Forest Creek Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 525 E Thompson Rd, Indianapolis, Indiana 46227
- CMS Provider Number
- 155241
- Inspections on file
- 32
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Forest Creek Village during CMS and state inspections, most recent first.
A resident with chronic pain and neuropathy, documented as cognitively intact, was found with two pill cups left on the dresser in the room, one labeled with the resident's name and one unlabeled. An LPN confirmed the cups contained the resident's prescribed medications, including melatonin 5 mg and gabapentin 300 mg and 600 mg, and acknowledged they should not have been left there. Review of the record showed active physician orders for these medications but no self-medication administration assessment or physician order authorizing the resident to self-administer, despite facility policy requiring both before allowing self-administration.
Surveyors found that three resident rooms were not maintained in a clean and sanitary condition. In one room, a full urinal with dark yellow urine was left on the floor for several days. In another, the bathroom had a strong urine and feces odor, dried feces on the toilet bowl and seat, and trash cans without liners that contained feces-soiled toilet paper and a urine-soiled brief; a CNA acknowledged the cans should have been lined and emptied and housekeeping notified. In a third room, a resident reported placing a folded hospital blanket on the bathroom floor to address a leaking toilet, resulting in a dark brown–stained blanket that staff stated was changed about weekly and should not have been left on the floor.
The facility failed to maintain an effective pest control program when roach-like insects were observed in two resident rooms. In one room, a meal tray from the prior evening with leftover food and an open pudding cup remained on a dresser, and a roach-like insect was seen crawling out of the food while the resident reported not having seen a roach for about a week. In another room, a roach-like insect was seen crawling up the bathroom wall under the sink. A prior pest control report documented cockroaches in resident rooms and hallways and noted that clutter and stored items in most rooms limited access for service, despite a facility policy stating it would maintain an effective pest control program so the facility is free of pests.
An Activity Assistant took a photo of a cognitively impaired resident and posted it on social media with an inappropriate caption, without authorization from the family or facility, violating policies on mental abuse and confidentiality.
Surveyors observed a buildup of dark substance, dust, debris, a screwdriver, and plastic lids under a kitchen freezer, as well as dust and debris under dry storage shelves. The dietary supervisor confirmed these areas should have been cleaned, and facility policy requires kitchen floors to be kept clean and sanitary.
A resident with multiple comorbidities and a history of falls was found with their bed not in the lowest position, despite care plan interventions and a physician's order requiring it. A QMA confirmed the bed should not have been left elevated, and facility policy mandates implementation of person-centered care plans.
Two residents received meals that were not at a palatable or proper temperature, with one resident unable to cut her sausage and reporting cold food, and another resident leaving half her meal uneaten due to it not being hot. Both residents indicated this was a recurring issue, and food was observed sitting in the hallway before delivery, contrary to facility policy.
Staff failed to follow enhanced barrier precautions for a resident with an indwelling urinary catheter during a transfer. An LPN wore gloves but not a gown, and a CNA wore neither gloves nor a gown, despite facility policy and the resident's care plan requiring both gown and gloves for such high-contact care activities.
A buildup of a thick, black, tar-like substance mixed with hair and debris was observed along the floorboards and trim in a hallway. The DON confirmed this should have been removed during regular cleaning, and the Housekeeping Supervisor stated that staff are expected to scrape such buildup daily. The facility could not provide a related policy during the survey.
A resident with minimal cognitive impairment and multiple diagnoses was found with a senna tablet at their bedside without a completed self-medication administration assessment, as required by facility policy. Staff confirmed that the necessary assessment to determine the resident's competence for self-administration had not been performed.
A resident with neurogenic bladder, severe morbid obesity, and diabetes was admitted with an indwelling urinary catheter, as documented in clinical records and physician orders. However, the admission MDS assessment failed to indicate the presence of the catheter, contrary to RAI Manual requirements. This inaccuracy was confirmed through record review and staff interview.
Three residents with respiratory conditions did not have their oxygen tubing, nebulizer machines, or nebulizer tubing changed or cleaned as required, with equipment found stained, dusty, or not changed for extended periods. Staff confirmed the equipment should be changed weekly, but no policy was available, and physician orders for weekly changes were not followed.
Prescription medications were found unsecured on top of an unlocked medication cart in a high-traffic area without staff supervision, and two vials of prescription aerosol medication were left in a resident's room who did not have a physician's order for them. An LPN confirmed these medications should have been secured, and facility policy required all medications to be stored in locked areas inaccessible to residents and visitors.
Two residents experienced incomplete and inaccurate medical record documentation, including missing entries for nebulizer treatment administration and urinary catheter output. Observations included a dirty nebulizer machine not properly stored and multiple omissions in required documentation, with the DON confirming that all documentation should have been completed.
Surveyors found that infection control practices were not followed for three residents: a nebulizer machine and mask were left dirty and improperly stored, a urinary catheter bag was placed on the floor, and soiled linens and a brief were left on the floor. Staff interviews confirmed these actions were not in line with facility policy.
A cockroach was observed outside a resident's room, and the resident confirmed seeing the pest near his door. Review of the facility's pest control policy showed a requirement to keep the environment free from pests, but the presence of the cockroach indicated a failure to meet this standard.
Surveyors found that the facility exceeded the acceptable medication error rate, with errors including a nurse failing to instruct a resident to rinse and spit after inhaler use and not priming insulin pens before administration to another resident, contrary to medication instructions and facility protocols.
A resident with diabetes and thyroid disorder was found with multiple pills left at the bedside without staff present, and there was no completed self-administration medication assessment in the clinical record. Facility policy requires medications to be securely stored, and staff confirmed the medications should not have been left in the room.
Surveyors found that a resident's Wixela inhaler and a Lantus Solostar insulin pen on a medication cart were not dated when opened, despite facility policy requiring opened dates for medications with shortened expiration periods. An RN confirmed these items should have been dated, and the DON provided the current policy supporting this requirement.
An LPN did not perform hand hygiene before putting on gloves or after removing them while administering insulin to a resident, and exited the room wearing used gloves. The facility's policies and competencies require hand hygiene at these steps and removal of gloves before leaving the room.
The facility failed to secure hazardous materials in the Soiled Utility Room, as observed on two occasions. The room's door was found unlocked with no staff present, and sharps containers were improperly stored, exposing used needles. Both the Maintenance Director and DON confirmed the door should have been locked, as per the facility's Bloodborne Pathogens Exposure Control Plan.
The facility failed to document drug dispositions for two residents, leading to a deficiency in pharmaceutical services. One resident with Alzheimer's and another with schizophrenia were transferred or discharged without proper documentation of medications sent with them. The facility's policy requires a Product Destruction form to be completed, which was not done.
A resident with respiratory failure, COPD, opioid dependence, and hepatitis C received a Fentanyl patch on the wrong day due to a QMA's error. The patch was administered a day early without notifying the nursing staff or physician, contrary to the physician's order and facility policy. The error was discovered when the resident reported it, highlighting a failure to follow medication administration protocols.
Unassessed Self-Administration and Unsupervised Medications Left in Resident Room
Penalty
Summary
The facility failed to ensure a resident was properly assessed and authorized to self-administer medications before leaving medications unsupervised in the resident's room. During observation, two pill cups were found on the resident's dresser. One cup, labeled with the resident's name, contained an unmarked small white pill. The second, unlabeled cup contained a large piece of candy, an unmarked small white pill, a yellow capsule, and a large white tablet. An LPN compared the pills in the cups to the resident's medications and identified them as melatonin 5 mg, gabapentin 300 mg, and gabapentin 600 mg, and stated the medications should not have been left in the room. Record review showed the resident had diagnoses including chronic pain and neuropathy and was cognitively intact per an annual MDS assessment. Physician orders included gabapentin 300 mg twice daily, gabapentin 600 mg at bedtime, and melatonin 5 mg at bedtime. However, the clinical record did not contain a self-medication administration assessment or a physician's order authorizing the resident to self-administer medications. The facility's policy on self-administration of medications required completion of a self-administration assessment and a physician's order specifying the resident's ability to self-administer, but these were absent in this case.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, sanitary, and safe environment in three randomly observed resident rooms. In one room, a full, closed urinal containing dark yellow urine was observed sitting on the floor near a cluttered window area with personal belongings along the wall. The resident in that room reported the urinal had been on the floor for a couple of days. When interviewed, an LPN acknowledged that the urinal should have been emptied and not left on the floor. In a second room, the bathroom had a strong odor of urine and feces, with dried feces visible on the rim of the toilet bowl and on the toilet seat. A trash can without a bag was almost full of toilet paper with dried feces on it, and another trash can without a bag contained a urine-soiled brief. A CNA stated the trash cans should have had bags and been emptied, and that staff should have notified housekeeping to clean the toilet. In a third room, a white hospital blanket folded on the bathroom floor in front of the toilet was stained dark brown. The resident reported placing a folded blanket on the floor because the toilet leaked, and that the blanket was changed every week or two. A CNA confirmed the blanket had been changed about weekly and stated it should not have been left on the floor.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program when roach-like insects were observed in two resident rooms during surveyor observations. In one room, a dresser held a meal tray from the previous night’s dinner with dried peas, potatoes, and an open chocolate pudding cup, and a small roach-like insect was seen crawling out of the peas; the resident in that room stated he had not seen a roach in his room for about a week and confirmed the tray was from the prior evening. In another room, a roach-like insect was observed crawling up the bathroom wall underneath the sink. A pest control report dated several months earlier documented that cockroaches had been noted in resident rooms and hallways, and that access for pest control service was limited due to clutter and stored items, with most resident rooms having too much clutter to be properly serviced. The facility’s pest control policy stated that the facility would maintain an effective pest control program so that the facility is free of pests. These observations and records show that despite an existing pest control policy and prior pest control service noting cockroach activity and access limitations, pests continued to be present in resident rooms, and environmental conditions such as clutter and leftover food impeded effective pest management.
Staff Member Posted Unauthorized Photo of Cognitively Impaired Resident Online
Penalty
Summary
A staff member, specifically an Activity Assistant, took a photograph of a resident who was severely cognitively impaired and resided on the secured memory care unit. The resident had diagnoses including Alzheimer's disease, delusional disorder, and cognitive communication deficit. The photograph depicted the resident sitting in a wheelchair holding a baby doll, staring at the camera without a smile. The image was posted online by the Activity Assistant, accompanied by a caption containing inappropriate language and referencing the resident and the baby doll. The staff member posted the photograph on a social media website without obtaining authorization from the resident's family or the facility. This action was in direct violation of the facility's policy, which prohibits mental abuse and the unauthorized sharing of confidential information. The incident was discovered and reported by the facility, and documentation confirmed that the staff member had violated both HIPAA and the facility's confidentiality policies.
Unsanitary Kitchen Floors and Storage Areas
Penalty
Summary
During a kitchen inspection, surveyors observed a buildup of an unknown dark substance, dust, debris, a screwdriver, and several plastic lids under a freezer in the main kitchen area. Additionally, there was a buildup of dust and debris under the shelves in the dry storage room. The dietary supervisor acknowledged that these areas should have been cleaned. Review of the facility's policy on cleaning floors, tables, and chairs confirmed that kitchen floors are required to be kept clean and sanitary. These findings indicate that the facility failed to maintain a sanitary environment for food service as required by professional standards.
Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
The facility failed to implement person-centered care plan interventions for a resident identified as high risk for falls. Observation revealed that the resident's bed was not in the lowest position, contrary to the care plan intervention and a current physician's order, both of which specified that the bed should be kept in the lowest position. The resident, who had diagnoses including congestive heart failure, diabetes, and respiratory failure, was moderately cognitively impaired and had a documented history of two or more falls with injury. During the observation, a QMA confirmed that the bed should not have been left elevated. Review of facility policy indicated that a person-centered care plan should be developed and implemented for every resident.
Failure to Serve Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to ensure that meals were served to residents at a palatable and proper temperature, as required by policy. Observations showed that a meal tray for one resident was left on a metal cart in the hallway for approximately 20 minutes before being delivered to the resident's room. When the resident attempted to eat, she was unable to cut the sausage, describing it as rubbery, and indicated that her food was cold. She also stated that she rarely received hot food because it often sat in the hallway before being served. Another resident was observed eating only about half of her meal and leaving the rest uneaten, with a balled-up napkin on the plate. She reported that her food was not hot and that she did not request reheating because it took too long. The facility's current policy requires that all hot and cold food be served at a palatable temperature at the time it is received by the resident. These findings were based on direct observation, resident interviews, and a review of facility policy.
Failure to Implement Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter, as required by both the resident's care plan and facility policy. During a transfer of the resident to bed using a mechanical lift, an LPN wore gloves but did not wear a gown, and a CNA wore neither gloves nor a gown. Personal protective equipment, including gowns and gloves, was available in the resident's room, but was not utilized as required during the high-contact care activity. The CNA later confirmed in an interview that staff should have been wearing a gown and gloves during the transfer. The resident involved had a diagnosis of obstructive uropathy and a documented indwelling urinary catheter, placing them at increased risk for colonization or infection with multi-drug resistant organisms. The care plan specifically identified the need for enhanced barrier precautions, including the use of gown and gloves during transfers. The facility's current policy, provided by the Director of Nursing, also required staff to wear gown and gloves for residents with indwelling urinary catheters during transfers, but this protocol was not followed during the observed event.
Failure to Maintain Sanitary Environment Due to Floor Buildup
Penalty
Summary
During an initial tour of the 100 Hall, surveyors observed a buildup of an unknown black substance along the floorboards and floorboard trim throughout the hallway. The substance was described as thick, black, tar-like, and mixed with hair and other debris. Further observation showed approximately six inches of this substance being scraped up, confirming its unsanitary nature. The DON acknowledged that the buildup should have been removed during routine housekeeping. The Housekeeping Supervisor stated that floors are cleaned daily and staff are expected to scrape off such buildup during cleaning. The facility was unable to provide a relevant policy regarding this issue by the time of survey exit.
Failure to Complete Self-Medication Assessment for Resident
Penalty
Summary
A deficiency occurred when a resident was observed with a pill cup containing a round brown tablet, identified as senna 8.6 mg, left on their bedside table. The resident, who had diagnoses including diabetes and metabolic encephalopathy and was assessed as having minimal cognitive impairment, did not have a completed self-medication administration assessment in their clinical record. Facility staff, including an LPN and the DON, confirmed that no such assessment had been performed. The facility's policy requires an interdisciplinary team assessment of a resident's competence before allowing self-administration of medications, but this process was not followed in this instance.
Inaccurate MDS Assessment for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident admitted with an indwelling urinary catheter. The resident, who had diagnoses including neurogenic bladder, severe morbid obesity, and diabetes, was admitted with an indwelling urinary catheter as documented in the clinical record and physician's orders. However, the admission MDS assessment did not indicate the presence of the catheter, despite the Resident Assessment Instrument (RAI) Manual requiring documentation of an indwelling urinary catheter if used at any time in the seven days prior to the assessment date. This discrepancy was confirmed through record review and staff interview.
Failure to Maintain and Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not ensuring that oxygen tubing, nebulizer machines, and nebulizer tubing were properly maintained and changed as required. Observations revealed that one resident's nebulizer machine was stained, dusty, and placed on the floor, with the face mask left uncovered on a heating unit and not changed since the date marked over a month prior. Another resident's oxygen concentrator was found with humidity water and nasal cannula tubing that had not been changed for nearly two months. A third resident was observed using a nebulizer mask with mist spraying into the air, with the oxygen concentrator on the floor and humidity water not changed for almost a month. In all cases, the equipment was not maintained according to the facility's expected weekly change schedule. Interviews with staff, including an LPN and the DON, confirmed that the respiratory equipment should have been changed weekly, but there was no policy available to support this practice. The clinical records for the residents indicated diagnoses such as chronic obstructive pulmonary disease, dementia, morbid obesity, encephalopathy, and neurogenic bladder, with physician orders specifying the frequency for changing respiratory equipment. Despite these orders, the facility did not ensure compliance, resulting in the cited deficiency.
Failure to Secure Prescription Medications and Improper Medication Storage
Penalty
Summary
Surveyors observed that prescription medications were not properly secured on two separate occasions. On one occasion, two prescription medications, H-Chlor12 wound cleanser and lactulose solution, were found sitting on top of an unlocked medication cart in a high-traffic resident area without staff supervision. An LPN confirmed that these medications should have been secured and the cart locked or supervised. On another occasion, two unopened vials of albuterol inhalation solution were found in a resident's room, next to a nebulizer mask, rather than being secured in the medication cart as required. The LPN acknowledged that these medications should have been secured. A review of the resident's clinical record revealed that the resident had diagnoses including chronic obstructive pulmonary disorder, dementia, and morbid obesity. The resident had a physician's order for ipratropium-albuterol inhalation solution, but not for the albuterol inhalation solution that was found in the room. Facility policy required all medications and treatment items to be stored in a locked cabinet, cart, or medication room inaccessible to residents and visitors. These observations and record reviews demonstrated a failure to follow the facility's medication storage policy.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents. For one resident with chronic obstructive pulmonary disorder, dementia, and morbid obesity, a dirty nebulizer machine was observed on the floor, with the face mask not stored in a bag and dated over a month prior. Review of the Medication Administration Record (MAR) revealed multiple instances where required documentation for administration of ipratropium-albuterol nebulizer solution was incomplete or missing, including omissions of pulse, respirations, breath sounds, and minutes of therapy before and after administration across several dates. For another resident with neurogenic bladder, severe morbid obesity, and diabetes, the physician's order required recording urine output from a urinary catheter every shift. The Treatment Administration Record (TAR) showed missing documentation of urinary output for several shifts during the period the order was active. During an interview, the Director of Nursing confirmed that all documentation should have been completed, and there was no facility policy on documentation.
Infection Control Lapses in Equipment and Linen Handling
Penalty
Summary
Surveyors observed multiple failures in infection control practices involving three residents. For one resident with chronic obstructive pulmonary disorder, dementia, and morbid obesity, a dirty nebulizer machine was found on the floor next to a heat unit, with the face mask not stored in a bag but left exposed on the heat unit. The nebulizer mask was dated over a month prior to the observation. An LPN confirmed that the nebulizer should not have been on the floor and the mask should have been bagged. The resident's clinical record indicated a physician's order for frequent nebulizer treatments. Another resident with encephalopathy and neurogenic bladder was found to have a urinary catheter bag sitting directly on the floor, containing approximately 400 ml of urine. Both a QMA and an RN acknowledged that catheter bags should not be left on the floor. In a separate incident, a soiled brief, gown, and linen were observed lying on the floor in a room of a resident with lung cancer, dementia, and dysphagia, who was always incontinent of bladder. A CNA confirmed that these soiled items should not have been left on the floor. Facility policy reviewed by the DON specified that urinary drainage bags should not touch the floor, contaminated linen should be bagged, and equipment should be stored to prevent contamination.
Failure to Maintain Pest-Free Environment
Penalty
Summary
A brown cockroach was observed crawling on the floor outside a resident's room during a random observation. At that time, the resident reported having seen a roach near his door. The facility's current pest control policy, dated September 2023, was reviewed and indicated that the facility is required to maintain an effective pest control program to ensure the environment is free from pests. Despite this policy, the presence of a cockroach was confirmed through direct observation and resident interview.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with surveyors identifying a 16 percent error rate during their review. In one instance, a registered nurse administered Wixela and Incruse Ellipta inhalers to a resident but did not instruct the resident to rinse and spit out water after administration, as required by both the medication instructions and the facility's competency guidelines. The nurse indicated that rinsing was not necessary, despite clear instructions to the contrary. In another instance, the same nurse administered Lantus Solostar and Humalog KwikPen insulin to a different resident without priming either insulin pen prior to injection. The nurse stated that priming was not needed, although both the manufacturers' instructions and the facility's competency guidelines specify that priming is required to ensure accurate dosing. These actions were observed and confirmed through interviews and record reviews, leading to the cited deficiency.
Failure to Complete Self-Administration Medication Assessment and Improper Medication Storage
Penalty
Summary
A resident with diagnoses including diabetes and thyroid disorder was observed with three pills—a small purple pill, a small white pill, and a yellow capsule—left in a plastic medication cup on the bedside table without staff present. Staff confirmed that these medications should not have been left in the resident's room. Review of the resident's clinical record revealed there was no completed self-administration medication assessment. Facility policy requires medications to be stored in a locked cabinet, cart, or medication room inaccessible to residents and visitors. The Director of Nursing confirmed that the required assessment was not present and that medications should not have been left at the bedside.
Failure to Date Opened Medications on Medication Cart
Penalty
Summary
Surveyors observed that medications on the 200 Hall medication cart were not dated when opened, as required by facility policy and professional standards. Specifically, a Wixela inhaler prescribed for a resident with chronic obstructive pulmonary disease was found in a clear bag in the medication cart with no opened date indicated on the package or inhaler, despite the label showing it was filled with 60 doses and 47 doses remained. Additionally, a Lantus Solostar insulin pen with a broken seal was present in the same cart drawer without an opened date on the label or pen. During interviews, a registered nurse confirmed that both the inhaler and insulin pen should have been dated upon opening. The facility's current policy, provided by the Director of Nursing, requires that the date opened be documented on medication containers when the expiration date is shortened after opening.
Failure to Follow Infection Control Protocol During Insulin Administration
Penalty
Summary
A deficiency was identified when an LPN failed to follow proper infection control practices during the administration of insulin to a resident. The LPN entered the resident's room with insulin pens, donned clean gloves, and administered the insulin without performing hand hygiene beforehand. After the procedure, the LPN exited the resident's room while still wearing the used gloves and only removed them after leaving the room, again without performing hand hygiene. The LPN acknowledged the lapse in hand hygiene and glove removal protocol. Review of the facility's current skills competency and infection prevention policy confirmed that hand hygiene should be performed before donning gloves and after removing them, and gloves should be removed prior to exiting the resident's room.
Failure to Secure Hazardous Materials in Soiled Utility Room
Penalty
Summary
The facility failed to ensure that potentially hazardous materials were kept secure, as observed during two separate instances. On January 27, 2025, at 9:05 a.m., the door to the Soiled Utility Room on the west hall across from the laundry room was found unlocked with no staff present. Inside the room, four full sharps containers were observed, with one container unsecured and lying on its side, exposing used needles. The Maintenance Director confirmed that the door was supposed to be locked. Later, at 10:00 a.m., the door was again observed to be unlocked with no staff in the area. The Director of Nursing (DON) also confirmed that the door should have been locked. The facility's Bloodborne Pathogens Exposure Control Plan, revised in December 2023, was provided by the DON, which included procedures for properly sealing sharps containers.
Failure to Document Drug Dispositions for Residents
Penalty
Summary
The facility failed to document the drug dispositions for two residents, leading to a deficiency in pharmaceutical services. Resident 295, diagnosed with Alzheimer's disease and transient cerebral ischemic attack, was transferred to another facility with medications including Eliquis, Norvasc, and Vitamin D3. However, the clinical record lacked documentation of the name, type, or amount of medications sent with the resident. The Regional Director of Nursing confirmed the absence of this documentation during an interview. Similarly, Resident 91, who had diagnoses of schizophrenia and anxiety disorder, was discharged home with family. The resident's medications included Clozapine, Miralax, Terbinafine HCl, and Sertraline. Like Resident 295, the clinical record for Resident 91 also lacked documentation of the medications sent home. The facility's Drug Disposition Policy requires a Product Destruction form to be printed, signed, and placed in the resident's clinical record, which was not adhered to in these cases.
Improper Administration of Fentanyl Patch
Penalty
Summary
The facility failed to ensure proper administration of pain medication for Resident B, who was diagnosed with respiratory failure, COPD, opioid dependence, and hepatitis C. A Qualified Medication Aide (QMA 2) administered a Fentanyl transdermal patch on the wrong day, contrary to the physician's order. The order specified that the patch should be applied every three days, with the old patch removed and disposed of properly. However, QMA 2 replaced the patch a day early, on the evening of 9/28/24, without notifying licensed nursing staff, a supervisor, or the physician. This error was discovered when Resident B informed the staff the following day. The Director of Nursing (DON) confirmed that the error occurred and that the Fentanyl patch was not scheduled to be changed until the next day. The facility's policy on medication administration, which requires verification of the correct time for medication administration, was not followed. The incident was related to a complaint, and the facility's policy dated 12/1/07 was reviewed, indicating the need for adherence to medication administration protocols.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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