Envive Of Indianapolis
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 45 Beachway Dr, Indianapolis, Indiana 46224
- CMS Provider Number
- 155077
- Inspections on file
- 43
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Envive Of Indianapolis during CMS and state inspections, most recent first.
A resident with severe protein-calorie malnutrition and dysphagia had inconsistent TF delivery, missed nutrition follow-up, and significant weight loss without documented reweighting or RD notification. Another resident with dementia and malnutrition was supposed to have weekly weights, but no order was entered and large weight discrepancies were not confirmed with reweights, leaving her nutritional status unresolved.
Failure to provide and document ADL grooming and hygiene assistance: Multiple dependent residents were observed with long, dirty fingernails, debris under nails, and in some cases food debris in facial hair or poor body hygiene. Records showed the residents needed staff help with personal hygiene, bathing, and grooming, but progress notes and shower documentation did not show fingernail care or beard cleaning was offered, provided, or refused. Staff interviews confirmed fingernail care should have been done with showers and as needed, and beard cleaning should have occurred after meals.
Incomplete side rail assessments were found for several residents, including a resident who used quarter side rails to reposition in bed and a memory care resident with dementia and TBI whose quarterly assessments conflicted on whether side rails were present. The facility also failed to ensure a sliding glass door in the memory care unit was properly secured; staff said routine checks focused on main doors, not the sliding doors, and the door could be pulled open slightly.
A resident who was yelling for help after needing toileting assistance was spoken to sternly by an LPN, and staff did not address his calls for help or his incontinence needs in a dignified manner. In dining, trays were passed in random order, leaving some residents waiting while others ate, and a totally dependent resident with cerebral palsy was repositioned and removed from the dining room with her meal left behind; when returned, staff did not meaningfully assist her, warm the meal, or offer an alternative.
Call lights were not kept within reach for three residents. One resident with a history of TBI, aphasia, and severe cognitive impairment had the call light on the floor behind the bed. A resident with vascular dementia was observed multiple times with the call light on the floor or draped over the bed and said she did not know where it was or how she would call for help. Another resident with altered mental status was lying on a mattress next to the bed with the call light between the bed and wall. Staff and the DON stated call lights should be within reach before leaving the room, and the facility policy required the call light to be accessible when in bed.
Advance directive documentation was incomplete for two residents whose records lacked orders for their desired full code status, even though their care plans stated those wishes. In addition, a resident with dementia had a POST form uploaded with her daughter’s name entered in the patient identification section, indicating the form was completed incorrectly.
A facility failed to document medication disposition for two residents after discharge. Records for both residents lacked documentation for numerous medications, while the VPCS stated the meds were sent back to the pharmacy and destroyed but there was no record of destruction; the DON also received an email from the pharmacy saying it could not find any returned medications. The facility policy required detailed disposition documentation, including the resident name, medication details, destruction date, quantity, method, reason, and witness signatures.
A resident with hemiplegia and hemiparesis after a subarachnoid hemorrhage was observed with the left hand closed and unable to be opened or moved, yet the admission MDS did not code any ROM limitation. The MDS Coordinator stated the assessment was coded incorrectly and should have reflected an impairment on one side of the upper extremities.
Failure to Re-evaluate PASRR After New Psychiatric Diagnosis: The facility did not ensure a resident's PASRR was re-evaluated after new psychotic disorder diagnoses were added to the chart. The resident had a prior PASRR Level I screen that found no SMI and no need for a Level II review, but the record lacked documentation of a new referral. The VP of Life Enrichment and the SSD both acknowledged the resident needed reassessment for possible Level II PASRR.
A resident with dementia and schizoaffective disorder had repeated falls, and IDT notes documented new interventions such as OT evaluation for bed mobility and PT for dynamic transfers, lower extremity strength, and bed mobility. Although the notes stated the care plan was reviewed and updated after each fall, the current fall care plan did not include those new interventions.
A resident with a G-tube reported irritation, pain, bloating, and that the tube was no longer used, while staff observed the tube to be excessively long, clouded, and poorly secured with an irritated insertion site. An LPN stated there were no orders for flushing, and record review showed no orders for routine or PRN site care, flushes, aspiration, anchoring, or infection monitoring, and the care plan was not updated to reflect that the tube was no longer in use.
Medication storage and dating errors were found on two med carts. An LPN observed multiple open inhalers without open dates, a discontinued antibiotic still stored on the cart, eye drops kept past a 7-day order, bisacodyl suppositories stored with eye drops and nasal sprays, and an unlabeled open lidocaine vial without a prescription label.
A resident with hemiplegia, a right AKA, and behavioral diagnoses requiring two-person assistance for transfers and showers was left in a shower room while one CNA sought additional help and another CNA remained at the doorway. The resident became upset, began banging and yelling, and a verbal altercation ensued between the resident and the CNA at the door. Multiple nurses reported hearing both the resident and the CNA yelling and cursing at each other from the shower room and later at the nurse’s station, while one CNA reported only hearing the resident’s racially charged and profane insults and seeing him spray the CNA with the shower head. In interviews, the resident stated that the CNA entered the shower room, yelled at him, cursed and called him names, and later yelled at him again at the nurse’s station. The facility’s investigation, under its abuse and neglect protocol that includes verbal abuse, substantiated that the CNA verbally abused the resident.
A facility did not complete a thorough investigation after a resident reported being struck by another resident following a disagreement in the smoking area. The affected resident, who had a history of stroke and amputation, reported pain and ongoing discomfort, but the investigation was limited to statements from the involved parties and an LPN who did not witness the event. No additional staff or resident interviews were conducted, and the Administrator was unaware of the ongoing psychosocial concerns.
A resident with diabetes and neuropathy sustained a full thickness burn to the left foot during wound care when an LPN failed to properly check water temperature and left the resident unattended. The burn was not promptly or thoroughly assessed, and documentation was incomplete. The resident's condition worsened, resulting in hospitalization and surgical intervention for the burn.
A resident with diabetes and neuropathy, who required staff assistance for foot care, sustained a full-thickness burn after an LPN prepared a basin of water for a foot soak, failed to verify the water temperature after filling the basin, and left the resident unattended. The resident, experiencing numbness, placed his foot in the hot water and developed a severe burn, ultimately requiring surgical intervention.
A facility failed to document the reasons for discharging a resident with multiple behavioral issues and did not allow the resident to appeal the discharge. The resident, who had antisocial personality disorder and other conditions, was not permitted to return after a hospital stay. The facility did not provide a discharge assessment or a 30-day notice, and there was a lack of communication with the resident's family and the ombudsman.
A facility failed to allow a resident to return after hospitalization, violating the resident's rights. The resident, with multiple mental health diagnoses, was transferred to a hospital after calling 911. The facility cited safety concerns due to the resident's behavior, including aggression and property damage, but lacked documentation justifying the denial of return. The decision was made without a discharge assessment, and the resident's mother was not informed of the reasons.
The facility did not update its Facility Assessment Tool to reflect current resident needs, affecting 102 residents. The tool lacked details on psychiatric care providers and their availability, and failed to address infection control and accident hazards. This oversight could impact the facility's ability to provide adequate care.
The facility failed to accurately code the MDS for four residents requiring Level II PASRR, as identified during a record review. Despite having Level II PASRRs, the MDS assessments for these residents did not reflect this requirement, contradicting their care plans. The MDS Coordinator, new to the facility, could not explain the discrepancies, which were against the facility's policy that mandates consistency between MDS assessments and care plans.
The facility failed to ensure symptomatic staff were tested or wore masks, and staff did not use PPE during high-contact care for residents requiring Enhanced Barrier Precautions (EBP). Staff members worked while ill without masks, and PPE was not available for residents with chronic wounds and indwelling devices, such as a resident with necrotizing fasciitis and another with a urinary catheter. This non-compliance with infection control protocols risked spreading infections.
The facility failed to maintain accurate Smoking Safety assessments and lacked clear policies for smokers, affecting 30 residents. A resident sustained facial burns from smoking with oxygen, and others were found smoking unsafely. Records lacked documentation of safety evaluations and care plan revisions.
A facility failed to update a resident's advance directive wishes in her medical record. The resident, with conditions including dementia and schizoaffective disorder, had changed her Physician Scope of Treatment (POST) form to Do Not Resuscitate (DNR) from a full code status. However, her physician orders and care plans were not updated to reflect this change. The Social Service Director confirmed the oversight, which was against the facility's policy requiring updates to be documented in the resident's medical record and plan of care.
A resident with hemiplegia, cerebral infarction, and major depressive disorder was not provided with adequate one-on-one activities as per her care plan. Despite expressing a desire to participate in activities, she was visited infrequently by activity staff, who did not leave her with activities to engage in. Records indicated insufficient visits, and the facility lacked a specific policy for one-on-one activities.
A resident with multiple diagnoses requested to be sent to the hospital, but the facility failed to assess and prepare him for transfer. There was no documentation of vital signs, patient condition, or notification to the nurse or physician. Discrepancies were found in the Leave of Absence log and Transfer-to-the-Hospital form, and the resident's care plans did not address his history of calling 911 or inconsistent use of the LOA policy.
A resident with hemiplegia and dementia developed new pressure ulcers due to the facility's failure to provide necessary treatments and services. Despite recommendations for a low air loss mattress, the resident developed a new stage 2 pressure ulcer. The facility's policy required at-risk individuals to be placed on appropriate support surfaces, which was not followed, leading to this deficiency.
A resident with COPD and schizophrenia did not receive necessary toenail care despite having an active physician's order for podiatry services. Observations showed the resident's toenails were long and discolored, and he reported having to rip them off due to lack of care. The facility's policies on nail care and ADLs were not followed, as the resident was not scheduled for the next podiatry visit.
A resident experienced an 11.26% weight loss over two months, and the facility failed to evaluate and address the nutritional status adequately. Despite the resident's significant weight loss and existing medical conditions, there were no active orders for nutritional supplements, and the care plan lacked new interventions. The Registered Dietician noted the need for reweight verification, but there was no documentation of physician notification or assessment of the weight discrepancy.
A facility failed to document pre and post dialysis assessments for a resident with ESRD receiving dialysis from an outside facility. The resident's medical records lacked documentation for multiple dates, despite a care plan requiring such assessments. The Vice President of Clinical Services admitted that the assessments could not be located, and the dialysis center's paperwork was only obtained upon request.
The facility failed to date and manage medications properly, with observations revealing undated Tubersol in the A wing medication room and insulin pens on medication carts lacking opening dates. An LPN noted a vial of Amikacin was opened without a date. The facility's policy requires multi-dose vials to be dated and discarded within 28 days, which was not followed.
A facility failed to maintain accurate medical records for a resident with schizoaffective disorder and mobility issues. After the resident experienced a fall, the facility was supposed to implement 15-minute safety checks for 72 hours. However, they could not provide documentation proving these checks were completed, violating their policy on Falls and Fall Risk Management.
A resident's privacy was compromised during incontinent care when staff left the door open, exposing her to passersby. Despite the presence of an RN and a CNA, the resident's bare bottom and wounds were visible from the hallway. The resident, who has spina-bifida and anxiety, expressed discomfort with the lack of privacy, which contradicted her care plan emphasizing dignity and respect.
The facility failed to install call light devices with pull cords in 16 out of 60 residents' bathrooms, as identified through interviews and observations. Resident B and Resident C reported issues with the absence of pull cords and call light devices, respectively. An environmental tour confirmed these deficiencies, which were not identified during weekly staff reviews, despite the facility's policy requiring operational and accessible call lights.
The facility failed to protect a resident's right to smoke, affecting one resident with multiple diagnoses. Despite being offered a smoking cessation aid, the resident reported not receiving it. The care plan was later updated to allow supervised smoking.
Failure to Maintain Nutritional Support and Weight Monitoring
Penalty
Summary
The facility failed to ensure adequate and consistent nutritional interventions for a dependent resident with a history of stroke affecting his left side and severe protein-calorie malnutrition. Resident 10 was observed to be very thin and frail, with dry, cracked lips and a tube feeding running. At other times, his tube feeding was disconnected while he remained in his room or in bed, including periods when the pump alarmed and remained inactive for extended time. A lunch tray of pureed food was left untouched, and a CNA stated the resident had previously eaten some but then began holding food in his mouth, making the tube feeding his only source of nutrition. The record showed that before hospitalization the resident weighed 138 lbs, and after returning from the hospital he weighed 128.4 lbs. The record lacked documentation of interdisciplinary team or RD follow-up after the hospitalization to address the weight loss and prevent further decline. His tube feeding orders were discontinued for several days after return from the hospital with no clear alternative nutrition plan, and later the feeding regimen was changed from one formula to another without documentation of rationale, gradual titration, or a dietitian-driven plan. The record also showed a significant weight loss from 127.8 lbs to 117 lbs in one week, but there was no documentation of a reweight after that loss or nursing notification to the RD in writing per facility policy. The facility also failed to appropriately monitor another resident at high risk for malnutrition. Resident 8 had diagnoses including dementia and malnutrition and was admitted for nutritional monitoring. The NP requested weekly weights, but the record lacked an order for weekly weights. The resident had a documented significant weight loss from 91 lbs at the hospital to 79 lbs at the facility, and the dietitian noted she was at high risk for malnutrition and that clinical staff would monitor weights weekly. Subsequent CAR assessments documented no weekly weights had been obtained, and later weights showed large unexplained changes, including a recorded weight of 104.2 lbs and then 192.8 lbs, with repeated requests for reweighs that were not completed before the resident discharged home.
Failure to Provide and Document ADL Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to ensure dependent residents received assistance with activities of daily living, including grooming and personal hygiene, for five of six residents reviewed. Observations showed multiple residents with long, untrimmed fingernails containing dark debris underneath them, and several residents also had visible food debris in facial hair or signs of poor hygiene. The record review showed these residents had diagnoses including traumatic brain injury, schizophrenia, vascular dementia, and stroke-related impairment, and their MDS assessments and care plans identified them as needing substantial to total staff assistance with personal hygiene, bathing, and grooming. For Resident 70, repeated observations showed long fingernails with debris and food debris in the beard over several days. The record indicated severe cognitive impairment, partial/moderate assistance with eating, and substantial/maximal assistance with personal hygiene. Progress notes did not document that fingernail care or beard cleaning was offered, provided, or refused, and shower documentation also lacked any notation that fingernail care was addressed during bathing. The resident’s behavior monitoring showed no occurrences of care refusal, and the bathing records documented scheduled baths without refusal documentation. For Resident 73, observations showed a puddle of urine under the wheelchair, foul body odor, and long fingernails with debris on repeated checks. The resident’s care plan identified dependence on staff for personal hygiene and bathing/showering, but progress notes did not document fingernail care being offered, provided, or refused. Shower documentation showed the resident was bathed on scheduled days, with one refusal noted in the bathing log, but the shower sheets still lacked documentation of fingernail care. Resident 78 and Resident 97 were also observed with long fingernails and debris, and their records similarly lacked documentation that fingernail care was offered, provided, or refused despite care plans and MDS assessments showing dependence on staff for bathing and personal hygiene. Resident 10 was observed thin and frail, unable to answer questions, contracted, dressed only in a hospital gown, with a bushy beard and long thick fingernails with debris underneath them. After a shower, the beard remained overgrown and the fingernails still had debris. The resident’s MDS assessment showed total dependence on staff for all ADLs, including personal hygiene and grooming, and the care plan identified dependence on staff for all ADL care. The DON and a QMA stated fingernail care should be provided with showers and as needed, and food should be cleaned from a resident’s beard after eating, but the documentation reviewed did not show that this care was provided or refused.
Incomplete side rail assessments and unsecured sliding glass door
Penalty
Summary
The facility failed to complete side rail assessments for 4 of 7 residents reviewed for accident prevention. Resident 29 was observed in bed with quarter side rails on both sides and stated he used the rails to move about in bed, but his record contained a side rail assessment dated 1/25/25 indicating he did not have side rails on his bed. Resident 52 was also observed in bed with quarter side rails on both sides, and his record contained an overdue side rail assessment. Resident 54 was observed sitting up in bed with quarter side rails, and his record also contained an overdue side rail assessment. Resident 20, a memory care resident with diagnoses including dementia and traumatic brain injury, was observed resting in bed with a quarter side rail on the left side; his quarterly nursing evaluations showed conflicting side rail assessments, with one dated 3/17/26 indicating no side rails and another dated 3/1/26 recommending bilateral side rails. The facility also failed to ensure a sliding glass door in a memory care resident room was appropriately secured. On observation, pulling on the door handle caused the top of the door to open approximately 1 to 2 inches, wide enough to stick a hand or small arm through, while other similar sliding glass doors on the unit did not move when pulled. Staff interviews indicated clinical staff checked main locked doors but did not check the sliding glass doors, and the memory care UM stated routine rounds did not include checking whether the doors could be opened. The Maintenance Director stated a screw was added to the top of the door to prevent movement and that there had not been regular checks in place for the sliding glass doors before this issue was identified.
Failure to Maintain Resident Dignity During Staff Interactions and Dining
Penalty
Summary
The facility failed to ensure residents were treated with dignity during staff interactions and during dining for two residents. One resident was repeatedly and loudly yelling in the hallway while an LPN told the resident, "I'm going to assist you, but you're still yelling in the hallway for no reason." Staff did not attempt to determine why the resident was yelling or provide a targeted intervention at that time. Later, the same resident was repeatedly calling out for help for several minutes while the Administrator found that the resident had been incontinent and was wet, yet two nurse aides at the nurses' station did not approach or address the resident's calls for help. The resident stated staff did not treat him with respect and dignity, that they did not follow his instructions, and that he had been yelling because he needed help getting to his urinal and then needed help getting changed after urinating in his pants. The resident's record showed diagnoses including dementia, a quarterly MDS indicating he was cognitively intact, dependent on staff for personal hygiene, and frequently incontinent of bladder. The care plan identified behaviors including physical and verbal aggression and urinating on the floor, with interventions to assess and anticipate needs such as toileting, redirect with non-pharmacological interventions, and provide a urinal with routine checks for incontinence and clothing changes after episodes. The SSD stated that a negative staff approach could worsen the resident's response and that the nurse's manner was not likely to help him calm down or de-escalate the situation. The SSD also stated the staff should have used the interventions in the care plan and could have involved the DON or SSD if needed. During a dining observation, lunch trays were passed in random order so some residents waited while tablemates ate, and at one table two residents were served while two others waited until their tablemates had already eaten and left. Another resident was seated in a Broda chair, slid down and leaned to one side with her head nearly resting on the armrest when her lunch plate was placed in front of her. Two unidentified staff members pulled her away from the table and repositioned her using the hoyer pad under her, then the ADON and a nursing aide removed her from the dining room and left her lunch plate at the table. When she was returned to the dining room, her plate remained there, she refused bites when staff attempted to feed her, no one offered to warm the meal or provide an alternative, and an aide stood and leaned over her while talking to another aide without meaningful engagement before leaving her to gather meal tickets. The resident had cerebral palsy and a quarterly MDS indicated she was totally dependent on staff for all ADLs including nutrition and eating.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure call lights were kept within the residents’ reach for 3 of 3 residents reviewed for call lights. During observation, Resident 70 was lying in bed with the call light on the floor behind the head of the bed and no call light within reach. Resident 70’s record showed diagnoses including a personal history of traumatic brain injury and aphasia, with an annual MDS indicating severe cognitive impairment and dependence on staff for most ADLs. The care plan identified communication deficits related to aphasia and included interventions to keep the call light within reach, as well as a fall-risk care plan that also directed staff to keep the call light within reach. Resident 78 was observed on multiple occasions lying in bed with the call light on the floor between the bed and wall or draped over the foot of the bed and not within reach. The resident stated she was not sure how she would call for help, did not know where the call light was, and said no one had given it to her that day; she also stated it bothered her not to have it within reach because she had to yell for help. Resident 78’s record showed vascular dementia with behavioral disturbance, an admission MDS indicating moderate cognitive impairment and dependence on staff for showering/bathing and personal hygiene, and a care plan directing staff to keep the call light within reach and encourage use. Resident 6 was observed lying on a mattress next to the bed with the call light between the bed and wall and not within reach; the resident’s record showed altered mental status, a quarterly MDS indicating cognitive intactness, and a fall/injury care plan that included keeping the call light within reach. Staff interviews confirmed call lights should have been within residents’ reach before staff left the room, and the facility policy stated the call light should be accessible when in bed.
Advance directive orders and POST form were not properly documented
Penalty
Summary
The facility failed to ensure that two residents had orders in place for their desired advance directives. Resident 75 had diagnoses including cerebral infarction, aphasia, dementia, major depressive disorder, anxiety disorder, and insomnia, and his record did not contain an order indicating he wanted full code status in the event of cardiac arrest. Although his care plan, dated 3/4/26, stated that he wished to be a full code and that his wishes would be honored, the corresponding order was missing from the record. Resident 113 had diagnoses including multiple rib fractures, essential HTN, hyperlipidemia, generalized anxiety disorder, depression, insomnia, and muscle weakness, and her record also lacked an order indicating she desired full code status. Her care plan, dated 3/3/26, stated she wished to be a full code, with a goal dated 3/4/26 indicating her wishes would be honored. The facility also failed to ensure a POST form was correctly completed for Resident 3, a memory care resident with dementia whose daughter was listed as her POA. Her uploaded POST form was filled out incorrectly because the daughter’s name was entered in the section for the patient’s last name, first name, and middle initial, indicating the form was completed for the daughter rather than the resident. The DON stated the form was likely filled out in error by the resident’s daughter and was not caught before being uploaded.
Missing Medication Disposition Documentation for Two Discharged Residents
Penalty
Summary
The facility failed to complete a medication disposition for two residents when they were discharged from the facility. For Resident 120, discharged on 2/27/26, the record lacked documentation showing the disposition of multiple medications, including magnesium oxide, Trintellex, ferrous sulfate, naloxone, methocarbamol, pantoprazole, glycolax powder, acetaminophen, senna-docusate, gabapentin, torsemide, ondansetron, loperamide, dulcolax, and Milk of Magnesia. For Resident 119, discharged on 2/28/26, the record also lacked documentation showing the disposition of multiple medications, including Risperdal, vitamin B12, metoprolol, lisinopril, Milk of Magnesia, methimazole, furosemide, amlodipine, sennosides-docusate, acetaminophen, Eliquis, omega 3 oil, cholecalciferol, and mirtazepine. During interview, the VPCS stated the residents' medications were sent back to the pharmacy and destroyed, but there was no record of the destruction. The DON later received an email from the pharmacy stating they could not find where either resident's medications had been returned. The facility policy titled, Discarding and Destroying Medications, stated that the medication disposition record must include the resident's name, medication name and strength, prescription number, dispensing pharmacy, date destroyed, quantity destroyed, method destroyed, reason for destruction, and witness signatures.
Inaccurate MDS Coding for Upper Extremity Limitation
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident. During observation, the resident was found lying in bed with the left hand closed and unable to be opened or moved. Record review showed diagnoses including hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage affecting the left non-dominant side. The admission MDS assessment dated 1/30/26 indicated no limitation in range of motion to the upper or lower extremities, but the MDS Coordinator later stated this assessment was not coded correctly and should have reflected an impairment on one side of the upper extremities. The facility identified the CMS RAI manual as its policy for completing MDS assessments, and the cited guidance for GG0115A states to code impairment on one side when an upper-extremity impairment interferes with daily functioning or places the resident at risk of injury.
Failure to Re-evaluate PASRR After New Psychiatric Diagnosis
Penalty
Summary
The facility failed to ensure a resident's PASRR was re-evaluated after new psychiatric diagnoses were added to the resident's record. Resident 78 had diagnoses of psychotic disorder with delusions due to a known physiological condition, dated 1/23/26, and psychotic disorder with hallucinations due to a known physiological condition, dated 1/30/26. The resident also had physician orders for psychotropic medications including Depakote, trazodone, and buspirone. The resident's record contained a PASRR Level I screening from 10/18/21 completed at another nursing facility that indicated the resident did not have a serious mental illness and did not require a Level II PASRR. The record lacked documentation that the resident was referred for a new PASRR assessment after the psychotic disorder diagnoses were added. During interview, the VP of Life Enrichment stated the resident needed reassessment for consideration of a Level II PASRR because of the new psychotic disorder diagnosis. The Social Services Director stated she believed the diagnosis was already present when the resident was admitted from another nursing facility, that the resident was on a list to be referred for a new PASRR assessment, and that the referral had not yet been completed.
Fall Care Plan Not Updated After Repeated Falls
Penalty
Summary
The facility failed to ensure Resident 12’s fall care plan was revised to reflect new interventions after multiple falls. Resident 12 was a memory care resident with diagnoses including dementia and schizoaffective disorder. The record showed that after a fall out of bed on 8/27/25, the Interdisciplinary Team noted that Occupational Therapy would evaluate the resident’s bed mobility and stated the care plan had been reviewed and updated, but the current fall care plan did not include that intervention. The same pattern occurred after additional falls. Following a bathroom fall on 10/11/25, the new intervention was for Physical Therapy to work with the resident on dynamic functional transfers to improve safety awareness, and the note again stated the care plan had been reviewed and updated, but the current fall care plan lacked that intervention. After a fall in the activity room on 10/15/25, PT was to work on lower extremity strength, and after a fall in the resident’s room while trying to go to the bathroom on 10/29/25, PT was to work on bed mobility; in both instances, the care plan was documented as reviewed and updated, yet the current fall care plan did not contain the new interventions.
G-tube Care Orders Missing and Tube Not Properly Managed
Penalty
Summary
The facility failed to ensure orders were in place and implemented to properly monitor, flush, and secure a resident’s G-tube for one of two residents reviewed for tube feeding. Resident 95 was observed in bed wearing a hospital gown and stated she had a G-tube but wanted it removed because it caused irritation and pain, and she reported the tube was no longer used. On a later observation, the resident’s G-tube and insertion site were seen with cut gauze at the site, and the resident reported discomfort, bloating, and pain. During the same observation, an LPN stated the only order related to the G-tube was to apply zinc oxide at the insertion site, and she did not know why the tube was so long. She also stated nurses had not been flushing the tube because there were no orders, and she was unsure why the tube was clouded or what might be in it. The regional nurse consultant observed the tube was excessively long and had to pull it out from between the resident’s thighs; he noted the insertion site appeared irritated and raw, likely from tugging and exposure to gastric contents, and identified the need for orders for aspiration, flushing, and anchoring. Record review showed no physician orders for routine or PRN G-tube site care, flushes, aspirations, anchoring, or monitoring for signs and symptoms of infection, and the care plan had not been revised to reflect that the G-tube was no longer in use or how to care for the equipment until removal.
Medication Storage and Dating Errors on Medication Carts
Penalty
Summary
The facility failed to ensure medications were properly stored and dated on both medication carts observed. On the B hall medication cart, an open Fluticasone inhaler, two open Albuterol inhalers for one resident, another open Albuterol inhaler, an open Incruse Ellipta inhaler, an open Albuterol inhaler for another resident, and an open Anoro Ellipta inhaler were found without an open date on either the box or the inhaler itself. The cart also contained a bottle of Amoxicillin for a resident that was prescribed for 7 days and had been filled on 2/5/26; the LPN stated the resident had stopped taking it a while ago and it had not yet been thrown out. The LPN also stated she did not know there was a separate expiration date for some medications, such as inhalers, once opened. On the A hall medication cart, a bottle of Moxifloxacin eye drops for a resident was found with a 7-day order and a fill date of 2/10/26. Bisacodyl suppositories were stored in the same compartments as eye drops and nasal sprays. An open glass vial of lidocaine was also found in a drawer compartment without a bag or box and without a prescription label identifying the resident or the order. The facility policy stated orally administered medications are kept separate from externally used medications and outdated medications are immediately removed from stock. The facility guideline listed specific expiration periods after foil opening for several inhalers, including Anoro Ellipta, Fluticasone, Incruse Ellipta, Albuterol, and Symbicort.
Failure to Protect a Resident From Verbal Abuse During Shower Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA during a shower episode. A resident with hemiplegia, hemiparesis following a cerebral infarction, a right above-knee amputation, intermittent explosive disorder, PTSD, and adjustment disorder was care planned as dependent on staff for transfers and bathing, used an electric wheelchair, and required care in pairs due to extensive attention-seeking behaviors and making false statements and accusations. On the day of the incident, the resident was in the shower room receiving care from two CNAs for transfer and showering, consistent with his need for two-person assistance. After the shower was completed, one CNA left to obtain a male staff member to assist with the transfer, and the other CNA (CNA 6) was positioned outside the shower room door to provide oversight and privacy. While the resident remained in the shower room, he became upset and began banging and yelling. Multiple staff witness statements and interviews indicated that a verbal altercation then occurred between the resident and CNA 6. Nurse witnesses reported hearing loud voices and both the resident and CNA 6 yelling and cursing at each other from the shower room, but did not see any physical altercation. One nurse supervisor reported that when she approached, she heard yelling and cursing from both the resident and CNA 6, and that CNA 6 ran out of the shower room stating the resident had hit her. When the supervisor and charge nurse spoke privately with the resident, he admitted he had been cursing at the CNA and stated she was cursing back at him, and that she lunged at him in a threatening manner "like a boxer," though he denied that anyone was hit. Additional staff accounts described the resident directing racially charged and profane insults toward CNA 6, including references to her "fat black African" appearance, and spraying her with the shower head. One CNA stated she did not hear CNA 6 engage verbally with the resident at that time, while another RN reported hearing both the resident and CNA 6 "cussing each other out" in the shower room and later again at the nurse’s station. In his own interview, the resident stated that CNA 6 came into the shower room and started yelling at him, cursing and calling him names, and that he yelled back and told her to get out. He reported that when he later passed the nurse’s station, CNA 6 again began to yell at him and he yelled back until another CNA intervened. The facility’s abuse and neglect protocol defined abuse as including verbal abuse that causes physical harm, pain, or mental anguish, and the internal investigation concluded that CNA 6 had engaged in verbal abuse of the resident during this incident.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following a resident-to-resident allegation of abuse involving two cognitively intact residents. The incident occurred in the smoking area, where a disagreement led to one resident making physical contact with the other's cheek. The affected resident reported moderate pain and was assessed by nursing staff, who found no visible injuries. Both residents were separated, and notifications were made to the physician, DON, Administrator, and resident representatives. However, the investigation documentation included only a written statement from an LPN who did not witness the event and a summary of brief interviews with the involved residents. The resident who was struck reported feeling embarrassed and uncomfortable after the incident, noting swelling on his face and a sense of unease around the other resident. He also expressed that staff did not address his feelings privately and that he continued to feel uncomfortable, choosing to smoke in his truck to avoid further misunderstandings. Despite these ongoing concerns, the Administrator was unaware of the resident's discomfort and did not interview other residents or staff who may have witnessed the incident or had relevant information. The facility's policy required all accidents or incidents to be investigated and reported to the Administrator, but the investigation was limited to statements from the involved residents and a non-witnessing LPN. No additional interviews or broader inquiry were conducted to fully assess the circumstances or psychosocial impact. The lack of a comprehensive investigation did not meet the facility's policy or regulatory expectations for handling resident-to-resident abuse allegations.
Failure to Provide Timely Assessment and Treatment of Burn Injury
Penalty
Summary
A resident with a history of diabetes mellitus type II and degenerative disease of the nervous system sustained a full thickness burn to the left foot during wound care. The incident occurred when a nurse prepared a basin of water for the resident to soak his foot prior to applying a treatment for an unrelated skin condition. The nurse checked the water temperature by hand but did not use a thermometer or recheck the temperature after filling the basin. The resident, who had decreased sensation in his feet due to diabetes, initially reported the water felt too hot and removed his foot. The nurse, after assuring the resident the water was not too hot, left the room to gather supplies, instructing the resident to wait. However, the resident placed his foot back in the water, and when the nurse returned several minutes later, a blister had formed on the top of his foot. Following the incident, documentation in the clinical record was incomplete. There was a lack of timely and thorough assessment and description of the burn wound, particularly on the day after the incident. Progress notes indicated the wound worsened over the next two days, with blisters, sloughing, copious drainage, and increased pain. The nurse practitioner did not remove the dressing or fully assess the wound during follow-up visits, and the physician was not immediately involved in the assessment. The resident's pain escalated, and the wound was eventually described as a third-degree burn with significant tissue damage. Due to the severity of the injury and inadequate initial assessment and intervention, the resident required emergency transfer to an acute care burn unit. Hospital records confirmed a full thickness scald burn, necessitating two surgical procedures for debridement and skin grafting. The facility's documentation and care planning did not accurately reflect the burn injury or the subsequent hospitalization, and staff interviews revealed lapses in communication, assessment, and documentation following the incident.
Resident Sustains Full-Thickness Burn Due to Improper Foot Soak and Inadequate Supervision
Penalty
Summary
A resident with a history of diabetes mellitus, neuropathy, and a diabetic foot ulcer required partial to moderate staff assistance for lower body dressing and footwear. The resident's care plan included an intervention to avoid exposure to extreme heat or cold. During a scheduled wound care session, an LPN prepared a basin of water for the resident to soak his foot, intending to clean the area before treatment. The LPN checked the water temperature by hand while filling the basin but did not verify the temperature after the basin was filled. The resident initially expressed that the water felt hot and removed his foot, but the LPN reassured him and left the room to retrieve supplies, instructing him to wait. While the LPN was out of the room for approximately five minutes, the resident placed his foot back into the basin. Upon the LPN's return, a blister had developed on the top of the resident's left foot. The resident, who experienced frequent numbness in his feet due to neuropathy, did not realize the water remained too hot. Subsequent nursing assessments documented the development of blisters, sloughing, copious drainage, and significant pain. The resident later described the pain as excruciating, and the wound was observed to be a third-degree burn with yellow slough, redness, and matted toes. The incident resulted in the resident being transferred to an acute care burn unit, where he was diagnosed with a full-thickness scald burn to the left foot and underwent two surgical procedures for debridement and skin grafting. Interviews with facility staff confirmed that soaking the resident's foot was not part of the wound care orders and that the LPN should not have left the resident unattended with the basin of water. The lack of proper supervision and failure to ensure safe water temperature directly led to the resident sustaining a serious burn injury.
Failure to Document and Allow Appeal for Resident Discharge
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident D, was able to appeal a facility-initiated discharge and did not document the reasons for the discharge. Resident D, who had multiple diagnoses including antisocial personality disorder, bipolar disorder, and traumatic brain injury, was not allowed to return to the facility after a hospital stay. The facility did not provide documentation of why the resident was discharged or how he posed a danger to himself or others, nor did they honor his right to return pending an appeal. Resident D had a history of aggressive and inappropriate behaviors, including throwing his colostomy bag at staff, making false allegations, and being non-compliant with care. Despite these behaviors, the facility did not document specific incidents that justified the denial of his readmission. The Executive Director acknowledged that the resident's admission documentation did not indicate such behaviors, and there was no clear documentation of the resident's current condition at the hospital. Interviews with the Social Services Director and the Executive Director revealed concerns about the safety of other residents and staff due to Resident D's behaviors. However, the facility did not complete a discharge assessment or provide a 30-day notice of intent to discharge, as required. The ombudsman and Resident D's mother were also unaware of the specific reasons for the discharge, highlighting a lack of communication and documentation regarding the facility's decision.
Facility Fails to Allow Resident Return Post-Hospitalization
Penalty
Summary
The facility failed to adhere to its policy by not allowing a resident to return after hospitalization, which was a violation of the resident's rights. Resident D, who had multiple diagnoses including antisocial personality disorder, bipolar disorder, and traumatic brain injury, was transferred to a hospital after calling 911. The facility did not document any specific incidents that justified the denial of his return, nor did it provide evidence that the resident was a danger to himself or others. The facility's decision was based on concerns about the resident's behavior, which included throwing a colostomy bag at staff, hitting a staff member, and causing property damage. Interviews with facility staff revealed that the decision not to readmit Resident D was made by the company due to safety concerns for other residents and staff. The Executive Director acknowledged that the resident's admission documentation did not indicate such behaviors, and there was no discharge assessment completed. The ombudsman confirmed witnessing the resident's behavior and advised the facility to issue a 30-day notice of intent to discharge. The resident's mother was unaware of the reasons for the denial of readmission and expressed concern about his belongings.
Failure to Update Facility Assessment Tool
Penalty
Summary
The facility failed to update its Facility Assessment Tool in a timely manner to accurately reflect the specific nursing needs, care, and treatment services for its resident population. During the survey, it was found that the Facility Assessment Tool provided by the Administrator was outdated, with the most recent assessment dated November 2024 containing identical information to the previous year's assessment. This oversight meant that the data did not accurately reflect the current population and resident needs, potentially affecting all 102 residents receiving care in the facility. The assessment tool failed to document critical information regarding the facility's ability to manage mental health and behavioral needs. It did not specify the psychiatric provider, their availability, or how residents' needs for psychiatric services were determined. Additionally, the tool lacked details on the staff members or contracted providers responsible for behavioral and mental health care, including their availability and the extent of services provided. Furthermore, during a QAPI interview, it was noted that concerns related to infection control practices and accident hazards, such as resident smoking procedures, had not been identified or discussed, indicating a gap in the facility's risk management processes.
Inaccurate MDS Coding for Level II PASRR
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents who required a Level II Pre-admission Screening and Resident Review (PASRR). The discrepancies were identified during a record review and interview process. Resident 52, diagnosed with schizophrenia, muscle weakness, and hyperlipidemia, had a Level II PASRR dated August 8, 2023, but his MDS assessment dated April 4, 2024, incorrectly indicated he did not require a Level II PASRR. Similarly, Resident 49, with diagnoses including schizophrenia and bipolar disorder, had a Level II PASRR dated August 11, 2022, but his MDS did not reflect this requirement. Resident 9, diagnosed with multiple psychiatric disorders, had a Level II PASRR dated September 12, 2023, yet his MDS failed to indicate the need for Level II. Lastly, Resident 14, with various mood and anxiety disorders, had a Level II PASRR dated March 7, 2024, but his MDS did not reflect this requirement. The MDS Coordinator, during an interview, admitted to being new to the facility and was unable to explain the inaccuracies in the coding of Level II PASRRs. The facility's policy on Resident Assessments, provided by the Vice President of Clinical Services, stated that information in the MDS assessments should consistently reflect the information in progress notes, care plans, and resident observations/interviews. However, the MDS assessments for these residents did not align with their care plans, which indicated the need for Level II PASRRs, highlighting a significant deficiency in the facility's assessment process.
Inadequate Infection Control and PPE Use
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by staff members who were symptomatic with illness not being tested or wearing source control measures to prevent the spread of infection. Several staff members, including the former Regional Nurse Consultant, the Memory Care Coordinator, and the Corporate Business Office Manager, were observed working while exhibiting symptoms of illness such as coughing, sneezing, and hoarseness, without wearing masks. The facility's policy required staff with symptoms of contagious illnesses to follow CDC guidelines, including wearing well-fitted source control and not reporting to work when ill, but this was not adhered to. Additionally, the facility did not ensure that staff donned personal protective equipment (PPE) while providing high-contact care to residents requiring Enhanced Barrier Precautions (EBP). Observations revealed that staff members, including registered nurses and certified nursing assistants, did not wear PPE while performing tasks such as wound care and hygiene assistance for residents with chronic wounds and indwelling medical devices. The facility's policy required PPE to be available and used for such residents to prevent the transmission of multi-drug-resistant organisms, but PPE was not readily available outside or inside the residents' rooms. Specific residents, such as Resident B and Resident D, who had conditions necessitating EBP, were not provided with the required precautions. Resident B had a history of necrotizing fasciitis, open wounds, and indwelling medical devices, while Resident D had chronic wounds and a urinary catheter. Despite their needs, staff did not use PPE during care, and EBP signs and equipment were not consistently present in their rooms. This lack of adherence to infection control protocols had the potential to affect multiple residents requiring EBP.
Deficient Smoking Safety Practices in Facility
Penalty
Summary
The facility failed to ensure that residents who chose to smoke had accurate and current Smoking Safety assessments and interventions. The facility also lacked clear, concise, and consistent policies and procedures for independent versus supervised smokers, and the storage and accountability of smoking materials. This deficiency had the potential to affect 30 of 56 residents reviewed for smoking. The report highlights several incidents where residents were found smoking unsafely, including Resident E, who sustained facial burns after lighting a cigarette while wearing oxygen. Resident E, a long-term care resident with multiple psychiatric and cognitive diagnoses, was involved in a serious incident where he lit a cigarette in a transport vehicle, causing burns to his face. Despite this incident, Resident E continued to obtain smoking materials and attempted to smoke, even while using oxygen. The facility's records lacked documentation of a comprehensive Smoking Safety evaluation or a revised care plan to address Resident E's unsafe smoking behaviors and his ability to adhere to the Leave of Absence policy. Other residents, such as Resident 6 and Resident 80, also demonstrated unsafe smoking behaviors. Resident 6 was found smoking in his room multiple times, and his care plan lacked revisions to address his non-compliance with the smoking policy. Resident 80 was witnessed with his hair on fire from a cigarette, yet the facility did not complete a Smoking Safety evaluation after the incident. Additionally, several residents refused to sign the Smoking Policy, and their records lacked individualized plans to address their refusal and ensure their safety.
Failure to Update Resident's Advance Directive Wishes
Penalty
Summary
The facility failed to update a resident's advance directive wishes in her medical record, leading to a deficiency. Resident 53, a long-term care resident with diagnoses including dementia, schizoaffective disorder, and peripheral vascular disease, had an original Physician Scope of Treatment (POST) form dated 10/2/23 indicating a full code status. However, an updated POST form dated 7/20/24 showed that the resident wished to change her status to Do Not Resuscitate (DNR). Despite this change, the resident's physician orders still reflected a full code status and had not been revised to align with the updated POST form. Additionally, Resident 53's comprehensive care plans, which included a care plan dated 10/4/23, indicated she wished to be a full code and were not updated to reflect her new DNR status after the POST form was changed. During an interview, the Social Service Director confirmed that the physician order and care plan had not been updated as required. The facility's policy on advance directives, revised in February 2024, mandates that the Director of Nursing Services or designee notify the attending physician of any changes in advance directives to ensure appropriate documentation in the resident's medical record and plan of care.
Failure to Provide Adequate One-on-One Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of one-on-one activities for a resident who was reviewed for activities. The resident, who had diagnoses including hemiplegia, cerebral infarction, and major depressive disorder, expressed a desire to participate in activities but was unable to do so due to pain when using a wheelchair. Despite being on a one-on-one activity schedule, the resident reported that activity staff would visit infrequently and not leave any activities for her to engage in, resulting in her spending most of her time in bed watching TV. The resident's care plan, dated December 2023, indicated that she should receive one-on-one activities as desired and tolerated. However, records showed that the resident was visited only 10 times in December, 7 times in January, and 5 times in the first half of February. An activity aide confirmed that there was a weekly schedule for residents unable to leave their rooms and that staff should visit these residents daily, recording any refusals and attempting revisits. Despite a request, the facility did not provide a specific policy for one-on-one activities, only a policy related to activity evaluation.
Failure to Assess and Document Resident Transfer to Hospital
Penalty
Summary
The facility failed to ensure that a resident who requested to be sent to the hospital was properly assessed and prepared for transfer. Resident E, a long-term care resident with multiple diagnoses including schizoaffective disorder, bipolar disorder, and dependence on supplemental oxygen, expressed a desire to go to the hospital. However, there was no documentation indicating that a nurse assessed the resident or prepared him for the transfer. The record also lacked documentation of vital signs, patient condition, or the reason for the hospital request. Furthermore, there was no evidence that the nurse or physician was notified of the resident's transfer to the hospital. The facility's records showed discrepancies in the documentation of Resident E's transfer. The Leave of Absence (LOA) log did not reflect that Resident E signed out to smoke or go to the hospital on the specified dates. Additionally, the Transfer-to-the-Hospital form was completed hours after the resident had already arrived at the hospital. Resident E's care plans did not address his history of calling 911 himself or his inconsistent use of the LOA policy. The facility's policy on discharging residents was not followed, as there was no transfer summary or telephone report to the receiving facility, and the resident's condition at discharge was not documented.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatments and services to promote the healing of a pressure ulcer and prevent new pressure ulcers from developing for a resident. The resident, who had diagnoses including hemiplegia and dementia, was observed with pressure ulcers on his body. A skin and wound note from December 12, 2024, indicated the presence of an abscess on the back of the resident's left thigh, an unstageable pressure ulcer on the right buttock, and a stage 3 pressure ulcer on the back of the right thigh. Treatment recommendations included the need for a low air loss (LAL) mattress. Despite having an active order for a LAL mattress dated December 20, 2024, the resident developed a new stage 2 pressure ulcer on the left buttock by December 19, 2024. The facility's policy on support surfaces, dated August 2024, indicated that individuals at risk for developing pressure ulcers should be placed on a redistribution support surface. The failure to implement the recommended support surface contributed to the development of a new pressure ulcer, indicating a deficiency in the facility's care for the resident.
Failure to Provide Podiatry Services for a Resident
Penalty
Summary
The facility failed to provide necessary toenail care for Resident 66, who was observed with long, rough, thick, and discolored toenails. Despite having an active physician's order for podiatry services, the resident reported that podiatry had not yet attended to him, and he had previously resorted to ripping his toenails off due to the lack of care. Observations on two separate occasions confirmed that the resident's nails remained untrimmed, and he continued to express dissatisfaction with the lack of podiatry services. Resident 66, a long-term care resident with chronic obstructive pulmonary disorder (COPD) and schizophrenia, had been recommended for a podiatry consult by a Nurse Practitioner (NP) due to thickened toenails and foot pain. However, despite being placed on the podiatry list, the resident was not scheduled for the next podiatry visit. The facility's policies on nail care and activities of daily living (ADLs) emphasize the importance of maintaining personal hygiene, yet these were not adhered to in the case of Resident 66.
Failure to Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to adequately evaluate and address the nutritional status of a resident, resulting in an 11.26% weight loss over two months. The resident, who had diagnoses including hemiplegia, major depressive disorder, dementia, and obsessive-compulsive disorder, was observed to have sores and reported uncertainty about their origin. Despite a significant weight loss from 231 pounds to 205 pounds, there were no active physician orders for nutritional supplements, and the resident's care plan did not reflect any new interventions to address the weight loss. The facility's records showed repeated notes from the Registered Dietician (RD) requesting a reweight to verify the weight loss, citing the use of a new scale as a potential factor. However, there was no documentation that the weight discrepancy was assessed by the dietician or that the physician was notified of the weight loss. Additionally, the resident's record lacked documentation of new care plan interventions to address his weight loss or his frequent refusals to be weighed. The facility's policy required staff to report significant weight changes to the physician, which was not adhered to in this case.
Failure to Document Dialysis Assessments for a Resident
Penalty
Summary
The facility failed to complete pre and post dialysis assessments for a resident who required dialysis services from an outside facility. The resident, identified as Resident 79, had a medical history that included diabetes mellitus type 2, heart failure, end-stage renal disease (ESRD), muscle weakness, and anxiety disorder. The review of Resident 79's medical records revealed a lack of documentation for pre-dialysis assessments on multiple dates spanning from November 2024 to January 2025. Similarly, post-dialysis assessments were also missing for several dates within the same timeframe. A comprehensive care plan dated July 2024 indicated that Resident 79 required hemodialysis due to ESRD and specified that appropriate assessments should be completed before and after dialysis sessions. During an interview, the Vice President of Clinical Services (VPCS) acknowledged that the pre and post assessments completed by the facility staff could not be located, and the paperwork from the dialysis center was not obtained until requested. The facility's policy on dialysis monitoring, dated November 2022, required vital signs to be obtained following dialysis treatment and assessments of the fistula and catheter sites for any signs of complications, which were not documented in the resident's medical record.
Medication Management Deficiency
Penalty
Summary
The facility failed to properly date and manage medications with time limitations, as well as remove expired medications from use. During an observation, a bottle of Tubersol in the A wing medication room refrigerator was found without a date indicating when it was opened. Additionally, an insulin pen on the A wing front cart, belonging to a resident, was dated but not within the appropriate time frame. Another insulin pen on the B wing front cart, belonging to a different resident, lacked an opening date. Furthermore, a vial of Amikacin on the B wing back cart, belonging to another resident, was opened without a date, although an LPN indicated it was opened that morning. The facility's policy requires multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer, which was not adhered to in these instances.
Failure to Document Safety Checks for Resident After Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 3, who was reviewed for medical record accuracy. Resident 3, a long-term care resident with diagnoses including schizoaffective disorder, unsteadiness on feet, and difficulty in walking, was observed yelling nonsensical things in her room. An Interdisciplinary Team note indicated that Resident 3 had a fall on January 7, 2025, and the intervention was to implement 15-minute safety checks for 72 hours to reduce falls and increase safety. However, the facility could not provide documentation proving that these 15-minute safety checks were completed for the specified duration. The facility's policy on Falls and Fall Risk Management required staff to monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure a resident's right to privacy during incontinent care, as observed on February 7, 2025. Resident B was seen from the hallway through her open door while receiving care in bed. The privacy curtain was not closed, and her bare bottom and several wounds were visible. Registered Nurse (RN) 6 and Certified Nursing Assistant (CNA) 22 were present, with CNA 22 removing a brief from under the resident. During this time, two unidentified male residents walked past the open door, and a housekeeper briefly entered the doorway before being redirected by RN 6. RN 6 later acknowledged that the door should have been closed, attributing the oversight to an aide leaving to get a hoyer lift and forgetting to close the door. Resident B, a long-term care resident with diagnoses including spina-bifida, borderline intellectual functioning, and anxiety, expressed discomfort with the situation, noting that staff often left doors open, which bothered her due to her modesty and religious beliefs. Her comprehensive care plan emphasized the need for dignity and respect, aligning with the facility's policy on dignity, which mandates that residents be treated with respect and privacy during personal care and treatment procedures. This incident was related to a complaint identified as IN00451140.
Deficiency in Call Light Devices in Residents' Bathrooms
Penalty
Summary
The facility failed to ensure that call light devices with pull cords were installed in the residents' bathrooms, affecting 16 out of 60 bathrooms reviewed. Specifically, 7 bathrooms lacked a call light device entirely, while 9 bathrooms had call light devices without pull cords. This deficiency was identified through interviews, observations, and record reviews. During an interview, Resident B expressed concern about the absence of a pull cord on the bathroom call light, which would prevent him from calling for assistance if he fell. Similarly, Resident C reported that her bathroom lacked a call light device altogether. An environmental tour conducted with the Executive Director (ED) and Maintenance Director confirmed the absence of call light devices and pull cords in several residents' bathrooms. The ED acknowledged that all residents' bathrooms should have a call light switch and a pull cord for staff assistance. Despite ongoing renovations, the facility's policy mandates that call lights be accessible and functional at all times, yet the weekly reviews by staff failed to identify these deficiencies. The facility's policy, dated August 2024, outlines the importance of ensuring call lights are operational and accessible to residents, but this was not adhered to in the identified cases.
Failure to Protect Resident's Right to Smoke
Penalty
Summary
The facility failed to protect a resident's right to smoke cigarettes, which affected one of the four residents reviewed for smoking. Resident B, who has multiple diagnoses including cerebral palsy, paraplegia, obstructive sleep apnea, and nicotine dependence, expressed frustration over not being allowed to smoke. He was observed in the lounge preparing to call the state due to his dissatisfaction. The resident's care plan, dated 8/11/22, indicated that his smoking privileges had been suspended due to unsafe smoking behavior, specifically nodding off during a smoke break. Despite being offered a smoking cessation aid, Resident B reported that he never received the gum he requested to help him quit smoking. The Vice President of Clinical Services (VPCS) confirmed that there was no order placed for the smoking cessation aid. A new smoking assessment was completed, and Resident B's care plan was updated to allow him to smoke under supervision with a smoking apron. The facility's policies on resident rights and smoking were reviewed, indicating that residents should be supported in exercising their rights and that a designated smoking area should be established. This deficiency relates to Complaint IN00429920.
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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