Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Greenfield during CMS and state inspections, most recent first.
A resident’s edema was not monitored and documented as care planned, a Broda chair with a broken footrest was kept in use despite the manufacturer’s instructions, an OB/GYN referral for a resident with heavy menses and hemiplegia was not scheduled, psychotropic side effects such as drooling and tremors were not monitored as planned, and neuro checks after an unwitnessed fall were missed. The record showed the residents had significant medical needs, but staff did not carry out the ordered or care planned interventions and required documentation.
Unsigned narcotic count sheets were found on both medication carts, with multiple blank shift entries showing that the off-going and on-coming nursing staff did not complete the required controlled substance reconciliation. In addition, an expired box of Bisacodyl suppositories for a resident was observed in the medication storage area, and the QMA stated she was unaware the resident used the medication regularly.
A facility failed to maintain resident dignity by not ensuring a resident had a bra on, leaving another resident with food debris on his face, shirt, and Broda chair, and pulling a resident backwards in his Broda chair during transport. The residents involved had significant cognitive and physical impairments, including dementia, vascular dementia, hospice status, and dependence on staff for dressing, hygiene, and wheelchair use.
A resident with bipolar disorder and COPD had an Annual MDS that coded hospice status despite records showing the resident had been discharged from hospice and was no longer on hospice care. The ADON confirmed the resident was not currently on hospice, and the MDS Coordinator stated the hospice coding had been based on active orders rather than the resident’s status at the time of assessment.
Failure to maintain fall interventions and safe resident conditions for two residents. One resident with dementia, unsteady gait, and prior traumatic injuries after a fall was observed wearing slippers without nonskid soles, despite a care plan calling for gripper socks and proper footwear; therapy records also showed no recent treatment found by staff. Another resident with dementia, hemiplegia, and COPD was found with the bed not in the lowest position, the TV remote out of reach, and the call light wedged between the wall and mattress instead of being accessible as care planned.
Failure to follow a physician's order for catheter care was identified for a resident with an indwelling catheter and diagnoses including neuromuscular dysfunction of the bladder, dementia, and BPH with lower urinary tract symptoms. The MAR showed multiple omissions of the ordered 30 cc NS catheter flush on day shift, and the DON stated the reason for the omissions was unknown.
Medication Bottle Found With Missing Resident Label: A bottle of Milk of Magnesia was observed in a med cart with only the manufacturer's label present and no resident-specific labeling, including the resident's name, MD instructions, Rx number, date opened, or pharmacy information. The QMA noted the label appeared torn off, and the facility policy stated medications with damaged or missing labels should not remain in use.
A resident with anxiety and depression reported abuse by a CNA, including physical and verbal mistreatment. The incident was communicated to the BOM, but due to miscommunication during the Administrator's absence, the report to IDOH was delayed, violating the facility's policy on timely reporting of abuse allegations.
The facility failed to properly dispose of garbage, affecting all residents. During a kitchen tour, it was observed that a dumpster lid was left open, with trash and a glove on the ground nearby. The DM stated she couldn't reach the dumpster door to close it. Observations on subsequent days confirmed the lid remained open, violating the facility's policy requiring covered trash receptacles.
The facility failed to provide fluids at the bedside for seven residents, as required by their policy. Observations showed that residents, including those cognitively intact and impaired, did not have access to fresh ice water. Interviews with staff indicated that water passing was inconsistent and dependent on workload, leading to a deficiency in accommodating residents' needs.
The facility failed to protect residents from physical abuse, with multiple incidents of resident-to-resident altercations involving residents with cognitive impairments and behavioral issues. Despite care plans and staff presence, residents engaged in physical fights, highlighting deficiencies in abuse prevention and intervention measures.
The facility failed to manage soiled linen and PPE disposal properly, leading to deficiencies. Observations showed unbagged soiled linen overflowing from bins in hallways and improper disposal of PPE in uncovered trash receptacles outside rooms of residents under Enhanced Barrier Precautions. Interviews revealed staff were not adhering to the facility's Linen Handling Principles policy, and the Assistant Director of Nursing was unaware of the location of trash receptacle lids.
The facility failed to maintain a homelike environment for two residents. One resident's room had a sticky bathroom floor, an uncovered bedpan, and peeling paint, while another resident's bathroom was cluttered with items on the floor and a removed toilet lid. The Executive Director acknowledged these issues, attributing some to resident behavior.
A facility failed to document that a resident's representative was given a bed hold policy during a hospitalization. The resident, who was cognitively intact and had a stroke diagnosis, was unaware of the policy and did not receive paperwork before a hospital transfer. The Executive Director confirmed the staff could not find the policy, although it was expected to be provided at transfer.
The facility inaccurately encoded MDS information for two residents. One resident with bipolar disorder was incorrectly recorded as not having a PASARR Level II assessment, despite documentation of a serious mental illness. Another resident with chronic obstructive pulmonary disease was inaccurately recorded as not having a terminal prognosis, despite receiving hospice services and having a certification of terminal illness. The MDS Nurse attributed these errors to oversight.
A facility failed to complete a PASARR Level II for a resident diagnosed with schizophrenia before admission. The resident's clinical record showed no PASARR Level II was conducted, despite a Level I screen indicating the need for further evaluation. The Social Service Director cited an oversight due to an influx of residents as the reason for the lapse.
A facility failed to hold scheduled care plan meetings for a resident with dementia and major depressive disorder. Despite completing MDS assessments, there was no documentation of care plan meetings, including a scheduled meeting that lacked verification of occurrence. The resident's family member reported not having any care plan meetings to discuss missed medical appointments, and the Social Services Director confirmed the absence of documentation for these meetings.
The facility failed to follow its activities calendar and provide outdoor activities for residents. A resident reported missing scheduled card games due to lack of cards and was denied outings due to transportation issues. Another resident, who enjoys outdoor activities, noted no outings since February. A third resident experienced a lack of scheduled activities, with no substitute activities provided. Observations confirmed the absence of organized activities, contrary to the facility's policy.
The facility failed to date and document dressing changes for a resident with a forehead wound and did not complete required skin assessments for another resident on antiplatelet therapy. An LPN confirmed the lack of documentation for the dressing, and the DON acknowledged missing skin assessments in the EHR.
A resident with multiple diagnoses, including hemiplegia and major depressive disorder, did not receive timely optometry services despite consenting and having a care plan in place. The facility's Social Services Director confirmed that the resident had not been seen by the optometry provider, contrary to the facility's policy to assist residents in arranging on-site health services.
A facility failed to complete quarterly smoking assessments for a resident with chronic obstructive pulmonary disease who was cognitively intact and a cigarette smoker. The resident's care plan required assessments upon admission, quarterly, and as needed, but staff could not locate the assessments for the past year. The responsibility for these assessments was shared between activities and social services, as per the facility's smoking safety policy.
A cognitively impaired resident with Alzheimer's disease was left unsupervised during an aerosol treatment, resulting in the nebulizer tubing being detached from the face mask. An LPN later confirmed the resident's inability to self-administer the treatment, contrary to facility policy requiring supervision.
The facility was found to have expired supplies in two medication storage rooms. A urinary catheter and tuberculin syringes were expired in one room, while expired tuberculin safety syringes were found in another. A nurse stated it was the staff's responsibility to check for expired items. The facility's policy requires expired items to be stored separately until disposal or return.
A resident with hypothyroidism did not receive a routine lab test to monitor thyroid levels as ordered by a physician. The lab was unable to obtain the necessary blood sample, and the test was missed. The facility's Executive Director confirmed the oversight, and the nursing staff was responsible for obtaining the labs.
A resident with hemiplegia and major depressive disorder did not receive timely dental services for bottom dentures despite consenting to care and having a care plan in place. The facility's Social Services Director could not confirm any dental services provided to the resident, highlighting a failure in executing the facility's policy to assist with scheduling and arranging dental appointments.
A resident with recurrent UTIs was inappropriately treated with Macrobid for a UTI caused by Proteus mirabilis, an organism naturally resistant to this antibiotic. Despite culture results indicating resistance, the treatment was continued, contrary to the facility's Antimicrobial Stewardship Program policy.
Failure to Follow Care Plans, Orders, and Required Monitoring
Penalty
Summary
The facility failed to implement the care planned interventions for Resident 7’s edema. Resident 7 had diagnoses including atypical atrial flutter and schizophrenia, and a cardiovascular care plan directed staff to monitor for, document, and notify the provider of any edema. During observations and interviews, Resident 7 repeatedly stated that his legs and ankles were swollen, and staff observed indentations from his socks and redness to his shins. The nurse practitioner had ordered a bilateral lower extremity doppler for bilateral lower leg swelling and redness, and the assistant director of nursing confirmed the resident was having swelling and redness to his legs, but the record showed no change in the resident’s condition between the provider visit and follow-up. The facility also failed to follow the Broda chair user manual for Resident 5. Resident 5 had diagnoses including bipolar disorder and COPD, was on hospice, and required staff assistance with activities of daily living, including use of a Broda chair. Staff observed Resident 5 seated in a Broda chair in the dining area with the footrest broken off, and a QMA stated the footrest had been broken for awhile. The administrator stated the chair had broken the day before and the facility was waiting for a replacement. The Broda Operating Manual stated that if a breakage, defect, or operational problem is detected, the chair must be successfully repaired, inspected, and tested for function before it is returned to service. Resident 18 did not have the ordered OB/GYN appointment scheduled. Her diagnoses included hemiplegia and hemiparesis, and the nurse practitioner documented heavy menstrual bleeding lasting about 7 days per cycle, difficulty managing hygiene because of her physical limitations, and a referral to OB/GYN for evaluation and possible hormonal IUD placement. The physician’s order also directed referral to OB/GYN for pap smear and IUD placement. The record contained no information showing that an OB/GYN appointment had been scheduled, and the ADON confirmed that the appointment still needed to be scheduled. The NP and ADON both described delays and uncertainty about the status of outside appointments. The facility failed to monitor and document psychotropic medication side effects for Resident 8 as care planned, and failed to complete neurological checks for Resident 40 after an unwitnessed fall. Resident 8 had diagnoses including paranoid schizophrenia and personality disorder and was prescribed Invega Sustenna and olanzapine. His psychotropic care plan required monitoring for side effects every shift and documentation/reporting of adverse reactions such as tremors and drooling, but there was no documentation in the record or MAR showing that this monitoring was being done as planned. Observations showed Resident 8 drooling and having continuous hand shaking, and staff interviews indicated the drooling had been present for a long time and the tremors had been occurring for months. Resident 40 had an unwitnessed fall from his wheelchair, and neurological checks were initiated, but the neuro check forms showed missed checks during the required 24-hour period. His diagnoses included cognitive communication disorder, unspecified lack of coordination, and major depressive disorder, and he was moderately to severely cognitively impaired and used a wheelchair. The facility’s neurological assessment policy required neuro checks every 4 hours for 24 hours unless otherwise ordered, but the record showed omissions at multiple scheduled times after the fall.
Unsigned Narcotic Counts and Expired Medication Found
Penalty
Summary
The facility failed to ensure narcotic reconciliation records were signed by both the off-going and on-coming nursing staff at each of three shift changes daily. During review of the east medication cart narcotic count sheets, several dates were found blank, including 9-3-25 first shift, 9-11-25 first shift, 9-17-25 second and third shifts, and 9-18-25 first shift. Review of the west medication cart narcotic count sheets also showed blank entries for 8-4-25 first shift, 8-18-25 first shift, and 8-31-25 first shift. The Administrator stated she was unaware of the unsigned narcotic count logs on either hall. The facility also failed to maintain expired medications within the facility for one resident. During observation of the west hall medication storage room and locked refrigerator, a box of six Bisacodyl Suppositories for Resident 24 was found with an expiration date of 2-28-25. The medication label indicated it was to be given every eight hours as needed for constipation. The QMA stated she was unaware of this resident using the medication on a regular basis.
Failure to Maintain Resident Dignity During Dressing, Hygiene, and Transport
Penalty
Summary
The facility failed to assist a resident with putting on a bra, provide a resident with clean clothes and a clean Broda chair, and transport a resident in a dignified manner by pulling him backwards in his Broda chair for 3 of 3 residents reviewed for dignity. Resident 38, who had diagnoses including multiple rib fractures, fractures of nasal bones, vascular dementia, and an unsteady gait, was observed on multiple occasions fully dressed but without a bra in place. Her quarterly MDS indicated she was severely impaired for daily decision making, had no behaviors of refusal of care, and required partial/moderate assistance with dressing and putting on footwear. The DON stated nursing staff would be responsible to ensure Resident 38 had a bra on. Resident 5, whose diagnoses included bipolar disorder and COPD, was not cognitively intact, was on hospice, and was dependent on staff for transferring and using a wheelchair. His care plan indicated he would have a clean appearance and that he was dependent on staff for hygiene needs. During observations, he was sitting in a Broda chair in the dining area with food debris on his face, shirt, and chair, and no staff were directly assisting him. Resident 24, who had dementia, hemiplegia, COPD, left thigh contracture, and right shoulder contracture, was observed being assisted out of the dining room when a QMA pulled him backwards in his Broda chair. The chair struck a vending machine, causing a metal strip to come loose and fall to the floor. The QMA stated it was easier to pull him backwards, while the DON stated staff should push residents in their Broda chairs and that pulling them was a dignity and safety concern.
MDS Hospice Status Was Inaccurately Coded
Penalty
Summary
The facility failed to accurately encode an MDS assessment for one resident reviewed for hospice status. The resident had diagnoses of bipolar disorder and chronic obstructive pulmonary disease. An Annual MDS dated 9/5/2025 indicated the resident was not cognitively intact, did not refuse care, had a prognosis of 6 months or less, and was on hospice. However, a nursing progress note dated 8/28/2025 stated the resident was discharged from hospice, and a census change dated 8/28/2025 showed the payor source was changed from hospice to Medicaid. During interviews, the ADON stated the resident had been discharged from hospice and was not currently on hospice care, while the MDS Coordinator stated the hospice status had been coded based on active orders and that a modification would be initiated to reflect the resident's status at the time of assessment.
Failure to Maintain Fall Interventions and Safe Resident Environment
Penalty
Summary
The facility failed to implement fall interventions after a resident’s fall, failed to provide appropriate footwear, and failed to maintain fall interventions that were already care planned for two residents reviewed for falls. One resident had diagnoses including multiple rib fractures, fractures of the nasal bones, vascular dementia, and an unsteady gait. The quarterly MDS indicated the resident was severely impaired for daily decision making and required partial/moderate assistance with putting on footwear. The care plan included interventions to encourage gripper socks, wear proper footwear, and have Physical Therapy evaluate and treat when the resident returned from the hospital, but no additional interventions were documented after the resident’s fall. The resident’s record showed a witnessed fall outside the shower room when the resident was walking and tripped on a shoe. The resident sustained an open area on the nose with bleeding, fractured ribs, and later required transport to the hospital and then to a major medical hospital for admission. During multiple observations after the fall, the resident was seen wearing house slippers without nonskid soles while sitting in a chair, in a wheelchair, and at the dining room table. Therapy staff stated they could not find evidence that the resident had been evaluated or treated since January 2025, and the Therapy Manager stated the resident was last treated from 1/23/25 to 2/20/25. The DON stated the IDT was responsible for ensuring a fall intervention was implemented after the fall and nursing staff were responsible for ensuring appropriate footwear. A second resident with diagnoses including dementia, hemiplegia, COPD, left thigh contracture, and right shoulder contracture had a fall care plan revised to include a television remote within reach, a safe environment with a working and reachable call light, call light within reach, and the bed in the lowest position. During observation, the resident’s bed was not in the lowest position, the television remote was not within reach, and the call light cord was wedged between the wall and mattress so the actual call light was not reachable. CNA staff had to pull the cord free, place the call light on the resident, retrieve the remote from a drawer, and lower the bed using the bed remote.
Failure to Follow Catheter Flush Order
Penalty
Summary
The facility failed to follow a physician's order to flush an indwelling catheter with 30 cc of normal saline every shift for Resident 40. The resident's clinical record showed diagnoses including neuromuscular dysfunction of the bladder, dementia, and benign prostatic hyperplasia with lower urinary tract symptoms, and the Quarterly MDS dated 6/20/25 indicated the resident had an indwelling catheter. A physician's order dated 2/24/24 directed catheter irrigation/flush with 30 cc of normal saline every shift, but the September 2025 MAR showed omissions on the day shift for 9/5/25, 9/12/25, 9/16/25, 9/17/25, 9/23/25, and 9/24/25. During interview, the DON stated they did not know why the omissions occurred and that the nurse caring for the resident was responsible to ensure orders were followed.
Medication Bottle Found With Missing Resident Label
Penalty
Summary
The facility failed to ensure that medications in use were labeled in accordance with accepted professional principles. During an observation of the west hall medication cart with a QMA, one bottle of Milk of Magnesia was found with only the manufacturer's label present. The bottle did not have labeling showing the resident's full name, physician's name, specific physician instructions for use, prescription number, date of issue, date opened, or the name and address of the dispensing pharmacy. The label appeared to have been torn off, and the QMA stated it appeared the label had been removed in some manner, with only a small piece of label-like material remaining on the side of the bottle. The manufacturer's label on the Milk of Magnesia included directions for use stating to administer 2 to 4 tablespoons daily, preferably at bedtime, in divided doses and/or as directed by the physician, and to give with 8 ounces of fluid with each dose. Later, the Assistant DON provided the facility's Medication Storage policy, dated 7-2-19, which stated that medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels should be destroyed and reordered.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the Indiana Department of Health (IDOH) in a timely manner for one resident. Resident B, who has diagnoses including anxiety and depression, reported an incident involving a Certified Nursing Assistant (CNA) who allegedly grabbed her arm, shook her, and verbally abused her. This incident was reported by Resident B to the night shift nurse and also communicated via email to the Business Office Manager (BOM) the following morning. Despite the BOM's acknowledgment and initiation of an investigation, the allegation was not reported to the IDOH until several days later. The delay in reporting was attributed to a miscommunication regarding responsibility for reporting in the absence of the Administrator, who was on vacation. The BOM assumed the Assistant Director of Nursing (ADON) was responsible for reporting the incident. The facility's policy mandates that any allegation of abuse must be reported immediately, but not more than two hours after the allegation, or within 24 hours if it does not involve serious bodily injury. The report to IDOH was only made on 10/11/24, several days after the incident was initially reported by Resident B.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, affecting all 52 residents. During a kitchen tour with the Dietary Manager (DM), it was observed that the outside dumpster area had issues with trash containment. Specifically, one of the dumpsters had its left lid completely open, with a clear bag of trash and a blue glove on the ground nearby. Several bags of trash were also visible inside the open dumpster. The DM indicated she was unable to reach the dumpster door to close it. Subsequent observations on the following days confirmed that the same dumpster lid remained open. The facility's Garbage and Rubbish Disposal policy requires all containers to have tight-fitting lids and for outdoor trash receptacles to be covered, which was not adhered to in this instance.
Failure to Provide Bedside Fluids for Residents
Penalty
Summary
The facility failed to ensure that fluids were available at the bedside for seven residents, leading to a deficiency in accommodating the needs and preferences of these residents. Observations and interviews revealed that residents did not have access to fresh ice water, which was supposed to be provided at least three times a day according to the facility's policy. Residents 21, 31, 35, 41, 43, 19, and 30 were all observed without water at their bedsides during various times, and some residents reported that they rarely received fresh ice water. Resident 21, who was cognitively intact, reported that ice water was no longer passed at night, and they had to get water themselves. Similarly, Resident 35, also cognitively intact, indicated that fresh ice water was rarely provided. Resident 41, who was cognitively intact, mentioned that the only water available was for flushing out their feeding tube. Resident 43, another cognitively intact individual, noted that ice water was hardly brought into their room. These observations were consistent over multiple days, indicating a systemic issue in the facility's hydration practices. Residents 19 and 30, both cognitively impaired and dependent on staff for daily tasks, were also found without fluids in their rooms. Interviews with staff, including CNAs, revealed that the passing of water depended on their workload and was not consistently done. The Executive Director confirmed that all staff could pass fluids, but it was primarily the responsibility of direct care staff to ensure fresh fluids were provided every shift. The facility's policy on hydration was not being adhered to, resulting in the deficiency noted by the surveyors.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident 45, who was severely cognitively impaired and had a history of combative behavior and hallucinations, was involved in several altercations with other residents. These incidents included being smacked by a male resident and engaging in physical fights with other residents, such as Resident 31 and Resident 2. The facility's care plans for these residents indicated goals to prevent harm and reduce aggressive behaviors, but these measures were not effectively implemented. Resident 31, diagnosed with bipolar disorder, depression, psychotic disorder, and schizophrenia, was involved in an altercation with Resident 45, where both residents physically attacked each other. Another incident involved Resident 31 slapping Resident 33, who had a traumatic brain injury, in the face and back of the head. These incidents were witnessed by staff, and the facility's investigative files included interviews with staff members who were present during the altercations. Despite the presence of staff and administration, the facility failed to prevent these occurrences of physical abuse. Resident 2, diagnosed with dementia and schizophrenia, was also involved in an altercation with Resident 45, where he struck her in the eye. Similarly, Resident 13, with schizoaffective disorder and major depression, was hit by Resident 45. The facility's policy on abuse prevention and reporting was not effectively enforced, as evidenced by the repeated incidents of resident-to-resident abuse. The facility's failure to protect residents from physical abuse and to implement effective interventions for residents with aggressive behaviors led to these deficiencies.
Deficiencies in Linen and PPE Management
Penalty
Summary
The facility failed to properly manage soiled linen and personal protective equipment (PPE) disposal, leading to several deficiencies. Observations revealed that soiled linen was not bagged and was overflowing from bins in the hallways, preventing the lids from closing. Certified Nursing Assistants (CNAs) were observed transporting soiled linen without using bags, contrary to the facility's Linen Handling Principles policy. This policy mandates that soiled linens be bagged at the location of use and not transported openly through corridors. Interviews with CNAs indicated a lack of adherence to these guidelines, as they admitted to placing unbagged linen into hallway bins. Additionally, the facility did not ensure proper disposal of PPE used in rooms with residents under Enhanced Barrier Precautions (EBP). Observations showed uncovered trash receptacles in hallways outside rooms of residents in EBP, containing visible used PPE such as gowns and gloves. Interviews with the Assistant Director of Nursing (ADON) revealed that staff were doffing PPE in the hallway and discarding it in uncovered receptacles, which lacked lids. The ADON acknowledged the issue but was unaware of the location of the lids, indicating a lapse in maintaining proper infection control measures.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as observed during a survey. Resident 43, who has diagnoses including type 2 diabetes mellitus, alcoholic cirrhosis of the liver, and schizophrenia, was found to have a sticky bathroom floor, an uncovered bedpan, an open bag of adult diapers on the floor, and peeling paint on the walls behind the bed frames. The Executive Director (ED) acknowledged awareness of the paint issue, attributing it to the residents moving their beds and scuffing the walls, despite maintenance efforts to repaint. Resident 31, with diagnoses including chronic obstructive pulmonary disease, cerebral infarction, heart failure, and hypertension, was observed to have a bathroom floor littered with a Styrofoam cup, lid, straw, wash basin, and toilet paper. Additionally, the toilet bowl lid was found off and placed on the floor. The ED indicated that the resident had removed the lid, which was later replaced. The resident's care plan, revised earlier in the year, stated the provision of a homelike environment, and the admission packet confirmed the right to a safe, clean, and comfortable environment.
Failure to Provide Bed Hold Policy Documentation
Penalty
Summary
The facility failed to maintain documentation that Resident 5's representative was provided with a bed hold policy during a hospitalization. Resident 5, who had a diagnosis of stroke and was cognitively intact according to a recent MDS assessment, went on a therapeutic leave from July 22 to July 26, 2024. During an interview, Resident 5 stated he was unaware of the bed hold policy and did not receive any related paperwork before his hospital transfer in July 2024. The Executive Director confirmed that the staff could not locate the bed hold policy for Resident 5's hospitalization, although it was expected that nursing staff would provide this policy at the time of transfer. A blank copy of the Bed Hold Policy Notice was later provided by the Executive Director.
Inaccurate MDS Encoding for Two Residents
Penalty
Summary
The facility failed to accurately encode Minimum Data Set (MDS) information for two residents, leading to deficiencies in their assessments. Resident 5, diagnosed with bipolar disorder, was inaccurately recorded as not having a PASARR Level II assessment, despite having a serious mental illness documented in a PASARR Level II dated 6/21/19. The Social Services Director confirmed the presence of this serious mental illness and the outdated PASARR Level II assessment. Resident 19, with a diagnosis of chronic obstructive pulmonary disease, was inaccurately recorded in a Quarterly MDS assessment as not having a prognosis of six months or less, despite receiving hospice services. A hospice care plan and a certification of terminal illness indicated a terminal diagnosis with a life expectancy of six months or less. The MDS Nurse acknowledged that these assessments were coded incorrectly due to oversight. The facility's policy requires all assessments to be completed timely and accurately, as per the Resident Assessment Instrument Manual.
Failure to Complete PASARR Level II for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level II was completed for Resident 11, who was diagnosed with schizophrenia, prior to their admission. The clinical record review revealed that the Admission Minimum Data Set (MDS) assessment dated February 1, 2024, indicated the absence of a PASARR Level II for Resident 11. According to the Indiana State Department of Family and Social Services Administration, all applicants to Medicaid-certified nursing facilities must undergo a Level I screen to initiate the PASARR process, and if necessary, a Level II evaluation is conducted to identify specialized needs for individuals with mental illness or intellectual/developmental disabilities. A PASARR Level I for Resident 11, dated January 24, 2019, indicated the need for an on-site Level II review, which was not completed. During an interview, the Social Service Director (SSD) acknowledged the lack of documentation for a Level II review after January 24, 2019, attributing the oversight to an influx of residents at the time of Resident 11's admission. The facility's policy on PASARR, provided by the Director of Nursing, stated that the facility would participate in or complete the Level I screen for all potential admissions and refer individuals requiring a Level II screening to the State PASARR representative.
Failure to Conduct Scheduled Care Plan Meetings
Penalty
Summary
The facility failed to hold regularly scheduled care plan meetings for a resident, identified as Resident 45, who was admitted with diagnoses including dementia and major depressive disorder. Upon review of the clinical records, it was found that although an Admission MDS assessment was completed on 11/14/23 and a Quarterly MDS assessment on 5/1/24, there were no corresponding care plan meetings documented. A care plan meeting was scheduled for 5/23/24, but there was no evidence that it took place. Additionally, there was no documentation of a care plan meeting following the resident's admission in November 2023. Family Member 2, who is associated with Resident 45, reported not having any scheduled care plan meetings with the facility to discuss missed medical appointments. The Social Services Director, in the presence of the ADON, confirmed the absence of documentation for the care plan meetings and was unable to verify if the scheduled meeting in May 2024 occurred. The facility's Comprehensive Care Plan policy requires that care plan meetings be held quarterly and that residents and their representatives be invited to participate, but this was not adhered to in the case of Resident 45.
Failure to Provide Scheduled and Outdoor Activities
Penalty
Summary
The facility failed to adhere to its scheduled activities calendar and provide outdoor activities for residents, as observed in the cases of three residents. Resident 35, who has multiple diagnoses including fibromyalgia and type 2 diabetes, reported that scheduled card games did not occur due to the unavailability of cards. Additionally, Resident 35 expressed a desire to participate in outings, but was informed by the facility that transportation limitations prevented such activities. Resident 41, diagnosed with conditions such as acute respiratory failure and major depressive disorder, also expressed dissatisfaction with the lack of outings. Despite being cognitively intact and having a care plan that noted his enjoyment of outdoor activities, Resident 41 reported that the facility had not organized any community outings since February 2024. The Activities Director confirmed the transportation constraints, noting the facility's small van capacity as a limiting factor. Resident 34, with diagnoses including hemiplegia and hypertension, experienced a lack of scheduled activities. On multiple occasions, activities listed on the calendar, such as the Daily Chronicle and Church services, did not occur. Resident 34 was unaware of certain activities and expressed a desire for more off-site activities, which were not reflected in his care plan. Observations confirmed that scheduled activities were not taking place, and the facility's activity policy was not being followed, as evidenced by the lack of organized activities and the absence of outings on the calendar.
Failure to Document Dressing Changes and Conduct Skin Assessments
Penalty
Summary
The facility failed to properly manage the care of two residents with skin impairments. For Resident 1, who has schizophrenia and is cognitively impaired, the facility did not date, time, or initial the dressing applied to a non-pressure wound on the forehead. Observations on consecutive days revealed that the dressing lacked these details, and the staff member responsible for the dressing change was not identified. An LPN confirmed the omission and was unaware of when the dressing was last changed. For Resident 34, who has hemiplegia, hemiparesis, and a history of cerebral vascular accident, the facility did not complete the required skin assessments as outlined in the care plan. Despite being on antiplatelet therapy, which can cause skin changes, only one skin assessment was documented in August, which did not include the resident's arms where dark spots were present. The DON acknowledged the lack of documentation for the required daily skin inspections and weekly assessments, as per the facility's policy.
Failure to Provide Timely Optometry Services
Penalty
Summary
The facility failed to provide timely optometry services to a resident who had consented to receive such services. Resident 34, who had diagnoses including hemiplegia, hemiparesis, major depressive disorder, and hypertension, was admitted to the facility and had a care plan indicating consent for optometry services. Despite a physician's order from October 2022 allowing optometry visits as needed and an assessment in August 2024 indicating the need for assistance with corrective lenses, there were no records of optometry consultations in the resident's clinical record. An interview with the Social Services Director (SSD) revealed that the facility used a specific provider for optometry services, who was responsible for gathering consent forms and scheduling appointments. The SSD, who had been working at the facility since November 2023, indicated that the optometry provider was in the facility in August 2024, but Resident 34 was not seen during that visit. The SSD confirmed that Resident 34 had not received optometry services at the facility since the SSD began working there. The facility's policy stated that it would assist residents in arranging on-site health services as needed, but this was not fulfilled for Resident 34.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for a resident who was reviewed for smoking safety. The resident, who was cognitively intact and had a diagnosis of chronic obstructive pulmonary disease, was identified as a cigarette smoker. The resident's smoking care plan required smoking assessments to be conducted upon admission, quarterly, and as needed. However, during an interview, the Executive Director acknowledged that the staff could not locate the quarterly smoking assessment for the resident for the past year. The responsibility for completing these assessments was shared between activities and social services. The facility's policy on smoking safety also stipulated that smoking assessments should be completed at admission, quarterly, and as needed.
Inadequate Supervision During Aerosol Treatment
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident, Resident 30, during the administration of an aerosol generating procedure. Resident 30, who has Alzheimer's disease and is dependent on staff for all activities of daily living, was observed with a nebulizer running but the tubing was detached from the face mask, which was placed under the resident's chin. This observation occurred while Resident 30 was alone in their room, indicating a lack of supervision during the administration of the aerosolized medication. Licensed Practical Nurse (LPN) 13, upon entering the room, acknowledged that Resident 30 frequently pulls off the treatment and confirmed that the resident should be supervised during the administration of aerosolized medication, as they are not capable of self-administering the treatment. The facility's policy on nebulizer medication administration requires staff to remain with the resident during treatment unless the resident has been assessed and authorized to self-administer, which was not the case for Resident 30.
Expired Supplies Found in Medication Storage Rooms
Penalty
Summary
The facility failed to ensure that medication storage rooms were free of expired supplies, as observed in two medication rooms. During an inspection, a urinary catheter with an expiration date of 2022 and a box of tuberculin syringes with an expiration date of 2023 were found in one medication storage room. In another room, a box of tuberculin safety syringes and six individual safety syringes were found to be expired. A registered nurse indicated that it was the responsibility of the nursing staff to check the medication storage rooms to ensure that supplies were not expired. The facility's policy on medication storage, revised on an unspecified date, stated that expired medications and biologicals should be stored separately until they are destroyed or returned to the supplier.
Missed Routine Lab Test for Resident with Hypothyroidism
Penalty
Summary
The facility failed to ensure that a routine laboratory test was conducted for a resident, identified as Resident 19, who was diagnosed with hypothyroidism. The resident's clinical record was reviewed, revealing a physician's order dated May 23, 2024, which required routine laboratory tests every six months to monitor thyroid levels. However, a nursing progress note from the same date indicated that the lab was unable to obtain the necessary blood sample for the tests and planned to try again on the next lab day. Despite this, the Executive Director confirmed during an interview that the facility could not find any record of the thyroid level lab being obtained in May 2024, resulting in a missed test. The nursing staff was responsible for ensuring that labs were obtained as per the physician's order.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services to a resident, identified as Resident 34, who required bottom dentures. Resident 34, who was cognitively intact and had diagnoses including hemiplegia, hemiparesis, major depressive disorder, and hypertension, was admitted to the facility with a care plan indicating the need for routine dental referrals. Despite consenting to dental services and having a physician's order for dental consultations as needed, there were no records of dental consultations in his clinical record. An observation and interview with Resident 34 revealed that he had not seen a dentist since his admission and was missing bottom dentures. The Social Services Director (SSD) confirmed that the facility used a specific provider for dental services, who was responsible for gathering consent forms and scheduling appointments. However, the SSD, who had been working at the facility since November 2023, could not confirm any dental services provided to Resident 34 during their tenure. The facility's policy stated that they would assist residents in scheduling dental appointments and arranging transportation if necessary, but this was not executed for Resident 34, leading to the deficiency.
Inappropriate Antibiotic Use for UTI Treatment
Penalty
Summary
The facility failed to ensure the appropriate use of antibiotics for the treatment of a urinary tract infection (UTI) in a resident with a history of dementia, psychotic disorder, and recurrent UTIs. On July 9, 2024, a urine specimen was collected for urinalysis with culture and sensitivity testing. The following day, a physician noted a possible UTI and planned to start the resident on Macrobid if the culture results were not available. By July 11, 2024, a care plan was initiated indicating the resident had a UTI, and Macrobid was prescribed. On July 12, 2024, the culture results identified the organism as Proteus mirabilis, which is naturally resistant to Macrobid. Despite this, the Nurse Practitioner was notified and decided to continue the Macrobid treatment. The facility's Antimicrobial Stewardship Program policy, which promotes appropriate antibiotic use, was not adhered to in this instance, as the prescribed antibiotic was not suitable for the identified organism.
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What surveyors actually found near you
We read the 750 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greenfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springhurst Health Campus | 0.6 mi | ★★★★★ | 1 | 1 |
| Greenfield Healthcare Center | 1.2 mi | ★★★★★ | 11 | 0 |
| Brickyard Healthcare - Brandywine Care Center | 1.4 mi | ★★★★★ | 11 | 0 |
| Majestic Care Of Mccordsville | 9.1 mi | ★★★★★ | 0 | 0 |
| Morristown Manor | 10.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.