Westside Retirement Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 8616 W 10th St, Indianapolis, Indiana 46234
- CMS Provider Number
- 155606
- Inspections on file
- 41
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Westside Retirement Village during CMS and state inspections, most recent first.
A resident with bipolar disorder, anxiety, and mild cognitive impairment, documented as cognitively intact and independent with ADLs, was transferred under an Emergency Detention Order to a psychiatric facility after refusing to go and being escorted by police. Facility staff reported to the psychiatric facility that the resident had recent physical and verbal aggression, including cursing at a roommate and spraying a staff member with chemicals, but these behaviors and alleged medication refusals were not supported by nursing documentation in the clinical record and were based on secondhand reports from social services. The DON later stated the resident had not shown aggressive behaviors, there was no documented medication refusal, and she was unsure why the resident was sent to a psychiatric hospital, while the resident reported she did not understand why she was transferred and that the reason was never explained to her, demonstrating a failure to ensure the resident was fully informed of and able to choose her treatment.
A cognitively intact resident with a history of brain neoplasm, muscle weakness, and depression reported that her roommate, who had bipolar disorder and a documented pattern of escalating behaviors and verbal aggression, became angry over use of a shared landline phone and threatened to kill her and her sister during a phone call. The resident told staff that the roommate kept threatening her, and the sister confirmed hearing explicit death threats, but the DON later characterized the event as only an altercation between the roommate and the sister and did not initiate an abuse investigation or timely report it as abuse. The resident subsequently reported that the roommate continued to intimidate her by walking past her door and making a finger gun gesture, contributing to her staying in her room and avoiding activities, while the SSD acknowledged being told of the gestures but did not interview staff, and the facility’s own abuse policy defining mental/verbal abuse as intimidating conduct was not applied to this situation.
A cognitively intact resident who required assistance with ADLs reported that her roommate became angry over use of a landline phone and repeatedly threatened to kill her and her sister, with the sister corroborating the threats during a phone call. The resident told a CNA that the roommate "keeps threatening me," and the CNA reported this to a UM. The SSD was informed that one resident was threatening and verbally aggressive toward another, directed that the resident be moved, and filed an APS report describing threats and listing the alleged victim as an endangered adult. The DON, however, understood the situation only as an altercation between the roommate and the resident’s sister over the phone, did not recognize it as resident abuse, did not initiate an abuse investigation, did not interview staff or residents about the threats, and did not report the allegation to the state agency as required by facility policy and regulations.
A cognitively intact resident who required assistance with ADLs reported that her roommate became angry over use of a shared landline phone and threatened to kill her and her sister, with the sister confirming she overheard these threats. The resident told a CNA and was moved to another room, but later reported that the roommate continued to intimidate her by making finger gun gestures when passing her door. The SSD was notified by a CNA of verbal threats and filed an APS report, but did not clearly ensure that the DON was informed or that staff were interviewed about ongoing gestures. The DON believed the incident involved only a phone altercation with the sister, concluded there was no resident abuse, and therefore did not initiate an investigation or report the allegation to the state agency, resulting in a failure to document, report, and thoroughly investigate the verbal abuse allegation.
A resident with cirrhosis and heart failure was admitted with a physician's order for a 1500 ml fluid restriction, but staff did not document fluid intake or include a care plan for the restriction. The ADON indicated the order was viewed as a dietary recommendation rather than a direct order, resulting in the fluid restriction not being tracked or implemented as required.
A resident with multiple health conditions, including COPD and a history of stroke, was left without access to her ordered oxygen and call light after staff assisted her with dressing. The oxygen equipment and call light were both out of reach, contrary to facility policy and the resident's care plan, which required staff assistance and accessibility to these essential items.
Surveyors observed that a shower room was not maintained in a clean and orderly condition, with feces, debris, and a used nicotine patch found on the floor and wall, as well as a persistent black substance around the shower base. Both the ADON and Lead Housekeeper confirmed the room was unclean, and the Administrator stated there was no specific cleaning policy or checklist in place.
Multiple residents received cold or unpalatable meals due to delays in tray delivery, inadequate food transport methods, and lack of accessible reheating options. Food was often left sitting in hallways before being served, and residents reported not receiving ordered meals or alternative menu options. Staff interviews and facility records confirmed ongoing complaints about food temperature and quality, with current practices failing to maintain food at safe and appetizing temperatures.
A resident's room and bathroom were found to be unclean, lacking basic supplies, and emitting foul odors due to infrequent cleaning and spills. Observations revealed soiled carpets, dust accumulation, and debris in both resident rooms and common areas, with insufficient housekeeping staff present to maintain cleanliness. Interviews confirmed that cleaning routines were inconsistently followed and some areas were left unattended, contrary to facility policy.
A resident with end stage renal disease and a dialysis port was not provided showers during her stay, despite her preference and ability to shower with her port covered. Staff delayed providing a dressing to cover the port, citing the need for a physician's order, but did not document attempts to obtain one or accommodate her request. The DON later confirmed that the necessary dressing was available without a physician's order, yet the resident only received sponge baths and was not assisted to shower as she preferred.
The facility did not adequately follow up, investigate, or resolve grievances related to cold meals, insufficient showers, and poor room cleaning for several residents, as well as ongoing food concerns raised in Resident Council meetings. Documentation of actions taken was vague, and residents reported persistent issues with food quality and dietary accommodations.
The facility failed to ensure residents who wanted to vote in the 2024 Presidential Election were registered and able to vote. Five residents faced obstacles, such as not being registered, not receiving absentee ballots, or not being assisted to vote. The Activity Director attempted to coordinate with the Mobile Voting Board, but issues persisted, and the Director of Nursing was unaware of the residents' voting needs.
The facility failed to respond to call lights in a timely manner, affecting all 11 residents who participated in a resident council meeting. Despite reeducation efforts, residents reported waiting 1 to 2 hours for responses, especially at night and on weekends. Grievance logs from February to September 2024 highlighted ongoing issues, with resolutions typically involving staff meetings or coaching. Interviews with the ED and DON revealed that monthly in-services and reeducation were the primary responses, but the problem persisted.
The facility failed to maintain a clean and homelike environment in the memory care unit's dining room and in two residents' rooms. Remnants of feces were not cleaned up after a resident's incontinent episode in the dining room, and stains remained despite cleaning attempts. Additionally, two residents' rooms had large areas of staining on the floors due to incontinent episodes, with no special cleaning or replacement requests made.
The facility failed to prevent falls for a resident with a history of falls, resulting in a nasal fracture. A resident with dementia exhibited intrusive wandering, entering other residents' rooms, causing distress. The Elopement Binder was outdated, missing residents at risk for elopement, and medications were left at the bedside without proper orders, posing potential risks.
A QMA failed to perform hand hygiene between administering medications to multiple residents and did not wear gloves while administering ear drops to a resident, violating the facility's infection control policy.
A facility failed to treat residents with dignity, as one resident was left waiting for over 20 minutes for restroom assistance, resulting in incontinence, while another resident experienced harsh treatment during a transfer and had privacy-compromising photographs displayed. The incidents reflect deficiencies in care practices and staff attentiveness.
The facility failed to document advanced directives for residents, leading to discrepancies and omissions in their medical records. A resident with multiple diagnoses lacked an advanced directive order upon admission, while another had conflicting code status documentation. A third resident was not asked about creating an advanced directive until later in their stay. The DON acknowledged issues with the process, indicating it was now everyone's responsibility to ensure completion.
The facility failed to accurately code MDS assessments for two residents, leading to deficiencies in care plans. One resident, observed wandering aimlessly, was not coded for wandering behaviors despite multiple notes indicating such tendencies. Another resident's MDS assessment omitted a significant mental health diagnosis, despite a PASRR Level II assessment identifying a major mental illness. These errors highlight lapses in assessment and documentation processes.
The facility failed to ensure accurate PASRR Level I screenings for two residents. One resident's Level I did not reflect her diagnoses of dementia and psychotic disorder, potentially requiring a Level II screen. Another resident admitted under a 30-day exclusion did not have a new Level I completed after the period expired. Staff were unable to explain the documentation lapses.
A facility failed to use a resident's G-tube for medications and nutrition as intended. The resident, who had a G-tube placed after a stroke, reported that it was not used for medications or feeding supplements. LPNs confirmed this, stating they only flushed the tube. The resident's MAR showed Glucerna was given despite her eating over 50% of meals. The DON and RDCS acknowledged the oversight and incorrect orders for G-tube use.
The facility failed to ensure proper oxygen administration and equipment hygiene for two residents. One resident's oxygen concentrator was set incorrectly, and her nasal cannula and humidifier bottle were not maintained properly. Another resident's oxygen concentrator was also set incorrectly, and his bipap mask and tubing were found uncovered and contaminated. The facility did not adhere to its policy on oxygen administration, compromising respiratory care for residents.
A facility failed to obtain a blood pressure reading before administering prazosin HCL to a resident, as required by the medication order. The resident had multiple diagnoses, including GERD, COPD, osteoporosis, and schizoaffective disorder. The order specified holding the medication if the systolic blood pressure was less than 100 or the pulse was less than 60, but did not include instructions to check blood pressure prior to administration. The DON acknowledged the omission, and the facility's policy emphasized the need to note parameters around drug administration.
The facility failed to manage medication storage and expiration properly, as observed in two medication rooms. A resident's lorazepam bottle lacked an opening date, and an expired aplisol bottle was found in the 100-medication room. In the 300-medication room, a resident's chlorpactin bottle was expired despite being claimed otherwise by an RN. The facility did not follow its policy on medication storage and expiration dating.
Two residents' wheelchairs were not maintained in safe conditions. One resident's wheelchair had a broken left arm, and despite claims of repair, the issue persisted due to a broken bolt. Another resident's wheelchair had a missing brake handle, leaving a hollow bar exposed, which was a safety concern. The facility lacked a specific policy for wheelchair maintenance, although a checklist and preventative maintenance policy were available.
A facility failed to update the care plan for a resident with dementia, who was observed without a required brace despite instructions in her room. The care plan, which was over a year old, indicated the need for a left edema glove and wrist orthotic, which were no longer necessary. The Director of Therapy confirmed the resident no longer required these interventions, but the care plan and room instructions had not been revised.
A resident with multiple health conditions did not receive necessary podiatry care, resulting in extremely long and jagged toenails causing discomfort. Despite being dependent on staff for ADLs, the resident was not seen by a podiatrist during scheduled visits. The facility's process for ensuring routine podiatry care was not followed, violating the resident's rights to reasonable accommodation.
A resident with dementia and a history of aggressive behavior was involved in multiple altercations with peers, resulting in injuries and police involvement. The facility failed to provide adequate supervision and did not update the resident's care plan with specific interventions after each incident, despite having a policy emphasizing person-centered care. The lack of individualized care planning contributed to ongoing aggressive behaviors.
The facility failed to properly label, store, and destroy medications, with several opened bottles lacking open dates and discrepancies in medication administration records. Over-the-counter medications were not properly labeled, and biologicals were stored incorrectly. The DON acknowledged these issues, indicating a lack of consistent adherence to facility policies.
A resident was not provided showers according to his preference of twice a week, as documented in his care plan. Despite being cognitively intact and having a preference for showers on specific days, the facility failed to document any refusals or interventions, resulting in the resident receiving fewer showers than scheduled. Staff interviews revealed that showers were prescheduled by room number, not individual preference, and there was a lack of documentation regarding the resident's refusal of care.
A facility failed to follow infection control practices during catheter care for a resident with a suprapubic catheter. A QMA changed the resident's catheter bag without sanitizing the catheter tip or washing hands after glove removal. The resident had a history of prostate cancer and was at risk for infections. Staff interviews revealed inconsistencies in following proper procedures, despite facility policies requiring aseptic techniques and hand hygiene.
The facility failed to address and track grievances from residents and their families over several months. Concerns included missed showers, delayed call light responses, and missing laundry items. Despite a process for documenting grievances, there was no follow-up or resolution provided. Interviews with residents and a family member confirmed ongoing issues with personal care and hygiene, with no feedback or resolution from the facility.
The facility failed to revise care plans for two residents. One resident had multiple pressure ulcers that were not addressed in the care plan until after a surveyor's review. Another resident had a worsening wound on the coccyx that was not documented in the care plan despite being noted upon admission.
A facility failed to ensure effective wound management for a resident admitted with an open area on the coccyx, which worsened into a stage 3 pressure ulcer. The resident's care plan was not effectively implemented, and the wound was not promptly assessed or documented, leading to significant deterioration. Staff interviews revealed inconsistencies in wound assessment and documentation practices, and the facility's policy on wound care was not followed.
Failure to Inform Resident and Obtain Consent for Involuntary Psychiatric Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was fully informed of and able to choose her treatment when she was transferred to a psychiatric facility against her will. The resident had diagnoses of bipolar disorder, anxiety disorder, and mild cognitive impairment, and a recent MDS assessment documented that she was cognitively intact, independent with all ADLs, and had no behaviors or rejection of care during the assessment period. An Emergency Detention Order (EDO) was completed stating that the resident had a psychiatric condition impairing her judgment, was unwilling to accept treatment voluntarily in the facility, and had demonstrated impaired judgment and the physical capacity to cause grave harm to herself and others, including verbal aggression, threats, and spraying chemicals. The order directed law enforcement to take her into custody and transport her to a psychiatric facility. A care management note documented that the resident was taken to a psychiatric hospital under a court order after she refused to go, and that she was escorted by police. On readmission, an NP note recorded that the resident was irritable and stated she intended to sue the facility for sending her to another facility without her permission. At the psychiatric facility, a progress note indicated the sending facility had reported that over the prior 72 hours the resident had been physically and verbally aggressive, cursing and yelling at her roommate, refusing to remove her belongings from the roommate’s side of the room, and spraying a staff member in the face with chemicals to cover a bowel movement odor. The psychiatric facility note also documented that the resident reported she was unclear why she had been sent there and that the reason for the transfer had never been explained to her. Interviews with facility staff showed discrepancies and lack of documentation supporting the behaviors and refusals cited in the EDO. The DON stated the resident had become manic, was pacing the halls, and refusing medications, and that she initially agreed to go to the hospital but refused when she learned it was a psychiatric hospital; the DON also stated the resident had not displayed aggressive behaviors and that documentation of refused medications and manic behaviors was only in the court order. Review of the MAR and progress notes revealed no nursing documentation of medication refusals, with refusals only noted by the SSD. The SSD reported she verbally relayed behavior information, including the alleged spraying incident, to the psychiatric facility based on staff reports that were not specifically documented in the clinical record and could not identify who was sprayed. The NP stated she completed the EDO using information provided by the SSD and that certain wording was needed to qualify for emergency detention; she acknowledged her own clinical notes did not support the description of the resident as verbally abusive to others and that she was not personally aware of specific behavior incidents. The DON later indicated she was unsure why the resident had been sent to a psychiatric hospital and had not been fully informed of the resident’s behaviors, underscoring that the resident’s transfer occurred without clear documentation and without the resident understanding or consenting to the psychiatric transfer.
Failure to Protect Resident From Verbal Abuse and to Investigate Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse and to recognize and investigate an allegation of abuse involving two roommates. Resident C, who was cognitively intact and required staff assistance with mobility, dressing, transfers, and personal hygiene, was admitted with diagnoses including a history of malignant brain neoplasm, muscle weakness, depression, and a need for assistance with personal care. After Resident B, who had a documented history of bipolar disorder and recent escalating behaviors including verbal aggression, verbal abuse of a roommate, and spraying a substance at a CNA, was sent to a psychiatric facility, Resident C used the landline phone in their shared room to communicate with her sister because her cell phone and charger were not working. When Resident B returned from the psychiatric facility, she became upset that Resident C was using the landline phone and an argument ensued. During this argument, Resident C reported that Resident B told her, "if anyone touches my stuff, I'm going to kill you," and also told Resident C’s sister over the phone that she was going to kill her as well. Resident C indicated to staff that Resident B kept threatening her, and Resident C’s sister confirmed hearing Resident B say that if she called the phone again, she would kill her, and that she heard Resident B tell Resident C, "If you touch my things, I will kill you. I will kill anyone who touches my things." CNA 5 responded to the roommates’ call light and heard Resident C say she needed to get out of the room because Resident B was being mean and kept threatening her; CNA 5 then reported the allegation to the Unit Manager. Despite these reports, the DON later stated she believed the incident was only an altercation between Resident B and Resident C’s sister and did not involve resident-to-resident abuse, and therefore no abuse investigation was initiated. Resident C reported that she remained fearful of Resident B after the incident, stayed in her room, and did not attend activities because of her fear. She stated that when Resident B walked by her door, Resident B would look at her and make a finger gun gesture. Resident C reported this behavior to the SSD, who acknowledged being told that Resident B would walk by Resident C’s room and make a finger gun gesture, but the SSD did not interview staff about these gestures and indicated she had not personally observed them. The SSD also indicated she had witnessed Resident B being verbally aggressive with other residents in the past but did not know her to have threatened to kill anyone and was unsure if the DON had been informed of the threats. The DON stated she was unaware of any threats to kill Resident C, was not aware that APS had been notified or that police were supposed to have been contacted, and did not consider the situation to be resident abuse, so she did not conduct staff or resident interviews. This sequence of events, combined with the facility’s own policy defining mental or verbal abuse as conduct causing or having the potential to cause fear or intimidation, led to the finding that the facility failed to protect Resident C’s right to be free from verbal abuse and failed to appropriately identify, report, and investigate the alleged abuse. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and defined mental or verbal abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, or agitation. Despite this policy and the known behavioral history of Resident B, including documented episodes of verbal aggression and verbal abuse of a roommate prior to this incident, the DON indicated she believed Resident B did not have a prior history of resident agitation or concerns that would preclude assigning her a new roommate. The DON also indicated that, because she believed the incident involved only Resident C’s sister, she did not treat it as an abuse allegation and did not initiate an investigation or report it to the state agency within two hours as would have been required if she had known of threats to kill Resident C. As a result, the facility did not fully recognize or respond to the reported threats and intimidating gestures directed at Resident C, and did not ensure that the resident was protected from verbal abuse as required by regulation and facility policy.
Failure to Report and Investigate Resident-to-Resident Verbal Abuse and Death Threats
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff reported and investigated an allegation of resident-to-resident verbal abuse, including death threats, in accordance with abuse reporting requirements. A cognitively intact resident, identified as Resident C, was newly admitted and required staff assistance with mobility, dressing, showering, transfers, and personal hygiene. After her cell phone and charger stopped working, staff arranged for her to use her roommate’s landline phone while the roommate, Resident B, was out of the room at a psychiatric facility. When Resident B later returned, she became upset that Resident C was using her landline phone and, according to Resident C and her sister, threatened to kill Resident C and her sister if they touched or used her belongings or called the phone again. Resident C reported that Resident B told her, “If anyone touches my stuff, I’m going to kill you,” and made similar threats toward her sister over the phone. Resident C stated she informed a CNA about the threats, and the CNA confirmed that Resident C said Resident B “keeps threatening me” and that Resident C’s sister reported ongoing threats over the phone. The CNA reported the allegation to the Unit Manager. Resident C was moved to another room the same evening, but she later reported that she did not feel safe and that Resident B continued to walk by her new room and make a finger-gun gesture toward her. Resident C’s sister corroborated hearing Resident B threaten to kill both Resident C and herself during the phone call. The Social Services Director (SSD) stated she was called at home after hours by a CNA and informed that Resident B was threatening Resident C and being verbally aggressive. She instructed staff to move Resident C and to contact the police, and she submitted an Adult Protective Services (APS) report listing Resident C as an endangered adult and Resident B as the perpetrator, with the allegation described as battery and threats to physically harm Resident C. However, the DON reported that she was only told there had been an altercation between Resident B and Resident C’s sister over the phone and believed the issue did not involve resident abuse. The DON stated there was no investigation because she understood the incident to be between Resident B and the sister, not involving Resident C as a victim, and she was unaware of any threats, APS report, or police involvement. She did not conduct staff or resident interviews related to the threats, and there was no report made to the state agency within the required timeframe for alleged abuse. The facility’s abuse-reporting policy required associates who suspect a crime against a resident to immediately notify the Executive Director, but the DON remained uninformed of the full nature of the threats and no formal abuse investigation was initiated.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to document, report, and conduct a thorough investigation of an allegation of resident-to-resident verbal abuse. Resident C, who was cognitively intact and required staff assistance with mobility, dressing, showering, transfers, and personal hygiene, reported that after her admission she used her roommate’s landline phone while the roommate (Resident B) was out of the facility. When Resident B returned, she became upset that Resident C was using her phone and threatened Resident C, stating that if anyone touched her belongings she would kill them. Resident C and her sister, who was on the phone at the time, both reported that Resident B threatened to kill Resident C and Resident C’s sister if they continued to use or call the phone. Resident C stated she informed a CNA about the threats and was moved to another room that evening, but she did not report the threats directly to a nurse. She later reported that Resident B continued to intimidate her by walking past her new room and making a finger gun gesture toward her. Resident C discussed these concerns with the Social Services Director (SSD) and expressed that she did not feel safe with Resident B in the facility, and she had considered finding another facility. An Adult Protective Services (APS) online report identified Resident C as an endangered adult and Resident B as the perpetrator, with the allegation described as battery and including threats of physical harm made on the night Resident B returned from a psychiatric hospital stay. The SSD reported that she was notified after hours by a CNA that Resident B was threatening Resident C and being verbally aggressive, and she instructed staff to move Resident C and to contact the police. However, she did not recall who called her, was unsure if the DON was informed, and did not interview staff about the reported ongoing finger gun gestures. The DON indicated she was only aware of an altercation between Resident B and Resident C’s sister over the phone and believed there had been no resident abuse, so no investigation was initiated. The DON was unaware of the reported death threats, the APS report, or any police contact, and later learned from law enforcement that no police report had been filed. As a result, the facility did not complete required documentation, did not report the alleged threats to the state agency within the required timeframe, and did not conduct a thorough investigation into the allegation of resident-to-resident verbal abuse.
Failure to Document and Implement Physician-Ordered Fluid Restriction
Penalty
Summary
A deficiency occurred when the facility failed to complete a physician's order for a resident with cirrhosis of the liver, diastolic congestive heart failure, and obesity, who was on a restricted fluid intake. The resident was admitted with a hospital discharge note and a current physician's order specifying a 1500 ml fluid restriction. However, the clinical record lacked documentation of fluid intake and did not include a care plan addressing the fluid restriction. During an interview, the ADON stated that the fluid restriction was considered a dietary recommendation rather than a direct order, leading to the order not being tracked or implemented as required. Facility policy on fluid-restriction diets was available but not followed in this case.
Failure to Ensure Resident Access to Oxygen and Call Light
Penalty
Summary
A resident with a history of stroke with left-sided weakness, chronic obstructive pulmonary disease, diastolic congestive heart failure, and depression was observed without access to her prescribed oxygen and call light. The resident had recently received assistance from staff to get dressed but was left without her oxygen reapplied. The oxygen concentrator and nasal cannula were placed on the opposite side of the bed, out of the resident's reach. The resident attempted to reach her call light to request staff assistance, but it was found coiled on the floor next to the bed, also out of reach. Facility policy requires that the call light be positioned within reach of the resident and that oxygen therapy be administered and stored safely. During the observation, the administrator confirmed that both the oxygen and call light were not accessible to the resident as required. The resident's care plan indicated she needed assistance with dressing and transferring, but staff failed to ensure her oxygen was reapplied and her call light was accessible after providing care.
Failure to Maintain Cleanliness in Shower Room
Penalty
Summary
The facility failed to maintain a clean and orderly shower room for resident use, as observed in one of three shower rooms. During an inspection of the 100 Hall shower room, surveyors found feces in three separate areas on the floor outside the shower, along with a used plastic bag, wet paper towels, and a used nicotine patch on the floor. The floor was visibly dirty throughout the room, and a used nicotine patch was also stuck to the shower wall. Additionally, a black substance was noted around the base of the shower area where the wall and floor meet. Both the ADON and the Lead Housekeeper acknowledged the unclean condition of the room during interviews, with the Lead Housekeeper stating that the floors should be swept and mopped and all debris removed, but that the dark substance remained despite cleaning attempts. The Administrator reported there was no specific policy or checklist for cleaning the bathrooms.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe and appetizing temperatures, resulting in multiple residents receiving cold or unpalatable meals. Observations revealed that residents who ate in their rooms frequently received food that was cold by the time it reached them, with some residents reporting that staff would not reheat their meals due to the lack of accessible microwaves. Several residents indicated that their food was often cold, and some left meals uneaten or sought food outside the facility as a result. Trays were observed sitting in hallways for extended periods before being distributed, and the plastic coverings intended to maintain temperature were sometimes removed prematurely. Dietary staff attempted to keep food warm using plate warmers and heated plates, but these measures were insufficient, as food lost heat quickly after plating. The facility relied on open metal carts for food transport, and delays in tray delivery by nursing staff further contributed to the problem. Residents also reported not always receiving the food they ordered, not being offered alternative menu options, and not always being served the prescribed diet. Resident council minutes and grievance logs documented ongoing complaints about cold food, limited choices, and poor food quality over several months. Interviews with dietary and administrative staff confirmed awareness of the issue, with acknowledgment that heated transport carts had only recently been approved and would not be available for some time. In the interim, there were no additional measures from the kitchen to keep food hot, and the process for timely meal delivery was inconsistently followed. The facility's own policy required food to be served at acceptable temperatures, but observations and resident feedback indicated this standard was not being met.
Failure to Maintain Clean and Sanitary Environment Due to Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment on one of two units observed for cleanliness. Multiple observations revealed that a resident's bathroom was not stocked with toilet paper or paper towels, the bathroom sink was loose, and the carpet was stained and emitted a foul odor due to frequent spills of bodily fluids. The resident reported that his room was not regularly cleaned, with dust accumulation on surfaces and debris, including food and paper, remaining on the floor for extended periods. The resident also indicated that staff did not prioritize his room's cleanliness, and debris he swept into the hallway remained unaddressed. Further observations on the same and following day showed that several resident rooms and bathrooms had soiled floors with unidentified dried substances, heavily stained carpets, and various debris such as used tissues, paper scraps, and food items. Common areas, including the front entry, hallways, and ice cream shoppe, were noted to have visible dust and dirt buildup, particularly on baseboards. Housekeeping staff were observed to be insufficiently present, with only one housekeeper seen working in certain areas and no staff observed cleaning other assigned areas during the survey period. Interviews with housekeeping staff and the supervisor revealed that the department was understaffed, with some housekeepers absent and no coverage for their assignments. Cleaning routines were inconsistently followed, with some areas only cleaned as needed and dusting in common areas performed weekly rather than daily. The facility's housekeeping policy required daily cleaning of high-touch areas and regular cleaning of carpets and bathrooms, but these standards were not met during the survey period, resulting in unsanitary conditions in resident rooms and common areas.
Failure to Accommodate Resident's Showering Preference Due to Inadequate Coordination for Port Dressing
Penalty
Summary
The facility failed to provide or document showers for a resident who was admitted with end stage renal disease requiring dialysis, a malignant neoplasm of the left breast, and a need for assistance with personal care. Despite the resident's expressed preference and ability to shower with her dialysis port covered, she did not receive a shower during her stay. The resident reported that prior to admission, she managed to shower safely by covering her port with a product from a pharmacy, but after admission, staff repeatedly told her they were waiting for a physician's order for a dressing to cover her port, which was never obtained or documented. The resident denied ever refusing a shower, stating she only needed her port covered to do so. Observations confirmed that the resident's shower was unused, and her towels remained dry and folded. Record review showed that the resident only received sponge baths and that documentation indicated refusals for showers, but there was no evidence of attempts to contact the physician for a dressing order or to accommodate her showering preference. The DON later confirmed that Tegaderm dressings, which could be used to cover the port, were available in stock and did not require a physician's order, and that the resident could have had a shower at any time. The facility's policy required that residents receive care in accordance with their choices and professional standards, but there was no documentation that the resident's preference for showers was accommodated or that appropriate steps were taken to enable her to shower safely.
Failure to Properly Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly followed up, investigated, and resolved for three residents and over three months of Resident Council meetings. Specific grievances included complaints about cold and sometimes frozen meals, inadequate showering opportunities, and insufficient room cleaning. The facility's grievance logs showed that while some resolutions were noted, such as conducting audits, temperature checks, and instructing staff to offer showers or clean rooms, the documentation of follow-up actions and investigations was vague and lacked detail. Resident Council minutes also reflected ongoing concerns about food quality, temperature, and variety, with repeated issues being raised over several months. Confidential interviews with residents further corroborated these concerns, with reports of consistently cold and inedible food, lack of alternative meal options, and improper diets being served. The Administrator acknowledged that responses to grievances and Resident Council concerns were not specific and that staff documentation did not clearly outline the actions taken to address the complaints. The facility's own grievance policy required prompt efforts to resolve grievances, thorough documentation of investigations, and communication of resolutions, but these standards were not met in the reviewed cases.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility failed to ensure that residents who wanted to register to vote were registered and that those who were registered were able to vote in the 2024 Presidential Election. This deficiency affected five residents who expressed a desire to vote but encountered various obstacles. Resident B indicated that his democratic right was violated because he was not registered to vote. Resident E did not receive his absentee ballot, and Resident F was not assisted in getting up to vote. Resident D expected someone to come to the facility to assist with voting, but this did not happen. Resident C signed papers to vote but did not receive an absentee ballot. The Activity Director (AD) attempted to facilitate the voting process by contacting the voting board, which sent representatives to register residents. However, the AD did not maintain a list of residents who wanted to register, leading to some residents being upset about not being able to vote. The Mobile Voting Board (MVB) visited the facility to register residents and was supposed to return to assist with absentee voting, but this did not occur as planned. The Executive Director's investigation noted that Resident B was the only known resident who did not get a chance to vote because he was not registered. Further interviews revealed that the MVB had left applications for voter registration and travel board voting at the facility, but some residents did not complete or return these applications. The Director of Nursing was unaware of the residents' desire to vote and the issues they faced. The facility's policy on resident rights, which includes the right to vote, was not effectively implemented, resulting in the residents' inability to exercise their voting rights.
Deficient Call Light Response Times
Penalty
Summary
The facility failed to ensure a timely and appropriate response to grievances related to answering call lights, affecting all 11 residents who participated in a resident council meeting. The issue was first documented in the resident council meeting minutes from July 2024, where residents reported waiting 1 to 2 hours for call lights to be answered, with the situation worsening at night. Despite reeducation efforts, the problem persisted, as noted in subsequent meetings in October and November 2024, where residents continued to report delays, particularly during night and weekend shifts. The residents expressed that the issue was a recurring topic in their meetings and that grievances had been filed multiple times, with only temporary improvements observed. The grievance logs from February to September 2024 further highlighted the ongoing issue, with multiple grievances filed by residents and their families regarding delayed call light responses. Resolutions to these grievances typically involved meetings with staff or coaching, but the problem persisted. Interviews with the Executive Director and Director of Nursing revealed that the facility's primary response to the issue was monthly in-services and reeducation, but no additional measures were identified. The facility's policy on call light response, dated January 2023, emphasized the importance of staff being aware of and responding to call lights, but the policy was not effectively implemented, as evidenced by the continued grievances and resident feedback.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the memory care unit's main dining room and in two residents' rooms. During an initial tour, remnants of feces were observed in the dining room corner, which were not cleaned up after a resident's incontinent episode. Despite attempts to clean the area with an industrial carpet cleaner, the stains and debris remained. A Certified Nursing Aide identified the stains as likely being from a resident with a history of using the bathroom in inappropriate places. The Floor Tech acknowledged that the area needed spot cleaning, which had not been done. Additionally, the facility failed to ensure the floors in two residents' rooms were free from large areas of staining due to incontinent episodes. In one room, a crumpled pile of linens with a large yellow/brown stain was observed, and the room smelled strongly of urine. The floor tiles were deeply discolored due to urine seeping under a fall mat. A similar situation was observed in another resident's room, where the tiles were also discolored. The Floor Tech admitted that the tiles needed special cleaning, but no request for work or replacement had been made.
Deficiencies in Fall Prevention, Supervision, and Medication Management
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident with a history of falls, resulting in a nasal fracture. Resident H, who had diagnoses including abnormalities of gait and mobility, lack of coordination, muscle weakness, difficulty in walking, and a history of falling, was observed without necessary safety measures such as a reachable call light and padded side rails. Despite having a care plan that required these interventions, they were not in place, leading to a fall that resulted in significant injury. The resident was found with bruising and was later diagnosed with a nasal fracture at the hospital. Another deficiency involved a resident with dementia who exhibited intrusive wandering behaviors, entering other residents' rooms and causing distress. Despite being on a secured memory care unit, Resident 193 was observed wandering without purpose and entering other residents' rooms, which led to altercations. The staff attempted to redirect her, but she continued to wander, indicating a lack of effective supervision and intervention to manage her behavior. Additionally, the facility's Elopement Binder was not up to date, failing to include current residents at risk for elopement. This oversight included residents with documented risks for elopement who were not listed in the binder, compromising their safety. Furthermore, medications were left at the bedside for two residents without proper orders or assessments, posing a potential risk for accidents. These deficiencies highlight the facility's failure to ensure a safe environment and adequate supervision for its residents.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during medication administration. On the morning of January 14, 2025, a Qualified Medication Aide (QMA) was observed administering medications to multiple residents without performing hand hygiene between each resident. Specifically, the QMA did not wash her hands after administering medications to three residents before proceeding to the next. Additionally, when administering ear drops to a resident, the QMA used an ungloved hand to manipulate the resident's ear and did not wear gloves on the other hand while administering the drops. This was contrary to the facility's policy on ear drop instillation, which requires the use of gloves to comply with standard precautions.
Failure to Ensure Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by two separate incidents involving Resident 40 and Resident 1. In the first incident, Resident 40, who resides in a secure memory care unit and requires assistance with personal care due to severe dementia and anxiety, was not assisted to the restroom in a timely manner. Despite multiple requests for assistance, Resident 40 was left waiting for over 20 minutes, resulting in incontinence. Staff members, including an LPN and two CNAs, were aware of the resident's need but failed to provide timely assistance. In the second incident, Resident 1, who has hemiplegia and hemiparesis following a stroke, was subjected to harsh treatment during a transfer from the toilet to her wheelchair. The resident expressed pain and distress during the transfer, and a staff member responded inappropriately by speaking harshly. Additionally, photographs of Resident 1 in her wheelchair, intended to guide staff on proper positioning, were displayed in a manner that compromised her privacy and dignity, as they were visible from the public hallway. The facility's failure to address these issues reflects a lack of adherence to policies that promote respect and dignity for residents. The Executive Director and Director of Nursing acknowledged the inappropriate actions and the need for staff to be attentive to residents' concerns, but the incidents highlight deficiencies in the facility's care practices.
Failure to Document Advanced Directives for Residents
Penalty
Summary
The facility failed to ensure that residents had advanced directives or code statuses documented in their medical records. Resident 250, who was admitted with multiple diagnoses including GERD, COPD, osteoporosis, and schizoaffective disorder, did not have an order or care plan addressing her advanced directive wishes upon initial review. The Director of Nursing (DON) later provided a care plan and order for her advanced directive, indicating that the documentation was not present until requested. The DON acknowledged that advanced directives should be obtained upon admission. Resident 48, with diagnoses including stroke, diabetes, hypertension, and major depressive disorder, had conflicting documentation regarding her code status. While a physician's order indicated a full code status, her care plan listed a DNR status. Resident B, admitted with COPD, diabetes, chronic kidney disease, and respiratory failure, did not have a physician's order or care plan for his advance directive status upon admission. He reported not being asked about creating an advance directive until later. The DON admitted to issues with creating residents' advance directive statuses, noting that it was now everyone's duty to ensure completion.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care plans. Resident 193, who was observed wandering aimlessly and entering other residents' rooms without purpose, was not coded for wandering behaviors in her MDS assessment. Despite multiple nursing progress notes indicating her confusion and wandering tendencies, the admission MDS inaccurately reflected no wandering behaviors during the assessment's 7-day look-back period. This discrepancy highlights a failure in accurately assessing and documenting the resident's behaviors, which are crucial for her care and safety. Similarly, Resident 81's MDS assessment failed to include his mental health diagnosis in the PASRR section, despite having a significant change in his condition with a new diagnosis of bipolar disorder with manic and psychotic features. The PASRR Level II assessment had previously identified him as having a major mental illness, yet this was not accurately reflected in the MDS. The Social Service Director acknowledged these coding errors, indicating a lapse in the facility's assessment and documentation processes, which are essential for providing appropriate care to residents with complex needs.
PASRR Screening Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure accurate information was submitted on a Pre-Admission Screen and Resident Review (PASRR) Level I for Resident 68. This resident, who was observed in the secured memory care unit, had diagnoses including psychotic disorder with delusions and unspecified dementia. However, the PASRR Level I indicated that Resident 68 did not require a Level II screen because it inaccurately stated she did not have a major mental illness or neurocognitive or dementia diagnoses. The Social Service Director acknowledged that the Level I should have included these diagnoses to determine if a Level II screen was necessary. Additionally, the facility failed to complete a new PASRR Level I for Resident 90, who was admitted under a 30-day exclusion for pre-admission screening. Resident 90 had diagnoses including schizophrenia, depression, and anxiety. Her initial Level I was completed, allowing a 30-day stay, but a new Level I was not completed after the 30 days expired. The Social Service Assistant and the Director of Nursing were unable to provide an explanation for the missing documentation. The facility's policy requires that a Level I PASRR screening be completed prior to admission and retained in the resident's medical record.
Failure to Utilize G-tube for Medications and Nutrition
Penalty
Summary
The facility failed to provide appropriate services and documentation for a resident with a gastrointestinal tube (G-tube). Resident 295, who had a G-tube placed after a cerebrovascular accident (stroke), was observed and reported that the G-tube was not being used for medications or feeding supplements. Interviews with multiple Licensed Practical Nurses (LPNs) confirmed that the G-tube was not utilized for its intended purposes, and the staff only followed orders to flush it. The resident was on a regular diet and had orders for Glucerna to be administered if she consumed less than 50% of her meals, but this was not necessary as she regularly ate over 50% of her meals. The medical record review revealed discrepancies in the administration of medications and nutritional supplements via the G-tube. The resident's Medication Administration Record (MAR) indicated that Glucerna was administered on several occasions, despite the resident's consistent meal consumption. Additionally, there was confusion regarding the resident's weight gain, initially suggesting a significant increase, which was later clarified with documentation from a previous healthcare provider. The Director of Nursing (DON) and the Regional Director of Clinical Services acknowledged the oversight in the resident's medical record and the incorrect orders for medication administration via the G-tube.
Deficiencies in Oxygen Administration and Equipment Hygiene
Penalty
Summary
The facility failed to ensure proper oxygen administration for two residents using nasal cannulas. Resident Z, who had a history of idiopathic peripheral autonomic neuropathy, diabetes mellitus, edema, and pneumonia, was observed with her oxygen concentrator set incorrectly at 1 liter per minute (lpm) instead of the prescribed 2 lpm. Her oxygen saturation levels were below the recommended threshold, and she experienced shortness of breath and dizziness. The nasal cannula was not dated, and the humidifier bottle had not been changed since 12/31/24, indicating a lapse in maintaining equipment hygiene and functionality. Resident B, diagnosed with chronic obstructive pulmonary disease (COPD), diabetes mellitus, chronic kidney disease, and obstructive sleep apnea, also experienced improper oxygen administration. His oxygen concentrator was set at 3 lpm instead of the prescribed 2 lpm. Additionally, his bipap mask and tubing were found uncovered and contaminated with dust, dirt, and debris, compromising their cleanliness and safety. Resident B reported delays in receiving his bipap mask at night, sometimes having to sleep without it, which could exacerbate his respiratory conditions. The facility's policy on oxygen administration, which requires humidifier bottles to be changed every 7 days and respiratory supplies to be stored properly, was not adhered to. The Director of Nursing confirmed that the bipap mask should be covered when not in use, and the tubing should not be on the floor. These deficiencies highlight a failure in maintaining proper respiratory care and equipment hygiene for residents requiring oxygen therapy.
Failure to Obtain Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to obtain a blood pressure reading as indicated in a medication order before administering a blood pressure medication to one of the residents reviewed. The resident, identified as Resident 250, had multiple diagnoses including gastro-esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), age-related osteoporosis, and schizoaffective disorder. The resident had an order for prazosin HCL, a blood pressure medication, to be administered at bedtime with instructions to hold the medication if the systolic blood pressure (SBP) was less than 100 or the pulse was less than 60. However, the order did not include instructions to obtain a blood pressure reading prior to administering the medication. During an interview, the Director of Nursing (DON) acknowledged that a blood pressure reading should have been included in the order. The facility's policy on medication administration emphasized the importance of noting the resident's history and any parameters around drug administration.
Medication Storage and Expiration Management Deficiency
Penalty
Summary
The facility failed to properly manage and store medications in accordance with accepted professional principles, as observed in two medication rooms. In one instance, a bottle of lorazepam belonging to a resident was found in the refrigerator without a date indicating when it was opened. This lack of proper labeling could lead to the use of expired or compromised medication. Additionally, in the 100-medication room, an opened bottle of aplisol, used for tuberculosis testing, was found with an expiration date that had already passed. Further observations in the 300-medication room revealed an opened bottle of chlorpactin belonging to another resident, which was sent by the pharmacy with an expiration date of 12/30/24. Despite the RN's assertion that the medication was still valid, it was determined that the medication had expired as it was only good for 10 days in the refrigerator. The facility's policy on the storage and expiration dating of medications was not adhered to, as expired medications were not separated from other medications for destruction or return to the pharmacy.
Wheelchair Maintenance Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain two residents' wheelchairs in safe operating conditions. Resident 1's wheelchair had a broken left arm that moved freely forward and backward, which was observed on multiple occasions. Despite the Regional Director of Clinical Services indicating that the wheelchair was fixed, the Certified Occupational Therapy Assistant noted that a bolt was completely broken, and a replacement part had been ordered but not yet received. The Maintenance Director mentioned that the wheelchair could be fixed within an hour if another wheelchair was available for temporary use. However, the alternative wheelchair was not suitable for Resident 1, leading her to sit on the bed while repairs were made. The Director of Nursing indicated that the broken wheelchair should have been reported to the Maintenance Director by the Certified Nursing Aides or therapy staff. Resident 14's wheelchair had a missing right brake handle, leaving a hollow metal bar exposed, which was a safety concern as the brake could not engage properly. This issue persisted throughout the survey week. Although a wheelchair extension bar was eventually replaced, it remained uncapped, posing a risk of skin tears. The Director of Therapy was unaware of the uncapped handle, and the Executive Director did not have a specific policy related to wheelchair maintenance, although a wheelchair inspection checklist and a preventative maintenance policy were provided. The policy indicated that wheelchairs with broken or missing parts should be taken out of use immediately and reported for repair.
Failure to Update Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised as needed for a resident with updated interventions. Resident 14, who resides in a secured memory care unit and has a diagnosis of dementia, was observed without a brace or splint throughout the survey week, despite a picture in her room instructing that a brace should be worn at all times. Her care plan, dated over a year prior, indicated the need for a left edema glove and wrist orthotic at all times, which was no longer necessary according to the Director of Therapy. The care plan had not been updated to reflect the resident's current needs, and the outdated instructions remained in her room.
Failure to Provide Routine Podiatry Care for Resident
Penalty
Summary
The facility failed to ensure that a resident's activities of daily living (ADLs) were completed, specifically in the case of a resident with multiple health conditions including chronic obstructive pulmonary disease, diabetes mellitus with chronic kidney disease, acute and chronic respiratory failure with hypoxia, and obstructive sleep apnea. The resident was dependent on staff for emotional, intellectual, physical, and social needs, as well as assistance with mobility and ADLs. On a specific date, the resident's toenails were observed to be extremely long and jagged, causing discomfort and preventing the resident from placing them under a blanket. The facility's records indicated that the resident was not seen by a podiatrist during scheduled visits on multiple occasions, despite being added to a recall list. The Director of Nursing acknowledged that residents should be seen routinely by the podiatrist, and the process involves nurses notifying the Social Services Director, who then compiles a list of residents to be seen. The facility's policy on resident rights emphasizes the right to reasonable accommodation of resident preferences, which was not upheld in this instance.
Inadequate Supervision and Care Planning for Aggressive Resident with Dementia
Penalty
Summary
The facility failed to provide adequate supervision, monitoring, and interventions for a resident diagnosed with dementia and a history of aggressive behaviors. This deficiency resulted in multiple incidents of verbal and physical threats, as well as resident-to-resident altercations. The resident, identified as having severe cognitive impairment, exhibited physical behavioral symptoms directed toward others, which significantly interfered with care and posed a risk to both the resident and others. The resident was involved in several incidents where they physically assaulted other residents, leading to injuries and the need for police involvement. Despite these incidents, the facility's care plan for the resident lacked specific interventions tailored to the resident's needs and did not adequately address the behavioral health needs. The care plan was not updated with new interventions following each incident, and the facility's response was limited to separating residents and placing them on safety monitoring. The facility's policy on dementia care emphasized the need for person-centered care and individualized interventions, but the implementation was lacking. The resident's medical record did not reflect person-centered, individualized care, and the facility failed to revise care plans effectively after each incident. This lack of appropriate care planning and intervention contributed to the ongoing aggressive behaviors and altercations involving the resident.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and destruction of medications and biologicals across multiple medication carts. During observations, several opened bottles of eye drops and nasal sprays were found without open dates, which is against the facility's policy that requires medications to be dated when opened. Additionally, some medications were found to be almost full despite records indicating they were administered daily, suggesting discrepancies in medication administration or documentation. The Director of Nursing (DON) acknowledged that medications should be dated and replaced according to the manufacturer's instructions. Further observations revealed that over-the-counter medications were not properly labeled with resident names or instructions for use. Some medications were found with worn and faded labels, and there were inconsistencies between the number of doses documented as administered and the remaining medication count. The DON indicated that residents could have multi-dose bottles provided by family members, but these should have been labeled with the resident's initials, drug name, and physician's order for use. Additionally, the storage of medications was not in compliance with facility policy. Biologicals such as PeriGuard ointment were found unbagged and stored among oral medications, which is against the policy that requires treatments to be stored separately in the treatment cart. Nebulizer vials were also improperly stored, and there was a lack of proper labeling and storage for these items. The DON and other staff members acknowledged these issues, indicating that night shift nurses were responsible for checking and cleaning the medication carts, but these tasks were not consistently performed.
Failure to Provide Showers as Per Resident's Preference
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident B, was provided showers according to his preference, which was twice a week on Mondays and Thursdays. Observations and interviews revealed that Resident B was not receiving showers as scheduled. The medical record review showed that Resident B had only received one shower in June, six in July, and three from August 1 to 16. Despite the resident's preference for two showers per week, there was a lack of documentation in the care plans regarding any specific refusal of showers or interventions to address this issue. Interviews with staff, including a CNA and the Director of Nursing (DON), indicated that if a resident refused a shower, the nurse was supposed to verify and offer a bed bath. However, the showers were prescheduled according to room numbers, not individual preferences. The DON acknowledged that there was no documentation in the medical record indicating the resident refused showers, except for one entry in the nurse's notes. The facility's policy on resident rights emphasized the resident's right to participate in care planning and receive services included in the plan of care, which was not adhered to in this case.
Infection Control Lapse in Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during catheter care for a resident with a suprapubic catheter. During an observation, a Qualified Medication Aide (QMA) changed the resident's foley catheter leg drainage bag to a regular urinary drainage bag without sanitizing the tip of the drain tube or catheter before connecting them. Additionally, the QMA did not wash or sanitize her hands after removing gloves and before handling the resident's drinking cup. The resident had a history of prostate cancer, diabetes with neuropathy, obstructive and reflux uropathy, bladder neck obstruction, and was at risk for infections. Interviews with staff revealed inconsistencies in following proper procedures for changing catheter bags. The QMA did not acknowledge the need to wash hands or sanitize the catheter drain tip, while other staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), described correct procedures that included hand hygiene and sanitizing the catheter tubing. The facility's policies on hand hygiene and urinary catheter management were provided, indicating the need for aseptic techniques and hand hygiene, but these were not followed during the observed incident.
Failure to Address and Track Resident Grievances
Penalty
Summary
The facility failed to adequately address and track grievances raised by residents and their families over a five-month period. The Resident Council meetings highlighted several unresolved concerns, including residents not receiving scheduled showers, delayed response times to call lights, and missing laundry items. Despite a process in place where the Activity Director was supposed to fill out grievance cards and distribute them to the appropriate department managers and the Executive Director, there was no evidence of follow-up or resolution. The Activity Director confirmed that she had not received any responses from the Executive Director or department managers regarding the grievances documented on the blue cards. Interviews with residents and a family member revealed ongoing issues with personal care and hygiene, such as residents not receiving their scheduled showers. Residents E, K, and Q reported not receiving the showers they were scheduled for, and Resident R's family member expressed concerns about the resident's hygiene and room cleanliness. Despite completing grievance cards, these individuals did not receive any feedback or resolution from the facility. The Executive Director, who had just started working at the facility, acknowledged the lack of a response system for grievances, which was contrary to the facility's policy that required follow-up on all complaints and suggestions presented at Resident Council meetings.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for two residents, GG and H, as required. Resident GG was observed on 4/16/24 with multiple pressure ulcers, including an unstageable pressure ulcer on the right ischium and deep tissue injuries on both heels. Despite these observations, a review of Resident GG's care plan on 4/17/24 revealed that it did not address the current status of her skin integrity, specifically the right ischium wound. The care plan was only updated after the surveyor's review on 4/17/24. Resident H was admitted on 4/5/24 with diagnoses including late-onset Alzheimer's disease and a traumatic hemorrhage of the cerebrum. Upon admission, Resident H had a pink open lesion on the coccyx, which was documented as worsening by 4/6/24. Despite this, the care plan dated 4/8/24 only indicated that the resident was at risk for skin integrity issues and did not document the existing wound. The facility's policy required comprehensive care plans to be reviewed and revised by the interdisciplinary team after each assessment, but this was not followed for Resident H.
Failure to Ensure Effective Wound Management
Penalty
Summary
The facility failed to ensure effective wound management for a resident admitted with an open area on the coccyx that worsened into a stage 3 pressure ulcer. Upon admission, the resident had a pink open lesion on the coccyx, but the documentation lacked detailed descriptions, measurements, or staging of the wound. The resident's care plan included interventions such as keeping the skin clean and dry, using a pressure-reducing mattress, and applying Calmoseptine ointment, but these measures were not effectively implemented or documented. The wound was not included in the wound tracking log, and the wound nurse did not follow up on the resident's condition promptly, leading to the deterioration of the wound to a stage 3 pressure ulcer with full-thickness tissue loss and serous drainage. The resident's responsible party expressed dissatisfaction with the care provided, noting delays in rehabilitative services, the resident being left in bed, and the room smelling of urine. Observations confirmed that the resident was often left lying flat in bed without proper positioning devices to offload pressure from the coccyx. The wound nurse and wound MD were not promptly notified or involved in the resident's wound care, and the wound was not assessed or documented accurately until it had significantly worsened. The facility's internal wound tracking log initially did not include the resident, and there was a lack of consistent documentation and communication regarding the resident's wound status. Interviews with staff revealed inconsistencies in wound assessment and documentation practices. Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) indicated that they were not responsible for staging wounds and that the wound nurse or DON should handle this task. However, the wound nurse and DON failed to ensure timely and accurate documentation and follow-up. The wound MD confirmed that the resident was not on the wound list during his previous visit, and the resident's wound was not assessed until it had worsened. The facility's policy on wound documentation and assessment was not followed, resulting in inadequate treatment and monitoring of the resident's pressure ulcer.
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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