Aperion Care Hanover
Inspection history, citations, penalties and survey trends for this long-term care facility in Hanover, Indiana.
- Location
- 410 W Lagrange Rd, Hanover, Indiana 47243
- CMS Provider Number
- 155208
- Inspections on file
- 46
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Aperion Care Hanover during CMS and state inspections, most recent first.
The facility failed to implement care-planned fall prevention interventions for three residents with significant fall histories and cognitive or neurological impairments. One resident with multiple fractures and repeated falls had a care plan requiring “Call, Do Not Fall” signage in the room, but surveyors repeatedly observed no signage present. Another resident with severe cognitive impairment and Huntington’s disease had an active physician order and CNA pocket-sheet intervention for a chair pressure alarm to be in place at all times, yet was observed in a wheelchair without any alarm, while staff were unsure of the alarm’s status and location. A third resident with dementia, seizure disorder, repeated falls, and recent hand injuries had a care plan calling for fall-prevention signage in the room and colored tape on the walker, but multiple observations showed no signage or tape, and a CNA reported not knowing about the signage requirement and only recalling that bright tape had been on the walker in the past.
Surveyors found that staff failed to follow physician-ordered hold parameters for cardiac, diabetic, and blood pressure medications and did not follow manufacturer instructions for insulin pen use. One resident with hypertension received Carvedilol even when systolic BP readings were below the ordered threshold to hold the dose. Another resident with heart failure, HTN, and diabetes received Insulin Glargine despite blood glucose levels below the ordered hold parameter and also received Midodrine when systolic BP readings were above the ordered limit. In a separate observation, an LPN administered Fiasp insulin from a pen without priming it as required by the manufacturer, and reported not having been taught to prime insulin pens.
Surveyors found multiple instances of improper medication storage and labeling, including several insulin pens and vials on different medication carts that were undated or had illegible dates, despite manufacturer instructions requiring discard after a set number of days in use. Loose, unidentified pills were present in drawers of several medication carts, and staff identified some of these as specific medications such as Sinemet, Namenda, Lasix, and others remained unknown. In a medication room, a partially used tuberculin serum vial in the refrigerator lacked an opened date, and the medication refrigerator contained several spots of an unknown brownish substance. Staff interviews confirmed that insulin and tuberculin should be dated when opened and that carts and storage areas should be clean and free of loose medications, consistent with the facility’s own medication storage policy and manufacturer guidelines.
A resident with ESRD and diabetes, assessed as cognitively intact, kept a tube of lidocaine ointment and a syringe of normal saline on an over-bed table and reported using them for skin numbing before dialysis and for eye flushing due to allergies. Surveyors observed the ointment and syringe left at the bedside, including when the resident was not present, and the ointment was found uncapped. Record review showed no MD order for the ointment and no authorization for self-administration, despite facility policy requiring attending physician authorization for residents to self-administer medications.
The facility failed to notify the State LTC Ombudsman of discharges for three residents, as required by its transfer and discharge policy and state regulation. One resident was discharged home with a spouse after an extended hospital stay, another was transported to a local ER and discharged per the census and billing records, and a third was discharged home with no anticipated return. The SSD reported she typically submitted a monthly list of discharges to the Ombudsman, first by email and later via a state website, but she missed the list for one month, had been ill during that period, and did not document Ombudsman notification in the residents’ records or maintain proof of submission.
A resident with severe cognitive impairment, respiratory failure, muscle wasting, and complete dependence for mobility was assessed as very high risk for pressure injuries, yet CNA shower skin monitoring records were repeatedly blank or incomplete and did not document changes to the left outer foot. A facility-acquired deep tissue injury on the resident’s left foot was later identified by the wound team, and an internal investigation confirmed it was in-house acquired, with no documentation that it was unavoidable and no facility pressure ulcer policy provided.
Surveyors found that staff failed to verify and accurately transcribe physician medication orders for two residents. In one case, an LPN administered a wound-healing liquid supplement by arbitrarily choosing a 5 cc dose when the EMAR order lacked a specified amount, instead of obtaining clarification. In another case, a resident admitted from the hospital with complex orders for midodrine and a tapered vancomycin regimen had those orders incorrectly entered, resulting in an erroneous midodrine dose and duplicate vancomycin orders. The same resident also had a continuous Veletri IV infusion order where the pump cartridge was changed about every 24 hours, but the EMAR only allowed evening documentation and an expected PRN documentation order was not entered, leaving cartridge changes outside the evening time undocumented. These issues occurred despite facility policies requiring complete orders, careful review of transfer records, and adherence to the five rights of medication administration.
A resident with a psychotic disorder and moderate cognitive impairment was receiving Risperidone, an antipsychotic requiring adverse effect monitoring via the AIMS assessment. Pharmacy recommendations specified that an AIMS be completed within 30 days of starting the medication and then every six months or with any dose increase. The last AIMS was documented many months earlier, and the Risperidone dose had been increased without a follow-up AIMS. The DON acknowledged that the AIMS assessment should have been completed in accordance with the pharmacist’s recommendation but was not, resulting in noncompliance with required drug regimen review and monitoring procedures.
A resident with heart failure, hypertension, and pulmonary hypertension had an order for continuous IV Veletri via a cardiac pump, with the medication changed out daily. Review of the EMAR showed missing documentation of this medication on multiple consecutive days, despite facility policy requiring the administering nurse to record each dose immediately and prohibiting leaving duty without documenting all administered medications. An RN confirmed there should never be blanks in the EMAR, and this failure to document medication administration constituted the cited deficiency.
A cognitively intact resident with ADHD, depression, and Huntington’s disease, whose MDS showed little interest or pleasure in activities, had a care plan calling for engagement in preferred activities such as sports-related groups, science lab, and table activities, along with encouragement of social interaction and food/fluid-promoting activities. Despite this, staff reported the resident had become bored, attention-seeking, tearful, and increasingly behaviorally dysregulated, with no person-centered activities that kept him engaged. Activity staff acknowledged they had not figured out how to involve him, noted his smoke break conflicted with the first scheduled activity, and described him walking away from activities he disliked. Observations showed the resident present but not participating during a scheduled cognitive activity and absent from other group sessions, while nursing documentation described escalating behaviors, all in contrast to the facility’s policy requiring individualized activity programs tailored to each resident’s interests and needs.
A resident with anxiety, depression, Huntington’s disease, and a history of aggressive behavior had a care plan identifying risk for physical aggression and an intervention to analyze and document triggers and de-escalation strategies. On one night and early morning, staff observed the resident pacing the hallway, repeatedly opening and shutting his door, and playing his TV at maximum volume, becoming upset when asked to close his door and refusing, with increased behaviors noted. Despite this escalation and prior assessments documenting aggressive tendencies, the resident later approached the nurses’ station and suddenly punched another resident in a wheelchair in the face, knocking him backward and kicking him, then cursed, threatened, and lunged at staff, attempting to hit an LPN. The DON reported the resident had strong behaviors and agitation with limited observable signs before negative behaviors, demonstrating a failure to ensure his emotional and mental well-being was closely monitored and supported during escalating behavior.
A resident with mild cognitive impairment and dementia was subjected to repeated yelling by a CNA during shower care, as reported by another cognitively intact resident and confirmed by an LPN who intervened. The incident involved the CNA telling the resident to be quiet and continued down the hallway, violating the facility's policy on resident dignity and respect.
The facility failed to maintain effective pest control, leading to gnats in resident areas, and did not address chipping concrete, resulting in a resident's fall. Observations showed inadequate cleaning and maintenance documentation, with pest control not treating resident rooms. A resident fell due to chipping concrete, previously reported but not addressed, causing minor injuries.
The facility did not make State survey results readily available for residents and visitors, as required. Observations showed that the results, meant to be in a white binder in the living room, were not visible. Instead, they were in the Administrator's office, inaccessible without staff assistance. The MDS Coordinator confirmed this issue, and the Administrator acknowledged the lack of a policy to ensure accessibility.
The facility failed to maintain a clean and safe environment in Wing 2 and the courtyard. Observations revealed dirty shower rooms, missing tiles, and a chipped concrete sidewalk. A resident fell in the courtyard due to the sidewalk issue, resulting in injuries. Housekeeping and maintenance practices were inadequate, with no documentation of completed tasks or inspections. Facility policies were not effectively implemented, compromising resident safety and comfort.
The facility failed to store medications appropriately in one medication storage room and on three medication carts. Unopened bags and boxes were found on the floor in the Wing 2 Medication Storage Room. Loose pills, including Tylenol, coenzyme, risperidone, baclofen, and trazodone, were found in the drawers of Wing 2 and Wing 3 Medication Carts. An LPN acknowledged the carts were dirty and stated they would be cleaned.
The facility failed to follow guidelines for hairnet use in the kitchen, with the Dietary Manager, two cooks, and the Corporate Dietary Consultant observed with exposed hair during food preparation. The DM acknowledged the requirement for hairnets to cover all hair, as per the facility's policy.
A resident with diabetes did not receive prescribed insulin on three consecutive evenings, as documented in the EMAR. The facility's policy required documentation and physician notification for missed doses, but records lacked explanations for the omissions. An RN confirmed that medication refusals or withholdings should be documented, indicating a failure to adhere to medication administration guidelines.
A facility failed to monitor a resident's meal consumption and provide prescribed nutritional supplements. The resident, with multiple health conditions, had incomplete meal records and missed doses of a prescribed mighty shake supplement. Despite facility policies requiring documentation and administration of prescribed nutrition, these were not followed, leading to deficiencies in care.
A resident with Huntington's disease did not receive their prescribed medication, Austedo, on multiple occasions due to unavailability from the pharmacy. The facility's records lacked documentation of notifying the physician or pharmacy about the issue, contrary to the facility's policy. An LPN stated the procedure for such situations, but the resident's clinical record did not reflect these actions.
The facility failed to address pharmacy recommendations for medication irregularities for three residents. A pharmacist's suggestions for reviewing duplicate orders, updating diagnoses, and considering dose reductions were not documented as being addressed by physicians. The DON confirmed that recommendations were not reviewed or acknowledged, contrary to facility policy.
The facility failed to follow infection control guidelines for enhanced barrier precautions during wound care for three residents. Despite signs indicating the need for gowns and gloves, an LPN and an RN provided wound care without donning gowns. The facility's policy requires such precautions to prevent the transmission of multidrug-resistant organisms.
A resident with Huntington's disease and a history of aggression had multiple incidents of physical and verbal aggression towards staff and other residents. Despite these behaviors, the care plans addressing the resident's aggression had not been updated since November, even after significant incidents in December and January. The MDS coordinator admitted to updating the wrong care plan, leading to a deficiency in maintaining current care plans.
A resident with psychosocial adjustment difficulties and a history of trauma did not receive appropriate psychiatric services despite exhibiting behaviors such as anger, threats, and refusal of dialysis. The resident, who was cognitively intact and had conditions like anxiety and depression, showed signs of needing psychiatric intervention, which was not provided, contrary to the facility's policy on Behavioral Health Services.
A facility failed to investigate an abuse allegation involving a resident who was allegedly cursed at by a CNA. An LPN witnessed the incident and instructed the CNA to leave, but the CNA returned to work the next day. The Administrator interviewed the resident, who denied the incident, and only provided customer service education to the CNA without further investigation. The facility's policy requires a thorough investigation, which was not conducted.
A resident was temporarily moved to a different room due to COVID-19 exposure, but several personal belongings were left behind, leading to the resident's distress. Despite being informed of the temporary nature of the move, the resident's behavior escalated, resulting in her transfer to a psychiatric facility. The facility's policy on resident rights was not fully adhered to, as the resident's right to retain personal possessions was compromised.
The facility failed to maintain an effective pest control program, resulting in the presence of rodents. Observations revealed multiple open doors, food debris, and mouse droppings in the kitchen and storage areas. Staff interviews indicated inconsistent pest control measures and a lack of awareness about the pest issues.
The facility failed to maintain a clean and sanitary kitchen, with open doors, food debris, and overflowing trash observed. Cleaning schedules were incomplete, and staff cited being short-staffed as the reason for not documenting cleaning. The Administrator was unable to find a kitchen policy.
The facility failed to report investigation outcomes to the IDOH within the required 5 working days for nine incidents involving multiple residents, including drug diversion, resident-to-resident incidents, falls with injuries, and a resident-to-visitor incident. The Administrator acknowledged the delay and the facility's policy was not followed.
The facility failed to administer medications and monitor residents with behavioral health concerns. A resident with Huntington's Disease did not receive prescribed Haldol on multiple occasions, and another resident with dementia was not adequately monitored after returning from a Neuropsychiatry Hospital. Facility policies on medication administration and behavioral health services were not followed.
Failure to Implement Care-Planned Fall Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall interventions for multiple residents identified as being at risk for falls. For one resident with moderate cognitive impairment, a history of repeated falls, and serious injuries including a cervical vertebra fracture, right hand fracture, and left hip fracture, the fall care plan included an intervention to place “Call, Do Not Fall” signage in the room. Surveyors repeatedly observed this resident in bed over several days with no such signage posted. An LPN familiar with the resident confirmed his history of multiple falls and stated he often forgot to use his call light, then acknowledged during a room observation that there were no signs posted, despite the care plan requirement. Another resident, who was severely cognitively impaired with Huntington’s disease, a history of falls, and an open-ended physician’s order for a chair pressure alarm to be in place at all times for safety, was observed sitting in a wheelchair in the dining room without any chair alarm in place. A CNA reported that the resident had experienced a few recent falls, had a bed pressure alarm, and tended to get up and move around, requiring staff to ask him to sit back down. The CNA initially believed the chair alarm had been discontinued when the resident changed from a Broda chair to a regular wheelchair, but then produced a pocket sheet showing an intervention for a chair alarm, while also stating the resident did not currently have one in place and that she would need to locate it. A third resident, cognitively intact but with diagnoses including dementia, seizure disorder, anxiety, repeated falls, and multiple falls with minor injuries, had a fall risk care plan that called for “Call for help do not fall” signage in several places in the room and colored tape on the resident’s walker. During multiple observations over several days, surveyors noted there were no signs posted in the room and no colored tape on the walker, despite the resident’s report of feeling “woozy” from a new medication and uncertainty about how she had injured her hands, which were bruised and covered with adhesive strips. A CNA on the dementia unit, who relied on a pocket sheet to know care plan interventions, stated she had no idea about the signage requirement and only recalled that bright tape had been on the walker at one time, but there was no tape present during the observation. The facility’s fall prevention policy indicated that care plans should incorporate interventions and address each fall with appropriate changes and preventive measures.
Failure to Follow Medication Hold Parameters and Insulin Pen Manufacturer Instructions
Penalty
Summary
The deficiency involves multiple failures by nursing staff to follow physician orders for medications with hold parameters and to follow manufacturer instructions for insulin administration. For one resident with hypertension who was cognitively intact, a physician order dated 11/24/2025 directed that Carvedilol 3.125 mg twice daily be held if the systolic blood pressure was less than 120. Review of the April 2026 EMAR showed that staff administered Carvedilol on numerous occasions when the resident’s systolic blood pressure readings were below 120, including readings of 110, 112, 116, 117, and 118 at various morning and evening medication times. These administrations occurred despite the explicit hold parameter in the order. A second cognitively intact resident with diagnoses including heart failure, hypertension, and diabetes had a physician order for Insulin Glargine 12 units subcutaneously twice daily, with instructions to hold the insulin if the blood glucose level was less than 110. Review of the February, March, and April 2026 EMAR showed that staff administered Insulin Glargine repeatedly when the resident’s blood glucose levels were below 110, including values as low as 62, 65, 68, 70, 74, 84, 89, 92, 94, 104, 105, and 109. During the same period, this resident also had an order for Midodrine 2.5 mg three times daily, with instructions to hold the medication if the systolic blood pressure was greater than 130. EMAR review showed that Midodrine was administered multiple times when the resident’s systolic blood pressure exceeded 130, with documented readings of 131, 133, 136, 139, 143, 144, and 146 at the time of administration. In interviews, an RN stated that when medications have hold parameters, she would obtain vital signs before administration and withhold the medication if the vitals were outside the ordered parameters, documenting the omission in a progress note. The DON similarly stated that if a medication had hold parameters and the resident’s vitals were outside those parameters, the medication would not be administered and this would be documented in the EMAR and a progress note. Despite these stated practices and a facility policy indicating medications are to be administered as prescribed in accordance with good nursing principles and practices, the documented medication administrations for these residents did not follow the hold parameters ordered by the physicians. A third resident was involved in a separate deficiency related to insulin administration technique. During a medication pass observation, an LPN removed a Fiasp insulin pen from the medication cart, attached a needle, dialed the dose to 10 units, and proceeded to the resident’s room without priming the pen. The LPN stated she was unaware that insulin pens needed to be primed and that she had never been taught to prime them. The Fiasp insulin pen package insert, provided by the DON, specifies that the pen must be primed by selecting 2 units, holding the pen with the needle pointing up, tapping to move air bubbles to the top, and pressing the dose button until the counter shows 0 and a drop of insulin appears at the needle tip. The observed administration did not follow these manufacturer instructions.
Improper Storage, Labeling, and Handling of Insulin and Other Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s storage and labeling of medications and biologicals, particularly insulin products and tuberculin serum, as well as the presence of loose, unidentified pills in multiple medication carts. On Wing 4’s medication cart, an opened Novolog insulin pen for Resident 71 had a partially smeared and unreadable date on the pen and a bag dated 03/05, a full undated Insulin Glargine pen for Resident 67 that the RN reported opening that morning, and an undated Fiasp insulin pen for Resident 67 with 50 units remaining. A Humalog insulin pen for Resident 14 was less than one-quarter full and dated 03/07. The same cart’s second drawer contained two loose small oval pills and two loose small white round pills. The RN stated that insulin was considered good for 30 days once removed from the refrigerator. On Wing 3/Cart 3, surveyors observed a loose small blue round pill, an oval pill, and a small round white pill in the second drawer; the LPN identified these as Sinemet, Namenda, and Lasix. In the top right drawer of this cart, there was an unopened Lantus insulin pen for Resident 2 and an undated vial of Humulin insulin with approximately one-quarter of the vial remaining for Resident 64. On Wing 2/Cart 1, a loose, unknown small tan pill was found in the second drawer. In the Wing 3 medication room, a half-full bottle of tuberculin serum in the refrigerator lacked an opened date, and the medication refrigerator had several spots of an unknown brownish substance on both the bottom and top shelves. Staff interviews confirmed that insulin should be dated when opened, unopened insulin should remain refrigerated, medication carts should be clean and free of loose medications, and tuberculin serum should be dated when opened. Manufacturer inserts and the facility’s medication storage policy required proper dating, discarding of medications after specified in-use periods, and maintaining clean, uncluttered storage areas.
Failure to Assess and Authorize Resident Self-Administration of Medications at Bedside
Penalty
Summary
Surveyors identified a deficiency when a cognitively intact resident with end stage renal disease and diabetes was observed with medications at the bedside without a physician’s order or documented assessment for self-administration. On one occasion, the resident was seen sitting in a recliner with an over-bed table nearby that held several personal items, including a white tube of ointment with a yellow label and a five cubic centimeter syringe of clear fluid. The resident stated the ointment was numbing cream he applied to his skin a couple of hours before leaving for dialysis and that the syringe contained normal saline he used to flush his eyes due to allergies. On a later observation when the resident was not in the room, the tube of ointment was found uncapped on the over-bed table and the syringe of clear fluid was also lying on the table; these items remained there during a subsequent observation the same day. Record review showed a Quarterly MDS assessment indicating the resident was cognitively intact and received dialysis treatments, but the clinical record lacked a physician’s order for the ointment and for the resident to self-administer the medication. During an interview, the MDS Coordinator identified the ointment as lidocaine and stated that the ointment and syringe should not be left at the bedside and that a physician’s order was required for medications to be left at bedside. The facility’s Medication Administration General Guidelines policy stated that residents are allowed to self-administer medications only when specifically authorized by the attending physician.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The deficiency involves the facility’s failure to notify the State Long-Term Care Ombudsman of resident discharges as required by policy and state regulation for three discharged residents. For one resident who had been admitted after a lengthy hospital stay and later discharged home with a spouse, the Nursing Home Discharge MDS showed a discharge to home with no anticipated return, and the EHR census showed the discharge date. The Social Services Director (SSD) stated she normally sent a monthly list of discharged residents to the Ombudsman but acknowledged she missed sending the list for the month in which this resident was discharged. For a second resident, the census report showed a discharge and cessation of billing, and a progress note documented that the resident was transported to a local emergency room; however, the clinical record contained no documentation that the Ombudsman was notified of this discharge. For a third resident, the MDS documented a discharge to home with no anticipated return. Interviews with the ADON and SSD revealed that the SSD was responsible for notifying the Ombudsman monthly, initially by email and later by uploading discharge reports to a state Ombudsman website, but she had no method to demonstrate that notifications were submitted and did not document them in the residents’ records. The SSD reported she had been ill during the relevant period and could not find evidence that the February discharge list had been sent. The facility’s written Notice of Transfer and Discharge policy required that a copy of the discharge notice be sent to the Ombudsman, which could be done via a monthly list of discharges.
Failure to Timely Identify Deep Tissue Pressure Injury in High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to timely identify a deep tissue pressure injury (DTI) for a resident who was severely cognitively impaired, non-ambulatory, bedfast, and extensively dependent on staff for mobility. The resident’s diagnoses included respiratory failure and muscle wasting, and a Braden Scale assessment documented the resident as being at very high risk for developing pressure wounds. Despite this high risk, CNA shower skin monitoring records on multiple dates were either blank or lacked documentation of new skin issues, and one record only noted that the resident’s heels were soft, with no documentation regarding the left outer foot. The facility’s wound assessment later identified a facility-acquired DTI on the resident’s left foot, and a subsequent investigation confirmed it was an in-house acquired wound. During an observation and interview, the wound nurse and Wound Doctor removed a soft protective boot and sock from the resident’s left foot and identified the wound as a DTI that was in the healing process, with decreased size and improved appearance. The wound assessment report indicated the DTI was identified on one date, while the facility’s investigation report listed the wound as identified on a different date, but both documents confirmed it was facility-acquired. The wound nurse stated that wound preventative measures should have been in place from the time the resident returned from the hospital until the wound was identified. The facility was unable to provide a policy related to pressure wounds, and the documentation did not indicate that the wound was unavoidable.
Failure to Verify and Accurately Transcribe Physician Medication Orders
Penalty
Summary
The deficiency involves failures to verify and accurately transcribe physician orders, and to ensure medication orders contained complete dosing information. During a medication pass, an LPN prepared a liquid Critical Procure supplement for a resident whose EMAR order did not specify the amount to administer. The LPN stated she would “just give” 5 cc despite the missing dose in the order and proceeded to pour 5 cc into a medication cup. The resident ultimately refused the supplement. The MDS Coordinator later confirmed that liquid supplement orders should include a specific amount based on individual factors such as weight and comorbidities, and that any order lacking a dose should be clarified with the physician, which had not been done in this case. For another resident, the facility failed to correctly transcribe complex hospital discharge medication orders, resulting in inaccurate and duplicate orders in the facility record. The hospital discharge summary included orders for midodrine 2.5 mg every eight hours and a tapered vancomycin regimen (125 mg four times daily for 14 days, then three times daily for seven days, then twice daily for seven days, then daily for seven days, then once weekly for seven weeks). In the facility’s physician orders and EMAR, the midodrine order was entered as 2.5 mg with directions to give 0.25 mg every eight hours, and vancomycin was entered as two separate orders: one for 125 mg four times daily for 14 days and another for 125 mg once daily for seven days. The DON acknowledged that the resident had duplicate vancomycin orders and that the 0.25 mg midodrine direction was an error. Nursing staff reported that when new or transfer orders are received, one nurse transcribes them and a second nurse is supposed to review and confirm them, but the errors in this case were not caught through that process. Additionally, the same resident had an open-ended order for Veletri IV solution to be administered via a continuous pump at 3.7 ml/hour in the evening for pulmonary hypertension. Staff described that the medication cartridge was changed approximately every 24 hours, with the pump set to deliver 89 ml over 24 hours from a 100 ml cartridge, and that the exact change time varied day to day. The EMAR, however, only provided an evening administration entry, and the LPN reported there was no place to document cartridge changes that occurred in the morning. The DON stated she believed there should have been an as-needed order in the record to allow documentation whenever the cartridge was changed, but that this order was not entered when the resident returned from the hospital, leaving only the evening order available for documentation. Facility policies required that medication orders include a dose, that transfer and discharge records be carefully reviewed and orders checked for accuracy after entry, and that medications be administered according to the “five rights,” including right dose, but these processes were not followed in the cited instances.
Failure to Follow Pharmacy Recommendation for AIMS Monitoring on Antipsychotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to follow pharmacy recommendations for adverse effect monitoring of an antipsychotic medication for one resident. Record review showed that a resident with a diagnosis including psychotic disorder, who was moderately cognitively impaired per a quarterly MDS assessment dated 03/04/2026, was receiving Risperidone, an antipsychotic medication. The consultant pharmacist’s recommendation dated 01/26/2026 specified that an Abnormal Involuntary Movement Scale (AIMS) assessment should be performed within 30 days of initiation of the medication and repeated every six months or with any dose increase while the resident remained on antipsychotic therapy. The record indicated the most recent AIMS assessment had been completed on 07/30/2025, and the Risperidone dose had been increased on 12/31/2025, but no subsequent AIMS assessment was documented. During an interview, the DON acknowledged that an AIMS assessment should have been completed following the pharmacy recommendation and that it was not done, indicating noncompliance with required drug regimen review and monitoring procedures. This failure occurred despite the facility’s obligation to ensure a licensed pharmacist performs a monthly drug regimen review, including review of the medical chart and adherence to irregularity reporting guidelines in the facility’s policies and procedures, as required by 410 IAC 16.2-3.1-25(i).
Failure to Document IV Medication Administration in EMAR
Penalty
Summary
The facility failed to document the administration of a prescribed intravenous medication for one resident. The resident, who was cognitively intact, had diagnoses including heart failure and hypertension, and had an open-ended physician’s order starting 04/10/2026 for Veletri intravenous solution at 3.7 milliliters per hour in the evening for pulmonary hypertension. Review of the April 2026 electronic medication administration record (EMAR) showed no documentation that this medication was administered on 04/10/2026, 04/11/2026, or 04/12/2026. An LPN reported that the resident used a cardiac pump for pulmonary hypertension and that the medication was changed out every day. An RN stated that medications were always to be signed out in the residents’ EMAR and that there should never be blanks in the EMAR. The facility’s undated policy titled “Medication Administration General Guidelines,” provided by the Administrator, stated that the individual who administers the medication must record the administration on the resident’s MAR directly after the medication is given and must not report off duty without first recording the administration of any medication. The lack of documentation for the Veletri doses on the specified dates was inconsistent with this policy and constituted the cited deficiency under 410 IAC 16.2-3.1-50(a)(1).
Failure to Provide Person-Centered Activities to Meet a Resident’s Psychosocial Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide person-centered activities that met a cognitively intact resident’s interests and supported his physical, mental, and psychosocial well-being. The resident had diagnoses including ADHD, depression, and Huntington’s disease, and his MDS mood assessment showed he had little interest or pleasure in doing things nearly every day. His care plan identified a potential for altered activity pattern related to preferences, with goals for him to attend group activities of interest such as sports-related groups, science lab, and table activities, and interventions including explaining the importance of social interaction and inviting him to activities that promote intake of food and fluids. Despite this, the resident’s activity participation declined steadily since November 2025, and he was noted to now participate only in church and singing activities. Staff interviews and observations showed that the facility did not effectively implement individualized, person-centered activities for this resident. A CNA reported that the resident had become obsessed with attention, bored easily, cried frequently, and became upset when family did not answer his calls, and that there were no person-centered activities that kept him engaged. An activities staff member stated they had not figured out how to get him more involved, that his scheduled smoke break conflicted with the first daily activity, and that he would get mad, say he was bored, and walk away if he did not like the activity. On observation, during a scheduled “Whole Brain” activity, the resident was present in the dining room but was only eating and not involved in the activity, and he was not present in the sunroom during later scheduled activities. A nurse’s note documented behavioral issues including unsteady gait, refusal to sit, yelling, attempting to hit staff, and demanding staff call his family. These findings contrasted with the facility’s policy requiring identification and involvement of each resident in an ongoing program of activities designed to appeal to their interests and needs, including specialized or extended programs.
Failure to Monitor and Manage Escalating Behavioral Symptoms Leading to Resident Assault
Penalty
Summary
The facility failed to adequately monitor and address a resident’s escalating behavioral health symptoms, resulting in an aggressive resident-to-resident altercation. The resident had an Annual MDS showing he was unable to complete the cognition interview and had diagnoses including anxiety, depression, and Huntington’s disease, with continual disorganized thinking. His care plan, initiated earlier, identified a potential for physical aggression such as hitting, kicking, punching, and choking staff and other residents related to an impulse control disorder, and included an intervention to analyze and document times of day, places, circumstances, triggers, and de-escalation strategies. An Aggressive Behavior Assessment documented a history or recent episodes of aggressive or agitated behavior and substantial non-compliance with medications, treatment, or care. On the night and early morning in question, nursing staff observed the resident pacing up and down the hallway, repeatedly opening and shutting his door, and playing his TV at maximum volume, which was disrupting other residents. He became upset when staff asked to close his door and refused to allow it to be closed, with increased behaviors noted afterward. Communication about his behavior was sent to the Assistant DON, and management voiced understanding. Later that morning, the resident exited his room, walked toward the nurses’ station with his hands behind his back, and, without prior verbal request, punched another resident sitting in a wheelchair near the nurses’ station in the face with a closed fist, knocking him backward out of the wheelchair and then kicking him. Staff separated the residents as the aggressive resident continued to curse, threaten, and lunge at staff, attempting to hit the on-duty nurse. The DON stated the resident had strong behaviors, became agitated, walked up and down the hallway, and did not show many signs before a negative behavior, indicating the facility did not ensure his whole emotional and mental well-being was closely monitored during his escalating behavior.
Failure to Maintain Resident Dignity During Shower Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with respect and dignity during the provision of care. According to interviews and observations, the CNA repeatedly yelled "Shut up" at a resident while attempting to provide a shower. This incident was witnessed by another resident, who reported hearing the yelling from her room next to the shower area, and by an LPN who observed the CNA getting loud and telling the resident to be quiet. The LPN intervened and instructed the CNA to calm down. The Director of Nursing (DON) confirmed receiving a report of the incident, which included the CNA yelling at the resident and telling her she did not need to go to the bathroom, with the yelling continuing down the hallway. The resident who was the subject of the incident was described as mildly cognitively impaired, dependent on staff for activities of daily living related to showers, and diagnosed with non-Alzheimer's dementia. Despite the incident, the resident later reported no concerns with care and stated that staff were always nice to her. Another resident who overheard the incident was cognitively intact and had diagnoses including depression and anxiety. The facility's policy on dignity requires staff to promote care in a manner that maintains or enhances each resident's dignity and respect, which was not followed in this instance.
Pest Control and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats or drain flies in residents' bathrooms and bedrooms. Observations over several days revealed sticky floors, strong urine odors, and black debris around toilet bases in the Wing 2 Shower Room. Multiple instances of gnats were observed flying in shared bathrooms and resident bedrooms, with residents indicating that the problem had persisted for some time. The pest control provider visited the facility bi-weekly but did not treat residents' bedrooms or bathrooms, focusing instead on common areas and the kitchen. Additionally, the facility's housekeeping practices were found lacking. Although there were check-off lists for cleaning tasks, the Housekeeping Supervisor could not provide completed checklists, and none included cleaning the walls of the shower rooms. The Maintenance Director conducted daily building inspections but did not document his observations. The pest control records showed only one documented service in the past three months, labeled as a 'One Shot' service, which was a one-time treatment for gnats and drain flies. In a separate incident, a resident fell in the courtyard while propelling himself in a wheelchair, which was attached to his back with a seat belt. The fall occurred due to chipping concrete, which had been reported in a maintenance request two weeks prior. The resident sustained a scrape on the forehead and a bump on the head. The facility's policies on housekeeping, preventative maintenance, and falls were not effectively implemented, contributing to the deficiencies observed.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to make the State survey results readily available for viewing by residents and visitors for two out of six days during the survey period. Observations on multiple occasions revealed that the survey results, which were supposed to be in a white binder in the living room, were not visible in the designated areas. Instead, the survey results were found in a pile in the Administrator's office, inaccessible without asking staff for assistance. The Minimum Data Set (MDS) Coordinator confirmed that the results were not accessible as required, and the Administrator admitted that there was no specific policy in place to ensure the survey results were available for public viewing, relying instead on following the regulation.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment in Wing 2 and the outside courtyard, as observed during a survey conducted from March 21 to March 27, 2025. In Wing 2, the shower room was found with sticky floors, a strong urine odor, and black debris around the toilet base and shower stall tiles. Additionally, a shared bathroom had a shallow pit in the floor where tiles were missing, posing a risk to residents, including one who was unsteady on his feet. The bathroom also had a strong urine odor, and a resident's bathroom door had brown stains and debris on the doorknob. Interviews revealed that the housekeeping staff had cleaning check-off lists, but no completed checklists were available, and the maintenance director did not document his daily observations. In the courtyard, Resident B fell while propelling himself in his wheelchair due to a chipped concrete sidewalk. The resident, who used a seat belt for positioning, fell forward with the wheelchair still attached, resulting in a scrape on his forehead and a bump on his head. A CNA had previously submitted a work order for the concrete issue two weeks prior, but no action had been taken. The facility's policies on housekeeping, preventative maintenance, and falls were not effectively implemented, as evidenced by the lack of documentation and the failure to address known hazards. The report highlights deficiencies related to the facility's failure to provide a safe, clean, and comfortable environment for its residents. The lack of proper maintenance and housekeeping practices contributed to unsafe conditions, such as the dirty shower room, missing tiles, and chipped concrete, which ultimately led to Resident B's fall. The facility's policies were not adequately followed, resulting in an environment that did not meet the residents' rights for safety and cleanliness.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications appropriately in one of its medication storage rooms and on three of its medication carts. During an observation, it was noted that the Wing 2 Medication Storage Room had three unopened bags of g-tube feeding formula and six unopened boxes sitting directly on the bare floor. The Director of Nursing indicated that these boxes were supplies. Additionally, a Wing 2 Medication Cart was found to contain a loose round tan pill inside a drawer, which was removed and disposed of by an LPN. Further observations revealed that a Wing 3 Medication Cart contained several loose pills, including a white round pill identified as Tylenol, an oval pill identified as a coenzyme, a small white pill identified as risperidone, and a small yellow/tan pill identified as baclofen. These pills were removed by an LPN and placed in a medication cup. Another Wing 3 Medication Cart was found to contain a loose white round pill, small papers, and powdered pill substances in the corners of the drawers. An LPN indicated that the loose pill was trazodone and acknowledged that the cart was dirty, stating that nurses were responsible for cleaning the medication carts and that she would clean it that day.
Failure to Properly Use Hairnets in Kitchen
Penalty
Summary
The facility failed to adhere to appropriate guidelines regarding the use of hairnets in the kitchen, as observed during three separate kitchen inspections. The Dietary Manager (DM) was noted to have three inches of hair exposed outside her hairnet on multiple occasions while in the food preparation area. Additionally, during another observation, two cooks and the Corporate Dietary Consultant were also found with hair exposed outside their hairnets. The DM acknowledged in an interview that hairnets should cover all hair and suggested using two hairnets if necessary. The facility's Hair Restraints policy, dated 2020, mandates that staff wear hair restraints in all food production, dishwashing, and serving areas.
Failure to Administer Prescribed Insulin
Penalty
Summary
The facility failed to administer prescribed insulin to a resident, identified as Resident 12, who was moderately cognitively impaired and had diagnoses including diabetes, hypertension, dementia, and paranoid schizophrenia. The physician's order required Humalog insulin to be administered after meals, but the Electronic Medication Administration Record (EMAR) for January 2025 showed that the insulin was not documented as given on three consecutive evenings. The resident's blood glucose levels on these dates were notably high, indicating a potential impact from the missed doses. The facility's policy required documentation if a medication dose was withheld, refused, or not available, and mandated physician notification if three consecutive doses of a vital medication were missed. However, the records lacked any documentation explaining why the insulin was not administered, and there was no indication that the physician was notified. An interview with RN 6 confirmed that any refusal or withholding of medication should be documented, and the EMAR should not have blanks, highlighting a lapse in following the facility's medication administration guidelines.
Failure to Monitor Nutrition and Provide Supplements
Penalty
Summary
The facility failed to adequately monitor meal consumption and provide necessary nutritional supplements for a resident diagnosed with Huntington's disease, anemia, seizure disorder, anxiety, depression, and abnormal weight loss. The resident's meal consumption records were incomplete, lacking documentation for numerous dinner meals over a span of nearly three months. A Certified Nurse Aide (CNA) confirmed that meal consumptions should be documented electronically after each meal, including instances where a meal is refused. However, the facility's policy on caregiver documentation was not adhered to, as evidenced by the missing meal records. Additionally, the resident was prescribed a nutritional supplement, a mighty shake, to be administered with meals. The Electronic Medication Administration Record (EMAR) showed that the resident did not receive the supplement on several occasions in March 2025. Progress notes indicated that the mighty shakes were unavailable during these times. A Licensed Practical Nurse (LPN) stated that if the shakes were unavailable, an alternate supplement should be provided and documented, although she was unaware of any shortages. The facility's policy on medication administration requires that medications be administered as prescribed, which was not followed in this case.
Failure to Ensure Medication Availability for Resident
Penalty
Summary
The facility failed to ensure the availability of a prescribed medication for a resident diagnosed with Huntington's disease, chorea, hypertension, and depression. The resident was supposed to receive Austedo, a medication for chorea, but did not receive it on multiple occasions as documented in the Electronic Medication Administration Record (EMAR). Specifically, the medication was not administered on several dates in September, October, and November 2024 due to its unavailability from the pharmacy. The clinical record lacked documentation that the physician or pharmacy was notified about the medication's unavailability. During an interview, an LPN indicated that if a medication was unavailable, they would check the emergency drug kit, contact the pharmacy, and notify the physician, documenting these actions in a progress note. However, the resident's clinical record did not reflect these steps. The facility's policy on medication administration requires that if three consecutive doses of a vital medication are not available, the physician must be notified, and the notification documented. This policy was not adhered to in the case of the resident, leading to the deficiency.
Failure to Address Pharmacy Recommendations for Medication Irregularities
Penalty
Summary
The facility failed to address pharmacy recommendations for three residents regarding medication irregularities. For Resident 37, the pharmacist recommended reviewing duplicate orders for Loperamide and updating the diagnosis for Topamax, as well as considering a dose reduction for Duloxetine. However, there was no indication that the physician responded to these recommendations. The Director of Nursing (DON) confirmed that recommendations were usually followed up within a week, but there was no documentation of the physician's response in this case. For Resident 32, the pharmacist recommended adding a 14-day stop date to the Lorazepam order, but the clinical record lacked evidence that the physician was informed of this recommendation. The DON acknowledged that the pharmacy review was not reviewed or acknowledged. Similarly, for Resident 4, the pharmacist suggested a trial dose reduction for Mirtazapine, Sertraline, and Trazadone, but there was no indication of a response from the physician. The facility's policy required the DON to notify the physician of any irregularities, but this was not documented in the residents' records.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to infection control guidelines related to enhanced barrier precautions during wound care for three residents. Resident 75, who was cognitively intact and diagnosed with conditions including Parkinson's disease and metastasized bone cancer, was observed receiving wound care without the attending LPN donning a gown, despite a sign indicating the need for enhanced barrier precautions. Similarly, Resident 4, who was moderately cognitively impaired and had diagnoses such as Parkinson's disease and diabetes, also received wound care from the same LPN without the use of a gown, contrary to the posted precautions. Resident 31, who was moderately cognitively impaired and diagnosed with conditions including dementia and diabetes, was also observed receiving wound care without the attending RN donning a gown, despite the presence of a sign indicating enhanced barrier precautions. The facility's policy on enhanced barrier precautions, which was revised in May 2024, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, this policy was not followed during the observed wound care activities for these residents.
Failure to Update Care Plans for Aggressive Resident
Penalty
Summary
The facility failed to update care plan interventions for a resident, identified as Resident C, who exhibited aggressive behaviors. Resident C, who was cognitively intact and diagnosed with anxiety, depression, and Huntington's disease, was involved in multiple incidents of physical and verbal aggression. These incidents included a physical altercation with another resident and several instances of verbal aggression and physical threats towards staff members. Despite these behaviors, the care plans addressing Resident C's potential for aggression had not been updated since November 2024, even after significant incidents occurred in December 2024 and January 2025. The facility's policy requires comprehensive care plans to be developed and revised to incorporate the resident's goals and needs. However, the MDS coordinator admitted to updating the wrong care plan following an altercation on December 1, 2024. The Social Service Director confirmed that the care plans for Resident C's aggressive behaviors had not been revised since November 2024, despite the noted increase in aggressive behavior. This oversight led to a deficiency in ensuring that care plans were current and reflective of the resident's needs and behaviors.
Failure to Provide Psychiatric Services for Resident with Psychosocial Difficulties
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident, identified as Resident C, who displayed psychosocial adjustment difficulties and had a history of trauma. Resident C, who was cognitively intact and diagnosed with conditions including renal insufficiency, diabetes, anxiety, and depression, exhibited several behavioral issues. These included slamming doors, making threats towards a roommate, and expressing anger towards staff. Despite these behaviors and a care plan intervention indicating the need for psychiatric or psychological services, Resident C did not receive such services. The Social Services Director acknowledged that the resident's behavior indicated a need for psychiatric services, yet these services were not provided. The clinical record and interviews revealed multiple incidents where Resident C expressed frustration and anger, including refusing dialysis due to dissatisfaction with transportation services and using offensive language towards staff. The facility's policy on Behavioral Health Services aimed to ensure residents received appropriate treatment to attain the highest practicable mental and psychosocial well-being. However, the facility did not adhere to this policy, as evidenced by the lack of psychiatric services for Resident C, despite clear indications of need. This deficiency was identified during a complaint investigation related to Resident C's care.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an abuse allegation involving a resident who was cognitively intact and had diagnoses including diabetes, hypertension, depression, and bipolar disorder. The incident occurred when a CNA allegedly cursed at the resident during dinner time. An LPN witnessed the CNA cursing at the resident and instructed the CNA to clock out and go home. Despite this, the CNA returned to work the next evening. Another CNA corroborated the LPN's account, indicating she also heard the CNA curse at the resident. The Administrator was informed of the incident and interviewed the resident, who denied the allegations. The Administrator only provided customer service education to the CNA and did not conduct a further investigation. The facility's policy requires a thorough investigation of abuse allegations, including interviewing or assessing all residents on the affected hall and usually suspending the employee in question for three days. However, the facility did not follow these procedures, and the resident's clinical record lacked documentation related to the allegation.
Failure to Honor Resident's Rights During Room Change
Penalty
Summary
The facility failed to honor a resident's rights concerning personal possessions during a temporary room change due to a COVID-19 situation. Resident E, who was cognitively intact and had diagnoses including COPD, hypertension, diabetes, arthritis, and depression, was moved to a different room to accommodate a male resident exposed to COVID-19. During this move, several of Resident E's belongings were left behind in her previous room, including personal items such as wall hangings, clothes, snacks, and a memorial board. Although staff indicated that non-essential items were left behind and could be retrieved upon request, Resident E became upset about the room change and the handling of her possessions. The Director of Nursing explained that the move was temporary and necessary due to the COVID-19 exposure, and Resident E was informed it would last about a week. However, the resident's behavior escalated following the move, leading to her being sent to an inpatient psychiatric facility. The facility's policy on resident rights, which includes the right to retain and use personal possessions to the maximum extent that space and safety permit, was not fully adhered to in this situation. This incident was part of a complaint investigation, highlighting a deficiency in respecting resident rights.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program was maintained, resulting in the presence of rodents. During an observation and interview, a gray mouse was seen running in the Social Service Director's (SSD) office, and the SSD indicated that the pest control measures in place were ineffective. Further observations revealed multiple open doors in the service hallway and kitchen, which could facilitate rodent entry. In the dry storage room, mouse droppings and chewed food packages were found, indicating a significant rodent problem. Additionally, the kitchen area was observed to have overflowing trash, food debris, and mouse droppings, further evidencing the pest issue. Interviews with staff revealed a lack of awareness and inconsistent pest control measures. The Cook was unsure of any pest issues, and the Dietary Aide mentioned not seeing the pest control company for about a month. The Administrator confirmed that the pest control company visited monthly and had been called recently due to the mouse sighting in the SSD office. However, pest control logs were not provided during the survey. The facility's pest control policy indicated regular and as-needed pest control services, but the observations and staff interviews suggested that these measures were not effectively implemented.
Facility Fails to Maintain Clean and Sanitary Kitchen
Penalty
Summary
The facility failed to provide a clean and sanitary kitchen, as observed during a survey. The service hallway doors leading to the kitchen were open, and no staff were present in the dish room or main kitchen. The dry storage room had a cardboard box of cheerios on the floor, and the floor and baseboard were black with food debris. A trash can between a milk cooler and the ice machine was overflowing with trash, and the lid was lying on the floor. Behind the stove, there was an open and empty jelly container, dried cooked green beans, and other food debris. The serving room contained steam tables with food crumbs and insulation underneath them. Cleaning schedules were provided but lacked documentation of cleaning on several dates, and staff indicated they were unable to check off the cleaning schedules due to being short-staffed. During an interview, the Administrator indicated that she thought the cleaning schedules were ready when the Dietary Manager left for vacation. However, the cleaning schedules were not completed. Later observations showed that some corrective actions were taken, such as removing the cardboard box of cheerios from the floor and emptying the trash can. The Administrator was unable to find a kitchen policy and had contacted corporate support, but a policy was not provided upon exit.
Failure to Timely Report Investigation Outcomes to IDOH
Penalty
Summary
The facility failed to ensure all investigations and outcomes of the investigations were reported to the Indiana Department of Health (IDOH) within 5 working days of the incident for nine reported incidents involving multiple residents. Specific incidents included a possible drug diversion, several resident-to-resident incidents, resident falls with injuries, and a resident-to-visitor incident. The follow-up outcomes of these investigations were significantly delayed, with all being reported on 04/24/24, well beyond the required 5-day period. During an interview, the Administrator acknowledged being behind on completing the 5-day follow-ups and indicated an intention to comply with State and Federal regulations. The facility's policy on verbal/mental abuse allegations and the quality assurance checklist was reviewed, which mandates that final reports be submitted to the ISDH. However, this policy was not adhered to in the cases reviewed, leading to the identified deficiency.
Failure to Administer Medications and Monitor Residents with Behavioral Health Concerns
Penalty
Summary
The facility failed to administer medications and monitor residents with behavioral health concerns for two residents. Resident B, who has Huntington's Disease, anxiety, depression, and a psychotic disorder, did not receive his prescribed Haldol medication on multiple occasions in March. An incident occurred where Resident B bumped into another resident's wheelchair, leading to a verbal altercation. Despite the incident, neither resident was placed on increased monitoring. Additionally, after Resident B returned from a Neuropsychiatry Hospital, there were no follow-up visits from Social Services until several days later, and he was not placed on 15-minute checks immediately upon return. Resident D, who has dementia, anxiety, and depression, was also not adequately monitored after returning from a Neuropsychiatry Hospital. The clinical record lacked any Social Service visits since her return. Resident D had a history of physical altercations and expressed violent intentions towards another resident. Despite this, she was taken off 15-minute checks without the SSD's involvement in the decision. The psychologist later recommended restarting the 15-minute monitoring due to the resident's impulsivity and recent hospitalization. The facility's policies on medication administration and behavioral health services were not followed. Medications were not documented in the EMAR after administration, and appropriate interventions consistent with individualized care plans were not implemented. The facility's failure to adhere to these policies resulted in inadequate care and monitoring for residents with behavioral health concerns.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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