Harcourt Terrace Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 8181 Harcourt Rd, Indianapolis, Indiana 46260
- CMS Provider Number
- 155149
- Inspections on file
- 31
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Harcourt Terrace Nursing And Rehabilitation during CMS and state inspections, most recent first.
A bedbound resident with chronic respiratory failure, anxiety, and depression was repeatedly subjected to verbal abuse, cursing, and threats from another resident who lived across the hall and had a documented history of alcohol abuse and aggressive behavior. The aggressor resident frequently stood in the doorway, yelled insults, and threatened to beat the bedbound resident, including during trach care, while staff were present. Staff and the resident’s family reported multiple incidents and expressed safety concerns, including fears that the aggressor, who came and went freely and sometimes returned intoxicated, could bring a weapon into the building. Despite prior documented behavior issues, the facility did not consistently document key altercations, including one requiring police involvement, did not implement a documented behavior contract or safety plan, and leadership minimized the events by asserting that the behavior did not constitute abuse because the victim did not admit psychosocial distress, resulting in ongoing exposure to verbal abuse and intimidation.
Two residents did not receive care according to physician orders and documented needs. One resident with diabetes missed a scheduled insulin dose when a unit manager, honoring the resident’s preference not to receive injections from her, attempted to hand off the task to another nurse who was not informed in time, resulting in the dose not being administered and no clear medication administration policy in place. Another resident with a history of stroke, dysphagia, and abnormal labs for calcium, sodium, and ammonia had orders to repeat a comprehensive metabolic panel and ammonia level, but the record showed no evidence these labs were obtained, despite subsequent abnormal labs at hospital admission. The same resident’s rehab discharge instructions for a dysphagia diet with 1:1 supervision, alternating sips and small bites, medications crushed in puree, and no straws were not fully transcribed into admission orders, and the EMR lacked specific orders for 1:1 supervision, alternating sips/bites, routine crushing of medications in puree, or no straws, leading to a reported incident where an RN gave an uncrushed pill instead of crushing it in applesauce.
A resident with chronic respiratory failure and sleep apnea had a tracheostomy with a physician’s order specifying a Bivona XL size 7 trach and directing that both a smaller and the same size tracheostomy cannula be kept at the bedside. During observation and staff interviews, it was determined that only a size 6 cannula was stored at the bedside, and staff were unsure whether a same-size cannula was available there. The DON believed the same-size cannula only needed to be stored somewhere in the facility, later acknowledging the order required it at the bedside, and also reported there was no tracheostomy policy in place.
A resident with neurologic deficits and dysphagia did not receive multiple ordered morning medications, including a Schedule II controlled substance, which were documented as not administered due to the resident’s condition. An RN signed out a controlled medication and reported discarding all of the resident’s medications in the room trash, but only two pills were later found and no liquids were located. The controlled substance was not destroyed with a second nurse or documented as wasted, contrary to facility policy and competency expectations requiring use of a Drug Buster system and witnessed destruction of unused controlled drugs.
A resident with a history of stroke, dysphagia, aphasia, and dysarthria was discharged from a rehab hospital with an order for an IDDSI Level 5 minced and moist dysphagia diet with thin liquids and 1:1 or close supervision due to aspiration risk. On admission, the facility initially ordered a regular diet, then changed it to a soft & bite-sized diet, which per IDDSI requires more chewing than the ordered minced and moist diet. Facility records showed the resident needed assistance with eating, and progress notes documented episodes of coughing, vomiting, and thick secretions during meals. The resident’s daughter reported that the resident was left unattended despite needing close supervision. The SLP stated the facility did not offer a minced and moist diet and considered soft & bite-sized an upgraded diet, while facility policy converted minced and moist orders to puree and required a therapy referral, demonstrating that the diet provided was not comparable or compatible with the diet ordered from the rehab hospital.
A resident with a history of stroke, dysphagia, aphasia, and dysarthria was admitted from a rehab hospital with documented swallowing deficits, an aspiration risk, and orders for a dysphagia diet with 1:1 supervision. On admission, the facility first ordered a regular diet, then a soft bite-sized diet, without notifying speech therapy or obtaining an evaluation, even though facility policy required a nursing-to-therapy referral when a resident admitted on a modified diet. The resident experienced coughing, vomiting, and thick secretions during meals on multiple occasions before speech therapy was finally ordered and the diet changed to pureed. The SLP later stated that a soft bite-sized diet was an upgrade from the ordered minced and moist diet and should not have been implemented without an SLP evaluation, and the resident’s daughter reported that he required close supervision at meals and had been left unattended.
A resident with dementia and multiple health conditions was treated roughly by a QMA during care, including being loudly instructed and physically placed in bed against her refusal, despite care plan interventions for safety and communication. An LPN observed the incident and intervened, and the facility determined the QMA violated the resident's rights to dignity and self-determination.
Two residents with significant mobility and cognitive impairments did not receive safe or comfortable assistance with ADLs. In one case, a QMA transported and transferred a resident without using a gait belt and handled her roughly, while in another, a resident with a recent fracture was provided incontinence care by a single staff member, causing her pain and distress. Both incidents violated facility policy and resident rights.
A room shared by two residents with dementia and incontinence was found to have a strong urine odor, multiple flies (including some on a resident and in a juice cup), unclean bedside commode, and fecal matter on the toilet. Staff interviews revealed lapses in cleaning routines and uncertainty about responsibilities, contributing to the unsanitary and non-homelike conditions.
A facility failed to ensure a resident's privacy during personal care. An LPN left a resident's door open while administering a gastrostomy tube bolus, exposing the resident's abdomen without closing the privacy curtain. The resident had multiple diagnoses, including acute respiratory failure and congestive heart failure. Interviews revealed the facility lacked a policy on providing privacy, despite a Resident Rights policy stating residents have the right to a dignified existence.
A facility failed to develop a comprehensive care plan for a resident with a hand splint, despite multiple observations of the resident wearing the splint. The resident had a history of transient ischemic attack, hypertension, anxiety disorder, and major depressive disorder. The electronic medical record lacked a physician's order or care plan for the splint, and the DON confirmed the absence of a care plan prior to a specific date. The facility's policy required interdisciplinary care plan reviews, which was not followed.
A facility failed to provide timely pharmaceutical services for a resident at risk for seizures, resulting in 26 missed doses of Lacosamide. Despite procedures to address medication unavailability, the medication was delayed for several days, and the facility's policy did not cover missing multiple doses.
The facility failed to conduct AIMS assessments for two residents on antipsychotic medications as per policy. One resident, with Alzheimer's and bipolar disorder, did not receive an assessment between January and August, while another resident with vascular dementia did not have an admission assessment. Both residents were on medications requiring regular monitoring for involuntary movements.
The facility failed to maintain accurate documentation for two residents requiring bedtime snacks due to unavailability, despite physician orders. A nurse improvised by finding alternative snacks, and the facility's competency checklist lacked guidance on accurate documentation.
A facility failed to assess a resident for self-administration of medications. A resident was found with a cup of pills left by a nurse, without a physician's order, care plan, or assessment for self-administration. The facility's policy requires an interdisciplinary team assessment and a physician's order, which were not followed.
The facility failed to ensure cups used for serving drinks were free of film from hard water. Observations revealed that many cups had a white film that could be scraped off, and residents were served drinks in these cups. The Executive Director acknowledged the issue, citing a lack of salt to soften the water, and noted that the film was from the sanitizer.
A facility failed to provide effective dementia care, resulting in an altercation between two residents. One resident, with a history of aggressive behavior, injured another resident, causing a fractured wrist and facial laceration. The aggressive resident had a complex medical history and frequently exhibited combative behavior, which was inadequately managed. Staff shortages and lack of evening activities contributed to the incident.
Failure to Protect a Bedbound Resident From Ongoing Verbal Abuse and Threats by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse, intimidation, and threats by another resident, despite an ongoing pattern of aggressive behavior. Resident B, who was bedbound with chronic respiratory failure with hypoxia, morbid obesity, anxiety, and depression, reported that Resident C, his former roommate who now lived across the hall, repeatedly came to his doorway, yelled, cursed, and threatened to "kick his a**" without provocation. Resident B stated that these incidents occurred while he remained in bed and that Resident C would position himself in the doorway, sometimes while staff were present providing tracheostomy care. Resident B reported difficulty sleeping because Resident C was allowed to leave and return to the facility at all hours, sometimes intoxicated, and he feared Resident C could bring a weapon into the building or enter his room while he slept. Resident B kept a back scratcher next to him for protection. Staff and family interviews corroborated that Resident C’s behavior was particularly directed toward Resident B and that there had been multiple incidents. An anonymous staff member indicated Resident C yelled and cursed at many staff and residents, but his behavior was especially bad toward Resident B. Resident B’s daughter reported at least three incidents in which Resident C came to her father’s room yelling, cursing, and threatening to beat him up, and she expressed concern that Resident C could bring a weapon into the facility and that staff had no control over him. The Social Service Director documented that after Resident B returned from the hospital and briefly roomed with Resident C, Resident C became angry about having a roommate and later about his TV not working after a room move; since then, every time Resident C passed Resident B’s room there was an altercation, including an event where Resident C yelled from the hallway, causing Resident B to become upset and shout back. The Social Service Director stated she had suggested room changes multiple times in IDT meetings after the first altercation, but these suggestions were rejected. The facility was aware of Resident C’s ongoing disruptive and aggressive behaviors, including documented alcohol abuse, returning intoxicated, yelling at staff and residents, using vulgar language, going in and out of other residents’ rooms, and making it clear he would make any roommate uncomfortable. A behavior event documented that Resident C stated he would not tolerate a roommate and would make it very uncomfortable for anyone placed with him. Another documented event showed Resident C returning intoxicated, yelling at staff, and stopping in Resident B’s doorway to verbally attack him, with staff making several attempts to redirect him. Despite these patterns and the facility’s own abuse policy defining resident-to-resident verbal and mental abuse, there was no documented behavior contract for Resident C, no documented safety plan for Resident B, and no nursing documentation of the 3/29 verbal altercation or the incident requiring police involvement in either resident’s record. Leadership, including the ED and DON, minimized the events by asserting that Resident B did not admit psychosocial distress and therefore the behavior did not meet the definition of abuse, and they believed Resident B or his daughter were aggressors or primarily bothered, even though Resident B’s record reflected anxiety, depression, mood distress, trouble sleeping, and anger. The facility’s failure to implement effective protections, document incidents, and follow its own abuse and resident rights policies led to Resident B being repeatedly subjected to verbal abuse and intimidation by Resident C. Resident B’s clinical record contained care plans for mood distress and risk of depression, with interventions to encourage expression of feelings, concerns, and fears, and to offer validation and support. Progress notes and psychiatric notes documented that Resident B was unhappy since his hospital stay, had issues with Resident C entering his room after moving out, and experienced low mood, trouble sleeping, worry, irritability, depression, and anger. During a follow-up by the Social Service Director, Resident C yelled, cursed, and called Resident B names from the hallway, causing Resident B to become upset until the door was closed and he was calmed. Resident C’s record showed multiple behavior events and progress notes describing irritation, suspected intoxication, disrespectful and vulgar language, encouraging other residents to verbally attack others, and explicit statements that he did not care about facility policy. Despite this, the facility did not document the 3/29 altercation or the police-involved incident in the clinical records, did not implement a documented behavior management plan or contract for Resident C, and did not put a documented safety plan in place for Resident B, contrary to the facility’s abuse prohibition and resident rights policies that require immediate protection, increased supervision, and room or staffing changes when resident-to-resident abuse occurs.
Failure to Follow Physician Orders for Medications, Labs, and Dysphagia Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and resident preferences, specifically related to medication administration and laboratory monitoring. For one resident with type 2 diabetes, anemia, and hypertension, a physician’s order dated 12/2/25 directed that 16 units of lispro insulin be administered three times daily with meals. The MAR showed that the 7:30 a.m. insulin dose on 2/7/26 was not administered. The resident reported that staff did not give his insulin that morning. The unit manager stated that, due to the resident’s preference, he did not want her to administer his insulin, so she attempted to pass the responsibility to another nurse. The LPN reported she was not informed she was supposed to care for this resident until it was too late, and the insulin dose was consequently missed. The DON indicated the facility did not have a medication administration policy, only a skills validation checkoff referencing the 5 rights of medication and timing parameters. Another deficiency involved a resident admitted from a rehabilitation hospital with diagnoses including cerebral infarction, right-sided hemiplegia and hemiparesis, dysphagia, aphasia, and dysarthria. The rehab hospital discharge summary documented that the resident had been assessed for hypercalcemia, hyponatremia, and hyperammonemia, and that lab levels should continue to be monitored. A lab report dated 1/16/26 showed low sodium (132) and high calcium (12.5). A physician progress note on 1/19/26 addressed hypercalcemia, hyponatremia, and elevated ammonia, with a plan to repeat a comprehensive metabolic panel in one week, and a corresponding order to repeat ammonia and a comprehensive metabolic panel on 1/26/26. The record contained a lab report dated 1/30/26 indicating insufficient blood for lipid and thyroid tests, but no evidence that the ordered comprehensive metabolic panel or ammonia level was obtained after 1/16/26. The resident was later admitted to the hospital with acute respiratory failure with hypoxia, hypercalcemia, acute renal insufficiency, and hypernatremia, and abnormal lab values including sodium, potassium, and calcium. The same resident from the rehabilitation hospital also had documented dysphagia and communication deficits. The rehab discharge summary specified a dysphagia diet with 1:1 supervision for all meals due to aspiration risk, including 1:1 or close supervision, alternating sips of liquids with small bites, medications crushed in puree, and no straws. Upon admission, a physician’s order allowed staff to crush appropriate medications and mix with applesauce or other food sources as needed. However, the electronic medical record did not include orders for 1:1 or close supervision for meals, alternating sips of liquids with small bites, crushing medications in puree as a standing requirement, or no straws. The resident’s daughter reported that her father had swallowing difficulties from a stroke and that she filed a grievance after an RN placed an uncrushed pill in his mouth instead of in applesauce, despite his need for medications to be crushed in applesauce. The unit manager stated that an order indicating the nurse may crush medications was not the same as an order to always crush them and did not believe the resident received medications crushed. The facility’s Nursing Admission/Return Admission policy required the admitting nurse to review the hospital discharge summary and physician orders and to transcribe admission orders from the original orders, which was not reflected in the resident’s EMR orders for dysphagia-related care.
Failure to Maintain Ordered Same-Size Tracheostomy Cannula at Bedside
Penalty
Summary
The facility failed to follow a physician’s order to keep the same size tracheostomy cannula at the bedside for a resident with a tracheostomy. During observation, the resident was noted to have a tracheostomy, and record review showed diagnoses including chronic respiratory failure and sleep apnea. A physician’s order dated 2/2/26 specified that the resident’s tracheostomy was a Bivona tracheostomy XL size 7 and directed staff to keep both a smaller tracheostomy cannula and the same size tracheostomy cannula at the bedside. However, during interviews, RN 2 and the MDS Coordinator each confirmed that only a size 6 cannula was stored at the bedside and indicated they would need to check whether the same size cannula was stored there. The DON stated that she believed the same size cannula only needed to be stored somewhere in the facility, not specifically at the bedside, and upon reviewing the physician’s order, acknowledged it required the same size cannula at the bedside. The DON also indicated the facility did not have a tracheostomy policy. This resulted in the facility’s failure to ensure the same size tracheostomy cannula was kept at the bedside as ordered for the resident reviewed for respiratory care.
Improper Medication Disposal and Incomplete Controlled Substance Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were disposed of in a secure and safe manner and to follow controlled substance destruction procedures for a resident with multiple neurologic conditions. The resident had diagnoses including cerebral infarction, right-sided hemiplegia and hemiparesis, dysphagia, aphasia, and dysarthria, and had been admitted from a rehab hospital where speech-language pathology had recommended medications be crushed in puree form. On a specified morning, the Medication Administration Record showed several medications, including aspirin, vitamin D3, lactulose, methylphenidate (a Schedule II controlled substance), sennosides-docusate sodium, rifaximin, and polyethylene glycol, were marked as not administered due to the resident’s condition. A controlled substance record indicated one tablet of rifaximin was signed out by an RN, but the record did not show that the tablet was disposed of or wasted with a second nurse. During interviews, the unit manager reported that the RN stated none of the medications were given that morning and that she had thrown all of the medications into the trash in the resident’s room, contrary to facility expectations. When the unit manager and a second staff member checked the resident’s room, they found only two pills in the trash can, despite six pills having been ordered for that morning, and no liquid medications were found. The RN later confirmed she did not administer any medications to the resident that morning. Facility documents, including a medication administration competency checklist and the controlled substances policy, indicated that wasted, dropped, or discarded medications were to be disposed of in a Drug Buster disposal system and that all unused controlled medications were to be destroyed with a witnessing licensed nurse and documented on the controlled substance record. These requirements were not followed in this incident.
Failure to Provide Ordered Minced and Moist Dysphagia Diet
Penalty
Summary
The deficiency involves the facility’s failure to provide a diet that was comparable and compatible with the minced and moist dysphagia diet ordered by a rehabilitation hospital for a resident with significant neurologic and swallowing impairments. The resident had diagnoses including cerebral infarction, right-sided hemiplegia and hemiparesis, dysphagia, aphasia, and dysarthria. The rehab hospital discharge summary documented mild oral phase deficits with right anterior loss and pocketing, intermittent cough with thin liquids and solids, impulsivity during feeding, and an aspiration risk, and ordered an IDDSI Level 5 minced and moist diet with thin liquids, 1:1 or close supervision, alternate sips and small bites, and no straws. Upon admission, the facility’s admission observation noted swallowing difficulties, but the initial physician order was for a regular diet, which was later changed the same day to a soft and bite-sized diet and remained in place until it was discontinued on a later date. According to IDDSI definitions, the ordered minced and moist diet (Level 5) requires minimal chewing and smaller particle size than the soft and bite-sized diet (Level 6) that requires regular chewing and tongue control. During the period the resident was on the soft and bite-sized diet, the care plan and MDS documented that the resident required assistance with eating related to dysphagia and dysarthria and needed partial to moderate assistance. Progress notes recorded that the nurse was called to the dining room on two separate occasions due to the resident coughing, vomiting, and having thick secretions while eating, yet the resident continued to eat and cough. A subsequent physician order changed the diet to pureed. The resident’s daughter reported that her father had swallowing difficulties from a stroke, that these had worsened, and that she had filed a grievance about him being left unattended while eating despite his need for close supervision. The speech therapist stated that the facility did not offer a minced and moist diet and that a soft and bite-sized diet would be considered an upgraded diet from minced and moist. Facility policy listed available diets as regular, puree, ground meat, and soft & bite-sized, and directed that if a minced and moist diet was ordered, it would be interpreted as puree and that nursing should refer such residents to speech therapy to ensure the most appropriate diet, indicating a discrepancy between the ordered minced and moist diet and the diet actually provided.
Failure to Initiate Speech Therapy and Appropriate Dysphagia Diet Management
Penalty
Summary
The deficiency involves the facility’s failure to initiate and provide ordered speech therapy services and appropriate dysphagia diet management for a resident admitted with a known swallowing disorder. The resident was admitted from a rehabilitation hospital with diagnoses including cerebral infarction, right-sided hemiplegia/hemiparesis, dysphagia, aphasia, and dysarthria. The rehab hospital discharge summary documented mild oral phase deficits, coughing with thin liquids and solids, impulsivity during feeding, and an aspiration risk, with a recommendation for continued dysphagia diet (IDDSI thin liquids and minced and moist/IDDSI 5 solids), 1:1 supervision at all meals, and ongoing monitoring for signs of aspiration or pulmonary compromise. On admission, the resident’s health problems included swallowing difficulties, and the care plan and MDS documented the need for assistance with eating related to dysphagia and dysarthria. Despite this, the facility initially ordered a regular diet, then changed it to a soft bite-sized diet the evening of admission, without a speech therapy evaluation. Over the following days, the resident experienced coughing, vomiting, and thick secretions while eating, as documented in progress notes on two separate occasions, which triggered a therapy evaluation. Only after these events did the physician order a speech therapy evaluation and treatment, along with a change to a pureed diet. Interviews revealed that the DON stated speech therapy was usually ordered upon admission for residents with worsening dysphagia or modified diets but believed this resident’s dysphagia was stable or improving. The speech therapist stated that when a resident is admitted with dysphagia and on a modified diet, speech therapy should be notified to evaluate, that the facility did not offer a minced and moist diet, and that a soft and bite-sized diet represented an upgraded diet that should not be made without a speech therapy evaluation. The resident’s daughter reported that her father’s swallowing difficulties had worsened after his stroke, that he was admitted for continued therapy, and that she had filed a grievance because he was left unattended while eating despite requiring close supervision. Facility policy required a nursing-to-therapy referral for speech therapy when a resident admitted with mechanical soft or minced and moist diet orders, which was not done in this case.
Resident Rights Violated During Rough Handling by QMA
Penalty
Summary
A deficiency occurred when a Qualified Medication Aide (QMA) failed to treat a resident with respect and dignity during care. The resident, who had diagnoses including dementia with behavioral disturbances, Alzheimer's disease, generalized anxiety disorder, pain, difficulty walking, and cognitive communication deficit, was taken to the shower room by the QMA. After the shower, the QMA transported the resident back to her room by having her sit on the seat of her rollator walker and pushing her. When the resident refused to stand up to be placed in bed, the QMA lifted her under the armpits and placed her on the bed, despite the resident's refusal and care plan interventions that emphasized offering other staff, ensuring safety, and using appropriate communication strategies due to hearing loss. An LPN witnessed the QMA speaking loudly and being rough with the resident, prompting the LPN to intervene and finish assisting the resident to bed. The facility's review determined that the QMA violated the resident's rights by disregarding her safety and not honoring her right to refuse care, although the actions were not deemed abusive. Facility policy states that residents have the right to be treated with consideration, respect, and recognition of their dignity and individuality, including the right to refuse any treatment or service.
Failure to Provide Safe and Respectful ADL Assistance
Penalty
Summary
The facility failed to provide safe and comfortable assistance with activities of daily living (ADLs) for two residents. For one resident with dementia, Alzheimer's disease, and mobility difficulties, a Qualified Medication Aide (QMA) transported her from the shower room to her bed by having her sit on a rollator walker and pushing her, rather than using a gait belt as required by facility policy. The QMA then attempted to transfer the resident to bed by lifting her under the armpits, which was observed by an LPN who intervened due to the rough handling. The QMA admitted to not using a gait belt and acknowledged the resident's refusal to stand, but proceeded with the transfer regardless of proper technique. For another resident with Parkinson's disease, vascular dementia, osteoporosis, and a recent pathological ankle fracture, care plans indicated the need for two-person assistance with bed mobility and transfers due to pain and risk of injury. During incontinence care, a QMA was observed by a CNA to be providing care alone, with the resident crying out in pain and being held in a position that caused distress. The CNA intervened and reported the incident to nursing staff. Both incidents were found to be in violation of facility policy and resident rights, as staff failed to follow established procedures for safe and respectful ADL care.
Failure to Maintain Clean, Sanitary, and Homelike Resident Room Environment
Penalty
Summary
A deficiency was identified in one resident room where the environment was found to be unclean, unsanitary, and not homelike. During observation, the room had a persistent urine odor, approximately seven flies were present, with some crawling on a sleeping resident and in a cup of juice. A sock was found on the bedside table, and the bedside commode contained a small amount of dark yellow urine. In the bathroom, a dried, dark brown substance, identified by staff as likely feces, was smeared on the toilet with flies crawling on it, and a puddle of dark yellow liquid was observed on the floor and trash can liner. Staff interviews revealed that the commode basin was not cleaned after each use as required, and there was uncertainty about when the bathroom was last cleaned. The two residents occupying the room both had diagnoses including dementia and required assistance with toileting due to decreased mobility, weakness, and incontinence, as documented in their care plans. Staff interviews confirmed that standard procedures, such as using liners in the commode and cleaning after each use, were not consistently followed. Housekeeping staff were unclear about cleaning responsibilities, and the facility did not have a specific policy for providing a homelike environment, although it was stated as a mission. The deficiency was cited under 3.1-19(f)(5) and related to a specific complaint investigation.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure a resident's right to privacy during personal care for one of the residents reviewed. During an observation, an LPN entered the room of a resident to administer a gastrostomy tube bolus of Jevity 1.5, a nutritional supplement. The resident's door was left open, and the LPN pulled back the resident's cover and lifted his gown, exposing his abdomen. The privacy curtain was not closed, and three people walked by the room during this time. The resident's clinical record indicated diagnoses including acute respiratory failure with hypoxia, convulsions, congestive heart failure, dysphagia, and atrial fibrillation. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility did not have a policy on providing privacy for residents, although the facility's Resident Rights policy stated that residents have the right to a dignified existence and self-determination.
Failure to Develop Comprehensive Care Plan for Hand Splint
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident who was observed wearing a hand splint on multiple occasions. The resident, who had a history of transient ischemic attack, hypertension, anxiety disorder, and major depressive disorder, was seen with a hand splint on her right hand during observations in the dining and activity rooms. However, the electronic medical record did not include a physician's order or a care plan for the hand splint. The Director of Nursing confirmed that there was no care plan for the hand splint prior to a specific date, and the facility did not have any additional care plan policies. The facility's policy indicated that care plan reviews should be interdisciplinary, involving nursing, therapy, and MDS, but this was not adhered to in this case.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to ensure timely pharmaceutical services for a resident, identified as Resident 376, who was at risk for injury related to seizure activity. The resident had a physician's order for Lacosamide, an anticonvulsant medication, dated 1/9/25, which was not available until 1/22/25. As a result, the resident missed 26 doses of the medication, which was critical for managing their seizure risk. The clinical record review revealed that the resident had diagnoses including convulsions, congestive heart failure, emphysema, and encephalopathy. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), indicated that there were procedures in place to address medication unavailability, such as checking the Pyxis system, contacting the pharmacy, and notifying the physician. However, these procedures were not effectively implemented in this case, as the medication remained unavailable for an extended period. The DON acknowledged that the medication should not have been unavailable for days, and the facility's medication administration policy did not address the issue of missing multiple doses of a scheduled medication.
Failure to Conduct AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to ensure that residents were assessed for side effects of antipsychotic medications using the Abnormal Involuntary Movement Scale (AIMS) as per their policy and procedure. For Resident 37, who had multiple diagnoses including Alzheimer's disease, bipolar disorder, and major depressive disorder, the AIMS assessment was not conducted between January and August, despite the policy requiring it every six months. The resident was on medications such as risperidone, sertraline, and buspirone, which necessitated regular monitoring for involuntary movements. Similarly, for Resident 45, who had conditions like vascular dementia, depressive episodes, and psychotic disorder, an AIMS assessment was not completed upon admission in March, as required by the facility's policy. The resident was prescribed medications including divalproex, risperidone, and sertraline. The Clinical Support Nurse confirmed the absence of the admission AIMS assessment, which should have been conducted with the new order. The facility's policy, revised in July, mandates AIMS assessments every six months and with new orders for residents on antipsychotics.
Deficiency in Accurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure complete and accurate documentation of care provided to two residents, leading to a deficiency in maintaining medical records according to professional standards. Resident 55, diagnosed with diabetes mellitus, dementia, and hypertension, had a care plan indicating a risk for altered nutritional status and required bedtime snacks as an intervention. However, the January 2025 Medication/Treatment record showed that snacks were not administered on several days due to unavailability, despite a physician's order to provide them. Similarly, Resident 18, with diagnoses including hypertension, chronic kidney disease, and Alzheimer's dementia, also had a physician's order for bedtime snacks. The January 2025 Medication/Treatment record indicated that snacks were not given on specific days due to unavailability. An interview with the Corporate Support Nurse revealed that snacks were supposed to be available, but the nurse responsible for documentation stated they were not, and she improvised by finding something else to give the residents. The facility's skills competency checklist for medication administration did not address the need for accurate documentation on the Medication and Treatment Administration Record.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident B, was assessed for the ability to self-administer medications. During an observation and interview, it was noted that Resident B had a clear plastic cup with approximately eight pills on her table, which were left by a nurse while the resident was bathing or dressing. The nurse instructed Resident B to take the medications with her meal, but the breakfast tray was observed to be untouched. Upon reviewing Resident B's clinical record, it was found that there was no physician's order, care plan, or assessment indicating that the resident was capable of self-administering medications. Interviews with RN 1 and the Director of Nursing confirmed that Resident B did not have the necessary documentation or assessment for self-administration of medications. RN 1 admitted to leaving the medications in the room and acknowledged that she should not have done so. The facility's policy on self-administration of medications, last reviewed in January 2015, requires an interdisciplinary team assessment, a physician's order, and an updated care plan for residents who wish to self-administer medications. These steps were not followed in the case of Resident B.
Deficiency in Cup Cleanliness Due to Hard Water
Penalty
Summary
The facility failed to ensure that cups used for serving drinks to residents were free of film or buildup from hard water. During an observation in the kitchen, clean cups stored in the dishwasher room were found to have a white film that could be scraped off. This issue was observed in 18 out of 29 cups and 9 out of 9 cups with handles. Dietary staff confirmed that these cups were used to serve fluids to residents. The Executive Director acknowledged the presence of hard water and indicated that salt was needed to soften the water, which was not available at the time. Residents were observed using these cups during meals, with several cups noted to have a white film inside. Resident B, Resident C, and Resident D all had cups with visible film, and Resident D specifically mentioned that the facility was using dirty cups. The Executive Director explained that the film was from the sanitizer and that soaking the cups would remove it. The facility's policy on cleaning dishes required items to be checked for cleanliness after washing, but this was not effectively implemented, leading to the deficiency.
Deficient Dementia Care Leads to Resident Altercation
Penalty
Summary
The facility failed to provide effective person-centered dementia care for two residents, leading to an altercation between them. Resident H, who had a history of physically aggressive behaviors, was involved in an incident with Resident J, resulting in Resident J sustaining a fractured left wrist and a laceration above his right eye. The altercation occurred in the men's memory care cottage, and staff did not witness the event, although a CNA heard a noise and found the two residents in a confrontation. Resident H had a complex medical history, including neurocognitive disorder with Lewy bodies, schizophrenia, and other psychiatric conditions. His care plan included various activities and interventions to manage his behaviors, but he frequently exhibited aggressive and intrusive behaviors, such as wandering into other residents' rooms and physically attacking staff and peers. Despite multiple psychiatric evaluations and hospitalizations, Resident H continued to display combative behavior, which was inadequately managed by the facility. Resident J, who had dementia with agitation and other medical conditions, did not initially display aggressive behavior but was involved in the altercation with Resident H. The facility's lack of sufficient activities and staff to manage Resident H's behaviors, particularly after 5:00 p.m., contributed to the incident. Staff interviews revealed that Resident H was difficult to manage due to his combativeness, and there were no structured activities in the evening to engage him, leading to increased risk of altercations.
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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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