Waters Of Castleton Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 8400 Clearvista Pl, Indianapolis, Indiana 46256
- CMS Provider Number
- 155271
- Inspections on file
- 38
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Waters Of Castleton Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A staffing shortage on one unit led to widespread missed medication doses when a nurse called off and the remaining LPN informed the DON she could not complete all medication passes for residents assigned to a medication cart. As a result, multiple residents with complex conditions such as HF, AFib, HTN, DM, COPD, psychiatric disorders, paraplegia, quadriplegia, and developmental disorders did not receive ordered day-shift medications, including antihypertensives, anticoagulants, antidiabetics, psychotropics, pain medications, respiratory agents, GI medications, and supplements. MAR review confirmed that these scheduled medications were not administered, and the facility could not provide a policy on sufficient nurse staffing.
Surveyors found that staff failed to consistently complete controlled substance shift-change count sheets for one medication cart. Over multiple days and shifts, required fields such as the total number of controlled medication packets in the cart and the signatures of off-going and on-coming nurses were frequently left blank. The ADON confirmed that facility practice and written policy require two nurses to count controlled meds at each shift change or key exchange, document any packets added or removed, record the total items, and both sign the count sheet, but this was not done as required for the affected cart.
The facility failed to prevent physical abuse when a resident with severe cognitive impairment and a documented history of verbal and physical aggression repeatedly punched another severely cognitively impaired resident in the head while seated in a common area, causing a raised knot on the forehead and requiring hospital evaluation. The aggressive resident had diagnoses including anxiety disorder, schizophrenia, and antisocial personality disorder, and the care plan called for line-of-sight supervision and avoiding the resident’s personal space when agitated. Despite an abuse prevention policy intended to prevent physical abuse, the assault occurred in a shared area and resulted in injury.
A resident with multiple medical conditions, including heart failure and morbid obesity, had an order for PRN oxycodone/acetaminophen 10-325 mg, with 30 tablets documented on the controlled drug record. Facility records showed that one tablet was removed on one day and two more the next, leaving 18 tablets, even though the resident had already been transferred to the hospital and had not returned. A QMA discovered the discrepancy during narcotic count reconciliation, and the DON confirmed that three tablets had been signed out while the resident was absent and that the facility could not identify the staff member whose initials appeared on the controlled drug record, resulting in misappropriation of the resident’s controlled medication.
Two residents who were cognitively intact and managing their own medications were observed with medication cups at their bedside, containing multiple pills left without staff present, including additional medications placed by an LPN and then left for self-administration. Record review showed multiple scheduled and PRN medications ordered for these residents, but no documented IDT self-administration assessments or physician orders authorizing self-administration, despite a facility policy requiring IDT approval, physician orders, and care plan updates for residents who self-administer medications.
A resident with dementia and depression, who had severely impaired cognition but could make himself understood, reported that another resident had been mean to him, was bothering him, and had hit him on the head in the dining room, causing him to try to avoid that resident. An incident report documented that one resident struck another on the head with an open hand, with no injuries noted, and an LPN separated the residents after being informed of the event by another resident witness; the aggressor did not deny the action, stating the other resident would not be quiet. Observation later showed the aggressor seated behind the abused resident in the dining room, despite an abuse prevention policy that defines physical abuse as willful infliction of injury, including hitting and slapping.
The facility failed to complete and maintain required written statements during an abuse investigation after a resident with Down Syndrome witnessed a verbal argument between a QMA and a CNA. The investigation file contained an incident report and a written statement from the QMA, but no written statement from the CNA, despite the CNA reporting that she had submitted one. The ED stated the CNA’s input was obtained verbally and over the phone and was not documented as a written, signed, and dated statement as required by the facility’s Abuse Prevention Program policy and state regulation.
A resident with paraplegia and neurogenic bladder, who was cognitively intact and on an intermittent self-catheterization regimen, did not consistently receive an adequate supply of single-use 16F straight catheters to follow the ordered every 4–6 hour catheterization schedule. The resident reported repeated delays in obtaining catheters, having only four for an entire day, not emptying his bladder since the prior night, and sometimes reusing catheters when staff either could not locate or reported no supplies. A provider note documented the resident’s concern about running out of catheters and the importance of sterile, single-use technique, while a QMA admitted she was unaware of the increased catheterization frequency and believed it was every 8 hours. Observation showed additional catheters available in the supply room, but only a few at the bedside, and leadership confirmed there was no policy addressing supply availability for self-catheterization.
The facility failed to document and monitor behavioral symptoms as ordered and care planned for two residents with identified behavioral health needs. One resident with dementia and bipolar disorder had a physician’s order and care plan requiring shift‑by‑shift monitoring of specific behaviors, yet no behaviors were recorded on the MAR during the month in which the resident struck another resident, and no behavior note was entered in the clinical record for that incident. Another cognitively intact resident with a personality disorder had an order to monitor and track multiple behaviors and implement specific interventions, but when the resident became curt and then screamed and yelled at an LPN about medication, no behavior was documented on the MAR/TAR and no interventions were recorded in the clinical record. These failures occurred despite facility policy requiring nursing to monitor and document target behaviors daily and to use MAR documentation to trigger progress notes.
A resident with multiple behavioral health diagnoses did not receive a scheduled antipsychotic injection despite the medication being available, and the provider was not notified of the missed dose. Nursing staff inconsistently documented and implemented interventions for frequent medication refusals, and the resident's care plan did not include all effective strategies known to staff, resulting in a deficiency related to behavioral health services.
A resident with cognitive impairment and a history of falls was found transferring from a wheelchair to bed without anti-roll backs in place and while wearing non-nonskid socks. The resident was confused about a wheelchair switch and refused staff assistance. Required fall interventions were not timely implemented or maintained after a fall event.
Two residents did not receive multiple scheduled doses of prescribed medications, including IV antibiotics and controlled substances, due to unavailability and lapses in medication administration records. Documentation showed repeated instances where medications were not on hand or not signed off as administered, despite facility policy requiring prompt action when medications are unavailable.
Two residents experienced significant delays in staff response to call lights, with one resident typically waiting at least 30 minutes and another waiting up to 30 minutes despite requiring substantial toileting assistance. Additionally, a resident and her family reported repeated, unwanted offers of incontinence briefs, which they found humiliating. These actions did not align with facility policies on prompt assistance and resident dignity.
The facility did not ensure timely notification to the physician and family for two residents who experienced significant changes in condition: one with a substantial weight loss while on enteral feedings, and another who developed a new open neck wound related to a trach collar. Documentation did not show that notifications were made promptly as required by policy.
A resident with multiple medical conditions and moderate cognitive impairment did not have a comprehensive care plan addressing their bathing and hygiene needs. Staff interviews confirmed that a care plan for ADLs was overlooked, and a family member reported the resident received very few showers.
A resident with significant medical and cognitive needs did not receive scheduled bathing and hygiene care, as records showed infrequent showers and incomplete documentation of care provided. The resident's care plan for ADLs was not developed as required, and a grievance about the shower schedule was not properly resolved in the documentation.
A resident dependent on continuous enteral feeding experienced an interruption in nutrition when the feeding solution became inaccessible to staff overnight. This resident also suffered a significant weight loss of over 10% in less than a month, which was not promptly identified or addressed by the interdisciplinary team, nor was the physician or family notified as required by facility policy. Documentation failed to reflect the feeding interruption or timely interventions related to the weight loss.
A resident with a tracheostomy developed a new laceration on the neck, but staff failed to document when the wound was first identified, what initial care was provided, and notifications to the physician, family, or administration. The family only became aware of the wound during a radiology appointment, and the nurse who first found the wound did not document the event, resulting in incomplete records.
The facility failed to maintain safe food temperatures during meal service, affecting nearly all residents. Observations revealed that mixed vegetables, fish filets, and French fries were held at temperatures below the required minimum of 135 degrees Fahrenheit, contrary to the facility's food safety guidelines.
The facility did not ensure RN coverage for at least eight consecutive hours a day, seven days a week, affecting all residents. The absence of RN coverage on specific dates was confirmed by the Staffing Coordinator and DON, with no agency staff used since early April. The facility also lacked a policy on RN coverage.
The facility failed to administer medications and collect urine samples as ordered, affecting multiple residents. A resident with a leg fracture did not have a timely orthopedic follow-up, while another relying on a gastric tube had inadequate weight monitoring. Additionally, a resident's urine sample was not collected, and another did not receive prescribed medications for diabetes and hypertension. These issues indicate non-compliance with physician orders and care plans.
The facility failed to document COVID-19 vaccination education and status for five residents, lacking records of whether they were informed about the 2023-2024 vaccine's benefits and risks, received the vaccine, or refused it. An interview with the Nurse Consultant confirmed the absence of verification for offering or administering the vaccine, despite the facility's policy emphasizing the importance of staying up to date with vaccinations.
A facility failed to maintain a resident's dignity during meal assistance. A resident with dementia and cognitive impairment required help with eating, as per her care plan. During an observation, a CNA was seen standing while assisting the resident with her meal, contrary to the facility's policy that emphasizes treating residents with respect and dignity. The Nurse Consultant confirmed that the CNA should have been sitting to align with the policy.
A resident, who was cognitively intact and had a history of stroke, was dissatisfied with a new rule requiring him to transport his teapot and tea bags from his room to the dining room for each meal. This change forced him to use a wheelchair instead of crutches, and he was not given a reason for the restriction. The Activities Director confirmed the resident's dissatisfaction, but a grievance form was not completed, and the facility's grievance policy was not followed.
The facility failed to submit accurate RN staffing data to CMS, as the PBJ report showed no RN coverage on several dates despite evidence of RN 9 working those days. The system may not have been updated to reflect RN 9's title change after obtaining her license. The facility lacked a policy for PBJ data submission.
The facility inaccurately coded MDS assessments for four residents, indicating bed rails were used as restraints when they were actually used for bed mobility. Interviews with the MDS Coordinator confirmed the coding errors, which were contrary to the facility's policy using the RAI Manual.
A facility failed to accurately complete an MDS assessment for a resident, missing two falls that occurred during the look-back period. The regular MDS staff was on medical leave, and the facility did not have a specific policy for MDS assessments, relying instead on the RAI manual.
Medication Administration Failures Due to Insufficient Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff to administer ordered medications to multiple residents assigned to the second-floor west hall medication cart. On a specific day, a nurse called off work, and the remaining nurse on that unit reported to the DON that she could not administer medications to all residents on the unit. The DON confirmed that, as a result, medications were not administered to all residents who were to receive medications from that cart. One resident reported that he did not have a nurse on the day shift that day and did not receive his day shift medications. Record review showed that 15 residents did not receive some or all of their ordered medications during the day shift on that date. These residents had multiple diagnoses, including hypertension, heart failure, atrial fibrillation, diabetes, depression, bipolar disorder, anxiety disorders, neuropathy, COPD, liver cancer, delusional disorder, personality disorders, paraplegia, quadriplegia, autistic disorder, Down syndrome, and others. Their ordered medications included antihypertensives (such as amlodipine, lisinopril, metoprolol, spironolactone), anticoagulants/antiplatelets (such as apixaban, Eliquis, aspirin, clopidogrel), antidiabetic agents (such as metformin, empagliflozin, Amaryl), psychotropic and mood-stabilizing medications (such as nortriptyline, escitalopram, fluoxetine, sertraline, bupropion, divalproex, olanzapine, deutetrabenazine, oxcarbazepine), pain medications (such as acetaminophen, naproxen, oxycodone, gabapentin), respiratory and allergy medications (such as montelukast, tiotropium, benzonatate, loratadine), and various supplements and GI medications (such as pantoprazole, omeprazole, folic acid, multivitamins, cholecalciferol, cyanocobalamin, ferrous sulfate, polyethylene glycol, sennosides, and probiotics). The MARs for each of the 15 residents documented that the ordered medications for the day shift on that date were not administered. For example, one resident with phantom limb syndrome, obesity, and depression did not receive multiple antihypertensives, pain medications, antidepressants, antianxiety medication, and neuropathic pain medication. Another resident with bipolar disorder, anxiety disorder, and asthma did not receive antihypertensives, antidepressants, antiepileptics, antidiabetic agents, supplements, and a pain patch. Similar omissions were documented for residents with heart failure and atrial fibrillation who did not receive ordered anticoagulants, beta-blockers, diuretics, and other daily medications. Additional residents with conditions such as neuropathy, COPD, dementia, liver cancer, ataxia, delusional disorder, paraplegia, quadriplegia, autistic disorder, Down syndrome, and urinary retention did not receive their scheduled medications as ordered. By the end of the survey, the facility was unable to provide a policy regarding sufficient nurse staffing.
Failure to Maintain Complete Controlled Substance Shift-Change Counts
Penalty
Summary
Surveyors identified a deficiency in the facility’s procedures for accurately accounting for controlled substances on one of three medication carts reviewed, specifically the second-floor west hall cart. Review of the change-of-shift controlled medication count sheet for this cart, covering 4/1/26 through 4/21/26, showed multiple instances where required documentation was incomplete or missing. On numerous dates and shifts, the "total items in cart" box was left blank, and on several occasions the off-going and/or on-coming nurse signature boxes were not signed. Examples included missing total item counts on multiple shifts across 4/1, 4/2, 4/3, 4/7, 4/8, 4/9, 4/10, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, and 4/21, as well as missing off-going or on-coming nurse signatures on several of those dates. During interview, the ADON stated that the controlled medication count sheet should be fully completed at every shift change, with the off-going nurse signing, documenting any packets added or removed, and recording the total items in the cart, followed by the on-coming nurse signing after reconciliation. The facility’s written policy on controlled substances, dated 7/2024, requires that two nurses count all controlled substances each shift or whenever keys are exchanged, inspect the medication packets, count the number of packets in the cart, document this on the shift change controlled substance count sheet, and each sign the appropriate boxes to acknowledge that the actual count and the count sheet match. The observed omissions on the west hall second-floor medication cart count sheets showed that these procedures and policy requirements were not consistently followed.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Area
Penalty
Summary
The facility failed to protect residents from physical abuse when one resident repeatedly punched another resident in the head while both were in a common area. On the date of the incident, an RN reported hearing someone yell and, upon looking over, saw Resident C standing over Resident B and punching Resident B in the head with a closed fist multiple times while Resident B was seated. A progress note documented that Resident B sustained a raised knot on the forehead and was sent to the hospital for further evaluation after being punched on the forehead, face, and back of the head. Police were called and Resident C was taken for psychiatric services. Resident B’s clinical record showed diagnoses including Down syndrome, pseudobulbar affect, and muscle weakness, with an annual MDS indicating severe cognitive impairment. Resident C’s record included diagnoses of anxiety disorder, schizophrenia, and antisocial personality disorder, with a quarterly MDS also indicating severe cognitive impairment. Resident C’s care plan, in place prior to the incident, documented a history of conflicts and altercations with other residents, including verbal and physical aggression, and included interventions such as keeping Resident C in line of sight and avoiding entering his personal space when agitated. Despite the facility’s Abuse Prevention Policy stating that it was the policy of the facility to prevent physical abuse, the incident occurred in the common area, resulting in physical harm to Resident B.
Misappropriation of Controlled Pain Medication While Resident Hospitalized
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when three tablets of a controlled narcotic pain medication were removed from the medication cart and signed out while the resident was hospitalized and not present in the facility. The resident, who had diagnoses including heart failure, morbid obesity, and adjustment disorder, had a physician’s order for oxycodone/acetaminophen 10-325 mg to be given orally every six hours as needed for pain. A controlled drug record dated late February documented 30 tablets of this medication. Documentation on the controlled drug record showed that one tablet was removed on one date and two tablets were removed on the following date, leaving 18 tablets in the cart, even though the resident had been transferred to the hospital prior to those administrations and had not yet been readmitted. During interviews, the DON reported being made aware that three tablets of the resident’s oxycodone/acetaminophen were missing from the cart and that a staff member had initialed the removals on the controlled drug record, but the facility was unable to identify to whom the initials belonged. A QMA stated that when reconciling narcotic counts, a discrepancy was noted because three tablets had been signed out when the resident was not in the facility, and confirmed that when they last worked there had been 18 tablets remaining. The facility’s Abuse Prevention Policy, provided by the Administrator, indicated it was the facility’s policy to prevent misappropriation of property, but the documented removal and signing out of the resident’s controlled medication while the resident was in the hospital constituted a failure to protect the resident’s belongings from wrongful use.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to have the interdisciplinary team (IDT) timely determine and document that self-administration of medications was clinically appropriate for two cognitively intact residents who were self-administering medications. For one resident with a diagnosis including personality disorder, record review showed multiple current physician orders for daily and scheduled medications such as aspirin, docusate sodium, acetaminophen, vitamin B-12, gabapentin, Prempro, hydroxyzine, and lisinopril. During observation, this resident was in bed with a bedside table holding a cup containing multiple morning medications, with no staff present. The resident stated she was able to take her own medications and would take them later due to heartburn. An LPN then entered to administer lisinopril, placed a second medication cup with the pill on the bedside table next to the first cup, and left the room, leaving the resident in possession of both cups. The clinical record for this resident lacked a current self-administration assessment and a physician’s order authorizing self-administration. For the second resident, who had a diagnosis including schizophrenia and was assessed as cognitively intact on admission, physician orders included Tums every six hours as needed and Buspar three times a day. Observation found this resident sitting on her bed with a bedside table holding a medication cup containing one greenish pill and one pinkish pill, which the resident identified as Tums. The clinical record for this resident also lacked a documented self-administration assessment and a physician’s order to self-administer medications. In an interview, the Nurse Consultant confirmed she was unable to locate current self-administration assessments for either resident. The facility’s self-medication assessment policy required that self-administration be ordered by the attending physician and approved by the IDT, with assessments offered during routine IDT assessments and care plans updated at least quarterly or with changes, but these steps were not documented for the two residents involved.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident struck another on the head with an open hand. The abused resident, identified as having dementia, depression, and severely impaired cognition per a recent MDS, was otherwise able to make himself understood, understood others, and had no behaviors noted during the assessment period. His care plan addressed impaired cognitive function with goals for maintaining orientation. A follow-up progress note documented that he had a resident-to-resident encounter over a weekend and that, although he reported not being bothered, staff observed he appeared anxious afterward. In an interview, he stated that another resident had been mean to him, was “messing with him,” had hit him, and sat behind him in the dining room, leading him to try to stay away from that resident. The facility’s investigation file documented an incident report stating that one resident made contact with the other resident’s head using an open hand, with no injuries noted. An LPN reported she separated the two residents after being informed of the incident by another resident witness, and that the alleged aggressor did not deny hitting the other resident, stating the other resident would not be quiet. Observation of the dining room showed the alleged aggressor sitting at a table behind the abused resident. The facility’s Abuse Prevention Program policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and specifically included hitting and slapping as physical abuse. Despite this policy, the resident experienced physical contact to the head from another resident.
Incomplete Documentation of Abuse Investigation After Staff Verbal Altercation Witnessed by Resident
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a thorough abuse investigation after a resident with Down Syndrome witnessed a verbal altercation between two staff members. The incident report, dated 12/27/25, indicated that the resident observed a verbal disagreement between a QMA and a CNA at the nurses’ station. The facility’s Abuse Prevention Program policy required the charge nurse to complete an incident report and obtain written, signed, and dated statements from the person reporting the incident and from any witnesses, with completed copies provided to the Administrator or person in charge within 24 hours of the incident. Record review and interviews showed that the investigation file contained an incident report and a written statement from the QMA, but did not contain a written statement from the CNA involved in the argument. The ED stated there was no written statement from the CNA and that the CNA had been interviewed verbally with the weekend supervisor, but the interview was not documented. In contrast, the CNA reported that she had written a statement on the date of the incident and given it to the ED, and described the argument as starting over her refusal to serve regular-consistency food to residents on mechanically altered diets. The ED later indicated the CNA’s statement had been taken over the phone and maintained that no written statement had been provided, resulting in incomplete documentation of the abuse investigation in violation of facility policy and state regulation 410 IAC 16.3.1-28(d).
Failure to Ensure Adequate Intermittent Catheter Supply for Self-Catheterizing Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an adequate supply of urinary catheters was available for a resident who performed intermittent self-catheterization. The resident had diagnoses including paraplegia and neuromuscular dysfunction of the bladder, with a care plan noting risk for infection related to neurogenic bladder and the need for intermittent self-catheterization. A physician visit note documented that the resident reported running low on straight catheters, expressed concern about being forced to reuse catheters, and referenced a history of recurrent UTIs with sepsis. The physician emphasized the importance of sterile, single-use technique and ordered 16F straight catheters for intermittent catheterization. Despite this order and plan, the resident reported ongoing problems obtaining sufficient catheter supplies and interruptions in his catheterization schedule. He stated he was supposed to catheterize every 4–6 hours, understood the plan, and was motivated to adhere to it, but indicated that on the survey day he had been asking since the morning for catheters and had not emptied his bladder since the previous night. He reported that staff were only giving him four catheters for the day instead of at least five as he had been told by the medical provider, and that he sometimes had to reuse catheters at night when staff either did not know where supplies were or reported that supplies were gone. During an interview, he showed his bedside drawer, which contained only three new packaged catheters, which he indicated was all he would receive for the day. Staff interviews and observations further demonstrated gaps in ensuring adequate catheter availability. The nurse practitioner confirmed the resident should receive enough catheters to empty his bladder at least every 4–6 hours and as needed, depending on fluid intake. The QMA responsible for ordering catheters stated she had previously given the resident nearly a full box of 20 catheters over a weekend and believed he was to catheterize every 8 hours; she was unaware that the frequency had changed to every 4–6 hours because nursing staff had not updated her. At the time of observation, there was a box with nineteen 16F catheters for the resident in the supply room, and evening and night staff had access to that room, yet the resident still had only a limited number of catheters at bedside. The nurse consultant acknowledged that the facility did not have a policy for self-catheterization that addressed the availability of supplies.
Failure to Document and Monitor Behavioral Symptoms for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to document and monitor behavioral health symptoms as ordered and care planned for two residents with identified behavioral health needs. Resident D had diagnoses including dementia and bipolar disorder, with a physician’s order dated 4/24/25 directing staff to monitor each shift for specific behaviors such as delusions, hallucinations, tearfulness, crying, verbal expressions of sadness, anger, yelling, cursing, insomnia, anxiety, skin picking, and physical aggression. A quarterly MDS dated 1/9/26 showed moderately impaired cognition and no behaviors during the assessment period, while a care plan revised on 1/21/26 identified multiple behavioral symptoms and directed staff to evaluate behavioral symptoms and intervene when inappropriate behavior was observed. Despite this, the February 2026 MAR indicated no behaviors for the month, and the clinical record lacked a behavior note addressing a resident‑to‑resident bodily contact incident in which Resident D struck another resident. On 2/24/26, an incident report in the facility’s investigation file documented that Resident D made contact with another resident’s head using an open hand, with no injuries reported. The Social Services Director stated that Resident D was not normally aggressive and that when a resident exhibits new behaviors, the nurse should document the behavior in the clinical record using a behavior progress note so it can be reviewed in the morning meeting. The Interdisciplinary Team discussed the incident but did not identify a root cause, and there were no new care plans or interventions added to Resident D’s behavior care plan following the event. LPN 12, who separated the residents, reported that another resident had witnessed the incident, that Resident D did not deny hitting the other resident, and that Resident D stated the other resident would not be quiet, which LPN 12 assumed was the reason for the behavior. The facility also failed to document and track behaviors for Resident B, who had a diagnosis including a personality disorder and was cognitively intact per a quarterly MDS dated 12/16/25. A physician’s order dated 8/12/25 required staff to monitor and track a range of behaviors, including calling emergency services, false accusations/beliefs, anxiety, tearfulness, insomnia, refusal of care, verbal aggression, throwing objects, OCD behaviors, crying, verbal expressions of sadness, racial slurs, self‑isolation, anger, yelling, and cursing, and to implement interventions such as redirection, snacks, fluids, diversionary activities, toileting, change of environment, pain assessment, rest, and comfort. The March 2026 MAR/TAR indicated no behaviors as of 3/11/26; however, during an observation and subsequent interview, Resident B was curt, then later screamed and yelled at an LPN about medication, and the LPN was unsure why the resident was upset. Resident B’s clinical record lacked documentation of this behavior and lacked any documented interventions implemented at that time, despite facility policy stating that nursing monitors for target behaviors daily and documents them, and that nurses should document behaviors on the MAR to trigger a progress note.
Failure to Administer Antipsychotic Medication and Notify Provider for Resident with Behavioral Health Needs
Penalty
Summary
A resident with diagnoses including anxiety, paranoid schizophrenia, dementia, and depression was readmitted to the facility following a psychiatric hospitalization, with orders to receive Uzedy, an atypical antipsychotic, via subcutaneous injection every 30 days. The medication was not administered as ordered on the scheduled date, and the medication administration record (MAR) indicated it was not given, with a note stating it was unavailable. However, pharmacy records and direct observation confirmed that the medication was present in the facility at the time it was due. The Director of Nursing (DON) confirmed there was no documentation that the physician or nurse practitioner was notified of the missed dose, as required by facility policy. Interviews with nursing staff revealed inconsistent practices regarding medication administration and documentation. One LPN reported not seeing the medication in the cart and did not prepare it in advance, assuming the resident would refuse, and could not confirm if the nurse practitioner was notified of the missed dose. The nurse practitioner stated she was not informed about the missed injection and emphasized the importance of the medication for the resident's stabilization, especially given his refusal of oral medications. The MAR also showed frequent refusals of oral Depakote, with varying documentation of interventions used to encourage acceptance, such as education, encouragement, and attempts to offer medication with food, though not all interventions were consistently documented or reflected in the care plan. The resident's care plans addressing refusal of care and medication did not include all effective interventions known to staff, such as offering snacks or crushing medications with food, despite these being recognized strategies by staff and discussed in interviews. The facility's policies required individualized care planning and prompt notification of the physician when medications were refused or missed, but these procedures were not fully implemented. The lack of administration of the antipsychotic medication, failure to notify the provider, and incomplete care planning and documentation for medication refusals led to the identified deficiency.
Failure to Timely Implement and Maintain Fall Interventions
Penalty
Summary
A deficiency was identified when a resident with multiple psychiatric diagnoses, including borderline personality disorder, bipolar disorder, schizoaffective disorder, generalized anxiety disorder, and major depressive disorder, experienced a fall while attempting to transfer from a wheelchair to bed. The resident was assessed as moderately cognitively impaired and had a history of two or more falls since the last MDS assessment. The care plan included interventions such as anti-roll backs for the wheelchair and the use of nonskid footwear, but these interventions were not consistently implemented. On the day of observation, the resident was found sitting in a wheelchair without anti-roll backs, and was wearing fluffy socks instead of nonskid socks while transferring herself from the wheelchair to the bed. The resident expressed confusion and frustration about her wheelchair being switched out by staff for maintenance to apply anti-roll backs, and refused assistance from the ADON during the transfer. The lack of timely implementation of fall interventions and failure to ensure interventions were in place contributed to the deficiency.
Failure to Provide and Administer Ordered Medications
Penalty
Summary
The facility failed to ensure that prescribed medications, including narcotic and IV antibiotics, were administered as ordered and were readily available for use for two residents. One resident with diagnoses including osteomyelitis, pressure ulcer, paraplegia, and muscle spasm did not receive multiple scheduled doses of IV ceftolozane-tazobactam due to the medication being unavailable or on hold, as documented in progress notes and the electronic medication administration record (EMAR). Additionally, this resident did not receive several scheduled doses of pregabalin for neuropathy pain because the medication was not available, with progress notes indicating repeated notifications to the pharmacy and delayed receipt of the medication. Another resident with multiple psychiatric diagnoses, including borderline personality disorder, bipolar disorder, schizoaffective disorder, generalized anxiety disorder, and major depressive disorder, experienced lapses in the administration of clonazepam, as evidenced by missing controlled drug record forms for several periods and instances where administration was not signed off. The facility's policy required contacting the pharmacy or supervisor if a medication was ordered but not present, but this was not consistently followed, resulting in missed doses for both residents.
Delayed Call Light Response and Inappropriate Incontinence Care Offerings
Penalty
Summary
The facility failed to honor residents' rights to dignity and timely assistance, as evidenced by delayed responses to call lights and inappropriate offers of incontinence briefs. One resident, who was cognitively intact and had resided in the facility for over five years, reported that it typically took a minimum of 30 minutes for staff to respond to her call light, with delays occurring on all shifts, especially at night. Another resident's family member reported that the resident, who was non-ambulatory, cognitively intact, and required substantial assistance for toileting, experienced similar delays, with call lights going unanswered for 20 to 30 minutes. On one occasion, the family member had to seek staff assistance directly, and even after intervention, the resident continued to wait for help. Additionally, the same resident and her family reported that staff repeatedly offered her an incontinence brief despite their explicit refusals, which they found humiliating, particularly given the resident's young age. The facility's policies required prompt response to call lights and emphasized respect for resident dignity and preferences, including changing residents upon discovery of incontinence and allowing them to wear what they choose. However, these policies were not consistently followed, resulting in residents experiencing undignified care and delayed assistance.
Failure to Timely Notify Physician and Family of Significant Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of significant changes in condition to the attending physician and family for two residents. In the first case, a resident with a history of multiple strokes, severe cognitive impairment, and requiring enteral feedings experienced a significant weight loss of over 10% in less than one month. Despite weekly interdisciplinary team reviews and documentation of weights, there was no evidence that the physician or family were notified of this significant weight loss at the time it occurred. Documentation inconsistencies were noted, and the significant weight loss was not clearly identified or communicated until much later, with no record of timely notification to the responsible parties. In the second case, a resident with severe cognitive impairment, tracheostomy, and feeding tube developed a new open area (laceration) on the neck, likely related to trach collar elastic. The open area was identified during a skin check, and while documentation indicated the physician and responsible party were updated, there was no clear record of when the wound was first identified, what immediate treatment was provided, or when notifications occurred. The family member only became aware of the wound during a radiology appointment, and there was a lack of documentation regarding the initial discovery and notification process. The facility's policy requires prompt notification of changes in resident condition to the physician and responsible party to ensure appropriate care and resident rights. In both cases, the documentation failed to demonstrate that timely notifications were made as required by facility policy and regulatory standards.
Failure to Develop Comprehensive Care Plan for Bathing and Hygiene Needs
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan addressing the bathing and hygiene care needs for one resident. The resident, who had diagnoses including pneumonia, cirrhosis of the liver, gait and mobility abnormalities, cognitive communication deficit, and general muscle weakness, was assessed as moderately cognitively impaired and required moderate staff assistance for bathing and supervision for hygiene care. Despite these needs, a comprehensive care plan for activities of daily living (ADLs), specifically bathing and hygiene, was not found in the resident's clinical record. Interviews with facility staff confirmed the absence of a care plan for the resident's ADLs. The MDS Coordinator acknowledged overlooking the development of a care plan based on the admission MDS and baseline care plan. The facility's policy requires a baseline care plan within 48 hours of admission and a comprehensive care plan to follow, but this process was not completed for the resident in question. A family member also reported that the resident received very few showers during their stay.
Failure to Provide Adequate Bathing and Hygiene Care
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including pneumonia, cirrhosis, mobility issues, cognitive impairment, and muscle weakness, did not receive adequate bathing and hygiene care as required. The resident's Minimum Data Set (MDS) assessment indicated a need for moderate staff assistance with bathing or showering and supervision for hygiene care, with a strong preference for choosing the manner of bathing. Despite a scheduled bathing routine, records showed that over a 25-day period, the resident received only three bed baths, one partial bath, and no showers. In the following month, the resident received three partial baths and one shower over 30 days. The lack of consistent bathing was confirmed by a family member, who reported that the resident received very few showers during their stay. Further review revealed that the MDS Coordinator failed to develop a care plan for activities of daily living (ADLs) based on the admission MDS and baseline care plan. Additionally, a grievance form submitted by the resident regarding the shower schedule was documented, and although the facility indicated that the concern was addressed and a shower was provided, the bathing documentation did not reflect that any bathing occurred on the date in question. These findings demonstrate a failure to provide necessary care and assistance for bathing and hygiene to a resident unable to perform these activities independently.
Failure to Provide Continuous Enteral Feeding and Timely Response to Significant Weight Loss
Penalty
Summary
A resident with a history of multiple strokes resulting in significant paralysis and an inability to swallow safely required continuous enteral (gastric) feedings via a feeding tube. On one occasion, the resident's feeding ran out during the night and was not resumed for several hours because the feeding solution was locked in an office and inaccessible to nursing staff. The feeding was not restarted until the morning, resulting in an interruption of the prescribed continuous nutrition. The resident's clinical record showed a significant weight loss of more than 10% in less than one month, dropping from 236.0 pounds to 205.3 pounds. Despite this substantial weight loss, interdisciplinary team notations failed to identify or address the weight loss in a timely manner. Documentation did not reflect that the attending physician or the resident's family had been notified of the significant weight loss on the relevant dates. Facility policies required prompt notification of changes in a resident's condition, including significant weight loss, to the physician and responsible party. However, the records and interviews confirmed that such notifications and timely interventions were not conducted as required. Additionally, the medication administration and nursing progress notes did not document the interruption in enteral feeding, further indicating a lack of appropriate monitoring and response to the resident's nutritional needs.
Failure to Document Identification and Notification of New Wound
Penalty
Summary
The facility failed to thoroughly document the identification and management of a newly discovered open area on a resident with a tracheostomy. The resident, who was severely cognitively impaired, nonverbal, nonambulatory, and dependent on staff for all care, was found to have a new laceration on the left side of the neck. The clinical record included a Weekly Skin Check and a Weekly Wound Event form, both dated the same morning, which noted the wound's size, drainage, and treatment with steri strips. However, there was no documentation indicating when the open area was first identified, what initial treatment was provided before the skin check, or any notifications to the attending physician, family, or facility administration regarding the new wound and the resident's departure for a radiology appointment. Interviews revealed that the family was not informed of any skin concerns prior to discovering the wound at a radiology appointment, and the nurse who initially identified the wound did not document the event. The DON confirmed being notified by the night shift nurse about the wound but found no documentation from that nurse, only from the wound nurse who assessed the area later. The facility also lacked a specific policy on documentation, as confirmed by the Corporate Nurse. These documentation gaps resulted in incomplete records regarding the resident's change in condition and communication with responsible parties.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe food temperatures during meal service, potentially affecting 48 of 49 residents. During an observation of the lunch service in the main kitchen, it was noted that the steam table contained mixed vegetables and fish filets at temperatures of 121.8 degrees Fahrenheit and 107 degrees Fahrenheit, respectively. These temperatures were below the required minimum of 135 degrees Fahrenheit, as indicated by Facility staff. Additionally, in the upstairs kitchenette, French fries were observed on the steam table at a temperature of 120 degrees Fahrenheit, also below the safe holding temperature. The facility's Food Safety Handout, dated 9/28/2020, specifies that hot foods should be held at temperatures between 135 degrees Fahrenheit and 170 degrees Fahrenheit.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, which had the potential to affect all 49 residents in the facility. The Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of the 2024 Federal Fiscal Year revealed that there was no RN coverage on specific dates, including 4/20/24 and 4/21/24. Interviews with the Staffing Coordinator and the Director of Nursing (DON) confirmed the absence of RN coverage on these dates, as the facility's RN weekend option nurse did not work, and no agency nursing staff had been used since 4/1/24. Additionally, the facility lacked a policy regarding RN coverage, as indicated by the Nurse Consultant during an interview.
Medication and Care Plan Deficiencies
Penalty
Summary
The facility failed to administer medications and collect urine samples as ordered, impacting several residents. Resident 42, who was admitted with a healing leg fracture, did not have a timely follow-up orthopedic appointment scheduled. Despite a physician's note indicating the need for an orthopedic follow-up, the appointment was only made after a delay, as observed during an interview with LPN 4. The Director of Nursing acknowledged that the appointment should have been scheduled sooner. Resident 30, who relies on a gastric tube for nutrition, did not have his weight monitored as recommended by the registered dietician. Despite a significant weight gain noted in August, there was no recorded weight for September, and weekly weights were not completed as requested. This oversight was confirmed during an interview with a Nurse Consultant, who noted that the facility's SWAT Program Meeting Guidance was not followed. Additionally, Resident 11's urine sample was not collected as ordered, and Resident 29 did not receive prescribed medications for diabetes and hypertension on multiple occasions. The Medication Administration Record showed several instances where insulin and clonidine were not administered as ordered, and there was no documentation to justify withholding these medications. Resident 95 also did not have a urine sample collected as ordered for a lab test. These deficiencies highlight a pattern of non-compliance with physician orders and care plans, as confirmed by interviews with the Nurse Consultant.
Lack of COVID-19 Vaccination Documentation for Residents
Penalty
Summary
The facility failed to ensure that the medical records of five residents included documentation indicating that the residents or their representatives were provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine. Additionally, there was no documentation on whether the COVID-19 vaccine was administered to these residents or if they did not receive the vaccine due to medical contraindications or refusal. The residents involved were identified as Residents 11, 18, 20, 24, and 30, and their clinical records were reviewed on October 3, 2024. During an interview with the Nurse Consultant on October 4, 2024, it was confirmed that there was no verification that the 2023-2024 COVID-19 vaccination was offered, refused, medically contraindicated, or that education regarding the vaccination was provided to the residents in question. The facility's policy, provided by the Nurse Consultant, emphasized the importance of remaining up to date with COVID-19 vaccinations and offering resources and counseling, but it did not reference the need for documentation in the residents' clinical records regarding education or vaccination status.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain a resident's dignity during meal assistance. Resident 2, who has a diagnosis of dementia and cognitive impairment as indicated in a Quarterly Minimum Data Set assessment, required assistance with eating according to her Activities of Daily Living care plan. During an observation in the dining room, a Certified Nursing Assistant (CNA) was seen standing while assisting Resident 2 with her meal, rather than sitting, which is contrary to the facility's resident rights policy. This policy emphasizes treating residents with respect and dignity, including providing care in a manner that enhances their quality of life. The Nurse Consultant confirmed that the CNA should have been sitting while assisting the resident, aligning with the policy to ensure a dignified existence for residents.
Failure to Address Resident Grievance Timely
Penalty
Summary
The facility failed to address a resident's grievance in a timely manner, as evidenced by the case of a resident who was cognitively intact and had a history of stroke. The resident had been storing a Tupperware container with a teapot and tea bags in the dining room for years. However, he was recently informed that he could no longer store it there and had to transport it back and forth from his room to the dining room for each meal. This change made it difficult for him, as he had to revert to using a wheelchair instead of crutches to carry the container, and he was not provided with a reason for this new restriction. The Activities Director confirmed the resident's dissatisfaction with the new storage rule and acknowledged that a grievance form was not filled out regarding the resident's concern. The facility's grievance policy outlines a process for addressing resident concerns, including completing a form, discussing it in a CQI meeting, and ensuring the resident is satisfied with the resolution. However, in this case, the process was not followed, as the resident's grievance was not documented or addressed according to the facility's policy.
Inaccurate RN Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) regarding the correct category of work for a Registered Nurse (RN) for all 49 residents. The Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of the 2024 Federal Fiscal Year showed no RN coverage on several dates, despite evidence from the Daily Nursing Schedule and time sheets indicating RN coverage on those dates. The Staffing Coordinator, who has been in the role for almost three years, indicated that RN 9, the weekend option nurse, worked on the dates in question but the system may not have been updated to reflect RN 9's title change to RN after obtaining her license in March 2024. The facility lacked a policy regarding PBJ data submission, as confirmed by the Nurse Consultant.
Inaccurate MDS Coding for Bed Rail Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to a deficiency in the accuracy of resident assessments. Resident 1, diagnosed with paraplegia, had an Admission MDS assessment indicating daily use of bed rails as a restraint. Resident 12, with dementia, had a Quarterly MDS assessment also indicating daily use of bed rails as a restraint. Resident 22, diagnosed with hypertension, had a Quarterly MDS assessment showing daily use of bed rails as a resident. Resident 42, with depression, had an Admission MDS assessment indicating daily use of bed rails as a restraint. Interviews with the MDS Coordinator and the Regional MDS Coordinator revealed that the MDS assessments were inaccurately coded, as the bed rails were used for bed mobility, not as restraints. The facility used the Resident Assessment Instrument (RAI) Manual as their policy.
Failure to Accurately Complete MDS Assessment for Falls
Penalty
Summary
The facility failed to ensure a Minimum Data Set (MDS) assessment was correctly completed for a resident, specifically regarding falls. Resident B, who was admitted with multiple diagnoses including encephalopathy, diabetes, rheumatoid arthritis, and cognitive function issues, had an MDS assessment dated 10-9-23. This assessment incorrectly indicated that the resident had no falls from the time of admission through the assessment reference date. However, the clinical record showed that Resident B had sustained two falls on 10-8-23, one at 2:00 a.m. and another at 5:30 p.m. Interviews revealed that during the time of the MDS assessment, the regular MDS staff was on medical leave, and a corporate MDS person was filling in. Despite this, it appeared that the regular MDS staff conducted the assessment. The Executive Director confirmed that the facility does not have a specific policy for MDS assessments but follows the most current Resident Assessment Instrument (RAI) manual. The manual requires a thorough review of all available sources for any falls during the look-back period, which was not adhered to in this case.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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