Columbia Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 621 W Columbia St, Evansville, Indiana 47710
- CMS Provider Number
- 155224
- Inspections on file
- 39
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Columbia Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified multiple failures in food storage and labeling practices in the kitchen, including expired mayonnaise, grape jelly, Worcestershire sauce, baking soda, mini marshmallows, yellow cornmeal, and orange juice, as well as several items such as syrups, ketchup, and pudding mix that lacked required open and use-by dates. The Dietary Manager acknowledged that opened food should be labeled with open and use-by or expiration dates, and the facility’s Kitchen Operations policy requires all refrigerated, ready-to-eat, non-potentially hazardous, and shelf-stable foods to be properly labeled, dated, and used or discarded within defined time frames.
A resident with a pressure ulcer and multiple comorbidities did not receive antibiotics and wound care as ordered by the physician, with missing documentation for several medication doses and treatments. Staff interviews revealed confusion about care plan requirements, and the resident was not consistently included on the assignment form for turning and repositioning, despite physician orders.
Several residents who required staff assistance for ADLs did not consistently receive scheduled showers or complete bed baths, with some going weeks without bathing and their preferences for timing and frequency not being honored. Observations included residents with unkempt hair and direct complaints about missed showers, while documentation and staff interviews confirmed lapses in both care delivery and record-keeping.
The facility was found to have significant cleanliness issues, including dust and dirt build-up in multiple halls, unclean linen closets, and improperly stored urinals in a shared bathroom. Shower rooms were not maintained, with discolored grout and broken tiles observed. A strong urine odor was present in various areas, and residents expressed concerns about inadequate housekeeping. The facility's housekeeping policy was not effectively implemented, leading to these unsanitary conditions.
The facility failed to ensure complete and accurate documentation for four residents' medication administration records. Insulin and nebulizer treatments were not properly documented, and the facility lacked a nebulizer treatment documentation policy. Staffing issues during the evening shift contributed to incomplete documentation.
A facility failed to follow its nebulizer treatment protocol for a resident, resulting in the resident being found unresponsive during the treatment. The RN left the resident unattended to contact a nurse practitioner, and required assessments were not documented. CPR was initiated, and the resident was transported to the hospital. The facility lacked a formal nebulizer treatment policy, although nurses received skills check-offs during orientation.
A resident with diabetes experienced dangerously high blood glucose levels, leading to diabetic ketoacidosis (DKA) and emergency hospitalization. The facility failed to document physician notifications and follow-up actions, despite critical readings and symptoms. Communication and documentation inconsistencies were noted, including the use of undocumented text messages.
The facility failed to ensure medications were properly dated, labeled, and not expired across multiple medication and treatment carts. Observations revealed insulin vials, nasal saline, sterile water, Betadine, and other medications were missing open dates, labels, or were expired. Non-medical items were found in medication carts, and interviews confirmed the need for proper labeling and dating.
A facility failed to notify a physician of a resident's critical blood glucose levels, which were outside the specified parameters. Despite a lab report indicating a critical level, there was no documented follow-up with the physician as required by the facility's policy. This deficiency highlights a lapse in communication and adherence to established protocols for managing changes in a resident's condition.
A facility failed to implement a care plan for a resident with frequent UTIs and multidrug-resistant organisms. The resident reported that improper cleaning by staff led to the infections. The DON acknowledged the absence of a care plan, which was required by the facility's policy to address the resident's needs, including ESBL colonization and recurrent UTIs.
A resident developed avoidable pressure ulcers due to the facility's failure to monitor skin under a knee immobilizer. Despite a care plan requiring weekly skin assessments, the facility did not conduct these assessments, resulting in two unstageable pressure wounds. The facility's policy to prevent pressure ulcers was not followed, as confirmed by the DON.
A resident with cancer diagnoses did not receive appropriate pain management before wound care. Despite requesting pain medication, the RN proceeded with the treatment, causing the resident to express pain. The facility's pain management policy was not adhered to, as the medication was not given time to take effect before continuing the procedure.
A facility failed to administer medications according to standards, resulting in a 7.69% error rate. An LPN did not prime insulin pens before administering Glargine and Lispro Insulin to a resident with diabetes and systemic lupus erythematosus. The LPN was unaware of the priming requirement, as indicated in the Humalog Kwik Pen instructions provided by the administrator.
A resident with diabetes mellitus experienced critically high blood glucose levels, but the LTC facility failed to document insulin administration and physician notifications as required. The DON admitted to lapses in documentation, and interviews revealed inconsistencies in communication and record-keeping practices, leading to incomplete records for the resident's insulin management.
The facility failed to follow infection control practices during care for three residents. A CNA did not sanitize hands or change gloves after handling soiled items for a resident with dementia. Another resident, who was cognitively intact and had frequent UTIs, received care from staff who did not sanitize hands between tasks. A resident with a stage 4 pressure ulcer did not receive proper enhanced barrier precautions during wound care, as the LPN did not wear a gown despite facility policy requiring it.
A resident with multiple health issues was discharged home without the arrangement of home health services and without completing necessary documentation. The resident left the facility with her husband before being evaluated by the hospice company, which later did not accept her. The facility did not follow its policy on discharge against medical advice and failed to notify outside agencies about the resident's safety concerns.
The facility failed to ensure dignity and timely care for three residents, leading to significant delays in assistance and disrespectful treatment. Residents reported waiting hours for care, being talked down to, and experiencing neglect despite their medical conditions requiring substantial assistance.
Improper Food Storage, Labeling, and Use of Expired Food in Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to store and label food in accordance with its own Kitchen Operations policy and professional standards during a kitchen tour. In the reach-in refrigerator, surveyors observed a bottle of mayonnaise past its manufacturer expiration date, a bottle of grape jelly with no open or use-by date and an expired manufacturer date, and bottles of caramel syrup, chocolate syrup, and ketchup without appropriate open or use-by dates consistent with policy. A container of Worcestershire sauce was labeled with an open date and a use-by date that had already passed. In the food preparation area, a box of baking soda was labeled with an open date and a use-by date that had already passed, a bag of mini marshmallows was beyond its use-by date, and two bags of pudding mix wrapped in plastic had no open or use-by dates. A bag of yellow cornmeal was also observed with a use-by date that had passed. In the dry storage area, three bottles of orange juice were found with use-by dates that had already expired. During an interview, the Dietary Manager stated that once food is opened it should be labeled with an open date and a use-by or expiration date. The Administrator provided the facility’s Kitchen Operations policy, which requires refrigerated, ready-to-eat food to be clearly marked with the date opened and the date by which it will be consumed or discarded, and specifies that opened food can be held at 41°F or less for no more than seven days, not exceeding the manufacturer’s use-by date. The policy also requires non-potentially hazardous condiments and shelf-stable items to be labeled, dated, and used or disposed of within specified time frames, and that all foods be covered or wrapped tightly, labeled, and dated. The observations showed multiple instances where these requirements were not followed.
Failure to Follow Physician Orders for Pressure Ulcer Care and Antibiotic Administration
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus and gout, and with a history of a right heel pressure ulcer and osteomyelitis, did not receive care and treatment as ordered by the physician. The resident's care plan required turning and repositioning every 2 hours and administration of antibiotics for a right heel infection. However, documentation was missing for several doses of prescribed antibiotics (Clindamycin and Cephalexin) and wound treatments on specific dates. The medication administration record (MAR) and treatment administration record (TAR) lacked evidence that these orders were carried out as scheduled. Additionally, the resident was not consistently included on the CNA assignment form for turning and repositioning, despite the care plan directive. Interviews with staff revealed inconsistencies in understanding and implementing the resident's care plan. A CNA stated the resident was not listed as needing to be turned and repositioned every 2 hours, while the DON confirmed that such interventions were required and should have been documented. The DON also indicated that staff should have attempted to wake the resident for treatments, and that MAR and TAR entries should not have been left blank. The facility did not have a specific policy related to following physician's orders, though the Assistant Administrator stated it was their practice to do so.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADLs), specifically bathing, received showers or complete bed baths as scheduled. Multiple residents reported or were observed to have gone extended periods without showers, despite care plans and preferences indicating the need for assistance with bathing at least twice per week, with partial baths in between. Documentation and interviews revealed that showers were missed on several scheduled days for seven out of eight residents reviewed, and in some cases, residents' preferences for shower timing and frequency were not honored. Residents affected included those with cognitive impairments such as Alzheimer's disease and dementia, as well as those with physical limitations like quadriplegia and major depressive disorder. Observations included residents with unbrushed, greasy, or oily hair, and direct complaints from residents about not receiving showers for up to two or three weeks. Clinical records and care plans consistently documented the need for staff assistance with bathing, and residents' preferences for shower frequency and timing were noted but not consistently followed. Review of the facility's documentation systems, including Point of Care (POC) charting and shower sheets, showed gaps where showers or bed baths were neither provided nor documented as refused. Staff interviews confirmed that information was sometimes not transferred correctly between documentation systems, and that reattempts or alternative shower times were not always offered when a resident initially refused care. The facility's policy on resident rights emphasized dignity, respect, and honoring resident schedules, but these standards were not met in practice for the residents reviewed.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment over the course of a two-day survey. Observations revealed a significant build-up of dust and dirt along the base of room doors and fire doors in multiple halls, including the 1200, 1400, 1500, 2100, 2200, and 2400 halls. Additionally, the fire doors leading to the second-floor dining room were also found to have dust and dirt accumulation. The facility's linen closets were not properly cleaned, with one closet on the 1100 hall containing a safety razor on the floor, and another on the 2500 hall having debris, trash, and gloves on the floor. The facility's policy indicated that floors should be swept and mopped daily, but this was not adhered to, as evidenced by the observations. The survey also identified issues with the cleanliness and maintenance of shower rooms. The 2500 hall shower room had discolored grout, a cracked tile, and a build-up of dust and dirt, while the 2100 hall shower room had broken window blind strings and a cracked tile. Furthermore, there were concerns about the improper storage of urinals in a shared bathroom, where two uncovered urinals were found on the floor near the commode. A resident expressed concerns about the lack of housekeeping on weekends and the poor quality of cleaning in their room and bathroom. Throughout the survey, a strong urine odor was detected in various areas of the facility, including the 1100 hall, the first and second floors, and the lobby by the front entrance. The facility's housekeeping policy outlined specific cleaning procedures, including sweeping and mopping under beds, corners, and edges, as well as wiping down walls and cove bases on designated days. However, these procedures were not effectively implemented, contributing to the unsanitary conditions observed during the survey.
Incomplete Documentation of Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation for four out of eight resident records reviewed. For Resident C, the Medication Administration Record (MAR) lacked documentation indicating whether insulin doses were administered on specific dates. The Director of Nursing (DON) was unable to confirm if the insulin was given as ordered due to the absence of documentation. Resident U's electronic medication administration record (eMAR) also lacked documentation for blood sugar results and insulin administration on a particular date. Resident M's eMAR was missing documentation for insulin administration and blood sugar results on two consecutive days. Similarly, Resident O's eMAR lacked documentation for the administration of ipratropium bromide and pre and post-nebulizer assessments on multiple occasions. The facility did not have a nebulizer treatment documentation policy, although nurses received skills check-off during orientation. An anonymous interview revealed that the facility was often understaffed during the evening shift, leading to incomplete documentation. The facility's current Medication Administration policy, revised in July 2023, requires that medication administration be recorded on the MAR/eMAR or TAR after being given. This deficiency relates to a complaint identified as IN00449174, highlighting the facility's failure to maintain accurate and complete medical records in accordance with accepted professional standards.
Failure to Follow Nebulizer Treatment Protocol
Penalty
Summary
The facility failed to adhere to its nebulizer treatment policy for a resident who had recently been discharged from the hospital. The resident, identified as Resident D, was not assessed prior to receiving a nebulizer treatment, and facility staff did not remain at the bedside during the treatment. This lapse in protocol resulted in Resident D being found unresponsive, without respirations or a pulse, during the treatment. Cardiopulmonary resuscitation (CPR) was initiated, and emergency medical technicians (EMTs) were called, leading to the resident's transport to the hospital. The incident occurred when a Registered Nurse (RN) left the room to contact a nurse practitioner, leaving the resident unattended during the nebulizer treatment. The facility's documentation was incomplete, lacking records of the required pre-treatment assessments, including pulse, respirations, and breath sounds. The Director of Nursing (DON) confirmed that assessments should have been completed and documented by a nurse before, during, and after each treatment. Additionally, the facility did not have a formal nebulizer treatment policy, although nurses received skills check-offs during orientation. The deficiency was related to a complaint investigation.
Failure to Manage Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to provide effective services for treating elevated blood glucose levels for a resident with diabetes mellitus, leading to a life-threatening condition known as diabetic ketoacidosis (DKA). The resident's blood glucose levels were significantly elevated on multiple occasions, with readings as high as 490 mg/dL and later exceeding 600 mg/dL. Despite these critical levels, there was a lack of documentation indicating that the physician was notified or that appropriate follow-up actions were taken by the facility staff. On several occasions, the facility's records lacked documentation of physician responses or follow-up actions between the initial high blood glucose reading and subsequent critical levels. The resident's condition deteriorated, showing symptoms such as increased heart rate, refusal to eat or drink, and excessive urination. Despite these signs, there was no documented evidence of timely communication with the physician or adjustments to the resident's insulin regimen. The facility's policies required such notifications and documentation, but these were not adhered to. The resident eventually became unresponsive, with a blood glucose level of 742 mg/dL, and was admitted to the hospital's intensive care unit for DKA treatment. Interviews with the Director of Nursing and the Nurse Practitioner revealed inconsistencies in communication and documentation practices, including the use of text messages that were not part of the clinical record. The facility's failure to document and act on critical blood glucose levels resulted in the resident's emergency hospitalization.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly dated, labeled, and not expired across multiple medication and treatment carts. Observations revealed that insulin vials and pens, nasal saline, liquid protein, sterile water, Betadine, and various other medications were either missing open dates, labels, or were expired. For instance, insulin vials and pens in the 1500 Hall Medication Cart lacked open dates and labels, while a bottle of nasal saline was expired. Similarly, the 1400 Hall Medication Cart contained a bottle of sterile water past its expiration date, and the First Floor Treatment Cart had an opened bottle of Betadine without an open date. Further observations in the Memory Care Unit's medication cart revealed non-medical items such as jewelry, alongside medications like Clonidine and MiraLAX that were not properly labeled. The ,d+[DATE] Hall Medication Cart contained an opened bottle of Nitroglycerin without a date, and the 2500 Medication Cart had multiple opened bottles of MiraLAX with no open dates. The Second Floor Treatment Cart was found with various medications, including Nystatin powder and antifungal cream, lacking labels or open dates, and some items were expired. Interviews with nursing staff confirmed that medications should be labeled and dated, and the Director of Nursing indicated that stock medications require labeling once opened.
Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of blood glucose levels outside of the specified parameters for a resident with diabetes mellitus. The resident's clinical record indicated that the resident was not assessed for cognitive impairment and received insulin regularly. Physician orders required notification if blood glucose levels were below 60 mg/dL or above 400 mg/dL. On a specific date, the resident's blood glucose level was recorded as greater than 600 mg/dL, but the physician was not notified as required by the facility's policy. Further documentation revealed that a critical blood glucose level of 526 mg/dL was reported by the lab, but there was a lack of follow-up with the physician between the time the lab called and the following morning. The facility's policy required that changes in a resident's condition be communicated to the physician and family, with appropriate and timely intervention. However, the clinical record lacked documentation of such communication and follow-up, indicating a deficiency in adhering to the facility's policies.
Failure to Implement Care Plan for Resident with Recurrent UTIs
Penalty
Summary
The facility failed to implement a care plan for a resident, identified as Resident 85, who experienced frequent urinary tract infections (UTIs) with multidrug-resistant organisms. On October 25, 2024, Resident 85 reported that the frequent UTIs were due to improper cleaning by the staff. A review of the clinical record on October 28, 2024, revealed that Resident 85 had several diagnoses, including a urinary tract infection, and required substantial assistance with personal hygiene. The resident was also noted to be incontinent of bowel and bladder, had a primary diagnosis of COPD, and had been on antibiotics and isolation precautions due to an intravenous catheter and colonization with ESBL. The Director of Nursing (DON) acknowledged on November 1, 2024, that there should have been an ongoing care plan addressing the recurrent UTIs and ESBL colonization in Resident 85's urine. The facility's policy, as provided by the Administrator, mandates that each resident should have a comprehensive, person-centered care plan developed and implemented based on the Resident Assessment Instrument process. This care plan should include measurable goals and resident-specific interventions to promote the resident's highest level of functioning. However, the facility did not adhere to this policy for Resident 85, resulting in a deficiency.
Failure to Monitor Skin Under Immobilizer Leads to Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of an avoidable pressure ulcer in a resident, identified as Resident 89, by not adequately monitoring the skin condition under a knee immobilizer. Resident 89, who was cognitively intact and fully dependent on staff for transfers, returned from a hospital stay with a knee immobilizer due to a fracture. Despite having a care plan that required weekly skin assessments, the facility did not conduct these assessments during several weeks when the immobilizer was in place. This lack of monitoring led to the development of two unstageable pressure wounds on the resident's right lateral calf, which were attributed to the knee immobilizer. The clinical record review revealed that there were no documented skin assessments during critical periods when the immobilizer was used, specifically from mid-June to late July. The facility's policy on skin management aimed to prevent pressure ulcers by evaluating residents' clinical conditions and implementing necessary interventions. However, the facility did not adhere to this policy, as evidenced by the absence of skin assessments and the subsequent development of pressure injuries. The Director of Nursing confirmed the lack of skin assessments during the missing weeks, highlighting a failure in the facility's monitoring and evaluation processes.
Failure to Administer Pain Management Before Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 104, who was observed during wound care. Resident 104, diagnosed with malignant neoplasm of lymph nodes and squamous cell carcinoma, was cognitively intact and dependent on staff for transfers and personal care. The resident's care plan included offering non-pharmacological interventions and administering medications as ordered. However, during an observation, RN 12 began wound care without administering pain medication, despite Resident 104's request for it. The resident expressed pain and requested medication multiple times during the procedure. RN 12 continued the wound care without repositioning the resident or postponing the treatment to allow the pain medication to take effect. Another nurse, RN 10, was called to provide the medication, which was administered during the procedure, but not given time to work before continuing the wound care. The facility's policy on pain management, which emphasizes individualized care and alternative pain relief techniques, was not followed. Resident 104 reported not receiving routine pain medications and that staff did not allow time for pain medication to take effect before wound treatments.
Medication Administration Errors Due to Lack of Priming Insulin Pens
Penalty
Summary
The facility failed to ensure medications were administered according to manufacturer and professional standards for one of five residents observed during a medication pass. Specifically, two medication errors were observed during 26 opportunities for error, resulting in a 7.69% error rate. The errors involved a resident with diagnoses including diabetes mellitus and systemic lupus erythematosus. During a medication administration, an LPN prepared Glargine Insulin and Lispro Insulin but did not prime the two insulin injection pens with two units prior to administering. The LPN indicated she was unaware of the need to prime the insulin prior to administration. The facility's administrator provided a patient information insert for the Humalog Kwik Pen, which stated that priming ensures the pen is ready and removes air that may collect in the cartridge during normal use.
Incomplete Documentation of Insulin Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation for a resident with diabetes mellitus who was receiving insulin. The resident's clinical record indicated that they were not assessed for cognitive impairment and received insulin over a seven-day period. However, there was a lack of documentation regarding the physician's response or follow-up actions taken by the facility staff when the resident's blood glucose levels were critically high on multiple occasions. On several instances, the resident's blood glucose levels exceeded 500 mg/dL, yet there was no documentation of insulin administration or physician notification as required by the facility's policies. The Director of Nursing (DON) acknowledged that the nurse did not document the notification to the Nurse Practitioner (NP), the new order, or the insulin administration amount in the progress notes. Additionally, there was confusion regarding whether the 8 A.M. dose of insulin was administered on a specific date, as the Licensed Practical Nurse (LPN) could not recall the details. Interviews with the facility's staff, including the Administrator and NP, revealed inconsistencies in communication and documentation practices. The NP indicated that she was not contacted regarding the resident's elevated blood glucose levels on certain dates and was unable to find records of rechecked blood glucose levels. The facility's policies required documentation of medication administration and communication of orders, but these were not adhered to, leading to incomplete records for the resident's insulin management.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during incontinence and wound care for three residents. In the case of Resident 64, a CNA did not sanitize hands or change gloves after touching soiled items and then proceeded to touch the resident's remote and bedside table. Resident 64 was not cognitively intact and required substantial assistance with personal hygiene. For Resident 85, who was cognitively intact and had a history of urinary tract infections, a QMA did not wash or sanitize hands after changing gloves during peri care, and a CNA did not change gloves or sanitize hands after handling a soiled bedpan. Resident 86, who had a stage 4 pressure ulcer and required enhanced barrier precautions, did not receive proper care as the LPN performing wound care did not wear a gown, despite the presence of a sign indicating the need for enhanced barrier precautions. The facility's infection preventionist confirmed that residents with wounds should automatically be placed on enhanced barrier precautions, which include wearing a gown and gloves during high-contact care activities. The facility's policy on enhanced barrier precautions was not followed, contributing to the deficiency.
Failure to Implement Proper Discharge Process
Penalty
Summary
The facility failed to ensure the proper implementation of the discharge process for a resident who was unable to care for herself. Resident B, who had multiple diagnoses including COPD, major depressive disorder, anxiety, chronic pain, history of falls, weakness, and unsteadiness on feet, was discharged home without the arrangement of home health services and without completing the necessary documentation according to the facility's discharge policy. The resident's hospital notes prior to admission to the facility indicated significant concerns about her safety and stability, both socially and mentally, and recommended an in-depth Adult Protective Services (APS) investigation into her well-being. The resident's care plan required assistance with activities of daily living and noted a risk for falls. Despite this, the resident was discharged home with an order for hospice services without confirmation of acceptance from the hospice company. The discharge summary for Resident B was completed but lacked a signature from the resident or a representative, rendering it invalid. The facility's social service staff indicated that the resident was alert and oriented but chose to leave the facility without a transition of care being completed. The record lacked documentation of the exact time or date the resident left the facility and did not include any education provided about leaving against medical advice (AMA). Interviews with facility staff revealed that the resident left the facility with her husband before being evaluated by the hospice company, which later did not accept her. The facility did not contact APS regarding the resident's return home, despite the significant concerns noted in her hospital records. The facility's policy on discharge against medical advice was not followed, as there was no documentation of the options offered, risks explained, or information given to the resident. Additionally, no AMA observation was completed in the resident's record, and the facility failed to notify outside agencies about the resident's safety and well-being concerns.
Failure to Ensure Dignity and Timely Care for Residents
Penalty
Summary
The facility failed to ensure dignity for three residents, leading to significant delays in care and disrespectful treatment. Resident B reported waiting two hours for care after turning on their call light, only for staff to turn off the light and leave without providing assistance. Resident B's medical history includes hemiplegia and muscle weakness, necessitating extensive assistance with toileting. The care plan indicated the need for assistance due to these conditions, but the facility did not adhere to it. Resident D also experienced neglect, having waited over two hours to be changed despite multiple requests. The resident's medical history includes hemiplegia and contractures, requiring substantial assistance with toileting. Despite a grievance being filed, the issue persisted, and Resident D reported being talked down to and labeled as the worst patient for frequently using the call light. This indicates a pattern of disrespect and neglect from the staff. Resident C faced similar issues, including delays in receiving medications, water, and assistance with toileting. The resident's medical history includes heart failure and COPD, requiring moderate assistance with daily activities. Despite filing multiple grievances, the resident continued to experience long wait times for care. An anonymous interview also revealed that a nurse had derogatorily referred to residents as druggies when administering pain medication. These incidents collectively highlight a failure to provide timely and respectful care to the residents.
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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