Hooverwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 7001 Hoover Rd, Indianapolis, Indiana 46260
- CMS Provider Number
- 155001
- Inspections on file
- 41
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Hooverwood during CMS and state inspections, most recent first.
MDS assessments were inaccurately coded for multiple residents. Several residents with documented falls, injuries, ER transfers, or hospitalization were marked as having no falls with injury or major injury on their MDSs, while one resident was incorrectly coded as having a tracheostomy despite no supporting clinical record, orders, or care plan. The MDS coordinator acknowledged the coding errors during interview.
The facility failed to follow physician orders for daily weights and medication hold parameters for several residents. A resident with CHF missed ordered daily weights, another resident had significant weight gains without physician notification, and a resident with BP-related PRN orders had multiple missed administrations when BP was outside ordered parameters. Another resident received metoprolol multiple times despite diastolic BP readings below the hold limit, even though staff interviews and facility policy stated orders with parameters should be checked before administration.
Call Light Not Kept Within Reach: A resident with Parkinson's disease, a T3/T4 vertebral dislocation, and a history of falls was observed with the call light out of reach while sitting in a Broda chair and again while lying in bed. The care plan directed staff to keep the call light within reach, and CAN, CNA, and DON interviews confirmed it should have been reachable.
Medications in 3 of 5 reviewed med carts were not labeled with open dates. An opened bottle of loperamide had another resident's name label on it and no open date, an opened bottle of alendronate had no open date, an opened bottle of liquid morphine had no open date, and an opened bottle of probiotic had no open date. An LPN, an RN, and the DON all stated opened medications should be labeled when opened.
A resident with dementia and a history of wandering exited a secured unit unsupervised by passing through an unlocked stairway and an unlocked, alarmed exit door. Staff reset the alarm without investigating, and the resident was later found outside the facility by a CNA. The care plan and elopement policy did not include updated interventions or clear staff response procedures for door alarms, contributing to the resident's unsupervised exit.
A resident who was fully dependent on staff for toileting and hygiene was left without incontinence care for an entire shift. The resident was found sitting in a recliner with saturated clothing and furniture, and no care or documentation was provided by the assigned CNA during the shift, despite facility policies requiring regular checks and assistance.
A nurse repeatedly signed out and documented the administration of Norco, a narcotic pain medication, for a resident who did not actually receive the medication during daytime hours. The resident, who was alert and cognitively intact, reported only taking the medication at night, and the MAR did not show daytime administrations. Facility policies required proper documentation and narcotic counts, but these were not followed, resulting in the misappropriation of the resident's medication.
Two residents were found with medications at their bedside without required self-administration assessments by the IDT, as confirmed by an LPN and Unit Manager. Both residents had multiple diagnoses, and facility policy mandates such evaluations before allowing self-administration of medications.
A resident with severe cognitive impairment was repeatedly observed with her breast exposed in a public area, and on another occasion, was left in soiled incontinence briefs for an extended period, resulting in discomfort and odor. Nursing leadership and staff acknowledged the need for closer monitoring and adherence to policies requiring regular checks and prompt hygiene care.
A dependent resident with severe cognitive impairment and blindness was transferred using a sit-to-stand mechanical lift without a prior safety evaluation, despite her inability to participate in the transfer as required. Staff used the lift contrary to the care plan and facility policy, and the resident did not hold the handlebars, resulting in an unsafe transfer that required physical assistance to complete.
The facility did not ensure that a licensed pharmacist completed required monthly drug regimen reviews for several residents receiving psychoactive medications, resulting in missing documentation for multiple months. The DON confirmed that pharmacy reviews were not available for certain periods, particularly during a change in pharmacy providers, despite facility policy requiring regular review.
A resident who required set-up assistance for meals was repeatedly left asleep with meal trays delivered to her room, resulting in food cooling to unsafe and unappetizing temperatures. Despite the resident's stated preference to be awakened for meals, staff did not consistently do so, and her care plan lacked documentation of her meal delivery preferences. Food temperature checks confirmed that meals were served below required standards, and other residents also reported receiving cold food in their rooms.
Two residents reported being treated without respect and dignity by CNAs. One resident felt hurt by a CNA's rough and grouchy behavior, while another resident reported being yelled at and scolded by a different CNA. Both residents had significant medical histories and were unable to be interviewed during the survey.
A resident with multiple health conditions fell during a Hoyer lift transfer when a CNA attempted the procedure alone, contrary to facility policy requiring two staff members. The resident moved her hands, slid out of the lift, and was repositioned onto the floor, resulting in pain and the need for medication.
A facility failed to properly administer and document narcotic medications for two residents. An agency nurse, RN 10, did not document the administration of prescribed narcotics in the EMAR, despite signing them out on the narcotic sheet. Resident C's and Resident D's records showed discrepancies, with Resident D reporting only receiving Tylenol instead of Oxycodone. Resident H also had missing documentation for Oxycodone. The facility's policy required accurate documentation, which was not followed, leading to a deficiency in pharmaceutical services.
A resident with severe cognitive impairment was sexually assaulted by a contracted housekeeper in the dementia unit. The housekeeper was found on top of the resident with his pants down, while the resident's gown and brief were open. The resident, who required maximum assistance with personal care and had a self-care performance deficit, was unable to communicate effectively due to her condition and language barrier. The incident highlighted a failure in the facility's protective measures.
A resident with dementia was physically abused by a staff member who pulled the resident by the ears, causing redness. The incident was witnessed by another staff member who reported it to the DON. The resident's medical history included dementia and other conditions. The facility's policy on abuse was violated.
The facility failed to protect the personal property and financial assets of two residents. One resident's AirPods were stolen and pinged to a CNA's address, leading to her termination. Another resident's credit card was used without permission for a restaurant purchase, despite her inability to leave the facility independently. These incidents highlight lapses in securing residents' belongings and preventing unauthorized access by staff.
A privacy breach occurred when a resident's medication list was incorrectly sent to a hospital, leading to a delay in medication administration. Two LPNs were involved in preparing the resident for transfer, and an error was made when the medication list for another resident was included in the envelope. The mistake was discovered by the resident's niece, who reported it to the hospital staff, prompting the facility to send the correct information.
MDS Assessments Were Inaccurately Coded for Falls and a Tracheostomy
Penalty
Summary
The facility failed to ensure MDS assessments were accurately coded for 5 of 7 residents reviewed for resident assessments. Resident 6 had a fall in her room on 3/27/26, sustained a hematoma to her forehead, and was sent to the emergency room, but the 3/29/26 MDS indicated no falls with injury since admission. Resident 22 had a fall on 2/24/26 with a head laceration, emergency room evaluation, and 12 staples to the head, but the 3/12/26 MDS indicated no falls with major injuries. Resident 46 was hospitalized on 3/14/26 after a fall that resulted in a right femoral neck fracture, yet the 3/23/26 and 4/16/26 MDS assessments indicated no falls with major injury since admission. Resident 105 had a fall on 1/9/26 with a left hip hematoma and emergency room transfer, but the 1/28/26 MDS indicated no falls with injuries. Resident 8’s 3/25/26 MDS indicated the resident had a tracheostomy, although the clinical record did not show a tracheostomy, physician orders, or a care plan for one. During interview, the MDS coordinator stated Resident 6 should have been marked for a fall with injury, Resident 22 had a fall with injury that should have been marked, Resident 46’s fall with injury should have been on the March MDS, and Resident 105 was not marked for falls. The MDS coordinator also stated Resident 8 was incorrectly marked as having a tracheostomy and that the assessment was modified, while the original MDS completion date remained the same.
Failure to Follow Orders for Weights and Medication Parameters
Penalty
Summary
The facility failed to follow physician orders for daily weights and medication administration for residents with congestive heart failure, blood pressure instability, and other chronic conditions. Resident 130 had CHF and a physician order to obtain a daily weight and notify the physician for a gain of more than 3 pounds in 24 hours or more than 5 pounds in 1 week, but the MAR showed daily weights were not obtained on 2/14/26 and 3/17/26. Resident 16 also had CHF and an order for daily weights with notification parameters, and the MAR showed a 6.2-pound weight increase on 2/28/26 and an 11.2-pound increase on 3/7/26, with no documentation that the physician was notified of either weight gain. Resident 108 had orders for PRN midodrine when systolic BP was less than 130 and PRN amlodipine when systolic BP was greater than 160, with instructions to check BP before meals and not administer after 6 p.m. The MAR showed multiple instances where midodrine was not administered when systolic BP was below 130 and multiple instances where amlodipine was not administered when systolic BP was above 160. The MAR for March 2026 also showed 13 times when systolic BP was less than 130 and midodrine was not given, and 2 times when systolic BP was greater than 160 and amlodipine was not given. Resident 14 had orders for metoprolol twice daily with hold parameters for systolic BP less than 100, diastolic BP less than 60, and heart rate less than 60. The MAR showed metoprolol was administered on multiple occasions when the diastolic BP was below 60, including several dates in April, as well as seven times in February and four times in March. Interviews with the DON, an LPN, and an RN indicated that medications with hold parameters should be checked against vital signs before administration and held when parameters were not met. The facility policy stated nursing shall follow physician orders as written and check parameters before administering medications.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a call light was within reach for Resident 11, who was reviewed for accommodation of needs. Resident 11 had diagnoses including Parkinson's disease, dislocation of the T3/T4 thoracic vertebra, and a history of falling. During an observation on 4/15/26 at 9:45 a.m., the resident was sitting in a Broda chair with the call light coiled on the nightstand out of reach. During another observation on 4/17/26, the resident was lying in bed with the call light on the ground under the bed. The care plan dated 7/8/24 identified the resident as at risk for falls and directed staff to keep the call light within reach and provide a safe environment with a reachable call light. During interviews, CAN 10, the DON, and CNA 9 each indicated the call light should be within the resident's reach when in bed or in a chair.
Medications Not Labeled With Open Dates
Penalty
Summary
The facility failed to ensure medications and biologicals were labeled in accordance with accepted professional principles because opened medications in 3 of 5 medication carts reviewed did not have open dates. During an observation on 4/17/26 with an LPN, the 1B [NAME] medication cart contained an opened bottle of loperamide hydrochloride 2 mg that was not labeled with an open date and also had another resident's name label on the bottle, as well as an opened bottle of alendronate 70 mg that was not labeled with an open date. The LPN stated the other resident's label should not have been on the medication and that the medication should have been labeled with an open date. During an observation on 4/20/26 with an LPN, the 2B East medication cart contained an opened bottle of liquid morphine 20 mg/ml that was not labeled with an open date, and the LPN stated it should have had an open date. During another observation on 4/20/26 with an RN, the 1A East medication cart contained an opened bottle of probiotic (Lactobacillus) that was not labeled with an open date. The RN stated that when a new bottle of medication is opened, the nurse should label it with the date and time it was opened. The DON also stated medications should be labeled with an open date at the time they are opened. The facility policy titled Medication Labeling, dated 5/2022, stated medications are to be labeled in compliance with State and Federal laws and maintained accurately labeled for safe and effective medication administration.
Failure to Prevent Elopement of Resident with Dementia and Wandering Behaviors
Penalty
Summary
A resident with dementia, severe cognitive impairment, and a known history of wandering and exit-seeking behaviors exited the facility unsupervised despite being on a secured locked unit and wearing a wanderguard device. The resident was able to leave the secured unit through an unlocked stairway door, descend to the first floor, and exit the building through an unlocked but alarmed door. The stairway door was supposed to be locked and checked daily by the Maintenance Director, but it was not checked on the day of the incident. The exit door alarm sounded, but staff reset the alarm without investigating the cause or checking outside, and the resident was not immediately located. The resident wandered approximately 0.4 miles away from the facility, crossing a two-lane road before being found by a CNA walking in the grass along the road. The resident's care plan and assessments documented her high risk for elopement, use of a wanderguard, and previous incidents of exit-seeking, including a prior event where she left the building and required intervention. Despite these documented risks and behaviors, there were no updated interventions in the care plan after the previous elopement incident, and the facility's elopement policy did not specify staff response to door alarms. Interviews and record reviews revealed that staff were not aware of the resident's exit until a code for a missing resident was called, and the alarmed door had been tampered with, preventing it from locking properly. Staff responding to the alarm did not open the door or check the area outside, and only later realized the resident was missing. The resident was eventually found without injury, but the incident demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision and monitoring were provided to prevent accidents for residents at risk of elopement.
Failure to Provide Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A dependent resident with a history of cerebral infarction, dementia, and type 2 diabetes mellitus was not provided incontinence care during an entire eight-hour shift. The resident was totally dependent on staff for toileting and hygiene, requiring a stand lift and assistance from two staff members. According to the care plan, peri-care was to be completed with each incontinence episode. However, documentation and interviews revealed that the assigned CNA did not provide or document any toileting or incontinence care for the resident during the shift. When the resident's daughter visited, she found the resident sitting in a recliner with a strong odor of urine and feces, and both the resident's clothing and recliner were saturated. The incontinence brief was so saturated it fell to the resident's knees when she was assisted to stand. The facility's point of care documentation confirmed that no toileting or incontinence care was recorded for the resident during the CNA's shift. The CNA later admitted to neglecting her duties during this period. The facility's policies and the CNA's job description required regular checks, assistance with toileting and incontinence needs, and proper documentation of care provided. These requirements were not met, resulting in the resident being left in soiled clothing and furniture for an extended period.
Misappropriation of Resident's Narcotic Medication by Staff
Penalty
Summary
A deficiency occurred when a nurse (RN) repeatedly signed out and documented the administration of Norco, a narcotic pain medication, for a resident who did not actually receive the medication. The resident, who was cognitively intact, alert, oriented, and a retired RN, consistently reported that she only took Norco at night to help her sleep and never during the day. Despite this, the narcotic count sheets showed that the RN signed out Norco for the resident on multiple occasions during daytime hours, often one tablet at a time, while the resident's order was for two tablets every six hours as needed for pain. The Medication Administration Record (MAR) did not reflect these daytime administrations, and the resident confirmed she had not received the medication during those times. Interviews with staff, including the DON and other nurses, confirmed that the facility's policy required all administered medications, especially PRN narcotics, to be documented both on the narcotic sheet and in the electronic MAR. If a medication was not documented in the MAR, it was considered not administered. The discrepancy was identified when another nurse noticed inconsistencies between the narcotic count sheet, the resident's order, and the MAR. The resident was able to identify her medications and was aware of what she had taken, further supporting that the narcotics were not administered as documented by the RN. The facility's policies also required a narcotic count at each shift change, with both off-going and on-coming nurses signing the count sheet. Despite these procedures, the RN continued to sign out and document the removal of Norco without actual administration to the resident, resulting in the misappropriation of the resident's medication. The resident's rights policy specifically stated that residents have the right to be free from misappropriation of property, which was not upheld in this instance.
Failure to Complete Self-Administration Medication Assessments
Penalty
Summary
The facility failed to ensure that residents who self-administer medications had appropriate assessments completed by the interdisciplinary team. Specifically, two residents were observed with medications, including Afrin nasal spray, lubricant eye drops, and diclofenac/lidocaine cream, on their bedside tables. Review of their clinical records revealed that neither resident had a documented self-administration evaluation by the interdisciplinary team, as required by facility policy. Interviews with an LPN and a Unit Manager confirmed that these residents should have had self-administration evaluations in their records if they were keeping medications in their rooms. The facility's policy states that residents wishing to self-administer medications must be assessed by nursing staff, with the assessment reviewed by the IDT and physician before approval. Both residents had multiple diagnoses, including hypertension, cataracts, diabetes, and pain, but lacked the necessary documentation to support self-administration of their medications.
Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
Staff failed to ensure a dependent resident with dementia and severe cognitive impairment was dressed appropriately to maintain her dignity and provided with timely incontinence care. On two separate occasions, the resident was observed sitting in a lounge area with her shirt pulled up, exposing her left breast. In both instances, nursing leadership noticed the exposure and adjusted the resident's clothing. Interviews with the Assistant Director of Nursing and Director of Nursing confirmed awareness of the issue and the need for closer monitoring. Additionally, the resident was observed sitting in the lounge for an extended period with bath blankets wrapped around her, emitting a strong odor of urine and bowel movement. The resident was visibly uncomfortable, leaning to one side. After being informed, the Unit Manager and a CNA provided care, finding the resident's brief soaked with urine and a large loose bowel movement. Staff interviews and facility policy confirmed that residents should be checked and changed at least every two hours or as needed, and that perineal care should be performed after episodes of incontinence to maintain cleanliness and comfort.
Failure to Evaluate and Safely Transfer Dependent Resident Using Mechanical Lift
Penalty
Summary
A dependent resident with severe cognitive impairment, dementia, and blindness was transferred using a sit-to-stand mechanical lift without a prior evaluation to ensure the transfer method was safe for her condition. During the transfer, the resident did not hold onto the handlebars as instructed, and the sling strap slipped under her armpits while she was not using her legs to stand. The transfer was completed with staff physically assisting the resident to the bed, despite the resident's refusal and inability to participate as required for safe use of the lift. The resident's care plan indicated total dependence and the need for assistance by two staff members for transfers, but did not specify the use of a sit-to-stand lift. There was no documentation of a safety evaluation for the use of this lift with the resident. Staff interviews confirmed that the assignment sheet was incorrect and that the sit-to-stand lift was not an appropriate transfer method for this resident. Facility policy required checking assignment sheets for approved transfer methods and ensuring residents could safely use mechanical lifts, which was not followed in this instance.
Failure to Ensure Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly drug regimen reviews, including review of the medical chart, for several residents as required. For one resident with diagnoses including Alzheimer's disease, psychotic disorder, severe kidney disease, diabetes, depression, and anxiety, pharmacy reviews were missing for July, with no documentation found for that month despite a change in pharmacy providers. The DON confirmed that neither the current nor previous pharmacy provider could produce the missing review. Another resident with seizure disorder, anxiety, and depression had missing pharmacy reviews for multiple months, including June, July, January, and February, with the DON confirming that several months' reviews were not available after contacting the previous pharmacy. A third resident with hypertension, anxiety disorder, and manic depression also lacked a pharmacy review for July, with the DON unable to locate the required documentation. Facility policy required psychoactive medications to be reviewed in accordance with regulatory requirements, but the required monthly pharmacist reviews were not consistently completed or documented for these residents.
Failure to Ensure Resident Meals Delivered at Safe and Appetizing Temperatures
Penalty
Summary
A deficiency occurred when a resident's meals were repeatedly delivered to her room while she was asleep, resulting in the food sitting unattended and cooling to unappetizing and unsafe temperatures. The resident reported that her meals were served cold and that staff did not always wake her up upon delivery. Observations confirmed that on multiple occasions, the resident was asleep with her meal tray left on her bedside table, and she was unaware that her food had been delivered. When asked, the resident expressed a preference to be awakened for meal delivery, contradicting staff statements that she did not want to be disturbed. Food temperature checks revealed that the meals were below required temperatures, with the eggs measured at 83 degrees Fahrenheit, well under the standard of over 140 degrees Fahrenheit for hot foods. The resident's care plans did not include her preferences regarding meal delivery, despite her need for set-up assistance and her stated wishes. Interviews with staff indicated a lack of clarity about the resident's preferences, and the facility lacked a specific policy for room tray delivery. Additionally, other residents reported receiving cold food in their rooms and felt they should not have to request reheating. Facility documents outlined expectations for timely and safe meal delivery and maintaining proper food temperatures, but these were not followed in practice for this resident.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by two separate incidents involving two residents. In the first incident, a resident reported that a CNA was rough and grouchy while assisting her, which hurt her feelings. The CNA was later suspended pending an investigation. The resident had a history of major depressive disorder, anxiety disorder, and other health issues, and was unable to be interviewed at the time of the survey. In the second incident, another resident reported a care concern with a different CNA, who allegedly yelled at her and her roommate, and scolded her for wanting to wear two briefs. The resident, who had a history of psychotic disorder with hallucinations, major depressive disorder, and dementia, expressed that she felt mistreated and did not want the CNA to care for her again. This resident was also unable to be interviewed at the time of the survey.
Failure to Follow Hoyer Lift Transfer Protocol
Penalty
Summary
The facility failed to ensure that two staff members were present during a Hoyer lift transfer, leading to an accident involving a resident. The incident involved a CNA who attempted to transfer a resident using a Hoyer lift without the assistance of a second staff member, as required by the facility's policy. During the transfer, the resident moved her hands, causing her to slide out of the lift onto a recliner, and then onto the floor due to poor positioning. The resident, who had a history of major depressive disorder, pain, anxiety disorder, frontotemporal neurocognitive disorder, moderate protein-calorie malnutrition, and difficulty walking, complained of pain following the incident and was administered pain medication. The root cause of the fall was identified as the CNA's decision to perform the transfer alone, despite being aware of the policy requiring two staff members for such procedures. The CNA admitted to knowing the requirement but chose not to wait for assistance. This incident was documented in the resident's clinical record and was further corroborated by an IDT progress note. The facility's policy on mechanical lift transfers, which mandates the presence of a second staff member, was not adhered to, resulting in the resident's fall and subsequent pain.
Failure in Narcotic Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure proper administration and documentation of narcotic medications for two residents, leading to a deficiency in pharmaceutical services. On 10/11/24, several residents reported not receiving their medications from RN 10, an agency nurse. The Electronic Medication Administration Record (EMAR) for Resident C showed no documentation of receiving prescribed doses of Cyclobenzaprine and Norco, despite the narcotic count sheet indicating administration by RN 10. Similarly, Resident D's EMAR lacked documentation for Oxycodone administration, although the narcotic sheet showed it was signed out by RN 10. Resident D reported receiving only Tylenol and not the prescribed Oxycodone, corroborated by a handwritten document noting RN 10's strange behavior. Resident H also experienced a lack of documentation for Oxycodone administration on the same date, with the narcotic sheet indicating it was signed out by RN 10. The facility's policy required documentation of all administered medications in the EMAR and on the narcotic sheet, which was not followed in these cases. The failure to adhere to the medication administration policy resulted in a deficiency, as the residents did not receive their prescribed narcotic medications, and the documentation was not accurately maintained.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a contracted housekeeping staff member. The incident occurred when a housekeeper was found on top of a resident in the dementia unit, with his pants down and the resident's gown and brief pulled up and open, respectively. This was witnessed by the Housekeeping Supervisor, who immediately intervened and called the police. The resident involved, identified as having severe cognitive impairment due to Alzheimer's disease and other conditions, was unable to understand or communicate effectively, which contributed to her vulnerability. The resident's care plan indicated she required maximum assistance with personal care and had a self-care performance deficit due to her dementia. She was also noted to have a functional limitation in her range of motion to both lower extremities. The resident's primary language was not English, and she was rarely understood even with translation assistance. At the time of the incident, the resident was found lying in bed, staring blankly at the ceiling, and did not appear to be in distress. The facility's policy on abuse, neglect, and exploitation, dated January 2024, emphasized the right of each resident to be free from abuse. However, the incident revealed a failure in the facility's protective measures, as the housekeeper was able to access and assault the resident. The housekeeper had a history of verbal warnings for tardiness and unsatisfactory job performance, which were documented in his employee file. The deficiency was identified as an immediate jeopardy situation, indicating a serious breach in resident safety and care standards.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to ensure a resident with dementia was free from physical abuse. A staff member, identified as CNA 1, was observed by another staff member, CNA 2, pulling a resident by the ears to remove him from another resident's room. This incident resulted in redness on the resident's ears. The resident, who was residing in the memory care unit, had a medical history that included dementia, chronic obstructive pulmonary disease, anemia, and peripheral vascular disease. The incident was reported to the Director of Nursing (DON) by CNA 2, who witnessed the abuse and intervened to protect the resident. The clinical records and nursing progress notes indicated that the resident's left ear was slightly red following the incident, and the redness was observed by a nurse practitioner the following day. CNA 1 claimed that the redness was due to shaving the resident earlier in the day, but CNA 2 reported that CNA 1 twisted the resident's ear while reprimanding him for entering another resident's room. The facility's policy on abuse, neglect, and exploitation emphasizes the residents' right to be free from abuse, and the incident was documented as a violation of this policy.
Misappropriation of Residents' Property and Financial Assets
Penalty
Summary
The facility failed to protect the personal property of two residents, leading to incidents of misappropriation. In the first case, a resident's daughter discovered that her father's AirPods were missing during a visit. The AirPods were later pinged to the address of a CNA employed at the facility. Despite the CNA's denial of involvement, the facility terminated her employment due to the evidence linking the AirPods to her address. This incident highlights a lapse in the facility's ability to secure residents' belongings and prevent unauthorized access by staff. In the second case, a resident's son noticed an unauthorized charge on his mother's credit card statement for a restaurant purchase. The resident was unable to leave the facility independently, suggesting that someone else used her card without permission. The facility's investigation revealed that the transaction was made in person at a nearby restaurant. Despite the resident's refusal to lock up her valuables, the facility failed to ensure the security of her financial assets, resulting in the misuse of her credit card.
Privacy Breach in Medication List Handling
Penalty
Summary
The facility failed to ensure the privacy of a resident's medication list during an admission process, affecting one of the five residents reviewed for resident-identifiable information. The incident involved Resident C, whose medication information was incorrectly sent to the hospital. This error led to a significant delay in administering the correct medications to the resident. The mistake was identified when the resident's niece discovered that the medication list in the envelope was for another resident, Resident N, instead of Resident C. The niece reported the discrepancy to the hospital staff, who then contacted the facility to obtain the correct medication list. The error occurred when two LPNs, LPN 8 and LPN 9, were preparing Resident C for a transfer to an appointment. LPN 8 printed the resident's face sheet, while LPN 9 printed the medication list for another resident, Resident N. Without verifying the name on the medication sheet, LPN 8 placed it in the envelope with the face sheet, which was then sent to the hospital. This breach of privacy was a violation of HIPAA regulations, as it involved the inappropriate disclosure of protected health information (PHI).
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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