Stay Ahead of Compliance with Monthly Citation Updates


In your State Survey window and need a snapshot of your risks?

Survey Preparedness Report

One Time Fee
$79
  • Last 12 months of citation data in one tailored report
  • Pinpoint the tags driving penalties in facilities like yours
  • Jump to regulations and pathways used by surveyors
  • Access to your report within 2 hours of purchase
  • Easily share it with your team - no registration needed
Get Your Report Now →

Monthly citation updates straight to your inbox for ongoing preparation?

Monthly Citation Reports

$18.90 per month
  • Latest citation updates delivered monthly to your email
  • Citations organized by compliance areas
  • Shared automatically with your team, by area
  • Customizable for your state(s) of interest
  • Direct links to CMS documentation relevant parts
Learn more →

Save Hours of Work with AI-Powered Plan of Correction Writer


One-Time Fee

$49 per Plan of Correction
Volume discounts available – save up to 20%
  • Quickly search for approved POC from other facilities
  • Instant access
  • Intuitive interface
  • No recurring fees
  • Save hours of work
F0659
D

Unqualified Staff Administered Medication to Resident

Indianapolis, Indiana Survey Completed on 06-26-2025

Penalty

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A certified nursing assistant (CNA) administered medication to a resident without being qualified or authorized to do so, in violation of facility policy and state regulations. The incident occurred when the resident requested pain medication for a headache, and the CNA, instead of notifying a nurse, retrieved two capsules from behind the nurses' station and gave them directly to the resident. The resident, who was cognitively intact and had a physician's order for acetaminophen as needed, noticed the pills did not resemble his usual Tylenol and subsequently reported feeling unwell. He informed the nurse, who then contacted the physician and sent the resident to the emergency room for evaluation. Toxicology results confirmed the medication given was acetaminophen. The facility's investigation included statements from the CNA, who admitted to giving the pills to avoid making the resident wait for a nurse, and from the RN on duty, who was unaware of the resident's pain or the medication administration. The CNA's job description and the Indiana State Department of Health Nurse Aide Curriculum both explicitly prohibit CNAs from administering medications. The resident's clinical record indicated ongoing pain issues, and the care plan required medication administration by qualified personnel, which was not followed in this instance.

An unhandled error has occurred. Reload 🗙