Willows Of New Castle
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Indiana.
- Location
- 1023 N 20th St, New Castle, Indiana 47362
- CMS Provider Number
- 155089
- Inspections on file
- 24
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Willows Of New Castle during CMS and state inspections, most recent first.
Surveyors found that the kitchen stove hood and sprinklers above a frequently used griddle/stove had heavy greasy buildup, a furry substance covering the back panels and sprinklers, and stringy dark debris hanging over the food preparation area. The Dietary Manager reported that the griddle/stove was used regularly, had noticed the buildup, but had been told not to clean the hood to avoid voiding the warranty. Documentation showed the exhaust system was only scheduled for cleaning every 180 days, and the observed conditions did not comply with the facility’s sanitation policy requiring food service areas to be kept clean and sanitary, potentially affecting all residents who dine at the facility.
A resident with multiple chronic conditions and moderately impaired decision-making received another resident’s dementia medication due to a medication administration error witnessed by an LPN. After the error was reported, an NP instructed that the resident’s vital signs be monitored and that the resident be observed for anxiety and tremors every shift for 24 hours. However, there was no assessment, no progress note, and no vital signs documented in the EHR following the error, despite facility policy requiring assessment, monitoring, and documentation after medication errors.
A resident with traumatic brain injury, dementia, and bilateral upper extremity contractures had physician orders and a care plan for daytime use of bilateral palm protectors/hand orthoses, but surveyors repeatedly observed the resident without one or both splints in place. The MAR showed no refusals, and the resident was documented as severely impaired in decision making and needing assistance with self-care. Despite a facility policy assigning nurses responsibility for consistent use and monitoring of orthotic devices, staff did not ensure both hand splints were consistently applied as ordered.
A resident with dementia, agitation, and anxiety was admitted in a confused and combative state and quickly began wandering, entering other residents’ rooms, handling their belongings, and becoming physically aggressive with staff when redirected. His ordered psychotropic medication (including Risperidone) was not available on admission and was delayed until the second day, during which time he continued to roam hallways, refuse to stay in his room, and intrude into rooms of multiple residents, causing them discomfort and fear. Behavior notes and staff interviews described ongoing episodes of the resident striking staff, spitting on a nurse, lying on the floor at the nurse’s station, attempting to get into other residents’ beds, and being difficult to redirect. Residents reported feeling uncomfortable and scared when he entered their rooms, closed doors, lay on their beds, or spoke to them in a threatening manner. Despite persistent behaviors and complaints, continuous one-on-one supervision and effective monitoring were not implemented promptly, resulting in a failure to provide appropriate dementia care and services consistent with the facility’s own dementia care policy.
A resident with dementia, agitation, and anxiety was admitted with hospital discharge orders for daily Risperidone and bedtime Trazodone, but these medications were not available or administered on the day of admission and were first given the following day. Nursing notes documented that shortly after arrival the resident was confused, combative, refused staff direction, entered a roommate’s area, moved items, made contact with the roommate, and later had to be moved due to screaming with a roommate and was found in another resident’s room while remaining combative. An LPN reported that the resident’s discharge medications, including scheduled Risperidone, were not available until the second day, and that an emergency behavior medication given in response to the behaviors had little to no effect, contrary to the facility’s pharmacy services policy requiring timely provision and administration of routine and emergency drugs.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report notes insufficient safety measures and supervision, but does not specify further details about those involved.
The facility failed to treat residents with dignity, as evidenced by delayed response to a resident's call light, resulting in incontinence, and rough treatment of a confidential resident. Resident 9 experienced frequent delays in receiving assistance, leading to distressing incontinence episodes. A confidential resident reported feeling disrespected by staff, who were rough and dismissive of their care preferences. Another resident confirmed the unkind treatment of the confidential resident, highlighting a lack of respect and dignity in care.
A resident with stress incontinence and osteoarthritis did not receive a bath or shower for seven days while in COVID-19 isolation, despite requesting one. The resident's care plan specified regular bathing, but documentation showed missed scheduled showers. Staff indicated that isolated residents could shower last in the day, but this was not followed, leading to the deficiency.
A resident, who is cognitively intact and has diabetes mellitus and cerebral infarction, did not receive routine dental care as required by the facility's policy. The facility had issues with their previous dental service provider and did not ensure annual dental exams were conducted, even after switching to a new provider. The Social Service Director confirmed that residents were only taken to outside providers if they had dental problems.
The facility failed to provide thorough and accurate assessments for two residents with c-diff infections. Documentation for both residents lacked details on stooling status and isolation measures. The DON acknowledged the inconsistency and expected daily assessments, but staffing changes and inadequate policy implementation contributed to the deficiencies.
The facility failed to provide prompt and accurate treatment for two residents with UTIs. One resident was prescribed an antibiotic despite resistance shown in the C&S report, and nursing assessments were incomplete. Another resident experienced a delay in obtaining a urine sample for testing, with insufficient documentation of symptoms. The DON acknowledged these issues and noted the absence of a specific documentation policy.
Unsanitary Grease and Debris Buildup on Kitchen Stove Hood and Sprinklers
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions of the kitchen stove hood that had the potential to affect all 58 residents who dine in the facility. During a kitchen tour with the Dietary Manager (DM), the stove hood above a regularly used griddle/stove was observed to have a significant amount of built-up greasy debris on the back panels and sprinklers, with the back panels appearing to have a furry substance completely covering them and the sprinklers. There was also stringy, dark debris hanging from one of the sprinklers directly above the food preparation area. The service sticker on the hood showed it was last serviced on 11/26/25 with the next service scheduled for May 2026, and a work order confirmed the kitchen exhaust system was scheduled for cleaning every 180 days for two years. During the interview, the DM acknowledged noticing the buildup but stated she had been told not to clean the hood because it would void the warranty. The facility’s Sanitation policy required all food service areas to be kept clean, sanitary, and free from litter and rubbish, and the observed condition of the stove hood did not meet this standard. No specific residents were individually identified in the report; the deficiency was cited as having the potential to affect all residents who receive meals prepared in the kitchen.
Failure to Assess and Monitor Resident After Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care, including assessment and monitoring, after a medication error involving Resident B. An LPN reported witnessing an RN administer one of Resident E’s morning medications to Resident B; this was later identified by the NP as rivastigmine 3 mg, a medication used to treat dementia. The NP stated that when the error was reported, she instructed the LPN to monitor Resident B’s vital signs and observe for anxiety and tremors every shift for 24 hours. The facility’s Medication Error policy required the nurse to assess and examine the resident’s condition, monitor and document the resident’s condition and response to interventions, and document actions taken in the medical record when a medication error occurs. Despite these requirements and the NP’s specific instructions, the Regional Nurse Consultant reported that there was no assessment, no progress note, and no vital signs documented in the EHR for Resident B following administration of Resident E’s medication. The floor nurse was identified as responsible for ensuring this was completed. Resident B’s clinical record indicated multiple diagnoses, including diabetes, chronic kidney disease, osteoporosis, hypertension, congestive heart failure, depression, anxiety disorder, intellectual disability, and a history of cerebral infarction, and an MDS assessment showed moderately impaired daily decision-making. The lack of documented assessment, monitoring, and vital signs after the medication error constituted the failure to provide care and services in accordance with physician orders, resident needs, and facility policy.
Failure to Consistently Apply Physician-Ordered Hand Splints for Contractures
Penalty
Summary
The facility failed to implement physician-ordered bilateral palm protectors/hand orthoses for a resident with bilateral hand contractures. On multiple observations over several days, the resident was seen without any splints in place on either hand, and later with a splint only on the left hand while the right-hand splint was on the bedside table or not in use. The resident’s care plan documented an alteration in functional performance requiring assistance with self-care and included an intervention for bilateral palm protectors per order. An Occupational Therapy assessment identified impaired ROM in both upper extremities due to contractures, and the quarterly MDS documented severe impairment in daily decision making and impaired ROM in both upper extremities. A physician’s order directed that the resident was to have bilateral palm protectors or hand orthoses during the daytime, removed at night and for bathing, with no documentation on the MAR of any refusals to wear the devices. Despite this, surveyors repeatedly observed the resident without one or both splints in place. During interview, the Regional Nurse Consultant stated that floor nurses were responsible for ensuring the resident had bilateral splints in place. The facility’s assistive device and splint policy stated that nurses were responsible to monitor for consistent use of such devices, including orthotic equipment and splints, to maintain or improve function, dignity, and quality of life.
Failure to Adequately Monitor and Manage Dementia-Related Wandering and Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and treat a resident’s dementia-related wandering and behavioral symptoms in accordance with its dementia care policy. Resident C was admitted with diagnoses including dementia with agitation and anxiety and was documented on admission as confused and combative. Within minutes of arrival, he refused to wait for a physical therapy evaluation, would not follow staff direction, moved into his roommate’s area, handled the roommate’s belongings, and made physical contact with the roommate. Verbal redirection was unsuccessful, and he became physical, striking staff. Later that evening, he and his roommate were screaming at each other, leading staff to temporarily move him to another room. During this period, he continued to leave his room, wander into other residents’ rooms, and remain physically combative with staff. The facility did not have Resident C’s discharge medications, including his scheduled Risperidone, available upon admission, and emergency medication obtained that night had little to no effect. His medications were not available until his second day at the facility. During this time, multiple female residents voiced that they wanted him kept away from them. Behavior notes documented that he was confused, ambulating in the hallways, refusing to stay in his bed despite repeated attempts, and wandering without purpose. He rummaged through his roommate’s belongings and irritated his roommate. Staff interviews confirmed that he repeatedly entered other residents’ rooms, was difficult to redirect, and was combative when staff attempted to intervene. One CNA reported that it was chaotic when he was not provided one-on-one supervision and that he wandered into other residents’ rooms, including climbing into bed with another resident as reported in shift report. Multiple residents described specific incidents of Resident C entering their rooms uninvited. One resident reported that he came into her room, shut the door, removed her wheelchair foot pedals from the bed, asked where to put them, and ultimately placed them in the trash before leaving. On another occasion, he lay on her bed until staff redirected him. Another resident stated that he entered her room, closed the door, sat on the empty bed, turned back the covers, made inappropriate hand signs, and told her to “shut up,” which left her feeling scared and uncomfortable. Behavior notes further documented that he continued to enter other residents’ rooms, strike staff during redirection attempts, spit on a nurse, lay on the floor at the nurse’s station, and exhibit exit-seeking behavior. Staff, including the Social Services Director and Administrator, acknowledged that he wandered everywhere, went into other residents’ rooms, and was aggressive with staff, and that he was not placed on one-on-one supervision until several days after admission, despite ongoing behaviors and resident complaints. These actions and inactions demonstrate the facility’s failure to provide appropriate monitoring and dementia care services to address his wandering and behavioral symptoms as required by its own dementia care policy. Additional documentation showed that Resident C wandered the facility for entire shifts, entered multiple residents’ rooms, upset residents, and at one point sat on another resident’s bed, removed his pants and socks, and attempted to lie down while the room’s occupant became angry and told him to leave. Staff required multiple attempts to redirect him from these rooms. Residents reported feeling uncomfortable and, in at least one case, scared by his presence and behavior in their rooms. The Social Services Director stated that the facility had believed he was not ambulatory and was surprised by his ability to walk everywhere upon admission, and also noted that he was more confused when off his original hospital medications. Despite the facility’s dementia care policy requiring assessment, individualized care planning, person-centered non-pharmacological approaches, environmental modifications, and ongoing monitoring of interventions for effectiveness, the record and interviews show that Resident C’s wandering and intrusive behaviors into other residents’ rooms persisted over several days without timely implementation of effective monitoring and supervision. The Administrator confirmed that Resident C wandered into other residents’ rooms and was aggressive with staff, and that other residents were upset because they were not used to residents entering their rooms. Staff accounts and behavior notes consistently described ongoing wandering, room entries, combative behavior, and difficulty with redirection over multiple days following admission. The delay in obtaining his scheduled psychotropic medications, the lack of immediate and sustained one-on-one supervision despite repeated incidents, and the continued reports from residents and staff about his intrusive and aggressive behaviors collectively demonstrate the facility’s failure to provide appropriate treatment and services for a resident with dementia-related wandering and behavioral symptoms, as required by its dementia care policy and regulatory standards.
Failure to Provide Ordered Psychotropic Medications at Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident’s ordered psychotropic medications were available and administered as scheduled upon admission. The resident, who had diagnoses including dementia with agitation and anxiety, was discharged from the hospital with orders for Risperidone 0.5 mg tablets (three tablets once daily, next dose due at 4:00 p.m.) and Trazodone 50 mg at bedtime (next dose due at bedtime). Review of the February medication administration record showed that neither the 4:00 p.m. dose of Risperidone nor the bedtime dose of Trazodone were given on the day of admission, and both medications were first administered the following day. The nurse admission note documented that shortly after arrival the resident was confused, combative, refused to wait for physical therapy, refused staff direction, entered the roommate’s area, moved items, and made contact with the roommate, with verbal redirection failing and the resident striking staff. A later nursing note the same evening documented that the resident had to be temporarily moved to another room because he and his roommate were screaming at each other, and that the resident was found in another resident’s room and remained combative with redirection. In an interview, the LPN on duty at admission stated that the resident’s discharge medications, including the scheduled Risperidone, were not available for administration when the resident arrived and were not available until the resident’s second day in the facility. The LPN reported that an emergency behavior medication was administered with little to no effect while the resident was having behaviors and was difficult to redirect. The facility’s Pharmacy Services policy stated that the facility would provide pharmaceutical services and procedures to assure accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet each resident’s needs.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or details about the residents involved are not provided in the report. No additional information regarding the medical history or condition of any resident at the time of the deficiency is included.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during care, as evidenced by the experiences of two residents. Resident 9 reported that it took an hour for staff to respond to her call light, resulting in incontinent episodes of urine and feces in bed. This situation occurred at least once a week, causing distress and feelings of unnecessary discomfort for Resident 9. The resident's clinical record indicated she was cognitively intact and required substantial assistance with personal hygiene and moderate assistance with toilet transferring. Despite care plans indicating that incontinent care should be performed every two hours, Resident 9 experienced delays in receiving assistance. A confidential resident also reported feeling disrespected during care, stating that staff were often rough, hollered at them, and did not listen to their care preferences. This resident, who was cognitively intact, felt disrespected and bad about themselves due to the staff's behavior. Another resident, Resident 155, corroborated these claims, indicating that staff were unkind to the confidential resident and did not stop care when the resident expressed pain. The facility's administrator acknowledged the expectation for staff to treat all residents with respect, yet these incidents demonstrate a failure to uphold this standard.
Failure to Provide Scheduled Bathing for Resident in Isolation
Penalty
Summary
The facility failed to provide a bath or shower upon request and as care planned for a resident who was reviewed for bathing. The resident, who was diagnosed with stress incontinence and osteoarthritis of the left hand, reported that during a period when she had COVID-19, she went several days without receiving a bed bath or shower. Despite requesting a shower, the staff informed her that she could not have one due to her COVID-19 status and would need to bathe in her room. The resident indicated that no bed baths were offered or given, and she had to wash up on her own in her bathroom. The resident's care plan indicated she was to receive tub baths or showers as she preferred, with staff providing supervision or assistance. However, documentation showed that she did not receive a shower or bath on her scheduled days, resulting in a seven-day period without a bath or shower. Interviews with staff revealed that residents in isolation could take showers, but they were scheduled last to allow for sanitizing afterward. The facility's policy stated that residents should be provided showers as requested, with partial baths given between regular shower schedules, but this was not adhered to in the resident's case.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide routine dental care to a resident, identified as Resident 2, who expressed a desire to see a dentist during an interview. Resident 2, who is cognitively intact and has diagnoses including diabetes mellitus and cerebral infarction, had not received a dental exam since September 2022, despite having signed consent for dental services in May 2021. The facility's policy requires an annual inspection of the oral cavity, which was not adhered to in this case. The deficiency arose because the facility had issues with their previous dental service provider, who did not conduct regular visits or annual screenings for residents. After switching to a new dental company, the facility still did not ensure that residents received routine dental care. The Social Service Director confirmed that the facility did not offer to take residents to an outside provider for annual screenings, only addressing dental issues when problems arose. This lack of routine dental care provision is a direct violation of the facility's policy and the residents' rights to receive necessary health services.
Inadequate Documentation and Assessment for C-Diff Infections
Penalty
Summary
The facility failed to ensure that two residents diagnosed with Clostridium difficile infection (c-diff) received thorough and accurate assessments on a routine basis. Resident B, who had a history of urinary tract infections, systemic inflammatory response syndrome, Alzheimer's disease, and generalized muscle weakness, was diagnosed with c-diff upon admission to the hospital and returned to the facility. The clinical records for Resident B lacked documentation of stooling status, including the presence of diarrhea, abdominal pain, nausea, vomiting, or changes in appetite. Additionally, the records did not consistently indicate that Resident B was in contact isolation, nor did they specify the initiation and discontinuation dates for isolation. Resident C, diagnosed with unspecified dementia, ulcerative colitis, diabetes, and a history of severe sepsis, was suspected of having c-diff after experiencing frequent, loose, watery, and foul-smelling stools. A stool sample confirmed the c-diff diagnosis, and Resident C was placed in contact isolation and started on oral medication. However, the documentation for Resident C also failed to consistently address stooling status and did not always indicate the resident's isolation status. The Infection Control Surveillance report did not include Resident C's c-diff infection, and the quality and frequency of documentation declined over time. Interviews with the Director of Nursing (DON) revealed that the documentation for both residents was inconsistent and lacked the expected detail. The DON indicated that assessments for c-diff should be thorough and conducted at least daily, but the facility's guidelines for isolation continuation were not consistently followed. The former Infection Preventionist left employment unexpectedly, and the DON was out for surgery, which may have contributed to the documentation issues. The facility's policy on managing c-diff infections was not adequately implemented, leading to deficiencies in resident care.
Failure to Provide Prompt and Accurate UTI Treatment
Penalty
Summary
The facility failed to provide prompt and accurate treatment for two residents with urinary tract infections (UTIs). Resident B, who had a history of UTIs, was prescribed Cipro despite the culture and sensitivity (C&S) report indicating resistance to this antibiotic. The Director of Nursing (DON) acknowledged that the error should have been caught by the nursing staff and communicated to the physician. Additionally, the nursing assessments for Resident B were incomplete, lacking documentation on urinary status such as color, odor, and presence of blood or sediment. Resident D, who also had a history of UTIs, experienced a delay in obtaining a urine sample for C&S testing after reporting blood in her urine. The sample was not collected until several days later, and there was a lack of documentation regarding her symptoms. The DON noted that the attending physician might have delayed antibiotic treatment due to the resident's concurrent Covid-19 treatment with Paxlovid. The facility lacked a specific policy on documentation, and the DON expected thorough daily assessments for UTIs, which were not conducted.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
