Brooke Knoll Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon, Indiana.
- Location
- 1108 Kingwood Drive, Avon, Indiana 46123
- CMS Provider Number
- 155814
- Inspections on file
- 27
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Brooke Knoll Village during CMS and state inspections, most recent first.
Failure to follow EBP and infection control practices occurred during care for three residents with invasive devices and wound care needs. An LPN and CNA did not consistently use gown, glove, and hand hygiene practices during IV antibiotic administration, catheter care, incontinent care, and wound care. One resident had a PICC line, Foley catheter, and antibiotic treatment; another had a chronic suprapubic catheter with an EBP order; and a third had a pressure ulcer, feeding tube, and EBP orders for wound care and tube-related care.
The facility failed to accurately code the MDS for a resident with unspecified dementia, hallucinations, depression, and anxiety disorder. The record contained a PASRR level II, but the MDS indicated the resident did not have one. The Corporate MDS Coordinator confirmed the MDS was inaccurate, and the DON stated the facility did not have an MDS policy and followed the RAI manual.
Failure to implement a baseline care plan for a resident with a PICC, Foley, and pain risk. The resident was observed in bed with an IV connected to a PICC and a Foley bag with dark yellow urine, and he reported being cold, tired, and in pain. Staff noted he called out during turning and repositioning, cried out when a PT tried to assist with socks, and later rated his pain as 7 to 9 while asking for Tylenol. The record lacked a baseline care plan addressing his PICC, Foley, and pain needs.
The facility failed to correctly administer insulin for a resident observed during insulin administration. An RN prepared a Humalog pen for a 2-unit dose based on the resident’s blood sugar, but did not prime the pen with 2 units before dialing in the dose and had to be corrected during the procedure. The DON was present, and the RN’s competency checklist later showed the priming step for the insulin pen.
Failure to Provide ADL Grooming Care: Three residents who depended on staff for personal care were observed with long, dirty, or jagged fingernails, and one resident repeatedly had an unshaved beard and mustache despite stating he wanted to be shaved. Records showed the residents required substantial or total assistance with ADLs, but documentation did not show nail care or shaving was offered, provided, or refused, even though facility policy called for assistance with shaving and fingernail care when needed.
Medication Labeling and Dating Deficiencies: Surveyors observed unlabeled OTC meds on a med cart and multiple medications without open dates on another med cart and in the med room refrigerator. A resident had Tylenol, B12, and Vitamin D3 without required labeling, and other residents had azelastine and lorazepam bottles without dates showing when they were opened.
A resident’s medical record contained Medicare progress notes entered by an LPN on days the resident was hospitalized. The notes documented A&O x4 status, stable VS, pain and muscle spasms, scheduled pain and anxiety meds, ADL dependence, meal set-up, and ongoing OT/PT, but the LPN and DON stated Medicare charting required a hands-on assessment and should not have been documented when the resident was not in the facility.
A resident with traumatic brain injury, dysphagia, known weight loss, and total dependence on G-tube nutrition had tube feedings that were not administered per physician orders. Surveyors observed the feeding pump not running with a partially full bag of IsoSource 1.5, despite an active order for Glucerna 1.5 at a specified rate and schedule, and no prior order allowing formula substitution. Later, the resident was connected to the tubing but the pump remained off, with minimal change in the volume of formula. The UM stated the feed was stopped because it was past the ordered stop time, while the DON reported that formula substitutions required NP approval and could only occur if the ordered product was unavailable, and the LPN reported that the time on the bag reflected when the feeding was started.
A resident’s suction canister was found about half full of yellow-tinged liquid with yellow sediment, and the canister label showed it had not been changed for an extended period despite facility policy requiring weekly and PRN changes. The ED reported the canister had been changed that day, which conflicted with the date on the canister and demonstrated failure to follow the facility’s infection prevention and control procedures for suction equipment.
A QMA was observed storing a resident's Tramadol tablets outside of their original labeled container by placing them into multiple pill crusher sleeves, some of which were stapled together and contained pills from different bottles. This practice was acknowledged by the ED as not following facility policy, which requires drugs to remain in their labeled dispensing containers and prohibits transferring medications between containers.
The facility failed to respect residents' privacy and dignity by not knocking or announcing themselves before entering rooms. A resident reported feeling disrespected, and during a Resident Council Meeting, several residents expressed similar concerns. Observations confirmed staff entering rooms without knocking, contrary to the facility's policy on Residents' Rights.
The facility failed to properly label and date medications on three of six medication carts, affecting multiple residents. Issues included insulin pens and nasal sprays without opening dates, and bottles of Tylenol and fish oil lacking labels. The Nurse Consultant acknowledged the difficulty in managing medication storage.
A facility failed to follow infection control measures during a nasal spray administration, as an LPN did not perform hand hygiene or use gloves. Additionally, the facility did not ensure consistent Enhanced Barrier Precautions (EBP) for residents with specific medical needs, as PPE was not accessible and signage was inadequate or missing, contrary to facility policy.
A resident with a history of kidney transplant and insomnia was repeatedly woken up too early for lab draws, despite expressing his preference for later timing to multiple staff members. The facility's policies on resident choice and timely lab draws were not effectively implemented, as evidenced by the resident's care plans lacking interventions for his lab work preferences.
A facility failed to conduct a new PASARR screening for a resident after a new diagnosis of bi-polar disorder was added to their medical record. The resident had multiple diagnoses, including dementia and major depressive disorder, and had previously undergone a Level I PASARR screening. Despite the addition of the new diagnosis, the facility did not determine if a Level II evaluation was necessary, contrary to their policy requiring notification of state authorities after significant changes in a resident's condition.
The facility failed to prevent potential accidents by leaving medications unattended at the bedside for two residents. A resident with multiple diagnoses was found with a cup of pills left unattended, and another resident reported a pill on the floor next to her bed from the night shift. The facility's policy requires residents to be observed taking medications and prohibits leaving medications in rooms without written authorization.
The facility failed to provide trauma-informed care for two residents with PTSD. One resident, with a history of trauma and depression, lacked a personalized care plan addressing her mental health needs. Another resident, with severe PTSD from past trauma, had an extensive but non-individualized care plan, and her preference for female caregivers was not documented. The facility's policies on trauma-informed care were not effectively implemented, leading to inadequate support for these residents.
A facility failed to follow up with pharmacy recommendations in a timely manner for a resident with multiple diagnoses, including palliative care and hypertension. The pharmacy recommended dosage reductions for aspirin and gabapentin, but the physician's response was delayed beyond the facility's 3-day policy. The DON indicated that recommendations were resent if no response was received within the specified time.
Failure to Follow Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were implemented per facility policy and failed to follow appropriate infection prevention practices for three residents. Resident 105 had a PICC line, Foley catheter, and was receiving antibiotics for a urinary tract infection. He was observed in bed with IV equipment and a Foley drainage bag at bedside, and staff provided care without wearing a gown during bathing and treatment. During IV antibiotic administration, the LPN did not perform hand hygiene before donning gloves, touched multiple surfaces including the pump, IV pole, bathroom door handle, and blankets, and then inserted the IV line into the PICC port without removing gloves or cleaning the port again after handling the flush syringe. Resident 77 had a chronic suprapubic catheter and an active order for enhanced barrier precautions related to the catheter. During incontinent care, a CNA switched the catheter bag to a leg collection bag and carried the old bag to the bathroom while wearing only gloves. The CNA then used the same gloved hands to search through the resident’s drawers and closet for supplies and continued with incontinent care without wearing a gown or mask. Resident 1 had moderate cognitive impairment, a pressure ulcer present on admission, and orders for enhanced barrier precautions related to a feeding tube and wound care. During wound care, the LPN wore a gown and gloves but used a gloved finger to apply zinc cream around the wound bed, continued the dressing change without changing gloves, and used metal scissors that had zinc cream on them. The scissors were wiped with a paper towel and placed in the LPN’s pocket to be cleaned later. After removing gloves and washing hands, the LPN touched the front of the isolation gown and left the room without washing hands again.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for 1 of 6 residents reviewed for MDS accuracy, Resident 11. Resident 11 had diagnoses including unspecified dementia, hallucinations, depression, and anxiety disorder. A Preadmission Screening and Resident Review (PASRR) level II dated 8/9/24 was present in the record, but the resident’s MDS assessment dated 6/17/25 indicated that she did not have a PASRR level II. During interview, the Corporate MDS Coordinator stated that Resident 11’s MDS was inaccurate. The Director of Nursing stated the facility did not have a policy for MDS and followed the Resident Assessment Instrument (RAI) manual.
Failure to Implement Baseline Care Plan for Immediate Needs
Penalty
Summary
The facility failed to ensure a baseline care plan was implemented within 48 hours of admission for Resident 105, who had a PICC, a Foley catheter, and was identified on the admission MDS as being at risk for pain. The record did not contain a baseline care plan addressing his immediate needs related to the PICC, Foley, and/or pain. During observations, Resident 105 was in bed with an IV pole connected to a PICC and a Foley drainage bag with dark yellow urine, and he stated he was very tired, cold, and had arm pain. Resident 105 continued to show discomfort during subsequent observations and interactions. He was heard calling out from his room, and an LPN stated that calling out during turning and repositioning was normal for him and that he experienced discomfort with care, turning, and repositioning. When a PT attempted to assist him with socks, he cried out in pain, stated he was aching all over, rated his pain as 7, 8, or 9, and asked for Tylenol. The LPN stated he was receiving antibiotics for a UTI and did not have an order for PRN or scheduled pain medication, and the DON later stated she could not find the baseline care plan and that there needed to be a better process for baseline care plans moving forward.
Incorrect Insulin Pen Administration
Penalty
Summary
The facility failed to correctly administer insulin for 1 of 1 resident observed for insulin administration, Resident 63. On 4/7/26 at 12:12 p.m., RN 6 was observed preparing a Humalog insulin pen to give 2 units based on the resident’s blood sugar of 153. RN 6 dialed in 2 units and held up the pen, but was intervened because the insulin pen had not been primed with 2 units before dialing in the dose. The correction was made and the insulin was then administered to Resident 63’s left lower abdomen. The DON was present during the procedure and later stated RN 6 had gone through the steps correctly and was nervous being observed. RN 6’s insulin administration competency checklist later showed item number 8 directing the nurse to dial a dose of 2 units to prime the pen, and he demonstrated competency with that task.
Failure to Provide ADL Nail Care and Shaving Assistance
Penalty
Summary
The facility failed to ensure ADL nail care was provided for residents who were dependent on staff for personal hygiene. Three residents reviewed had documented needs for assistance with ADLs, but observations showed their fingernails were long, dirty, jagged, or had debris under them, and the records did not show that nail care was offered, provided, or refused. The deficiency was cited under 410 IAC 16.2-3.1-38(a)(3)(D) and (E). Resident 51 was observed lying in bed in a hospital gown with unbrushed, greasy hair and long fingernails with debris under them. The resident stated the nails were long and jagged and wanted them cut. On later observations, the nails remained long and dirty, and an LPN observed they were jagged and needed to be cut. The resident’s MDS showed he was cognitively intact and requested maximum or total dependence on staff for all ADL care, while CNA documentation indicated nail care was marked as completed each shift. Resident 61 had an unshaved beard and mustache on multiple observations and stated he wanted to be shaved and that staff had not offered to help him shave. His record showed diagnoses including need for assistance with personal care, hemiplegia, and hemiparesis following a stroke, and the MDS indicated he was cognitively intact and required substantial/maximal staff assistance with bathing. Resident 1 was observed on multiple occasions with long fingernails on both hands, chipped nail polish, and dark debris underneath the nails. The resident’s record showed multiple sclerosis, need for assistance with personal care, and dependence on staff for showering/bathing. For both residents, the care records and shower documentation lacked evidence that shaving or fingernail care was offered, provided, or refused, despite facility policy stating male residents may be assisted to shave and fingernail care should be provided when nails appear soiled or jagged.
Medication Labeling and Dating Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles. On 4/7/26 at 12:28 p.m., surveyors observed the 200 hall medication cart, the 300 hall medication cart, and the medication room. On the 200 Hall Medication Cart, Resident 103 had Tylenol 650 mg, B12 1000 mcg, and Vitamin D3 without a label showing the resident’s name, room number, or physician’s name. On the 300 Hall Medication Cart, Resident 7 had azelastine 137 mcg in the cart without a date showing when it was opened. In the medication room refrigerator, Resident 24 had a bottle of lorazepam 2 mg/ml without an open date, and Resident 18 had a bottle of lorazepam 3 mg/ml without an open date. The facility policy titled Storing Drugs, dated 7/2025, stated that outdated, contaminated, or deteriorated drugs, or drugs with cracked, soiled, or unsecured containers, must be removed from stock and destroyed according to policy.
Inaccurate Medicare Charting for Hospitalized Resident
Penalty
Summary
The facility failed to ensure documentation in one resident’s medical record was accurate for 1 of 18 records reviewed. Resident 4’s chart contained Medicare progress notes entered by LPN 14 on 2/19/26, 2/20/26, and 2/21/26 that described the resident as alert and oriented x4, vital signs stable, reporting lower and upper back pain with muscle spasms, receiving scheduled pain and anxiety medications, dependent with all ADLs, eating with set-up, and continuing OT/PT. During interview, LPN 14 stated Medicare charting required a hands-on physical assessment and should include the resident’s level of alertness and orientation, pain complaints, scheduled medications, ADL completion, vital signs, and resident-specific care needs, and that Medicare charting should not be documented if the resident was not in the facility. The DON also stated the notes should have been based on a hands-on physical assessment and should not have been documented if the resident was not in the facility. Review of the chart showed the Medicare notes were entered on days when the resident was hospitalized, and the DON confirmed the notes were entered while the resident was out of the facility.
Failure to Administer G-Tube Feeding per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who received all nutrition via G-tube was provided tube feedings in accordance with physician orders. Surveyors observed that the resident’s feeding pump, set up next to the bed, was not running on the morning of 2/2/26, with approximately 800 ml remaining in a 1000 ml bag of IsoSource 1.5 that was labeled as started at 2:15 a.m. Review of the medical record showed an active order, dated 1/29/26, for Glucerna 1.5 at 75 ml/hr for 20 hours per day, from 4:00 p.m. to 12:00 p.m. the following day, with no special instructions allowing substitution of another formula. The resident was a long-term care resident with traumatic brain injury and dysphagia and was known to have weight loss, relying entirely on G-tube feedings for nutrition. Later that day, the resident was observed sitting in a Broda chair with the G-tube tubing connected, but the pump was turned off, and only about 100 ml less formula was in the bag than at the earlier observation. The Unit Manager stated the tube feeding was not running because it was past the ordered stop time of noon. The DON stated IsoSource should only be used instead of Glucerna if Glucerna was unavailable and that any substitution required NP approval, and she was unsure why there was 400 ml more than expected in the bag, speculating that the night nurse may have spiked a new bag early. However, the LPN who started the tube feeding on night shift stated that the time written on the bag was the time the feeding was actually started. A dietician quarterly assessment note allowing substitution of IsoSource for Glucerna if Glucerna was unavailable was documented later, on 2/2/26 at 2:50 p.m., after the observations.
Failure to Change Suction Canister per Infection Control Policy
Penalty
Summary
Surveyors observed that the facility did not follow its infection prevention and control practices for suction equipment for one resident. On 2/2/26 at 10:34 a.m., a suction canister in Resident B’s room was observed to be approximately half full of yellow-tinged liquid with a layer of yellow sediment settled at the bottom, and the canister was dated 1/13/26. Later that morning at 11:05 a.m., the Executive Director stated that the canister had been changed on 2/2/26, which conflicted with the date on the canister. In the afternoon, surveyors reviewed the facility’s current “Supply Change Out” document, dated 6/2024, which directed that suction canisters and tubing should be changed weekly and as needed, indicating that the observed canister had not been changed in accordance with facility policy. This deficiency was cited under 3.1-18(b) and related to Intake 2731013.
Improper Storage and Handling of Controlled Substances
Penalty
Summary
During a narcotic count observation on the 500 hall medication cart, a Qualified Medication Aide (QMA) was found to have stored controlled substances, specifically Tramadol 50 mg tablets prescribed to a resident, in a manner inconsistent with facility policy and accepted professional standards. The QMA had removed the tablets from their original labeled dispensing container and placed them into multiple pill crusher sleeves, with each sleeve containing 20 half-tablets, some of which were stapled together. The QMA explained that this practice was sometimes done to make counting easier and that pills from different bottles of the same prescription were combined. The Executive Director confirmed that this practice was not in line with facility policy, which requires each drug to be kept in its labeled dispensing container and prohibits transferring drugs from one container to another.
Failure to Respect Residents' Privacy and Dignity
Penalty
Summary
The facility failed to uphold residents' rights to privacy and dignity, as evidenced by multiple instances where staff entered residents' rooms without knocking or announcing themselves. Resident 25 reported feeling disrespected and undignified when staff entered her room or bathroom without knocking, and also mentioned that staff made demeaning comments about odors. During a random observation, two CNAs entered Resident 34's room without knocking, further demonstrating a lack of respect for residents' privacy. Additionally, during a Resident Council Meeting, several residents expressed that staff often entered their rooms without knocking, especially when the call light was on, which made them feel disrespected and deprived of privacy. CNA 14 also entered Resident 46's room without knocking while explaining enhanced barrier precautions. The facility's policy on Residents' Rights, reviewed in January 2025, clearly states that staff should knock and request permission before entering a resident's room, which was not adhered to in these instances.
Medication Labeling and Dating Deficiencies
Penalty
Summary
The facility failed to properly label and date medications on three of six medication carts reviewed, affecting multiple residents. Specifically, Resident 34 had an insulin pen lispro that was not dated correctly, expiring 28 days after opening. Resident 47 had two bottles of latanoprost eye drops without any indication of when they were opened. Resident 5's nasal deep-sea spray also lacked an opening date. Resident 64 had a bottle of Tylenol without a label, and Resident 49's insulin pen lantus was similarly not dated correctly, expiring 28 days after opening. Additionally, Resident 11 had a bottle of Tylenol and a nasal spray, nanogel, both without labels or opening dates. Resident 44 had a bottle of fish oil without a label, and Resident 59's fluticasone nasal spray lacked an opening date. The Nurse Consultant acknowledged the difficulty in managing medication storage, although she indicated that the carts were now correct. The facility's policy on medication expiration requires that multi-dose injections like insulin expire 28 days after opening unless otherwise noted by the manufacturer, and that staff should date the label of any multi-use vial when first accessed.
Infection Control Deficiencies in Nasal Spray Administration and EBP
Penalty
Summary
The facility failed to ensure appropriate infection control measures during the administration of a nasal spray for a resident. During an observation, an LPN was seen administering a nasal spray to a resident without performing hand hygiene or donning gloves, both before and after the procedure. This was in direct violation of the facility's policy on nasal spray instillation, which requires the use of gloves and hand hygiene as part of standard precautions. Additionally, the facility did not maintain consistent and effective infection control practices related to Enhanced Barrier Precautions (EBP) for several residents. Observations revealed that EBP signage was either inadequate or missing, and personal protective equipment (PPE) was not readily accessible in the rooms of residents who required EBP due to conditions such as feeding tubes, amputations, dialysis, pressure ulcers, and indwelling medical devices. Staff interviews confirmed the lack of PPE availability and signage, which contradicted the facility's policy that mandates the posting of EBP signs and the availability of PPE in resident rooms.
Failure to Honor Resident's Preference for Lab Draw Timing
Penalty
Summary
The facility failed to honor a resident's preference regarding the timing of routine lab draws, which led to the resident being woken up too early for blood tests. The resident, who had a history of a kidney transplant and insomnia, expressed dissatisfaction with being disturbed as early as 2:00 a.m. for lab work. Despite communicating his preference to multiple staff members, including a CNA and a QMA, the issue persisted, causing the resident to feel grumpy and have difficulty returning to sleep. Interviews with staff members, including a CNA, QMA, and the Activity Director, confirmed that the resident was not an early riser and disliked early morning lab draws. The Director of Nursing acknowledged that labs were typically drawn between 3:00 and 4:00 a.m. but stated that residents had the right to refuse and that nurses could perform the draws later if necessary. However, the resident's care plans did not reflect any interventions or goals related to his lab work preferences. A review of the resident's lab records showed multiple instances where blood was drawn too early, including several occasions where the timing did not align with the medication schedule for Tacrolimus, an immunosuppressant. The facility's policies on laboratory orders and resident choice emphasized the importance of timely lab draws and supporting resident self-determination, but these were not effectively implemented in the resident's case. The Social Service Director was unaware of the resident's preference until prompted to create a new care plan addressing the issue.
Failure to Initiate New PASARR Screening After New Diagnosis
Penalty
Summary
The facility failed to initiate a new PASARR screening for a resident after a new mental health diagnosis was added to their medical record. The resident, who had diagnoses including bi-polar disorder, dementia, essential hypertension, chronic kidney disease, and major depressive disorder, had a Level I PASARR screening completed earlier in the year, which listed major depression as a diagnosis. However, when a new diagnosis of bi-polar disorder was added, the facility did not conduct a new PASARR screening to determine if a Level II evaluation was necessary. During an interview, the Social Services and Activities Consultant suggested that the resident's dementia diagnosis might not have triggered a Level II screening. The facility's policy requires notifying the state mental health or intellectual disability authority promptly after a significant change in a resident's mental or physical condition, which was not adhered to in this case.
Medication Safety Lapses in Resident Rooms
Penalty
Summary
The facility failed to prevent potential accidents related to medications being left unattended at the bedside for two residents. Resident 60, who has diagnoses including hypertension, arthritis, weakness, and anxiety, was observed sitting in his wheelchair with a cup of pills on a table behind him. The pills were white, orange, and red, totaling approximately eight, and were left unattended despite instructions to the Qualified Medication Assistant not to do so. Additionally, Resident 33 reported to an LPN that there was a pill on the floor next to her bed, which had been there since the night shift. The LPN picked up the unidentified, oblong-shaped, tan pill and disposed of it in the sharps container. The facility's policy on medication self-administration states that residents should always be observed taking their medications and that medications should not remain in the resident's room unless authorized in writing by the attending physician.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with significant past trauma and PTSD. Resident 25, who has a history of trauma including her father's suicide and physical abuse, was not provided with a personalized care plan to address her mental health needs. Despite her documented struggles with sleep and depression, her care plan lacked updates or revisions to incorporate her trauma history, and the Social Services Director was unaware of her past trauma due to a lack of communication with the psychology group. Resident 65, who has severe PTSD from past sexual assault and experiences as an EMT, also did not receive adequate trauma-informed care. Her care plan did not document her PTSD triggers or interventions, and CNAs were unaware of specific interventions beyond general calming techniques. Her care plan was extensive but lacked individualized interventions for her mental health conditions, and her preference for female caregivers was not documented, leading to her being labeled as refusing care. The facility's policies on trauma-informed and culturally competent care, as well as care plan development and review, were not effectively implemented. The Social Services Director and Regional Nurse Consultant acknowledged the challenges in accessing and updating care plans, suggesting that the CNA assignment sheets should include triggers and interventions for easier access. However, these deficiencies in care planning and communication resulted in inadequate support for residents with trauma histories.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up with pharmacy recommendations in a timely manner for a resident. The resident had diagnoses including palliative care, hypertension, sleep apnea, and pain. On February 5, 2025, the pharmacy recommended a reduction in the resident's aspirin and gabapentin dosages. However, the physician did not respond to these recommendations until February 12, 2025, which was beyond the facility's policy of a 3-day response time. The Director of Nursing (DON) indicated that if there was no response from the physician within 3 days, the recommendation would be sent again. The facility's policy required the DON or designee to ensure the attending physician's review and response within three business days for non-emergent recommendations.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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