Richland Bean Blossom Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellettsville, Indiana.
- Location
- 5911 State Road 46, Ellettsville, Indiana 47429
- CMS Provider Number
- 155523
- Inspections on file
- 34
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Richland Bean Blossom Health Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
A resident with dementia and pain disorder did not receive proper reconciliation of narcotic pain medication when an LPN failed to follow facility procedures for accepting and documenting the delivery of oxycodone-acetaminophen. The medication was never located, and the required documentation was not completed as per facility policy.
Multiple residents reported that their bread often became soggy when served with wet items like corn, an issue that had been ongoing and communicated to staff several times. Observation of a meal tray confirmed that corn was placed under a hamburger bun and onion rings, causing them to become soggy. The Administrator acknowledged the problem, and the Dietary Manager was not previously aware of these concerns.
Residents repeatedly reported that wet foods served on the same plate as bread or sandwiches caused their meals to become soggy and unappetizing. Despite raising this issue in multiple resident council meetings and requesting separate dishware for liquid foods, the concern was not addressed. Direct observation confirmed the ongoing problem, and the Dietary Manager was unaware of the residents' complaints.
All residents on the secure dementia unit were left without a structured activities program for several months, as no activities schedule was posted or implemented. Residents were observed without engagement in planned activities, and staff only provided unscheduled activities inconsistently. The Executive Director confirmed the absence of a regular activities program, despite facility policy requiring one.
Staffing on the secured dementia unit was inadequate, with only one nurse and one or two CNAs or QMAs present at times, leaving residents—many of whom required extensive or total assistance for transfers and toileting—unattended when staff were occupied elsewhere. This resulted in increased risk of falls and unmet care needs, particularly during late afternoon and overnight shifts when staffing was reduced and residents experienced more confusion and agitation. A review showed a high number of falls occurred during these lower-staffed hours, despite the facility's assessment tool indicating that resident care needs and negative outcomes should guide staffing decisions.
A resident with multiple diagnoses, including psychosis, was prescribed Olanzapine for ongoing hallucinations following recommendations from her primary care doctor and psychologist. The facility did not document that informed consent was obtained from the resident or her representative regarding the risks, benefits, and alternatives to the psychotropic medication. The DON confirmed there was no policy for obtaining informed consent or for initiating psychotropic medications.
A resident with a history of hemiplegia, hemiparesis, and moderately impaired cognition was not included in care planning conferences, and neither the resident nor their family was involved in the development of the care plan. Documentation showed the last care conference was nearly a year prior, and the required quarterly conferences and documentation of participation were not completed, contrary to facility policy.
A resident with mobility and cognitive impairments did not have access to her call light for an extended period after staff deep-cleaned her room, leaving the device under a plastic container and out of reach. Multiple observations confirmed the call light remained inaccessible, contrary to facility policy requiring call lights to be within reach.
A resident with multiple health issues experienced several significant changes in condition and received new treatments, but the facility did not notify the resident's representative of these changes as required by policy. Documentation showed that while the family was informed of initial dehydration treatment, they were not notified of subsequent health declines or new interventions, and staff interviews confirmed gaps in communication.
Two residents did not have accurate MDS assessments: one with serious mental illness was not identified as PASARR Level II on the MDS, and another receiving hospice care was not marked as such in the assessment. The Clinical Reimbursement Director confirmed these errors and noted the facility follows the RAI manual for MDS coding.
A resident with significant mobility deficits and incontinence developed a Stage 3 pressure ulcer after staff failed to consistently implement required interventions such as regular turning, repositioning, and floating of the heels, despite care plans and repeated recommendations. Observations confirmed the resident's heels were not floated, and staff interviews indicated the resident did not refuse care.
A resident with left-sided hemiplegia and limited ROM did not receive a prescribed hand splint or range of motion exercises as outlined in the care plan. Despite the resident's request and documented need, the splint order was not processed, and staff did not perform ROM interventions. The facility lacked restorative aides and did not implement a restorative program for the resident, resulting in a failure to provide necessary services to prevent further decline.
A resident with a stage 3 pressure ulcer did not receive proper infection control during a dressing change, as staff failed to change gloves, perform hand hygiene, or use gowns as required by facility policy. Enhanced barrier precautions were not implemented or documented in the care plan or physician orders, despite the resident's condition necessitating these measures.
Residents were not adequately informed about state and local advocacy organizations or how to file complaints. Advocacy information was posted in a location that was not easily identifiable or accessible, especially for wheelchair users, and was not discussed during resident council meetings. The facility lacked a specific policy for posting this information.
A facility failed to accurately account for controlled substances for a resident with end-stage renal disease and pain. Although 60 hydrocodone-acetaminophen tablets were delivered and signed for by an LPN, only 30 were documented in the facility's records. The Controlled Substance Acceptance Log was not filled out, and the facility could not locate the missing tablets.
A facility failed to inform a resident's representative of the baseline care plan within the required timeframe. The resident, admitted with Alzheimer's, anxiety, and insomnia, had an interim care plan started on admission day. However, there was no documentation of a care plan meeting with the family within 72 hours, as required by facility policy.
A facility failed to complete a discharge summary for a resident with multiple diagnoses, including COPD and bipolar II disorder, who required supervision for self-care. The resident planned to return to Missouri without home health services. The discharge note indicated no cognitive impairment, and medications were called into a local pharmacy. However, the discharge summary, including a recapitulation of the stay and a post-discharge care plan, was not completed due to a system transition.
A resident with a history of respiratory issues did not receive proper respiratory care as the facility failed to change the oxygen tubing weekly, as required by the care plan and physician's orders. Observations showed outdated nasal cannula and portable oxygen tubing, which were confirmed by the DON.
A vial of Tubersol in a medication room was found without an opened date, contrary to facility policy requiring such labeling. The DON confirmed the oversight, and the facility's policy indicated Tubersol should be used within 30 days once opened and refrigerated.
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
Failure to Reconcile Narcotic Medication Upon Delivery
Penalty
Summary
The facility failed to ensure that narcotic pain medication was properly reconciled upon delivery from the pharmacy for a resident diagnosed with dementia, pain disorder, and hypertension. On 9/21/25, an LPN signed for the delivery of 30 oxycodone-acetaminophen 7.5-325 mg tablets but did not follow the facility's procedure for reconciling the controlled medications with the delivery slip before signing. The LPN placed the medications in the locked drawer on the medication cart but did not immediately record them on the narcotic disposition record as required by facility policy. The medication for the resident was never located after delivery. The resident's clinical record indicated a physician's order for oxycodone-acetaminophen as needed for pain, which was active at the time of the incident. The LPN later provided a written statement acknowledging that she did not thoroughly review the medications listed on the delivery document and could not recall any medication delivered for the resident. The facility's policy required immediate recording of controlled medications on the appropriate drug disposition record by the nurse accepting the delivery, which was not followed in this instance.
Failure to Serve Palatable and Appealing Food
Penalty
Summary
The facility failed to ensure that food was served with a palatable texture and appearance, as evidenced by multiple residents reporting that bread became soggy when served with wet items such as corn. During a resident council meeting, several residents stated that this issue was ongoing and had been reported to staff multiple times without resolution. Direct observation of a test tray revealed that the corn was placed beneath the hamburger bun and some onion rings, resulting in the bottom of the bun and the onion rings becoming soggy. The Administrator acknowledged the issue during an interview, and another resident confirmed that the sogginess was due to the corn liquid. The Dietary Manager was unaware of these concerns prior to the survey.
Failure to Address Resident Grievances Regarding Meal Presentation
Penalty
Summary
The facility failed to promptly respond to grievances raised by residents during resident council meetings regarding the issue of soggy bread and food items when wet foods were served on the same plate. Five residents reported that when meals included wet items such as corn, their bread would become soggy and unappetizing, and they had communicated this concern to staff multiple times without resolution. Review of resident council meeting minutes over several months showed repeated requests for separate dishware or bowls for liquid foods, but the issue persisted. Direct observation of a meal confirmed that wet food was served on a flat plate, resulting in a soggy hamburger bun and onion rings. The Dietary Manager was interviewed and stated he was not aware of the residents' concerns about soggy food.
Failure to Provide Ongoing Resident-Centered Activities Program on Dementia Unit
Penalty
Summary
The facility failed to implement an ongoing, resident-centered activities program for all 13 residents residing on the secure dementia unit. Over multiple days and time periods, residents were observed walking in hallways or sitting in dining and common areas without any structured activities taking place. There was no activities schedule posted or available on the unit, and confidential interviews confirmed that no activities calendar or schedule had been posted for several months. Residents had not participated in scheduled activities for several months, and activities were only provided inconsistently and on an unscheduled basis, either by an activities assistant or by nursing staff when they were not engaged in direct care. The Executive Director acknowledged the lack of regularly scheduled activities on the secure dementia unit. A review of the facility's Admission Statement indicated that an activities program, including a planned schedule for recreational, motivational, social, and other activities, was to be provided under the daily basic rate for all residents. Despite this, the facility did not ensure that such a program was in place or consistently implemented for residents on the secure dementia unit.
Insufficient Nursing Staff on Secured Dementia Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff on the secured dementia unit for all 13 residents residing there. Observations showed that at various times, only one nurse and one or two CNAs or QMAs were present on the unit, with staff often occupied in different areas, leaving residents unattended. Several residents required extensive or total assistance for transfers and toileting, and many were at risk of falling. During periods when staff were assisting one resident or were off the unit, other residents were left without supervision, increasing their risk of falls and unmet care needs. Staff interviews confirmed that staffing was reduced from three to two staff members during the late afternoon and overnight shifts, coinciding with times when residents were more likely to experience increased confusion and agitation due to sundowner's syndrome. A review of the staffing schedule and clinical records indicated that the unit was consistently staffed with three nursing staff from 7:00 a.m. to 3:00 p.m., but only two staff from 3:00 p.m. to 7:00 a.m., despite the high level of assistance required by residents. Between 5/1/24 and 5/7/25, there were 53 falls among the 13 residents, with 39 of those falls occurring during the lower-staffed hours. The facility's own assessment tool stated that resident care needs and negative outcomes should be considered in staffing decisions, but the observed staffing levels did not meet the needs of the residents on the secured dementia unit.
Failure to Obtain Informed Consent Prior to Initiating Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that informed consent was obtained prior to initiating an antipsychotic medication for a resident diagnosed with myotonic muscular dystrophy, psychosis, and senile degeneration of the brain. The resident experienced hallucinations and was subsequently prescribed Olanzapine 2.5 mg daily by her primary care doctor and psychologist. Although the clinical record indicated that the family was aware of the situation, there was no documentation that informed consent was provided to the resident or her representative regarding the treatment options, risks, and benefits of the psychotropic medication. Additionally, the facility did not have a policy in place for initiating psychotropic medications or for obtaining informed consent, as confirmed by the DON during interviews.
Resident Not Included in Care Plan Development
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following a cerebral infarction, dysphagia, and moderately impaired cognition was not involved in the development or implementation of their person-centered care plan. The resident reported that neither he nor his family had been included in care conferences, and he could not recall ever being involved in the care planning process. Review of the clinical record confirmed that the last documented care conference occurred nearly a year prior, despite the resident's need for assistance with personal care and ongoing medical conditions. Further review of the resident's record showed that the most recent care conference was not conducted in accordance with the facility's policy, which requires regular care plan conferences and documentation of resident or representative participation. The DON confirmed the absence of recent care conference documentation and acknowledged that such conferences should occur quarterly. The facility's policy also states that if resident participation is not practicable, an explanation must be documented, which was not present in this case.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs for one resident, as evidenced by the lack of access to a call light. During a resident council meeting, a resident reported not having access to her call light after staff had deep-cleaned her room, stating that the call light had been inaccessible for 24 hours and was currently under a stack of plastic totes. Direct observation confirmed that the call light was on the floor, under a plastic storage container, and not within the resident's reach. The resident had diagnoses including unsteadiness on feet, difficulty walking, need for assistance with personal care, and glaucoma, and was assessed as having moderately impaired cognition. Despite these needs, the call light remained inaccessible during multiple observations, and the resident confirmed she could not reach it. Facility policy requires that call lights be within reach and accessible to residents, but this was not followed in this instance.
Failure to Notify Resident Representative of Significant Change in Condition and Treatment
Penalty
Summary
The facility failed to notify the resident's representative of significant changes in the resident's condition and treatments. The resident, who had diagnoses including dementia, muscle weakness, and stage 3 chronic kidney disease, experienced several notable changes in health status, such as fatigue, altered mental status, dark urine, congestion, fever, productive cough, lethargy, and abnormal vital signs. Although the family was notified when sodium chloride was ordered for dehydration, subsequent changes and new treatments, including the administration of D5W/NaCl and further sodium chloride infusions, were not communicated to the family as required by facility policy. Progress notes for these events did not indicate that the family had been informed. The deficiency was further highlighted by staff interviews and policy review. An LPN was unaware of the resident's death, and the DON confirmed the facility's policy required family notification for significant changes in condition or treatment. The lack of documentation and communication regarding the resident's deteriorating condition and new interventions directly led to the deficiency identified during the review.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents. For one resident with diagnoses including bipolar disorder, dementia, and mood disorder, the clinical record showed a PASARR Level II determination for serious mental illness. However, the annual MDS assessment did not indicate the resident as PASARR Level II, as section A1500 was incorrectly marked 'no.' The Clinical Reimbursement Director confirmed this was an error and acknowledged the absence of a specific MDS assessment coding policy, relying instead on the Resident Assessment Instrument (RAI) manual. For another resident with diagnoses including heart disease, chronic respiratory failure with hypoxia, and dementia, the clinical record indicated the resident was receiving hospice services. Despite this, the quarterly MDS assessment did not reflect hospice care in section O0110. The Clinical Reimbursement Director confirmed that hospice services were being provided during the assessment period and that the MDS should have been marked accordingly. Both deficiencies were identified through record review and staff interview, with reference to the RAI manual for correct coding procedures.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, diabetes mellitus, muscle weakness, and incontinence developed a Stage 3 pressure ulcer. The resident was assessed as being at moderate risk for pressure ulcers and was dependent on staff for mobility and repositioning. Despite care plans and wound management recommendations specifying the need for regular turning, repositioning, and floating of the heels to prevent further skin breakdown, these interventions were not consistently implemented. Multiple observations over several days showed the resident lying in bed on her back with her heels resting directly on the bed surface, rather than being floated on pillows as required. There was no documentation in the clinical record indicating that the resident refused these interventions. Staff interviews confirmed that the resident did not refuse care and was dependent on staff for activities of daily living, including repositioning and heel offloading. The facility's own policy required redistributing pressure, including offloading heels, as part of basic pressure injury prevention. However, the care plan lacked documentation of specific interventions such as turning, repositioning, or floating heels after the development of the pressure ulcer. Despite repeated discussions of preventive measures with staff, the necessary interventions were not observed to be in place, leading to the deficiency.
Failure to Provide Range of Motion Services and Splint for Resident with Limited Mobility
Penalty
Summary
A resident with a history of hemiplegia and hemiparesis following a cerebral infarction, resulting in limited range of motion on the left side, did not receive appropriate services to prevent further decline in mobility. The resident expressed that his left hand could not open and requested to try a splint to improve function. Observations over several days confirmed that the resident did not have a splint in place and reported that staff were not performing range of motion exercises with him. The care plan indicated the resident was to wear a left hand brace daily, and an occupational therapy discharge summary documented that a splint had been ordered, with plans for OT to assess fit and provide education once delivered. Interviews with facility staff revealed that the order for the splint may not have been placed, and there was confusion regarding its status. The Business Office Manager was unsure if the order had been submitted, and the Executive Director later confirmed the order had not gone through. Additionally, the facility did not have restorative aides at the time, and the resident was not on a restorative program, which would typically be implemented after therapy discharge. The facility's policy required staff to assist residents with range of motion exercises and use of assistive devices, but these interventions were not provided to the resident as outlined.
Failure to Implement Infection Control Practices During Wound Care
Penalty
Summary
During a pressure ulcer dressing change for one resident, infection control practices were not followed by facility staff. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) failed to change gloves and perform hand hygiene at appropriate times. Specifically, the CNA did not wash hands or use hand sanitizer before donning new gloves after providing incontinent care, and the ADON did not change gloves after removing a soiled dressing before applying a new one. Additionally, both staff members were not observed wearing gowns during the dressing change, and treatment supplies were placed on the resident's bed and later returned to the treatment cart without proper infection control measures. The resident involved had a stage 3 pressure ulcer of the sacral region, along with other diagnoses including dementia, diabetes mellitus, and muscle weakness. The resident's care plan identified the risk for complications from the pressure ulcer but did not include interventions for enhanced barrier precautions. Physician orders also lacked documentation for enhanced barrier precautions, despite facility policy requiring gloves and gowns during high-contact care activities for residents with wounds. Staff interviews confirmed that enhanced barrier precautions should have been implemented during the dressing change.
Failure to Inform Residents of Advocacy and Complaint Procedures
Penalty
Summary
The facility failed to ensure that residents were adequately informed about the state and local advocacy organizations and how to file complaints. During a resident council meeting, residents reported not knowing where the State Survey Agency (SSA) or State Long-Term Care Ombudsman information was posted, nor how to file a complaint. Observation revealed that the advocacy information was posted by the front entrance, but it was among other papers, not easily identifiable, and not within the line of sight for residents using wheelchairs. Review of resident council meeting minutes showed that the SSA or ombudsman information was not discussed during meetings. An interview with the Clinical Nurse Consultant confirmed that while residents received a copy of the information at admission and staff were expected to review it during meetings, there was no specific facility policy regarding the posting of local advocacy agencies.
Failure to Accurately Account for Controlled Substances
Penalty
Summary
The facility failed to ensure accurate acquiring and accounting of controlled substances for Resident E, who was diagnosed with end-stage renal disease and pain. The physician orders indicated that Resident E was prescribed hydrocodone-acetaminophen, a Schedule II controlled substance, to be taken as needed for pain. On a specific date, 60 tablets of this medication were delivered to the facility, as confirmed by the pharmacy's packing slip, and were signed for by an LPN. However, the Controlled Substance Acceptance Log, which should have documented the receipt of these medications, was left blank. Further investigation revealed that only 30 tablets were accounted for in the facility's records, despite the packing slip indicating that 60 tablets were delivered. The facility's Controlled Drug Record also showed only 30 tablets, suggesting that one card of 30 tablets was missing. Interviews with the Administrator confirmed that the nurse responsible for accepting the delivery failed to complete the necessary documentation, and the facility was unable to locate the missing card of narcotics.
Failure to Inform Resident's Representative of Baseline Care Plan
Penalty
Summary
The facility failed to ensure that the representative of a resident, who was admitted with diagnoses including Alzheimer's disease, anxiety, and insomnia, was informed of the baseline care plan. The resident was admitted on 6/6/24, and an interim 48-hour baseline care plan was initiated on the same day. However, the clinical record did not contain documentation that the resident's representative was informed of this care plan. Interviews with the Social Service Designee (SSD) revealed that the facility's practice was to conduct a care plan meeting with the family within 72 hours of admission, but there was no documentation of such a meeting in the clinical record. The facility's policy, revised in 4/2017, also required a care conference with the resident or representative within 72 hours of admission, which was not documented in this case.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure the completion of a discharge summary for a resident, identified as Resident 58, who was reviewed for discharge. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, bipolar II disorder, and cognitive communication deficit, among others. The discharge Minimum Data Set (MDS) assessment indicated the resident required supervision for self-care and ambulation. On the day of discharge, the resident informed the social worker of her plan to leave the facility and return to Missouri without home health care or services. The resident's discharge note indicated she was a DNR and had no cognitive impairment or behavioral issues. Her medications were called into a local pharmacy, and she left the facility with her family and belongings. However, the facility did not complete a discharge summary that included a recapitulation of the resident's stay, a final summary of her status, and a post-discharge plan of care developed with her participation. The Social Services Director (SSD) acknowledged the absence of the discharge summary in the resident's clinical record, attributing it to a transition between systems at the time of discharge. The facility's policy on discharge planning did not specify the need for documentation of a discharge summary or recapitulation of the resident's stay, which contributed to the oversight.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 18, by not changing the oxygen tubing as required. Observations on multiple occasions revealed that the nasal cannula used for oxygen administration was dated 6/8/24, and the portable oxygen tubing was dated 4/28, indicating that the tubing had not been changed weekly as per the care plan and physician's orders. The care plan specifically required the tubing to be changed, dated, and labeled weekly, but this was not adhered to. Resident 18 had a medical history that included altered respiratory status, sleep apnea, muscular dystrophy, pneumonia, and a history of pulmonary embolism. The resident was observed both with and without oxygen, despite having orders to maintain oxygen saturations above 90% with 2 liters of oxygen via nasal cannula. The Director of Nursing confirmed that the tubing was outdated and acknowledged that it should have been changed weekly on Saturdays, as per the facility's policy and physician's orders.
Failure to Label Opened Vial of Tubersol
Penalty
Summary
The facility failed to label a vial of Tubersol with the opened date in one of the two medication rooms observed. During an observation on July 12, 2024, at 9:20 a.m., a vial of Tubersol was found in the refrigerator of the medication room without an opened date on either the vial or its box. The Director of Nursing (DON) confirmed the absence of an opened date and acknowledged that all opened vials should have this information. The facility's policy, titled 'Determining Expiration Dates,' was reviewed and indicated that Tubersol should be used within 30 days once opened and refrigerated. However, the policy itself was undated.
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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.
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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