.
Multiple residents reported and were observed experiencing long delays in call light response, lack of engagement from staff and management, and disrespectful or dismissive behavior from staff, including refusal to assist with personal hygiene and derogatory remarks. Staff were also observed failing to follow privacy protocols and not providing timely care, resulting in residents feeling neglected and devalued.
Staff were unable to administer all prescribed medications to three residents due to unavailability of medications in the medication cart, Cubex, and overflow cart, resulting in a medication error rate of 29%. The DON and an LPN confirmed that pharmacy delivery delays were a recurring problem, causing residents to miss multiple essential medications during observed medication passes.
Twelve residents, many with complex medical conditions, reported that meals were repetitive, poorly seasoned, sometimes cold, and served in small portions. Residents described food as unappetizing, with some noting spoiled smells, tough meat, and overcooked or flavorless items. Direct observation confirmed issues with meal presentation and preparation.
A resident with dementia, congestive heart failure, and a history of myocardial infarction was discharged to another LTC facility without proper documentation in the EHR, including the absence of a physician's discharge order and required notifications, as mandated by facility policy.
A resident with paraplegia and major depressive disorder, who was cognitively intact, was not invited to any care plan meetings after admission, with only one meeting documented. Although a quarterly care plan meeting was scheduled, it was cancelled and not rescheduled, and the facility could not provide a reason for this. Facility policy requires quarterly review and resident notification for care plan meetings, but these steps were not followed.
A resident with multiple health conditions and limited mobility was not provided timely perineal care despite being care planned for assistance. The resident reported difficulty cleaning himself after a bowel movement and stated that staff refused to help, resulting in prolonged discomfort. Staff failed to respond promptly to his requests, and a QMA indicated the resident should clean himself, contrary to the care plan and facility policy.
Two residents did not receive medications as ordered: one received cardiac medications despite vital signs outside prescribed parameters, and another missed multiple doses of both fast-acting and long-acting insulin without documented reasons. The DON and Nurse Consultant confirmed these deviations from physician orders and facility policy.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and lack of availability in the facility's medication dispensing system. One resident missed several doses of trazodone for insomnia, while another did not receive a scopolamine patch for nausea as scheduled. These lapses occurred despite facility policy requiring timely pharmacy services.
A resident with a history of substance use and depression was given half of a 10 mg oxycodone tablet when the ordered 5 mg dose was unavailable. An LPN saved the remaining half tablet in the narcotics lock box instead of destroying it in the presence of two licensed staff, as required by policy. Documentation was incomplete, and the remaining half tablet was later administered by another staff member.
A resident with severe cognitive impairment, as documented in the clinical record and MDS assessment, electronically signed a binding arbitration agreement during admission. Facility staff reported that admission paperwork, including the arbitration agreement, could be signed electronically by residents even when no guardian or family member was present, leading to the agreement being signed without proper assessment of the resident's capacity.
Staff failed to follow infection control protocols during medication administration, including not performing hand hygiene before resident contact, not donning new gloves before handling medications, touching medications with bare hands, administering medications after they were dropped on a cart, and not disinfecting insulin pen hubs prior to use for three residents. Facility policies requiring hand hygiene and proper glove use were not followed.
The facility failed to maintain the floors in good repair, affecting all 39 residents. An environmental tour revealed cracks, broken tiles, and improperly installed vinyl flooring in various areas. Interviews with residents and staff confirmed the flooring issues, with descriptions of bumpy and uneven surfaces. The facility's leadership acknowledged the problems, attributing them to the building's age and improper installation.
The facility failed to ensure food items were stored closed and labeled with open dates, potentially affecting 38 of 39 residents. Several food items in the refrigerators and freezers were found opened and not labeled with open dates, contrary to the facility's food storage and date marking policies.
The facility failed to immediately notify the Administrator of abuse allegations for two residents. One resident reported being physically abused by another resident, and another reported verbal abuse by a roommate. Both incidents were not promptly reported to the Administrator, violating the facility's abuse prevention policy.
A facility failed to provide scheduled showers as per a resident's care plan and preferences. Despite the resident's cognitive intactness and preference for showers, records showed inconsistencies with the care plan, indicating a failure to adhere to the resident's needs and preferences.
The facility failed to administer medications and monitor conditions as ordered for three residents. One resident did not receive Haloperidol as per the Psyche NP's recommendation, another resident's elevated blood sugar levels were not rechecked as required, and a third resident's blood pressure was not monitored before administering metoprolol.
A resident with type 2 diabetes mellitus, who had signed a consent for vision services, reported vision problems and a desire to see an eye doctor. Despite vision services being available, the resident was not seen during the scheduled visit. The Social Services Director confirmed the consent but cited delays with the vision service provider.
The facility failed to provide dental services for two residents with type 2 diabetes mellitus, despite signed consents and observed dental issues. The Social Services Director was unaware of one resident's dental problems and had not followed up on the other's pending payer source status.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident with a diagnosis of gastro-esophageal reflux disease (GERD) was observed to have a medication cup containing a pink tablet, identified as a chewable calcium carbonate tablet (TUMS), left unattended on their bedside table. The resident was not present in the room during the observations, nor was any staff member. The medication was ordered to be administered three times daily, but there was no documentation or assessment indicating that the resident had been evaluated for the ability to safely self-administer medications. The Director of Nursing confirmed that no self-administration assessment had been conducted for this resident and acknowledged that medications should not have been left at the bedside. Facility policy requires an interdisciplinary assessment and physician order before allowing residents to self-administer and store medications in their rooms, but this process was not followed in this instance.
Failure to Timely Obtain and Administer Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were obtained and available for administration to three residents as ordered by their physicians. For one resident with a history of GERD and recent bilateral leg fractures, hydrocodone-acetaminophen was not available for several scheduled doses, resulting in missed pain medication. The resident reported that the facility often ran out of her pain medication, and the DON confirmed that staff were not reordering medications in a timely manner when supplies were low. Another resident with chronic pain due to migraine and sciatica missed multiple scheduled doses of oxycodone, with documentation showing several instances where the medication was not administered as ordered. The resident reported severe pain during these periods without medication. A third resident, with diagnoses including anxiety and schizoaffective disorder, did not receive scheduled doses of clonazepam on multiple occasions due to delays in reordering and waiting for a new prescription. The DON acknowledged that the medication had not been reordered timely, and the facility's policy required a valid prescription before narcotics could be ordered from the pharmacy.
Failure to Ensure Resident Dignity and Timely Response to Needs
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple observations, interviews, and record reviews involving 15 residents. Several residents reported that staff did not engage with them or listen to their concerns, with one resident stating that management prioritized budget over resident needs and rarely interacted with residents. During a resident council meeting, numerous residents agreed that call lights often went unanswered for extended periods, sometimes over thirty minutes, and that staff would sometimes turn off call lights without providing assistance, leaving residents feeling helpless and undervalued. One resident expressed that the long wait times for assistance made him feel like he wanted to die. Direct observations confirmed that call lights were left unanswered for significant periods, with staff walking past without responding. In one instance, a resident waited in her wheelchair for over 30 minutes after activating her call light before receiving assistance. Residents also reported overhearing staff discussing spending time on their phones instead of providing care. Additionally, there were reports of staff making disrespectful or derogatory remarks to residents, such as calling a resident a drug addict and dismissing their pain complaints. Some staff were described as rude, and management was noted to rarely leave their offices to check on resident needs. Further deficiencies included staff failing to provide necessary personal care, such as refusing to assist a resident with hygiene needs after a bowel movement, stating it was not their job. Observations also noted that staff did not consistently follow facility policies for maintaining resident privacy and dignity, such as knocking and announcing themselves before entering rooms. The facility's own dignity policy outlined expectations for respectful communication and prompt care, but these standards were not consistently met, as evidenced by the findings.
Medication Availability Failures Lead to High Medication Error Rate
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered, resulting in a medication error rate of 29% during observed medication passes. On multiple occasions, staff, including an LPN and the DON, were unable to locate or obtain several prescribed medications for three residents. These medications were not available in the medication cart, Cubex machine, or overflow cart, and had been previously reordered from the pharmacy but had not yet been delivered. As a result, residents did not receive all of their prescribed morning medications. Specifically, one resident did not receive four of thirteen prescribed medications, another did not receive six of fourteen, and a third was missing at least one medication. The DON confirmed that delays in pharmacy delivery were a recurring issue, often requiring additional follow-up with the pharmacy. The observed medication administration errors involved missing essential medications such as vitamins, inhalers, patches, and other prescribed drugs, directly leading to the cited deficiency.
Failure to Provide Palatable and Properly Prepared Food
Penalty
Summary
The facility failed to provide palatable, attractive, and appropriately prepared food for 12 of 14 residents reviewed. Multiple residents, all cognitively intact, reported dissatisfaction with the quality, taste, and variety of the food served. Specific complaints included repetitive menus, poor taste, lack of seasoning, and food being served cold or in small portions. During a resident council meeting, several residents agreed that the food quality had declined, possibly due to a change in suppliers. Direct observation of a test tray revealed unappetizing presentation, overcooked noodles with a slimy texture, and missing components such as cheese on the chicken parmesan. Residents with significant medical histories, including hypertension, congestive heart failure, diabetes, malnutrition, and chronic obstructive pulmonary disease, reported issues such as spoiled-smelling meat, tough and inedible meat, soggy and flavorless food, and insufficient portion sizes. One resident noted weight loss since admission, attributing it to inadequate food portions. Another resident stated that the food was often cold and tasted bad. These findings were based on interviews, record reviews, and direct meal observations.
Failure to Document Resident Discharge and Required Notifications
Penalty
Summary
A deficiency occurred when the facility failed to adequately document the discharge process for a resident with diagnoses including congestive heart failure, dementia, and myocardial infarction. The resident was admitted to the facility and later discharged to another LTC facility. Although a care plan meeting note indicated discussions about alternative living arrangements due to the resident's dementia and need for 24-hour supervision, and a Discharge MDS assessment noted the discharge, there was no documentation of a physician's discharge order in the electronic health record (EHR). Additionally, there was no other documentation or discussion of discharge or discharge planning found in the resident's EHR. The facility's policy requires a physician's order for discharge and documentation of notifications to the resident, responsible party, and family members, but these steps were not documented for this resident. The Regional Director of Operations confirmed that no additional discharge documentation was available.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted quarterly for a resident with diagnoses including paraplegia and major depressive disorder. Review of the clinical record showed that the resident was cognitively intact and had not been invited to any care plan meetings since admission in January, with only one care plan meeting progress note available from late January. The MDS Nurse confirmed that a quarterly care plan meeting scheduled after late April had been cancelled and was not rescheduled, and could not provide a reason for this lapse. Facility policy requires that residents be notified and encouraged to attend care plan conferences, and that comprehensive care plans be reviewed and updated at least quarterly, but no evidence was provided that these requirements were met for this resident.
Failure to Provide Timely Perineal Care for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to provide timely perineal care to a resident who was unable to perform this activity independently. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic heart failure, pulmonary embolism, weakness, vertigo, and difficulty walking, was documented as needing assistance with toileting hygiene and perineal care according to his care plan. Despite these documented needs, the resident reported difficulty reaching his bottom to wipe after a bowel movement and stated that staff told him it was not their job to help him. The resident further indicated that he still had stool on his bottom from the previous day, causing discomfort, and that his request for assistance from a CNA was not fulfilled in a timely manner. Observation confirmed that no staff entered the resident's room after his request for help, prompting him to activate his call light. A Qualified Medication Aide eventually entered the room but expressed the belief that there was no reason the resident could not clean himself. The facility's policy required staff to provide routine and as-needed assistance with activities of daily living, including perineal care, as outlined in the resident's care plan. The failure to provide this assistance as required led to the identified deficiency.
Failure to Follow Medication Administration Parameters and Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and established parameters for two residents. For one resident with diagnoses including hypertension and congestive heart failure, digoxin and metoprolol were administered despite physician orders specifying that these medications should be held if the resident's pulse was below 60 beats per minute. Documentation showed that on multiple occasions, both medications were given when the resident's pulse was below the prescribed threshold. The Director of Nursing confirmed that these medications should have been withheld under those circumstances. For another resident with a history of substance use and major depressive disorder, insulin orders were not followed as prescribed. The resident was to receive both fast-acting and long-acting insulin at specific times, but the Medication Administration Record indicated several missed doses without documentation explaining the omissions. The Nurse Consultant was unable to provide any reason for the missed insulin administrations. The facility's Medication Administration Policy required vital signs to be obtained as necessary and medications to be administered as ordered, but these procedures were not followed in these cases.
Failure to Provide Timely Pharmacy Services for Medications
Penalty
Summary
The facility failed to ensure that medications were received in a timely manner from the pharmacy for two residents. One resident with diagnoses including hypertension and congestive heart failure had a physician's order for trazodone to be administered nightly for insomnia. According to the Medication Administration Record, this resident did not receive the prescribed trazodone for three consecutive days because the medication was not delivered from the pharmacy and was not available in the facility's medication dispensing system. Another resident with dysphagia and a history of aspiration pneumonia, who was dependent on a feeding tube, had a physician's order for a scopolamine transdermal patch to be applied every 72 hours for nausea. The Medication Administration Record indicated that the patch was not applied on two separate days due to it not being available, as it had not been sent to the facility in a timely manner after being reordered from the pharmacy. The facility's Pharmacy Services policy requires routine and timely pharmacy services, but this was not met in these instances.
Failure to Properly Destroy and Document Partial Dose of Controlled Substance
Penalty
Summary
A deficiency occurred when a partial dose of a controlled substance, oxycodone, was not destroyed and recorded in the presence of two licensed personnel as required by facility policy and federal regulations. A resident with a history of cocaine abuse, opioid use, and major depressive disorder, who was cognitively intact, had a physician's order for oxycodone 5 mg every six hours as needed for pain. On one occasion, the facility ran out of the 5 mg tablets, and an LPN obtained a one-time order to administer half of a 10 mg oxycodone tablet. The LPN split the tablet, administered half to the resident, and saved the remaining half in a medication cup stored in the narcotics lock box for later use, rather than destroying it as required. The Controlled Drug Receiving Record/Disposition Form showed that the half tablet was administered, but the record lacked the administering staff member's signature for the initial dose. The remaining half tablet was later administered and signed off by staff on the following shift. The LPN involved admitted to saving the half tablet for the next shift and forgetting to complete the narcotic record sheet. Facility policy, provided by the Nurse Consultant, specified that unused partial tablets must be destroyed and recorded in the presence of two licensed personnel, which was not followed in this instance.
Failure to Prevent Severely Cognitively Impaired Resident from Signing Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment did not enter into a binding arbitration agreement. The clinical record review showed that the resident had a diagnosis including stroke and was assessed as severely cognitively impaired on the admission MDS. Despite this, the resident was able to make himself understood and respond to simple direct questions. On admission, the resident electronically signed a Voluntary Binding Arbitration Agreement, which included language stating that the agreement should not be submitted to a resident deemed incompetent by two physicians. Interviews with facility leadership revealed that there was not always a guardian or family member available to complete admission paperwork with the resident. The admission paperwork process allowed for electronic signing of all forms, including the arbitration agreement, regardless of the resident's capacity to make such decisions. This resulted in the resident with severe cognitive impairment signing the agreement without proper assessment of decision-making capacity or involvement of a legally authorized representative.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for three residents. In one instance, an LPN was observed administering medications to a resident with hypertension and did not clean the medication cart before preparing medications. A capsule was dropped onto the cart and then picked up with bare hands and placed into a medication cup. The LPN also handled and opened capsules without performing hand hygiene or wearing gloves. The LPN stated she did not consider a pill dropped unless it fell on the floor and routinely opened capsules without gloves. In another case, the DON administered insulin to a resident with diabetes but did not cleanse the hub of the insulin pen before attaching the needle, although she performed hand hygiene and donned gloves. Additionally, during medication administration for a resident with chronic obstructive pulmonary disease and chronic bronchitis, the DON failed to perform hand hygiene after contact with high-traffic surfaces and before entering the resident's room. The DON also touched and moved pills with a gloved finger after administering a nasal spray, without changing gloves or performing hand hygiene. Facility policies required hand hygiene before and after glove use and before resident contact, as well as cleansing the insulin pen hub prior to use, but these were not followed.
Facility Fails to Maintain Floors in Good Repair
Penalty
Summary
The facility failed to maintain the floors in good repair, affecting all 39 residents. During an environmental tour, several areas of concern were noted, including cracks in the floor tiles, broken tiles, stained and dirty tiles, and improperly installed vinyl flooring. Specific locations with issues included hallways outside various rooms, the metal threshold between building sections, and the area by the janitors' closet. The cracks and damage varied in size, with some cracks extending up to 25 feet long and 3 inches wide, and divots in the floor measuring up to 2 inches by 2 inches and 1/4 inch deep. Interviews with residents and staff confirmed the flooring issues. One resident described the floors as being like a roller coaster in some parts of the building, while another mentioned the bumpy nature of the flooring. The Executive Director, Regional Director of Operations, and Director of Maintenance acknowledged that the building floors had settled, causing the cracks, and that the vinyl flooring had been installed improperly, leading to unevenness. Despite regular cleaning and waxing, some tiles remained permanently stained due to their age.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to ensure food items were stored closed and labeled with open dates, potentially affecting 38 of 39 residents who consume food prepared in the kitchen. During an observation of the kitchen, several food items in the refrigerators and freezers were found opened and not labeled with open dates. Specifically, a half-full container of orange sherbet, a box containing individual lime sherbet containers, a bag of french fries, a bag of chicken, and a half-full bag of spring salad mix were all found without open dates. Cook 5 confirmed that all food items should be labeled with open dates and sealed shut. The facility's food storage policy and date marking policy both require that opened food items be labeled with the date they were opened and used by the safe food storage guidelines or the manufacturer's expiration date.
Failure to Immediately Report Abuse Allegations
Penalty
Summary
The facility failed to immediately notify the Administrator of an allegation of abuse for two residents. Resident 1 reported that another resident grabbed and kicked him in the back of his wheelchair. Although the incident was documented in a nursing progress note and a risk management entry, the Executive Director was not informed until two days later. The nurse responsible for the documentation assumed the Executive Director would find out through the risk management system, which was not the correct protocol. Resident 1 did not sustain any apparent injuries, but the delay in reporting the incident to the Administrator was a clear deficiency in the facility's abuse reporting procedures. In another case, Resident 28 reported verbal abuse by her roommate to a nurse, but this information was not relayed to the Executive Director or management staff. The verbal abuse incident, which occurred several months prior, was not reported to the Indiana State Department of Health until the Executive Director was informed during an interview. The facility's Abuse Prevention Program policy mandates immediate reporting of any abuse allegations to the Administrator, which was not followed in these instances. This delay in reporting and investigating the abuse allegations constitutes a significant deficiency in the facility's compliance with abuse prevention protocols.
Failure to Provide Scheduled Showers as Per Resident's Care Plan
Penalty
Summary
The facility failed to provide showers as care planned and preferred for a resident diagnosed with parkinsonism and tremors. The resident's care plan, initiated on 8/1/23, indicated a need for assistance with ADL care, including bathing per resident preference twice weekly and as needed. Despite the resident's preference for showers and his cognitive intactness, he reported not always receiving his scheduled showers. The resident believed his shower day was Friday, but the DON indicated his showers were scheduled for Wednesday and Sunday evenings. The CNA confirmed that the resident normally did not refuse showers. Review of the shower records for March and April revealed inconsistencies with the care plan. The resident received showers on 3/6, 3/9, 3/23, 3/27, and 3/30, a bed bath on 3/16, and refused a shower on 3/20. This did not align with the scheduled shower days, indicating a failure to adhere to the resident's care plan and preferences. The facility's ADL policy emphasizes providing care as planned and according to resident preferences, which was not consistently followed in this case.
Failure to Administer Medications and Monitor Conditions as Ordered
Penalty
Summary
The facility failed to clarify and administer a resident's medication as ordered, ensure physician orders were followed for a resident with elevated blood sugars, and monitor blood pressure as ordered prior to administering medication for three residents. Resident 10, diagnosed with paranoid schizophrenia, did not receive Haloperidol as per the Psyche NP's recommendation. The medication was incorrectly ordered for intramuscular administration, and an LPN changed the order without proper authorization, leading to the resident receiving an incorrect dosage and schedule of Haloperidol from 3/24/24 through 4/3/24. Resident 21, diagnosed with type 2 diabetes mellitus, had elevated blood sugar levels on two occasions. The physician's order required rechecking the blood sugar levels within 1-2 hours after administering insulin, but the clinical records did not indicate that these rechecks were performed. The Regional Nurse Consultant confirmed the absence of notations for the required rechecks on 3/6/24 and 3/7/24. Resident 11, diagnosed with hypertension and congestive heart failure, was to receive metoprolol twice daily with the condition to hold the medication if the systolic blood pressure was less than 100. The MAR indicated that the medication was administered as ordered, but there were no recorded blood pressures at the time of administration to ensure compliance with the physician's order. The DON confirmed that blood pressures should have been taken prior to administering the medication, but this was not done as required.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure vision services were provided for a resident with type 2 diabetes mellitus. The resident, who was admitted to the facility and had signed a consent for vision services, reported having trouble with his vision and expressed a desire to see an eye doctor. Despite vision services being available at the facility, the resident was not seen during the scheduled visit. The Social Services Director confirmed the consent but was unsure why the resident had not been seen, citing delays with the vision service provider.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure dental services were provided for two residents, both diagnosed with type 2 diabetes mellitus. Resident 38, admitted on an unspecified date, had signed a dental consent on 12/6/23 but had not seen a dentist since admission. An observation on 4/2/24 revealed Resident 38 had missing and broken teeth and was experiencing dental issues. Similarly, Resident 25, also admitted on an unspecified date, had signed a dental consent on 8/9/23 but had not received dental services. An observation on 4/2/24 showed Resident 25 had a dark, rotten front tooth and expressed a desire to see a dentist. Despite dental service visits on 3/22/24 and 4/3/24, neither resident was seen by the dental provider on those dates. The Social Services Director (SSD) confirmed that both residents had signed consents for dental services and acknowledged that it should take approximately a month to arrange routine dental services. However, she was unaware of Resident 38's dental issues until a care plan meeting on 4/2/24 and had not followed up on Resident 25's pending payer source status since receiving a dental report on 12/18/23. The facility's policy mandates providing medically related social services, including dental care, to maintain residents' well-being, but this policy was not adhered to in these cases.
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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