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 Envive Of Muncie during CMS and state inspections, most recent first.
The facility failed to provide and document required written notices of transfer/discharge rights and bed-hold policies for three residents who were transferred to the hospital for acute changes in condition, including stroke-related symptoms, severe respiratory distress, and suspected urosepsis. In each case, staff notified providers, obtained orders for ER evaluation, contacted EMS, and documented the transfers and subsequent hospital admissions, but the clinical records lacked evidence that the residents or their representatives received the mandated written notices. Interviews with the SSD, DON, and an RN showed that bed-hold and related paperwork were routinely placed in packets sent with EMTs to the ER rather than being given directly to residents or their representatives, and there was no documentation that these notices were received, contrary to facility policy requiring provision and documentation of such notices after emergency transfers.
A resident was admitted and did not receive a written or verbal summary of the baseline care plan, as required by facility policy. Record review showed no documentation that the resident or the resident’s representative was given baseline care plan information within the required timeframe. The SSD acknowledged that no baseline care plan conference note was completed, no care plan conference had occurred since admission, and no phone contact was made with the resident’s representative to convey baseline care plan details, despite the resident having generally intact cognition. This was inconsistent with the facility’s policy requiring development of a baseline plan of care within 48 hours of admission and provision and documentation of a written summary to the resident and/or representative.
Two residents were not appropriately offered or administered pneumococcal vaccinations per CDC guidance and facility policy. One resident with a history of tonsillar cancer, traumatic brain injury, and diabetes had only a historical PPSV23 documented prior to admission, with no consent/declination form and no record of being offered current PCV15, PCV20, or PCV21 vaccines. Another resident with cardiac conditions and muscle weakness had a signed pneumococcal vaccine consent on file but no documentation of any pneumococcal vaccine being offered or given, and no updated consent or declination. The DON reported difficulty locating current vaccination forms and noted that an off-site company provides vaccinations, but no clinic had yet been scheduled, resulting in missing documentation and incomplete pneumococcal vaccination offerings for these residents.
A resident with cardiac conditions and moderate cognitive impairment had signed consents for a COVID-19 vaccine and booster through a representative, but review of records showed the resident never received a COVID-19 vaccination and lacked an updated consent or declination. The DON could not locate current vaccination forms, reported that vaccines were administered by an off-site company, and acknowledged that another vaccine clinic had not yet been scheduled, despite stating vaccines were to be offered yearly. The Infection Preventionist stated residents were offered COVID-19 vaccinations, while CDC guidance cited by surveyors recommended updated COVID-19 vaccines for adults, including those in LTC, with two doses for those 65 and older and consent required.
Surveyors found unsecured disposable razors stored in unlocked mirrored vanities in two shared bathrooms on a dementia unit, including one bathroom accessible from the main dining room. The bathrooms were used by four cognitively impaired residents with dementia, some with severe cognitive impairment, hallucinations, agitation, anxiety, and cognitive communication deficits, who were able to toilet and stand at the sink independently. The Memory Care Director acknowledged razors should not be left in resident bathrooms and stated that some razors had been brought in by families, while a CNA reported she did not usually keep razors in bathrooms. The Administrator was unable to locate a policy governing disposable razor storage.
A resident with moderate cognitive impairment, COPD, and multiple respiratory diagnoses received a prescribed ipratropium-albuterol nebulizer treatment ordered to be administered by a clinician, but nursing staff did not remain in the room during the treatment as required by facility policy. The resident was observed alone in bed with the nebulizer running while an RN was at the nurses' station, and the RN later confirmed she typically did not stay with residents during nebulizer treatments. The resident had not been assessed as able to self-administer medications, and the care plan called for medications to be administered as ordered, including adherence to the policy requiring staff to remain with the resident throughout the nebulizer treatment.
Surveyors found that multiple shared bathrooms on a dementia unit contained unlocked vanities with partially used and unlabeled personal care items, such as wound cleanser, deodorant, toothpaste, lotions, toothbrushes, and incontinence briefs, used by several cognitively impaired residents. Staff, including the Memory Care Director and a CNA, acknowledged that these items should have resident identifiers and typically would be stored in shower rooms, drawers, or closets, and the Administrator was unable to produce a policy governing storage of residents’ personal care items.
Inconsistent narcotic count reconciliation was documented across multiple shifts, with several shift-to-shift count sheets left blank, illegible, or showing mismatched counts after controlled medication cards were added or removed. The DON acknowledged the documentation problems and stated the sheets did not identify which hall or cart they came from, while facility policy required the oncoming and offgoing nurses to count controlled substances together and document discrepancies.
The facility did not consistently complete shift-to-shift narcotic reconciliation for three medication carts, with missing signatures and counts on controlled substance records and unreported discrepancies. Nursing staff failed to follow policy requiring both incoming and outgoing staff to verify and document controlled medication counts, impacting residents receiving controlled medications from these carts.
The facility did not document that required bed hold policies and transfer/discharge notifications were provided to residents or their representatives during hospitalizations, and failed to ensure that appropriate transfer information was communicated to a receiving provider when a resident was discharged to another facility. Although forms and policies were attached in records, there was no evidence of who received them, and staff interviews confirmed the lack of documentation.
A resident with multiple medical conditions experienced a significant, unplanned weight loss while on a carbohydrate controlled diet. Despite the RD's recommendations to liberalize the diet to provide more calories and protein, the diet was not changed, and the physician was not notified of the weight loss or the recommendations. Documentation and staff interviews confirmed these failures, and the facility's policy for multidisciplinary nutritional assessment and intervention was not followed.
Staff failed to consistently use Enhanced Barrier Precautions (EBP), including gowns and gloves, during high-contact care for a resident with a stage 3 sacral pressure injury. Multiple staff members were observed not following EBP protocols, lacked knowledge about EBP, and did not receive documented education on EBP requirements, despite facility policy and physician orders mandating these precautions.
Two residents were not properly offered, educated about, or administered pneumococcal vaccines as required by CDC guidance. One resident did not receive the vaccine despite consent and education, while another lacked documentation of education and consent. The DON confirmed gaps in the facility's process for vaccine administration and documentation.
A resident with chronic pain, hypertension, and diabetes was admitted with a history of prior COVID-19 vaccinations, but the facility failed to provide education, offer the vaccine, or document consent/declination as required. The DON reported no recent vaccine clinics and was unable to locate necessary documentation, resulting in a deficiency related to immunization procedures.
An LPN failed to disinfect glucometers and the surfaces they contacted during blood glucose monitoring for multiple residents. The devices were placed on the medication cart and over-bed tables without cleaning, and were returned to storage without disinfection, contrary to facility policy and manufacturer guidelines.
The facility failed to secure potentially hazardous items on the dementia unit, impacting 11 mobile residents. An unlocked cabinet contained gel hand sanitizer, denture cleaning tablets, and razors, posing a risk to residents with dementia. The Dementia Unit Manager acknowledged the cabinet should have been locked, as per facility policy.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide written notice of transfer/discharge rights and the facility’s bed-hold policy to residents and/or their representatives when residents were transferred to the hospital. For one resident with cerebral infarction, atrial fibrillation, and vascular dementia, progress notes documented a change in condition with lethargy, garbled speech, and intermittent responsiveness, leading to a family request for transfer to the ER and subsequent transport by EMTs. The clinical record did not contain documentation that a Notice of Transfer rights or bed-hold policy was provided to the resident or her representative at the time of this hospitalization. A second resident with diagnoses including hyperosmolality, hypernatremia, tonsillar cancer, and nontraumatic subarachnoid hemorrhage experienced respiratory distress with moist respirations, labored breathing, and low oxygen saturation, prompting provider notification, an order for ER transfer, and EMS transport. Later that same month, the same resident had an unresponsive episode in the dining room with low oxygen saturation and decreased responsiveness, again resulting in provider notification and ER transfer. For both hospitalizations, progress notes documented the transfers and subsequent hospital admissions, but the clinical record lacked documentation that the Notice of Transfer rights and bed-hold policy were provided to the resident or his representative. A third resident with anemia, hypertension, and dementia exhibited a change in condition characterized by abnormal urine appearance and odor, altered mental status compared to baseline, and a family request for ER evaluation. The provider was notified, an order for ER evaluation was obtained, 911 was called, and the resident was transported and later admitted for urosepsis. The record did not show that the Notice of Transfer rights and bed-hold policy were provided to the resident or his representative. Interviews with the Social Services Director, DON, and an RN revealed that bed-hold paperwork and related forms were routinely placed in a packet sent with EMTs to the hospital, with no direct provision of these notices to residents or their representatives and no documentation that such notices were received, despite facility policy requiring that bed-hold and return policies be provided to residents and representatives within 24 hours of emergency transfer and that provision of appropriate notice be documented in the medical record.
Failure to Provide and Document Baseline Care Plan Summary After Admission
Penalty
Summary
The facility failed to ensure that a resident and/or the resident’s representative received a copy of the resident’s baseline care plan following admission. Record review for Resident 8 showed that the resident was admitted on an identified date, but the clinical record did not contain documentation that a written summary of the baseline care plan was provided to the resident or the resident’s representative. The facility’s policy, dated 8/2024, required that a baseline plan of care to meet the resident’s immediate health and safety needs be developed within 48 hours of admission and that the resident and/or representative be provided a written summary of this baseline care plan, with documentation of this provision in the medical record. During interviews, the Social Services Director (SSD) stated that she had not completed a baseline care plan conference review note for Resident 8 because the resident had not yet had a care plan conference since admission, and therefore no baseline care plan information was provided to the resident or the resident’s representative. The SSD further indicated that baseline care plan information was to be conveyed to residents or their representatives within 72 hours after admission and could be relayed over the phone, but no phone contact was made with Resident 8’s representative. Although Resident 8’s cognitive status was intact, with some fluctuation in cognitive function, the SSD did not provide baseline care plan information verbally or in writing to the resident. This failure was contrary to the facility’s written policy and the requirement to document provision of the baseline care plan summary in the medical record.
Failure to Offer and Administer Pneumococcal Vaccines per CDC Guidance
Penalty
Summary
The facility failed to offer and administer pneumococcal vaccinations in accordance with CDC guidance and its own policy for two residents. Resident 27, who had diagnoses including tonsillar cancer, traumatic brain injury, and diabetes, had a historical PPSV23 (Pneumovax 23) documented from 12/19/11 prior to admission. The clinical record did not contain a Pneumococcal Vaccine Consent or Declination Form and lacked any documentation that the resident had been offered or received the currently recommended pneumococcal conjugate vaccines (PCV15, PCV20, or PCV21) as outlined by CDC recommendations for adults 50 years and older. This was inconsistent with the facility’s written policy requiring assessment of pneumococcal vaccination status upon or shortly after admission and administration of vaccines per current CDC recommendations. Resident 45, with diagnoses including aortic valve insufficiency, heart disease, and muscle weakness, had no record of receiving any pneumococcal vaccination. The record contained a Pneumococcal Vaccine Consent signed on 12/6/24, but there was no updated consent or declination and no documentation that any pneumococcal vaccine had been offered or administered. During interviews, the DON stated she could not locate current pneumococcal vaccination forms for these residents, explained that vaccinations were administered by an off-site company, and acknowledged that another vaccine clinic needed to be scheduled but had not yet been arranged. The DON and Infection Preventionist both stated that pneumonia vaccinations were offered per guidelines, but the clinical records for these two residents did not support that pneumococcal vaccines had been appropriately offered or administered in accordance with CDC guidance and the facility’s policy.
Failure to Ensure Appropriate COVID-19 Vaccination and Documentation
Penalty
Summary
The facility failed to administer appropriate COVID-19 vaccinations in accordance with CDC guidance for one resident. Resident 45 had diagnoses including aortic valve insufficiency, heart disease, and muscle weakness, and a quarterly MDS dated 3/9/26 documented moderately impaired cognition. A COVID-19 vaccine consent and a COVID-19 booster consent were signed by the resident’s representative on 12/6/24. However, a review of the vaccination record showed the resident had not received any COVID-19 vaccination, and the record also indicated that the family representative had refused the vaccination in December 2024. The clinical record lacked an updated or yearly COVID-19 vaccination consent or declination. During interviews, the DON stated she was unable to locate current COVID-19 vaccination forms for this resident and confirmed that the facility did not administer vaccinations directly, instead using an off-site company to provide vaccines. She acknowledged that another vaccine clinic needed to be scheduled but had not yet done so, and also stated that COVID-19 vaccinations were to be offered yearly. The Infection Preventionist reported that residents were offered COVID-19 vaccinations. CDC guidance reviewed by surveyors indicated that adults, including those in LTC settings, should receive an updated COVID-19 vaccine, and that individuals aged 65 and older should receive two doses of an updated vaccine six months apart, with consent required from LTC residents. The deficiency was cited under 410 IAC 16.2-3.1-18(b)(5).
Unsecured Disposable Razors in Dementia Unit Bathrooms
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents by allowing disposable razors to be unsecured in shared bathrooms on a dementia unit. During an observation of one shared bathroom used by two cognitively impaired residents, an unlocked tri-fold mirrored vanity above the sink was found to contain a disposable razor. The Memory Care Director, present at the time of the observation, stated that razors should not be left in residents' bathrooms. Record review showed that one of these residents had diagnoses including hallucinations, cognitive communication deficit, and unspecified dementia with severe cognitive impairment per a quarterly MDS, while the other had unspecified dementia and moderate cognitive impairment per a quarterly MDS. In a second shared bathroom, also on the memory care unit and accessible from the unit’s main dining room, surveyors observed two disposable razors stored in an unlocked tri-fold mirrored vanity above the sink. The Memory Care Director reported that family members had brought in the razors and acknowledged they should not have been left in the bathroom. Record review for the two residents using this bathroom showed diagnoses of unspecified dementia with severe cognitive impairment and cognitive communication deficit for one resident, and moderate unspecified dementia with agitation and anxiety for the other, with both needing assistance or having needs related to personal care. A CNA reported that these residents could toilet themselves and stand at the sink independently and that she did not normally keep razors in residents’ bathrooms. During an interview, the Administrator stated he was unable to locate a facility policy for storage of disposable razors.
Failure to Supervise Nebulizer Treatment for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves a resident receiving a nebulizer treatment without required staff supervision, despite not being assessed as able to self-administer medications. During an observation, the resident was found lying in bed with a nebulizer machine running while an RN was seated at the nurses' station. After approximately two minutes, the RN entered the room, turned off the nebulizer, assessed the resident's lung sounds, and then left. The RN stated she did not normally remain with residents during their nebulizer treatments. Another RN also reported that she did not stay with residents during nebulizer treatments, but would return to check on them during the treatment. The resident had diagnoses including cognitive communication deficit, vascular dementia with moderate cognitive impairment, schizophrenia, acute bronchitis, COPD with acute exacerbation, acute cough, dyspnea, and other respiratory and circulatory symptoms. The resident’s medication orders included ipratropium-albuterol inhalation solution to be inhaled four times daily for shortness of breath and wheezing, with the medication specifically ordered to be administered by a clinician. The care plan identified a potential for impaired gas exchange related to COPD, dyspnea, rhinitis, shortness of breath, and wheezing, with interventions to administer medications as ordered. The clinical record did not show that the resident had been assessed as able to self-administer medications, and the facility’s policy for administering medications via small volume nebulizer required staff to remain with the resident for the duration of the treatment, which did not occur in this case.
Unlabeled and Cohorted Personal Care Items in Shared Dementia Unit Bathrooms
Penalty
Summary
Surveyors identified a failure to implement an effective infection prevention and control program related to the storage and labeling of residents’ personal care items in shared bathrooms on a dementia unit. In one shared bathroom used by two cognitively impaired residents with dementia, an unlocked tri-fold mirrored vanity above the sink contained multiple personal care items with no resident identifiers, including an empty bottle of Vashe wound cleanser, after shave gel, shaving cream, perfumed body cream, two denture brushes, and a toothbrush. The Memory Care Director stated that no one currently had wounds and could not explain why the wound cleanser was present. Record review showed one resident had severe cognitive impairment and the other had moderate cognitive impairment and needed assistance with personal care. In another shared bathroom used by three residents, the unlocked vanity contained a roll-on deodorant, partially used toothpaste, lotion, and a toothbrush in a foam cup, all without resident identifiers. One of these residents had diagnoses including schizoaffective disorder, psychotic disorder with delusions, paranoid schizophrenia, dementia with behavioral disturbance, and Alzheimer’s disease with late onset, and was assessed as having moderate cognitive impairment. A third shared bathroom, accessible from the memory care unit’s main dining room and used by two residents with dementia and moderate to severe cognitive impairment, contained an unlocked vanity with unlabeled personal care items including skin repair cream, a toothbrush, baby lotion, cornstarch powder, and four incontinence briefs. During interviews, the Memory Care Director and a CNA confirmed that personal care items should have resident identifiers and were normally stored in shower rooms, residents’ drawers, or closets, and the Administrator reported he could not locate a policy for storage of residents’ personal care items.
Inconsistent Narcotic Count Reconciliation
Penalty
Summary
The facility failed to ensure consistent shift-to-shift reconciliation of narcotics to reduce the risk of misappropriation. Review of the August, September, and October 2025 narcotic shift-to-shift count sheets showed multiple dates and shifts where narcotic counts were not reconciled, including several first and second shifts across all three months. The record also showed instances where the count was incorrect, blank, or illegible, including counts that were not documented, counts written over with another number, and counts that did not match the documented additions or removals of controlled medication cards. The Director of Nursing stated she had been employed since August 2025 and did not like the current system in which cards were counted and documented during shift changes. During interview, she agreed that some of the documentation was illegible and that inaccurate counts, blank spaces, or incomplete documentation could allow diversion. She also stated the narcotic shift-to-shift sheets did not specify which hall or cart they were pulled from, and she only knew which carts correlated with the sheets. The facility policy required controlled substance inventory to be monitored and reconciled, with the oncoming and offgoing nurses counting together and documenting and reporting discrepancies to the DON.
Failure to Complete Shift-to-Shift Narcotic Reconciliation for Multiple Medication Carts
Penalty
Summary
The facility failed to ensure that shift-to-shift narcotic reconciliation was completed for three of four medication carts reviewed, specifically on the A Unit, Cottage Unit, and C Unit medication carts. During medication storage observations, it was found that required signatures and counts were missing from the Shift To Shift Narcotic Count records at the beginning of shifts. For example, an LPN did not sign or record her count when taking over the cart, and discrepancies in the number of controlled medication cards and sheets were not recognized or reported as required. Review of records revealed multiple instances in May and June where shift-to-shift reconciliation was not documented for these carts. Interviews with nursing staff confirmed that both the incoming and outgoing staff were required to count and verify controlled substances together, document the count, and sign the records. However, staff admitted to not completing these steps consistently, and in some cases, discrepancies in the controlled substance counts were not reported to the DON as required by facility policy. The DON confirmed that incomplete reconciliation records made it impossible to verify if the process had been completed and that any discrepancies should have been immediately reported and investigated. The facility's current policy required strict compliance with laws and regulations regarding the handling, storage, and documentation of controlled substances, including shift-to-shift inventory reconciliation and immediate reporting of discrepancies. Despite this, the observed and documented lapses in reconciliation and documentation created opportunities for unrecognized discrepancies in controlled medication counts, affecting a significant number of residents who received controlled medications from the affected medication carts.
Failure to Document Provision of Bed Hold Policy and Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide proper documentation and notification regarding bed hold policies and transfer/discharge notifications to residents and/or their representatives during hospitalizations. For three residents with varying cognitive statuses and medical conditions such as respiratory failure, COPD, hypertension, dementia, and post-stroke deficits, the clinical records showed that while the required forms and bed hold policies were attached, there was no documentation indicating to whom these documents were provided. In each case, the records lacked evidence that the resident or their representative received the necessary notifications at the time of transfer or discharge to the hospital, as required by facility policy. Additionally, for one resident discharged to another long-term care facility, the clinical record did not contain documentation that the resident's discharge information was communicated to the receiving provider. Although the resident's daughter was given a packet of information and medications, there was no record of the receiving facility being provided with the required transfer information, such as the basis for transfer, practitioner contact, care plan, and other essential details for continuity of care. Interviews with facility staff confirmed that while procedures were in place to print and distribute documentation, there was no evidence in the clinical records to verify that the required notifications and information were actually provided to the appropriate parties. Facility policies reviewed specified the need for written notification and documentation of attempts to notify representatives, as well as the communication of comprehensive transfer information to receiving providers, but these requirements were not met in the reviewed cases.
Failure to Follow Dietitian Recommendations and Notify Physician for Significant Weight Loss
Penalty
Summary
The facility failed to follow the registered dietitian's (RD) recommendations and did not notify the physician regarding a resident who experienced a significant, unplanned weight loss. The resident, who had diagnoses including schizoaffective disorder, muscle weakness, obesity, and type 2 diabetes mellitus, was on a consistent carbohydrate diet. Over a six-month period, the resident lost 10.29% of her body weight, with meal consumption records indicating she typically ate only 51-75% of her meals. Despite the RD's repeated recommendations in March and April to liberalize the resident's diet to a regular diet to provide more calories and protein, the resident continued to receive the carbohydrate controlled diet. The clinical record did not contain documentation that the physician was notified of the significant weight loss or the RD's recommendations, nor was there an order to change the resident's diet or any indication that the physician declined the recommendation. Interviews with facility staff confirmed that the RD communicated her recommendations to the interdisciplinary team (IDT) via email and documented them in the electronic medical record, but the DON was unaware that the resident's diet had not been changed. The facility's policy required a multidisciplinary approach to nutritional assessment and intervention, but this process was not followed in this case.
Failure to Implement and Educate Staff on Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to ensure that staff were properly educated in and implemented Enhanced Barrier Precautions (EBP) during high-contact care for a resident with a stage 3 sacral pressure injury. Observations revealed that staff, including an RN and multiple CNAs, did not consistently wear gowns as required during wound care and other high-contact activities, despite gloves being used. During wound care, the RN did not don a gown and her clothing came into contact with the resident's bed linens. The resident's care plan and physician orders specifically required EBP, including the use of gowns and gloves during high-contact care, but these precautions were not followed. Interviews with staff indicated a lack of knowledge and awareness regarding EBP requirements. Several CNAs were unfamiliar with what EBP entailed, how to identify which residents required EBP, or what personal protective equipment (PPE) was necessary. Assignment sheets and signage were not consistently used or noticed, and staff did not always perform hand hygiene or change gloves appropriately during care. One CNA was observed providing incontinence care, changing clothing, and manipulating a feeding tube without wearing a gown, performing hand hygiene, or changing gloves, despite EBP signage being present in the resident's closet. The Director of Nursing (DON) confirmed that EBP was required for residents with wounds, invasive lines, or indwelling devices, and that gowns and gloves should be used during high-contact care. However, the DON was unable to provide documentation of when EBP education was provided to staff or which staff had received it. Agency staff also reported not receiving EBP education prior to providing care. Facility policy required EBP for residents with wounds or indwelling devices, specifying gown and glove use for high-contact activities, but this policy was not consistently implemented.
Failure to Offer, Educate, and Administer Pneumococcal Vaccines per CDC Guidance
Penalty
Summary
The facility failed to offer, educate, and/or administer pneumococcal vaccines according to CDC guidance for two of five residents reviewed for immunizations. For one resident with diagnoses including COPD, type 2 diabetes with neuropathy, and a stage 4 pressure ulcer, the clinical record did not contain an order for the pneumococcal vaccine. Although a consent form was completed and education was provided, the vaccine was not administered as required. Another resident with chronic pain syndrome, hypertension, and type 2 diabetes had historical documentation of receiving pneumococcal vaccines prior to admission. However, the clinical record lacked documentation of education and a signed consent or declination form for the pneumococcal vaccination. The DON confirmed that the facility had not held a vaccine clinic with the outside provider and was uncertain about the process for administering vaccines when due between clinics. The facility policy required education, consent, and documentation for immunizations, which was not followed in these cases.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to provide education, offer, and document COVID-19 vaccination status in accordance with CDC guidance for one resident reviewed for immunizations. The resident, who had a history of chronic pain syndrome, hypertension, and type 2 diabetes mellitus, was admitted to the facility with a prior history of receiving multiple COVID-19 vaccinations before admission. Upon review of the clinical record, there was no documentation of education or a signed consent/declination form for the COVID-19 vaccination as required by facility policy. Interviews with the DON revealed that the facility had not conducted a vaccine clinic since the change in ownership, and the process for administering vaccines between clinics was unclear. The DON was unable to locate documentation or consents for the resident's COVID-19 vaccinations, despite the facility's policy requiring that information and consent forms be provided and retained in the medical record upon admission. The lack of documentation and unclear processes led to the deficiency identified during the survey.
Failure to Disinfect Glucometers and Surfaces During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during blood glucose monitoring for five residents. During medication administration, an LPN was observed removing each resident's glucometer from a plastic bag in the medication cart, placing it directly on the medication cart and then on the resident's over-bed table without cleaning or disinfecting these surfaces. After performing the blood sugar check, the LPN returned the glucometer to the medication cart and then to the plastic storage bag without disinfecting the device. This process was repeated for each resident observed, and at no point were the glucometers or the surfaces they contacted cleaned or disinfected. Interviews with facility staff confirmed that the expectation was for glucometers to be cleaned and allowed to dry before being stored, in accordance with manufacturer guidelines and facility policy. The policy specifically required cleaning and disinfecting reusable equipment between uses. The failure to follow these procedures was observed for all five residents reviewed for infection control during medication administration, as neither the glucometers nor the medication cart and over-bed tables were disinfected before or after use.
Failure to Secure Hazardous Items on Dementia Unit
Penalty
Summary
The facility failed to ensure that potentially hazardous items were securely stored on the dementia unit, which could have impacted 11 of the 13 mobile residents residing there. During an observation, it was noted that residents were moving freely within the unit, some using wheelchairs and others with assistance devices. Although employees were present and interacting with residents, not all residents were within their line of sight. A specific observation revealed an unlocked cabinet in the dining area, which was supposed to remain locked at all times according to a sign on its face. The cabinet contained hazardous items, including two bottles of gel hand sanitizer, an open box of denture cleaning tablets, and 13 disposable razors, all of which had warning labels indicating potential harm if ingested. The Dementia Unit Manager confirmed during an interview that the cabinet should have been locked. All residents on the unit had a diagnosis of dementia or a related disorder, with 11 of them capable of independent locomotion. The facility's policy on the storage and security of potentially hazardous items emphasized the importance of providing an environment free from hazards, including the safe storage of toxic chemicals and sharp items, especially for residents with cognitive impairments. The failure to secure the cabinet posed a risk to the residents, who could have accessed these hazardous items.
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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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Nursing homes near Muncie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cardinal Care Strategies | 1.7 mi | ★★★★★ | 30 | 3 |
| Brookside Care Strategies | 3.4 mi | — | 49 | 0 |
| Waters Of Muncie, The | 4.9 mi | ★★★★★ | 0 | 0 |
| Parker Health Care & Rehabilitation Center | 5.1 mi | ★★★★★ | 10 | 0 |
| Signature Healthcare Of Muncie | 5.2 mi | ★★★★★ | 30 | 0 |
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