Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Vincennes during CMS and state inspections, most recent first.
A resident with ESRD and dependence on renal dialysis had orders and a care plan for dialysis three times weekly, but the facility could not retrieve dialysis communication forms and the binder was empty. An LPN said the forms were used to share pre- and post-dialysis vital signs and new orders, while the DON stated the dialysis center changed the resident’s schedule to two treatments per week without notifying the facility. A handwritten note and dialysis attendance record showed the resident was scheduled for two weekly treatments and often missed appointments.
Pharmacy services failed to ensure ordered meds were available for two residents. One resident with ESRD, CHF, cirrhosis, and pneumonia missed multiple doses of hydrocodone-acetaminophen, and an antibiotic ordered after hospital discharge was delayed because the facility initially received incomplete discharge paperwork. Another resident with polyneuropathy, IBS, and glaucoma missed doses of pregabalin, Artificial Tears, and Lomotil because the meds were pending from pharmacy, not in the EDK, and staff documented pharmacy transition and insurance issues.
A resident with ESRD, CHF, cirrhosis, and A-fib had a physician order for daily PT/INR testing for two weeks due to increased results, but the MAR/TAR showed missed lab draws and the order was later discontinued. Nursing notes stated the lab could not come to the facility that weekend, and the DON, Facility Administrator, and RN reported the contracted lab service was only available once weekly and the hospital lab could not come to the facility.
A facility failed to ensure accurate MDS coding for several residents. One resident with documented PASRR approval was not marked as having PASRR, two residents receiving hospice were coded as not on hospice despite records and orders showing hospice services, and another resident with a dementia diagnosis was not identified as having dementia on the MDS. The MDS Coordinator acknowledged the coding errors, including an entry error and an incorrect assumption that dementia should only be marked if the resident was taking dementia medications.
The facility failed to follow physician orders for wound care, weekly weights, and post-hospital medication review. A resident with stage 3 and stage 4 pressure ulcers missed multiple ordered wound treatments, three residents with dementia and weight loss did not receive ordered weekly weights, and a resident returning from the hospital had discontinued psychotropic medications that were not documented as reviewed with the PCP. The DON and other staff described gaps in documentation, unclear weight-obtaining procedures, and lack of medication clarification after return from the hospital.
Unsecured Medication Cart and Unattended Medications: An LPN left the D Hall med cart unlocked and unsupervised in a dining area while residents and staff walked by, and later left multi-use medication cards with remaining meds on top of the cart while walking away to administer meds to A resident. The Administrator provided a policy stating meds and biologicals must be securely stored in a locked cabinet/cart or locked med room inaccessible to residents and visitors.
Missing bed hold, transfer/discharge, and ombudsman notification documentation was found for multiple residents who were sent to the ER or hospitalized. Records for residents with conditions including dementia, COPD, CHF, pneumonia, diabetes, and other diagnoses lacked required forms and notifications, and the ombudsman confirmed no notice was received for the reviewed transfers/discharges.
A facility failed to provide dependent residents with scheduled ADL care, including showers and oral care. Three residents had repeated missed showers and numerous missed oral care entries despite care plans and MDS assessments showing they needed staff assistance. During Resident Council, all residents present said they were not getting showers as scheduled, and an anonymous interview also reported that oral care and showers were not being performed.
A resident with epilepsy and severe cognitive impairment had a routine lorazepam order discontinued even though a physician had documented that stopping the medication was contraindicated and likely harmful. While the order was discontinued, the resident had seizures and required PRN lorazepam. The record lacked documentation of physician communication or family notification, and the family stated she was not told and would not have agreed to the change.
A resident receiving hospice care with chronic pain had uncontrolled pain, and staff did not consistently administer ordered routine pain medication, including a fentanyl patch that was missed on multiple scheduled dates. The record lacked consistent documentation of pain characteristics, non-pharmacological interventions, and MD notification. Progress notes and interviews showed confusion about the fentanyl order, inconsistent communication with hospice, and ongoing complaints of pain despite PRN analgesics.
Inaccurate resident record documentation was found for 2 residents. One resident had vital signs documented in the chart while in the hospital, and another had a shower documented even though it was not given. A resident with pneumonia, DM2, TBI history, trach, G-tube, and a Stage 4 PU was dependent on staff for care, while another resident was observed with greasy hair, scalp flakes, urine odor, and no shave; an LPN said CNAs should document showers only when completed, and the Administrator said shower documentation practices were inconsistent.
A resident receiving hospice services had no hospice communication documented in the clinical record. The resident was cognitively intact, dependent on staff for several ADLs, and had diagnoses including anxiety, depression, chronic pain, gastroparesis, and malnutrition. An LPN said hospice and nursing staff communicated verbally and a binder at the nurse’s station was not used or updated, while the DON said the facility had never documented hospice communication that way. The hospice contract and hospice services policy required regular communication and documentation in the record.
A resident with an indwelling urinary catheter did not receive routine catheter care as ordered on numerous day and night shifts, and CNA documentation showed repeated missed care. The resident later left the facility by EMS and was admitted to the hospital with sepsis and a CAUTI. An LPN stated catheter care should be done each shift and documented by CNAs, and the DON said she expected it to be done per order and documented in the EHR.
Survey results were not readily available to residents, visitors, or other individuals. The survey binder could not be located at first, residents and the Receptionist did not know where it was, and when it was later viewed it lacked the past 3 years of survey results. The Administrator stated only annual surveys had been placed in the binder and complaint surveys were not included, even though the past 3 years should have been available.
Failure to Post Nurse Staffing Information at All Entrances: The facility did not ensure the nurse staffing form was posted at all entrances, with the form only observed near the main office and time clock while multiple hall entrances lacked the posting. Staff interviews confirmed visitors used all entrances, and the Administrator stated the state regulation was provided as policy.
Two residents receiving hospice care did not have collaborative care plans established, and required routine assessments and physician orders were not completed or documented. Pain and oxygen assessments were missed, and the effectiveness of PRN medications was not consistently monitored or recorded, contrary to facility policy.
A resident with significant mobility impairments was given a cup of hot water by a CNA who did not check the temperature or monitor the resident. The resident accidentally spilled the hot water while adjusting her bed, resulting in second-degree burns to her abdomen, back, and hip. The incident occurred due to staff not following facility procedures for serving hot beverages.
The facility did not ensure a safe, clean, and homelike environment in certain resident units and a dining room, as evidenced by missing paint, missing cove base, a window covered with plywood, peeling door coverings, and black discoloration on a ceiling. Maintenance issues were observed in multiple areas, and repairs were delayed due to reliance on outside contractors.
Surveyors found that food was stored directly on the floor in both dry storage and the walk-in freezer, and there was a buildup of dust and debris in multiple kitchen areas. Staff interviews revealed daily cleaning checklists were not being completed or were unknown to some, and the kitchen was short-staffed. The Dietary Manager confirmed that cleaning and proper food storage practices were not being followed, in violation of facility policy.
A facility failed to provide necessary treatment and services for pressure injuries in three residents. One resident with heart failure and diabetes had unstageable pressure ulcers on the heel and coccyx, with incomplete care plans and inconsistent treatment. Another resident with hemiplegia had an unstageable ulcer on the buttock, with delayed care planning and treatment inconsistencies. A third resident with paraplegia had a Stage 4 ulcer, with treatment delays and discrepancies in assessments. These deficiencies highlight inadequate pressure ulcer care.
The facility failed to employ a certified Dietary Manager, as the current manager's certification had expired and she had not completed the necessary training. Despite being on a 30-day Performance Improvement Plan, the Dietary Manager had not yet passed her certification test, and the Administrator was aware of the situation.
The facility failed to provide timely transfer or discharge notices to residents or their representatives for five hospitalizations. Clinical records lacked documentation of notices, and staff interviews revealed gaps in the process. The Social Services Director could not verify sending reports to the ombudsman, and the facility's policy was not provided.
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, affecting five residents. Clinical records lacked documentation of the policy being given, and staff interviews confirmed the oversight. The facility's bed hold policy requires notification upon admission and transfer, but this was not followed.
The facility failed to update comprehensive care plans for several residents, including one with an outdated catheter care plan, another with unaddressed declines in eating and mobility, a resident on an NPO diet without corresponding care plan interventions, and a resident with bed and chair alarms not reflected in their care plan. The facility's policy required care plans to be reviewed and revised by the IDT after each assessment, which was not followed.
A facility failed to provide appropriate care for a resident with dementia, as a CNA was reported to provide substandard care and exhibit intimidating behavior. The resident, who required assistance with ADLs, was observed with unkempt hair and left unattended. Staff reported the CNA's conduct, including denying residents' requests and neglecting duties, but no corrective action was taken.
The facility failed to ensure safe medication storage and administration for five residents. Medications were pre-prepared and stored in medication carts against facility policy. A QMA admitted to pre-preparing medications for four residents, while an LPN stored refused medications for another resident in the cart. The DON was unaware of the policy, which states medications should be administered when prepared.
The facility failed to ensure dietary staff followed menus, as identified during a kitchen review. The Administrator, who took over in December 2024, found significant issues with kitchen operations, leading to a Performance Improvement Plan (PIP) for the Dietary Manager. The PIP highlighted the need for staff to follow menus, order correctly, and complete inventory checks. The majority of resident grievances were related to dietary services, indicating a widespread issue.
The facility failed to maintain infection control standards, as observed in the care of several residents. CNAs did not sanitize hands between glove changes during incontinence care for a resident, and a glucometer was used without cleaning between residents. Additionally, Enhanced Barrier Precautions were not consistently implemented for residents with open wounds or indwelling devices, as staff did not wear gowns or follow proper protocols.
The facility failed to treat residents with dignity and respect, as evidenced by incidents involving three residents. A resident reported rude and unresponsive night staff, another faced a degrading confrontation for calling his sister for help, and a third was subjected to inappropriate comments by the ADON during medication administration. These incidents highlight a lack of adherence to the facility's Resident Rights policy.
The facility failed to conduct timely care plan conferences for three residents, including one with chronic conditions and dementia, another with severe cognitive impairment, and a third with chronic kidney disease. The Social Services Director confirmed that care plan conferences were not held quarterly as required, despite the facility's policy.
A facility failed to clarify a resident's code status, leading to a discrepancy between the physician's order and the POST form. The resident, with severe cognitive impairment and multiple diagnoses, was listed as Full Code in the physician's orders but as DNR on the POST form. A nurse indicated she would follow the Full Code status despite the inconsistency, contrary to the facility's policy requiring matching documentation.
A facility failed to provide a detailed incident report for an alleged abuse involving a CNA and a resident with severe cognitive impairment. The report lacked specifics about the incident where the CNA was accused of inappropriate conduct during care. An investigation found no signs of abuse, but the initial report did not meet the facility's policy requirements for detailed documentation.
The facility failed to develop care plans for residents receiving specific treatments. A resident on hospice lacked a hospice care plan, while another with severe cognitive impairment had no care plans for bed and chair alarms or antiplatelet medication. Additionally, a resident on anticoagulants did not have a corresponding care plan, contrary to facility policy.
The facility failed to ensure proper catheter care and documentation for two residents, leading to deficiencies in preventing UTIs. One resident had a catheter bag incorrectly placed under his leg, while another had a Foley catheter without a physician's order or care plan. Staff interviews confirmed these lapses in compliance with facility policies.
A facility failed to timely administer antibiotics to a resident post-hospital discharge, leading to missed doses. The resident, with multiple health conditions, was discharged with orders for cefdinir and doxycycline, but the facility did not continue these antibiotics promptly. The cefdinir dose was missed, and the doxycycline was not transcribed, causing a delay. The issue was identified during a pharmacy review, and the facility's administrator noted it was the receiving nurse's responsibility to input medication orders. The Infection Preventionist stated that medications are usually available from the emergency drug kit or delivered promptly.
The facility exceeded the acceptable medication error rate of 5%, reaching 6.45%, due to two incidents involving insulin administration. An ADON failed to prime an insulin pen before administering Lyumjev to a resident, and another resident missed a Novolog insulin dose because the insulin was misplaced. The facility's policy requires insulin pens to be primed, which was not followed.
A resident missed a scheduled insulin dose due to the medication being misplaced in another cart, leading to a significant increase in blood sugar levels. The ADON was unable to locate the insulin initially and planned to request it from the pharmacy. The resident's blood sugar rose significantly by noon, requiring a higher insulin dose. The facility failed to document notification to the physician about the missed dose, as required by policy.
The facility failed to enforce smoking safety policies, leading to residents smoking in non-designated areas without protective devices. A housekeeper took residents to smoke after a delay, and they smoked under a covered patio near the facility without an ashtray. Used cigarette butts were improperly disposed of, and the smoking schedule was not updated, causing confusion about departmental responsibilities.
The facility failed to maintain a sanitary kitchen environment, with staff not fully containing hair within hairnets and not adhering to proper hand hygiene practices. The Dietary Manager and another staff member were observed with exposed hair during food preparation, and handwashing times were significantly shorter than the facility's policy requirements.
The facility failed to ensure a safe, sanitary, and homelike environment in two resident halls, with issues such as dirty floors, uncovered bedpans, and uncleaned wheelchairs. Residents and family members reported inadequate housekeeping services, and observations confirmed non-functioning restroom lights and holes in walls. The maintenance director acknowledged being behind on work, and the facility administrator noted the absence of a cleaning schedule for wheelchairs.
A facility failed to ensure accurate and complete documentation for a resident's pressure wound and diabetic care. The resident's TAR lacked documentation for wound treatment on several dates, and the MAR did not record insulin administration or blood sugar levels on specific occasions. An LPN confirmed the requirement for complete documentation, which was not followed according to the facility's policy.
The facility failed to ensure a safe, sanitary, and homelike environment, with deficiencies observed in resident halls and shared restrooms, including stained toilet bowls, missing window trim, and cracked tiles. Maintenance staff shortages and reliance on staff to report issues contributed to the problem, despite a policy requiring daily inspections.
The facility failed to provide routine catheter and ostomy care for three residents, as observed during a survey. A resident with paraplegia and a stage 4 pressure ulcer reported waiting through multiple shifts for colostomy bag changes, while another resident with benign prostatic hyperplasia indicated staff did not routinely empty his catheter drainage bag. A third resident with hemiplegia and chronic kidney disease reported providing her own catheter care despite needing assistance. Documentation showed missed care on several dates, contrary to the residents' care plans.
A facility failed to ensure a resident was clinically appropriate to self-administer medications without supervision. The resident was found alone with a cup of medications, had no physician order or self-administration assessment, and staff confirmed the need for supervision. The facility's policy required a written order for self-administration, which was not present.
A resident with a history of dysphagia and cognitive impairment was hospitalized after staff failed to follow his care plan, administering medications while he was lying flat. The care plan required two staff members to be present due to the resident's behaviors and risk of aspiration, which was not adhered to, resulting in a medication getting stuck in his throat and causing a burn.
The facility failed to provide assistance with bathing for two residents according to their care plans and schedules. One resident, with multiple health issues, received only two showers and two bed baths over a month, while another resident, requiring substantial assistance, had only one bed bath and three showers documented, with one refusal noted.
Missing Dialysis Communication and Unnotified Schedule Change
Penalty
Summary
The facility failed to maintain ongoing communication for a resident receiving dialysis services. Resident B had diagnoses including end stage renal disease and dependence on renal dialysis, was cognitively intact, and had a care plan and physician orders for dialysis three times per week on Monday, Wednesday, and Friday. The resident’s record contained no dialysis communication forms after 3/20/26, and the dialysis communication binder behind the nurse’s station was empty when reviewed. LPN 3 stated the dialysis communication forms were used to communicate pre- and post-dialysis vital signs and any new orders or instructions from the dialysis center. During interview, the Facility Administrator stated the binder had been emptied after the resident died and that the transportation service may have had the communication sheets. The DON stated the dialysis center changed the resident’s dialysis order from three days per week to two days per week without notifying the facility. A handwritten note with dialysis appointment dates indicated the resident had been scheduled two days per week and often missed dialysis appointments. The facility later provided a dialysis contract stating the center would maintain reports of services rendered and the facility could photocopy those reports, along with a treatment attendance record showing dialysis treatments were prescribed two times per week on Monday and Friday.
Pharmacy Services Failed to Provide Ordered Medications
Penalty
Summary
The facility failed to ensure adequate pharmaceutical services were available to provide physician-prescribed routine medications to 2 of 3 residents reviewed for pharmacy services. Resident B had diagnoses including end stage renal disease, chronic heart failure, cirrhosis of the liver, and pneumonia. The record showed multiple missed doses of hydrocodone-acetaminophen 10-325 mg ordered every 4 hours, with nurses’ notes documenting the medication was awaiting pharmacy or waiting on pharmacy on several occasions before the order was discontinued. Resident B was also readmitted from the hospital, and the facility initially received incomplete discharge paperwork that did not include a complete amoxicillin order. For Resident B, the hospital discharge summary later showed a diagnosis of pneumonia and included amoxicillin 500 mg by mouth twice daily for 8 days, but the facility did not have the complete order when the resident returned. Staff contacted the hospital for clarification after the resident stated he was supposed to be taking an antibiotic, and the DON stated the hospital had originally sent only every other page of the discharge summary. The amoxicillin order was not started until the following day after the complete discharge summary was received. Staff interviews indicated discharge orders should be clarified as soon as possible, and documentation of attempts to clarify the antibiotic order should have been completed. Resident C had diagnoses including polyneuropathy, irritable bowel syndrome, and glaucoma. Physician orders included pregabalin 225 mg twice daily, Artificial Tears ophthalmic solution one drop in both eyes four times daily, and diphenoxylate-atropine 2.5-0.025 mg three times daily. The MAR showed missed administrations of pregabalin, Artificial Tears, and Lomotil over several days. Nurses’ notes documented that these medications were pending from pharmacy, not available in the EDK, and that the physician was aware. The DON stated the facility had been between pharmacies during the transition period, some medications were briefly unavailable, and there had been insurance coverage issues when a resident returned from another facility.
Missed PT/INR Lab Testing
Penalty
Summary
The facility failed to ensure laboratory services were provided for 1 of 3 residents reviewed for quality of care. Resident B had diagnoses including end stage renal disease, chronic heart failure, cirrhosis of the liver, and atrial fibrillation, and the most recent quarterly MDS dated 5/11/26 indicated the resident was cognitively intact and received dialysis services. Physician orders included PT/INR testing daily for two weeks due to increased results, starting 5/13/26, but the May 2026 MAR/TAR showed the lab test was not completed on 5/15/26, 5/16/26, and 5/17/26 before the order was discontinued on 5/18/26. Nurse's notes documented that the lab could not come to the facility that weekend to draw the resident's PT/INR and that the physician was aware. During interview, the DON and Facility Administrator stated the contracted lab service was unrealizable and would only come to the facility once a week, and that the facility attempted to use a local hospital lab service but hospital lab staff was unable to come to the facility. RN 4 stated the facility did not have a contract with the hospital lab. The facility later provided an outsourced lab contract that included PT/INR as STAT testing, but the ordered daily lab draws were not completed as documented.
MDS Assessments Were Inaccurate for Hospice, Dementia, and PASRR Status
Penalty
Summary
The facility failed to ensure accurate MDS assessments for residents with hospice services, dementia, and PASRR status. Resident 12’s record showed diagnoses including schizoaffective disorder, depressive type, and dementia, severe, with psychotic disturbance, and the most current quarterly MDS dated 2/25/26 indicated moderate cognitive impairment and assistance needs for eating, toileting, mobility, and transfers. However, the MDS indicated the resident did not have a PASRR with diagnosis, even though the clinical record showed a PASRR Determination completed on 7/17/23 with an effective date of 7/7/23 for Long Term Approval without Specialized Services. The MDS Coordinator stated the resident did have a PASRR II and should have been marked yes. Resident 4 stated during interview that he received hospice services, but the quarterly MDS dated 3/16/26 indicated he was not receiving hospice services. The clinical record included physician’s orders showing admission to hospice for severe protein calorie malnutrition. Resident 24’s significant change MDS dated 3/3/26 indicated no diagnosis of dementia, although the clinical record listed dementia as a diagnosis; the DON provided a note from the MDS Coordinator stating dementia was not marked because the resident was not currently taking medications related to dementia. Resident 63’s annual MDS dated 2/20/26 indicated no hospice, despite current physician orders showing hospice admission dated 11/26/25, and the MDS Coordinator stated hospice should have been marked but was omitted due to entry error.
Missed wound treatments, incomplete weekly weights, and failure to review hospital discharge medications
Penalty
Summary
The facility failed to follow physician orders for wound treatments for a resident with multiple pressure ulcers. Resident 3 had diagnoses including anxiety disorder, moderate cognitive impairment, a stage 3 pressure ulcer to the right heel, and a stage 4 pressure ulcer to the right trochanter. The resident had current orders for wound care to the right hip and right outer foot and heel, including cleansing with normal saline or wound cleanser, applying calcium alginate, wet-to-moist packing, bordered foam or gauze dressings, and betadine at specified frequencies. Review of the MAR showed multiple missed treatments, including missed wound care on several dates in March for the right hip and right outer foot and heel. The DON stated the MAR should not be left blank and that nursing staff should document when the wound nurse completed the treatment. The facility also failed to complete ordered weekly weights for three residents with dementia and weight-related concerns. Resident 6 had a diagnosis of dementia, moderate cognitive impairment, and significant weight loss, with an order for weekly weights every Sunday. Resident 24 had dementia and an order for daily baseline weights for 3 days and weekly weights every Sunday. Resident 35 had dementia and an order for weekly weights every Sunday. For each of these residents, the March MAR showed weekly weights were not completed on two consecutive Sundays. A CNA stated she did not know where the scale was for the A/B Halls where the residents lived and was unsure of the current protocol for obtaining weights. The Infection Preventionist stated that weekly weights should still be obtained when sheltering in place by donning the resident in a gown and mask to go off the unit to weigh, and that staff on the A/B units required education for obtaining weights when there were residents with COVID on the unit. The facility further failed to ensure medications were reviewed by the PCP after a resident returned from the hospital. Resident 4 had diagnoses including personality disorder, anxiety, depression, chronic pain, panic disorder, gastroparesis, and malnutrition, and was cognitively intact per the most recent MDS. ER discharge records indicated several medications for anxiety, depression, and insomnia were to be stopped upon return, including alprazolam, lamotrigine, sertraline, and trazodone. The clinical record lacked documentation that these discontinued medications were discussed with the PCP for clarification after the resident returned. Progress notes after the return documented agitation, yelling, refusal of medications and treatments, statements that he wanted to die, and ongoing pain complaints. The DON stated she was not sure why the medications were discontinued in the ER and said medications should be reviewed every morning when a resident comes back from the hospital.
Unsecured Medication Cart and Unattended Medications
Penalty
Summary
The facility failed to ensure safe medication storage for 1 of 3 hall carts observed. On 3/19/26 from 12:15 P.M. until 12:40 P.M., the D Hall medication cart was observed in the dining room against the wall by the nurses station while residents were eating lunch. During the observation, five residents and two staff members walked by the cart. At 12:40 P.M., an LPN stated she was going to give insulin to residents but had been asked to assist feeding a resident and forgot to lock the medication cart; she also indicated the cart should always be locked. On 3/23/26 at 7:20 A.M., an LPN prepared medications for Resident 67, including Protonix 40 mg, bupropion 150 mg, acetaminophen 325 mg x2, clozapine 100 mg, famotidine 40 mg, propranolol 40 mg, and sucralfate 1 gm. The medications were removed from a multi-use medication card into a medication cup, and the medication cards with remaining medications were placed on top of the medication cart. The LPN then walked away, leaving the medication cards on the cart and the cart unlocked while a resident sat directly in front of it. The LPN later returned and stated she normally would not have left the medication cards out. The Administrator provided a Medication Storage policy stating medications and biologicals must be securely stored in a locked cabinet/cart or locked medication room inaccessible to residents and visitors.
Missing Bed Hold, Transfer/Discharge, and Ombudsman Notification Documentation
Penalty
Summary
The facility failed to ensure clinical records contained bed hold policy information, completed transfer/discharge forms, and documentation that a representative of the Office of the State Long-Term Care Ombudsman was notified for residents who were transferred or discharged to the hospital or emergency room. Surveyors reviewed 7 residents with hospitalizations or emergency transfers and found the records lacked the required bed hold documentation and ombudsman notification for each reviewed resident. Resident 12, who had diagnoses including severe dementia with psychotic disturbance, schizoaffective disorder, diabetes mellitus with diabetic polyneuropathy, and emphysema, had two psychiatric hospitalizations documented in the record. The clinical record lacked a bed hold policy, transfer/discharge form, and documentation that the ombudsman was notified for both hospitalizations. Resident D, who had pneumonia, type II diabetes mellitus, a history of traumatic brain injury, tracheostomy status, and gastrostomy status, was sent to the ER for a clogged G-tube and later hospitalized for high sodium and pneumonia with G-tube replacement pending; his record also lacked a bed hold policy, transfer/discharge form, and ombudsman notification for both hospitalizations. Additional reviewed residents also had missing documentation. Resident 6 was sent to the ER after falls, but the record lacked documentation that a bed hold was sent with the resident, given to the representative, or sent to the ombudsman. Resident B, who was cognitively intact and had COPD and CHF, was sent out by EMS for evaluation, but the record lacked transfer/discharge forms, bed hold policy notification, and ombudsman notification; the ombudsman’s office stated it had not received notice. Resident 1, Resident 4, and Resident 3 also had records lacking bed hold policy documentation and ombudsman notification after ER or hospital transfers, and the ombudsman confirmed she had not received notification for any of the seven residents reviewed.
Missed ADL Care Including Showers and Oral Hygiene
Penalty
Summary
The facility failed to ensure dependent residents received ADL services, including showers and oral care, for 3 of 4 residents reviewed and for 3 of 3 residents who spoke during Resident Council. Resident D’s record showed diagnoses including pneumonia, type II diabetes mellitus, traumatic brain injury history, tracheostomy status, and gastrostomy status. His most recent MDS indicated he was never or rarely understood and was dependent on staff for toileting, bathing, mobility, and transfers. His ADL care plan included oral hygiene interventions for morning, after meals, and bedtime, but the CNA task form showed multiple dates when oral care was not provided. Resident C was observed on multiple occasions with greasy hair, white flakes on the scalp, a strong odor of urine, and being unshaved. He stated he was not sure when his last shower was, preferred to shower, depended on staff for showering, and needed help with mouth care. His record showed diagnoses including high blood pressure, stroke, and intellectual disability. The quarterly MDS indicated moderate cognitive impairment, dependence on staff for toileting, transfers, personal hygiene, and showering, and supervision for oral care. His ADL care plan called for staff assistance with showering, oral hygiene, and personal hygiene, but the CNA task list showed repeated missed showers and numerous missed oral care entries over the reviewed period. Resident B’s record showed diagnoses including high blood pressure, COPD, CHF, and a flaccid neuropathic bladder. His MDS indicated he was cognitively intact, had no refusals, needed set-up assistance for oral care and personal hygiene, partial to moderate assistance for bed mobility, toileting hygiene, and showering, and substantial to maximum assistance for transfers. His ADL care plan included oral hygiene, showering, and personal hygiene interventions, but the CNA task list showed missed showers and many missed oral care entries. During Resident Council, all 3 residents present stated they were not getting showers when scheduled, and an anonymous interview also reported oral care and showers were not being performed. Staff interviews indicated showers and oral care were expected to be documented on CNA task lists or shower forms, and refusals were to be documented, but the records reviewed showed repeated omissions.
Failure to Follow Physician Orders for Lorazepam Discontinuance
Penalty
Summary
The facility failed to follow physician orders when Resident 63’s routine lorazepam was discontinued despite a physician’s documented contraindication to discontinue the medication. Resident 63 had diagnoses including epilepsy and severe cognitive impairment, and the current seizure care plan directed staff to administer medications as ordered and monitor for side effects. The resident’s routine lorazepam order had been in place for seizures, and the record also included PRN seizure medications such as Valtoco and injectable lorazepam. During the period when the routine lorazepam was discontinued, Resident 63 experienced seizures on two occasions and required PRN lorazepam administration. The record showed that a pharmacy recommendation dated earlier had been signed by a physician indicating the dose reduction was contraindicated, that the benefits outweighed the risk, that no weaning was needed, and that discontinuation would likely be harmful to the resident. Despite this, the DON entered the discontinuation order, and the psych NP was the provider who discontinued the medication. The clinical record lacked documentation of physician communication regarding the discontinuance and lacked documentation that the resident’s representative was notified. The family member stated she had not been notified before or when the lorazepam was discontinued and said she would not have allowed it because the medication kept the resident calm and decreased seizure activity. The DON stated there was an issue getting pharmacy recommendations signed by providers and that the hospice nurse questioned the lorazepam orders and told staff to discontinue the routine order. The DON also stated the medication was later renewed after discussion with the NP, physician, and the resident’s sister, and acknowledged that when a psychotropic is discontinued there should have been communication with the NP, provider, and family.
Inadequate Pain Management and Documentation
Penalty
Summary
Safe, appropriate pain management was not provided for a resident who was receiving hospice services and had diagnoses including chronic pain, anxiety, depression, panic disorder, gastroparesis, and malnutrition. During interview, the resident stated his pain was not controlled and that staff were not giving routine pain medication as ordered. The quarterly MDS indicated he was cognitively intact, dependent on staff for several activities of daily living, on a pain medication regimen, and had received PRN pain medication, but no pain was noted within the prior 5 days and no non-medication interventions were documented. Physician orders included Percocet every 6 hours PRN, Tylenol every 4 hours PRN, morphine concentrate every hour PRN for pain or shortness of breath, and a fentanyl patch every 72 hours for pain. The chronic pain care plan directed staff to administer analgesics as ordered, anticipate pain relief needs, evaluate effectiveness, monitor and record pain characteristics, and notify the physician if interventions were unsuccessful or pain changed significantly. The MAR/TAR showed the fentanyl patch was not administered on multiple scheduled dates, with comments such as allergy, pending pharmacy, patch unavailable, pending script, out of patches, or no comment at all. The resident’s documented pain levels ranged from 5 to 10, and the record lacked documentation of pain characteristics and non-pharmacological interventions tried. Progress notes showed inconsistent documentation related to the fentanyl patch and pain management. Hospice and nursing notes documented concern about a fentanyl allergy, with hospice stating it was not a true allergy and that fentanyl should continue, but later entries showed the patch was not given because it was unavailable, pending a script, or out of patches. On one occasion, the resident refused morphine and initially refused crushed Percocet, then accepted a whole Percocet tablet and later rested comfortably. The DON stated there were communication issues with hospice and the facility, was unaware the resident was not receiving fentanyl as ordered, and could not provide documentation of pain discussions or confirm whether the hospice MD or PCP had been notified about the resident’s ongoing daily pain complaints.
Inaccurate Resident Record Documentation
Penalty
Summary
The facility failed to ensure accurate documentation in resident clinical records for 2 of 2 records reviewed. One resident was in the hospital, yet a progress note in the clinical record documented vital signs. Another resident had a shower documented in the CNA task list even though the shower was not given. The deficiency was identified during observation, interview, and record review. Resident D’s record showed diagnoses including pneumonia, Type II diabetes mellitus, personal history of traumatic brain injury, tracheostomy status, and gastrostomy status. The most current MDS indicated the resident was never or rarely understood and was dependent on staff for toileting, bathing, mobility, and transfer, with a tracheostomy, oxygen use, suctioning, a foley catheter, and a Stage 4 pressure ulcer present on admission. Resident C was observed with greasy hair, white flakes of skin around the scalp, a strong odor of urine, and was unshaved; the resident stated not being sure when the last shower was, preferred to shower, and depended on staff for showering. An LPN stated CNAs were to document showers when given and that tasks should only be documented as completed when they were done, while the Administrator stated shower forms in the DON’s office were not part of the clinical record and documentation practices were inconsistent.
Lack of Hospice Communication and Documentation
Penalty
Summary
The facility failed to ensure hospice communication and documentation occurred between the facility and the hospice company for 1 of 1 residents reviewed for hospice. Resident 4 stated during interview that he was receiving hospice services. The resident’s clinical record, reviewed on 3/24/26, included diagnoses of unspecified disorder of adult personality, anxiety, depression, chronic pain, panic disorder, gastroparesis, and malnutrition. The most recent quarterly MDS, dated 3/16/26, indicated the resident was cognitively intact, had no behaviors, was dependent on staff for toileting, showering, transfers, and bed mobility, was on a pain medication regimen, and was not receiving hospice services. Physician’s orders showed the resident was admitted to the hospice company for severe protein calorie malnutrition on 2/26/26, and the current hospice care plan, last revised 2/27/26, included an intervention to maintain good communication with hospice. During interviews, an LPN stated staff could call hospice at any time, that the resident’s nurse and hospice staff spoke verbally when they were present, and that a binder at the nurse’s station was not used or updated. The DON stated the facility had never documented communication with hospice in that way and described ongoing problems with hospice orders, signatures, and information not being shared with nursing staff. The hospice contract required the facility and hospice to communicate regularly and document such communications in their respective clinical records, and the hospice services policy required hospice staff to write a progress note for each resident visit.
Failure to Provide Ordered Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received routine catheter care as ordered to help prevent a urinary tract infection. Resident B had diagnoses including high blood pressure, COPD, CHF, and a flaccid, neuropathic bladder, and the quarterly MDS indicated the resident was cognitively intact and had an indwelling catheter. Physician orders required Foley catheter care every shift as needed, and the catheter care plan included monitoring for discomfort and pain related to the catheter. Review of the CNA task list showed catheter care was not documented on numerous day and night shifts over a period from 12/2/25 through 2/10/26. A nurse note indicated Resident B left the facility by EMS on 2/12/26 for evaluation, and hospital records showed the resident was admitted that day with sepsis and a catheter associated UTI. During interviews, an LPN stated catheter care should be done each shift and documented by CNAs, and if it was not documented then it was not done; the DON stated she expected catheter care to be done per order every shift and documented in the EHR. The facility policy stated catheter drainage bags would be emptied one time on each shift or as needed and routine hygiene was appropriate.
Survey Results Not Readily Available
Penalty
Summary
The facility failed to ensure the past 3 years of state survey results were readily available to visitors, residents, and other individuals without having to ask to review them. On 3/18/26, the survey binder could not be located. During the resident council meeting on 3/19/26, residents stated they did not know where the state survey binder was located. On the same day, the Receptionist stated she did not know where the survey binder was located. Later that day, the survey binder was observed, but it did not contain survey results for the last 3 years. During interviews on 3/24/26 and 3/26/26, the Administrator stated she had updated the binder and placed only annual surveys in it, that complaint surveys were not placed in the binder, and that the past 3 years of survey results should have been in the binder. The Administrator also stated the facility policy was to follow state regulations for the survey binder.
Failure to Post Nurse Staffing Information at All Entrances
Penalty
Summary
The facility failed to ensure the posted nurse staffing form was displayed at all entrances of the building for 8 reviewed days. During observation on 3/17/2026 at 9:25 A.M., the staffing form was seen on the wall at the first set of doors entering the building near the main office, but the entrances to halls A, B, C, D, G, H, and I did not have a posted nurse staffing form. The same condition was observed on 3/18/26 through 3/26/26. During interview on 3/20/26 at 1:43 P.M., the MDS coordinator stated visitors enter through all of the entrances. During interview on 3/26/26 at 9:39 A.M., the Scheduler stated the posted nurse staffing was only displayed by the main office and the time clock. On 3/25/26 at 8:56 P.M., the Administrator provided the state regulation as a policy and stated it was their policy to follow the regulation.
Failure to Provide and Document Hospice Services and Assessments
Penalty
Summary
The facility failed to ensure that two out of three residents reviewed for hospice care received appropriate end-of-life care. For one resident with chronic kidney disease and malignant cancer, the facility did not establish a collaborative plan of care for hospice services, and routine assessments and physician orders were not completed. Although hospice was notified and assessed the resident upon readmission from the hospital, the facility did not document further assessments of pain, discomfort, restlessness, or oxygen saturation after the initial hospice visit. No as-needed medications were administered between readmission and the resident's death, and required routine observations were not documented. For another resident with large B-cell lymphoma, the facility also failed to include a hospice care plan in the resident's care plan. Physician orders for pain assessments and supplemental oxygen were not consistently followed, as oxygen levels were not assessed every shift as ordered. After administration of PRN pain medication, there was no documented reassessment to monitor the effectiveness of the medication. Facility policy required documentation of all treatments and services, but this was not consistently done for these residents receiving hospice care.
Failure to Monitor Hot Beverage Temperature Results in Resident Burns
Penalty
Summary
A resident with diagnoses including spastic paraplegia, demyelinating disease of the central nervous system, hypertrophic osteoarthropathy, cerebellar ataxia, lack of coordination, and muscle spasm, who required setup assistance for eating due to limited mobility, requested a CNA to heat a cup of water. The CNA heated the water in a microwave and placed it on the resident's bedside table without monitoring or checking the temperature of the water. When the resident raised the head of her bed, the cup of hot water was knocked over, spilling onto her abdomen, back, and hip. As a result of the spill, the resident sustained second-degree burns to her abdomen, lower back, and left hip. The burns were described as partial thickness with large blisters, reddened areas, and peeling of the outer skin layer. Wound assessments documented significant areas of injury, with pain rated at 4 to 5 on a scale of 0 to 10. The resident required topical treatments and dressings for the burns, and the incident was reported to the physician, who ordered further care and assessment. The facility's policy required staff to monitor, serve, and hold hot beverages in a safe manner, including checking temperatures and monitoring high-risk residents. However, there was no documentation or indication that the temperature of the water served to the resident was checked, and the staff did not monitor the resident while serving the hot beverage. This failure to follow established procedures for serving hot beverages directly contributed to the resident's injuries.
Failure to Maintain Safe and Sanitary Resident and Dining Areas
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in one of three resident units and one of two dining rooms observed. Observations revealed missing paint on the walls under windows, around air conditioning units, and behind beds in multiple resident rooms. Additionally, cove base was missing from the wall behind beds, and one resident room had a window completely covered with plywood due to a previous breakage. A shared restroom door near the nurse's station had a protective covering that was peeling away, and the dining room's activity area had approximately 80% of its paint peeled off the wall, with a black discoloration noted on the vaulted ceiling. Interviews with the maintenance director indicated that repairs and renovations are typically performed after residents move out of their rooms, and that larger projects require outside contractors. The maintenance director had only been at the facility for four weeks and noted that an assistant maintenance staff member was soon to be hired. The facility was awaiting a replacement window and had scheduled an outside source to bid on the dining room repairs. Facility policy requires the environment to be maintained in accordance with all governing rules and regulations to protect the health and safety of residents, personnel, and the public.
Failure to Maintain Sanitary Food Storage and Kitchen Environment
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen and food storage areas, as observed during a survey. Inspectors noted that containers of food were stored directly on the floors of both the dry food storage room and the walk-in freezer, contrary to facility policy requiring food to be stored at least six inches off the floor. Additionally, there was a significant buildup of dust and debris over the cookstove hood, on the ceiling and vents above the dishwashing area, on top of the dishwasher, and along the base of the walls and floor in the dishwashing area. These conditions were confirmed through direct observation. Interviews with kitchen staff revealed that daily cleaning task checklists were not being completed, and some staff were unaware of the existence or location of such checklists. The kitchen was reported to be short-staffed, and recent food deliveries had not been properly stored according to policy. The Dietary Manager acknowledged that certain areas of the kitchen required cleaning and that food should not be stored on the floor. Facility policies reviewed by surveyors confirmed the requirements for proper food storage and sanitation, which were not being followed at the time of the survey.
Inadequate Pressure Ulcer Care in LTC Facility
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and promote healing of pressure injuries for three residents. Resident 20, who had diagnoses including heart failure, diabetes mellitus, and dementia, was observed with unstageable pressure ulcers on the left heel and coccyx. The facility did not develop specific care plans for these ulcers, and physician orders were not consistently followed. Assessments were incomplete, and there were gaps in documentation and treatment administration, leading to the worsening of the pressure ulcers. Resident 7, with severe cognitive impairment and a history of hemiplegia, had an unstageable pressure ulcer on the left buttock. The care plan for this ulcer was delayed by 15 days, and there were inconsistencies in following physician orders. The wound nurse and physician assessments differed, and there were multiple instances where treatments were not documented or completed as ordered. The facility's failure to adhere to treatment protocols and documentation requirements contributed to the persistence of the pressure ulcer. Resident 25, diagnosed with paraplegia, had a Stage 4 pressure ulcer on the left buttock. The facility did not update treatment orders in a timely manner, and there were discrepancies between the wound nurse and physician assessments. The resident's treatment was not consistently administered, and the wound nurse was unable to perform dressing changes due to the resident's positioning. These lapses in care and documentation resulted in inadequate management of the pressure ulcer, highlighting the facility's failure to provide appropriate pressure ulcer care.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills set to carry out the functions of the food and nutrition service. The Dietary Manager, who was responsible for overseeing the kitchen, was not certified at the time of the survey. She had started working at the facility in August 2024, and her previous certification had expired. Despite being aware of the need for certification, the Dietary Manager had not completed her training and was on a 30-day Performance Improvement Plan (PIP) due to failing her certification test. The Administrator acknowledged the requirement for a certified Dietary Manager and indicated that the Dietary Manager was working on completing her training, which had been addressed multiple times but remained incomplete.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents or their representatives, as well as the ombudsman, for five residents who were hospitalized. The clinical records of these residents lacked documentation of a notice of transfer or discharge at the time of hospitalization. Specifically, Resident 30 was transferred to the hospital and returned without any record of a notice being given. The Administrator confirmed the absence of such documentation. Similarly, Resident B, Resident 48, and Resident 79 were hospitalized, and their records also lacked hospital transfer notices. Resident D's clinical record indicated a transfer to the hospital without a completed transfer/discharge notice, and the transfer assessment lacked information about the appeals process and ombudsman contact details. Interviews with staff revealed that the floor nurse was responsible for filling out transfer forms electronically, but no additional documentation was provided. The Social Services Director mentioned sending monthly transfer reports to the ombudsman's portal but could not verify this due to email issues. The State Long-Term Care Ombudsman Program Deputy Director confirmed only receiving reports for October and an unspecified date, with no records after that. The facility's current Transfer/Discharge Notice Policy was requested but not provided.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, as required. This deficiency was identified for five residents who were hospitalized and subsequently returned to the facility. The clinical records of these residents, including those of Resident D, Resident B, Resident 79, Resident 48, and Resident 30, lacked documentation of a bed hold policy being given at the time of their transfer to the hospital. Interviews with facility staff, including the Administrator and an LPN, confirmed the absence of such documentation and revealed that the responsibility for issuing bed hold notices had been neglected. Resident 30 was admitted to the hospital on November 8, 2024, and returned on November 15, 2024, without receiving a bed hold policy. Similarly, Resident D was transferred to the hospital on January 18, 2025, and returned on January 22, 2025, without documentation of a bed hold notice. The facility's current bed hold policy, revised in 2017, mandates that residents and their representatives be notified of the bed hold policy upon admission and at the time of transfer. However, the facility's practice did not align with this policy, as evidenced by the lack of documentation and staff interviews indicating that bed hold notices were no longer being issued.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both comprehensive and quarterly review assessments. This deficiency was observed in several residents, including Resident C, who was noted to have an outdated care plan indicating the presence of an indwelling catheter, despite the absence of such a catheter during an incontinence care observation. Similarly, Resident 4 experienced a decline in eating and mobility, which was not reflected in the care plan, even though staff were aware of the changes and therapy was involved. Additionally, Resident 73, who was on an NPO diet with a feeding tube, lacked care plan interventions related to the NPO status. Resident 79, who had orders for bed and chair alarms following a fall, did not have these interventions included in the care plan. The facility's policy required that care plans be reviewed and revised by the IDT after each assessment, but this was not adhered to, leading to discrepancies between the residents' current needs and their documented care plans.
Inadequate Care for Dementia Resident Due to CNA Conduct
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, identified as Resident B, to maintain his highest practicable physical, mental, and psychosocial well-being. Observations revealed that Resident B, who had severe cognitive impairment and required assistance with activities of daily living (ADLs), was not receiving adequate care. On multiple occasions, Resident B was observed in a wheelchair with unkempt hair and was left unattended in common areas. The resident's clinical record indicated diagnoses of heart failure, diabetes, dementia, anxiety, depression, and a psychotic disorder, highlighting the need for comprehensive care. The deficiency was further compounded by the conduct of CNA 31, who was reported to provide care that did not meet company standards. Interviews with staff revealed that CNA 31 was perceived as gruff, loud, and intimidating, often failing to communicate with residents before providing care. Additionally, CNA 31 was reported to deny residents' requests for coffee and was observed neglecting duties by disappearing for extended periods and using a resident's bed for personal phone calls. Despite these issues being reported to the Assistant Director of Nursing (ADON), no corrective action was taken, contributing to a negative atmosphere on the dementia unit.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for five residents during two random observations of the medication carts. During the first observation, a Qualified Medication Aide (QMA) was found to have pre-prepared medication cups for four residents, with pills placed in the cups and stored in the medication cart. The QMA acknowledged that the medication cups were prepared for the upcoming medication pass and admitted awareness that pre-preparing medications was against facility policy. In a separate observation, an LPN was found with a medication cup containing eight pills for a resident who had refused their morning medications. The LPN indicated that the medications were locked in the cart after the refusal, awaiting another nurse to attempt administration. The Director of Nursing was unaware of the facility's policy regarding pre-preparing medications, while the Vice President of Operations provided a policy stating that medications should be administered at the time they are prepared and not pre-poured in advance.
Failure to Follow Menus in Dietary Services
Penalty
Summary
The facility failed to ensure that menus were being followed by the dietary staff, as observed during a review of the kitchen. The Administrator, who took over on December 9, 2024, identified significant concerns with the kitchen operations within two days of her tenure. The Dietary Manager was already on a 30-day Performance Improvement Plan (PIP) for not adhering to the menus as required. The Administrator noted that the lack of accountability among staff and turnover in administration contributed to the issues, as staff were left to manage on their own. The majority of resident grievances were related to dietary services, indicating a widespread issue. The PIP for the Dietary Manager, dated December 2, 2024, and January 15, 2025, highlighted several areas needing improvement. These included ensuring staff followed menus, ordering the correct items, completing inventory before placing orders, and monitoring and educating cooks. The Administrator emphasized that it was policy to adhere to regulations and follow the assigned menus. This deficiency was related to a specific complaint, IN00449788, and was documented under citation 3.1-20(i).
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to the potential transmission of infections among residents. During an observation of incontinence care for Resident C, it was noted that the Certified Nurse Aides (CNAs) did not follow proper hand hygiene protocols. The CNAs changed gloves multiple times without sanitizing their hands in between, and they did not follow the expected procedure of wiping from clean to dirty areas. This lack of adherence to infection control practices was confirmed by the Infection Preventionist, who stated that staff should sanitize hands between glove changes and follow specific wiping techniques during incontinence care. In another instance, the Assistant Director of Nursing (ADON) was observed using a glucometer machine for Resident D without cleaning it between uses. The ADON admitted that she could not confirm if the glucometer had been cleaned after its last use, as she had just taken over the medication cart. The Director of Nursing (DON) later confirmed that the expectation was for the glucometer to be cleaned at the beginning of each shift and between each resident use, which was not adhered to in this case. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with specific needs. Resident H, who had an open elbow wound, did not have the required EBP signage, and staff did not wear gowns during dressing changes. Similarly, Resident G, who had an indwelling catheter, did not receive care with the necessary EBP measures, as the CNA did not wear a gown despite the presence of an EBP sign. The Infection Preventionist confirmed that residents with indwelling devices or open wounds should have EBP in place, which was not consistently practiced in the facility.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple incidents involving three residents. Resident C, who had a history of stroke, hemiplegia, and dementia, reported that night shift staff were rude and unresponsive to her requests for ice and assistance getting out of bed. This led to her becoming upset and throwing her call light onto the floor. The facility's administrator acknowledged the incident but was uncertain of its occurrence, attributing it to agency staff who were being phased out. Resident E, who had a history of stroke, dementia, and diabetes, experienced a delay in response to his call light, prompting him to call his sister for assistance. A staff member reportedly confronted him in a degrading tone for contacting his sister instead of using the call light. The resident's sister had previously reported similar concerns to the Social Services Director, but no changes were made. The SSD was aware of the incident and had planned a care plan conference, but the grievance was not documented in the resident's chart. Resident F was subjected to disrespectful comments by the Assistant Director of Nursing (ADON) during medication administration. The ADON made remarks about the resident's behavior within earshot, which were deemed inappropriate. The facility's Resident Rights policy emphasizes the importance of treating residents with dignity and respect, which was not upheld in these instances.
Failure to Conduct Timely Care Plan Conferences
Penalty
Summary
The facility failed to ensure timely care plan conferences with residents and/or their representatives for three of the seven residents reviewed. Resident D, who has diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type II, and dementia with behaviors, did not have quarterly care plan conferences as required. The clinical record showed that Resident D had care plan conferences on 1/26/24, 4/26/24, and 10/4/24, but no other conferences were held in the last year, as confirmed by the Social Services Director (SSD). Similarly, Resident 4, with severe cognitive impairment and dementia with behaviors, had care plan conferences on 2/12/24, 6/14/24, and 9/27/24. The SSD was unable to contact Resident 4's guardian to set up a conference, but acknowledged that a conference should have been held regardless. Resident 35, who is cognitively intact and has diagnoses including stage 5 chronic kidney disease and hypertension, did not receive a care plan conference between 7/23/24 and 12/17/24. The SSD confirmed that care plan conferences should be completed quarterly, as per the facility's Comprehensive Care Plan policy.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to clarify a resident's code status, resulting in a discrepancy between the resident's current facesheet, physician's order, and the Indiana Physician Orders for Scope of Treatment (POST) form. The resident, who had severe cognitive impairment and multiple diagnoses including heart failure and dementia, was documented as having a Full Code status in the physician's orders and care plans. However, the POST form indicated a Do Not Attempt Resuscitation (DNR) status. This inconsistency was identified during a review of the resident's clinical record. During an interview, a registered nurse (RN) indicated that she would refer to the computer to determine the resident's code status and believed the resident was a DNR. However, upon checking the computer, it showed a Full Code status, conflicting with the POST form's DNR indication. The RN stated that if the resident coded, she would follow the Full Code status, acknowledging that the order and POST form should match. The facility's Advance Directives policy requires that a written physician's order be specific and address each advanced directive, which was not adhered to in this case.
Incident Report Lacks Detailed Explanation of Alleged Abuse
Penalty
Summary
The facility failed to ensure that an incident report contained a detailed explanation of the circumstances surrounding an alleged incident involving a Certified Nurse Aide (CNA) and a resident. The incident report, dated 1/22/25, lacked specific details about the alleged incident where a staff member reported that CNA 31 was providing care that did not meet company standards for Resident B. Resident B, who had severe cognitive impairment and multiple diagnoses including heart failure, diabetes, and dementia, was reportedly involved in an incident where CNA 31 allegedly grabbed the resident's testicles and pressed her arm against his neck during care. However, upon investigation, no signs or symptoms of abuse were found, and the resident did not express any pain. The report indicates that the initial complaint was made by CNA 29, who observed the alleged incident and reported it to the Administrator. The Administrator conducted an immediate investigation, which included a full body assessment of the resident and a demonstration by CNA 31 of how she provided care. The investigation did not find any physical evidence of abuse, and the resident's family was notified. Despite the investigation, the initial incident report failed to include a comprehensive account of the circumstances, which is a requirement according to the facility's Abuse Prevention and Reporting policy.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for residents receiving specific medical treatments and services. Resident 67, who had diagnoses including non-traumatic brain dysfunction, anxiety, and depression, was admitted to hospice care but did not have a corresponding care plan. The facility's President of Operations confirmed that a hospice care plan should have been initiated for residents on hospice services. Resident 79, with severe cognitive impairment and multiple diagnoses such as hypertension, hip fracture, diabetes, and dementia, was on medications including antianxiety, antidepressant, and antiplatelet. However, the resident's clinical record lacked care plans for the use of bed and chair alarms, as well as for the antiplatelet medication. Similarly, Resident D, who had conditions like chronic obstructive pulmonary disease, diabetes, and deep vein thrombosis, was receiving an anticoagulant but did not have a care plan for this medication. The facility's policy required comprehensive care plans to be developed within seven days after a comprehensive assessment, but this was not adhered to in these cases.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, leading to deficiencies in preventing urinary tract infections (UTIs). Resident D was observed with a catheter bag placed incorrectly under his leg, contrary to the care plan that required the bag to be positioned below the bladder. The resident's clinical record indicated multiple diagnoses, including chronic obstructive pulmonary disease, diabetes, sepsis, UTI, flaccid bladder, and dementia. Despite having a physician's order for catheter care, the catheter bag was not managed according to the specified guidelines, as confirmed by a Certified Nurse Aide (CNA) who stated that the bag should not be on the resident's leg. Another resident, Resident 48, was found to have a Foley catheter without a corresponding physician's order or care plan. The resident's clinical record showed severe cognitive impairment and occasional urinary incontinence, but no documentation of catheter use. The catheter was inserted during a hospital stay for pneumonia and UTI, and hospital staff were unable to remove it before discharge. Interviews with facility staff, including a Registered Nurse (RN) and the President of Operations, confirmed the absence of a necessary order and care plan for the catheter. The facility's policy required catheters to be positioned to prevent backflow, but there was no specific policy for catheter orders, highlighting a gap in compliance with established procedures.
Failure to Timely Administer Antibiotics Post-Hospital Discharge
Penalty
Summary
The facility failed to ensure that pharmaceutical services met the needs of a resident, specifically in the accurate acquiring, receiving, dispensing, and administering of antibiotics. Resident D, who had multiple diagnoses including COPD, diabetes mellitus type II, DVT, sepsis, UTI, flaccid bladder, and dementia, was discharged from the hospital with orders to continue antibiotics cefdinir and doxycycline. However, the facility did not continue these antibiotics in a timely manner. The cefdinir dose was missed, and the doxycycline was not transcribed from the discharge orders, leading to a delay in administration. The issue was identified during a pharmacy review, which noted the missed doses and the lack of transcription for doxycycline. The facility's administrator indicated that it was the responsibility of the receiving nurse to review and input medication orders upon a resident's readmission from the hospital. Despite the cefdinir being available, the doxycycline was not received from the pharmacy for an unknown reason. The nurse notified the MD about the missed doses, and once the doxycycline was received, the resident was administered all doses. The facility's Infection Preventionist mentioned that they follow an antibiotic stewardship program and that medications are usually available from the emergency drug kit or delivered promptly by the pharmacy.
Medication Error Rate Exceeds 5% Due to Insulin Administration Issues
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 6.45 percent. This deficiency was observed during a medication pass involving two residents. The first incident involved the Assistant Director of Nursing (ADON) administering 16 units of Lyumjev insulin to a resident without priming the insulin pen, contrary to the facility's policy. The ADON expressed uncertainty about the need to prime the pen, indicating a lack of adherence to proper medication administration procedures. The second incident involved another resident who missed an 8:00 A.M. dose of Novolog insulin due to the ADON's inability to locate the insulin. The insulin was later found in a different medication cart, but the resident did not receive the required 4 units of insulin based on their blood sugar level of 223. The Director of Nursing confirmed that the facility's policy required insulin pens to be primed before use, highlighting a deviation from established protocols.
Significant Medication Error Due to Missed Insulin Dose
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who missed a scheduled dose of insulin. On the morning of the incident, the Assistant Director of Nursing (ADON) was unable to locate the resident's insulin in the medication cart or storage room and planned to request it from the pharmacy for afternoon delivery. Later that day, it was discovered that the insulin had been misplaced in another medication cart, resulting in the resident missing their 8:00 A.M. dose. The resident's clinical records indicated a blood sugar level of 223 at 8:00 A.M., which required 4 units of insulin according to the sliding scale. By noon, the resident's blood sugar had increased to 362, necessitating 10 units of insulin. The clinical record did not show any notification to the physician about the missed dose. The Vice President of Operations confirmed that the ADON was advised to contact the physician, but no documentation of this communication or the physician's response was provided. The facility's policy requires notifying the attending physician or Medical Director in such cases, but this was not documented.
Failure to Enforce Smoking Safety Policies
Penalty
Summary
The facility failed to enforce its smoking policies related to smoking safety for two observed instances involving residents. During a random observation, three residents were seen waiting in wheelchairs in a common area for staff to take them outside to smoke. The scheduled smoke break was delayed because the dietary department, responsible for escorting the residents, did not have time. Eventually, a housekeeper agreed to take the residents outside. However, the residents were not offered protective devices such as smoking aprons, and they smoked in a non-designated area under a covered patio close to the facility, where no ashtray was available. Used cigarette butts were improperly disposed of in a stone plant pot containing dried plant material, posing a potential fire hazard. Further observations revealed that the facility's smoking schedule was not updated to reflect changes in departmental responsibilities, leading to confusion and non-compliance with the smoking policy. The dietary department had stopped taking residents to smoke, and the responsibility was shifted to the laundry staff, but this change was not communicated effectively. The Administrator was unaware of the outdated schedule posted in the facility, and the residents continued to smoke in non-designated areas without appropriate safety measures in place, contrary to the facility's Smoking Safety policy.
Sanitation and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as observed during two separate kitchen inspections. The Dietary Manager (DM) and another staff member were seen with hair not fully contained within their hairnets, with loose strands exposed during food preparation and service. Despite the Facility Administrator previously addressing this issue with the DM, the problem persisted. The facility's policy, dated 2020, requires all dining services staff to wear hair restraints in food production and serving areas, which was not adhered to during these observations. Additionally, the facility did not ensure proper hand hygiene practices were followed by kitchen staff. During observations, the DM and a cook were noted to wash their hands for significantly less time than the 20 seconds recommended by the facility's posted instructions and policy. The DM was observed washing hands with no scrubbing time after handling a bowl of ice, and the cook washed hands for only 9 seconds. The facility's policy outlines a detailed handwashing procedure, including scrubbing for 15 to 20 seconds, which was not followed. These deficiencies were related to complaints IN00448562, IN00447164, and IN00442047.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in two of the six resident halls observed. Observations revealed multiple issues, including holes in walls, dirty and unmopped floors, uncovered bedpans, missing cove base in a restroom, a vent fan without a cover, and used Styrofoam cups left in a resident's room. Additionally, resident wheelchairs were not cleaned, and there were complaints about the lack of housekeeping services. Specific incidents included a family member reporting that a resident's room had not received housekeeping services for days, resulting in a filthy environment and a lack of toilet paper. Resident council minutes also indicated concerns about inadequate restroom cleaning. Further observations noted that a resident's restroom had a non-functioning light, an uncovered bedpan with a brown substance, and a hole in the wall. Another resident's restroom lacked cove base, had an uncovered bedpan, and had toothpaste and splatter marks on the walls. Common areas were observed to be unmopped, with visible wheelchair markings and stains on the floor. Interviews with residents and staff confirmed that wheelchairs were not routinely cleaned, and the maintenance director acknowledged being behind on necessary maintenance work. The facility administrator admitted that there was no existing cleaning schedule for resident wheelchairs.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that resident records were accurate and complete for a resident reviewed for pressure wounds and diabetic care. Specifically, the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for Resident D were not documented completely. Resident D, who had diagnoses including diabetes mellitus, morbid obesity, and chronic kidney disease, had a care plan that included treatment for a left toe infection and diabetes management. However, the TAR showed that the wound treatment to the left toe was not documented as completed on several specified dates, and there was no documentation explaining why the treatment was not completed. Additionally, the MAR for Resident D indicated that the sliding scale insulin was not documented as administered on certain dates, and there was no documentation of the required blood sugar levels for specific times in November. During an interview, an LPN confirmed that all ordered medications and treatments should be documented as completed in the resident's MAR and TAR, and any deviations should be documented with an explanation. The facility's policy on medication administration also required documentation of any withheld or refused doses, but this was not adhered to in Resident D's case.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in several areas, including three of four resident halls and two of three shared restrooms. Observations revealed multiple deficiencies such as stained toilet bowls, missing window trim, and thresholds in resident rooms. Shared shower rooms were found to have missing light covers, cove base, corner trim, cracked or broken tiles, a broken switch plate, and old screw holes in the walls. Additionally, hall floors were missing baseboards and had worn spots and paint splatters. During interviews, it was revealed that the facility was experiencing a shortage of maintenance personnel, with one staff member having recently left. Maintenance staff indicated that they conduct routine checks weekly but rely on other staff to report missing or broken items. The facility's policy on daily inspections was not adhered to, as evidenced by the undated policy provided by the Facility Administrator, which stated that buildings and grounds should be inspected daily and repairs should be addressed immediately. This deficiency was related to a specific complaint, IN00437748.
Failure to Provide Routine Catheter and Ostomy Care
Penalty
Summary
The facility failed to provide routine catheter and ostomy care for three residents, as observed during a survey. Resident C, who has paraplegia, neuromuscular dysfunction of the bladder, and a stage 4 pressure ulcer, reported waiting through multiple shifts for her colostomy bag to be changed. Her care plan required catheter and colostomy care every shift, but documentation showed these were not completed on several occasions in July 2024. Resident D, with benign prostatic hyperplasia and neuromuscular dysfunction of the bladder, indicated that staff did not routinely empty his catheter drainage bag or provide catheter care. His care plan also required catheter care every shift, yet records showed missed care on multiple dates in July and August 2024. Resident F, who has hemiplegia, chronic kidney disease, and a cystocele, reported providing her own catheter care despite requiring substantial assistance. Her care plan mandated catheter care every shift, but documentation indicated missed care on several dates in July 2024. An RN confirmed that staff should document reasons for any missed routine care. The facility's policies on colostomy and urinary catheter care were reviewed, but the care was not provided as ordered by the residents' physicians.
Failure to Ensure Resident Appropriateness for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate to self-administer their medications without supervision. During a random observation, a resident was found alone in their room with a cup of medications on their bedside table. The resident indicated that they did not know what the medications were and intended to take them after lunch. The resident's diagnoses included heart failure and anxiety, and their most recent MDS assessment indicated no cognitive impairment. However, there was no physician order or self-administration assessment in the resident's record to support self-administration of medications. Interviews with staff revealed that the resident should have been supervised during medication administration. The LPN confirmed that the resident should be observed when taking medications, and the DON stated that residents who do not self-administer should not be left alone with their medications. The facility's policy required a written order from the attending physician for a resident to self-administer medications, which was not present in this case. The resident was also not listed on the facility's self-administration list.
Failure to Follow Care Plan Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's care plan was followed, resulting in an allegation of staff negligence. Resident B, who had a history of cerebral infarction, dysphagia, cognitive communication deficit, and hemiplegia, was hospitalized after nursing staff administered medications orally while he was lying flat in bed. This caused a medication to get stuck in his throat, leading to a burn and subsequent hospitalization. The resident's care plan required that he receive care from at least two staff members due to his behaviors and risk of aspiration, but this was not followed during the incident on 2/16/24. During the investigation, it was revealed that the Qualified Medication Aide (QMA) elevated the resident's bed and administered the medications, but the resident reported difficulty swallowing and indicated that he was lying flat when the medications were given. The Speech Therapist and Licensed Practical Nurse (LPN) confirmed that two staff members should be present when providing care to Resident B. The facility's policy on comprehensive care plans was not adhered to, leading to the resident's hospitalization and subsequent changes in his care plan, including the initiation of a feeding tube and an NPO diet.
Failure to Provide Assistance with Bathing
Penalty
Summary
The facility failed to provide assistance with bathing for two residents, Resident B and Resident C, according to their care plans and bathing schedules. Resident B, who had diagnoses including cerebral infarction, cognitive communication deficit, and hemiplegia, was observed with multiple stains on his shirt and yeast growing in the palm of his left hand. His care plan indicated he was dependent on staff for bathing, with scheduled shower days on Mondays and Thursdays. However, from 3/19/24 to 4/19/24, Resident B only received two showers and two bed baths, which did not meet the scheduled frequency. Resident C, diagnosed with nontraumatic intracranial hemorrhage, difficulty in walking, nausea with vomiting, morbid obesity, and major depressive disorder, required substantial to maximum assistance with bathing. Despite this, Resident C's documented bathing records from 3/19/24 to 4/19/24 showed only one bed bath and three showers, with one refusal noted. The facility's policy required offering a shower, tub bath, or bed/sponge bath at least twice weekly according to the resident's preference, which was not adhered to in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 152 citations issued within 25 miles in the last 12 months — including the 1 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vincennes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgepointe Health Campus | 4.8 mi | ★★★★★ | 5 | 0 |
| Gentle Care Strategies | 6 mi | ★★★★★ | 0 | 0 |
| Lodge Of The Wabash | 6.1 mi | ★★★★★ | 18 | 0 |
| Oak Village | 13.4 mi | ★★★★★ | 15 | 0 |
| Prairie Village Nursing And Rehabilitation | 13.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.