Waters Of Dunkirk Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunkirk, Indiana.
- Location
- 11563 W 300 S, Dunkirk, Indiana 47336
- CMS Provider Number
- 155571
- Inspections on file
- 23
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Waters Of Dunkirk Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A facility failed to protect cognitively impaired residents from sexual abuse when a resident with moderate dementia was observed performing oral sex on a resident with severe dementia and a documented history of sexually inappropriate behaviors. The male resident had prior episodes of inappropriate touching, exposure, and agitation when redirected from female peers, and his care plan for inappropriate personal boundaries had been resolved despite ongoing concerns. The female resident had impaired cognition, poor memory, and a care plan that allowed companionship and affectionate contact but did not reflect a formal assessment of her capacity to consent to sexual activity. Staff interviews and records showed that no sexual consent capacity assessment was completed before the incident and that behavior monitoring and interventions for the male resident’s hypersexuality were inconsistent, leading surveyors to cite the facility for failing to protect residents from abuse and to assess and manage sexual behaviors appropriately.
The facility failed to monitor and develop individualized interventions for sexually focused behaviors in multiple cognitively impaired residents. Several residents with dementia had documented histories of inappropriate touching, hypersexuality, or intimate relationships with other residents, yet behavior monitoring orders and tools focused only on depression, anxiety, or general boundary issues. One resident was observed performing oral sex on another resident, and another was found receiving oral sex, while another made explicit sexual comments and requests to CNAs. Care plans for companionship emphasized hand holding and social engagement but did not include specific monitoring or tailored interventions for sexual behaviors, and the facility had no formal assessment for sexual behaviors despite policy requiring daily monitoring of target behaviors and social services involvement in behavior care planning.
Two residents with dementia and significant cognitive impairment were involved in an incident where one was observed performing oral sex on the other, with the male resident’s pants partially down and his buttocks exposed. A QMA intervened, directed the male resident to leave, and reported the event to the charge nurse (an RN). The RN documented a behavioral note but did not immediately report the allegation to leadership, believing residents could have a sexual relationship. As a result, the DON and Administrator were not informed until the following day, delaying required notification to the State Agency, contrary to the facility’s abuse reporting policy that mandates immediate reporting of suspected abuse up the chain of command and to state authorities.
The facility failed to adhere to menus and residents' preferences, affecting several residents. Observations showed discrepancies between posted menus and actual meals served, with frequent shortages of items like hot dogs and milk. A resident who often refused meals did not receive her preferred hot dog due to shortages. Another resident reported unmet meal preferences, leading to dissatisfaction. The facility's outsourced dining service struggled with maintaining adequate food supplies, impacting residents' dietary needs.
The facility's dishwasher failed to meet sanitization requirements, operating at 113°F instead of the required 150°F, potentially affecting all 31 residents. Additionally, food storage practices were unsanitary, with uncovered items in the refrigerator and freezer, and a dirty toaster. Staff acknowledged these issues, which violated facility policies.
The facility failed to provide palatable and quality meals, as residents and staff reported issues such as watery eggs, overly salty gravy, and hard muffins. Residents with specific dietary needs were dissatisfied with the meals, which were often inedible. Staff interviews confirmed these complaints, and the facility's policies on meal presentation and satisfaction were not followed.
The facility failed to notify residents and their representatives in writing of transfer/discharge appeal rights during hospitalizations. Three residents were transferred to the hospital for various medical reasons, but there was no documentation of them receiving the necessary appeal rights paperwork. Interviews with staff revealed inconsistencies in providing these notifications, and the facility lacked a specific policy on transfer/discharge appeal rights.
The facility failed to ensure that the results from their last annual IDOH survey report were accessible to residents. The State Survey Binder was repeatedly observed on a lower shelf, making it difficult for residents with mobility limitations to access it. Interviews confirmed the binder's inaccessibility, and the Administrator was unaware of its relocation. The facility's policy required the survey results to be posted in a prominent, accessible area.
A resident with right side hemiplegia required extensive assistance for mobility, but a CNA, unaware of the need for a two-person assist, attempted a transfer alone, resulting in the resident sustaining a right ankle fracture. The facility lacked specific policies for staff-assisted transfers, and the CNA did not reference assignment sheets, leading to the improper transfer.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse and Inadequate Consent Assessment
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse by not adequately assessing capacity to consent to sexual activity and not implementing effective interventions for a resident with known sexually inappropriate behaviors. Resident B had diagnoses including unspecified dementia, major depressive disorder, and a cognitive communication deficit, with an MDS showing moderate cognitive impairment and moderate impairment in decision-making for daily tasks. Her care plans addressed impaired cognition, poor safety awareness, and impulsiveness, and she used a position change alarm due to attempts to self-transfer. A care plan for promotion of safe intimate/sexual practices, created shortly before the incident, stated she was alert, aware, and coherent in choosing to engage in an intimate/sexual relationship and included interventions such as assessing her understanding of the nature of the act and her ability to refuse, encouraging appropriate touch, and reminding her that sexual partners must be able to provide mutual consent. Her representatives were notified that she was seeking companionship with a male resident and agreed to hand-holding and companionship, but they did not agree to more intimate acts. Resident C had diagnoses including unspecified dementia with behavioral disturbance and delusional disorders, with an MDS indicating severe cognitive impairment. His record documented a history of inappropriate personal boundaries manifested by inappropriate touching, such as rubbing another person’s back, reaching for a leg, and shoulder rubbing. He had been treated with medroxyprogesterone for hypersexuality and was also on risperidone. Behavior notes and staff interviews described increased friendliness and physical contact with multiple female residents, including patting arms, hand holding, rubbing arms and legs, and entering female residents’ rooms, sometimes becoming agitated or hostile when redirected. Staff, including a housekeeper and an RN, reported that he had been seen with his penis exposed in a lounge, asking a female resident to put her hands in his pants, pulling a female resident’s hand toward his genital area over clothing, and touching a female resident’s breast. Despite this pattern, his care plan for inappropriate personal boundaries was resolved, and the Social Service Director and DON indicated that, after discussions with the Ombudsman, care plans regarding sexual behaviors were resolved based on the view that such behaviors were residents’ rights rather than maladaptive behaviors. On the evening of 3/22/26, a Qualified Medication Aide observed Resident C in Resident B’s room with his pants partially down, exposing his buttocks, while Resident B, seated in her recliner and leaning forward, was performing oral sex on him. Resident B’s roommate was in the hallway at the time. The QMA instructed Resident C to leave; he became angry but complied. Resident B said little and, after the incident, had forgotten that anything had occurred. Subsequent nursing documentation noted that Resident B would not or could not discuss the incident, described the male resident as a friend, and denied unwanted touching. Interviews with Resident B’s representative indicated that Resident B had moderate to severe dementia, sometimes did not recognize family, frequently asked where she was and when she was going home, and that performing oral sex was not consistent with her prior behavior or values. Resident B later demonstrated significant disorientation, unable to state where she was, what town she was in, or the year, and denied having a male friend or male visitors in her room. Additional interviews and records showed that staff were aware of Resident C’s ongoing sexually focused behaviors and the need for redirection. Behavior notes shortly before the incident documented increased agitation and interactions with female peers, his anger when asked to visit females only in public areas, and an episode of inappropriate behavior with a confused female resident from whom he was redirected. The Psychiatric NP reported that the facility had been concerned about Resident C’s sudden focus on female residents and that he had required medication to prevent escalation of inappropriate touching. The NP also stated that staff had to redirect Resident C several times related to female residents and that he became agitated when redirected. The acting Administrator acknowledged that a Sexual Consent Capacity Assessment was not completed for the residents prior to the incident and that behavior documentation was only maintained if behaviors were considered maladaptive. The surveyors determined, using the reasonable person concept, that this failure to assess capacity to consent and to implement interventions to mitigate Resident C’s sexually inappropriate behaviors resulted in severe psychosocial harm, including dehumanization and humiliation, for Resident B. Other residents and staff expressed concerns related to Resident C’s behaviors. A cognitively intact resident reported hearing from staff and in the hallway that a female resident had performed oral sex on Resident C and expressed fear that he might enter her room and touch her, stating she did not want to be touched. The Social Service Director described Resident C as social with many female residents, with hypersexuality increasing as he formed more relationships, and acknowledged that staff struggled to distinguish between appropriate social interaction and infringement on residents’ rights. Several residents, including Residents F and E, had histories of dementia and prior care plans for inappropriate personal boundaries that were later resolved, and some had care plans for companionship with male peers that included general interventions such as assessing understanding and ability to refuse, but the records lacked individualized monitoring and interventions specifically addressing intimate or sexual behaviors for all involved residents. The combination of Resident C’s known sexually inappropriate behaviors, his severe cognitive impairment, Resident B’s moderate cognitive impairment and poor memory, the absence of a formal sexual consent capacity assessment prior to the incident, and the lack of sustained, effective behavioral interventions for Resident C led to the cited deficiency for failure to protect residents from sexual abuse. The surveyors concluded that the facility failed to ensure residents were protected from sexual abuse when Resident B, with moderate cognitive impairment, was found performing oral sex on Resident C, who had severe cognitive impairment and a known history of sexually inappropriate behaviors. They found that the facility did not assess the residents’ capacity to consent to sexual activity prior to the incident and did not implement interventions to mitigate Resident C’s sexually inappropriate behaviors. Using the reasonable person concept, they determined that this deficient practice resulted in severe psychosocial harm, including dehumanization and humiliation, for Resident B.
Failure to Monitor and Individualize Care for Sexually Focused Behaviors in Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to monitor and develop individualized interventions for cognitively impaired residents who exhibited sexually focused or intimate behaviors. Five residents with dementia or significant cognitive impairment had either documented sexually focused behaviors, hypersexuality, or intimate relationships with other residents, yet their behavior monitoring and care plans did not include specific assessments, monitoring, or individualized interventions for sexual or intimate behaviors. Instead, behavior monitoring orders and tools focused on depression, anxiety, delusions, or general boundary issues, and there was no structured assessment for sexual behaviors in use at the facility. One resident with moderate cognitive impairment and dementia (Resident B) had behavior monitoring ordered for depression-related symptoms and a care plan for impaired cognition and poor safety awareness, but no monitoring or individualized interventions for intimate or sexually focused behaviors. Social services documented that she sought companionship with a male resident, ate meals with him, and sat in the lounge with him, with her representatives agreeing to the relationship and the facility stating it would continue to monitor. Subsequently, staff observed her performing oral sex on a male resident in her room, after which staff intervened and removed the male resident. Prior to this event, her record lacked behavior monitoring or care plan interventions specifically addressing intimate or sexual behaviors. Another resident with severe cognitive impairment and delusional disorder (Resident C) had a history of inappropriate personal boundaries, including touching others’ arms and legs, and was treated with medroxyprogesterone for hypersexuality with multiple dose adjustments and a failed gradual dose reduction. His resolved care plan for inappropriate boundaries included general boundary-setting strategies, and a current care plan acknowledged his companionship with female peers and allowed affectionate acts such as hand holding and putting his arm around them. However, his clinical record did not include monitoring tools or individualized interventions specifically targeting intimate or sexual behaviors. Nursing and social service notes documented increased friendliness and physical contact with female residents, agitation when redirected, and an incident where he was found in a female resident’s room receiving oral sex, but behavior monitoring tools reflected only irritability, anxiety, and searching for family, not sexual behaviors. Residents D, E, and F, all with dementia and varying levels of cognitive impairment, had prior care plans for inappropriate personal boundaries that were later resolved and replaced with care plans describing mutual companionship with male peers, including hand holding and arm-around contact. These care plans emphasized acknowledging the need for connection, assessing understanding and ability to refuse, encouraging appropriate touch, offering privacy, and psychosocial visits, but did not include individualized monitoring or interventions specifically for sexually focused behaviors. Resident E exhibited verbally explicit sexual comments toward CNAs, including references to genital areas and suggesting sexual acts involving staff and another male resident, yet her behavior monitoring orders and tools addressed only depression and did not capture or target sexualized behaviors. Resident F’s record showed a long-standing close relationship with a male resident, family awareness of his frequent touching of her hands and legs, and discussion of possible environmental interventions, but her behavior monitoring focused on anxiety and searching for her daughter, with no documented monitoring or individualized interventions for intimate or sexual behaviors. The Social Service Director confirmed that the facility did not have a sexual behavior assessment, that behavior tools used by CNAs did not include sexual behaviors for these residents, and that decisions about resolving or framing care plans were influenced by discussions with the Ombudsman about residents’ rights rather than by structured behavioral health assessment and monitoring. Overall, the facility’s behavior management process, as described in policy and interviews, required nursing to monitor target behaviors daily and social services to maintain a list of residents with behaviors and assist with behavior care plans. However, for these five residents with documented sexually focused behaviors, hypersexuality, or intimate relationships, the facility did not implement behavior monitoring specific to sexual behaviors, did not develop individualized behavioral health interventions addressing those behaviors, and did not use a formal assessment tool for sexual behaviors. Behavior sheets and monitoring focused on other symptoms such as depression, anxiety, irritability, and confusion, leaving sexually focused behaviors unmonitored and without individualized, documented interventions in the clinical record.
Failure to Immediately Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of abuse to the Administrator, which delayed required reporting to the State Agency. Resident B, who had diagnoses including unspecified dementia with moderate cognitive impairment, major depressive disorder, and cognitive communication deficit, was observed on 3/22/26 by a Qualified Medication Aide (QMA 7) performing oral sex on Resident C in her room. QMA 7 saw Resident C standing in front of Resident B with his pants partially down, exposing his buttocks, while Resident B, seated in a recliner and leaning forward, was performing oral sex. QMA 7 instructed Resident C to leave the room, and he became angry but complied. QMA 7 then reported the incident to the charge nurse, and staff kept Resident C away from Resident B and other female residents. Resident C, who had diagnoses including unspecified dementia with severe cognitive impairment and delusional disorders, was later documented in an SBAR summary as having been observed receiving oral sex from a female resident, after which he was asked to leave the room and was closely monitored. When QMA 7 reported the initial observation to Registered Nurse (RN) 16, RN 16 did not report the allegation to anyone else at that time and only made a behavioral note, indicating she believed residents were allowed to have a sexual relationship. The Administrator later stated that the incident was not reported to the State Agency until the day after it occurred, because RN 16 did not notify the DON until the following morning, and the DON then notified the Administrator. This sequence of events conflicted with the facility’s Abuse Prevention Program policy, which required the person observing suspected abuse to immediately report it to the charge nurse, and the charge nurse to immediately report it to the Administrator, who must immediately notify the State Licensing and Certification Agency.
Inconsistent Menu Adherence and Food Shortages in Dining Services
Penalty
Summary
The facility failed to ensure that menus and residents' preferences were consistently followed, affecting 3 of 5 residents reviewed for dining services. Observations revealed discrepancies between the posted menu options and the meals actually served. For instance, a sign indicated options like grilled cheese and hot dogs, but these were not available on certain days, leading to unmet resident preferences. Resident 14, who often refused meals but would eat a hot dog, did not receive one because the kitchen ran out. This issue was compounded by frequent shortages of other items, such as milk and hot dogs, which disrupted meal service. Resident 12 reported that the meals served often did not match the menu or her requests. She noted that the facility frequently ran out of eggs and that her meal preferences, such as receiving scrambled eggs in a bowl, were not honored. This inconsistency led to dissatisfaction and a loss of appetite. Her clinical record indicated dietary needs for a consistent carbohydrate diet, which were not consistently met due to these discrepancies. Resident 26 also experienced issues with meal service, noting that her requests for alternatives like hot dogs and cottage cheese were not fulfilled due to shortages. She frequently received items she did not prefer, such as Italian dressing instead of ranch, and meals that did not match the posted menu. The facility's dining service, outsourced to another company, faced challenges in maintaining adequate food supplies, leading to these deficiencies in meeting residents' dietary needs and preferences.
Dishwasher and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure the high-temperature dishwasher functioned at the required sanitization level, potentially impacting all 31 residents receiving meals from the kitchen. During an inspection, the dishwasher's washing temperature was recorded at 113°F, below the required 150°F. The Maintenance Director confirmed the issue, noting the temperature had been below range since the previous Friday, yet the dishwasher continued to be used. The Dietary Manager initially believed the dishwasher was safe to use, and the Maintenance Assistant identified a loose thermostat wire as the cause of the problem. The facility's policy mandates stopping the dishwashing process if it is not sanitizing properly and contacting the appropriate personnel. Additionally, the facility failed to store and distribute food under sanitary conditions. Observations during a kitchen tour revealed uncovered drinks and fruit in the refrigerator, an uncovered bowl of fruit in the freezer, and loose biscuits. The toaster was found with crumbs and a white substance on it. Dietary staff acknowledged that items should have been covered and labeled, as per the facility's food storage policy, which requires food to be stored and prepared in a clean and sanitary manner in compliance with guidelines.
Facility Fails to Ensure Palatable and Quality Meals for Residents
Penalty
Summary
The facility failed to ensure the palatability and quality of meals served to residents, as evidenced by multiple complaints and observations. Residents reported that the food was often unappetizing, with issues such as green meatloaf, watery eggs, and overly salty gravy. Observations confirmed these complaints, with meals being described as bland, mushy, or excessively salty. The facility's outsourcing of kitchen services was noted as a potential factor in the decline of food quality. Several residents, including those with specific dietary needs due to medical conditions such as diabetes and gastroparesis, expressed dissatisfaction with the meals. They reported that the food was either over-seasoned or under-seasoned, and often inedible. The facility's failure to provide meals that met the residents' dietary requirements and preferences was evident in the repeated complaints and observations of uneaten food. Staff interviews corroborated the residents' complaints, with reports of hard muffins, watery eggs, and a lack of flavor in the meals. The facility's policies on meal presentation and resident satisfaction were not adhered to, as meals were not served attractively or at appropriate temperatures. The facility's administrator acknowledged previous concerns about food quality, but the issues persisted, indicating a systemic problem with the dining services.
Failure to Notify Residents of Transfer/Discharge Appeal Rights
Penalty
Summary
The facility failed to ensure that residents and their representatives were notified in writing of their transfer/discharge appeal rights during hospitalizations. This deficiency was identified in the cases of three residents who were transferred to the hospital for various medical reasons. Resident 77 was sent to the hospital for evaluation after experiencing large amounts of dark red stool, but there was no documentation indicating that the resident or their representative received written notification of appeal rights. Similarly, Resident 17, who was his own representative, was transferred to the emergency room on multiple occasions due to chest pain and other symptoms, yet there was no record of him receiving the necessary appeal rights paperwork. Resident 127 was transferred to the emergency room following complications with a catheter, but again, there was no indication that the resident or their representative was informed of the appeal rights in writing. Interviews with facility staff, including the Assistant Director of Nursing, LPN, Social Services Director, and Director of Nursing, revealed that while certain transfer documents were sent with residents to the hospital, the appeal rights paperwork was not consistently provided to residents or their representatives. The facility also lacked a specific policy on transfer/discharge appeal rights, contributing to the oversight.
Inaccessible Survey Results for Residents
Penalty
Summary
The facility failed to ensure that the results from their last annual Indiana Department of Health (IDOH) survey report were posted at an accessible height for residents. The State Survey Binder, which contained the survey results, was observed multiple times on the lower shelf of a sofa table, approximately four inches off the floor, right outside the Administrator's office. This placement made it difficult for residents, particularly those with mobility limitations, to access the binder. The deficiency was noted during observations conducted over several days, from March 17 to March 20, 2025. Interviews with Resident 23 and QMA 10 confirmed that the binder's location was not reachable by all residents due to mobility limitations. The Administrator, who was responsible for the binder, indicated that it was generally kept on the top shelf of the sofa table and was unaware that it had been moved to the bottom shelf. The facility's policy, dated August 2017, required that the most recent annual survey and the facility's response to the findings be clearly posted in a prominent area easily accessible to residents, their family members, and legal representatives, as well as the public.
Inadequate Staffing and Transfer Protocols Lead to Resident Injury
Penalty
Summary
The facility failed to ensure adequate staffing and consistent procedures for physical transfers, resulting in a resident, identified as Resident B, sustaining a fracture to her right ankle. Resident B, who had a history of right side hemiplegia and hemiparesis following a stroke, required extensive assistance for mobility. On the day of the incident, a CNA, who was unaware of the resident's need for a two-person assist, attempted to transfer Resident B alone. During the transfer, the resident's right foot did not turn with her body, causing pain and eventually leading to the discovery of an acute ankle fracture. Resident B's care plan indicated she required extensive assistance with transfers, and her condition included moderate cognitive impairment and dependency on staff for daily activities. Despite these documented needs, the CNA involved in the incident was not informed of the requirement for a two-person assist and had observed other staff transferring the resident independently. The CNA assignment sheets, which contained critical information about resident care needs, were not referenced by the CNA, leading to the improper transfer. Interviews with staff revealed a lack of awareness and communication regarding the resident's transfer needs. The Assistant Director of Nursing (ADON) acknowledged that the CNA was expected to reference assignment sheets, but there was no specific policy in place regarding staff-assisted transfers. Other CNAs confirmed that Resident B was a two-person transfer prior to her injury, and the facility's failure to ensure this protocol was followed directly contributed to the resident's injury.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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