Willow Crossing Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Indiana.
- Location
- 3550 Central Ave, Columbus, Indiana 47203
- CMS Provider Number
- 155535
- Inspections on file
- 30
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Willow Crossing Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, depression, anxiety, and dementia, who used a wheelchair, was observed on video removing linens from a cart and flipping it, after which a CNA forcefully pulled the resident’s wheelchair backward twice, causing the resident to fall to the floor. The CNA then left the resident lying on the floor near the nurse’s station, repeatedly walked past and around the resident, wheeled another resident around the resident on the floor, and mimed tipping the linen cart again, without providing assistance. When an RN returned from break, the CNA reported that the resident had flipped the cart and slid to the floor, and the RN followed fall protocol based on that account. The resident later reported no memory of the fall, and the facility’s abuse policy defined such willful, intimidating actions as abuse.
A resident with dementia, depression, anxiety, and a history of hallucinations had a violent behavioral outburst at the nurse’s station, verbally threatening to kill another resident, attempting to pull the other resident’s chair backward, and trying to grab the resident’s shirt. Staff separated the two residents, but then retreated into a nearby room without a window, leaving the aggressive resident alone and unmonitored at the nurse’s station, where he threw a drink, the phone, and attempted to throw the computer monitor. This occurred despite a care plan and a dementia aggression policy that called for ensuring safety and assessing the potential for harm to self or others.
The facility failed to follow physician's orders for two residents regarding medication hold parameters. One resident received Lisinopril despite having a systolic blood pressure below the specified threshold, while another received Amlodipine when their blood pressure was below the required level. Facility policies on medication administration were not adhered to, as confirmed by an RN and the Assistant Director of Nursing.
A resident with multiple health issues, including cognitive impairment and incontinence, developed a Stage III pressure ulcer due to the facility's failure to identify and assess a wound in a timely manner. Despite being at risk, the resident's wound was not documented by the DON when first noted, and it was only assessed by a wound specialist days later, by which time it had worsened.
The facility failed to document meal consumption for two residents, one with a history of weight loss and another with malnutrition. Despite care plans requiring monitoring of meal intake, records were incomplete for several meals. A QMA confirmed that meal consumption should be recorded after each meal, but the facility's policy was not consistently followed.
The facility failed to store medications appropriately in two medication carts. Loose pills and debris were found in both the Back 200 and Front 100 Medication Carts. A QMA indicated she did not clean the cart, and the ADON confirmed that loose pills should not be present. The facility's policy requires drugs to be stored safely and securely.
A resident with cognitive impairment and multiple diagnoses experienced a delay in urinalysis collection due to the facility's failure to follow timely specimen collection procedures. A physician's order for a urine dip test and subsequent urinalysis was not executed promptly, leading to a five-day delay in obtaining the urine sample.
The facility failed to follow infection control guidelines during dining service in the Dementia Unit. An Activity Aide handled meal trays without proper hand hygiene after touching a trash can, serving two residents without sanitizing her hands in between. A CNA indicated the correct protocol involves sanitizing hands after each tray and washing hands after every third tray or immediately if anything else is touched.
A resident with a UTI did not receive timely antibiotic treatment due to a failure in communication and protocol adherence. The resident's urine culture showed resistance to the current antibiotic, but the RN did not inform the NP, delaying the appropriate treatment.
The facility failed to store medications appropriately, with controlled medications being preset for the next pass and an unattended, unlocked medication cart observed. Staff indicated they usually preset medications, which is against policy. The DON confirmed that controlled medications should not be preset and carts should remain locked when unattended.
The facility failed to ensure food was served in a sanitary manner, with multiple staff members observed handling dinner rolls with bare hands and not following proper glove use protocols, contrary to the facility's policy.
The facility failed to protect resident information by leaving computer screens on medication carts unlocked and visible on multiple occasions. The DON and QMA were observed closing the screens after they were left unattended, displaying resident names and medication lists. The facility's Employee Handbook mandates protection of identifiable health information in compliance with HIPAA.
A resident with severe cognitive impairment was subjected to verbal threats and physical aggression by a CNA, who became agitated during care. The incident was witnessed by another CNA, who intervened and reported the abuse. The resident was unable to recall the incident due to low cognition. The facility's investigation substantiated the abuse, leading to the termination of the CNA.
The facility failed to follow physician's orders for a resident's blood pressure medication by not documenting the required blood pressure and heart rate prior to administration. Despite the medication being given daily, the necessary vital signs were not recorded, leading to a deficiency.
The facility failed to follow physician's orders for a resident with multiple diagnoses, including dementia and diabetes, by not ensuring the resident wore Blue Prevalon boots to prevent pressure ulcers. The resident was repeatedly observed without the prescribed boots, and staff did not document any refusal to wear them, contrary to facility policy.
A facility failed to provide appropriate urinary catheter care for a resident with frequent UTIs. A CNA was observed performing catheter care without following proper hygiene protocols, including not changing gloves after touching various surfaces and not using a clean area of the washcloth for each motion. The resident had a history of frequent UTIs and was moderately cognitively impaired.
The facility failed to implement interventions and complete behavior forms for a resident with severe cognitive impairment and dementia. The resident exhibited physical aggression and wandering behaviors, but the facility did not consistently document or implement effective interventions, such as the use of a door frame alarm. Staff interviews revealed inconsistencies in reporting and handling the resident's behaviors.
Failure to Protect a Resident From Staff-Inflicted Abuse and Inaccurate Fall Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and mental abuse and to ensure accurate reporting of a fall event. Resident B, who was moderately cognitively impaired with diagnoses including depression, anxiety, and unspecified dementia, used a wheelchair and walker for mobility and had not exhibited behaviors during the MDS assessment period. A facility-reported incident and subsequent review of hallway video footage revealed that a CNA (CNA 2) was aggressive with the resident and caused him to fall from his wheelchair in a common area on the locked dementia unit. Video footage showed Resident B sitting in his wheelchair near the central nurse’s station, removing linens from a linen cart, throwing them on the floor, and flipping the cart so that it and additional linens fell around him. CNA 2 exited a nearby resident room, then aggressively grabbed the back of Resident B’s wheelchair with both hands and purposely, forcefully pulled the wheelchair backward toward the nurse’s station with two jerking motions. After the second pull, Resident B fell from the wheelchair, landing on his buttocks and then onto his back, partially out of camera view. CNA 2 stood over the resident briefly, then walked away to right the linen cart and return linens to it, moved the cart down the hallway, and re-entered a resident room, leaving Resident B on the floor. The video further showed that CNA 2 continued to leave Resident B on the floor while she wheeled another resident around him and walked past him multiple times, including standing at the nurse’s station looking down at him and pointing toward the linen cart, without providing assistance. Another resident in a wheelchair attempted to maneuver around Resident B, who tried to scoot out of the way and eventually sat up on his buttocks, appearing to yell toward the nurse’s station. CNA 2 later walked around Resident B and mimed tipping the linen cart and throwing linens without actually touching them, while Resident B remained on the floor. RN 3, who had been off the unit on lunch during the incident, stated that when she returned, Resident B was already sitting on the floor with his wheelchair in front of him, and she was told by CNA 2 that the resident had flipped the linen cart on himself and slid to the floor; she followed fall protocol based on that account. Resident B reported no memory of the fall. The facility’s abuse policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included mental abuse such as humiliation and harassment.
Resident with Dementia Left Unsupervised During Violent Behavioral Outburst
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate supervision and behavioral health services for a resident with major mental illness during a physical and verbal outburst. Resident B, who was moderately cognitively impaired and diagnosed with depression, anxiety, unspecified dementia, and a history of visual hallucinations, resided on a locked dementia unit and used a wheelchair and walker for mobility. On the night of the incident, Resident B approached the nurse’s station from behind where another resident, Resident F, was seated next to an RN. Resident B stated, "I'm going to kill you tonight. I don't need anything to do it; I will strangle you," then attempted to grab the back of Resident F’s chair and pull it backwards, and tried to grab Resident F’s shirt. Staff intervened to move Resident F away from Resident B. As Resident B continued toward staff and Resident F in an intimidating manner, he obtained a colored pencil from behind the nurse’s station desk and advanced toward them. The RN and a CNA then went into a resident’s room directly in front of the nurse’s station and closed the door, leaving Resident B alone and unmonitored at the nurse’s station during his outburst. The room door lacked a window, and no staff remained present to observe Resident B’s actions. While unmonitored, Resident B threw a drink, the phone, and attempted to throw the computer monitor off the desk. Resident B’s care plan, initiated the day before the incident, identified delusions that someone was out to get him and included interventions such as ensuring the resident’s safety and ascertaining potential for harm to self or others. The facility’s dementia aggression/anger policy directed staff to assess and decrease the level of danger for themselves and the resident with dementia, but during this event, staff actions resulted in the resident being left unsupervised during an active behavioral outburst.
Failure to Follow Medication Hold Parameters for Two Residents
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication hold parameters for two residents, leading to deficiencies in quality of care. Resident 71, who was cognitively intact and diagnosed with conditions including schizoaffective disorder, heart failure, hypertension, diabetes, and depression, had a physician's order to receive Lisinopril with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 130 or the heart rate was less than 60. Despite these orders, the resident received the medication multiple times in January and February 2025 when the SBP was below the specified threshold. Similarly, Resident 5, who was also cognitively intact and diagnosed with stroke, coronary artery disease, hypertension, and dementia, had an order to receive Amlodipine with instructions to hold the medication if the SBP was less than 120. The medication was administered on several occasions in January and February 2025 when the resident's SBP was below the specified limit. This indicates a failure to follow the physician's orders and monitor the resident's vital signs as required. The facility's policies on physician orders and medication administration, which require checking vital signs before administering certain medications and holding them if the parameters are not met, were not followed. An RN interviewed confirmed the procedure to check vital signs and hold medication if necessary, but the records show this was not consistently done. The Assistant Director of Nursing provided the relevant policies, which emphasize the importance of adhering to physician's orders and ensuring follow-through, highlighting the discrepancy between policy and practice.
Failure to Prevent and Identify Stage III Pressure Ulcer
Penalty
Summary
The facility failed to prevent and identify a resident's wound before it developed into a Stage III pressure ulcer. The resident, who was moderately cognitively impaired, had multiple diagnoses including stroke, hemiplegia, malnutrition, dementia, and peripheral vascular disease. The resident was always incontinent of bowel, had an indwelling urinary catheter, and was dependent on staff for toileting, hygiene, and mobility. Despite being at risk for pressure ulcers, the resident had no pressure ulcers at the time of the last assessment. However, a red open area was noted above the resident's buttocks on a shower sheet dated 08/24/24, but there was no documented assessment of the wound by the Director of Nursing (DON) at that time. The wound specialist later assessed the wound on 08/29/24, documenting it as a Stage III pressure ulcer. The wound measured 1.2 cm by 1 cm with a depth of 0.1 cm, containing 70% granulation tissue and 30% slough. By 02/17/25, the wound had increased in size to about 3 cm in diameter with a depth of 1 cm and showed signs of undermining. The facility's policy required daily observation of residents receiving assistance with bathing and pericare, with any red or open areas to be reported for further assessment. However, the lack of timely documentation and assessment of the wound by the nursing staff contributed to the deficiency in care for the resident.
Failure to Document Meal Consumption for Residents
Penalty
Summary
The facility failed to document meal consumption values for two residents, leading to a deficiency in monitoring their nutritional intake. Resident 55, who was cognitively intact and had a history of weight loss, had missing meal consumption records on several occasions in January and February 2025. Despite having a care plan in place to monitor and encourage 100% meal consumption, the records lacked documentation for specific meals, indicating a failure to adhere to the care plan. Similarly, Resident 62, who was severely cognitively impaired and diagnosed with malnutrition, also had numerous undocumented meal consumption values in December 2024, January, and February 2025. The resident's care plan required monitoring of meal intake, but the facility did not consistently document this information. During an interview, a Qualified Medication Aide confirmed that meal consumption should be recorded after every meal, yet the facility's policy was not followed, resulting in incomplete records.
Medication Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to store medications appropriately in two of the three medication carts reviewed. On the Back 200 Medication Cart, loose pills were found in the bottom of the drawers, including two small round white tablets, one small oval white tablet, and one small oval blue tablet. The cart also contained several bits of debris and paper scattered throughout. During an interview, the Qualified Medication Aide (QMA) indicated that she did not clean the medication cart and only passed medications. Similarly, the Front 100 Medication Cart was found to have loose pills, including one small round white tablet, one medium round white tablet, and one large round white tablet, along with debris and paper scattered throughout the cart. The Assistant Director of Nursing (ADON) confirmed that there should not be any loose pills in the medication carts. The facility's current policy on storing drugs, dated April 2021, states that drugs and biologicals should be stored in a safe, secure, and orderly manner.
Delayed Urinalysis Collection for Resident
Penalty
Summary
The facility failed to obtain a urinalysis in a timely manner for a resident who was moderately cognitively impaired and had diagnoses including vascular dementia, diabetes, and stroke. A physician's order was given to perform a urine dip test, and if positive, to collect a urine sample for urinalysis and culture and sensitivity testing. The order was placed on January 2nd, but the urine sample was not collected until January 7th, resulting in a delay in diagnosis and treatment. Interviews with facility staff revealed that the process for obtaining and sending urine samples to the lab was not followed promptly. The RN responsible for entering the order and collecting the sample indicated that she would document any difficulties in obtaining a sample, but there was no mention of such documentation. The Assistant Director of Nursing confirmed that the delay in collecting the urine specimen was unusual, as the lab typically collected specimens daily. The facility's policy on specimen collection emphasized obtaining a fresh urine specimen as per physician's orders, which was not adhered to in this case.
Infection Control Breach During Dining Service
Penalty
Summary
The facility failed to adhere to infection control guidelines during dining service in the Dementia Unit Dining Room. During an observation, an Activity Aide was seen handling meal trays without proper hand hygiene. The aide opened a trash can lid with her bare hand, disposed of trash, and then proceeded to handle and serve meal trays to residents without sanitizing her hands in between these actions. This occurred twice, once when serving a meal tray to Resident 102 and again when serving Resident 15. The aide only sanitized her hands after serving the trays, not before handling them after touching the trash can. A Certified Nurse Aide later indicated that proper protocol involves sanitizing hands after every tray served and washing hands after every third tray, or immediately if anything other than the tray is touched. The facility's meal service policy, dated October 2014, was referenced but not followed in this instance.
Delayed Antibiotic Treatment for UTI
Penalty
Summary
The facility failed to ensure timely antibiotic treatment for a resident with a urinary tract infection (UTI). The resident, who was moderately cognitively impaired and had diagnoses including stroke, diabetes, renal insufficiency, and neurogenic bladder, was incontinent of bowel and bladder. On July 10, a family member requested a urine test for a UTI, and a urinalysis with culture and sensitivity (C&S) was ordered by the nurse practitioner (NP). The results, available on July 13, indicated that the bacteria present in the resident's urine were resistant to the antibiotic Macrodantin, which the resident was currently receiving. The RN received the C&S results on the evening of July 13 but did not review them, assuming that the NP would change the antibiotic if necessary on the following Monday. The RN did not contact the NP to inform them of the results, as the resident was already on an antibiotic. This oversight led to a delay in administering the appropriate antibiotic, ceftriaxone, which was not ordered until July 15. The facility's policy required that abnormal lab results be communicated to the NP for immediate action, but this protocol was not followed in this instance.
Failure to Store Medications Appropriately
Penalty
Summary
The facility failed to store medications appropriately for two of three medication carts reviewed and for six of fifteen resident medications reviewed. During an observation, it was found that controlled medications for several residents were preset for the next medication pass and stored in the top drawer of the medication cart. LPN 8 and QMA 9 both indicated that they usually preset resident medications for the next pass, which is against the facility's policy. The Director of Nursing confirmed that controlled medications should not be preset. Additionally, an unlocked medication cart was observed on the 200 Hall, parked outside a resident's room with no staff around. The QMA returned to the cart, prepared medications, and then locked the cart before returning to the resident's room. The Director of Nursing indicated that medication carts are to remain locked when unattended. The facility's current policy states that controlled medications must be stored by a double-lock in a separate area from all other medications.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner during dining observations in both the Memory Care Unit and the Main Dining Room. Specifically, multiple CNAs and a QMA were observed handling dinner rolls with their bare hands, contrary to the facility's policy that requires gloves to be worn when touching ready-to-eat foods. For instance, CNA 3 and CNA 17 were seen removing dinner rolls from plastic packages with their bare hands and placing them on the table or on top of the packages. Similarly, QMA 16 and CNA 5 were observed handling food items without proper glove use, with CNA 5 even touching multiple food items and trays while wearing gloves, then removing the gloves without proper hand hygiene practices in between tasks. During an interview, QMA 9 indicated that gloves should be worn when touching a resident's food and that nothing else should be touched after donning gloves. The facility's current policy, titled 'Glove Use & Meal Service,' explicitly states that employees may not touch ready-to-eat foods with bare hands and must wear gloves. The observations and interviews indicate a clear deviation from this policy, leading to the cited deficiency in food service sanitation practices.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect resident information by leaving computer screens unlocked and visible on multiple occasions. During an observation, a medication cart on the 200 Hall had a computer screen open to resident names and medication lists, with no staff present within 20 to 30 feet. The Director of Nursing (DON) closed the screen upon noticing it. In another instance, a computer tablet on a medication cart was left open to resident names and pictures while the Qualified Medication Aide (QMA) was in a resident's room. The QMA returned and picked up the tablet after a few minutes. Further observations revealed similar incidents where computer screens on medication carts were left open and unattended, displaying resident information. The DON was observed closing the screens on two separate occasions. During an interview, the DON confirmed that computer screens should be closed when staff are not present to prevent unauthorized access to resident information. The facility's Employee Handbook, dated April 2022, mandates that all identifiable health information be protected from unauthorized access, use, or disclosure, in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a resident was free from mental and physical abuse. On 12/30/23, CNA 20 became agitated and spoke inappropriately to Resident 203 during care. Resident 203, who was severely cognitively impaired with diagnoses including hypertension, diabetes, Alzheimer's disease, stroke, anxiety, and stage 4 chronic kidney disease, was subjected to verbal threats and physical aggression. CNA 20 told Resident 203, 'if you hit me again I'll hit you back,' and then smacked the resident's face with a wet wipe and pushed her head down to the pillow when she attempted to sit up. This incident was witnessed by CNA 21, who intervened and reported the abuse to the QMA and ADON. The resident was unable to recall the incident due to her low cognition. The Administrator was informed of the incident on the same day, and CNA 20 was immediately asked to leave the building pending an investigation. Written statements were collected from witnesses, and the ADON assessed each resident for signs of abuse. The Social Service Director interviewed residents who could be interviewed. The abuse was substantiated, and CNA 20 was terminated from employment. The facility's policy on abuse prohibition, reporting, and investigation, last revised in January 2015, was reviewed and indicated that the facility should prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation.
Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to follow physician's orders related to hold parameters for a blood pressure medication for one resident. The resident, who was moderately cognitively impaired and had multiple diagnoses including dementia, heart failure, hypertension, stroke, diabetes, anxiety, and depression, was prescribed losartan 100 mg daily for hypertension. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 110 or the heart rate was less than 60. However, the clinical record lacked documentation of the resident's blood pressure and heart rate prior to the administration of the medication from 03/29/24 to 04/18/24, despite the medication being administered daily during this period. Interviews with staff, including an RN, a Qualified Medication Aide, and a Clinical Consultant, confirmed that the blood pressure and heart rate should have been documented on the Electronic Medication Administration Record (EMAR) if there were hold parameters for the medication. The facility's policy on medication administration, revised in 04/2017, also indicated that pulse and blood pressure should be taken as ordered prior to administering certain cardiac or antihypertensive drugs. The failure to document these vital signs as required led to the deficiency noted in the report.
Failure to Follow Physician's Orders for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to prevent and follow physician's orders related to a pressure ulcer for a resident with multiple diagnoses, including dementia, heart failure, and diabetes. The resident had a physician's order to wear Blue Prevalon boots at all times to prevent pressure ulcers. However, during multiple observations on different days, the resident was found in bed without the prescribed boots. The boots were observed on the top shelf of her closet instead of on her feet. Additionally, during wound care, the staff did not place the boots back on the resident's foot after treatment, contrary to the physician's order. Interviews with the facility wound physician and a Qualified Medication Aide (QMA) confirmed that the resident should have some form of off-loading, such as boots or a pillow, to prevent pressure ulcers. The clinical record lacked documentation indicating that the resident refused to wear the boots. The facility's policy on pressure ulcer prevention, which includes repositioning residents every two hours and floating heels, was not followed. This failure to adhere to physician's orders and facility policy led to the deficiency.
Failure to Provide Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident with frequent urinary tract infections. During an observation, a CNA was seen performing catheter care without following proper hygiene protocols. The CNA's gloves ripped, and she picked up the glove from the floor with her gloved hand, then continued to perform tasks without changing gloves. She also touched various surfaces and objects, including the resident's bedside table, nightstand, and bathroom fixtures, without changing gloves. Additionally, the CNA did not use a clean area of the washcloth for each motion while cleaning the catheter tubing, which contained dark urine with sediment. The resident's urinary catheter tubing was also observed lying on the bed, which is not a sanitary practice. The resident involved was moderately cognitively impaired and had a history of frequent UTIs, as indicated by multiple physician orders for antibiotics over several months. The facility's policy on catheter care, which aims to promote good hygiene and reduce infection risk, was not followed. The QMA confirmed that the resident had frequent UTIs and that catheter care was supposed to be performed every shift with proper hygiene protocols, including changing gloves if anything was touched before starting the catheter care.
Failure to Implement Interventions and Document Behaviors for Resident with Dementia
Penalty
Summary
The facility failed to implement interventions and complete behavior forms related to dementia care for a resident diagnosed with severe cognitive impairment, Alzheimer's disease, dementia, anxiety, depression, and psychotic disorder. The resident exhibited several behaviors, including physical aggression towards staff and other residents, wandering, and refusal to stay in his wheelchair. Despite these behaviors, the facility did not consistently document or implement effective interventions, such as the use of a door frame alarm, which lacked a physician's order and regular checks for functionality. The resident's aggressive behaviors were documented in multiple Mood and Behavior Communication Memos, indicating incidents of physical aggression towards staff and other residents. These incidents included hitting another resident, refusing to leave other residents' rooms, and being combative with staff. The interventions attempted, such as redirection, one-to-one observation, and providing a quiet environment, were often unsuccessful, and the outcomes of these interventions were frequently documented as unchanged or worsened. Interviews with staff revealed inconsistencies in the reporting and handling of the resident's behaviors. Staff members indicated that behavior sheets were not always completed, and there was confusion about the use of the door frame alarm, which was not consistently checked or ordered by a physician. The facility's policies on position change alarms and mood and behavior programs were not adequately followed, leading to a lack of proper documentation and intervention for the resident's behaviors.
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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